of varicose veins in the latter situation ; from overfilling of the capillaries due to overaction of the heart, as, for example, in diseased conditions of that organ, or due to severe exercise, as in the general vascular agitation of the body which accompanies violent expiratory efforts, such as coughing, sneezing, vomiting, and the like, or dancing (Alibert), and coitus ; * from the corrosion of the mem- brane produced by the inhalation of irritating vapors and powders (bichromate of potash, iodine, chlorine, ipecac, veratrum, chloroform, etc.), or from poisonous doses of those drugs that are eliminated through the mucous sur- face of the upper respiratory tract; from the solution of continuity of structure, occasioned by ulceration of vari- ous kinds, the separation of crusts, the presence of tu- mors (notably carcinoma and sarcoma); from foreign bodies, insects, and parasites in the nasal and accessory cavities. Under this head, too, may be included the haemorrhage from the nostrils which occurs in certain surgical injuries of the skull, and particularly fracture of the base, and those affections of the nasal passages ac- companied by caries or necrosis. It may also result from concussion. In the famous naval combat between the Merrimac and Monitor, during the civil war, blood spouted from the nostrils of the crew of the former when the round top was struck by the hostile iron-clad. When slight traumatic causes give rise to nasal haemor- rhage, the explanation is almost always to be found in some local or constitutional predisposing condition, such as a pre-existing catarrhal affection, the previous ten- dency to epistaxis, the sanguine temperament, or disturb- ances in the vascular system induced by a host of debili- tating influences, such as luxurious living, and excesses of all kinds (over-indulgence in alcohol, tobacco, venery, etc.), the presence of a diathesis, as the haemorrhagic, scorbutic, etc., and possibly from some imperfectly un- derstood inherited or acquired proclivity, or vaso motor neurosis. In such persons, over-exertion of the mental faculties, anxiety, violent emotions, and even forcing the voice in declamation and singing, are sufficient to induce copious haemorrhage from the nose. Anything that tends to produce an increased flow of blood to the nose, or to delay or obstruct its return to the heart, that increases vascular tension or lessens the resistance of the vessel-walls, predisposes to, and may be the exciting cause of, nasal haemorrhage. Thus, epistaxis is common in the plethoric, in those addicted to the use of stimulants, and in the so-called apoplectic, and is the crowning symptom of the group of phenomena refera- ble to general excitation of the vascular system, known under the technical name of the nixus haemorrhagicus. It is also often met with as the result of passive venous liyperaemia from organic disease of the heart, lungs, pleura, kidneys, etc.; from pressure on the venous trunks of the neck, thorax, and abdomen (tumors, dropsy, tight clothing, etc.); in various congestive conditions of the brain, meninges, and cerebral sinuses. It is not infre- quently the forerunner of extravasation of blood into the brain-substance, and of retinal apoplexy in connection with renal affections.1 It is also predisposed to by ha- bitual interference with the bodily excretions, notably the intestinal. It is a familiar accident in the rapid pas- sage from a dense to a rarefied atmosphere in balloon and mountain ascensions, where it is due to the diminu- tion in the atmospheric pressure and the consequent de- termination of blood to the mucous membrane of the air- passages. Epistaxis occurs as a symptom of a number of acute febrile diseases, in some of which, as, for example, ty- phoid fever, it is considered as a diagnostic sign. It is also a frequent accompaniment of the haemorrhagic diath- esis, scurvy, purpura, and allied affections ; in impover- ishment of the blood from other causes, as in chlorosis, leucocytliaemia, syphilis, tuberculosis, malarial fevers, etc.; in congestion and other diseases of the liver and spleen.-f NOSE: H/EMORRHAGE FROM THE NASAL PAS- SAGES. The term epistaxis (4nl and arafa) was used by the ancients in an extended sense to denote bleeding from the nose in general, whether it proceeded from lesions of its external or internal surface, but its use has been re- stricted by modern authors to those haemorrhages which take place from the nasal and accessory cavities. The great vascularity of the mucous membrane of the nasal passages, its spongy or cavernous structure, the in- timate connection of its blood-vessels with those of ad- jacent organs, and their corelation with other vascular tracts in remote portions of the body ; its constant expos- ure to the exciting causes of liyperaemia, together with a certain amount of vulnerability begotten of its natural delicacy of structure, combine to make epistaxis the most common of the haemorrhages of man.* Haemorrhage from the nostrils may be active or pas- sive ; may be the result of traumatic causes, symptomatic of various intrinsic pathological conditions, or occur as a critical or vicarious phenomenon. Traumatic epistaxis follows contusions, fractures, and other surgical injuries of the nose, or occurs as the result of mechanical irritation of its interior from scratching, rubbing, or picking with the finger; from instrumental interference within, or the application of caustic medica- ments to, the nasal fossa? or nasal pharynx; from rupture * On the other hand, absolute continence is said to produce it occa- sionally (Cloquet, Osphresiologie, p. 554, Paris, 1821). + The hfemorrhage which takes place in hepatic disease was said to proceed from the right nostril (Galen, de crisibus, lib. iii., cap 3); that from splenic affections, from the left. * It was the opinion of Pliny (Nat. Hist., lib. xi., cap. 91) that “ man is the only creature from whom blood flows at the nostrils.” Nose. N ose. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. It sometimes occurs from the suppression of a cutane- ous eruption, from the sudden cessation of a normal flow, as the menses, perspiration, urine, etc., or of a pathologi- cal discharge, as in the disappearance of a hsemorrhoidal flux. Fabricius of Hilden,'2 relates a case where it fol- lowed the stoppage of haemorrhage from varicose veins in the leg. It occurs in boys at or near the age of puberty in whom a predisposition to haemorrhage in general exists, and in women as the vicarious representative of menstruation. In the latter case, it may establish the menstrual function, the nasal haemorrhage being replaced subsequently by the uterine flow, or it may continue throughout the men- strual life of the individual, in which case some derange- ment or malformation of the sexual organs seems to be responsible for the nasal flow.* Vicarious nasal menstru- ation was considered a favorable sign by Hippocrates,3 and by Celsus,4 who followed closely in his footsteps. In sudden suppression of the menses, the nasal haemor- rhage may terminate in death, as happened in a case re- ported by Alibert.5 Haemorrhage from the nose is met with also during pregnancy, and may be due to vicarious action, or to the pressure of the enlarged uterus upon the abdominal veins. It occasionally occurs Howard the close of menstrual life, and has been observed as a recurring phenomena after removal of the uterus and its appendages by the Porro operation.6 It may, furthermore, be symptomatic of re- flected irritation from the gastro-intestinal (piles, worms in the intestines) and genito-urinary tracts, and in chil- dren, from diseases of the gums or eruption of the teeth. The sudden impressions made upon the cutaneous sur- face in its entirety, or upon its individual parts, such as the feet, neck, hands, scrotum, etc., of extremes of heat and cold, as in sudden exposures to temperature vari- ations, hot and cold baths, etc., are sometimes sufficient to induce copious haemorrhage from the nose.f In some instances the bleeding seems to arise from psychical impressions, conveyed through the sense of smell, from various articles of food,7 such as cheese, ap- ples, the odor of the rose, etc., from the pollen of certain plants, or from the presence of minute forms of animal life in the atmosphere, and this perverted sense seems to be pe- culiar to certain families. It is highly probable that this so-called “idiosyncrasy ” is explicable on the hypothesis of coincident local nasal disease, or of some functional vaso- motor neurosis. Blancard8 relates a case where the ring- ing of bells always produced epistaxis. In this connec- tion may be mentioned the case recorded by Salmuth,9 where a young man was habitually so affected by the sight of a haemorrhage from his mistress’ nose, that blood began to flow immediately from his own, and a similar observation is related by Rhodius.10 Now and then, epistaxis is encountered as an intermit- tent or periodical condition occurring at regular intervals (Taunton n), and depending in some instances on a malarial cause, as evidenced by its disappearance on the exhibition of quinine (Millet12). The so-called epidemic occurrence of epistaxis is prob- ably explicable by the prevalence of some malignant sys- temic disease with prominent local complications, or by the existence of meteorological conditions favorable to congestive states of the nasal mucous membrane. Haemorrhage from the nose is a not uncommon symp- tom of nasal catarrh. It may be small in amount, or be sufficiently copious to produce considerable depression, and even collapse. It is generally excited by picking, scratching, rubbing, or blowing the nose, by sneezing and coughing, by the separation of crusts, and a multitude of other exciting causes that determine an increased flow of blood to the nasal membrane. Sometimes such haemor- rhages occur at night, from unconscious irritation of the nose with the finger during sleep. Quite extensive loss of blood occurs, however, without the intervention of traumatic influences in chronic inflammatory conditions of the nasal tissues, perhaps from congestion of the cav- ernous structure and loss of resistance in the erectile cellu- lar walls, or from stoppage of the nostrils,13 for when the nose is freed of mucus and crusts, or when the redundant tissue is removed and the normal aerial pathway is restored, the recurring haemorrhages cease. The bleeding in many such cases comes from the cavernous tissue. Indeed, nasal obstruction from any cause (deflection of the septum, hypertrophic enlargements of the nasal structures, etc.), predisposes to epistaxis, in all probability from the crea- tion of a more or less complete vacuum behind the seat of obstruction. The writer has seen very alarming haem- orrhage occur from such a condition, the blood flowing into the stomach and air-passages and leading to the suspicion of pulmonary disease. This is probably also the explanation of many cases of so-called “ spontaneous” epistaxis. The same is also true in regard to obstruction in the retro-nasal space, closure of the posterior nares plus the consequent congestion of the nasal passages, and the altered relations in regard to atmospheric pressure conditioning the predisposition to haemorrhage. In cases, moreover, wherein no bleeding-point is discoverable in the nasal passages, it must he remembered that the flow may come from one of the accessory sinuses, or even from the middle ear. Epistaxis is, perhaps, most commonly met with in in- fancy, is less common in youth and manhood, while in later life, the tendency to haemorrhage reappears, a fact to be explained by the degenerative changes in the vas- cular system which accompany the processes of old age. The symptoms of rhinorrhagia do not differ from those of haemorrhage in general. Usually the amount lost is small and insufficient to give rise to constitutional dis- turbance. It escapes drop by drop from the nose, or it may flow in a continuous stream. The literature of the last two centuries contains accounts of cases where large quantities of blood were lost in a short while, and if we can believe the reporter,14 as much as seventy-five pounds has been known to escape in the space of ten days. Those who suffer from habitual epistaxis are subject to derange- ments of vision. The bleeding generally comes from one nostril, hut may occur from both. When the bleeding-point is seated anteriorly, the blood flows from the anterior naris, while, if it is located in the posterior portion of the nostril, the blood escapes into the throat, aided in its passage to that region by the natural obliquity of the nasal floor. Gain- ing the throat, it is either expectorated or enters the air- passages, and is removed by coughing ; or it may gravi- tate into the oesophagus and be swallowed. Its presence in the stomach may excite vomiting, or it may pass through the alimentary canal and be voided at stool. Finally, the blood may be discharged through the lachry- mal ducts and puncta. Pathological Anatomy.—The haemorrhage may take place from the surface of the mucous membrane, or into the submucous tissues. The latter generally occurs in connection with blood-poisoning or traumatism. Bloody tumors (hsematomata) of the nasal fossae, especially of the septum, are occasionally encountered as the result of mechanical injury.15 The writer has observed, on microscopic examination, quite extensive haemorrhages into the cavernous tissue in long-standing cases of hypertrophic catarrh. The ex- travasation may take place into the meshes of the cav- ernous body, or between it and the mucous membrane. When the bleeding has been slight, the only macroscopi- cal evidence of its existence will consist in minute ex- travasations (ecchymoses) or capillary apoplexies. Usu- ally the nasal mucous membrane is intensely hypenemic. The haemorrhage generally arises from solution of con- tinuity of the membrane at isolated spots or over circum- scribed areas, rarely, if ever, from the whole surface of the nasal fossa. The point of origin of traumatic epis- taxis will obviously depend upon the nature and mode of operation of the mechanical or chemical irritant, or upon the situation of the lesion which produces it. In view of the intimate vascular communication be- * A case of this kind has come under the observation of the writer, t According to Cloquet (op. cit., p. 554) there are certain springs in Auvergne the temperature of whose waters is so low that copious hem- orrhage from the nostrils occurs from immersion of the hands during the heated term. 220 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Nose, Nose. tween the erectile tissue and the cerebral circulation, it is highly probable that the so-called “critical” haemor- rhages and those by which congestive conditions of the brain are relieved, and perhaps also those of vicarious origin, take place from the cavernous bodies, which lat- ter may be looked upon, therefore, among other physio- logical properties which they possess, as serving, in that respect, a certain teleological purpose. Whether this be true or not, the writer is convinced that many nasal haem- orrhages originate primarily from the vascular spaces of these bodies, and that the latter play an important role in the pathology of epistaxis. The bleeding-point is very frequently found upon some portion of the cartilaginous septum. As Valsalva pointed out long ago,16 it frequently occurs at the junction of the “alae nasi with the bone, about a finger’s-breadth, more or less, from the bottom of the nostrils.” The respiratory region, being more exposed to the ex- citing causes, is consequently more often the seat of haemorrhage than the olfactory portion of the nose. On microscopic examination, various changes are found in the vascular walls, such as degenerative ap- pearances from atheroma, syphilis, softening, sloughing, and rupture of the vessels, etc. Extreme tenuity of the fibrous trabeculae of the cavernous tissue is also occasion- ally met with. Diagnosis. — Haemorrhage from the posterior nares may be confounded with haemoptysis, haematemesis, or bleeding from the bowels {rid. supra), an error which may generally be avoided by examination of the nostrils, when some evidences of its occurrence will be found. In fevers, care should be taken to discriminate between a critical haemorrhage and that which results from a seri- ous nasal complication, the former being a favorable sign, the latter one of grave moment, and calling for prompt attention. Finally, the possibility of its origin from the accessory sinuses, the middle ear, and' even from the cerebral vessels,17 should not be overlooked, and, on the other hand, the possibility of simulation for purposes of malingering should be borne in mind. The Prognosis depends upon the cause of the hasmor- rliage. In the majority of instances it is good. Critical and vicarious haemorrhages which serve to relieve conges- tive conditions of neighboring or remote organs, or to com- plicate local disease of a curable nature, afford also a favor- able prognosis. When, however, the bleeding is dependent upon a diathesis, or occurs as the complication of serious structural disease from acute blood-infection, especially in the course of certain epidemic influences, or of organic visceral changes, the result is less favorable. Collapse may occur from the loss of large quantities of blood, or the constant losses of small quantities may beget an im- poverished condition of the system, with derangement of nutrition, and an enfeebled state of the special senses, and may even awaken the predisposition to more serious organic disease. Treatment.—When one is called to a case of epistaxis, the first thing to determine is its nature. Vicarious and critical haemorrhages should be left to nature unless the flow be so excessive as to jeopardize the life of the pa- tient. Slight bleeding from the nose, of whatever nature, may also be disregarded, as the tendency is to spontaneous arrest. The measures usually employed for the stoppage of more profuse nasal haemorrhage may be conveniently considered under the following heads: (1) rest ; (2) po- sition ; (3) revulsives, and measures designed to produce reflex contraction of the nasal blood-vessels; (4) opiates and narcotics ; (5) astringents; (6) remedies to slow the action of the heart; (7) caustic applications to the bleed- ing-points ; (8) pressure, external and internal; (9) trans- fusion. In moderately severe cases of epistaxis, the patient should remain perfectly quiet in the sitting position, with the head inclined very slightly downward and forward, to throw the floor of the nostrils into a perfectly horizontal plane. All tight clothing about the neck and thorax should be loosened, and the sufferer should be directed to avoid, if possible, all tendency to sneeze or cough, and all down- ward or backward movements of the head. Respiration may be carried on through the mouth. The fears of the patient should be quieted ; in nervous people, the very sight of the blood often serves to increase the haemor- rhage. Great weakness or tendency to vertigo may re- quire that the patient be placed in the recumbent position, or he may be propped up iu bed with pillows in the semi- liorizontal decubitus. Holding both arms above the head, throwing, suddenly, the arm corresponding to the af- fected nostril vertically upward, and compressing the bleeding naris with the fingers of the opposite hand (Negrier18), pressure at the root of the nose, above the upper lip, or on the corresponding facial or carotid ar- tery, and similar devices, have been from time to time re- commended and employed. Measures applied to excite reflex contraction of the blood-vessels in the nasal mucous membrane are often of service; such are the application of cold to the nape of the neck (cilio-spinal centre), to the hands, feet, breast, scrotum, rectum (ice clyster of Sydenham), or forehead, dashing cold water in the face, or on the back, etc., or various revulsives applied to these regions. A method in use among the ancient Greek and Arabian physicians consisted in opening a vein in the foot. The Greeks used cupping-glasses to the liypocliondrium, and local deple- tion for the nostril from which the blood flowed. In the Middle Ages, a favorite method was to apply the actual cautery to the soles of the feet, and several centuries ago it was recommended to bend the little finger on the bleed- ing side backward, which procedure, it was thought, acted as a revulsive by the great pain which it produced, and the consequent determination of blood to the part. Cup- ping the blood in the extremities is also an old practice, which led to the famous Jounod’s haemostatic boot. It is highly probable that the old-fashioned method of vene- section from the arm did more good by the subsequent compression of the bandage and the retention of blood in the forearm than by the way in which it was alleged to act. In some cases the flow of blood may be arrested by opiates and narcotics. Of these, the most serviceable is morphine given liypodermatically. The principal astringents employed for the relief of nasal haemorrhage are hot and cold water, alcohol, per- chloride of iron in solution or crystalline form, alum, chloride of zinc, ammonio-ferric alum, tannic and gallic acids in powder or suspension, kino, and catechu ; the internal administration of turpentine, the mineral acids, etc., and the hypodermatic use of ergot and morphine are recommended. Hot water and alcohol are especially efficacious. Great caution should be exercised in the use of the percliloride of iron, for it not only often fails to arrest the haemorrhage, but also gives rise to a dirty mass in the nostril, which may even, through decomposition, excite septicaemia. A case is on record in which the in- jection of percliloride of iron led to pharyngo-bronchitis, and death from gangrene of the lungs. The introduc- tion of cobwebs into the nostril will often suffice, by act- ing as a styptic, and at the same time allowing coagula- tion of blood in its meshes, to arrest the haemorrhage. Astringents can also be employed on tents, as originally recommended by Valsalva and Morgagni, or by means of soluble bougies. In severe cases it is sometimes of service to slow the action of the heart with digitalis and similar drugs. The ancient custom of introducing wicks, and strips of various substances, for the purpose of promoting coagu- lation, is, as a rule, successful, or a feather or similar ob- ject may be used for the same purpose. If a bleeding point can be discovered, it is usually suf- ficient to apply some caustic, such as chromic acid, to prevent recurrence of the haemorrhage ; or the same end may be attained by the electric, or even the actual, cau- tery. By means of the above measures, the necessity for tamponing the nares may generally be obviated. If the haemorrhage be at all alarming, plugging the nostril should be at once resorted to, as it is useless to temporize with less radical measures. Of all methods of 221 Nose. Nose. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. arresting haemorrhage, the best is pressure. This may be accomplished by simply pressing the ala against the septum and the opening of the nasal fossa, or by the in- troduction of the finger within the nostril and making direct pressure on the bleeding point, or by tamponing the vestibule and anterior portion of the fossa with absorbent cotton, sponge, cliarpie, strips of lint, oak- um, etc. If the haem- orrhage arise from the posterior portion should be made for the source of the haemorrhage. Apart from well-defined lesions in the nose, it will be not infre- quently discovered that the haemorrhages come from little spots or areas, which will generally be found either on the septum, just within the vestibule, or on the mid- dle and lower turbinated bodies. These turgid or bleed- ing areas should be touched with the galvano-cautery or with chromic or acetic acid. When great turgidity (chronic puffiness) of the turbinated bodies is present, producing obstruction of the nostril, a stellate cut may be made into them with the cautery knife. In the con- traction of the tissues which ensues, the nostril becomes free, and the haemorrhages usually cease. The internal treatment of epistaxis does not differ from that of haemorrhages in general. Syncope de- mands stimulation, general prostration tonics, and even transfusion may be resorted to with success in extreme cases. In examples of the “haemorrhagic diathesis” the bleeding may continue in spite of plugging, until it stops through heart failure. John Noland Mackenzie. 1 Hughlings Jackson: London IIosp. Clin. Lect. and Reports, vol. iii., p. 251 (S. Watson, Dis. of the Nose, etc., Lond., 1875, p. 51). 2 Cited by Friedreich: Virchow’s Handb. d. Path. u. Ther., 1855, Bd. V., 1 Abth., s. 389. 3 Op. omnia. Ed. Kuhn, Lips., 1827, tom. ii., p. 174. Demorbis, lib. i., and Aph., Sect. 5, Art. 33. 4 De medicina, lib. ii., Cap. 8. 6 Nosologie naturelle, etc., Paris and Lond., 1838, p. 353. 8 Arch, de Tocologie, April, 1884. Am. J. Med. Sc., July, 1884, p. 292. 7 Bruyerius: De re cibaria, lib. i., Cap. 24. 8 Collect. Med. Phys., Cent. VI., Obs. 74. 9 Obs. Med., Brunswick, 1648, Cent. 4. 10 Cent. I., Obs. 89 (cited by Good, Study of Medicine, Phila., 1824, vol. ii., p. 460). 11 Lond. Med. and Surg. Journal, 1830, vol. iv., p. 489. 12 Journal de Connais. Med. Chir., Aout, 1844 (Friedreich, op. cit., k. 388). 13 See paper by author in Trans. Med. Chir. Fac. of Maryland, 1883, on Naso-Aural Catarrh and its Rational Treatment. 14 Act. erudit. Lips., 1698, p. 205. 15 yiemming: Dublin Journ. Med. Sci., 1883, vol. iv.: also, Jarjavay (cited by Beaussenat, Des tumeurs sanguines et purulentes de la cloison des fosses nasales, Th&se de Paris, 1864). 16 Morgagni: De sedibus et causis morborum, tom. i., xiv., 24, in. fin. 17 See case of Koppe, Arch. f. Ohrenheilkunde, Bd. ii., S. 181 (Fraen- kel, Ziemssen’s Cyc., Am. ed., 1876, vol. iv., p. 159). , 18 Archives generates de medecine, vol. xiv., p. 168^D<), and even gangrene of the face (Crequy20) may possibly complicate the case. I have also seen unilateral convul- sions of the muscles of the face, neck, and extremities follow the retention of a plug in the nostril, and imme- diately subside on its removal. Care should always be taken "to affix a string securely to the plug, in order to insure removal and prevent gravitation into the throat. In a case under the care of Dr. Oscar Coskery, of Balti- more, in which the patient himself had tamponed his own nares, the plug was loosened during sleep, and,be- coming impacted in the larynx, caused death by suffoca- tion. Posterior plugging is, furthermore, occasionally open to an additional danger from tetanus. Such a case has come under my notice, occurring in the practice of a well-known physician of this city, and another in the ex- perience of Dr. Colies, of Dublin, is frequently referred to by writers on epistaxis. After the plugs have been taken out (which should be done, if possible, within twenty-four hours), careful search Fig. 2512.—Plugging the Posterior Narea by Means of Bellocq’s Sound. * On Nasal Cough and the Existence of a Sensitive Keflex Area in the Nose, American Journal of the Med. Sciences, July, 1383. The results of these experiments were first brought before the Baltimore Medical As- sociation in the early part of 1883, and subsequently before the Medico- Chirurgical Faculty of Maryland (April, 1883, vide Transactions) and the American Laryngological Association (May, 1883, vide Transactions). 222 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Nose. Nose. cliian catheter, etc.) within the nasal fossae, paroxysms of coughing were induced, which only subsided upon the withdrawal of the instrument, or upon changing its po- sition in the nasal chamber. The cough varied greatly in character, from a succession of short expiratory acts to convulsive paroxysms which interfered seriously with the use of the instruments. These attacks occurred, fur- thermore, only when the foreign body came in contact with the deeper portions of the nostril ; in several cases where the snare was used, they seemed to be excited only at one particular spot in its passage through the nose, and ceased when the loop entered the naso-pharynx. My clini- cal experience, too, furnished me with cases where distress- ing cough existed, the etiology of which was rendered obscure by the absence of disease or irritation in phar- ynx, windpipe, or lungs. In this latter case, one of two conditions was invariably present—viz., either a liyper- aemic or slightly swollen state of the mucous membrane, chiefly affecting the turbinated bodies, or pronounced hypertrophic enlargement of these structures. It was in the clinical study of this reflex cough that I was led to assume the existence of a certain area or areas in the nose, the irritation of which would culminate in a reflex act or in a series of reflected phenomena. The ex- istence of such an area had been demonstrated in the larynx and trachea, and it seemed, therefore, legitimate to assume the presence of similar spots in the nasal cham- ber. The well-known occurrence of reflex asthmatic at- tacks in some cases of nasal polypus, and their absence in others, together with similar observations which I had made in regard to hypertrophic nasal catarrh, lent fur- ther support to the hypothesis of a reflex area. In order, if possible, to throw some light upon this subject, I made a series of experiments upon a large number of hospital patients, upon myself, and upon sev- eral of my medical friends who were kind enough to place their nasal organs at the disposal of science. The experiments consisted essentially in the systematic irrita- tion of all accessible portions of the nasal mucous mem- brane, the irritants used being silver and rubber probes and the steel wire, such as is used in the polyp-snare. It may be here remarked that the nose of the negro is admirably adapted for experiment, on account of the great capacity of the nasal chambers anteriorly, render- ing dilatation by artificial means unnecessary, and hence eliminating a source of error Avhich might vitiate the re- sult of the experiment. The great width of the vesti- bule, too, brings into greater prominence the anterior ends of the turbinated bones, or, rather, their mucous cover- ing, wdiich, in the black race, is much more puffy ante- riorly than in the white man, giving the appearance of what in the latter would be taken for an anterior hyper- trophy. It is also very flabby, collapses under the probe, and can be pressed with ease against the external wall of the nostril. The patients experimented on presented varying de- grees of susceptibility to irritation ; in some instances, the slightest touch was sufficient to provoke the reflex act, while in others it was only excited by repeated irri- tation or long-continued pressure. In some cases no re- flex whatever could be obtained. The results of these may be briefly given as follows : So long as the stimulation was confined to the vesti- bule—to the interior of the fleshy, cartilaginous part of the nose—the result was negative ; no reflex action was ob- tained. The sensation created was simply that of a foreign body, or, if the stimulus was increased, a feeling of pain. So far I have been unable to excite cough by stimulation of this part of the nose. Irritation of the membrane cloth- ing the anterior extremities of the middle and inferior turbinated bones was in some instances negative ; in oth- ers a half-tendency to cough was produced, which in- creased as the irritant was applied farther back, and finally culminated in the act when it was directed upon the posterior half of the turbinated body. Irritation of the floor of the nose was negative in result. In cases where stimulation of the remaining portions of the nose failed to excite them, paroxysms of cough were induced when the irritant was applied to the mucous membrane covering both the inferior and middle turbinated bones ; but the act was most constantly obtained from the pos- terior end of the inferior turbinated bone and the portion of the septum immediately opposite. Indeed, my ex- periments seem, thus far, to show that these portions are the most sensitive spots in the reflex area. In passing along the pars nasalis of the roof, coughing was occa- sionally produced when the probe or wire impinged on the anterior extremity of the middle turbinated bone ; but no decided results could be obtained from the upper olfactory region. We have thus experimental proof that all parts of the nasal mucous membrane are not equally susceptible to the impression by which reflex cough is produced, and, furthermore, that the cough or reflex area is probably limited to the mucous membrane covering the middle and inferior turbinated bodies and the posterior half of the septum. Now, this is the area occupied by the erectile tissue of the nose, and it is hard to resist the conclusion that this structure is in some connected with the evolution of the reflex act, and that the peculiar suscep- tibility to irritation is to a great extent intimately asso- ciated with its physiological functions, whatever they may be. Roughly speaking, the greater the congestion, or in- flammation, the more constant the reflex obtained. I have succeeded, however, in producing violent parox- ysms of laryngeal cough by simply touching, with the aid of the rhinoscope, the posterior extremity of the infe- rior turbinated bone in persons whose noses were free from disease. In some cases, stoppage of the nostril with discharge of mucus was produced, while in others this was not observed. That the sensitive area is principally confined to the parts already indicated—viz., the posterior half of the in- ferior turbinated body and septum—is furthermore ren- dered exceedingly probable by the following clinical facts : (1) That in cases where reflex cough exists, these are the portions chiefly, if not solely, involved. (2) That the act may be produced here at will by ar- tificial stimulation of the parts invaded by the morbid process. (3) That it may be dissipated by local applications to, or removal of, the membrane covering the diseased sur- face. (4) That foreign bodies, such as pins, lodging in this area sometimes give rise to cough, which latter is not ob- served when they become impacted in other portions of the nose. (5) That polypi give rise to reflex phenomena only when they arise from, or impinge upon, the sensitive portions of the area. (6) That where complete atrophy of the turbinated structures exists, as, for example, in ozsena, reflex cough is not present, nor can it be induced by artificial stimu- lation. These facts are the outcome of personal experience; and, as they represent the result of solitary observation, are, of course, open to correction. I have never seen, nor do I know of, a single case where a foreign substance impacted in the non-sensitive portions of the nose has given rise to cough ; but I do know of cases where that act was excited by its presence in the reflex area. In regard to reflex asthma from polypi, the literature acces- sible to me shows that, where the position of the tumor is accurately defined by the reporter, it is always in the posterior portions of the nostril, in a situation which would lead to irritation of the sensitive tract. So far as my experience goes, it would appear that the cough is present only when the growths spring from or are brought in contact, in some way or other, with a por- tion of the erectile area, and generally its posterior por- tion. Or, in other words, it is only when the polypus acts as a mechanical irritant by causing irritation of the mucous membrane, and thereby exciting reflex action, that the explosive cough is produced. The probability, therefore, of cough-excitation will depend, other things being equal, upon the position of the growth. Thus, for 223 Nose. Nose. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. example, a polypus situated high up in the nostril may fail to give rise to the reflex act which its presence lower down in the nasal fossa would excite. Or a movable growth in the more anterior portion of the nasal cham- ber may awaken no reflex when the head is in the verti- cal position, while, when the vertical diameter of the nostril becomes horizontal, as, for instance, in the re- cumbent position, the growth may by force of gravity be brought in contact with the posterior portion of the nos- tril or', what is the same thing, with the most excitable spot in the sensitive area. In the same way the asth- matic attacks, which have been observed in connection with nasal polypi, may be explained. At all events, such an explanation is more plausible than the assumption, which may be urged, of direct nervous irritation starting from the polypus itself ; since the ordinary mucous polyp is destitute of nerves, and can, therefore, only awaken reflex phenomena in an indirect or mechanical manner. Moreover, I have tried to obtain the reflex by direct stim- ulation of the growth, but so far without success. Fi- nally, I wish to observe that the change in position of the polypus does not depend altogether upon the law of gravitation, but in some instances may be due to an in- crease in volume, either from local irritation of various kinds or from the well-known hygroscopic character of the gelatinoid outgrowth. The augmentation in bulk thus brought about would obviously bring it into contact with parts which in its original position would not be encroached upon, and therefore not subjected to the pressure and irritation which it might occasion. Nasal cough has become so common in my experience, that I have long since ceased to regard it as a curiosity. It is worthy of remark that in a fair proportion of cases there are few, if any, symptoms which would direct at- tention to disease of the nose ; and this fact emphasizes the importance of examining the nasal chambers in all cases of the kind, even though the testimony of the pa- tient may lead to neglect of their systematic exploration. My clinical observation leads me to the belief that re- flected irritation from nasal disease plays a not inconspic- uous part in the etiology of laryngeal congestion and in- flammation. The short, hacking cough ancl hypergemia of the larynx which occur in acute coryza are probably more often explicable on the theory of reflex action than upon the extension of the inflammation to the laryngeal vesti- bule. The physiological explanation of this phenomenon may possibly be found in the doctrine of correlated areas, the reflex taking place through the vaso-dilator nerves from the superior cervical ganglion of the sympathetic. In chronic coryza, on the other hand, the constant laryngeal liypersemia induced by reflex nasal irritation, augmented, perhaps, by the frequent occurrence of cough-paroxysms, may, if prolonged, eventuate in catarrhal conditions of that organ. In other words, on theoretical grounds, and clinical observation would seem to sustain them, it is legitimate to assume the existence of a reflex laryngitis, evoked through the constant irritation of the vaso-motor centres from chronic nasal inflammation. Clinical and experimental investigation would appear, then, to lead to the following conclusions : (1) That in the nose there exists a definite, well-defined, sensitive area, whose stimulation, either through a local pathological process or through the action of an irritant introduced from without, is capable of producing an ex- citation, which finds its expression in a reflex act or in a series of reflected phenomena. (2) That this sensitive area corresponds, in all proba- bility, with that portion of the nasal mucous membrane which covers the turbinated corpora cavernosa. (3) That reflex cough is produced only by stimulation of this area, and is only exceptionally evoked rvhen the irritant is applied to other portions of the nasal mucous membrane. (4) That all parts of this area are not equally capable of generating the reflex act, the most sensitive spot being probably represented by that portion of the membrane which clothes the posterior extremity of the inferior turbinated body and that of the septum immediately op- posite. (5) That the tendency to reflex action varies in differ- ent individuals, and is probably dependent upon the varying degree of excitability of the erectile tissue. In some the slightest touch is sufficient to excite it; in oth- ers chronic liypersemia or hypertrophy of the cavernous bodies seem to evoke it by constant irritation of the re- flex centres, as occurs in similar conditions of other erec- tile organs, as, for example, the clitoris. (6) That this exaggerated or disordered functional ac- tivity of the area may possibly throw some light on the physiological destiny of the erectile bodies. Among other properties which they possess, may they not act as sentinels to guard the lower air-passages and pharynx against the entrance of foreign bodies, noxious exhala- tions, and other injurious agents to which they might otherwise be exposed ? Apart from their physiological interest, the practical importance of the above facts in a diagnostic and thera- peutic point of view is sufficiently obvious. Therein lies the explanation of many obscure cases of cough which heretofore have received no satisfactory solution, and their recognition is the key to their successful treat- ment.* In calling attention to this area as containing the spots most sensitive to reflex-producing impressions, I did not, nor do I now (as has been wrongly inferred), desire to maintain that reflexes may not originate from other por- tions of the nasal mucous membrane. Indeed, wherever there is a terminal nervous filament it may be possible to provoke sneezing, lachrymation, and other reflex move- ments. My contention is simply this, that the area indi- cated in my original paper represents by far the most sensitive portion of the nasal cavities, and that patho- logical reflex phenomena are in the large majority of cases related to diseased conditions of some portion of this sensitive area. That all pathological nasal reflexes arise from irritation of this particular area is a proposi- tion which I do not, and never have, maintained. The determination of these sensitive areas is of especial im- portance and interest in the solution of the pathology of the nasal reflex neuroses. Their location has formed the basis of the modern treatment of these affections. These views of the sensitive area were, at their time of publication, opposed by Dr. Wilhelm Hack,1 of Freiburg, who, in an exceedingly interesting and instructive bro- chure, maintained, as the result of his wide experience, that the anterior extremity of the inferior turbinated bone is the point from which all reflexes take their origin, and that those arising from stimulation of other portions of the nostril occur only secondarily, through congestion of the cavernous tissue of this circumscribed locality. In proof * The above account of nasal cough and the reflex sensitive area is a verbatim abstract taken from my original article in the American Journal of the Medical Sciences. The remarks on the production of reflex' cough by change of position in nasal growths are taken verbatim from an ar- ticle in the Transactions of the Medico-Chirurgical Faculty of Maryland for 1884, entitled, “Cases of Reflex Cough due to Nasal Polypi, with Remarks.” At the time of publication of my original thesis I could find only two recorded cases of nasal cough. Dr. Hack, in the Berliner klinische Wochenschrift, No. 2B, 1882, S. 881, relates a case where paroxysms of spasmodic cough, induced by a fibrous polyp which sprang from the right middle turbinated bone, were dissi- pated by removal of the growth. He regards the case as unique, but adds that, in the course of some physiological experiments on the normal nasal membrane, he had, in a small proportion of cases, noticed convul- sive motions of the laryngeal adductors, which sometimes amounted to complete closure of the glottis, followed by an explosive cough-like sound, and suggests that this may also happen under pathological con- ditions of the naBal membrane. In the Archives of Laryngology, vol. iii., No. 3, p. 240, 1882, Dr. Seiler reports two cases. In one, severe spasmodic cough, accompanied by a peculiar grunting or barking noise, was dependent upon a deflected sep- tum and a large anterior turbinated hypertrophy ; in the other, an ex- coriation of the mucous membrane of the septum gave rise to reflex cough, which was relieved by treatment of the nasal affection. Dr. Seiler observes that he has not found a single instance in which the irritation causing reflex cough was seated in the nasal membrane. He seems, fur- thermore, to regard the direct irritation of the inter arytenoid fold (la- ryngeal-cough centre), by mucus dropping from the post-nasal space, as an important factor in the production of the cough in the two cases de- scribed. It is quite certain that cough may be, and is, often produced in the manner suggested; but in that case it obviously cannot be re- garded as nasal, i.e., due to an irritation originating in the mucous mem- brane of the nose. 224 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. N osc. Nose. of his contention he asserts that when the swelling of the anterior end of the turbinated body is present, if the ex- ternal blade of the speculum be pressed firmly against the swollen turbinated tissues, the remaining portion of the nostril will remain insensible to the reflex-produc- ing impression. In referring to my own conclusions, Dr. Hack suggests that it would be of great value if I should repeat my experiments from the stand-point of his own extensive experience. In a later publication, however, while still decidedly opposed to my doctrine, he has con- siderably modified his exclusive views upon the subject. He admits that secondary reflexes may take their origin from the middle turbinated bone, especially in the case of migraine, more rarely in that of asthma ; he also makes the important admission that in certain cases, after careful extirpation of the swelling at the anterior end, sooner or later a return of the nasal obstruction and the nervous reflex phenomena is observed. In such cases the rhinoscope shows that the parts operated on are rep- resented by a cicatrix so depressed that the parts can scarcely be distinguished, beyond which the cavernous tur- binated body is seen, greatly swollen, in the deeper por- tion of the nostril at such a position that its appearance can only be made out by the most thorough illumination. In regard to the swelling of the posterior end, Dr. Hack observes that, while admitting its possible influence in bringing about the return of the reflex symptoms, his expe- rience compels him to regard this as of infrequent occur- rence, having observed only symptoms referable to pure- ly mechanical obstruction, and never reflex phenomena originating in swelling of the posterior area. Hack, then, stands, as he expresses it, in direct opposition to my view, viz., that the posterior end of the inferior turbinated body and posterior half of the septum are the most sensitive spots in the reflex area, and seeks to reconcile the dis- crepancy in our observations by the supposition of the greater frequency of post-nasal catarrh in America, and the relative infrequency of that affection in Germany, thus affording different conditions for observation and experiment. He furthermore adds, in defence of his own view, that in a number of specimens removed by the galvano-cautery loop from the anterior and posterior ex- tremities of the turbinated bones, and examined micro- scopically by one of his scholars, the cavernous cells of the anterior portions were very much dilated, and the glandular substance between them was very inconspicu- ous, while in the posterior portions the cavernous cells were much smaller, and between them the connective tissue was very markedly hypertrophied. In defending my own position in the matter I wish, at the outset, to distinctly affirm that I do not for one mo- ment call into question the accuracy of Dr. Hack’s obser- vations in this direction, which are entitled to the highest respect, and I gladly testify to the pleasure and interest Avhich the perusal of his contributions has afforded me. I simply desire to record my own experience, which, as the result of solitary observation, is open, of course, to correction, and to offer some anatomical grounds for the localization of the most sensitive spots in the reflex area in the lower and posterior portions of the nostrils. Since I became aware of Dr. Hack’s interesting re- searches, and came into possession of his brochure, in which a repetition of my experiments from the author’s stand-point is suggested, I have repeated my observa- tions and put my own views in practice to careful and critical tests. The result has been that I have arrived at essentially the same conclusions as given in my orig- inal communication on the subject, viz., that wfliile the reflex may be obtained from any portion of the nasal passages, and especially that portion covered by erectile tissue, the area occupying the posterior and lower por- tions of the nasal fossae is that above all others specially concerned in the reflex excitation. Just as in the larynx, wffiile a reflex (e.g., cough) may be obtained from any portion of its internal surface, both clinical and experi- mental observations have demonstrated that the most sen- sitive spots are localized in tl;e interarytenoid commis- sure. In this country, and I see no reason why the rule Vol. V.—15 should not apply elsewhere, according to my experience, inflammatory conditions of the nasal passages are most marked in the area covered by erectile tissue, and are more pronounced in the lower or respiratory region, in the bony nostril than in the vestibule, and in the posterior more frequently than the anterior portions of the nasal fossae. The posterior end of the inferior turbinated body is, according to the united testimony of all observers, the most frequent seat of simple catarrhal inflammation and its consequences. Hence this portion of the nostril is the most commonly subjected to pathological irritation—a fact which may explain, in a measure at least, the rela- tive frequency of reflex symptoms arising from this por- tion of the nostril as compared with those arising from the more anterior parts. The tendency to sudden filling of the more anterior portions of the erectile tissues, or to permanent enlarge- ment of the same, proceeds generally from two causes: (1) from existing disease of the posterior portion—simple inflammation, hypertrophy, atrophy—in which event it may be regarded, in the majority of instances, as a phe- nomenon of collateral engorgement; or (2) it occurs in connection witli a general engorgement of the cavernous tissue, which may be limited to the respiratory passages, or may extend into the region of olfaction. It may also be laid down as a rule that changes in the anterior extremity of the turbinated body rarely occur without corresponding, and generally more advanced, dis- ease of the posterior parts of the nasal fossae—a position which I think will be sustained by my colleagues on this side of the Atlantic ; on the other hand, marked changes are frequently met with in the posterior portions of the nasal chambers without corresponding, or even appre- ciable changes in its more anterior segments. It is, there- fore, highly probable, from an anatomical stand-point, that the swelling of the anterior end of the turbinated body occurs through influences which affect, either pre- viously or coincidently, its posterior portion. Turning now to the anatomy of the turbinated corpora cavernosa, we find that the erectile tissue is most marked and exhibits more strikingly its cavernous nature in the lower and posterior portions of the nostril, and this is not- ably true of the posterior end of the inferior turbinated body, and the septum immediately opposite. As the more anterior portions of the nostril are reached this tissue be- comes less conspicuous, and in the latter situation the mucous membrane is more closely adherent to the under- lying tissue, while over the posterior part of the fossa it is loose and separated more completely from the peri- osteum by the erectile body, which becomes a thin layer as the anterior extremity of the turbinated body is reached. This affinity of the erectile tissue for the posterior por- tions of the nasal apparatus is strikingly shown in the fact that erectile tissue is found on the posterior ends of all three turbinated bodies. How the most sensitive zone covers an area which corresponds to the distribution of the spheno-palatine branches of the superior maxillary nerve, as distinguished from the nasal branch of the ophthalmic. The former nerve, derived through the spheno-palatine ganglion, probably contains, therefore, the vaso-motor fibres which govern the erection of the turbinated tissue, and as the sympathetic filaments which have been traced to the nasal passages are found in greater abundance over this area, we may, for practical purposes, speak of a nasal plexus located in the sensitive area and intimately associated with the evolution of the nasal reflex. My clinical observation teaches me that this is precisely the area of greatest irritation and turges- cence in the paroxysms of vaso-motor coryza and allied affections, and the localization of the sensitive area may be accordingly looked upon as a key to the mechanism of the attack. I would like also to call attention to a property of erec- tile tissues which is consonant with the ideas of reflex excitability formulated above. In the human body, wherever erectile tissue is found, it is intimately related to reflex or sympathetic acts; there seems to be con- nected with it a certain receptivity to reflex-producing impressions, a certain power of reflex excitability depend- 225 Nose. Nose. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ent upon its structure and functions. It is thus pecu- liarly a tissue of sympathy, in which we may most sat- isfactorily study the mechanism of purely reflex or sympathetic acts. Now, as the nasal corpora cavernosa belong to this class of sympathetic tissues, there will be little difficulty in explaining the role which they play in the paroxysms of affections which are probably connected with, if not dependent upon, an excitation of the sympa- thetic nerve-centres, and in more clearly defining the in- timate relation which they bear to the reflex neuroses of the nose. It seems to me, then, that the above anatomical and physiological considerations strikingly correspond with the results arrived at by clinical observation and actual experiment, and, while open at all times to correction, I cannot but feel that my former observations were at least in the main accurate, and that the most sensitive spot in the reflex zone is represented by the area indicated above. Sneeze-cough.—I have never seen this condition re- ferred to by writers, but, in my experience, it is of not very infrequent occurrence. It is a most peculiar sound, which, when once heard, is not forgotten, and can be best described, as I have said above, as the result of an attempt to sneeze and cough at the same time. . It is neither a cough nor a sneeze, but partakes of the characr ters of both. In the cases in which I have had an oppor- tunity to examine the nasal cavities and throat, it has apparently resulted from irritation of the lower and pos- terior portions of the nasal cavities. In two instances in which the sneeze-cough was very severe, the paroxysms were preceded by burning and tickling sensations, which the patients referred to the region above and behind the palate, where, upon examination, the posterior nares were very much congested and swollen, and exquisitely sensi- tive to the touch of the probe. II. Tiie Neuroses Proper of the nasal cavities may be divided into Sensory, Motor, and Vaso-motor (neuro-vas- cular, sympathetic). All these varieties may exhibit them- selves simultaneously, or at different times, in the same individual, or each may appear as an isolated phenom- enon. Care should be taken to separate (1) those which are of purely nasal origin, (2) those which depend upon central disturbance, and (3) those which result from irri- tation reflected from more or less remote regions of the body. Or, in other words, it should be clearly deter- mined whether the neurotic symptoms referable to the nasal apparatus and its appendages be due to a purely local intra-nasal affection, or whether they be the symp- tomatic expression of a more central or general neurosis, and the proper relation as to cause and effect between the nasal symptoms and those referable to other parts of the system should be accurately and intelligently made out. As the neuroses of the nasal passages may be peripheral, central, or essentially reflex in origin, their classification upon a strictly logical and scientific basis is a somewhat difficult matter. For purposes of convenience, however, and bearing in mind the fact that the three varieties are often combined in individual cases, they will be described in this article as above—sensory, motor, and vaso-motor. A. Sensory Neuroses.—The sensory neuroses of the nasal chambers may be divided into those which spring from interference with the functions of the fifth nerve and those which depend upon some lesion or abnormal condition in the domain of the olfactory. 1. Neuroses of the Fifth Nerve.—1. Anaesthesia. Complete anaesthesia of the nasal mucous membrane is very rarely met with, and, when present, is due to paral- ysis of the fifth nerve from central trouble, as syphilis, brain tumors, extravasations, etc. Less frequently the anaesthetic condition is the result of pressure on the nerve after its exit from the cranium. Occasionally a more or less anaesthetic state of the nasal passages is en- countered in atrophic conditions of the mucous mem- brane. Anaesthesia of the nasal passages is commonly associated with a corresponding absence of tbe sense of taste. 2. Hypercesthesia is, on the other hand, a very common affection, and may be physiological or pathological. It is occasionally observed during a physiological epoch, as, for example, menstruation. Abnormal sensibility of the nasal mucous membrane may owe its origin to central or peripheral causes, or may be the result of reflected irritation from remote regions of the body. Excessive irritability of the nasal passages may be produced by neu- ralgic affections of, or pressure upon, the fifth nerve ; it is often present in extremely neurotic, hysterical, and hypochondriacal persons. Almost any local pathological process in the nasal chambers is accompanied with vary- ing degrees of hyperesthesia, and the hypersesthesic con- dition is especially well marked in the vaso-motor affec- tions of the mucous membrane. It may also occur as a reflex vaso-motor phenomenon from irritation or disease of the eye, aural apparatus, lower respiratory, gastro- intestinal, utero-ovarian, and genito-urinary tracts. II. Neuroses of the Olfactory Nerve.—The chief and most common of the olfactory neuroses is anosmia, or the loss of smell. 1. Anosmia may be congenital or acquired. When congenital both nostrils are commonly affected, and the loss of smell is complete and permanent, while in anos- mia due to other causes the two sides may be equally or unequally affected, or the interference with olfaction may be limited to one nostril; the anosmia, too, may be com- plete or incomplete. Congenital anosmia is generally due to absence or im- perfect development of the olfactory nerves and bulbs, and it is conceivable that imperfect structural develop- ment of the olfactory region of the nasal passages them- selves may be responsible for the anomaly, although no cases of this condition are, to my knowledge, as yet re- corded. Acquired anosmia may be due to centric or eccentric (peripheral) causes. Among central causes may be men- tioned disease or wounds of the olfactory tract or centre, fracture of the base of the skull, dislocation of the olfac- tory bulbs from falls, concussion, etc. ; compression of the anterior portions of the brain from tumors, abscesses, or haemorrhagic, serous, muco-purulent, or fibrinous exu dations ; and plugging of the anterior or middle cerebral arteries (Hughlings J.ackson,2 Fletcher3). Partial or com- plete loss of smell may also result from atrophy of the olfactory nerve, either from disease or the degenerative processes of old age. Of central origin, too, may be re- garded the loss of smell in syncope, hysteria, epilepsy, acute alcoholism, and other nervous affections. All those influences that interfere with the physiolog- ical integrity of the olfactory region, or eliminate one or all of the conditions essential to the sense of smell, may be regarded among the eccentric or peripheral causes of anosmia. Thus (1) complete or partial destruction of the terminal filaments of the olfactory nerve, either from ac- cident or disease, disappearance of pigment from the or- gan of Scliultze (Hutchison,4 Ogle6); (2) all obstructive lesions of the nasal passages and pharynx which prevent the access of the inspired air and odorous particles to the olfactory region, and (3) unnatural dryness or loss of moisture in the latter diminish correspondingly the power of smell, or may cause its complete disappearance. Under the first class of causes may be mentioned abro- gation or destruction of the conductivity of the olfactory nerves from swelling or ulceration of the mucous mem- brane, the presence of inflammatory exudations, atrophy of the olfactory region, absence of pigment in the olfac- tory cells, blunting of the sense of smell from wounds, incautious surgical interference, the injudicious use of powders and liquids in the nasal cavities (as, for exam- ple, the constant saturation of the nasal mucous mem- brane which accompanies the prolonged use of the nasal douche, syringe, and similar contrivances); the applica- tion of strong solutions of such substances as zinc, car- bolic acid, iodine, alum, etc. ; the constant inhalation of noxious gases or irritating particles of solid matter, mechanical and chemical, such as sewer-gas, ammonia, or ether; the habit of snuff-taking ; the inspiration of the floating dust in chemical works, etc. Anosmia may also accompany the atrophic changes in the mucous membrane which follow paralytic conditions of the fifth nerve. 226 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Nose. N ose. tlie source of irritation within the nasal cavities. These seemingly purely neurotic conditions have received the name of the nasal reflex neuroses, and embrace a host of sensory, motor, and vaso-motor phenomena, varying greatly in nature and anatomical sphere of operation. Various neuralgic conditions of the branches of the fifth and other nerves, cough, asthma, vertigo, nightmare, “ hay fever,” various spasmodic affections, general con- vulsions, diseased states of the nose, eye, ear, larynx, and bronchial tubes, symptoms referable to irritation of the gastro-intestinal, utero-ovarian, and genito-urinary tracts, even chorea, epilepsy, melancholia, retarded sex- ual development, and exophthalmic goitre have been mitigated or known to disappear with the cure of the nasal affection. While in some of the recorded instances of these “ re- flex nasal neuroses,” the enthusiasm and hasty judgment of the reporters have carried them too far, and while in many cases the direct connection between the nasal dis- ease and the reflected phenomena is not sufficiently evi- dent, still the fact is established beyond the possibility of doubt that a causal relationship often does exist between certain conditions of the nasal passages and other por- tions of the respiratory tract, and a host of phenomena referable to other and remote organs of the body—a di- rect dependence or connection which justifies us in the belief of their reflex reciprocal relationship. These affections are sensory, motor, or vaso-motor in nature. As all these varieties are intimately associated, and as their separate discussion would involve ceaseless repetition, they will be considered in this article under the common head of the reflex nasal neuroses. At the present day, when, by common consent, our knowledge of this class of affections is confined within the narrow limits of scarcely two decades, it may be in- teresting to glance for a moment, away from the writers of the present epoch, to the literature of more remote times. Historical Sketch.* — “Nullum est jam dictum, quod non dictum sit prius ” (Terence). “ Multa re- nascentur, quas jam eecidere” (Horace). In the “Sym- posium ”6 of Plato, when the time came for Aristopha- nes to speak, he was seized with the hiccups, and upon requesting Eryximaclius to stop them and speak in his stead, was told that, be the hiccups ever so violent, if the nose were tickled they would cease at once. This popu- lar recognition of the sympathy between the nose and diaphragm is also distinctly affirmed in the sixth book of the “Aphorisms” of Hippocrates: “If sneezing comes upon a man in a fit of the hiccups, it puts an end to the disorder. ”1 The consensus or sympathy between the nose and eye seems also to have attracted- popular attention.. Thus Aristotle8 devotes two paragraphs of the thirty-third sec- tion of his “ Problems” to the consideration of the ques- tion why rubbing the canthi of the eyes puts an end to sneezing. Avicenna,9 to prevent sternutation, recom- mends rubbing the eyes, ears, extremities, ancl palate ; wdiile Rhazes,10 in his chapter on acute and chronic ob- struction of the nose (De Alcasem), mentions, among the symptoms of the latter, abrogation of the sense of smell, with a coexisting diseased condition of the ejms. Rhazes also recommends the induction of sneezing, “when the mouth is convulsed and drawn to one side,” 11 and men- tions the fact that running at the nose, a cold in the head, and hoarseness may occur from the odor of violets, etc.12 The relation of certain affections of the head, and not- ably hemicrania to congestion, and even inflammatory disorders of the nasal apparatus, seems also to have been foreshadowed in the writings of the earlier physicians. Thus, in the “Medical Compositions” of Scribonius Largus f is found the following direction for the cure of Under the head of obstructive lesions may be placed partial or complete closure of the meatuses from swell- ing, acute and chronic, of the mucous membrane and cavernous bodies ; congenital or acquired malformations or abnormal positions of the septum and other portions of the bony and cartilaginous framework of the nostril; nasal, post-nasal, and pharyngeal growths and adhesions ; foreign bodies ; dried and accumulated secretion, crusts ; inactivity of the dilatores nasi and orbicularis palpe- brarum from paralysis of the facial nerve, etc. The third class, finally, includes all those influences which cause an arrest of the secretion of the normal nasal lialitus, or interfere with its properties as a solvent of odorous particles. Thus, in acute and chronic catarrhal inflammation the viscid, ropy condition of the exudation alters the physical quality of the nasal secretion and mili- tates against the proper preparation of the odoriferous par- ticles for contact with the olfactory nerves. In atrophic rhinitis, on the other hand, partial or complete anosmia may result from the dryness of the membrane and the disappearance of its glands and follicles. The nasal mucous membrane is, as is well known, to a certain extent, supplied with moisture from the lachrymal apparatus. Anything, therefore, which interferes with the passage of the tears through the lachrymal duct will tend to militate indirectly against the proper apprecia- tion of odorous bodies. When no apparent cause can be made out for the loss of function, it is customary to describe the condition as “ essential anosmia.” Symptoms and Diagnosis.—Bearing in mind the fact that anosmia is very commonly unilateral, the olfactory power of the two nostrils should be determined by sepa- rate tests. Care should also be taken to use only odorif- erous substances, and not those which act by purely me- chanical or chemical irritation. The pathology and treatment of anosmia will obviously depend upon the lesion or condition of which it is the ac- companiment or sequel; and the same may be said of the prognosis of the affection. Parosmia.—Perversion of the sense of smell may be due to central or peripheral causes. Among the first class may be mentioned tumors, inflammation and degen- erative processes of the brain or olfactory lobes, and Inemorrhagic or serous exudation in the fore-part of the cerebrum, or in the region of the olfactory nucleus. Of central origin may be regarded, too, the olfactoiy halluci- nations of the insane, and the curious disturbances of ol- faction met with in the hypochondriacal and hysterical. Parosmia constitutes not infrequently the aura or pre- monitory symptom of an epileptic attack, or it may only make its appearance at the close of the paroxysm. The various idiosyncrasies in regard to olfaction may also be referable to central disturbance. Of peripheral causes the most common are acute and chronic catarrhal rhinitis, or new-growths of the nasal fossse. In all cases there is a neurotic element present which must be looked upon as an essential etiological factor. The pathology of parosmia is obscure. Future re- search will doubtless discover in some cases an essential anatomical lesion ; but in many others the explanation of the condition must be sought for in the domain of meta- physics. The prognosis will depend upon the cause, and the ra- tional treatment involves the elimination, if possible, of the same. B. Motor and Vaso-motor Neuroses (Nasal Reflex Neuroses—Coryza vel Rhinitis Sympathetica *).—With- in the past few years the attention of the medical world has been more prominently called to a series of morbid phenomena, some directly referable to the nasal appara- tus, others to regions of the body more or less remote from the nose, which seem to depend upon irritation or well-marked structural changes in the intra-nasal tissues, and which not infrequently disappear after removal of * In the American Journal of the Medical Sciences for January, 1886, I have given an account of the earlier literature of so-called ‘4 hay asthma’’and “ rose cold.” t Scribonius Largos: De oompositionibus medicamentorum, liber unus. Parisiis, 1529. Ed. Yuechel, comp. vi. The ancients included under the generic term headache the affections known as cephalalgia, cephalea, and hemicrania or heterocrania, the latter term being employed by Are- tseus (De caus. et sig. morb. chron., liber i., cap. ii.). Aretasus says the sense of smell is vitiated in heterocrania. * The substance of this section was communicated to the Clinical So- ciety of Maryland in April, 1885, and an abstract of the paper was printed in the Maryland Medical Journal of April 11th of the same year. 227 Nose. Nose. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. certain forms of headache: “ Oportet vero permanente capitis dplore, materiam quoque detraliere ex eo nares, vel os.” The dependence of catarrh, coryza, asthma, syncope, convulsions, and a host of other phenomena upon the presence or odor of roses, lilies, peonies, and other flow- ers, has been recognized for centuries. For, although Pliny * informs us that the seed of the rose inhaled into the nostril has the effect of clearing the brain, there are many cases to be found among the older writers in which the odor of various substances, such as the rose, has been known to result in epilepsy, syncope, and even death; f and there is a tradition that the Roman ladies conceived an especial aversion to the odor of the queen of flowers. The diagnostic acumen of Galen53 led him to the obser- vation that in certain persons the presence of various foods is sufficient to excite a coryza, and, scattered here and there through the literature of succeeding centuries, isolated cases are found in which similar peculiarities in regard to flowers and other objects are recorded.:): In the light of our present knowledge of the affection known as “ hay fever,” it is scarcely conceivable that it made its first appearance at the beginning of the present century. As Dick, and afterward Matthew Baillie, thought that in describing their first cases of laryngitis they had discovered a new disease, so Bostock, in por- traying the symptoms of “ Gatarrhus cestivus,” was led into a similar error. For no one can arise from the pe- rusal of the older writers on asthma without the convic- tion, or, at least, the suspicion, that this disease has de- scended to us through the centuries as a species of the “ convulsive asthma ” and “ periodic coryza” of the more ancient nosologists, who, in their state of medical science did not resort to the nosological refinements which pro- ceed from the more advanced pathological research of the present day and century. I have shown elsewhere14 that the so-called “ idiosyn- crasy,” by virtue of which the presence or odor of cer- tain flowering plants is sufficient to create disturbances referable to the nasal chambers and other portions of the respiratory apparatus, was familiar at a remote period of medical history. In the days when medical writings were published in Latin, the necessity of recording one’s observations in a foreign tongue led to a terseness of style and incompleteness of description which often surrounds with uncertainty the exact nature of the cases reported ; but whether the records referred to wei’e examples of true vaso-motor coryza or not, they may be placed in the same category of affections, and the predisposing influ- ences may be considered identical with those provocative of the disease called in the present century “ rose cold.” To Voltolini (1871) is universally and erroneously at- tributed the credit of pointing out the interesting rela- tionship between asthma and nasal disease. I have shown elsewhere,15 however, from the writings of Aurelian, Zeccliius (1650), Schneider, Floyer (1726), Bree (1811), Trousseau, Follin and Duplay, and Ferber (1869), that the association of these two conditions was known long before the time of Voltolini. Among these writers Ferber, refer- ring to the frequent association of sneezing, migraine, hay fever, and bronchial asthma, advanced the theory that these phenomena were the expression of a neurosis of the trigeminus nerve—a view which has recently been resurrected in a modified form by Schadewaldt (vide in- fra).* In 1682 Wedel16 treated of the association of vertigo and sneezing, and in the same year Van Helmont.f in several chapters of llis work, discussed the effects of sweet odors in the production not only of epilepsy, hut head- ache, nausea, vomiting, cough, hiccup, vertigo, apo- plexy, dysentery, and other affections. He also alludes to the fact that, while sweet odors give rise to asthma in some, in others they produce, instead of asthma, hemicra- nia, palpitation, and syncope. This writer regards such disturbances as of frequent occurrence, and is looked upon by some as the first to recognize the affection known as “ hay asthma.”11 In the early part of the last century Baglivi18 called at- tention to the fact that irritation of the nostrils by snuff (or tobacco) may provoke a desire to go to stool. This same observer also called attention to the association of asthma and urticaria (see below, under Pathology). A few years after the publication of Baglivi’s work Gumprecht19 discussed the sympathetic troubles con- nected with the inhalation of vapors into the nostrils, and explained them on the theory that the vapor taken into the nose affects preternaturally the branches of the fifth pair of nerves, and is reflected to the fauces, stomach, heart, and lungs through the medium of the intercostal and eighth pair (Willis). This nerve theory, which was the outcome of the neuro-pathology of Willis20 and Vieussens,21 was subse- quently insisted upon by Henricus Josephus Rega, in an elaborate general discussion of the sympathies between the different organs of the body.22 During the first part of the last century there appeared a ponderous work by Johan Jacob Wepfer,23 consisting of a collection of cases illustrative of the external and in- ternal diseases of the head, in which the relationship of hemierania and other pathological phenomena to nasal inflammation and obstruction was distinctly and em- phatically announced. Nothing seems to have escaped the far-reaching experience and accurate observation of this writer, to whose powers of description and diagnostic acumen it would be difficult to do justice within the lim- its of this review. So instructive is every case and page that it is hard to make a selection, and I shall, therefore, only refer briefly to the following : Obs. 84, pp. 75, 76. Association of cephalalgia with sternutation, screatus, cough, and coryza, supposed to be due to irritation of the dura mater. Obs. 36, pp. 80-82. Paroxysms of violent headache, vertigo, pain from the nucha to the head, debility of memory and vision, tremor, cough, pain in the eye and about the nose, due to obstruction of the nostril from abuse of tobacco, which caused retention of mucus within the nostril, and awakened the above symptoms from the sympathy of the latter with the meninges about the tor- cular lieropliili. In this case the mucfis retained in the deeper portions * The association of epileptiform seizures, or even true epilepsy, with some irritation in or about the nasal passages, or peculiar susceptibility on the part of certain individuals to be thrown into epileptic convulsions through the application of some forms of matter to the nasal mucous membrane, seems to have been familiar from the earliest times. We learn, for example, from AreUeus (De causis acut. morborum, lib. i., cap. 1, Ed. Boerhaave, Lugd. Bat., 1735) that the gagate stone (a species of hard coal or jet) was utilized by the ancients as a test for epilepsy, for when applied to the nostrils the sufferer was thrown into epileptiform convulsions. Pliny (lib. xxxvi., c. 34) also alludes to this test, and to the power of the smell arising from burning goat’s horns or deer’s antlers in accomplishing the same result (lib. xxviii., cap. 63). According to this historian the secundines of a she-ass, placed under the nostrils of the pa- tient when the fit is approaching, will effectually dispel it. It is also a curious historical fact that Avicenna (Op. omn., Venet., 1608, lib. iii., Fen. i., tract, v., cap. 8, p. 409) mentions (1. c., Fen. v., tract, ii., cap. 15, p. 585) *‘rosa cum suis pilis” among the milder measures resorted to to provoke sternutation, and regarded sneezing itself as a mild form of epilepsy (epi- lepsia levis), and that a similar opinion was entertained long afterward by the learned Fernelius (Medicina, Lutetise Parisiorum, 1554, de epilepsia). t Johan Baptist van Helmont: Op. omnia, Francofurti, 1682. Imago fermenti impregnat massam semine, p. 110, § 10, p. 344, § 10, and p. 348, § 41. This author also refers to the case of a monk, employed in pulling down buildings, who grew asthmatic from the constant inhalation of dust. * Nat. Hist., lib. xxi., cap. 73. The same writer (lib. vii., cap. 7) also observes that the smell of a lamp which has been extinguished will often cause abortion, and that the latter ensues should the female happen to sneeze just after the sexual congress. + While there is a remote possibility that this observation of the an- cients, which finds its reflection in the poetic imagery of Pope, may have some slight foundation in fact, it is extremely doubtful whether, in the cases referred to, death was .due to the simple inhalation of the odorous particles of the flower, for in some of the recorded instances the victims were confined to closed chambers, and were possibly poisoned by the dis- placement of the oxygen of their bedrooms by the noxious exhalations from the plants. It should also be remembered that our less civilized and punctilious brother-man of a few centuries back did not hesitate to dispose of an enemy through the covert instrumentality of poisoned flow- ers and other equally insidious devices, by means of which the deadly agent was introduced into the system through the respiratory mucous membrane. + In certain individuals, or even families, this peculiar antipathy or sus- ceptibility to particular flowers or foods takes the form of nose-bleed ; in others violent purging occurs, or even epileptiform convulsions. 228 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Nose. Nose. of the nostrils {profunde intra caternas narium retentus et inspissatus ab aere ex pulmonis expiraio prmservido) was supposed to draw the meninges into consent. Obs. 88, pp. 84, 85. Association of pains in the head, tinnitus, pains in the humerus, various nervous symp- toms, and vomiting, with inflammation of the fauces. A very interesting case. Obs. 40, pp. 94. Says he has frequently observed hemi- •crania due to obstruction of the nares. Obs. 42, pp. 100-102. Case in which intense paroxysms of periodic cephalalgia and hemicrania were preceded by stupor of the head with gravedo. The patient suffered from obstructed nostrils, with tendency to somnolence ;and delirium. When the acme of the paroxysm was reached, vomiting of a tenacious mucus with bile oc- curred, with relief to the symptoms. Obs. 48. Case of a man suffering from obstructed mares, who wTas troubled for seven years with daily pain in the head in the morning, when he arose from his couch, to which were soon added heaviness of vision, ver- tigo, tinnitus aurium, debility of the joints, with tremu- lous movements of the same. These symptoms were relieved by drawing the mucus from the head and nose into the fauces. The mucus was removed with difficulty, •owing to the narrowness of the nostrils from obstruction. He explains the case on the theory of sympathy, and laxity of the pores in the spongy bones. Wepfer believes the trouble to have been an invasion of the spongy (tur- binated) bones, and observes that in such cases the indi- cation is to remove the inspissated mucus from the nares. A most interesting case. Obs. 44. Hemicrania from an acrid serous discharge. About the middle of the last century Daniel Lang- lians24 published an elaborate dissertation, which deserves special mention, in which he adverts to the role of the superior cervical ganglion in the evolution of sympathetic (reflex) acts, such as asthma, cough, etc., from irritation of the stomach, uterus, and other organs of the body. In 1760 Morgagni25 explained more fully the sympathy between the nostrils and the diaphragm and abdominal viscera, calling attention at the same time to the com- munication between the fifth pair of nerves and the inter- costals (Willis). In illustrating his theory, he called at- tention to the case of a nobleman in whom epileptiform convulsions were preceded by a fetid smell only per- ceptible to himself ; also to that of an old drunkard who sneezed for two or three years, for a quarter of an hour each day, and finally died suddenly. On post-mortem there was discovered hypertrophy of the heart.26 In an- other place he tells of a man of forty, an habitual drinker, who suffered for some time from dyspnoea (asthma), with frequent and severe fits of sneezing. One day, in a paroxysm of sneezing, he felt a sudden contrac- tion of the heart, sneezed once more, and died. In 1761 H. Boerliaave,21 speaking of sneezing in con- nection with intestinal parasites, makes the assertion that if a healthy man fasts longer than is his wont, he feels a disagreeable sensation about the prsecordia, sneezes, and then vomits. Following Avicenna, he compares the sneezer to the epileptic. In the same year Thomas Bartholini28 tells us that, after phlebotomy, when the wound is closed and the cicatrix is yet tender, some are taken with sneezing. In commenting on this remarkable association he states that he has observed sneezing dur- ing coitus. In 1765 appeared a thoughtful treatise on nervous dis- eases by Robert Whyte,29 of Edinburgh, in which he calls attention to the fact that “ several delicate women, who could easily bear the smell of tobacco, have been thrown into fits by musk, ambergris, or a pale rose, which, to most people, are either grateful, or at least not disagreeable ” (p. 125). He also mentions similar antipathies in regard to cinnamon and other substances. Whyte alluded to the sympathies between the larynx, pharynx, and ear, and advanced the doctrine that the impressions made upon the terminal filaments of the nerve (as, for example, in ear cough) must be first referred as a particular feel- ing to the sensorium commune, before being reflected to other parts of the body. In 1785 Tissot30 called attention to the fact that very violent paroxysms of migraine are sometimes terminated by slight haemorrhage from the nose, and relates the case of a man of his acquaintance, an habitual sufferer from migraine on the same side in which he had a polypus in the nose, and to which it owed its origin.31 In 1797 we find Darwin32 reporting a case of nasal polypi, due to the irritation of worms in the intestines ; and, in 1801, Gruner33 alludes to sneezing in hysterical women as a prodrome of the attack, and in retention of the after-birth; to the same reflex in the dissipation of cough, hiccup, and allied evils ; to its occurrence in those suffering from hernia, in pregnancy, and skin eruptions. This writer says34 the nose becomes warm and red in the hysterical, in women at the menstrual period, and in the victims of onanism. In 1802 Heberden35 observes that “ a large suppuration of an inflamed sore throat has been attended with a con- siderable quantity of pus at the bottom of the vessel which held the urine, for three or four days. As soon as the abscess broke and discharged itself, this purulent appear- ance in the urine ceased.” Heberden, as is well known, was supposed to have approached very -nearly the dis- covery of the disease known as “hay fever.”36 In 1804 Descliamps31 maintained the view that liemi- crania is a disease of the frontal sinus, and related some experimental observations illustrative of the great sensi- bility of this cavity; and in the same year Portal ob- serves that he has seen pains, vertigo, and even epileptic affections in connection with disease of the nasal mem- brane, and refers to a case accidentally cured by the fumes of cinnabar, given with other intention. The limited space allotted to the present article pre- cludes a critical review of the diversity of opinion with which the different theories concerning these neuroses have been received. Those who wish to familiarize themselves with the recent literature of the nasal reflex neuroses should consult, in addition to the writings al- ready referred to, the subjoined list of articles which rep- resent the principal contributions to the discussion of the subject. The section of neuroses of the naso-pharynx will be found in the Appendix. Ashhurst, S.: Handbook, vol. iv., on Hay Fever. Allen, H.: The Headaches which are Asso«iated Clinically with Chronic Nasal Catarrh, Med. News, Phila., March 13, 1886. Baber: Reflex Nasal Cough, Practitioner, Bond., July, 1886. Also Brit. Med. Journal, November 29, 1884. Baruch and McBride: Reflex Symptoms in Nasal Affections, Med. Rec., New York, January 30, 1886. Beschorner: Ueber Heufleber, etc., Jahresbericht d. Gesellschaft f. Na- tur u. Heilkunde, zu Dresden, 1885-86. Bobone : Un caso di spasmo sternutatorio, Bull, della mal. degli ore- chio, etc., No. 4, 1886. Boeker: Die Bzhg. d. erkr. Scht. d. Nase zum Asthma, etc., D. Med. Woch., Nos. 26 and 27, 1886. Bresgen : (1) Zur Entwickelung von Refractions- u. Stellungsanomalien des Auges in Folge von Nasenerkrankung, Med. Chir. Centralblatt, Wien, 1884, xix., s. 266. (2) Die Beziehungen der erkrankten Nasen- schleimhaut zum Asthma, etc., D. Med. Woch., No. 22, 1886. (3) Der Circulations-Apparat in d. Nasenschleimhaut, etc. ; ibid., Nos. 34, 35, 1885. Browne, L.: The Treatment of Hay Fever, Brit. Med. J., June 12, 1884. Cardone : Archiv. internaz. di otoloiia, etc., Fas. iv., 1885, cases 6 and 7. Cortez : Des nevroses reflexes d’origine nasale, France medicate, August 1 and 4, 1885. Chiari, O.: Casuistische Beitrage zur Lehre iiber den Zusammenhang zwischen nerv. Leiden u. Nasenkrankheiten, Zeitschr. f. Therapie mit Einbeziehung d. Elect, u. Hydrotherapie, Wien, 1884, ii., 8, 33, 35. Christopher and Rumbold : Disease of the Scalp due to Inflammation of the Pharyngo-nasal Cavity, St. Louis M. and S. Journal, xlvi., 527, 1884. Elsberg : Reflex Phenomena due to Nasal Disease, Trans. Am. Laryng. Assoc., 1883. Ensing : Weekblad van het Nederland. Tydschr. voor Geneeskunde, No. 22, 1885. Fraenkel, B.: Yon der Nase aus geheilter Facialskrampf, Berlin, klin. Woch., No. 24,1884. Fraenkel E.: Zur Diagnostik u. Therapie gewisser Erkrankungen der mittleren u. unteren Nasenmuscheln, Volkmann’s Vortrage, No. 242, 1884. See, also, D. Med. Woch., No 42, 1884. Fer6 : Les eternuments nevropathiques, ProgiAs Med., No. 4, 1885. Finke: Epilepsie geheiltdurch Nasenpolypen—Operation, Deutsch. Med. Woch., No. 4, 1885. Fenykovy: Ein Fall von Asthma bronchiale mit gleichzeitigem Auftreten von Urticaria, Wiener med. Presse, No. 49, 1884. French : The Effects of Dis. of the Nasal Passages on other Portions of the Resp. Tract, New York Med. J., 1886, xliv., 533-535. 229 Nose. Nose. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gazdar : Case of Foreign Body in Nose for Seven Years ; Persistent Neu- ralgia of Half of the Face—Recovery, Indian Med. Gaz., xviii., 188S. Gleitsman: Annual Rep. of Throat Department, German Dispensary, New York Med. Record, January 16, 1886. Gordon, N. R.: Chronic Conjunctivitis dependent upon Diseases of the Intra-nasal Tissues, Journal of American Med. Assoc., November 14, 1885. Gotze : Beitrage zur Frage nach dem Zusammenhang gewissen Neuro- sen, etc., Monatsschr. f. Ohrenheilkunde, xviii., 163, 177, 1884 (Nos. 9 and 10). Gruening: Reflex Ocular Symptoms in Nasal Affections, Med. Record, New York, January 30, 1886. Gennaro : Archiv. Ital. di laringolojia, Fasc. ii. and iv., 1886. Hack: (1) Ueber die Entstehung von exudatiren sog. rheumatisch. Pro- cess von der Nasenschleimhaut aus, Fortschr. der Med., Berlin, 1883, i., 645-651. (2) Ueber Chiriu-g. Behandlung asthmatischen Zustande, Berl. Klin. Woch., 21 and 22, 1885. Ueber CatarrhuB Autumnalis u. Heufieber, Deutsche Med. Woch., No. 9, 1886. (3) Zur operativ. Ther. d. Basedowschen Krankheit, ibid., No. 25, 1886. Hartman, A.: Partielle Resection der Nasenscheidewand, etc., D. Med. Woch., No. 51, 1882. Hendrix : The Relationship of Diseases of the Eye to those of the Nasal Passages, St. Louis M. and S. Journ., January, 1886. Hull : Multiple Polypi producing Asthma, etc., Alabama M. and S. J., 1886, i., 384. Heyman : Ueber path. Zustande die von der Nase ihre Entstehung fin- den konnen, Deutsche Medicinal Ztg., Heft 66, 1886. Hedinger : Ueber Rhinochirurgie, Med. Correspbl. d. Wurtemb. Aerzt. Verein, Stuttgart, 1886, 1vi., 257-265. Hoffmann: (1) Spasmus glottidis, Reflexneurose, Monatsschr. f. Oh- renheilkunde, No. 7, 1885. (2) Zusammenhang von Nasen u. Augenaf- fectionen, Deutsche Med. Woch., No. 25, 1885, mentions a case of one- sided Basedow’s disease cured by treating the nose. (3) Ueber Reflex Neurosen, etc., Tagbl. d. Versamml. Deut. Naturforscher u. Aerzte, Strassburg, 1885, lviii., 321-328. Jacobi: Reflex Symptoms in Nasal Affections, Med. Record, N. Y., Jan- uary, 30, 1886. Partial and Sometimes General Chorea Minor from Naso-pharyngeal Reflex, Am. J. Med. Sc., April, 1886. Kupper: Ueber den Einfluss von chr. Erkrankungen d. Nasenschleim- haut auf nerviises Herzklopfen, Deutsche Med. W., x., 828, 1884. Lefferts: Art. on Diseases of the Nose, in Ashhurst’s Cyclopaedia of Surgery. Lowe : Ueber Epilepsie bedingt durch Schwellung d. Nasenschleimhaut, Allg. Med. Central Ztg., 1882, No. 76. Lublinski: Asthma u. Nasenleiden, Deutsche Medicinal Ztg., No. 41, 1886. MacCoy : Observations on Night Cough, especially in Young Children. Med. News, Philadelphia, February 28, 1885. Mackenzie, H.: Nasal Asthma, etc., British Med. J., May 10, 1885. Mackenzie, J. N. : Irritation of the Sexual Apparatus as an Etiological Factor in the Production of Nasal Disease, Am. J. Med. Sciences April, 1884. Mackenzie, M.: Diseases of the Throat and Nose. London, 18S4, vol. ii., p. 361. Masini : Asthma and Nasal Disease, Gazz. d. Osp., iv., 611, 620, 627, Milano, 1883. Moure: Manuel prat, des maladies des fosses nasales, etc. Paris, 1886. Mulhall: Recent Progress in the Treatment of Hay Fever, St. Louis Courier of Med., February, 1886. Myerson : Gazeta Lekarska, Nos. 18 and 19, 1884 (Asthma and Nasal Polypi). Palmer : Reflex Phenomena from Nasal Disease, Canadian Practitioner, October 10, 1884. Raaf : Zur Therapie des Asthma bronchiale von der Nase ausgelost. Bonn, 1886. Rethi: Ueber Reflexneurosen, etc., Wiener med. Presse, Nos. 37, 38, and 39, 1886. Richey : Prophylaxis in Rhinitis Sympathetica, Chicago Med. J. and Examiner, liii., No. 6, 42-45, 1886. Robinson, B. : (1) On Respiratory Neuroses of Nasal Origin (Vaso-motor Coryza—Asthma), Medical Record, January 30. 1886. (2) Reflex Ocu- lar Symptoms in Nasal Disease, ibid, April 3, 1885. (3) A Contribu- tion to the Study of Hay Fever (so called), Med. News, Philadelphia, July 17, 1886. (4) Nasal Catarrh. New York, 1885. Roe: Asthma from Nasal Disease, Journal of Am. Med. Assoc., Sep- tember 15, 1883; also papers on Hay Fever in N. Y. Medical Journal, May 3 and 10, 1884. Rosenbach, O. : Ueber die auf myopathischen Basis beruhende Form der Migraine, Deutsche med. Woch., Nos. 12 and 13, 1886. Roth : Zur Diagnose und Therapie der mit Nervenkrankheiten Zusam- menhiingende Reflex Neurosen., Wiener med. Woch., Nos. 16 and 17, 1885. Rousch : Treatment of Hay Fever, Cincinnati Lancet and Clinic, Au- gust 30, 1884. Rumbold: Rhinitis. Pruritus, or Itching Nasal Catarrh, Weekly Med. Review, Chicago, Nos. 21, 22, 23, and 24, 1884. Sajous : Papers on Hay Fever in Med. and Surg. Rep., Philadelphia, De- cember 22, 1883, and Trans. American Laryngological Assoc., 1884, p. 106; also Hay Fever, etc. Philadelphia, 1885. Schiiffer, M.: Chirurgische Erfahrungen in der Rhinologie u. Laryngo- logie. Wiesbaden, 1885. Nasenleiden u. Reflex Neurosen, D. med. Woch., Nos. 23 and 54, 1884. Schech : Die sog. Reflex Neurosen, etc. Reprint. Schmalz : Ueber den Werr.h einer rhinochirurg. Behandlung des Asthma Nervosum, etc., Berliner Klin. Woch., Nos. 29 and 32, 1885. Schmiegelow: Hospitals-Tidende, March, 1885, and Nordisk med. Ar- kiv., Bd. xvii., No. 27. Schnitzler : Wiener med. Presse, 18S3. Schwanabach : Ein Beitrag zur Casuistik der Nasenkranlcheiten, St. Petersburger med. Wochenschrift, No. 46. 1884. Schweig : Reflex Symptoms in Nasal Disease, Med. Record, New York, January 30 and February 20, 1886. Simanowski: Vratch, 44-50, 1885 (Cough and Asthma—Polypi). Sommerbrodt, J. : Nasen Reflex Neurosen, Berliner Klin. Woch., Nos. 10 and 11, 1884, and Nos. 10 and 11, 1885. Terillon: Rapports des polypes muqueux des fosses r.asales avec l’asthme. Medecin. prat., Paris, 1885, vi., pp. 217-222. Wagner, Clinton: Diseases of the Nose. New York, 1884. White, J. A. : Journal Am. Med. Assoc. Wille : Der Trigeminushustcn, Deutsche med. Woch., Nos. lti and 17, 1885. Ziem : (1) Ueber die Abhangigkeit der Migraine von Krankheiten der Nasenhohle, etc., Allg. med. Central Ztg., Nos. 35 and 36, 1886. (2) Ueber die Einwirkung aromat. Substanzen auf die Nasenschleimhaut, Deutsche med. Woch., No. 30, 1885. (3) Ueber die Abhangigkeit der Enuresis nocturna von Nasenobstruction, Allg. med. Central Ztg.. No. 64. 1885. (4) Zahnkrankheiten u. Nasenleiden, ibid., liv., pp. 1117-20, 1885. (5) Ueber neuralgische u. nerviise Begleiterscheinungen bei Na- sen u. Rachenlcrankheiten, Monatsschrift der Ohrenheilkunde, Nos. 8 and 9, 1886. Zuckerkandl: Wiener med. Woch., No. 3S, 1884. In 1871 Voltolini,38 of Breslau, reported a case of asthma cured by removal of nasal polypi—an observa- tion which attracted considerable attention, and which was followed, shortly, by communications on the rela- tion of asthma to nasal disease, by Hanisch,39 Porter,40 II. Hartmann,41 Schaffer,42 Daly,43 Spencer,44 Todd,46 B. Fraenkcl,46 Mulhall,41 Porter,48 Rumbold,49 Joal,50 Jac- quin,51 Bresgen,62 and others. Among these writers Porter called attention to the role of hypertrophic nasal catarrh in the production of asthma, and pointed out the fact that obstruction of, or irritation in, the nares may cause the reflex affection, apart from the presence of a polypus. Among Rum- bold’s cases was one in which attacks of so-called “hay fever ” were dissipated with the cure of the nasal disease. The mechanism of the asthmatic attack was variously interpreted. According to some, the irritation of the sensitive nerves in the pharynx and larynx by mouth- breathing, and the creation of a vacuum behind the seat of nasal obstruction, originated the impression, which was conveyed to the pulmonary branches of the pneu- mogastric; while others adopted the more natural ex- planation of irritation directly reflected through the sensitive branches of the fifth nerve. In May, 1881, at the meeting of the American Laryn- gological Association, Dr. William H. Daly,63 of Pitts- burg, called attention to the fact that in a fair propor- tion of cases of “liay-asthma” there is local disease of the nose and nasal pharynx (from simple hyperesthesia to pronounced structural changes, such as hypertrophic catarrh, polypi, etc.), without which the exciting cause (pollen, bacteria) is innocuous, and that the cure of the affection may be accomplished through removal of the local intrinsic condition (by cauterization with acid, elec- tric cautery, etc.)—a position which he established by most convincing practical proof. To this observer be- longs the credit of formulating the treatment of the dis- ease by measures addressed to the nasal and naso- pharyngeal chambers. According to Daly, we are only justified in looking upon “hay fever” as a neurosis when the affection persists after removal of the local nasal disease. Daly attempted no explanation of the mechanism of the disease, but simply announced a clini- cal fact and the treatment based upon it.* The following year, Dr. Roe,64 of Rochester, published the successful results of his treatment of the disease by the operative method, and related a number of cases in which a cure had been effected. According to him, the affection is due to the action of pollen upon the nasal mucous membrane, which in some persons is rendered peculiarly susceptible by active or latent disease of the naso-pharynx associated with hypertrophic catarrh of the nasal passages. The asthma and other manifesta- tions of the paroxysm are due, he believes, to reflex con- gestion of the mucous membranes of the several organs in which their effects are manifested. While Dr. Roe believes the exciting cause to be pollen, he at the same time contends that, in order to the production of a parox- ysm, “ latent or active ” nasal disease must be present, that * Dr. Edson (letter to N. Y. Medical Record, 1878. vol. ii., p. 317) had previously called attention to the fact that all cases of the disease presented one or more of certain symptoms referable to the nose, such as great sensitiveness of the nasal membrane, coryza, persistent sternuta- tion, naso-pharyngeal catarrh, etc. 230 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Nose, Nose. the nervous symptoms are secondary to the hyperaesthetic condition of the nostrils, and that the latter is not the effect but the cause of the neurotic feature of the dis- ease. At the meeting of the Verein der Aerzte Steiermarks, 1881, Dr. Josef Herzog66 advanced the view that “hay- asthma ” is simply a form of the neurasthenic condition described by Beard, and held that local treatment is of secondary importance. In the same year in which Roe’s papers appeared I published the results of some experiments made by me with reference to the production of nasal cough and the localization of reflex sensitive areas in the nasal passages, which, I ventured to think, threw some further light upon the subject of reflex nasal neuroses. These obser- vations, and the views of Professor Hack upon the sub- ject, have already been considered at the commencement of this article. Hack’s able monograph, which was pub- lished in Wiesbaden in 1884, was based upon a series of instructive cases, including nightmare, asthma, migraine, cough, muscse volitantes, supra-orbital neuralgia, vertigo, epilepsy, swelling and redness of the external nose, “hay-fever,” etc., reported in the Wiener Medizinische Wochenschrift, in the latter part of 1882 and in 1883, and is a most valuable contribution to the literature of the nasal reflex. It excited a great deal of comment, and was followed rapidly by a number of communications on the subject. Hack holds that the reflex excitability of the mucous membrane in this class of neuroses is dependent solely upon the tendency to sudden swelling of the cavernous bodies, and he explains the mechanism of the reflex as follows: When an irritant is applied to the nasal mucous membrane, the first thing that happens is swelling of the ei’ectile bodies from a determination of blood to their cel- lular spaces. The extreme tension of the mucous mem- brane, thus brought about by the engorgement of the cavernous bodies beneath it, acts as the exciting stimulus to the terminal filaments of the sensitive nerves, with the subsequent production of the reflex. The chain of events is then (1) swelling of the cavernous bodies ; (2) tension of the mucous membrane; (3) irritation of the terminal nerve-filaments ; (4) the reflex phenomena. Hack main- tains, furthermore, that should the irritation start from portions of the mucous membrane other than that cover- ing the anterior end of the turbinated bone, the swelling in the latter circumscribed situation occurs only indi- rectly or secondarily through the influence of ‘ ‘ nervi eri- gentes.” This turbinated engorgement then forms the connecting link between the nasal symptoms and those referable to other parts of the body, and must be present in order to the production of the reflex. As the pres- ence of an inflammatory condition prevents or interferes with the cavernous swelling, he maintains that the fre- quency of nasal reflexes is in inverse ratio to inflammatory conditions of the mucous membrane. Like Daly and Roe, Hack holds that morbid conditions of the nose itself play the essential part in the etiology of the disease, and believes that the neurasthenic symptoms are secondary to the nasal affection, calling attention at the same time to the fact that the latter may coexist with a general neurosis without having any connection with it. In 1884 a still more exclusive view was put forth by Dr. Harrison Allen, of Philadelphia. According to Allen, “hay-fever” and allied neuroses depend solely upon obstruction of the nostrils (from de- flection of the septum, hypertrophy of soft parts and bone, turgescence of the nasal mucous membrane), and that the cure consists simply in removing the obstruction (or tendency thereto) in the nasal chambers. According to his experience, sufferers from these affections have one feature in common—the inferior turbinated bones lie well above the floor of the nostril, an anatomical peculiarity which subjects their overlying mucous membrane to ad- ditional irritation from extraneous substances. It would appear, then, that the truth is irresistibly emerging into recognition that certain abnormal condi- tions of the nasal passages are necessary to the produc- tion of the ensemble of phenomena which form the clinical picture of so-called hay-asthma and allied nasal neuroses. Although the results arrived at by different observers, working independently of each other, and starting out in some instances from different stand-points, are not alto- gether harmonious, they present, nevertheless, a singular unanimity in their convergence to a common point—in their recognition of the importance of remedial measures addressed to the nasal chambers as a prime factor in the therapeutic management of the disease. Several months after the publication of Dr. Allen’s view I endeavored to reconcile the discrepancies met with in the results of different observers,66 and in several sub- sequent publications advanced the doctrine which is ad- vocated in the present article (see Pathology and Treat- ment). Note.—Since the completion of the above historical sketch, Dr. Schacle- waldt. of Berlin (Die Trigeminus-neurosen, Deutsche med. Wochenschrift, Nos. 37 and 38, 1885), has advanced a theory very closely resembling the one insisted upon by Ferber, of Hamburg, in 1869 (see Historical Sketch). According to Schadewaldt, “nasal asthma,” cough, and various other well-known nervous phenomena referable to the respiratory tract are to be regarded as the symptoms of a neurosis of the trigeminus nerve, as functional disturbances of the normal reflex function of sneezing— “ qualitative changes with quantitative exalted reflex excitability.” To illustrate—the physiological results of irritation of the nasal fosste are, in the order in which they occur, swelling, secretion, sneezing. It often happens, however, as in chronic inflammation, that only one of these ele- ments (swelling) is present, sneezing and secretion being replaced by cough, which latter may be regarded as their pathological vicarious rep- resentative. This cough, then, may be looked upon as the pathological inversion of the act of sneezing, and the rational method of therapeutic procedure would therefore involve, for the dissipation of the cough, the production of both secretion and sneezing. Asthma likewise represents a pathological disturbance of the normal nasal reflex. Schadewaldt’s ob- servations on the subject of cough tend to substantiate, essentially, the re- sults arrived at by me, viz.: that the lower and posterior parts of the nasal fosste are the spots generally most sensitive to the reflex-producing im- pression. Since the appearance of Schadewaldt’s article, Dr. Bosworth (N. Y. Med. Journal, April 24 and May 1, 1886), of New York, has modified the obstruction-theory as follows: Bosworth argues that, as the mucous mem- brane of the air-passages is endowed with no special secretory apparatus, and as its glands secrete mucus alone, the surplus moisture taken up by the inspiratory current during the day cannot possibly come front that structure. As, furthermore, the delivery of such a large amount of moisture to the inspiratory current by the respiratory membrane would involve the destruction of the latter by producing excessive dryness, he assumes that the erectile tissue of the turbinated bodies is endowed with that peculiar privilege, and that “the respiratory function of the nose is simply an exosmosis of serum.” Starting out with this physiological postu- late, he theorizes as follows: The essential anatomical feature in this class of cases is stenosis of the anterior portions of the nasal fossae. In such an event every act of inspiration causes rarefaction of air be- hind the point of obstruction, from diminution of atmospheric pressure and the production of a vacuum (as pointed out by Andrew H. Smith), and that not only in the nasal cavities, but along the whole naso-bronchial tract. This finally begets a tendency on the part of the mucous mem- brane “to sag down or pouch into the cavity,” a condition attended with dilatation of the blood-vessels, especially those of the turbinated tis- sues, and tending to local inflammation—a sort of dry-cupping process, as it were. This results finally in a weakening of the muscular fibres which regulate the calibre of the vessels, and “ their escape, to a certain extent, from the control of the vaso-motor nerve ”—a vaso-motor paralysis which leads to an enormous transudation of serum, with a sodden con- dition of the membrane, and “ an unlocking of the whole activity of the respiratory function,” which causes a “ flooding of the membrane rather than a flooding of the cavity, and therefore causes extreme turgescence of the blood-vessels, with complete stenosis of the passage.” The sodden, prolapsed membrane pressing on the terminal nerve-filaments gives rise to the nervous phenomena. Although the latter are the result, therefore, of nerve-pressure, Dr. Bosworth, singularly enough, denies that a reflex agency is necessary to their production (see N. Y. Med. Journal, Feb- ruary 26, 1887, p. 246); indeed, he is disposed to think there is no such thing as a reflex disorder, and considers that “ direct continuity of sur- face from the nasal chambers to the bronchial tubes,” and a relation be- tween the blood-vessels of the larynx and those of the nose, so that a close sympathy exists between them, are sufficiently explanatory of the fact that congestion in one place may produce congestion in another. The fallacies involved in the obstruction-theory will be sufficiently in- dicated below. Unfortunately for its advocates, in a large proportion of cases there is no nasal obstructive lesion whatever. The view violates the two most essential criteria of a logical hypothesis—the facts do not exist, and the assumption is inadequate to even partially explain the phenom- ena. To take one of a multitude of illustrations, how could rarefaction of air in the bronchial tubes, the result of nasal obstruction (even admit- ting the existence of such a fact) or of direct continuity of the nasal and bronchial tissues, account for the sudden and immediate production of a paroxysm of asthma, cough, or other reflex disorder from the simple con- tact of a probe or other indifferent substance with the nasal mucous mem- brane—a result which I have often observed ? Etiology.—Age ; Sex ; Condition of Life.—No age or condition is exempt. I meet •with these reflex phenom- ena at all ages and in every condition of life, in private and in hospital practice. While the majority of cases 231 Nose. Nose. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. that apply for treatment come from the educated classes, it must not be forgotten that it is precisely persons of this class that seek intelligent medical advice or are likely to come across circulars distributed by those investigat- ing the complaint. Several of my patients dated their trouble from infancy, and two of the most distressing and typical instances of asthma and vaso-motor coryza first appeared at the ages of two and three months respectively. I find these neuroses more common among women than is generally supposed, and am inclined to regard the question of sex as one of unimportant etiological signifi- cance. Inheritance; Family Peculiarities.—I think there can he no doubt that a peculiar excitability or deranged con- dition of the nerve-centres may descend from father to son, and determine the appearance of the affection in the latter. The question of inheritance in regard to pei’iodic vaso-motor coryza has been established beyond all ques- tion by the able researches of Wyman67 and Beard,58 and my own observations not only support their conclusions in this direction, but also demonstrate the certainty of transmission of other members of the group of “ reflex neuroses ” from generation to generation. It is not un- common to find several members of the same family sim- ilarly affected, and it not infrequently happens that one or both of the parents of children suffering from this class of sympathetic rhinal disease either bear the exact re- production of the affection in their own persons or labor under some allied respiratory neurosis. In a fair propor- tion of cases it will also be found that more remote rel- atives of the individual suffer from asthma and various other nervous conditions. In other instances the gen- eral family temperament is essentially neurotic, with a tendency to epilepsy, chorea, or some other pronounced nervous affection. Temperament.—The predominant temperament among individuals affected with these reflex neuroses is un- questionably the neurotic. While they may, in many instances, not necessarily belong to the so-called “ ner- vous” or “ hysterical” variety of individual, while they may give no outward and visible sign of a deranged nervous system, there will generally be found, on careful examination, a delicacy or sensitiveness of the nervous apparatus, either in whole or in part. Race Peculiarities; Origin.—Taking the view which I do of these affections, it does not seem to me justifi- able to confine the operation of their causes within the limits of a particular century, or to explain their phe- nomena on the hypothesis of national or race peculiari- ties. More accurate observations are necessary to the for- mulation of definite conclusions concerning the occur- rence of these neuroses in the inferior races. While it is doubtless true that the physical and moral forces of civ- ilization encourage their development in the higher walks of life, they probably do so only in so far as they predispose to abnormal excitability of the nervous system in general, or to catarrhal and asthmatic affec- tions. The absence of so-called “ hay-fever ” in the negro has been brought into prominence by recent writers on the subject, and notably by Beard, as an argument in favor of the important role which race is supposed to play in the etiology of that disease. I have recently,59 however, pointed out the fact that this race is by no means exempt from this curious disease, and I now and then meet with reflex phenomena in the negro, referable to disease of the nose and belonging to the same category of affections ; and it is possible that a fair proportion of cases of the convulsive asthma which occur in that race may have a similar origin. One of the most pronounced cases of “ reflex asthma” which I have ever seen, and in which the asthmatic paroxysm could be produced at will by irri- tation of the nasal sensitive area with the probe, occurred in the person of one of the blackest representatives of the Ethiopian race. In this people the exquisite delicacy of the sense of smell, the prominent development of the turbinated bodies, and the consequent increased amount of surface exposed, would seem to invite the paroxysm in those surrounded by the conditions that provoke it.* Structural Peculiarities.—In persons affected with the sympathetic forms of coryza or rhinitis, the mucous mem- brane of the nasal passages, and, in some instances, of the whole respiratory tract, is the seat of a peculiar hyper- sesthesia, whose origin and characteristics will be more fully discussed, later on, under Pathology. During the paroxysm this hypersestliesia is altogether out of proportion to that which is ordinarily met with in simple inflammation of the nasal passages, and is often increased by remedies which ordinarily control effect- ually the deranged sensibility of simple coryza or chronic rhinitis. Indeed, in a large number of the class of cases commonly known as “reflex nasal neuroses” this irri- tability is so exquisite as to render the contact of the blandest applications unbearable to the patient, and this apart from the presence of any of the exciting causes of the paroxysm. This often renders the topical treat- ment of existing nasal disease a matter of considera- ble difficulty, not only at the time of the paroxysm, but also in the interregnum of so-called immunity. It also often predisposes to coryza from apparently trivial causes. The hypersestliesia is commonly associated with a marked tendency to erection of the corpora cavernosa; and both hypersestliesia and cavernous engorgement I believe, in opposition to Daly, Roe, and Hack, to he purely sec- ondary phenomena, dependent, in all probability, upon some central irritation or paresis (see, also, section on Pathology). The swelling of the corpora cavernosa is not, therefore, absolutely necessary to the production of the nasal reflex, and must he considered, in many instances at least, not the originator, but the vaso-motor accompaniment of the reflex act. Repeated or permanent engorgement of these bodies undoubtedly predisposes to and increases the reflex irritability of the nasal fossae, and their erection may precede, in point of time, the evolution of the reflex act; but it is at the same time equally true that the latter may occur without any change in the cavernous bodies appreciable to the eye. I have not been able to discover any structural pecu- liarities in the skeleton of the head which might serve to differentiate this class of cases from other intra-nasal pro- cesses. While in some the inferior turbinated hones, as pointed out by Harrison Allen, lie well above the floor of the nostril, I am inclined to regard this elevated condition as an inconstant anatomical feature. Glasgow60 has observed in cases of sympathetic rhinitis an abnormal pallor of the mucous membrane, which he explains on the theory of spasm of the arterioles—due to an increased vascular tone caused by an augmented action of the vaso-constrictors. With this arterial spasm occurs general arterial tension, the onward flow of the more solid portions of the blood is prevented, and the cavern- ous bodies of the mucous membrane become infiltrated with escaping white corpuscles and the liquor sanguinis. This view, he thinks, is supported by the favorable action of remedies which cause arterial dilatation, such as atro- pin and amyl nitrite. This prominent feature—i.e., pro- nounced paleness—disproves, he believes, the possibility of congestion of the cavernous bodies. In the class of cases we are discussing, the nasal pas- sages may he entirely free of any well-defined structural lesion ; or, on the other hand, may he the seat of almost any pathological process met with in these cavities. A common condition is the hypertrophic stage of ordinary inflammation, or pronounced congestion of the mucous membrane, more marked over the area of the cavernous tissue. In another case we find a deflected septum, an unusually prominent turbinated hone, or other deform- ity of the intra-nasal framework ; in still another, one or more nasal polypi, and so on. Sometimes the nasal fossae are more or less completely obstructed, while in others the lumen of the nostrils is normal or even very ♦Since reporting my first case of “hay-asthma” in the negro, two similar cases have come under my observation. 232 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Nose. Nose. capacious. Atrophic conditions are very seldom met with ;61 very extensive atrophy I have never seen. The role of intra-nasal disease in the production of re- flex phenomena will be considered under the head of Pathology. The appearances of the pharynx and lower air-passages will depend usually upon the diseased condition of the nasal fossae, and may accordingly be of the most mani- fold nature. Symptoms. — General Characteristics. — The attacks which characterize the affection are paroxysmal, occa- sionally showing a decided tendency to periodicity, and may occur at any time, but more commonly at night, when the recumbent posture is assumed, or when the patient lies on the more affected side. Varying greatly in duration from a few moments to several hours, the paroxysm either passes off spontaneously or is terminated by sneez- ing, with or without a copious discharge of mucus or serum from the nostrils. Several attacks may occur dur- ing the day or night, except when the paroxysm is pro- longed, in which event only one seizure takes place dui’ing the twenty-four hours. The onset may be sudden and without warning, or it may be preceded by a variety of sensations either referable to the nasal apparatus itself or to a distant organ. Under the former head may be men- tioned sneezing, itching, tickling, sense of a foreign body present, dryness or fulness of the nasal passage or throat, or sudden and complete stoppage of one or both nasal passages. Under the latter are itching and other sensa- tions in the eyes or ears, or a sense of formication in various parts of the body, and a sense of fulness, dul- ness, or even pain in some organ remote from the nasal fossae. There are generally one or more symptoms which pos- sess more prominence than the others; or a number may be prominently associated in the same individual, nota- bly in the case of coryza vasomotoria periodica. The grouping together of several of the more common symp- toms of this disease was formerly, and is now generally, known as hay-asthma. In some persons they only ap- pear in connection with some physiological process, as menstruation, coitus, etc.; in others, only during certain months of the* year or in the presence of brusque temper- ature-changes. When the paroxysms show a decided tendency to periodicity, coming on at or about the same hour every day, it will be obsei’ved that in this case a more or less pronounced neurotic temperament is present, and that apart from any so-called hysterical manifesta- tions. Analysis of Individual Symptoms.—Symptoms Referable to the Organs of Special Sense. Nasal Apparatus. The most prominent symptoms which arise from the peculiar irritability of the nasal passages in this disease are cough ; perversion, abrogation, or complete suspension of the ol- factory function; persistent itching, generally referred to the end of the nose ; epistaxis; redness of the external in- tegument, with occasional desquamation of the cuticle; sneezing, obstruction, and the discharge of a limpid fluid from one or both nostrils ; pain along the bridge of the nose, with occasional tenderness on pressure. Nasal cough is exceedingly common, is always parox- ysmal, and varies in character from a short, explosive, cough-like sound to paroxysms of great violence. In one case under my observation these were so distressing and severe that the patient, a woman, on their approach had to kneel upon the floor and fix the body against some un- yielding substance, so great was the convulsive bodily agi- tation. The cough is generally short, dry, hacking, or bark- ing* in character, and may be the only symptom for which the patient seeks relief. It is unaccompanied by expectoration, and may be preceded or accompanied by uneasy sensations (prickling, tickling, dryness, sense of foreign body, etc.) referable to the larynx, and generally to the region of the crico-thyroid space. In some per- sons a distinct laryngeal cough is added to the nasal; that is to say, a double cough is present—a condition which may be described under the title dibechia. Itching at the end of the nose is very commonly a symptom of irritation about the posterior portions of the nasal fossae, and the same be said of the intense redness of the external nose so frequently symptomatic of nasal affections. The paroxysms of the disease are sometimes terminated by a copious haemorrhage from the nose, or the latter may be present from the outset of the attack. Sneezing is a prominent feature. It may occur at any period of the day or night; but most commonly early in the morning, on rising, or in the evening after sun- set. The paroxysms vary greatly in duration and severity, and are brought on by the most trivial circumstances. Getting out of bed, the exposure of the eyes to light, mental impressions, the slightest draught of air, opening a dusty hook, and a host of such agencies are alone suf- ficient to provoke them. In one case they were excited whenever the patient cleaned his teeth; in another the simple act of combing the hair invariably gave rise to at- tacks of sneezing and tinnitus aurium. In both these cases a cure was effected by removal of the intra-nasal irritability. A frequent nasal symptom is the copious discharge of a thin, watery fluid, which at times is sufficiently acrid to excoriate the nares and upper lip. It varies greatly in amount; in some instances the patient has to sit for hours over a basin or bucket, into which the discharge literally pours. Organ of Hearing. The symptoms referable to the or- gan of hearing are tinnitus, pain in the ear, itching of, and accumulation of wax in, the auditory meatus, sud- den stoppage of the Eustachian tubes, redness of the drum-membrane, and clicking and snapping noises in the ear. In 188362 I called attention to certain reflex aural phe- nomena from nasal disease, to the recognition of which I was led by their accidental production during operative procedures in the nose ; and suggested their probable de- pendence on morbid states of the turbinated bodies, for in certain cases I found that they could be reproduced by artificial stimulation of these structures. Quite re- cently Dr. C. H. Burnett,63 of Philadelphia, in an excel- lent article, describes certain peculiar clicking or snap- ping noises in or about the ear, which he refers to reflected irritation from the turbinated bones to the muscular tis- sues of the velum and the superior pharyngeal constrictor and pterygoid muscles, producing clonic spasm. In one instance Dr. Burnett produced the sounds artificially, when the medicated substance was pushed along the in- ferior turbinated bone into the nasal pharynx.* Occasionally a peculiar beating noise is heard, appar- ently upon the drum-membrane, which may possibly be due to spasm of the tensor tympani. The tinnitus which occurs from nasal disease is inconstant, and often depend- ent upon the condition of the turbinated tissues. Itching of the auditory canal is often a prominent symptom, and the physician is not infrequently consulted on account of this condition alone. If the nasal symptoms are incon- spicuous, as they sometimes are, and if nothing wrong is discoverable by physical examination of the ear, the case is liable to be looked upon as one of hysteria, or as the expression of some illy-defined neurosis. The diagnosis of the reflex nature of these phenomena depends upon the absence of disease of the Eustachian tubes and auditory apparatus, their immediate disappear- ance with the cure of the nasal affection, and, in some cases, the possibility of their artificial reproduction by irritation of the nasal mucous membrane. Now and then an enormously swollen and congested condition of the auricles, coming on suddenly and disap- pearing as rapidly, is observed, which may be regarded * The so-called hysterical, barking cough of children sometimes finds its explanation in irritation about the nasal cavities which is overlooked by the attendant. * Clonic spasm of the soft palate, with objective noises in the ear. de- pendent upon neuralgia of the trigeminus, have since been observed by Schech (Munchner med. Presse, 1886, No. 23, Reprint). 233 Nose. Nose. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. as analogous to the appearance of these structures after section of the sympathetic in the neck. It is sometimes associated with intense itching of the auditory meatus. Organ of Vision. The congested and, in some in- stances, inflammatory condition of the conjunctive, which is so often observed in connection with nasal dis- ease, is generally explained on the theory of extension of inflammation through the nasal duct; but it is probable that such an event occurs less frequently than is gener- ally supposed, and I am inclined to regard the dilatation of the conjunctival vessels, in a large proportion of cases, as a reflex vaso-motor phenomenon, the vessel-dilatation being kept up by constant irritation of the most sensitive spots in the nasal passages. In the same manner may be explained the recurrent herpes and keratitis which are observed in connection with nasal diseases, the phenom- ena in these cases being called forth by trophic disturb- ances.64 In long-standing cases the conjunctival vessels may become permanently dilated, and even varicose, a condition best seen on eversion of the lids. Added to this there is generally irritation of the Meibomian glands, and a tendency to the collection of yellowish secretion at the inner canthi. Itching in the latter locality is not un- common. Associated with these symptoms is a more or less constant sense of constriction about the forehead and between the eyes, and a dull feeling, sometimes amount- ing to pain, in the eyeballs. During the paroxysm there is increased lachrymation, the eyelids become puffy and oedematous, and even a state of chemosis may develop. Sometimes vision is com- pletely interfered with, and everything becomes blurred before the eyes until the attack passes off. Muscse voli- tantes have been not infrequently observed. I have several times seen a peculiar spasmodic twitch- ing of the eyelids which seemed to depend upon re- flected irritation, for it occurred only during the tempo- rary aggravation of the nasal affection. The abnormally hyperemic condition of the orbital tissues may lead eventually to increased intra-ocular pressure and the con- sequences dependent thereon. Organ of Taste. Owing to the close physiological al- liance between the senses of taste and smell, morbid con- ditions of the former are frequent accompaniments of the impeded discharge of the latter function. The reflex neuroses of taste are imperfectly understood ; they usually consist in abrogation, perversion, or destruction of the special sense. The perversion of taste is sometimes so great as to interfere with digestion, hy creating a distaste for food and the consequent interference with its proper reception by the digestive apparatus. Pharynx, Larynx, Mouth. Patients suffering from rhinitis sympathetica frequently complain of tingling or itching sensations in various portions of the larynx, pharynx, and roof of the mouth. In the larynx they create a tendency to cough; in the mouth and pharynx there is, in addition, often an irresistible desire to scratch the itching surfaces. Sudden congestion of the oro- pharyngeal and laryngeal membranes is not infrequently observed, alternating sometimes with pronounced pallor of the parts. The engorged conditions of the vessels is occasionally such that rupture occurs, with considerable loss of blood. In a professional colleague the prostra- tion from the haemorrhage was sufficiently great to con- fine him to bed for several days. Marked increase in the amount of the salivary secre- tion, a swollen, sodden condition of the gums, and her- petic eruptions about the mouth and throat, are also ob- served in connection with the paroxysms of this class of neuroses. Lower Respiratory Apparatus; Dyspncea, Asthma. The dyspnea which proceeds from reflected nasal irrita- tion varies greatly in degree. At times it is slight, pro- voking only a faint oppression or consciousness of ob- struction to the respiratory forces—a perceptible sense of antagonism between the acts of expiration and inspira- tion. At others the difficulty in breathing is violent, spasmodic, and, in some instances, apparently dangerous to life. This symptom is one of the most interesting of the phenomena of sympathetic rhinitis. Dyspnoea may be the result of purely mechanical causes, or, as in the case of sympathetic rhinitis, may be due to reflected irritation from the nose. It is generally sup- posed that difficulty of respiration from the former cause only occurs when the impediment to breathing is situ- ated in the lower meatus, which latter channel has, by common consent, been invested with the peculiar and ex- clusive privilege of conducting the air to and from the lower air-passages. It is therefore stated authoritatively that the difficulty of breathing through the nose, which may be termed nasal dyspncea, occurs only when the in- ferior meatus is in some way or other obstructed. This is in part erroneous, for I now and then see cases in which slight nasal dyspncea is a prominent symptom, and in which the lower meatus is perfectly free, the obstruction being confined to the upper and middle channels. The cause of the dyspncea in these cases springs, it seems to me, from a twofold source : (1) From obstruction to the air-current; and (2) from disturbance of the physiological relations between the olfactory sense and the respiratory process. Not infrequently the dyspncea assumes the form of a distinct asthmatic attack, which comes on, as a rule, sud- denly and lasts for a few moments only, or may be pro- longed for hours. During the paroxysm the patient pre- sents the characteristic distressing appearances of one suffering from so-called nervous asthma. He breathes with open mouth, and the sibilant and sonorous rales are generally loud enough to be heard without auscultating the chest. The paroxysm, which may be occasionally excited by artificial stimulation of the nasal mucous mem- brane, passes away gradually, sometimes as suddenly as it came, leaving the patient in a state of great weakness or nervous prostration. The nose is usually filled with a more or less fluid mucus, upon the expulsion of which the paroxysm subsides. Children are by no means exempt from the asthmatic manifestation ; on the contrary, I am inclined to regard it as of frequent occurrence in early life. I have met with well-marked asthmatic paroxysms of the greatest severity in children suffering from this affection at the ages of one month, two years, and five years, and in one case the parents stated that the child had from asthma ever since it was born. In the asthma of child- hood the nasal passages should always be systematically and carefully explored, to exclude or determine the pres- ence of any source of reflected irritation. Especially remarkable is the association of reflex asthma in children with affections of the skin, and notably milk- crust and nettle-rash. Nervous System. The symptoms referable to the nervous system proper are sufficiently numerous. The most frequent, perhaps, are those which are referable to disturbance in the domain of the fifth nerve, its branches and connections. Of these, the most commonly encoun- tered are supra- and infra-orbital, facial, occipital, and dental neuralgia. Less frequently met with are neural- gic affections of the pharynx, larynx, and neck. Headache of varying intensity is often associated with swelling of the intra-nasal tissues, and it is not improb- able that a certain proportion of the headaches occurring at the menstrual epoch may depend upon the physiolog- ical erection of these tissues which is sometimes seen at the monthly period. It has been known for a long time that convulsions, and even a condition resembling acute hydrocephalus, may every now and then occur in connection with the ordinary nasal inflammation of childhood. The depend- ence of choreiform attacks and epileptic seizures upon affections of the nasal passages has also been inferred from their complete dissipation with the cure of the nasal disease. I have once seen marked choreic convul- sions disappear during the treatment of a nasal catarrh, and it is quite possible that in the cases of epilepsy in which the “aura’' starts in the nose it may be connected in some way with structural disease of that organ. Among the symptoms referable to disturbance of the nervous apparatus may be mentioned cardialgia, attacks resembling angina pectoris, rheumatic pains, itching, 234 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Nose. Nose. horripilation and formication in various parts of the body, spasm of the laryngeal adductors, of the muscles of the face, neck, etc., and functional and spastic aphonia, In some cases of long standing the whole nervous ap- paratus is profoundly involved, and there is scarcely a known neurotic symptom which may not make its ap- pearance at some period or other of the disease. Exciting Causes of the Paroxysm.—The exciting causes of this form of neurosis are legion. Anything that tends to increase the unnatural hypersesthesia of the respiratory membrane may provoke an attack (see article on Larynx, Catarrhal Affections of the, in vol. iv.). My own observations, based on the analysis of a large number of cases, teach (1) that there is practically an in- finite number of causes which may precipitate the attack ; (2) that one irritant is of itself insufficient to produce the paroxysm, the latter being only possible from abnormal functional activity of the nerve-centres, inherited or ac- quired ; (3) that in the majority of cases the paroxysms are induced by a variety of agencies differing entirely in character and mode of operation, and even in those cases in which there is apparently only one exciting cause it will generally be discovered that there are conditions which bring about the attack other than the alleged solitary ex- citing cause; (4) that the latter may be operative only dur- ing certain periods of the year, or may provoke a par- oxysm, without regard to season, whenever applied ; (5) that it may be said, in general, that the exciting cause may produce its effect by direct or indirect (reflex) irrita- tion of the sensitive nerves of the nasal and other mucous membranes, through olfactory impression or through simple association of ideas, or the same result may be brought about by physical or mental over-exertion or emotional excitement; (6) that typical paroxysms occur in some persons at any season of the year, from a variety of causes, but especially from sudden changes in the tem- perature, or from electrical disturbances of the atmos- phere ; (7) that paroxysms may be produced as reflex phenomena from irritation of a distant organ, or from some excitation starting in the nerve-centres themselves ; (8) finally, that pollen is only one of a host of exciting causes, and there is reason to believe that in some cases in which it is supposed to be the excitant it has little or no influence at all. As an illustration of the effect of a purely psychical impression in the production of the paroxysm, I would call attention to my experiment with an artificial flower, related at the seventh annual meeting of the Laryngo- logical Association,65 and reported afterward in full in the American Journal of the Medical Sciences, January, 1886. Pathology.—We are at present passing through a rev- olution of sentiment 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 ex- planation in morbid conditions of these structures, linked to a disordered state—imperfectly defined, it may be—of the vaso-motor sympathetic. Especially is this true of that interesting group of symptoms known as “ hay-fe- ver,” but for which, I think, the term coryza vasomotoria periodica is a more appropriate appellation. The various theories advanced in explanation of the nasal reflex neuroses have already been considered, and it remains for me to recapitulate, as briefly as possible, the principal articles of my own belief. According to my conception, as outlined in several ar- ticles published during the last few years, the so-called nasal reflex neuroses, whether taken singly or collective- ly, as in the case of the ensemble of phenomena known as “hay-fever,” may be regarded as the protean manifesta- tions of a morbid condition to which I have given the name rhinitis, or coryza sympathetica, and which is char- acterized by a hypersestlietic condition of the vaso-motor nerve-centres, linked to a peculiar excitability of the nasal mucous membrane and cavernous tissues. For, if we inquire what condition or conditions are common to them all, what morbid process is capable of producing, them, either singly or in combination, and how phenomena apparently so widely different in character and anatomi- cal sphere of operation may be traced to a solitary source, we find the answer in certain more or less clearly defined changes in the nasal apparatus, and in a certain exalted state of the sympathetic nervous system, to which latter we instinctively turn as the organ most conspicuously concerned in the evolution of purely reflex acts. In whatever relation the local nasal affection and the condi- tion of the sympathetic stand to each other in the matter of cause and effect, they must both be regarded as insep- arable factors in the production of the phenomena under consideration. It matters not to what hypothesis the path of speculation may lead. Of this we can be reason- ably sure, that in order to the production of the charac- teristic symptoms of this disease a certain excitability of the nasal passages is necessary, plus an exalted state of the central nervous system. From our present knowledge of the disease falsely called “hay-fever,” for example, it seems difficult to es- cape the conclusion that its pathology is intimately in- terwoven with a morbid condition of the vaso-motor sympathetic, and probably a hypersensitive state of the nerve-centres themselves. When we recall the fact that in the famous section of the sympathetic in the neck, by Claude Bernard, symptoms similar, or closely allied, to the phenomena of hay-fever were produced ; when we reflect upon the results reached by Prevost in his experi- ments on the splieno-palatine ganglion, is there not a clew to lead us through the labyrinth of our difficulties to a rational solution of the question ? Whatever be the es- sential cause of the disorder, do not its phenomena point directly to a circumscribed disturbance of the vaso-motor sympathetic ? What the histological condition of the centres or the nerves themselves may be, is, in the pres- ent state of our knowledge, a matter of conjecture ; but this much is probable, that their normal impressibility is so increased that when subjected to various forms of stimulation an explosion of nerve-force takes place, which is represented to our senses by certain vaso-motor dis- turbances in the nasal passages and other portions of the mucous tract dominated by the cervico-occipital sympa- thetic. The organs which bear the bnmt of the attack are the nasal passages, and the exalted condition, qye- thism of the turbinated corpora cavernosa, is therefore the leading, distinguishing, and characteristic feature of the paroxysm, constituting, as it were, the central symp- tom/ around which the other phenomena of the paroxysm are grouped, and from which many of them proceed, eithef as the result of mechanical causes or from reflex action. Whatever be the exciting cause of the paroxysm, the tendency to secondary erection of this tissue plays an important role in its mechanism, and, just as in an ordi- nary coryza, the central symptom, the most prominent condition, is represented by the swelling of the cavernous bodies. For practical purposes, then, we may regard the affec- tion as a coryza dependent upon some derangement of the nerve-centres as its essential cause. In calling special attention to the irritability of the nasal erectile—or contractile—tissue, I do not by any means seek to overlook the vaso-motor manifestations in other portions of the respiratory apparatus, and even in other organs not directly connected with it. On the contrary, the explosion of vaso-motor force expends itself upon other portions of the tract dominated by the cervico- occipital sympathetic. Just as in a cold in the head we have symptoms referable to the lower respiratory tract, aural apparatus, eye, etc., so in this form of sympathetic coryza we have disturbances in these and other organs of the body. But when the nose is the organ chiefly involved, the symptoms which stand out in conspicuous prominence are those which spring from the erection of the turbinated tissues. That the manifestations included under the head of asthma, cough, congestion of the conjunctiva, etc., may proceed from this source alone, is shown by their immedi- ate dissipation upon the removal of the source of irritation in the nasal passages by topical applications, instrumental interference, or by the artificial contraction of the swollen Nose. Nose. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tissues. I have been able to illustrate this by the follow- ing experiment: In the course of treatment of one of my cases with the cautery, I noticed that, when the applica- tions were confined to one nostril, the phenomena refera- ble to the corresponding side of the head were completely dissipated, while those of the opposite side persisted and were only removed upon cauterization of the mucous membrane of that side. While, then, it is probably true that certain states of the nasal passages are necessary to the production of a paroxysm, it is, at the same time, equally demonstrable that these are not always dependent upon w7ell-defined local nasal disease, but that, in a number of cases, such conditions are originally brought about by abnormal ex- citability of the vaso-motor centres from inherited or acquired disease. The problem, then, presents for con- sideration two important conditions—on the one hand, the local nasal phenomena, and, on the other, the etio- logical relations of the central nervous system. In allot- ting to each its respective causative significance, care should be taken, in avoiding the Scylla of the neurologist, not to be too closely attracted to the Charybdis of another form of specialism. I am inclined, therefore, to transfer the point of great- est excitability from the peripheral ends of the nerve- filaments to the nerve-centres themselves. While I do not deny the possibility of a hypersesthetic condition, or even of organic changes in the terminal filaments of the sensitive nerves, as an occasional factor, and while aware of the want of experimental proof in favor of the view advanced, still the theory of a central excitability seems to me to offer a more adequate and comprehensive explana- tion of the varied phases of the disease. Upon this the- ory can be best explained, moreover, the occurrence of paroxysms from irritation reflected from various parts of the body remote from the nasal passages. The weight of clinical evidence, too, is in favor of disordered func- tional activity of the nerve-centres, as against organic alteration of the peripheral sensitive nerves. Finally, it is probably not at the terminal ends of these filaments, but in the centres themselves, that the perception is awakened which differentiates one form of irritant from another ; that the nerves themselves are but the passive channels through which the impression is transmitted, and that the production of a paroxysm by a given irritant will depend, other things being equal, upon the, so to speak, discriminating power or peculiar susceptibility of the centres themselves. In accordance with the views expressed above, I pro- posed some time ago to substitute, for the various names given to this affection, the term coryza vasomotoria peri- odica—a term which, while it does not meet all the re- quirements of a logical definition, may nevertheless be used provisionally until more exact knowledge of this and allied processes furnishes data for the construction of a better. In assigning to the condition that sets in motion this peculiar group of sympathetic acts, embraced under the common terms “hay-fever” and the “reflex nasal neuro- ses,” the name rhinitis, or coryza sympathetica, as ex- pressive of the two leading pathological factors in its etiology, I believe that the pathway will be opened for the more rational interpretation of this series of nasal neuroses, and the more scientific generalization of their phenomena. Approaching the problem from this stand-point, and guided by my personal observation, I believe the pathol- ogy of the respiratory vaso-motor neuroses may be summed up in the following propositions: 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 dis- turbances, in which paroxysmal explosions of nervous force play a conspicuous part, and which depend, it is reasonable to assume, upon some form of sympathetic or vaso-motor nerve-irritation. The vascular changes, with their associated nervous phenomena, may affect the up- per x’espiratory tract in its entirety, either appearing simul- taneously or successively in its different segments, or may be chiefly manifested or localized in some individual por- tion of the tract (nose, pharynx, larynx, bronchial tubes). In the latter case the nasal cavities and the bronchial tubes are most frequently the areas upon which the ner- vous shock is expended, the two territories being seem- ingly held in close reciprocal relationship by virtue of a physiological law of sympathy between the two extrem- ities of a mucous tract. In the one 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-centres, and an abnormal excitability of certain portions of the naso-bronchial tract. The derangement of the nervous apparatus may be transmitted from father to son, or it may be acquired in a number of different ways. Thus, for example, it may be the result of prolonged irritation of the respiratory membrane {e.g., from nasal congestion and inflammation, polypi, etc., chronic affections of the larynx, pharynx, and bronchi), leading to repeated and continuous vascular disturbances over certain areas (as, for example, the fre- quent engorgement of that portion of the nasal cavities covered by erectile tissue), with subsequent abnormal irritation of the nerve-centres. It thus comes to pass, after a time, that the constant ex- citation of the nerve-centres by the peripheral irritation so alters their reflex excitability that they respond more readily to reflex-producing impressions. When, there- fore, an increase of peripheral irritation occurs, from either extraneous influences or internal causes, a corre- sponding excitation of the centres is produced, which ex- presses 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 ner- vous system from abuse or disease of the generative ap- paratus. The exalted state of the centres may be conditioned in another series of cases, entirely independently of any lo- cal irritative process in the respiratory tract, by a con- stant wear and tear of the general nervous system from a multitude of causes—from the faulty nervous constitu- tion which Beard has termed neurasthenia. Such a con- dition, it is not difficult to imagine, might produce in time a disordered state of the sympathetic and an abnormal functional activity of the vaso-motor centres. In individuals affected with this form of neurasthenia, local organic irritation would be more likely to lead to reflex phenomena referable to the region of the affected part than in those whose nerve-centres had not been sub- jected 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 re- flexes occur will depend, other things being equal, on the seat of the local pathological process—on the localization of the area of peripheral irritability. A polypus in the nose, for example, would excite in such a person symp- toms referable to the respiratory system, while a similar growth in the rectum would cdicit 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 wThich may be pro- pounded : Why is it that these vaso-motor disturbances are so often encountered in the respiratory tract, and notably in the nasal passages ? In still another class of cases the excessive irritability of the nerve-centres may find its predisposing cause in pathological states of the system as a whole, as, for ex- ample, certain diathetic conditions ; or it may be the re- sult of reflected irritation from individual parts of the body. There are certain diseases that tend to abrogate the functional activity of the nerve-centres, and at the same * Hence we may speak of coryza, pharyngitis, laryngitis sympathetica, and so on, according to the organ in which the vaso-motor phenomena are chiefly manifested. 236 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Nose. Nose. 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, syphi- lis, etc., and it is a clinical fact that the origin of the trouble may be traced to such a source. It is a familiar fact that vaso-motor coryza was, and is by some at pres- ent, supposed to be one of the protean manifestations of gout, from the alleged frequency with which it is en- countered in those of a gouty diathesis. It is scarcely necessary, however, to point out the inadequacy of this theory, and to lay stress upon the proposition that gout enters as a factor into the etiology of the affection only in so far as it is one of a host of diathetic conditions which lead to weakness of the nerve-centres and inflammatory conditions of the respiratory tract. I should like to call attention briefly to the occasional remarkable behavior of this group of respiratory neuroses under the influence of certain acute diseases. I have ob- served the whole group of symptoms—coryza, asthma, sneezing, cough, etc.—completely disappear during an at- tack of acute rheumatism, while in another case a recur- rence of the nasal affection and asthma took place during an attack of measles after a prolonged interregnum of immunity from these conditions. Let us now consider the bypersesthetic condition of the respiratory membrane. Is this factor constant, is it pri- mary, 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 central nerve-irritation ? These questions have an important practical bearing on the treatment. The existing confusion in regard to these questions arises from failure to separate the hypersesthesia natur- ally associated with the local pathological process and the excessive irritability principally met with during the paroxysms of this class of affection. According to my belief, the intense liyperaesthesia characteristic of the paroxysm is, like the vaso-motor phenomena (engorge- ment, swelling, etc.) which accompany it, a purely secondary phenomenon, and occurs only through the in- tervention of central irritation or paresis. This charac- teristic irritability may pass away with the subsidence of the attack, or may be more or less constantly present in the interregnum, according, presumably, to the amount of structural injury which the nerve-centres have under- gone. This secondary hyperesthesia may be brought about, then, either by a direct impression made upon the terminal nerve-filaments in the respiratory mucous mem- brane, or by an indirect influence conveyed or reflected through the vaso-motor centres from a distant organ, or, finally, from an excitation starting in the centres them- selves. The hyperesthesia met with in these conditions may be general, or localized in individual segments of the respiratory tract. In either case, while all portions of the tract, as a whole or in part, may share in the general hyperesthesia, there are certain areas in which the latter is usually more pronounced, in which a greater suscepti- bility to the impressions 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 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. These affections, then, are intimately related to some dis- turbance of the sympathetic nerve, and probably to a de- ranged condition of the vaso-motor centres themselves.66 The neurasthenic phenomena, whatever the condition may be upon wThich they depend, may, as has been pointed out above, be due entirely to a primary irritation or Avell- defined disease in the nostril or in other parts of the re- spiratory tract; hut until this condition is produced the case is simply one of ordinary nasal inflammation, and does not become true vaso-motor coryza until the nervous apparatus is markedly involved. In other words, 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 support 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 etiology, mech- anism, etc., to vaso-motor coryza. Suffice it to say here that in this affection we have to deal with, if we may thus express it, a sort of hay-fever of the ear. When to this we add the recent observation of Dr. Gradle * con- cerning a periodical affection of the conjunctiva closely analogous to hay-fever, we have, it seems to me, addi- tional evidence in favor of the sympathetic origin of the affection under review. In vaso-motor coryza the area over which the reflex vaso-motor disturbances are mani- fested is chiefly the territory which receives its vaso- motor nerve-supply from the spheno-palatine ganglion; in the aural neurosis the phenomena are localized or more pronounced in the area presided over by the otic ; in Dr. Gradle’s cases of recurring conjunctivitis the parts involved are supplied by the ophthalmic, 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 affection—viz., the occasional marked swelling of the thyroid gland, and to an enormously swollen and con- gested condition 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 disturbances are the nasal passages and bronchial tubes. This leads me to refer briefly to the question of asthma and its relation to nasal disease. The older writers, as has already been pointed out,67 were doubtless familiar with the disease known as “liay- fever,” which they considered as a species of, or identi- cal with, the so-called bronchial asthma of the present day. It was not until after the observations of Bostock that the asthma arising 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 classification of the older nosolo- gists. 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 patho- logical entity ; but if we consider exactly what is in- volved in the ordinary conception of this condition— 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 simultane- ously 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 to discuss the mechanism of the asthmatic paroxysm ; whether the bronchial constriction be essentially a spasmodic phe- nomenon, or whether it be due to an engorged condi- tion 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 correct- ness of the latter view, which was advanced by Weber,68 and which has recently found an eloquent defender in * Am. Jour, of the Med. Sci., April, 1886. Morill Wyman (Autumnal Catarrh, p. 20, New York, 1816) had before called attention to a certain conjunctivitis which is met with in June, which resisted ordinary treat- ment. and which he suspected owed its origin to a cause similar to that of “ June cold.” 237 Nose. Nose. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sir Andrew Clark,* and while such transferrence prob- ably does take place in a large number of cases, still it were unwise, in the present state of our knowledge, to eliminate completely the element of spasm as a possible 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 association of urticaria, asthma, and coryza. The rela- tion of asthma to skin affections was familiar long before the days of Trousseau. Thus the illustrious Hoffmann f mentions, as a fact of common experience, that asthma sometimes follows the suppression of a cutaneous rash ; and before him Baglivi \ had recommended, 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. 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 at- tack of coryza ; or, finally, instead of alternating the one with the other, they may appear simultaneously in the individual. At the Eighth Annual Meeting of the Amer- ican Laryngological Association I stated my belief that these phenomena seemingly depend on an imperfectly defined neurosis or vaso-motor influence (possibly some derangement of the eervieo-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 ex- ternal organ of respiration. To justify this assumption, it is only necessary to recall the physiological importance of the skin in respiration among some of the lower ani mals, and the embarrassment of respiration in man from pathological or experimental suppression of the cutane- ous function. We may accordingly regard this neuro- vascular disturbance of the external surface as a natural symptom of the respiratory vaso-motor neuroses, and as- sume that, while the relation of asthma and coryza may be explicable by a possible normal sympathy existing be- tween the two extremities of the internal respiratory tract, both asthma and coryza may be linked to the skin affection by a sympathetic bond which holds in equilib- rium and close consent the whole mechanism of the re- spiratory function. Complications and Sequels.—The disease may lead to various structural changes, usually of an inflamma- tory nature, in the respiratory tract ; or may induce a general depression of the nervous apparatus, with de- rangement of the bodily health ; and its effect on the men- tal faculties may even lead to a condition of melancholia. I have known congestion of the lungs and extensive em- physema to occur in cases in which asthma is a prominent symptom. In one instance the termination of the asth- matic paroxysm was accompanied by a peculiar disturb- ance of the circulation in the extremities. The fingers and toes became purplish-black and cold—almost gan- grenous—from localized arrest of the circulation, and at times the arms and legs were covered with small circum- scribed areas resembling the spots of purpura. Occa- sionally the auricles become enormously swollen and congested,- and the thyroid gland is distended and sur- charged with blood. Various localized vaso-motor dis- turbances are also observed in other parts of the body. Thus I have known sudden reddening, accompanied by itching and burning sensations and a slightly swollen condition, confined to the fingers of one hand, to occur, and pass away at once with the subsidence of the parox- ysm. In one patient—a boy, ten years of age—the appli- cation of medicines to the nasal mucous membrane in- variably brought out an eruption resembling urticaria on the neck and chest, which necessitated a discontinuance of topical medication. In children, especially, eczema and tinea capitis not infrequently complicate the case, and seem to be directly related to the nasal disease through the nervous apparatus. In one child a vesicular erup- tion came and disappeared with the advent and subsi- dence of the nasal symptoms. Indeed, the skin seems to be unusually vulnerable and sensitive. Profuse sweating sometimes occurs, which may involve the general sur- face or be confined to individual portions of the head and neck—the parts most frequently affected being the forehead and cheeks. The so-called “erysipelas” of the face, chiefly mani- fested on the cheeks and nose, may perhaps be regarded simply as a reflex vascular disturbance directly referable to central irritation or paresis, and comparable to an ac- centuation of the act of blushing. Diagnosis.—Whether a special sensitiveness in certain portions of the nasal mucous membrane exists or not, the agitation of the question has led to more rational methods of procedure in the treatment of a large class of nasal af- fections, and to more conservative methods in intra-nasal surgery. Before the location of the sensitive area or areas, the nasal tissues were destroyed with an almost ruthless recklessness. The localization of the sensitive areas has not only greatly facilitated the treatment of this class of disease, but has also furnished us with what is often a ready means of diagnosis. In a fair proportion of cases it is possible to reproduce the attacks of cough, asthma, etc., by artificial stimulation of the nasal mucous membrane, either by means of a probe or similar contrivance, or by the electric current. Before coming to a decided opin- ion, other accessible portions of the respiratory tract should be systematically tested ; for, as has been seen in the section on Pathology, there may be a number of sen- sitive points along the whole respiratory system and pharynx, whose irritation may awaken the reflex. If it be not possible to produce the reflex by stimulation of the mucous membrane, the diagnosis must be made by exclusion, and from the absence of disease in the regions in which the reflex symptoms are manifested of sufficient magnitude to cause the disturbance. At the same time it should be remembered that in long-standing cases structural changes of considerable importance take place, which may lead to confusion of cause and effect. The local use of menthol69 and cocaine, as a rule, temporar- ily dissipate the reflex symptoms, and may be regard- ed, within proper limits, as valuable adjuvants to diag- nosis. Finally, the amelioration or cure of the reflex disorder by local applications to the nasal passages will demon- strate the nature of the trouble. Prognosis.—In regard to prognosis I can only repeat* that it will depend, not only upon (1) the nature of the predisposing and exciting causes, and the facility with which they can be removed, but also (2) upon the amount of structural injury done to the respiratory apparatus, (3) to the central nervous system, and (4) to other parts of the body included in the arc of the reflex, neuro-vascular, and motor disturbance. I have found children, as a rule, more amenable to treatment than adults, although the severest types of the * American Journal of the Med. Sciences, January, 1886. In simple 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 respii'ation sometimes associated with urticaria was “oc- casioned by an eruptive or congestive state of the mucous membrane of the bronchial tubes analogous to the eruption and congestion on the skin” (op. cit., vol. ii., p. 284). t “ Ita experientia docemur, a scaMe retropulsa ... a tinea capitis male curata . . . nostram passionem exoriri." F. Hoff- mann, Op. omnia physico-medica, part ii., § ix., p. 257, Genevse, 1760. In speaking, too, of the symptoms of asthma, he adds, “Mucus per nares excluditur.” + Opera omnia med. practica, ed. octava, Lugduni, 1714, Prax. med., appendix de asthmate, p. 104. '•'•Ex scabie retropulsa si asthma flat, cum scabioso dormiendum est, ut scabies revocelur, vel urticis cedenda cutis." * See my former publications. 238 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Nose. Nose. disease often occur at an early period of life ; and in the management of this class I have been, almost without ex- ception, successful. Each case has its peculiarities and difficulties, and must be studied on its individual merits. It is therefore dif- ficult to lay down any definite law which will apply in all instances. I believe, however, that with our advancing knowledge of the respiratory neuroses, and with a proper conception of these cases in all their bearings, the prog- nosis, in general, may be written down as good. If the above principles be faithfully carried out, relief can al- ways be secured, and in a fair proportion of cases a per- manent cure may be effected. Treatment.—In the management of this form of neurosis we should at the outset carefully distinguish between two sets of cases, viz.—(1) those in which the nervous system is just beginning to suffer; and (2) those in which it is more markedly involved, or in which it is the starting-point of the neuro-vascular disturbances. To illustrate : A patient with disease of the nose, either well-marked or unsuspected, suffers from paroxysms of cough, becomes asthmatic, or is troubled with some other symptom referable to reflex agency or some other so- called “ reflex neurosis.” There are no other appreciable signs of a disordered nervous organization. Perhaps this is the sole symptom for which he seeks relief. He is otherwise in apparently excellent health. Examination of the nasal fossae is made, with the discovery of a con- gested or catarrhal condition of the mucous membrane, a nasal polypus, or a deflected septum; and upon the re- moval of the local affection the asthmatic paroxysms cease, or the cough subsides, and the patient is restored to apparent health without the administration of consti- tutional agents. Now, what is the explanation of this curious relation- ship ? When we consider the fact that hundreds of this patient’s neighbors suffer from precisely the same nasal affections, and that only a comparatively small propor- tion of them are affected with similar reflex troubles, there seems to be no escape .from the assumption of an abnormally excitable nervous apparatus and its constant irritation by the pathological condition in the nose. As the irritation produced by worms, or morsels of un- digested food retained for a long time in the gastrointes- tinal canal, sometimes gives rise to convulsions, cough, and other reflex disturbances through the constant irritation of the readily impressionable nerve-centres of the infant, so the prolonged excitation of the hypersensitive nerve- centres of the sufferer by the local pathological process may evoke the reflex disturbances which are under con- sideration. The cause of the convulsion is not the worm or the undigested particle of food, but the prolonged ac- tion of a local irritant upon a naturally excitable nervous organization. So in the hypothetical case which has been just considered. It is manifestly unwarrantable to assume that there is anything in a nasal polypus, an hypertrophied membrane, or a deflected septum to cause asthma and allied nervous disorders ; but, in the absence of more definite knowledge, it is reasonable to infer that such an event or events probably occur through the in- tervention of a more central cause. The explanation sug- gests itself that, in this particular case, the nasal passages may be the sole avenues through which the nerve-centres are influenced; and with the removal of the irritant, and their consequent physiological rest, the disorder has been apparently, and, in the course of time, may be actually, dissipated. Let us follow this individual a little farther on in his life-history. Perhaps the relation of his paroxysmal cough to the nasal affection has been unrecognized. In a little time asthma is added to his disease ; later on, af- fections of the eye, ear, and other organs, with various other symptoms referable to a disordered state of the general nervous apparatus, develop. He has no longer one troublesome reflex symptom, but a dozen; he con- sults his physician, and if it be in the summer-time, is told he has “hay fever,” and that pollen is responsible for his trouble. I have called this an hypothetical case. It is not. It is the accurate record of clinical fact. It is the histori- cal narrative of one way in which the nervous system may be affected in the sympathetic affections of the respira- tory tract. The first thing to determine, then, in a given case of nasal reflex neurosis, is to ascertain whether the nervous phenomena he due primarily to respiratory irritation, to central causes, or to disease in remote organs of the body ; whether the symptoms referable to the respiratory tract be primary or secondary, and if primary, to what ex- tent the nervous system is involved. The class of cases in which relief and cure may be expected from local remedies alone is that in which the respiratory mem- brane is the primary seat of the disease, and in which the nervous system lias not become markedly involved. In this set of cases, or, to look at the subject from an- other stand-point, at this stage of the disease, are included a number of the simple forms of nasal reflex neuroses. At this stage the removal of a nasal polypus may cure a troublesome asthma or cough, the cauterization of the nasal mucous membrane may dissipate an inveterate hemicrania, and so on. Even at the later stage, when the group of symptoms commonly known as “hay- fever ” develop, it may be possible, by securing physio- logical rest for the nerve-centres, to give temporary and even permanent relief. But when the central nervous apparatus becomes more profoundly impressed, when nearly every organ of the body seems to be included within the arc of the neuro-vascular disturbance, when permanent structural changes occur in different parts of the respiratory and other systems, it is manifestly un- natural to expect that the disorder may be dissipated by the touch of the galvano-cautery, as the evil spirit disap- pears before the magician’s wand. 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 four years, and with a most gratifying result. In that time a large number of cases of paroxysmal vaso-motor neuroses of the re- spiratory 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 dis- turbance, 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 my experience, this is an exceptional event. While the sympathetic nerve-disturbances manifest themselves most frequently in the nasal cavities, in a certain pro- portion 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 conditions of these structures. The vaso-motor disturbances, of both 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 characterized by an excessive degree of hypersesthesia, the very act of opening the mouth giv- ing rise in some cases to retching, and even vomiting. Indeed, a considerable number of cases of so-called hy- perajsthesia and paraesthesia of the larynx and pharynx are traceable to some vaso-motor disturbance or sympa- thetic nerve-irritation. The changes in the vascularity of the mucous membrane often take place with great rapidity, the vessel-dilatation being quickly replaced 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 vessels 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 conspicuous. The reflex phenomena symptomatic of this class of pharyngo-laryngeal neuroses need not detain us at present. Suffice it to say that they are sufficiently nu- 239 Nose. Nose. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. merous, and consist chiefly of various sensory and motor disturbances in the path of the nerves that radiate from the pharyngeal plexus, and in spasmodic contraction of the pharyngo-laryngeal 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 treatment are in each and every case essentially the same. When, some time ago,70 I formulated the view accord- ing to which the so-called nasal or respiratory reflex neu- roses—the group of phenomena known as “hay-fever,” “asthma,” and other reflex conditions found in connec- tion 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 conclu- sions 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 have to deal with paroxysmal cough, asthma, or with the ensemble of those phenomena known as “hay-fever,” “rose-cold,” etc., the therapeutic indications are iden- tical. 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 vasomotoria 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- centx*es that they may not respond so easily to reflex- producing 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 respiratory 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 dis- turbance is most marked. 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 that the peculiar condition of the sympathetic is, like epilepsy, with the patient by 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 treatment, therefore, undertaken a short while before the expected attack, or during its course, is almost wholly palliative, and can rarely, if ever, accomplish any per- manent good. And thus the innumerable remedies (such as chloral, belladonna, opium, stramonium, etc.) which have been used from time to time can accomplish no last- ing good, and in many cases either lose their beneficial effects altogether, or, in the end, by their constant phys- iological effects upon the nerve-centres, may tend even to aggravate the predisposition to the affection. In this category I would place cocaine. As I pointed out some time ago,71 and also at the seventh annual meeting of the Laryngological Association,7'2 the long-continued use of this drug in the nose and throat begets an increased irri- tability 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 terminates in some cases in a subparalytic condition of these structures, and subsequent puffiness of the mem- brane. As the habitual use of cathartics eventuates, sooner or later, in constipation, so the prolonged use of cocaine will result, in a certain proportion of cases, in a hyperxesthetic condition of the mucous membrane. In the case of the erectile tissues it is especially open to the objection that, by bringing repeatedly into play the contractile power of these structures, it may ultimately weaken their walls and lay the foundation for a perma- nent dilatation of tlie erectile cells. In calling attention to these disadvantages of its continuous use in these affec- tions, I do not by any means desire to question the many excellent virtues of this remedy. In certain acute affec- tions of the mucous membrane, and for its effect on the nasal erectile structures, pointed out by Bosworth, it is a Godsend, but I am convinced that at present it is too in- discriminately and injudiciously employed. In the dis- ease under review, it has in my hands utterly failed to dis- sipate, except temporarily, its symptoms, or to abridge, in the slightest degree, its course. For a short while ame- lioration 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 com- mencement of the treatment, accordingly, should date from the first appearance of the patient for consultation, and terminate, it may be, long after he is apparently free from his disease. I cannot 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 in- curable lesion—when the intervals between the paroxysms will be longer, and the attacks themselves less severe, until finally they cease altogether. 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 pa- tient’s mind that there is nothing the matter with him in the intervals of exemption; and his natural discourage- ment when, in spite of treatment, he may have an occa- sional return of liis old disorder. The general tonic and hygienic treatment will vary with the individual peculiarities of the subject and the con- ditions of his environment, and will usually consist, to speak in general terms, of prophylactic measures directed against the development of nervous and catarrhal affec- tions. Among the many remedies I have tried in the consti- tutional management of this class of affections, I would mention and recommend arsenic, phosphorus, zinc, qui- nine, and nux vomica. These drugs may be used alone or in combination for an almost indefinite time, if the usual precautions in regard to their physiological effects are exercised. The* following method of administration, although it has failed me at times, has nevertheless been so generally beneficial in my practice that I do not hes- itate to recommend it for trial: (1) B. Zinc, pliosphid g1'-iV Quin, sulph gr. ij. Ext. nuc. vom gr. £ M. Ft. pfl. no. j. Sig. : To be taken before meals. (2) B. Liq. arsenic, et bydrarg. iodid., gtt. iij. ad v. Sig. : In a wineglassful of water, after meals. Formerly I used Fowler’s solution, but for the past year have substituted the iodide of arsenic and mercury (Donovan’s). The quantity of the ingredients should be increased 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 treatment, that for several years I have employed the above-mentioned lines of treatment in simple inflamma- tory conditions of the nasal passages and throat, and have 240 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Nose. Nose. found them important auxiliaries, especially in the ear- lier 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.73 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 passing the other extremity of the current alternately over the region of the superior cervical gan- glion and through the nasal passages. In one, apparent, and in the other decided, relief to the symptoms was ob- tained. Although my experience with this agent has not been sufficient to warrant me in pronouncing either for or against its use, I consider it, nevertheless, worthy of further trial. In one case a satisfactory result, as far as the ameli- oration of the symptoms was concerned, was secured by partial 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 condi- tion 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 sevei’e. 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 cham- bers accomplishes one result, and one only—it closes one door against ab extra irritation of the nerve-centres. In many cases, it is true, this will be of itself sufficient. The nasal passages may be the sole avenues through which the nerve-centres are influenced, and, with the re- moval of the irritant and the consequent physiological rest of the centres, the disorder may be apparently, and in the course of time actually, dissipated. But there are other cases in which, from what I have indicated above, such a course will obviously fail. In order to the intelligent appreciation of the local or topical management of this affection, the principles which underlie the etiology and mechanism of the paroxysms should be considered. It should be borne in mind, in the first place, that the liypersesthesia of the mucous membrane and the excita- bility of the turbinated nasal tissue are secondary phe- nomena, dependent, as a rule, upon a direct impression made upon the sensitive nerves of the mucous membrane and upon the terminal filaments of the olfactory ; upon an indirect influence conveyed or reflected through the vaso- motor centres from a distant organ; or, finally, upon some excitation starting in the centres themselves. This stim- ulation of the nerve-centres, from whatever cause orig- inating, is reflected outward, probably through the sym- pathetic filaments which reach the turbinated structures with the spheno-palatine nerves. Now, as these nerves are distributed over the posterior and inferior portions of the nasal fossse (sensitive reflex area), the turgescence of the erectile substance is more noticeable over that particular area; and it will be found that this surface represents the most sensitive spot to reflex-producing expression—at least this is my experi- ence. If, then, we destroy the terminal filaments of the sensi- tive nerves, it follows that one avenue at least is closed against the irritative action on the nerve-centres of sub- stances derived from the external world. My practice, therefore, is to simply sear the most sensitive portions of the membrane, as determined by experiment with a probe, with the flat cautery-knife, taking care to include only that portion in the operation which has been found most sensitive to irritation. I have found this proced- ure alone sufficient to arrest the paroxysms and give pro- longed immunity from them. In order to exclude completely the influence of ab extra irritation, it is necessary to remove all sources of local irritation, from whatever cause arising. If this be radi- cally done, it will put a stop to the production of parox- ysms from external influences acting directly on the Vol. V.—16 nasal mucous membrane—that is all. When paroxysms are induced by agencies operating within the organism, or from reflected irritation from other parts of the body, the destruction of the sensitive nerve ending in the nasal mucous membrane will obviously be insufficient to secure immunity from further attacks. The indication here is to search carefully for any such source or cause of irrita- tion, and to direct treatment accordingly. In the destruction of the vessels and sinuses over the most sensitive areas, the surgeon should proceed with caution, taking care to destroy as little tissue as is com- patible with the radical removal of the disease. In the large majority of cases extensive destruction of the cav- ernous tissue is neither necessary nor advisable. Total extirpation of the corpora cavernosa is a practical impos- sibility. Even if practicable, it would be warrantable only as a last and desperate resource. The amount of tissue to be sacrificed must be determined by the exigen- cies of each particular case. Having determined the area or areas of special reflex excitability, the nerves of the mucous membrane and cavernous structures may be de- stroyed by an acid (chromic, glacial acetic, nitric, etc.), or extirpated with the cold-wire snare or cautery.* In this country and in Germany, where the surgical treatment of nasal neuroses had its origin, the operators invariably start out with the idea of extirpation of the cavernous tissues. To that end large portions of the offending bodies are removed en masse with the cautery- loop, or allowed to slough off after numerous incisions and punctures with the knife-electrode. I have rarely found such procedures necessary, and believe that I ac- complish an equally good, if not better, result by operat- ing on a somewhat different principle. Having mapped out the area of most pronounced vascular disturbance, I make a stellate incision through the mucous mem- brane and cavernous body with the cautery-knife. The vessels in the pathway of the incision become thereby obliterated, a star-shaped cicatrix results, resembling somewhat a syphilitic scar, and the mucous membrane and turbinated tissue become, so to speak, bound down or depressed upon the bony wall of the nostril. In order to avoid extensive sloughing, the incisions may be made at different sittings. By means of this method a suf- ficient patency of the nostril is secured, the erection of the turbinated bodies is brought under control, and the patient escapes with a comparatively small loss of func- tion. In answer to the question as to whether the operation should be performed during the so-called “ season,” or whether it were better to wait for the interregnum of im- munity from the attacks, I would answer that there is nothing to be gained by delaying radical treatment, and it has therefore always been my custom to operate in the interval between the paroxysms. By this means I have succeeded in preventing their return, even when the in- dividual has been exposed to the exciting causes of the attack. If the theory upon which I base my plan of treatment be accepted, it will readily be seen that those who con- sider the removal of nasal obsti’uction or irritation as the sole remedy for this disorder base their belief upon an incomplete conception of its pathology. The value of the galvano-cautery and other therapeutic measures addressed to the nasal passages will depend, to a large extent, 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 Avhether it is a purely accidental phenomenon. Whether primary, secondary, or accidental, it always acts as an * In regard to the operative measures to be used in a given case of hy- pertrophic inflammation of the nasal passages, the following are my rules of practice: 1st. Posterior hypertrophic enlargements of the turbinated bodies are most satisfactorily removed, if practicable, with the cold-wire snare. 2d. For destruction of anterior hypertrophic swelling, both of the tur- binated bodies and septum, and in the rare cases when operation is nec- essary on the enlarged erectile bodies of the posterior portion of the sep- tum, the galvano-cautery is the most available and satisfactory agent. 3d. Extensive destruction of cavernous tissue is most satisfactorily ac- complished by means of the galvano-cautery or electrolytic process. 241 Nose. Nose. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 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 phenomena stands the neuro- sis, and that, until the sympathetic nerve-irritation is overcome, we cannot expect to thoroughly eradicate the disease. Addendum.—In L’Union Medicale for January 22, 1884 (La toux na- sale), M. Longuet believes, with me, in the existence of a tussigenic area (zone tussigene) in the posterior end of the inferior turbinated bone and septum, which he compares to the hystero- and epilepto-genic zones found elsewhere in the body by Brown-Sequard. Professor Baratoux, of Paris (Revue mensuelle de laryngologie, d’otologie, etc., decembre, 1885), in calling attention to the general acceptance of the fact that the posterior ends of the turbinated bodies are the seat of a sensitive area endowed with peculiar properties, states that, according to his experience, it is not the turbinated bodies that this peculiar property should be attributed to, but a circumscribed area on the septum, viz.: the posterior part of the septum. Professor Baratoux thus believes that the sensitive area is rep- resented by only a circumscribed portion of the area located by me in 1883. Dr. Hering, of Warsaw, on the other hand (Annales des maladies de l’oreille, du larynx, etc., fevrier, 1886), writing some time afterward, says : “While many authors call into question the existence of the sen- sitive area of Mackenzie, my experience justifies me in admitting it, but with a certain restriction. I believe that it must be made to embrace the whole segment of the mucous membrane which covers the nasal septum, and not alone the posterior part, as claimed by Mackenzie.” Finally, I would call attention to some exceedingly interesting experi- ments made by Dr. L. Lichtwitz, at the Hospital of Saint-Andrd, in Bor- deaux, under the direction of Professor Pitres (see Revue mensuelle de laryngologie, etc., decembre, 1886: Des zones hystdrogenes observees sur la muqueuse des voies ariennes supdrieures et des organes des sens). Without going at length into the important experiments of Lichtwitz, suf- fice it to say that in all the six cases (hysterical and hystero-epileptic) ex- perimented upon, the nasal fossae were the seat of “spasmogenic” zones. Six times they were bilateral; once they existed only on one side, while in the other side there was found a “ hypnogenic ” area. The spasmogenic areas were found in the posterior portions of both nasal fossa;; touching them provoked the crisis. The right area seemed to be more sensitive than the left. 36 Op. cit., chap. 2t., p. 135, 136. 37 Traite des mal. des fosses nasales, etc. Paris, 1804. 33 Ueber die Anwendung der Galvanokaustik, etc., S. 249, 312. Wien, 1871. 39 Berliner klin. Wochenschrift, 1874, No. 40, S. 503. 40 N. Y. Medical Record, October 11, 1879. 41 Deutsche med. Wochenschrift, 1870, p. 373. 43 Ibid., 1879, Nos. 32 and 33, Fall 12, p. 419; and 1882. 43 Meeting of Am. Laryngological Assoc., 1880. See Archives of Laryn- gology, April, 1881, p. 147. 44 Quoted by Porter and Todd. 46 Trans, of the Missouri State Medical Assoc., 1881. 46 Berliner klin. Wochenschrift, 1881, 16, 17. 47 St. Louis Med. and Surg. Journal, February, 1882. 48 Archives of Laryngology, April, 1882, p. 112. 49 Ibid., p. 118. 60 Gazette des Hopitaux, 1882, No. 56, 13 mai. 61 Ibid., No. 64, 3 juin. 62 Volkmann’s klinische Yortriige, No. 216, 1882. 53 Archives of Laryngology, April 1, 1882. 64 N. Y. Medical Journal, May 12 and 19, 1883. 56 Quoted by Hack, op. cit. 66 A Contribution to the Study of Coryza Vasomotoria Periodica, etc., N. Y. Med. Record, July 19,1884. Trans. Amer. Lar. Assoc., 1884, p. 113. Coryza Vasomotoria Periodica in the Negro, etc., N. Y. Med. Record, Oc- tober 18, 1884. Rhinitis Sympathetica, Maryland Med. Journal, April 11, 1885. Origin and Cure of Coryza Vasomotoria, etc., Trans. Med. Chir. Faculty of Maryland, 1885. Review of the Subject in Am. Journal of the Medical Sciences, October, 1885, pp. 511-528. Production of Rose Cold by an Artificial Rose, etc., ibid., January, 1886, etc. 57 Autumnal Catarrh (Hay Fever). New York, 1876. 68 Hay Fever, etc. New York, 1876. 39 N. Y. Med. Record, October 18, 1884. 60 Trans. Am. Laryngological Assoc., June 24, 1885, p. 26 et seq. 61 See my paper in Am. Journal of the Med. Sciences, July, 1883. 62 Trans. Medico-Chirurgical Faculty of Maryland, 1883; Trans. Am. Laryngological Association, 1883 ; Trans. Virginia State Society, 1883. 65 Trans, of the American Otological Society, 1884, p. 273, Reprint. 64 See Trans. Med. Chir. Fac. of Maryland, 1883. 65 See Transactions, 1885, pp. 31, 32. 68 For an elaboration on this point, see, especially, Am. Journal of the Med. Sci., October, 1885, loc. cit. 67 Trans, of the Med. Chir. Fac. of Md., loc. cit.; Am. Journal of the Med. Sci., January, 1886. 68 Ueber Asthma nervosum. See Tageblatt d. 45 Versammlung deutsch. Naturforscher u. Aerzte in Leipzig, 1872, p. 159. 69 A. Rosenberg: Berliner klinische Wochenschrift, 1885, No. 48. 70 Maryland Med. Journal, April 11, 1885. 71 Discussion on Cocaine, May 15, 1885, Trans, of the Med.-Chir. Fac. of Maryland, 1885, p. 189. 72 Discussion, June 26, 1885, Trans, of the Am. Laryngol. Assoc., 1885, p. 142. I may add that since then Beverley Robinson (Med. Record, Oc- tober 17, 1885), Ingals (Journal of the Am. Med. Assoc., February 20, 1886). and others have recorded similar observations. 73 See article by the writer in the Medical News, Philadelphia, April 4, 1885. John Noland Mackenzie. 1 Ueber eine operative Radical-Behandlung bestimmter Formen von Mi- graine. Asthma, Heufieber, etc. Wiesbaden, 1884. 2 Medical Times and Gazette, August 13, 1864. 3 British Medical Journal, April 30, 1864. I am indebted for these references to Spencer Watson’s work on Dis- eases of the Nose. 4 Ogle: Am. Journal of the Med. Sciences, vol. xxiii., 1852. 6 Medical and Chirurgical Transactions, 1870, vol. liii. 6 Plato: Symposium, § 13. 7 Aph. 13. Compare also Celsus, lib. ii., cap. 8. 8 Opera omnia grseco-latin., vol. iv. Problem xxxiii., 2 and 8. Pari- eiis, 1858. Ed. Didot. 9 Op. omnia, Venet., 1608, lib. iii., Fen. 5, tract. 2, cap. 14. 10 Opera medica., Basiliae (date uncei'tain; 1544 or 1450. Lib. S. G. O.) Divisionum, lib. i., cap. 43. II Op. cit., Ad. mansor. de re med., lib. ix. 12 Ibid., cap. xiii. 13 Fragment, ex Aphor. Rabi Moyses. Good : Study of Medicine, Boston ed., 1823, vol. i., p. 311. 14 Trans. Med. Chir. Fac., 1885; Am. Journal of the Med. Sciences, Jan., 1886. 15 N. Y. Medical Journal, February 26, 1887. 16 Dissertat. aeger vertigine laborans. Jena;, 1682. Diss. de vertigine. Jenaa, 1707 and 1741. 17 Bergeron : These d’agrdgation, 1872, referred to by Louis Villemsens. These de Paris, No. 494, 1872. Utude sur le cat. spasmodique d’etd, etc. 18 In op. infra citat., spec. lib. i., cap. x., p. 342 et seq. 19 Georg Gottlieb Gumprecht: Diss. de consensu partium praecipuo pathologic et praxeos medica; fundamento. Halae-Magdeburgicae, 1717. 20 Cerebri anatome cui accessit nervorum descriptio et usus. Amstelo- darni, 1666, inter al. cap. 21, 25, 26, and 27. 21 Neurographia universalis. Lugduni, 1685, lib. iii., caput v., de nervis intercostalibuB, eorumque muniis. 22 De sympathia seu consen. part. corp. humani, ac potissimum ventri- culi, in statu morboso, diss. medica. Harlemi, 1721. 23 Observations medico-practica de affectibus capitis internis et exter- nis. Scaphusii, 1728. 24 Diss. de consensu part. corp. humani. Gott., 1749 ; also in Haller’s Collect, dissertat. pract., vol. vi., No. 220. 25 De sedibus et causis morborum. Epist. xiv., 28. 20 Op. cit., xxvii., 281. 27 Pnedilectiones academic® de morbis nervorum, etc. Lugd. Bat., 1761, tom. ii., p. 835. 28 Historiarum anatomic, et medic, rariorum., cent. v. et vi., ed. Hafniae, 1761, v., p. 184. 29 Observations on the Nature, Causes, and Cure of those Diseases which have been commonly called Nervous, Hypochondriac, and Hysteric. Sec- ond edition, Edinburgh, 1765, p. 125. 30 Giuvres. Lausanne, 1788, vol. ix. Traite des Nerfs et de leursMala- dies. A Gendve, 1785, chap. xxii. De la Migraine, p. 105. 31 Op. cit., p. 169. 32 Darwin, Charles: Experiments establishing a criterion between mucaginous and purulent matter. 33 Christian Gottfried Gruner : Physiologische u. pathologische Zei- chenlehre, etc. Jena, 1801, p. 122. 34 Op. cit., p. 377. 36 William Heberden : Commentaries on the History and Cure of Dis- eases. London, 1802 ; also published in Latin, chap, ci., p. 472. 242 Nose!"Cla*Ure' REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. is more or less febrile movement, headache, throbbing, and lancinating pain, which is increased on pressure, or upon blowing the nose. The inflammation at the same time extends to the face, giving it an cedematous or ery- sipelatous appearance. The nasal passages are obstructed, with the result of shutting off nasal respiration, and caus- ing loss of the olfactory sense and change in the quality of the voice. Secretion is diminished until opening of the abscess takes place, when it becomes purulent or sani- ous. Examination of the nares reveals a swelling, usu- ally symmetrical, on both sides of the septum, and gen- erally well down toward its anterior and inferior part. The tumefaction, if at all pronounced, effectually cuts off further examination of the nasal cavity by anterior rhi- noscopy. The mucous membrane is red and sodden, and fluctuation may often be detected. The septum is likely to suffer perforation from destruction of more or less of the cartilaginous part, so that the abscess-cavities coalesce, and pressure upon one produces fluctuation in the other. Cold abscess of the septum must be extremely rare, al- though such cases have been reported. Their onset is gradual, and unmarked by the acute symptoms described above. The course of acute septal abscess may be rapid, and early diagnosis is, therefore, of great importance, since, if treatment be delayed, extensive destruction of the septum and marked external deformity of the nose may result. In the case of an acute abscess the diagnosis may be made with comparative ease. Chronic abscess may be identified by the presence of fluctuation, particu- larly if the septum has become perforated, and, if neces- sary, aspiration may be resorted to as an aid to the diag- nosis. Abscess of the septum may be complicated with facial erysipelas, destruction, more or less extensive, of the bones and cartilages of the septum, and even of the nose itself, and possibly by meningitis and phlebitis. Of the sequels most likely to follow, loss of the septum and consequent deformity of the nose will take precedence. Treatment should be both general and local. The for- mer will be suggested by the necessities of the case in hand. The local condition should be treated with great promptness and thoroughness. If an abscess is impend- ing, efforts should be made to dissipate it, by means of inhalations of steam. As soon as the presence of pus can be detected free incision should at once be made into both sides of the septum and at a point from which the cavity can be well drained. Should the septum be per- forated, drainage may be effected by means of several strands of lamp-wick, or other suitable material passed through the incisions. Meanwhile, absolute cleanliness of the nasal passages by means of some mild antiseptic f solution should be maintained. I). Bryson Delavan. I NOSE: AFFECTIONS OF THE NASAL PHARYNxV I Anaemia.—The pharyngeal membrane shares in the leral pallor of the mucous membranes of the body in loss lof blood from any cause, or in derangements of its circu- lation, and in all diseases in which the number of its red i |globules is diminished. It occurs in hysteria, and is char- acteristic not only of the incipient stage of tuberculosis but also of the later throat history of that disease. It is met with in atrophic conditions of the mucous membrane, and may occur suddenly from emotional excitement or from depression of the nervous apparatus in syncope or shock. Wendt1 observes that the approach of fainting, during the examination of the pharynx, may be fre- quently recognized by the coldness and pallor of the mucous membrane. Inspection reveals the dark-purplish or wine-colored vessels thrown on the yellowish or whitish background of the anaemic membrane. The follicles often appear as small, transparent, shining nodules, scattered in profu- sion over the bloodless membrane. In some diseases, as in hysteria and tuberculosis, the reflex excitability of the pharynx is very pronounced, while in others, as in glosso- labio-laryngeal paralysis, it is diminished or almost de- stroyed. Hyperhsmia and Haemorrhage.—Hypersemia and haemorrhage of the nasal pharynx are of frequent occur- NOSE; ABSCESS OF THE SEPTUM. Abscess of the nasal cavity rarely occurs excepting in the septum, and even here it is seldom met with. It is generally due to traumatism, but maybe caused by extension of inflam- mation from a furuncle, or, more rarely, may occur as the result of irritation from chronic or purulent coryza. It is sometimes symptomatic of general affections, such as small-pox, scarlet fever, typhoid fever, and phlegmonous erysipelas. In rare instances, one of which has been re- ported by the writer, it has been idiopathic. The symptoms of acute abscess vary in intensity with the severity of the causes by which the abscess is pro- duced, and with the extent of the abscess itself. There 206 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Nomenclature. Nose. rence as the result of direct injury, either chemical or mechanical; as sequels of a host of blood diseases, in- cluding purpura, scurvy, haematophilia, the exanthemata, erysipelas, typhoid fever, septicaemia, diphtheria, etc.; in poisoning from various drugs, as iodine, mercury, phos- phorus, etc.; they may be due to mechanical obstruction to the venous circulation in the neck, thorax, or abdo- men, or occur as complications of organic disease of the kidney, heart, lungs, etc. They may also follow over- filling of the vessels from increased arterial tension, or proceed from various constitutional affections, such as syphilis and tuberculosis, from ulceration of various kinds, morbid growths and obstruction in the nasal pas- sage. An occasional cause of naso-pharyngeal hasmor- rliage is encountered in a varicose condition of the pharyn- geal veins. The bleeding comes generally from the rupture of su- perficial vessels ; but in affections of the blood it is often parenchymatous. The amount may be very slight and the rupture be represented by a small extravasation or ecchymosis, or extensive haemorrhagic infiltration of the tissues may occur, constituting a veritable blood tumor or haematoma. Acute Inflammation.—Acute inflammation of the retro-nasal space may occur as a primary affection from operative interference in that region, or from the appli- cation of chemical irritants to its mucous membranes, and possibly from the inhalation of irritating vapors and dust through the nostrils. It may also occur as a symp- tom of morbid growths and ulceration of the upper phar- ynx and pharyngeal tonsil. Localized inflammation of this region is not uncommon after diphtheria and scarlet fever and other blood diseases. It is generally, however, due to an extension of inflammation from the nose or lower pharynx, or occurs as a part of general diffuse in- flammation of the upper respiratory tract (see also article on Catarrhal Inflammation, vol. iv., p. 400). The rhinoscopic appearances are those of intense hy- persemia, either diffused over the whole space or localized in individual parts, with swelling of the mucous mem- brane. The mouths of the Eustachian tubes are swollen, and give to the eye the appearance of an enlarged in- flamed cervix uteri. Their calibre is diminished by the swelling, and thick shreds of mucus hang from their ori- fices. Especially noticeable is the increase in volume of the pharyngeal tonsil, which presents a great variety of appearances, and is occasionally so much enlarged as to exert considerable pressure on the Eustachian tubes and produce obstruction of the posterior nares. The upper portion of the posterior edge of the septum is generally swollen and presents a more or less heart-shaped appear- ance ; its vessels are enlarged and tortuous. In some blood diseases, as in small-pox, pyaemia, scurvy, purpura, etc., haemorrhagic, and even purulent infiltra- tion of the mucous and submucous tissues takes place; this may be quite extensive or may occur as minute ex- travasations or capillary apoplexies. Sometimes a granular condition of the mucous mem- brane is a conspicuous feature, and is due to participa- tion of the follicles in the inflammatory process. I have never observed ulceration in this cavity from an acute simple inflammation. Secretion is always profuse; at first it is mucous, glairy, tenacious, and sometimes streaked with blood; later it becomes muco-purulent or purulent, accumulates rapidly, and fills the cavity with a yellowish discharge. This is partially removed by inspiration through the nostrils and hawking ; or it gravitates into the lower pharynx and is expectorated. Its voluntary removal here is, however, more difficult than in the lower pharynx, and hence in- spection always reveals more or less secretion adhering to the vault and pharyngeal walls. The accumulation of secretion and the swelling of the mucous membrane occasionally produce obstruction of the posterior nares, with its consequences (see article on Chronic Nasal Catarrh, in the Appendix. If the secre- tion be allowed to remain in the retro-nasal cavity, headache, general malaise, slight febrile movement, and symptoms referable to obstruction of the Eustachian tubes develop. During convalescence from diphtheria, scarlet fever, and similar affections, I have observed considerable elevation of temperature produced by the retention and decomposition of the secretion in the retro-nasal space. The inflammatory process not infrequently extends into the nose and lower pharynx, or through the Eusta- chian tubes to the middle ear, and its symptoms are lost or become inconspicuous by comparison with those of the disease to which it leads. Pathology.—The affection is a simple inflammation of the retro-nasal space, and presents no characteristics which differentiate it from the ordinary forms of ca- tarrhal inflammation. Occasionally the inflammatory ex- udation assumes a membranous form, especially in con- genital syphilis. Prognosis, Course, and Sequels.—Recovery here is, as a rule, less rapid than in acute inflammation of the lower pharynx, and the tendency to result in chronic inflam- mation is greater. This is probably due to the fact that, as the symptoms of ordinary subacute cases are such as give rise to comparatively slight discomfort, the proper treatment of the affection is almost invariably neglected. The gravitation of the secretion into the lower pharynx leads the patient, moreover, to refer his trouble to that re- gion, a diagnosis which is often accepted unreservedly by his medical attendant. The inflammation of the retro- nasal space which occurs in children, as, for example, after the exanthemata, is, as a rule, neglected, and the foundation thereby laid for chronic catarrhal disease of the nasal passages and middle ear in after-life. Properly treated, a mild, uncomplicated, acute inflam- mation of the nasal pharynx will get well in a few days, but in cases of more than ordinary severity recovery may be delayed for several weeks. Treatment should be conducted on the general princi- ples which will be considered in the article on Chronic Nasal Catarrh, in the Appendix. The retro-nasal space should be kept as free as possible from secretion, and mild astringent and alterative remedies applied in fhe form of spray. Soothing inhalations through the nose may also be employed with advantage, and, as resolution occurs, may be followed by those of a more stimulating character. Chronic Catarrhal Inflammation.—Chronic retro- nasal catarrh may be primary or secondary to inflamma- tory conditions of neighboring organs, especially of the nasal fossae. As an independent primary affection it not infrequently occurs as the result of a subacute attack or repeated acute attacks, the tendency being somewhat greater here than in the lower pharynx, as above re- marked, to pass into the chronic form of inflammation. Chronic retro-nasal catarrh is due to the operation of causes similar to those considered in the article on Chronic Nasal Catarrh, in the Appendix. What influ- ence, if any, the conformation of the retro-nasal space, as to breadth and depth, exerts as a predisposing in- fluence, has not as yet been satisfactorily determined. Naso-pharyngeal inflammation prevails in every country in which the intense, frequent, and rapid changes of atmospheric conditions occur which have been discussed under the head of Etiology of Catarrhal Affections in General, vol. iv., p. 400. Anatomical Changes.—Changes in color. The mucous membrane may be uniformly hyperaemic, presenting a diffuse injection varying from a yellowish-red to a deep- bluish hue, or the hyperaemia may be more pronounced in certain situations than in others. Small extravasations of blood are common, and result from the rupture of capillaries and enlarged veins. These appear generally in the form of ecchymoses ; but in some cases, as in the retro-nasal catarrh of certain blood diseases, the haemor- rhagic infiltration may be considerable ; or true bloody tumors may be formed. Anaemia, or at least a less pronounced coloration of the mucous membrane, is com- mon in those diseases characterized by impoverishment of the blood, and especially is this true of the form which accompanies pulmonary tuberculosis. In these conditions 207 Nose. Nose. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the enlargement and overfilling of the venous plexuses is most conspicuous. Later on, when atrophy of the mem- brane supervenes, the prominence of the veins becomes more pronounced. A varicose condition of the vessels on the posterior edge of the septum is not infrequently encountered, and those surrounding the orifices of the Eustachian tubes are often dilated and tortuous, forming a more or less vascular, wine-colored net-work which ex- tends into the nasal fossae and ramifies over the inferior and middle turbinated bodies. Occasionally the vessels show signs of atheromatous degeneration. There is almost always more or less swelling of the mu- cous membrane of the parts. This is most marked on the pharyngeal tonsil and the septum. The swelling of the former is at first inconsiderable, but later in the disease hypertrophy of its tissues takes place and it appears as a well-defined, irregularly lobulated mass, or a uniformly smooth, sessile tumor. This hypertrophic condition of the pharyngeal tonsil is at times so excessive as to ma- terially diminish the lumen of the Eustachian tubes and posterior nasal orifices. Occasionally it presents a nod- ular appearance or is covered by grooves or furrows with corresponding elevations of tissue. In other cases the hypertrophy of the glandular tissue of the vault exhibits itself as a mass of adenoid or polypoid vegetations, and especially is this true in children, as the result of the naso- pharyngeal complications of acute febrile disease, and notably after diphtheria and scarlet fever. The orifices of the Eustachian tubes are generally en- larged, tumefied, and reddened ; they are dilated and patulous. This gives the tube the appearance of an en- larged cervix uteri in a state of chronic hyperplastic inflammation. Occasionally a granular condition is ob- served, due to swelling of the muciparous glands of the tube (tubal tonsil of Gerlach). The tubes themselves are sometimes occluded, or their orifices displaced by press- ure of the enlarged pharyngeal tonsil, and, in rare in- stances, of the hypertrophied turbinated bodies. In long-standing cases there is almost always a corre- sponding hypertrophy of the posterior half of the sep- tum, which causes a bulging on either side of the median line, which, with the central depression, presents some- times a heart-shaped appearance. In cases of long duration, too, true papillary growths de- velop, which should not be confounded with the so-called adenoid vegetations of this region. I have met with these papillomatous formations more frequently on the posterior part of the palate and septum ; but they may occur also in other parts of the cavity. In other instances, simple thickening of the epithe- lium occurs, which gives the membrane an irregular, nodular appearance. The changes in the granular or glandular disease of the naso-pharyngeal space will be given in the article on Chronic Nasal Catarrh, in the Ap- pendix. We cannot confirm the observations of certain German writers, that well-marked ulceration occurs in this local- ity as the result of simple inflammation. Erosions and small follicular ulcerations occur ; but the former are usually the result of accident (e.g., from separations of crusts, etc.) and the latter are of minor clinical importance. On the other hand, cystic formations are frequently met with, especially in the substance of the pharyngeal tonsil. They vary greatly in size, from a pin's head to that of a hazel-nut, and are filled with an opaque, colloid substance containing cliolesterine, fatty debris, and some- times calcareous matter. These cysts may be formed in the usual way, by closure of the gland-ducts, or, as Wendt2 has pointed out, may originate from newly formed depressions of the mucous membrane, due to hy- pertrophic enlargement in ridges, or to swelling of the membrane and the consequent temporary interference with their communication with the external surface. The mucous glands and lacunae are generally enlarged and surcharged with secretion, and haemorrhages occa- sionally take place into the latter. The appearance of the posterior nares will be given in the article referred to above. Changes in secretion. The changes in quantity and quality of the naso-pharyngeal secretion are the most conspicuous clinical features of the disease. The pharyn- geal tonsil is generally covered with a thick, tenacious, yellowisli-white or greenish-yellow secretion, which is often further discolored by the admixture of extraneous particles of matter from the atmosphere, the rupture of cysts, and small haemorrhages from the mucous membrane. The exudation soon loses its aqueous constituents by evap- oration, and tough masses are formed, which cling with great tenacity to the walls of the pharynx, become im- pacted in the fossae of Rosenmuller, in the posterior nares, or, finally, hang from the orifices of the Eustachian tubes. When they are not removed they become so dense in consistence as to resemble a leathery or mem- branous formation, and come away as casts of various portions of the cavity. The tenacity with which the dried secretion adheres to the membrane is sometimes so great as to require instrumental aid for its removal. Symptoms.—The most prominent symptom of retro- nasal catarrh is the accumulation of the secretion in the back of the nose and upper portion of the pharynx, from which it is sometimes poured out as from some inexhaust- ible reservoir. This is removed by forcible inspiration through the nose, followed by hawking, or by the forcible contraction of the pharyngeal and palatal muscles in the acts of deglutition and sneezing. In the latter case it is expelled through the nasal passages or mouth, according to the completeness with which it is separated from the pharyngeal walls. It may also be loosened and discharged by various methods of expiration or by the rapid alterna- tion of inspiration and expiration through the nose. Oc- casionally the tongue of the patient becomes the medium of its removal. A number of cases illustrating this ab- normal motility of the tongue have been reported. One of my patients, a physician of Baltimore, and suffering from posterior hypertrophic catarrh, made a complete and accurate diagnosis of the condition of his upper pharynx and posterior nares by means of his tongue, with which organ he was also accustomed to remove the secretion from the retro-nasal space. When the tongue is depressed a more or less tenacious, thick, ropy mass of secretion is seen hanging down from behind the palate, or appears in a few seconds on the con- traction of the pharyngeal and palatal muscles. The presence of this post-nasal plug is characteristic of the disease. Occasionally a frothy liquid discharge precedes the descent of the plug. Another characteristic to which we wrould also call attention is the peculiar odor of the post-nasal pharyngeal secretion, which is of considerable diagnostic value. It is altogether peculiar and sicken- ing, and when once appreciated by the sense of smell is never forgotten. The voluntary removal of secretion from the retro- nasal space is, for obvious anatomical and physiological reasons, not accomplished with the same facility as it is from the lower pharynx. Hence accumulation and in- spissation are more likely to occur in the former locality. It is probable, too, that the toughened secretion gains in hardness and tenacity by the admixture of colloid mate- rial from the cystic formations which constitute such a striking anatomical feature of the disease. A certain amount of dulness of the head accompanies the retention of these masses, and the patient becomes ir- ritable and incapacitated for vigorous mental labor. Much of the exudation gravitates into the lower pharynx and is swallowed, producing irritation of the stomach, with a host of symptoms referable to disordered nutrition ; or the masses become loosened during sleep, and, falling within the laryngeal vestibule, excite choking sensations or veritable spasm of the glottis. This latter may be pro- duced also by reflex action from the irritation induced by the presence of the inspissated mucus in the naso-pharyn- geal space. Various other reflex phenomena are also ob- served, which will be discussed farther on, under the head of Neuroses. In some persons, especially those predisposed to liyper- aemic conditions of the air-passages in general, quite extensive haemorrhages occur upon exposure to appar- 208 REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. Nose. Nose. ently trivial causes. In this way several ounces, or more, of blood, may be lost. The blood is swallowed and vom- ited, or it may excite cough and be expectorated, and create in the mind of the patient and his attendant a be- lief in its pulmonary origin. This post-nasal haemorrhage usually takes place suddenly and during attempts to for- cibly clear the nose. The symptoms of retro-nasal catarrh are always aggra- vated in the morning upon rising, but are diminished in severity after the moistening of the throat and the deglu- titory movements which take place during the morning meal. They are also increased by excessive smoking, drinking, and other unnatural indulgences. The breath is more offensive after talking or confinement in close or crowded rooms. Complications.—Retro-nasal inflammation derives much of its importance from its intimate relation to catarrhal affections of the Eustachian tubes and middle ear. Be- sides these common complications, it may lead to insuf- ficiency of the palatal muscles, various laryngeal, nasal, oesophageal and gastric disturbances, and to a host of neurotic phenomena (see farther on, in article on Neu- roses). Diagnosis.—The diagnostic characteristics of the disease have been given in connection with its clinical and path- ological history. When rhinoscopic examination is pos- sible there will be no difficulty in recognizing the affec- tion. If this be not practicable, as, for example, in young children, the introduction of the index-finger behind the velum will determine the presence or absence of adenoid growths, polypi, and hypertrophic conditions of the posterior nares with which the disease may otherwise be confounded. Prognosis.—The prognosis in catarrhal affections of the nose and nasal pharynx will be more fully discussed in the article on Chronic Nasal Catarrh, in the Ap- pendix. Suffice it here to say, that in simple, uncom- plicated inflammation of the retro-nasal cavity that has not lasted for over a year, the prognosis is good. It is also favorable when the morbid process proceeds from neoplastic changes in the pharyngeal tonsil, and when it depends upon some removable nasal affection. As the local expression of a constitutional condition, as, for example, gout, rheumatism, chronic alcoholism, etc., it is a more difficult affection to deal wfith. Whether sim- ple, complicated, or symptomatic of diathetic conditions, chronic nasal pharyngitis is one of the most difficult of all inflammatory troubles to cope with. The more experience the physician has in the management of this affection the less inclined will he be to paint its prog- nosis in roseate colors. Given an inflammation of several years’ duration, more or less clearly confined to the naso- pharyngeal space, without obstructive lesions of the nose or nasal pharynx removable by surgical means, in an in- dividual subjected to improper hygienic conditions and surrounded by the constant changes of temperature of a capricious climate, the chances of complete recovery are decidedly problematical and unfavorable. Marked relief may be given, and the affection be even temporarily dissipated, but sooner or later the inflammatory process reasserts itself, and perfect cure is only secured in an equable climate and under favorable hygienic conditions. There are exceptional cases in which this rule does not hold good, but they are, unfortunately, in a deplorable minority. It may be said, in general, that the disease is more amenable to treatment in early life, less so in manhood and after forty, while later in life it furnishes the most striking confirmation of the Hippocratic dictum that, “ Catarrhs in the aged are not concocted.” Treatment.—As I have stated elsewhere,3 I regard the retro-nasal cavity as practically an accessory nasal cham- ber, and the management, therefore, of inflammatory conditions of its membrane will be governed by the laws which regulate the treatment of catarrhal affections of the nasal passages. These will be fully discussed in the Appendix. Of prime importance is the hygienic management of this affection. Next in efficacy is the surgical—not a Vol. V.—14 meddlesome surgery—but a surgery inspired by a proper conception of the physiological importance and patho- logical conditions of the structures to be dealt with. Less reliance can be placed on topical applications. While in some cases they accomplish all that can be desired, in many others they are wTorse than useless, and may tend even to aggravate the inflammatory condition. (For the treatment of Catarrhal Inflammation of the Nose, see ar- ticle on Chronic Nasal Catarrh, in the Appendix; also the one on Catarrh, Nasal, vol. ii.) Atrophy. —Concerning the etiology and pathological nature of this condition, see articles just mentioned. The disease is most frequently met with in adults or in old persons, rarely in children. Occasionally it seems to develop at some physiological epoch, as at the age of pubei’ty, in subjects whose blood is contaminated by some constitutional taint or whose nutrition is impaired from insufficient nourishment or improper hygienic sur- roundings. In most instances it is the sequel of a pre- existing chronic retro-nasal, pharyngeal, or nasal catarrh. The condition of the mucous membrane, as revealed by rhinoscopy, is one of atrophy, either affecting the whole region, or confined to individual portions, as the pharyngeal tonsil, the posterior wall, orifices of the pos- terior nares, fossae of Rosenmiiller, etc. The tenuity of the membrane is sometimes so great that the underlying muscular fibres may be easily distinguished. The microscope reveals a process of contraction of the different layers of the mucous membrane ; partial or to- tal disappearance of the glandular elements, degenera- tive changes (fatty degeneration, total loss) of the epi- thelium, and the development of dense fibrous bands from hyperplasia of the submucous connective tissue. The principal symptoms are excessive dryness of the throat, and, in many instances, a disagreeable odor of the expired breath. In other cases the secretion is more pro- fuse, and the same tendency to crust-formation exists, which will be considered under the head of Chronic Nasal Catarrh, in the Appendix. The removal of crusts from this region often takes place with considerable difficulty, and can in some instances only be accomplished by in- strumental aid. The disease is incurable. Relief to the symptoms can almost always be obtained by stimulating the healthy tissues to vicarious action and by thorough, systematic cleansing of the retro-nasal space (see article mentioned above), but restoration of function in the atrophied struct- ures is obviously out of the question. John Noland Mackenzie. 1 Ziemssen’s Cyclopaedia, Am. Ed. (Buck), vol. vii., p. 33, 18?6. 2 Op. cit., p. 41. 3 See article on Etiology of Chronic Catarrhal Affections, vol. iv., p. 406 ; also, Trans. Am. Laryngological Assoc., 1885. NOSE, ANATOMY AND PHYSIOLOGY OF THE. Tha nose is the special organ of the sense of smell. Besides this it performs other important functions, and through its free communication with the cavities of the pharynx, mouth, and lungs is concerned in respiration, voice pro- duction, and taste. Through the muscles upon its ex- terior it assists to some extent in the production of ex- pression. It consists of two parts: one external, the nose ; the other internal, the nasal fossas. The nose is the anterior and prominent part, composed of bone, cartilages, and muscles which slightly move the cartilages. It is of triangular form, directed vertically downward, and projects from the centre of the face im- mediately above the upper lip. Its summit is connected with the forehead. It possesses two orifices, the anterior nares, which open downward. The lateral surfaces of the nose form by their union the dorsum, the direction of which varies in different individuals. The dorsum terminates below in a rounded eminence, the lobe of the nose. The nose is composed of a framework of bones and cartilages, covered externally by integument, internally by mucous membrane, and supplied with vessels and nerves. The bony framework occupies the upper part of the organ. It consists of the nasal bones and the nasal 209 Nose. Nose. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. processes of the superior maxillary. The cartilaginous framework consists of five pieces, the two upper and the two lower lateral cartilages, and the cartilage of the sep- tum. The upper lateral cartilages are situated in the upper part of the projecting portion of the nose, imme- diately below the free margin of the nasal hones. Each cartilage is flattened, and triangular in shape. Its anterior margin is thicker than its posterior, and is connected with the lateral cartilage of the opposite side above, and with the cartilage of the septum below. Its inferior margin is connected by a fibrous membrane with the lower lateral cartilage. The posterior edge is inserted into the ascending process of the superior maxilla and the free margin of the nasal bone. One surface looks out- ward, the other inward toward the nasal cavity. The low- er lateral cartilages are thinner than the preceding, below which they are placed, and are curved in such a manner upon themselves as to form both the inner and the outer walls of each orifice of the nostril. By this arrangement they serve to keep the nostrils open. The outer portion is somewhat oval and flattened, or irregularly convex ex- ternally to correspond with the ala of the nose. Behind, they are attached to the margin of the ascending process of the superior maxilla by a tough fibrous membrane, in which are two or three cartilaginous nodules, the carti- lagines minores, or sesamoid cartilages; above, they are fixed, “also by fibrous mem- • brane,” to the upper lateral car- ,va\ tilages, and to the lower anterior jQ| fin part of the cartilage of the sep- AjOf \tl' turn. Their outer extremity, free, l\ j/m j rounded, and projecting, forms, k |(|! ii That part of the nasal canal which is surrounded by the anterior cartilages of the nose, as above described, is sometimes called the vestibulum nasi. It is covered with a continuation of the exterior skin, which gradually as- sumes the characteristics of a mucous membrane, and possesses several layers of pavement epithelium, the up- permost of which is composed of horny cells. This epi- thelium extends backward to the anterior margin of the inferior turbinated body and the inferior meatus, where it becomes ciliated. The integument has also vascular papillae, with both simple and compound loops, and, in the lower part of the nose, long, stiff hairs, called vibris- sae, as well as large sebaceous follicles. It is sparingly supplied with blood-vessels. The nerves are derived from the trigeminus, and consist of filaments, which probably end in terminal bulbs. The nasal fossae proper, * with the exception of a limited * The following description of the bony structures, of the nasal cavity, from dray’s Anatomy, is appended, in order to render the general de- scription more clear: “ The nasal fossse are two large irrregular cavities, situated in the middle line of the face, extending from the base of the cranium to the roof of the mouth, and separated from each other by a thin vertical sep- tum. They communicate by two large apertures, the anterior nares, with the front of the face, and with the pharynx behind by two poste- rior nares. These fossae are much narrower above than below, and in the middle than at the anterior or posterior openings ; their depth, which is considerable, is much greater in the middle than at either extremity. Each nasal fossa communicates with four sinuses, the frontal above, the sphenoidal behind, and the maxillary and ethmoidal on either side. Each fossa also communicates with four cavities : with the orbit by the lachry- mal canal, with the mouth by the anterior palatine canal, with the cranium by the olfactory foramina, and with the spheno-maxillary fossa by the spheno-palatine foramen; and they occasionally communicate with each other by an aperture in the septum. The bones entering into their formation are fourteen in number : three of the cranium, the fron- tal, sphenoid, the ethmoid, and all the bones of the face, excepting the malar and lower jaw. Each cavity is bounded by a roof, an inner, and an outer wall. “ The upper wall or roof is long, narrow, and concave from before backward ; it is formed in front by the nasal bones and nasal spine of the frontal, which are directed downward and forward ; in the middle, by the cribriform lamella of the ethmoid, which is horizontal; and be- hind, by the under surface of the body of the sphenoid and sphenoidal turbinated bones, which are directed downward and backward. This surface presents, from before backward, the internal aspect of the nasal bones ; on the outer side, the suture formed between the nasal bone and the nasal process of the superior maxillary ; on their inner side, the ele- vated crest which receives the nasal spine of the frontal and the perpen- dicular plate of the ethmoid, and articulates with its fellow of the opposite side ; while the surface of the bones is perforated by a few small vascular apertures, and presents the longitudinal groove for the nasal nerve ; far- ther back is the transverse suture, connecting the frontal with the nasal in front and the ethmoid behind, the olfactory foramina and nasal slit on the under surface of the cribriform plate, and the suture between it and the sphenoid behind; quite posteriorly are seen the sphenoidal or superior turbinated bones, the orifices of the sphenoidal sinuses, and the articulation of the alee of the vomer with the under surface of the body of the sphenoid. “ The floor is flattened from before backward, concave from side to side, and wider in the middle than at either extremity. It is formed in front by the palate process of the superior maxillary; behind, by the palate process of the palate bone. This surface presents, from before backward, the anterior nasal spine ; behind this the upper orifice of the anterior palatine canal; internally, the elevated crest which articulates with the vomer ; and behind, the suture between the palate and superior maxillary bones, and the posterior nasal spine. “ The inner wall or septum is a thin vertical partition, which separates the nasal fossae from one another; it is occasionally perforated, so that the fossae communicate, and it is frequently deflected considerably to one side. It is formed, in front, by the crest of the nasal bones and nasal spine of the frontal; in the middle, by the perpendicular lamella of the ethmoid ; behind, by the vomer and rostrum of the sphenoid ; below, by the crest of the superior maxillary and palate bones. It presents, in front, a large triangular notch, which receives the triangular cartilage of the nose ; above, the lower orifices of the olfactory canals ; and behind, the guttural edge of the vomer. Its surface is marked by numerous vas- cular and nervous canals and the groove for the naso-palatine nerve and is traversed by sutures connecting the bones of which it is formed. “ The outer wyall is formed, in front, by the nasal process of the supe- rior maxillary and lachrymal bones ; in the middle, by the ethmoid and inner surface of the superior maxillary and inferior turbinated bones ; behind, by the vertical plate of the palate bone, and internal pterygoid process of the sphenoid. This surface presents three irregular longitud- inal passages, or meatuses, formed between three horizontal plates of bone that spring from it; they are termed the superior, middle, and in- ferior meatuses of the nose. The superior meatus, the smallest of the three, is situated at the upper and back part of each nasal fossa, occupy- ing the posterior third of the outer wall. It is situated between the su- perior and middle turbinated bones, and has opening into it two fora- mina, the spheno-palatine at the back of7 its outer wall, the posterior ethmoidal cells at the front part of the upper wall. The opening of the sphenoidal sinuses is usually at the upper and back part of the nasal fossae, immediately behind the superior turbinated bone. The middle meatus is situated between the middle and inferior turbinated bones, and occupies the posterior two-thirds of the outer wall of the nasal fossa. It presents two apertures. In front is the orifice of the infundibulum, by Fig. 2501.—Vertical Antero-posterior Section of Skull and Soft Parts im- mediately to the Bight of the Nasal Septum. The pharyngeal tonsil is not shown, a, Vestibule ; 6, nasal fossa ; c, anterior naris ; d, nos- tril ; e, naso-pharyngeal cavity; /, floor of nasal fossa, raised in front into the eminence g; h, roof of nasal fossa, anterior ascending por- tion ; i, roof of nasal fossa, middle horizontal portion ; j, roof of nasal fossa, posterior descending portion ; k, superior turbinated body ; l, middle turbinated body ; m, inferior turbinated body; n, anterior bor- der, middle turbinated body ; o, inferior-border, middle turbinated body; p, inferior meatus ; q, middle meatus; r, superior meatus ; s, posterior part of septum, left in situ; t, soft palate and uvula ; v, Eustachian orifice; w, salpingo-pharyngeal fold: x, root of naso- pharynx ; y, Eustachian cushion; z, salpingo-palatine fold; aa, fossa of Bosenmuller. (Cresswell Baber.) with the thickened integument and subadjacent tissue, the lobe of the nose. The lower and most prominent part of the ala of the nose, like the lobule of the ear, is formed of thickened skin with subjacent tissue, and is unsup- ported by cartilages. The cartilage of the septum has a somewhat triangular outline, and is thicker at the edges than near the centre. It is placed nearly vertically in the middle line of the nose, and completes anteriorly the separation between the nasal fossae. The anterior margin of the cartilage, thickest above, is firmly attached to the back of the nasal bones near their line of junction. Below this it lies suc- cessively between the upper and lower lateral cartilages, united firmly with the former and loosely with the latter. The posterior margin is fixed to the lower and central plate of the ethmoid bone, and the lower margin is re- ceived into the groove of the vomer, as well as into the median ridge between the palatal processes of the su- perior maxillae. 210 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Pharmacopoeia. Pliarynx. petent critics, both at home and abroad, has been that this is one of the best Pharmacopoeias ever issued, and that it does not even suffer by comparison with works that have appeared later. It has long been felt that the Pharmacopoeia contains a considerable number of prep- arations which are not frequently prescribed, and are only retained for the reason that, if called for at all, their uniform composition may be insured. There is a move- ment on foot, which it is hoped will relieve the Pharma- copoeia of the task of providing a standard for such prep- arations. The American Pharmaceutical Association is engaged in the compilation of a “ National Formulary of Unofficial Preparations ” (to be subject to the approval of, and expected to receive the support of, the medical pro- fession), which is primarily designed to establish uniform formulas for any compound used in legitimate pharmacy or prescribed by physicians, and for which there is no recognized official standard. This formulary may eventu- ally be made the repository of all such pliarmacopceial articles as are no longer deemed of sufficient importance to be included in the official list. The next convention for revising the U. 8. Ph. will assemble at Washington on the first Wednesday of May, 1890. General Pharmacopoeias.—Many works have been pub- lished, designed to comprise the text of all, or at least the most, prominent Pharmacopoeias. Among the earlier authors of such works are Lemery, Charas, Spielmann, Swediaur, Quincy, Brugnatelli, etc. Of more recent works the following deserve special mention : A. J. Jour- dan, “Ph. Universelle” (Paris, 1828, second, ed. 1840); P. L. Geiger, “ Ph. Universalis ” (Heidelberg, 1835-45); B. Hirsch, “ Universal-Pharmakopoe ” (Leipzig, 1885, vol. i.). International Pharmacopoeias.—Many years ago efforts began to be made to bring about greater harmony in the different Pharmacopoeias, and the proposition was finally made to inaugurate an International Pharmacopoeia. Opinions differed greatly for a long time, not only as to whether the plan was feasible at all, but also in regard to details. Steps were finally taken to have a draft of the work prepared, but national jealousy on several occa- sions rendered its acceptance impossible. It was not to be expected that each civilized nation would abandon its own Pharmacopoeia, specially adapted to the hab- its of its own people and its own domestic resources, for one elaborated without regard to such considerations,! and possibly introducing unfamiliar preparations on changing the strength of such as were in common use. The utmost that could be expected was that the different nations, whenever revising their own Pharmacopoeias, would gradually approximate such preparations as were regarded worthy of international regulation to the pro- posed standard. Another hope which was expressed was this, that the International Pharmacopoeia might be used and followed as an independent work in different countries in this way, that prescribers would designate preparations contained in it in their prescriptions. At the last International Pharmaceutical Congress, held at Brussels in 1886, the draft of an international Pharmaco- poeia was presented by the President of the International Commission, Baron A. von Waldheim, of Vienna. Yet, in its preparation the other members of the commission had not been sufficiently consulted, and it is, therefore, not probable that the draft will be accepted in its present form. While an international Pharmacopoeia, in the sense in which it was first contemplated, is not likely ever to be established, it is, on the other hand, possible, by interna- tional conventions, to establish uniform methods for re- vising the several Pharmacopoeias, so as to bring about, at least gradually, an equalization in the strength of the potent remedies and their preparations. General Remarks.—A Pharmacopoeia is supposed to represent the broad results of therapeutic investigations and observations accepted by, or acceptable to, the med- ical profession at large in the country for which it is written. In general, therefore, it should not introduce insufficiently tried new remedial substances or methods, but should accept only such as have, by matured and careful study, been found worthy of recognition. Ex- ceptions to this rule are, however, admissible where it can be clearly demonstrated that an innovation will be an improvement. As an instance of such exception may be quoted the introduction of abstracts in the last U. 8. Ph., these being merely dry extracts, brought into a definite proportion with the crude drug from which they are prepared (2 parts of abstract = 1 part of drug). In most countries the Pharmacopoeia is recognized by law as the authority for deciding questions relating to the identity, quality, purity, or strength of all substances for which it provides a norm. In the United States it is thus recognized expressly by a number of States, as well as by the general Government for the public service. In most European countries the official text of the Pharmacopoeia is written in Latin, as it is argued that this will insure better mutual understanding as well as a smaller risk of ambiguity in expression than if the vernacular were used. This argument, however, is becoming less valid in propor- tion as the rapid progress in chemistry and other sciences renders it constantly necessary to coin new words for ex- pressing terms or methods. No objection, however, can be advanced against a Latin nomenclature of pharmaco- poeia! titles, as this will insure uniformity in prescribing and safety in dispensing. Since the medical and pharmaceutical professions are equally interested in the production of as perfect a work as can be produced, co-operation of the two professions in the revision is absolutely necessary, and the more un- hampered the revisers are in the choice of their unofficial assistants, the better will be the result. It has been rec- ognized that a successful periodical revision of a Phar- macopoeia is much facilitated by the establishment of a permanent commission to collect and digest all criticisms and proposals for improvement that may be made in the interval between two revisions. The example set by the United States has been followed by several other nations, and the good results of this will become evident in the future. Charles Bice. / PHARYNX AND NASAL PHARYNX, SYPHILITIC (LESIONS OF THE. The initial lesion of syphilis is oc- casionally found in the pharynx, and almost invariably on one of the tonsils, the posterior wall being singu- larly exempt. Sometimes the upper pharynx is the seat of the primary sore, and not a few cases are on record in which the constitutional disease was communicated by means of the Eustachian catheter. The diagnosis of pharyngeal chancre is often a difficult matter, as the characteristics of the primary sore of syphilis are not always well marked, and the diagnosis must be made from the subsequent development of constitutional symp- toms. By far the most common lesions of syphilis in this re- gion are erythema and catarrhal inflammation. A sym- metrical arrangement of the erythematous patches is re- garded as characteristic of syphilis. There is nothing peculiar to the pharyngeal catarrh of syphilis. In a cer- tain proportion of cases, however, there is a somewhat characteristic discoloration of the mucous membrane, which is suggestive of the disease. When to this is added a tendency to symmetrical patches of cloudy swelling of the epithelium, suspicion of its specific nature may be aroused. Mucous patches are constant accompaniments of pha- ryngeal syphilis, and are found most commonly on the soft palate, faucial pillars, and tonsils, rarely on the pos- terior wall. Varying in size, they appear as whitish or bluish-white elevations—circular, oval, or stratiform—ar- ranged symmetrically on the swollen and liypergemic mucous membrane. They may be fugitive in nature, disappearing spontaneously in a few weeks, or the epi- thelium may be cast off and superficial ulcers result. The ulceration from a mucous patch is sometimes so ex- tensive that it may be confounded with the destruction of a tertiary lesion. The characteristic lesions of the tertiary stage, found in the pharynx, are gummata, diffuse infiltration, and ulceration. I have also met with extensive fibroid de- 629 Pharynx. Pharynx. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. generation of the pharyngeal structures similar to that described in the section on Larynx, Trachea, and Bronchi, Syphilis of the (vol. iv.). The mode of development of tertiary ulcers in the pharynx is identical with the man- ner in which they appear in the larynx (see section re- ferred to). They are found in all portions of the upper and loAver pharynx. When seated on the soft and hard palate they show a marked tendency to perforate. The ravages produced by tertiary syphilitic ulceration of the pharynx are sufficiently familiar. In addition to the perforations already referred to, wide-spread destruc- tion of the palate, tonsils, posterior wall, and other parts may occur ; caries and necrosis of the posterior wall and pharyngeal vault may complicate the case, or extensive adhesions may form, with partial or complete obliteration of the pharyngeal cavities. Occasionally a perforating ulcer opens a large artery, and alarming haemorrhage oc- curs, or the ulcerative process may extend to the brain or spinal cord, with a fatal result. Of great interest are syphilitic affections of the pharynx in the congenital form of the disease. The fauces, velum, and posterior wall present simply an erythematous efflo- rescence, or are the seat of lardaceous infiltration. Occa- sionally the follicles seem to be the starting-point of the disease. They stand out prominently, are filled with a yellowish secretion, and are surrounded by a well-defined inflammatory areola. Although mucous patches are frequently found on the uvula, tonsils, and faucial pillars, the posterior wall is singularly exempt. Hypertrophy of the tonsils is present in a large proportion of cases. It is simple in character, or the glands may be the seat of lardaceous infiltration. In the latter case they have a square outline, and a uniform, smooth, waxy appearance, in which it is diffi- cult to recognize the mouths of the follicles and lacunae. Warty growths are found in the pharynx, both in the acquired and in the congenital form of syphilis. With deep ulceration of the pharynx stomatitis is commonly associated. The parts are thickened, infiltrated, and present a characteristic albuminous appearance. On this pale ground ramify arborescent wine-colored vessels, and here and there small haemorrhages are seen beneath the mucous membrane. There is often a scarlet line along the gums at the insertion of the teeth, which stands out in striking contrast to the surrounding pallor of the mem- brane. This is most easily determined by the carious condition of the teeth, and may be analogous to the in- flammatory zone which surrounds other syphilitic le- sions. Morell Mackenzie has called attention to the absence of the characteristic notching of the teeth in those in whom the throat is affected. Out of seven cases exam- ined by me in 1879, in reference to this point, there were three in which the notching was not present. In one of these there was a deficiency in the left central upper incisor, giving it a more or less V-shaped appearance, and in another, a roughening of the lateral edge of the lower central incisor of the right side. In the third, the teeth were apparently sound. It is generally laid down in the text-books that deep ulceration of the mouth and pharynx, in congenital syphi- lis, is very rare ; and Mr. Holmes1 went so far as to say that the affection of the palate, so common in syphilis of the adult, is “so rare in children that it is doubtful whether the few cases which occur in infants during syphilis may not be mere coincidences.” A great deal of confusion prevails concerning this question in con- sequence of the persistent adherence to the old supersti- tion which regards them as of “ scrofulous” origin. It is impossible to exaggerate the role of congenital syphilis in the production of the deep destructive pharyngeal ulceration of childhood. The subject is not one of purely pathological interest: under a misconception of its true nature, syphilis, uncontrolled, will lead to destruction and deformity, and influence for evil the future happi- ness and usefulness of the individual. Deep ulceration may invade the bucco-pliaryngeal cav- ities at any period of life from the first week up to the age of puberty. Out of thirty cases analyzed with refer- ence to the period of invasion, fourteen occurred within the first year, a proportion of nearly onedialf, and of these, ten within the first six months. Whitehead2 has observed putrid ulceration of the throat in an infant three days old. Of the remaining cases, the majority occurred at a period more or less advanced toward pu- berty. It is an accepted fact that syphilis may lie in a state of potential activity within the system for many years after birth. Lying thus quiescent, it seems to await the advent of some physiological epoch to call its phenomena into activity. Thus puberty and its surrounding years is often selected as the chosen period of its outbreak. When the eruption of the disease is thus deferred, it is on the palate and in the pharynx that it most frequently makes its appearance, and deep palato-pliaryngeal ulceration often first attracts attention to the existence of a diathesis of which it is the sole pathological expression. Lesions of these structures are found with a peculiar constancy, and upon them syphilis apparently concentrates all its energy and exhibits most of its virulence. Females are attacked more frequently than males. Out of sixty-nine cases of pharyngeal ulceration forty-one occurred in the female sex. That the pharyngeal cavity should be frequently at- tacked is easily understood, when we refiect upon its great vascularity and the irritation to which it is constantly subjected. Ulceration may occur in any situation, but its favorite seat is the palate, and especially the hard palate. When it takes place at the posterior part of the hard palate the tendency is to involve the soft palate and velum, and thence to invade the posterior nares and naso-pharynx. Seated anteriorly it seeks a more direct pathway to the nose by perforation of the bone. Simultaneous or consecutive ulceration of the palate, pharynx, and nose seems to be characteristic of syphilis. The next most common seats of ulceration, in the order of their frequency, are the fauces, the naso-pharynx, the posterior pharyngeal wall, the nasal fossae and septum, the tongue and' gums. A peculiarity of these ulcers, and especially those of the palate, is their centrality of position. They are gen- erally found in the median line of the vault, at the junc- tion of the palatal processes of the superior maxilla, and the areas of destruction on either side are equal and symmetrical. Often more acute in their development, and advanc- ing with more rapid strides than in the tertiary syphilis of the adult, the special tendency of these ulcerations is to attack the bone and lead to caries and necrosis. Dis- organization of the bone occurs in over three-fifths of recorded cases. The great vascularity of the periosteum and medullary membrane in youth, doubtless, invites in- vasion of the osseous structures. This, however, is con- trary to the experience of Colles,3 who never saw a case; of West,4 who has seen necrosis only once; of Holmes,6 who has seen sloughing of the soft palate, but not exca- vated ulcers or caries of the hal'd palate ; and of Cooper Foster,6 who has never met with an example in which syphilis had advanced to disease of the bone. The tendency to necrosis exists at all periods of life ; but especially in early youth, at which time it is more destructive and less amenable to treatment. When ulcer- ation occurs on the hard and soft palate, perforation of these structures takes place in very nearly one-tliird of the cases. As a rule, the ulcers originate upon the palate or within the pharynx, but they are also consecutive to deep, ulcer- ating sypliilides of the nose and face. Whatever their point of departure, the palate is often the structure upon which the destructive process ultimately descends. The palate, pharynx, and nose, then, constitute a well- defined territory singularly obnoxious to these ulcerative products, and within whose confines we may best study the development and growth of these degenerate lesions of syphilis. Ulceration of the tongue occurs in a certain proportion of cases. I have met with it three times in congenital syphilis. In the first case the ulcer was situated on the 630 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Pharynx. Pharynx. right side of the tongue, near its tip; in the second, in the left glosso-epiglottic fossa ; while the third followed the breaking down of a large gumma on the upper sur- face of the tongue near its base. The ravages of the disease present the typical appear- ances that are found in the tertiary syphilis of the adult. (For the diagnostic characters of the syphilitic ulcer, its differential diagnosis, the article on Larynx, Trachea, and Bronchi, Syphilis of the, should be consulted.) The appearance of the ulcer will vary to a certain extent with the general condition of the patient. In a badly nour- ished, cachectic child the granulations may assume a pale, unhealthy,'and indolent look, and the red corona may fade into a purplish ring, or even be entirely wanting. But in all there is a strict adherence to the true syphilitic type of ulcer. As a result of cicatrization, adhesions may form be- tween the velum and the pillars of the fauces, or between the latter and the pharyngeal wall, and there may be stenosis and obliteration of the pharynx and naso- pharynx ; in fine, all the sequela? are found which follow constitutional syphilitic ulceration in these localities.* The prognosis in syphilis of the pharynx is generally good, provided the patient be seen before extensive de- struction has taken place. In congenital syphilis it is greatly influenced by the age of the patient; the earlier the pharynx is attacked, the graver the prognosis. Plia- ryngo-laryngeal ulceration occurring within the first year is almost invariably fatal. Pharyngeal ulceration ap- pearing late, or as a manifestation of “ tardy syphilis,” yields readily to iodide of potassium, and the topical application of iodoform or the vapor of the iodate of zinc. The separation of syphilitic ulceration of the pharynx from that of tuberculosis, lupus, lepra, and cancer should be made upon the principles of differential diagnosis laid down in the article on Syphilis of the Larynx. It should not be forgotten, too, that typhoid fever, diphtheria, and other acute systemic disorders may lead to destruction which resembles that of syphilis so closely as to render an appeal to the history of the case imperative. The soft palate and pharynx may also be destroyed by trau- matic causes, or be badly scarred from chemical irritants. Sloughing may also occur from poisonous doses of drugs, such as mercury in its various forms. Treatment should be carried out on the principles al- ready indicated in the section on Syphilis of the Larynx. In my experience the best application to the mucous patch is the solid stick of silver nitrate, while for the tertiary ulcer iodoform may generally be relied upon as a rapid promoter of cicatrization. Adhesions may be di- vided with the knife or galvano-cautery, but \mless seri- ous interference with function is threatened, they had better be left alone. Partial stenosis of the upper and lower pharynx may be treated by systematic dilatation with sounds, by divulsion, or by the use of the cautery or knife. When the stenosis is complete, and the phar- ynx is filled with dense fibroid tissue, the treatment will depend upon the circumstances of the case and the in- genuity of the surgeon. In cutting through the new- formed tissue in the nasal pharynx, it is always best to previously introduce a catheter or similar contrivance through the nose, upon which to cut as a guide. The re- sults of treatment in this class of cases cannot be said to be brilliant, The tendency to recurring stenosis is great, and the surgeon is fortunate "who obtains a satisfactory permanent opening. Delavan, of New York, profiting by the observation of Andrew H. Smith—that the eschar after the use of monochloracetic acid remains attached until cicatrization has taken place beneath it,—in a case of adherent velum, divided the adhesion with curved scis- sors and cauterized the raw surfaces freely with this acid. Although the surfaces remained in contact, no adhesion took place afterward, and the operation was a permanent success.1 John N. Mackenzie. 1 Sux-gical Treatment of the Diseases of Children, p. 350. London, 1868. 2 On the Transmission from Parents to Offspring of some Forms of Disease, p. 137. London, 1851. 3 Venereal Diseases, p. 271. London, 1837. 4 Lectures on Diseases of Children, p. 747. s Op. cit., p. 351. 8 Surgical Diseases of Children, p. 291. London, 1860. 7 See Trans, of the American Laryngological Association, 1883, p. 185. PHARYNX AND PALATE, ANATOMY AND PHYS- IOLOGY OF THE. The pharynx belongs to both the respiratory and the digestive tracts, although it is usually described as a part of the latter. Its upper portion is concerned exclusively in respira- tion, while the lower regions participate in both func- tions. Its relations to the formation of the voice are accessory to the respiratory function, and will be described in the article on the Voice. It is a hollow, musculo-inembranous structure, sus- pended from the base of the skull and reaching as far downward as the interspace between the fourth and fifth cervical vertebrae. It is attached above to the pharyngeal spine on the inferior surface of the basilar process of the occipital bone, and to two membranous bands extending thence to the apex of the petrous portion of the temporal bone, on either side. It is then attached anteriorly to the posterior border of the internal pterygoid plate of the sphenoid, to the pterygo-maxillary ligament, to the pos- terior extremity of the mylo-liyoid ridge on the inferior maxillary, to the base of the tongue, to the mucous mem- brane of tlie mouth, to the posterior extremities of the greater and lesser cornua of the hyoid bone, to the thyro- hyoid ligament, to the posterior border and external sur- face of the ala of the thyroid cartilage, and to the lateral aspect of the cricoid cartilage. Posteriorly, it lies against the anterior surfaces of the five upper cervical vertebrae and the longus colli and recti anteriores muscles, from which it is separated by some loose connective tissue. Below, it is continuous with the oesophagus, which has its superior attachment to the posterior surface of the cricoid. It communicates above, with the nasal passages and Eustachian tubes ; below, with the mouth, larynx, and oesophagus. The pharynx is divided, for convenience in description, into three portions : the superior, or naso-pharynx, the middle, or oro-pliarynx, and the inferior, or laryngo- pharynx. The naso-pharynx is limited above by the roof or vault, and extends as far downward as the in- ferior border of the velum pendulum palati. It receives the orifices of the Eustachian tubes, and of the posterior nares, or choance. The former orifices, which project into the pharynx somewhat as the cervix uteri pro- trudes into the vagina, are just posterior to the openings of the posterior nares. Anteriorly to them is a depres- sion, on either side, bounded in front by the crescentic margin of the orifice, which has been named by Tortual the sinus pharyngis superior. Posterior to them is a de- pression known as the fossa of Rosenmuller, or recessus pharyngeus. The oral portion, or oro-pliarynx, is that which extends from the level of the lower margin of the velum to the plane of the greater cornua of the hyoid bone. In front it looks toward the mouth and epiglottis, with the depen- dent uvula forming a very incomplete anterior wall. Two folds of mucous membrane, tlie pharyngo-epiglottic folds (see Larynx), help to bound it laterally. The inferior or laryngeal portion (laryngo-pliarynx), extends from the greater cornua of the hyoid bone to the inferior border of tlie cricoid cartilage. It looks ante- riorly toward the epiglottis and ary-epiglottic folds, and is continuous, centrally, with the vestibule of the larynx ; more laterally, with the pliaryngo-laryngeal sinus, or sinus pyriformis (see Larynx). The pharyngeal walls are composed of three layers : an internal or mucous, a middle or fibrous, and an external or muscular. The muscles of the pharynx are fourteen in number, though two of them—one pair—are common to it and * The views and conclusions given above were first published by the writer in the American Journal of the Medical Sciences for October, 1880 (see also article on Larynx, Trachea, and Bronchi, Syphilis of the, in vol. iv.). 631 Pharynx. Pharynx. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the soft palate. They are the superior, middle, and in- ferior constrictors, which form the bulk of its walls and give to it its form and the greater part of its attachment; the stylo-pharyngei, and the palato-pharyngei. The mus- cles of the soft palate are intimately associated with its functions. The superior constrictor (Fig. 2867) (eephalo-pharyngeus) is broad and flat. It takes its origin from the lower third of the posterior border of the internal pterygoid plate; from the pterygo-maxillary ligament, the base of the tongue, and the posterior extremity of the mylo- hyoid ridge. Those fibres which are connected with the base of the tongue enter its substance and pass inward ; some of them penetrating as far as the fibrous septum. All the fibres pass backward and somewhat upward. The most superior are attached to the ligament which sus- pends it from the base of the skull, the ligamentum sus- pensorium pharyngis. The others, in part, interlace with those of the opposite side, while the remainder attach upward, interlacing in the median line. The middle and inferior bundles pass horizontally backward in a similar manner. The lowermost bundles are in close contact with those of the oesophagus. The stylo-pharyngeus (levator laryngis) is long and slender. It arises from the base of the styloid process of the temporal bone. Its fibres pass downward, forward, and inward. At first they lie in contact with the outer surface of the superior constrictor, but subsequently penetrate between it and the middle constrictor, and spread out in the fibrous layer of the pharynx, the pha- ryngeal aponeurosis. They are, finally, inserted into the superior and posterior borders of the thyroid cartilage. The palato-pharyngeus will be described with the mus- cles of the soft palate. The action of the constrictors is to contract the lumen of the pharynx in swallowing. This action begins in the superior constrictor, and extends from above downward in a vermicular or peristaltic manner, so as to carry the bolus onward into the oesophagus. The action of the stylo-pharyngei, which might, per- haps, more properly be called the levatores laryngis, is to draw the larynx upward toward the base of the tongue. It, at the same time, raises the lower portion of the pharynx, shortens the tube, and facilitates the entrance of the morsel into the oesophagus. The middle, or fibrous, layer of the pharynx, known to anatomists as the pharyngeal aponeu- rosis, is made up of tough, closely woven, fibrous connective tissue. Above, it is attached to the pharyngeal spine, on the basilar process of the occipital bone, by means of the suspensory liga- ment, and to the petrous portion of the temporal bone. Between these points it forms a festoon above the concavity of which the Eustachian tube passes downward, forward, and inward to its opening into the naso-pharyngeal space. Anteriorly it is attached to the internal ptery- goid plate, the pterygo-maxillary ligament, the mylo-liyoid ridge, the cornua of the hyoid bone, the thyro-hyoid ligament, the superior and pos- terior borders of the thyroid cartilage, and the cricoid cartilage. Below, it blends with the fibrous coat of the oesophagus. The pharyn- geal aponeurosis, besides giving strength to the pharynx, affords attachment to the free ends of the muscular fibres. ' It is pierced, in the interval be- tween the superior and middle constrictors, by the glos- so-pharyngeal nerve, which lies just below the stylo- pharyngeus muscle, and between tiie middle and inferior constrictors by branches of the superior laryngeal branch of the pneumogastric. The posterior median raphe is a thickened portion of the fibrous aponeurosis. It is more marked above than below. The mucous membrane of the pharynx is continuous with that of the nasal passages, Eustachian tubes, mouth, larynx, and oesophagus. Superiorly, it arches over, be- neath the base of the skull, so as to completely close the cavity, forming the roof or vault of the pharynx. It is closely attached to the subjacent tissues in the upper portions, but in the vicinity of the larynx its at- tachment is much looser, and it may, in the cadaver, be easily raised with the forceps. Above the level of the inferior border of the soft palate, that is, in the naso- pharyngeal space, it is covered by columnar, ciliated epi- thelium, throughout its entire extent in infancy, and in the neighborhood of the nasal and Eustachian orifices in adults. In the oral and laryngeal regions, it is supplied with stratified pavement epithelium. The mucous membrane is liberally furnished with mucous glands, particularly in the lower regions. In the vault of the pharynx are many so-called follicular or adenoid glands, most numer- ous behind the orifices of the Eustachian tubes, and pass- ing across from one tube to the other. The glandular tissue of the vault, from its resemblance to that of the tonsils, was called by Luschka the pharyn- geal tonsil. Beside these glandular structures, the con- Fig. 2867.—The Constrictor Muscles of the Pharynx. (Drawn by Dr. A. H. P. Leuf.) 1, Anterior arch of atlas; 2, body of axis; 3, 4, 5, 6, bodies of third, fourth, fifth, and sixth cervical vertebrae; 7, basilar process of occipital and body of sphenoid ; 8, the superior constrictor ; 9, the middle constrictor; 10, the inferior constrictor; 11, crico- thyroideus; 12, thyro-hyoideus; 13, the body of the hyoid bone; 14, mylo-hyoid muscle ; 15, buccinator. tliemselves to the more or less distinct fibrous raphe which extends, in the median line, throughout the length of the pharynx. The middle constrictor (hyo-pharyngeus) (Fig. 2867), arises from the greater and lesser cornua of the liyoid bone and the lower end of the stylo-hyoid ligament. From this narrow origin the fibres spread out in a fan- like shape. The more superior bundles pass upward and backward, on a plane external to the superior con- strictor, ascending almost to its superior border. The middle fibres take a horizontal direction, and the lower ones pass downward, internally to those of the inferior constrictor. Part of the fibres end at the median raphe, into which they are inserted ; the remainder interlace with those of the opposite side. The inferior constrictor (laryngo-pkaryngeus) is a some- what quadrilateral muscle, situated at the lower portion of the pharynx on a plane posterior to the middle con- strictor. Its origin is from the posterior border of the thyroid cartilage and the triangular space behind the ob- lique ridge into which the sterno thyroid muscle is in- serted, and from the lateral aspect of the cricoid carti- lage. The superior fibres extend backward and slightly 632 Pharynx. Pharynx. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. nective tissue of the mucosa contains many lymphoid cells. Normally, the color of the mucous membrane of the naso-pharynx is a little paler than that in the oral and laryngeal, portions. The pharynx receives its vascular supply from the as- cending pharyngeal, from the vidian and pterygo-palatine branches of the internal maxillary, and from the ascend- ing palatine and tonsillar branches of the facial artery— all originating from the external carotid. Its veins are branches of the internal maxillary, inferior palatine, and internal jugular. The lymphatics, which are numerous, are connected, with the deep cervical glands in the neighborhood of the cornua of the hyoid bone, and in the pterygoid region. The sensory nerves of the pharynx are the fifth, glosso- pharyngeal, and branches from the pharyngeal plexus, which is made up of communicating fibres from the pneumo-gas- 1 trie, glosso - pharyn- g e a l, superior laryngeal, a n d branches from the superior and middle cervical ganglia of the sympathetic. The second division ortlie fifth supplies the vault of the pharynx and the upper portion of the opening of the Eustachian tube, while the lower por- tion of the naso- pharynx has some fibres from the infe- rior division. Below this the sensory fibres are from the glosso- pharyngeal and the pharyngeal plexus. The fact that abnormal irrita- tions of the region sup- plied by the glosso-phaiyn- geus give rise to vomiting has led some to call this nerve “ the nerve of nau- sea.” The pharyngeal branches of the glosso- pliaryngeus are not en- dowed with the gustatory sense. Motor Fibres.—The stylo- pliaryngeus is supplied with motor fibres by the glosso- pharyngeal nerve. The con- strictors are supplied by the glosso-pharyngeus and the pharyngeal plexus. The in- ferior constrictor also re- ceives a branch from the superior laryngeal branch of the pneumogastric. Physiologically, the pharynx is concerned" both in respiration and in alimen- tation. During the greater part of life it remains relaxed and open, so as to admit the free access of the current of air, as it passes downward from the nasal passages to the larynx and trachea. During deglutition the respira- tory function is suspended ; the mouth is closed, and communication with the naso-pharynx is entirely cut off by the elevation and tension of the soft palate. The soft palate, velum pendulum palaii, is a musculo- membranous curtain, depending from the posterior ex- tremity of the palate plates of the palate bone. It inclines somewhat backward, and has a depth of from an inch to an inch and a half. Its thickness is from a fourth to half an inch. It forms an arch, made double by the downward projection of the uvula from its highest cen- tral point. It separates the buccal from the pharyngeal cavity. The sides, or pillars, divide, as they descend, into two diverging columns called the anterior and posterior pillars of the fauces. The anterior pillar is continuous with the base of the tongue ; the posterior shades off into the lateral wall of the pharynx. Between them, as they diverge, is a recess or cavity known as the fauces, in which the tonsil is contained. The space between the anterior pillars and the base of the tongue, which is closed during the second part of the act of deglutition, i.e., after the morsel has reached the pharynx, is called the isthmus of the fauces. The soft palate is covered by mucous membrane which, on its anterior or buccal surface, corresponds in structure to the buccal mucous membrane. It contains numerous conglomerate mucous glands, identical with the buccal glands which can be seen in certain inflammatory condi- tions, such as buccal catarrh, scarlatina, etc., as little round elevations on its surface. On the posterior surface are the follicular glands of the naso-pharynx, besides many mucous glandules. The epithelium on the anterior surface is of the stratified squamous variety. The pos- terior surface is covered by columnar ciliated epithelium near the orifices of the Eustachian tubes. Elsewhere it is squamous. In infancy the entire posterior surface is covered by ciliated epithelium. The muscles of the soft palate are ten in number, five on either side. They are the levator palati, tensor palati, palato-pharyngeus, palato-glossus, and azygos uvulae. The levator palati (petro-salpingo-staphylinus) (see Fig. 2869) is a rather broad muscular band, which has its origin from the inferior surface of the apex of the petrous portion of the temporal hone. Its fibres incline inward as they descend, and, spreading out, are inserted into the fibrous tissue of the velum ; many of them pass over to the opposite side. This muscle forms a slight eminence under the base of the opening of the Eustachian tube, and when it contracts, during the first part of the act of deglu- tition, tends to close the tube. Its principal function, however, is to draw the velum upward and backward, against the posterior wall of the pharynx. The tensor palati, or circumflexus palati (spheno-salpingo-staphylinus), arises from the scaphoid fossa at the base of the pterygoid process. It descends perpendicularly to the outer side of the hamular process around which it curves. A bursa is interposed between the muscle and the bone. Its fibres then assume a horizontal direction and spread out in an aponeurosis, which is partly attached to the palate plate. This muscle lies in a plane anterior to the levator. The tensor palati performs two very important functions. First, it makes the velum tense and unyielding, as it is drawn upward and backward by the levator in swallow- ing. Second, by means of its attachment to the inferior aspect of the Eustachian tube, it draws it open and ad- mits air to the tympanum. The palato-pharyngeus (Fig. 2869) is a long, round muscle, arising in the substance of the soft palate as far inward as the uvula. In the velum, its fibres are separated into an anterior and a posterior fasciculus, by the levator palati. They join, below the latter muscle, to form a nar- rower portion which soon widens out again into two parts, an anterior and a posterior. The anterior portion joins with the stylo-pliaryngeus and is inserted into the supe- rior and posterior borders of the thyroid cartilage ; while the posterior portion spreads out, some of the fibres being lost on the lateral and posterior walls of the pharynx, others passing entirely beyond the median line to interlace with those of the opposite side. This muscle, with the mucous membrane covering it, forms the posterior pillar of the fauces. When it contracts, it draws the larynx and laryngo-pliarynx upward, and through the shorten- ing and straightening of the posterior fibres, pulls the posterior pillar inward and backward, so that it forms nearly a straight line from before backward. The slight space left between the two pillars, as they are thus approximated, is closed by the uvula. In this way a complete septum is formed between the oro- and naso- Fig. 286S.—Posterior Yiew of the Pharynx. (Drawn by Dr. A. H. P. Leuf.) The median raphe is drawn too broad. 1, Base of the skull; 2, fibrous membrane of the pharynx; 3. superior con- strictor ; 4, middle constric- tor ; 5, inferior constrictor; 6, oesophagus ; 7, trachea. 633 Pharynx. Pharynx. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. geal branches from the ascending pharyngeal, and the descending palatine from the internal maxillary. The veins are collected into two plexuses, anterior and posterior. The anterior are connected with the veins of the base of the tongue, while the posterior communicate with those of the nose. The motor nerves are branches of the second and third divisions of the fifth, the facial, and Meckel’s ganglion. The tensor palati is supplied by a branch from the otic ganglion, derived, originally, from the third division of the fifth. The levator palati and azygos uvulae receive their motor innervation from the facial, by way of the great superficial petrosal and vidian nerves. The palato- glossus and palato-pharyngeus are supplied by twigs from the palatine branches of the splieno-palatine (Meckel’s) ganglion. They also send some branches to the levator palati and azygos uvulae. The mucous membrane is sup- plied with sensory filaments from the palatine branches of Meckel’s ganglion, and the tonsillar branches of the glosso-pliaryngeus. Benjamin F. Westbrook. _ pharynx. In the absence of the uvula, the palato-pharyn- gei may, and frequently do, close this space (isthmus pharyngis), so that deglutition is not impaired. The palato-glossus {constrictor isthmi faucium), with the fold of mucous membrane covering it, forms the an- terior pillar of the fauces. It is situated the most anteriorly of all the muscles of the palate. It arises in the median line. The fibres of the opposite muscles interlace, and continue from one arch into the other. Thence it passes downward and forward to the side of the tongue, where it is lost beneath the mucous membrane of the mouth. The contraction of the palato-glossi approximates the sides of the isthmus, draws down the uvula, and, as the base of the tongue is raised in swallowing, cuts off all communication between the mouth and pharynx. The azygos uvulaj (Fig. 2869) is a small, slender mus- cular bundle which derived its name from the supposed PHARYNX, CATARRHAL AFFECTIONS OF THE* cute Catarrhal Pharyngitis. — Etiology. — Tliel causes of this affection are those of catarrhal in-1 flammation of the upper air-tract in general, and have been considered elsewhere (see vol. iv., pp. 400-406). Among its most common exciting causes ■are the conditions embraced under the conception of “ catching cold.” It may also arise as one of the complications incident to moutli-breathing from nasal obstruction ; from extension of inflammation from adjacent organs; from the suppression of a cutaneous exanthem ; as a reflex phenomenon from gastro-intestinal or genito-urinary irritation ; as the local expression of a constitutional d3’scrasia or acute systemic infection ; as the manifestation of organic disease of a distant organ, or as the direct result of local irritation. The improper use of the voice in the various forms of vocal strain is a fertile cause of pharyngeal affections. Symptoms.—The severity of the symptoms will vary with the cause of the disorder. In mild cases there is little, if any, febrile disturbance, the pa- tient complains of dryness of the fauces with a disagree- able sense of constriction about the throat, and of diffi- cult or painful deglutition. There is often a peculiar, short, explosive cough which is easily recognized as a reflex act. Occasionally pain in the course of the nerves that radiate from the pharyngeal plexus is complained of, and the writer has met with intense, lancinating pain in the eyeball, brought about by localized inflammation in this region. The disease is very frequently associated with inflam- mation of the naso-pharynx and may extend through the Eustachian tubes to the middle ear. Not infrequently hoarseness and the sensation of a foreign body in the larynx are added to the pharyngeal symptoms. This may be due to an irritation of the larynx, or to collateral or reflex hypersemia of that organ, or to the presence of the pharyngeal secretion in the posterior portions of the larynx where it excites localized hyperaemia or acts as a damper on the vocal cord. The sudden loss of voice which occurs during the presence of pharyngeal inflammation is doubtless due to the latter cause. At first, there is little or no secretion ; the throat is dry and parched and is exquisitely susceptible to irritation. Later, a more or less profuse mucous or muco-purulent discharge occurs, which is expectorated by coughing or hemming. The redness of the pharynx is generally diffuse ; but is almost always more pronounced in certain portions. A common seat of the hyperaemia is along the inner and anterior aspect of the anterior faucial pillars and the pal- atal arcade. The veins of the posterior wall are often enlarged and prominent, and the tonsils swollen and engorged. There is slight oedema of the pharynx, wdiich principally affects the uvula, probably owing to its de- pendent position, and the palatal muscles are somewhat restricted in their motions. In some cases, and especially Fig. 2869.—Copied from Gray. fact that it was single. It is now known to be bilateral, like the other skeletal muscles. This is particularly well demonstrated in cases of bifur- cated or double uvula, a not very uncommon anomaly. The azygos muscles, with their covering of mucous mem- brane, form the uvula, or central dependent portion of the velum palati. They arise together, partly from the connective tissue and partly from the posterior nasal spine of the palate bone. They diverge slightly as they descend, and are lost in the submucous connective tissue near the end of the uvula. When they contract they shorten and contract the uvula, and at the same time draw it upward and backward. This assists in closing the isthmus of the pharynx in deglutition, and is also an important factor in the production of speech (see Voice). The arterial supply of the soft palate is derived from the ascending palatine and tonsillar branches of the facial; the dorsalis lingme from the lingual; the pharyn- 634 Pliarynx. Pharynx. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. when the disease occurs in epidemic form, a yellowish- white pultaceous deposit takes place, which is distributed over the pharynx in small, easily detached patches. This thickened secretion is glandular in origin and it is accordingly associated with tumefaction and prominence of the pharyngeal follicles.1 Occasionally cheesy masses are expectorated, hut this is an uncommon symptom ex- cept when the acute inflammation is engrafted on chronic follicular disease. In severe cases of acute pharyngitis the above symptoms are accentuated. (Edema occurs, which may be so great as to threaten asphyxia, or to precipitate tracheotomy, owing to direct extension of the effusion to the submu- cous connective tissue of the larynx. The motility of the muscles of the palate and pharynx are interfered with, deglutition is rendered difficult or impossible, and the voice acquires the familiar nasal twang which is charac- teristic of paralytic states of the soft palate. The condi- tion of the muscles here is generally that of paresis from inflammatory or cedematous infiltration, and disappears with the subsidence of the inflammatory process ; hut oc- casionally a true paralysis is produced which persists after the original cause lias been removed. Pathology.—The anatomical appearances are those of simple catarrhal inflammation—engorgement of the ves- {ls, round-cell infiltration of the mucous membrane, llargement of the glands, and serous infiltration of the ibmucous tissues and muscular walls. Diagnosis.—The affection is at once recognized by in- spection. Care should he taken not to confound the whitish patches on the tonsils and pharynx, as is often done, with follicular ulceration, nor to mistake the epi- demic occurrence of pharyngitis with exudation for a mild type of diphtheria. The easy removal of the de- posit, the absence of abrasion after its extrusion, its obvious origin from the glandules, and its pultaceous character are sufficient to differentiate it from the organ- ized, closely adherent membraniform exudation of true diphtheria. At the same time it should be remembered that the latter affection may originate in the follicles of the pharynx, or develop from what may seem at the first sight a simple folliculitis. Prognosis, Complications, Sequels.—The prognosis in simple acute pharyngitis is always good. The disease generally lasts from three to seven days and ends in reso- lution. Repeated attacks increase the susceptibility, especially in those suffering from constitutional diseases or impoverishment of the blood from any cause. The acute pharyngitis which occurs in blood-poisoning is often a dangerous affection, death taking place from suffocation from pharyngo-laryngeal oedema; or a para- lytic condition of the muscles of deglutition may he in- duced with the consequences which the abrogation of their functions entails. Treatment.—The general principles governingthe con- stitutional and local treatment of pharyngeal inflammation are indentical with those considered under the head of Acute Laryngitis (vol. iv.). Of constitutional remedies the most reliable are opium and quinine taken at the onset of the attack. Alcohol, in the form of whiskey-punch or like concoction, sometimes cuts short the duration of the disease. Local applications should he made with the spray or cotton-carrier. The act of gargling, so univer- sally employed, is open to the objection that it brings into action parts which should he at rest. As a substitute for gargling irrigation may be resorted to or the fluid may he allowed to gravitate into the back of the throat. An ex- cellent and simple method of overcoming the disagree- able symptoms of pharyngeal inflammation is to use in this manner, repeatedly through the day, very hot water, either alone or holding in solution soda, potash, boric acid, or allied substances. Potassium chlorate dissolved in claret wine is an agreeable and effective combination. Relief may also be had from sedative, demulcent, and astringent lozenges. Caution should be exercised in the use of cocaine. While it undoubtedly gives complete temporary relief, I am convinced that in many instances its employment prolongs the duration of the disease. Chronic Catarrhal Pharyngitis.-—Etiology.—The causes of chronic catarrh of the pharynx have been con- sidered in another portion of this work (vol. iv., p. 400 et seq.). It may follow the acute or subacute form, or be due to the extension of chronic inflammation from neigh- boring organs, most commonly the nose and nasal pharynx. There is almost always more or less pharyn- geal irritation or inflammation associated with obstruc- tive diseases of these regions from the mouth-breathing which they necessarily involve. The habitual use of alcoholic drinks and the improper use of the voice are common causes of the disease, and in some persons the use of tobacco seems to play an important part in its pro- duction. It is occasionally the result of reflected irrita- tion from various parts of the body or may occur as a complication of paralytic states of the muscular walls of the pharynx. It may also he the result of direct irrita- tion from impurities in the atmosphere or from various articles of food and drink. The sudden changes from hot to cold, and vice versa, in the temperature of the in- gesta and the injudicious stimulation of the palate by the use of condiments are sometimes important factors in chronic inflammatory conditions of the pharyngeal mem- brane. Symptoms.—The symptoms of this affection are gener- ally most marked upon arising in the morning or after prolonged and improper use of the voice and over-indul- gence of the appetites. There is an accumulation of mu- cus in the throat which gives rise to various sensations, as of a foreign body, sense of constriction, etc. The throat is harsh and dry, the voice frequently hoarse, and the accumulated secretion, which is generally adherent, is removed by hawking or by a peculiar tickling reflex cough. These symptoms may disappear after breakfast, and in mild cases may be absent the remainder of the day. In severer cases there is a constant dryness of the throat with hawking and expectoration of viscid mucus. At night the patient may he awakened from his sleep by a sense of impending suffocation, wThich is only relieved upon moistening the throat and the removal of the inspis- sated secretion. These symptoms generally last for a long time without exciting alarm, hut if neglected, the affection will ultimately end in atrophy. The membrane becomes glazed, dry, and presents a beef-tongue appear- ance ; there is a tendency to crust-formation, and the symptoms detailed above are proportionately aggravated. As chronic pharyngitis is almost always associated with nasal or naso-pharyngeal catarrh, the individual will suf- fer, in addition, from the symptoms characteristic of these diseases. Pathological Anatomy.—The anatomical changes con- sist in a dilated and varicose condition of the blood-ves- sels, especially the veins, with swelling and relaxation of the mucous and submucous tissues. The glands are en- larged and swollen, and present the appearance of mi- nute and shining nodules scattered over the palatal arcade and uvula. In long-standing cases the contents of the follicles undergo caseous degeneration, and pellets or plugs of an offensive odor are formed, which impart a disagreeable odor to the breath (follicular pharyngitis). These are most commonly encountered in the follicular crypts of the tonsils and occasionally acquire a stony hardness (tonsillar calculus). Minute follicular ulcers often result from the discharge of the imprisoned con- tents of the closed follicle. In the so-called glandular or granular pharyngitis, we may distinguish clinically and pathologically two varie- ties. In the one, the chief anatomical characteristic is the presence of elevations of various size and form on the free surface of the membrane (hypertrophy), and to this the term “granular” should he limited, or, perhaps, a better name would be hypertrophic pharyngitis; while in the other, changes in the pharyngeal follicles leading to caseous and calcareous degeneration of their contents are the distinguishing anatomical feature. On inspection of the pharynx, the redness is found either uniformly distributed over the whole pharynx or confined to particular portions, as the palatal arcade, uvula, etc. In the pharyngitis of chronic alcoholism the mucous membrane acquires an angry red look and is 635 Pharynx. Pharynx. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. especially sensitive to local irritation. The inflammatory thickening is not always well marked, but a slightly cedematous condition, especially of the uvula, is frequent- ly present. In many cases the whole mucous membrane presents a relaxed and flabby appearance. The pharyn- geal vessels are commonly enlarged, congested, and vari- cose, and the glandules and follicles of the membrane are enlarged and filled with a whitish or yellowish secretion. Of common occurrence are the familiar pharyngeal gran- ules whose nature has been variously interpreted. Accord- ing to the old idea, they represented enlargements of the glands themselves. Stoerck, on the other hand, main- tained that they are simply hypertrophies of the epithe- lium, while the researches of Saalfeld seem to demonstrate the fact that they consist of an increase in the lymphatic tissue which is found in the neighborhood of the gland- ducts. In many cases these granules seem to constitute the sole pathological element of the pharyngeal affec- tion. Prognosis, Complications, Sequels.—In chronic pharyngi- tis dependent upon a removable nasal or naso-pharyngeal affection the prognosis is good. When due to chronic alcoholism, gout, rheumatism, and allied diseases, the prospects of permanent recovery are less favorable, while in the ‘ ‘ dry ” variety (pharyngitis sicca) temporary relief is, in the vast majority of cases, all that can be looked for. The most interesting complications of chronic pharyngitis are certain motor, sensory, and vaso-motor neuroses, winch will be considered in the Appendix. Treatment. — The treatment of chronic pharyngitis should be conducted on the same general principles which have been discussed in the article on Larynx, Chronic Catarrhal Inflammation of, and which will receive further mention in the section on Chronic Nasal Catarrh in the Appendix. The great secret of success in the manage- ment of this disease lies in the recognition of the fact that, in the large majority of instances, it is a purely secondary affection, and that the chief source of pharyngeal catarrh is an inflammatory condition of the nasal passages or retro-nasal space. It is worse than useless to spray a con- gested or inflamed pharynx with an untreated nasal ob- structive lesion or retro-nasal catarrh; The use of gargles, sprays, and the like in the granular forms of pharyngitis is a sheer waste of time. The granules should be destroyed, and the best agent for the accomplishment of this end is the galvano-cautery. My practice is to bury the end of a small spiral electrode in the centre of the granule, and, in cases in which the growdli is nourished by enlarged vessels, to make a cross- section of the latter with the cautery knife. This soon causes atrophy of the granule and marked relief to the individual. John N. Mackenzie. or, in consequence of inflammatory irritation, it may be covered with granulations and hardly large enough to admit a probe. The internal opening is found in the lateral wall of the pharynx, behind the cornu of the hyoid bone and near the tonsil, or in the pliaryngo-pala- tine arch. The canal varies in length and in diameter, is usually quite tortuous, and sometimes so much so as to be almost impassable to a probe. Its diameter is always greater than that of the external opening, and it can be much increased by retained secretions, when, for any rea- son, the opening lias become stopped. The walls of the passage are thick, and they excrete a discharge which contains pavement epithelium. I). Bryson Delavan. PHARYNX, TUMORS OF THE. I. Fibrous Tumors. — These growths, of fibrous structure, are generally- found to originate from the vault of the pharynx, whence they may extend considerably in many directions, causing absorption or destruction of the neighboring parts, and giving rise to much annoyance and danger to the patient. The disease is rare. Dr. R. P. Lincoln, of New- York, has, however, succeeded in tabulating a list of fifty-eight cases, three of which are original. Of these, not less than thirty-eight wTere genuine fibromata. All occurred in males under the age of twenty-five. Observers agree that this is a disease incident to youth, and almost unknown among females. Some believe- that it may be caused, in some instances, by a scrofulous con- dition of the patient, or by bad hygiene, although there is little to support this view. More plausible is the ex- planation of Morell Mackenzie, who believes that the dis- ease is probably due to the irregular evolution, during the growing period, of a tissue which, under normal con- ditions, is exceptionally abundant on the under surface of the base of the skull. The age (fifteen to twenty-five) at which these growths are prone to originate is pre- cisely the time at which the greater part of the fibrous structures of the body are at the most important stage of their development. It is then that the articular liga- ments are acquiring their firmness, and it seems not un- likely that it is to an exaggerated plastic activity during this phase of growth that fibrous tumors of the pharynx owe their origin. The early symptoms are those of obstruction to the nostril, and of the presence of an unusual object in the pharynx. Obstruction to respiration increases with the en- largement of the growth, and in case the tumor extends far downward, dyspnoea may become severe. As in cases of adenoid hypertrophy at the vault of the pharynx, deaf- ness may result, from pressure upon the orifice of the Eustachian tube, and the sense of smell may be lost. Ar- ticulation may become thick and indistinct, and, in cer- tain cases, there may be severe dysphagia. The secre- tion is generally purulent, and it may be abundant and very fetid. Epistaxis is a common symptom. It is apt to be severe, and to recur often and under slight provo- cation, so that it may be a prominent and dangerous feat- ure of the case. Mackenzie calls attention to the fact that marked drowsiness and a sense of great fatigue are often observed in this condition. The appearance of the tumor is usually smooth, its consistence hard and unyielding, and its color red or bluish-purple. Its surface is often ulcerated. As to the exact seat of its implantation, Nelaton held that the pri- mary point of origin is, in all cases, the periosteum cov- ering a limited area on the under surface of the base of the skull corresponding to the basilar process of the oc- cipital bone and to the body of the sphenoid. When the tumor appears to be attached to other parts, either in the naso-pharynx or in the nose, these are merely points where secondary adhesions have been formed in the course of the expansion of the growth. In the majority of cases, at least, this view is correct, as may be demon- strated by a careful exploration of the pharyngeal cavity. Later in its development it begins to cause deformity of the adjacent bony structures. The nature of this will depend upon the direction taken by the growth. Thus, it may push the soft palate forwmrd and downward, cause exophthalmus, invade the maxillary antrum, causing 1 Flint: Buffalo Med. Journal, vol. xii., p. 718.- PHARYNX, CONGENITAL MALFORMATIONS OF THE. Congenital malformations of the pharynx are of rare occurrence. Fistulous openings are sometimes found, communicating with the pharynx or the trachea, which are evidently of congenital origin. The condition has been described as an embryonic cleft-formation, and has sometimes been called fistula colli congenita. Of congenital malformations of the neck, the pharyn- geal fistula is by far the most common. To this class belong all fistulae which open into the pharynx, or in its direction. They are divided into two varieties, the com- plete and the incomplete. According to Dr. George Jackson Fisher, of New York, they are apt to be heredi- tary, and more than one member of a family may be afflicted. Again, it lias been observed that cleft-forma- tions in other parts of the body have occasionally been associated with this variety of malformation. Pharyngeal fistulae are, as a rule, unilateral, and they occur more commonly on the right side than on the left. They are usually incomplete, and are found with equal frequency in males and females. Their external open- ing is always found upon the side of the neck, and it oc- curs anywhere between the sterno-clavicular articulation and the angle of the lower jaw. It may present the or- dinary characteristics of a congenital fistulous opening, 636