[Reprinted from THE CLIMATOLOGIST, December, 1891.1 
NOTES ON GENERAL versus LOCAL TREATMENT 
OF CATARRHAL INFLAMMATIONS OF 
THE UPPER AIR-TRACT. 
By BEVERLEY ROBINSON, M.D., 
NEW YORK. 
One of the constantly recurring topics of discussion between 
the general practitioner and the specialist is the relative import- 
ance of general and local treatment of catarrhal inflammations of 
the upper air-tract. This depends, no doubt, in great part, upon 
the differences in the field of their observation. Thus the gene- 
ral practitioner regards the body as a whole made up of very 
numerous parts. In the diseases of any particular organ he is 
prone to trace the relations which exist between them and suffer- 
ings elsewhere, and to remark that very frequently it is only in 
proportion as some, more or less remote, organ is favorably modi- 
fied as to its structural or functional disturbance that the disease, 
for which advice is sought, is benefited or cured. True, the 
specialist will say that he makes similar researches to those of the 
general practitioner as far as he is able; and, when at fault, seeks 
other and, as he believes, helpful advice. But is it possible for 
him to do so in all cases, and even if he could, would his final 
judgment of what it is best to do for the patient be as good as if 
the latter had in the beginning the broader advice and treatment 
of a general physician ? These and many other questions of a 
similar kind have been presented and answered, as we all know, 
in opposite manners from the time specialism first showed its 
real strength. In the relations which specialism bears to the 
treatment of inflammatory diseases of the upper air-tract, it is 
often difficult to determine to what extent her influence has been 
useful. At the present time if any one who is thoroughly con- 
versant with general medicine raises his voice before an assembly 2 
of throat and nose specialists in favor of many time-honored 
views, such as the importance of diathesis in the causation of 
these affections, their relations with errors of diet, habit, or mode 
of life; their dependence upon malaria, syphilis, or tuberculosis, 
it is scarcely too much to say that such views are often shown to 
be unpopular and antiquated by the manner in which they are 
received. A few, it may be, of those present are willing to ac- 
knowledge that there is more than a grain of truth in opinions 
thus expressed; but the majority shakes its head negatively and 
merely considers the writer, or teller of the story, as a benighted 
person of a past era. 
The reverse of the picture is, however, also true and not seldom 
encountered. And here I mean those very conservative practi- 
tioners who still regard the knowledge acquired by the laryn- 
gologist and rhinologist as of very doubtful value, and who no 
more believe in the untold ills occasioned by hypertrophy of the 
turbinated bodies, or a deviation of the septum, than they do in 
anything else that to them is somewhat mythical. I believe, and 
I always have believed, that the true position is held, and only 
can be held by the general practitioner, who has sufficient special 
training to allow him to be fully appreciative of what is being 
done properly in that line, but who is in daily contact, also, with 
the multiform diseases of the human economy in almost every 
organ. 
On the latter ground, which I regard as terrafirma, figura- 
tively, I have long stood. Each year, as it passes, more 
thoroughly convinces me of the soundness of my views. 
To pass from these general remarks to the study of our sub- 
ject, I would begin by asking, What does it profit a man's nose 
to be sawed, gouged, or trephined, because the pituitary mem- 
brane is inflamed ? Does it improve more rapidly than if the old 
methods of inhaling, spraying, and douching were continued ? To 
these queries, of course, no general answer can be given which does 
not, of necessity, carry with it numerous exceptions. After all, 
however, it is useful to point out certain rules of guidance which 
shall enable us to practise intelligently, and to do what is sensible 
with the various special cases as they arise. 
I am of the opinion that in instances of marked obstructive 3 
disease of the nasal passages due to the presence of mucous polyps, 
or a bony or cartilaginous overgrowth of tissue, that freedom should 
be given to nasal respiration by means of suitable operative 
interference, provided always that the obstruction is wholly depend- 
ant upon one or other of these conditions. When, however, the 
obstruction is only of such a character as to be really objection- 
able when inflammatory disease of the mucous membrane of the 
nasal passages is, so to speak, grafted upon, or attached to it, the 
problem is not so easily solved. A large proportion of adult 
persons have more or less obstruction of one or the other nasal 
passages in a certain sense. I mean by this that one nasal pas- 
sage is less free than the other. 
This can be readily determined by those present in pressing 
gently upon one naris, and then breathing in and out through the 
other nasal passage. When they have tested one nasal passage 
in this manner, let them reverse the process by pressing on the 
other naris and drawing the air with each inspiration into the 
nasal passage, which was at first closed, with the finger. The 
statement which I have just made, and which has been repeated 
by me on several occasions, proves conclusively to my mind, that 
we must not expect all adults to breathe equally well through both 
nasal passages. Are such persons to be considered in an abnormal 
or unhealthy condition and requiring operative interference ? My 
anwer is: If the obstruction be permanent, and evidently causes 
disease in adjacent organs, as the eye, ear, or larynx; or if the 
patient be visibly annoyed, or distressed by the existing condi- 
tion, it should be removed. If, however, the obstruction be 
only occasionally objectionable, and at such times depends upon 
the swelling and engorgement of the pituitary membrane, then 
some suitable local applications are all that is required, unless the 
constitutional condition, or the condition of some organ be such 
that we find the indications for general treatment. If local appli- 
cations alone be required, it is, of course, very important to make 
those that are beneficial. And here it is that the wisdom of the 
practitioner,is essential. If the lining membrane of the nose be 
already acutely or chronically inflamed, we must not increase 
these conditions. It will not do, for example, to try warm inha- 
lations, or warm sprays, upon an inflammatory condition of a few 4 
hours' standing, and afterwards allow the patient to go into the 
open air. Especially is this true, if there be any febrile move- 
ment in connection with the inflammatory process. 
Again, whilst there is a small proportion of patients who ob- 
viously get a measure of relief, usually temporary, from the use 
of the nasal douche, yet this means of treatment has been shown 
to occasion additional obstruction of the nasal passages in very 
many cases. Not infrequently, even when certain precautionary 
measures have been adopted, the ears have become acutely in- 
flamed, and gone on to suppuration, following its use. Applica- 
tions in the form of spray of a soothing and protective coating 
like that of vaseline, or cosmoline oil (or the proprietary distilla- 
tions called variously albolene, benzomo, glymol, etc.) have a 
great advantage in that they do no harm, and often ameliorate 
the unpleasant symptoms from which the patient suffers. 
Although this statement is undoubtedly true, I have always 
present to my mind the fact, that with an engorged liver and 
portal system, unless a few repeated moderate doses of salts be 
given, the nasal obstruction will often continue most obstinate 
and rebellious. A passing bilious attack, with coated, broad, 
flabby, indented tongue, coppery taste in the mouth, slight nausea, 
belching of wind, tenderness on pressure over the epigastrium, 
torpid or relaxed bowels, will often be the forerunner or accom- 
paniment of nasal inflammation producing obstruction, which will 
only yield definitely to abstemious living and the use of appro- 
priate alkaline remedies. These attacks may be infrequent or 
frequent, depending much upon the habits and constitutional 
tendencies of the patient. After many such attacks the liver has 
slight permanent enlargement, and the stomach fixed catarrhal 
inflammation. When this is the case we shall often find chronic 
hypertrophy of the turbinated bodies, doubtless occasioned by 
frequent recurrent inflammations, and which can only be reduced 
to a condition permitting free nasal respiration by one or more 
cauterizations with acid or electro-cautery. And here I would 
direct attention to the fact of the very great relief afforded to the 
patient in this manner. Patients who, previous to the cauteriza- 
tion, had been uncomfortable during the day, and sometimes almost 
sleepless during the night, owing to their absolute inability to get 5 
air through their nasal passages, are restored to peace and tran- 
quillity in a few days, or even twenty-four hours, by an innocuous 
operation in the great majority of cases. To any one who has 
witnessed the great discomfort, or even absolute suffering, of an 
individual who has pronounced nasal obstruction, caused in part 
by thickening of the nasal mucous membrane, and aggravated by 
an acute inflammatory attack, the amount of positive relief 
afforded by this local interference is a source of great satisfaction, 
and, if seen for the first time, of genuine wonder. Whilst entire 
relief may frequently be afforded by one or more simple cauter- 
izations, there are times where more positive action still is re- 
quired on account of a thickened, or deviated septum. In these 
instances we must make use of Jarvis's or Weir's forceps, the nasal 
saw, or the nasal trephine. Here I would, however, throw out a 
warning note, that these instruments should be used only when 
really required, as their employment makes a raw surface which 
requires time and care to heal entirely, and in rare instances 
leaves an ulceration or scarred area, which causes long-continued 
pain and irritation. Usually speaking, however, the operative 
procedures on thickened turbinated bodies, or a deviated or 
thickened septum in a nose in which the condition inside is 
markedly hypertrophic, are not followed by unpleasant sequelae 
nearly so often as when the inflammatory condition takes on an 
atrophic character. There is, however, a wide-spread belief, not 
only amongst general practitioners, but also amongst specialists, 
that the hypertrophic variety of rhinitis, with considerable occlu- 
sion of the nasal passages, is the form of disease which occasions 
most of the distressing symptoms connected with adjacent organs, 
as the eyes, ears, tonsils, pharynx, larynx, and bronchi. 
In my belief, this is not true, for several reasons. Tn the first 
place, when nasal obstruction becomes very pronounced, it is 
usually so distressing that the patient demands local interference, 
and this latter occurs usually before serious complications arise. 
Besides, so soon as the nasal passages are freed by cauterization, 
or other operative procedure, the relief afforded to the patient is, 
as a rule, rapid and evident. Finally, to repeat myself, the com- 
plications of an obstructed nose are not so considerable or fre- 
quent as one is led to infer by reading late periodical literature on 6 
this subject. Of course, suppurative otitis, sunken drum mem- 
branes, ankylosed ossicles, chronic conjunctivitis, hay fever, or 
bronchitic asthma, may all be occasioned by occluded nasal 
passages. 
It is well to remember, however, that the worst forms of these 
troubles are usually found in patients who have free nasal respira- 
tion, and are unmindful, to a great degree, of their intra-nasal 
condition until their attention is directed to it by the specialist 
as the cause, or concomitant condition, of disease in adjacent 
organs. The relatively free nasal passages with dry irritable 
membrane, somewhat glazed surface and obvious thinning of the 
membrane itself, whilst the vessels often bleed profusely from the 
slightest irritation, are the cases which I dread the most, so diffi- 
cult do I find it to improve or wholly relieve this condition. 
Here, again, the question comes up, How must we treat these 
cases, locally or generally, or by a happy combination of both 
kinds of treatment ? In these instances, all harsh local measures 
should be absolutely avoided. In some of them I have found 
that cauterizations, especially with the electro-cautery, have 
healed with great difficulty. Indeed, on one occasion that I 
recall with considerable regret, although fortunately I was not 
the operator, I doubt very much if the ulceration ever got 
entirely well. There seems to be so little vitality in the tissues 
that they are unable to recover from any loss of substance, 
except with the greatest care and attention on the part of the 
physician. 
In the way of local remedies of very many kinds that I have 
tried in the form of inhalations, sprays, and powders, there are 
none which have been of very great value in establishing a cure. 
I am of the opinion, however, that mild carbolized ointments, 
applied upon cotton-wrapped probes, have been most useful in 
relieving the dryness and irritability of the nasal mucous mem- 
brane. 
In those individuals particularly, in whom the tendency to the 
formation of crusts and scabs is most pronounced, there is nothing 
so beneficial locally as keeping the surfaces constantly coated with 
an ointment, the base of which is vaseline or oil. Goulard's 
cerate is one of my favorite remedies, 'when it is freshly made and 7 
when the crusts are attached to the septum near the nares. In- 
deed, whenever these crusts are intimately adherent to an ulcera- 
tion of the septum at this level, and are related to it either as a 
cause or a result, I have found latterly that I have obtained as 
good or better results by keeping the crusts and underlying mu- 
cous membrane thoroughly lubricated with an ointment, as by 
occasional applications of any astringent or caustic fluid. The 
saturated solution of the sulphate of copper was formerly much 
used by me in these cases, but during the past two years, especi- 
ally with my patients who will carry out my instructions care- 
fully, I rarely employ this application. Inasmuch as I find a 
diathetic condition present in many instances, notably rheumatism 
or gout, I have sent such patients to Sharon or Richfield, during 
the summer, and during the winter I find judicious alkaline 
treatment, with or without the addition of colchicum, as the most 
beneficial I can institute. Indeed, without this general medica- 
tion, I find that local treatment has comparatively little value. 
Take, for example, those too frequent cases of atrophic catarrhal 
inflammations of the nasal and naso-pharyngeal mucous mem- 
brane, which ultimately produce such regrettable results in caus- 
ing chronic dry proliferative aural catarrh. The sunken drum- 
heads aud ankylosed ossicles are, in these instances, as we all 
know, the anatomical factors connected with greatly impaired 
hearing and tinnitus aurium of a sort to relieve which anything 
done locally, short of removal of the membrane and ossicles them- 
selves, seems wholly powerless. 
Whilst I cannot claim from any general treatment to have 
cured these conditions when they were far advanced, or when the 
tinnitus had become a constant symptom in the disease, I am 
quite sure that I have prevented the local stage more than once 
from reaching that state in which life itself is at times almost 
unendurable from unceasing noises in the head. This surely is no 
small thing accomplished, if we once realize how many bright 
intellects have gone to waste, and how many times the happiness 
of a household has been destroyed by an affliction which the 
aurist alone claims to treat, and which, I believe, properly under- 
stood, may surely be helped by the timely intervention of the 
general practitioner. 8 
I know a lady in middle life, formerly a patient of mine, who was 
a constant subject for eye, ear, and throat treatment during several 
years, who now allows these organs to remain unmolested because 
she does not suffer with them, and because she has been greatly 
improved in general health by strictly carrying out treatment 
suitable to her rheumatic dyscrasia. 
I had a young lawyer friend and relative under my care some 
years ago, who has since died, after a too brief and brilliant 
career, who was more relieved of the distressing symptoms con- 
nected with chronic aural catarrh by two seasons at Aix-Les- 
Bains than he ever was by the continuous treatment of different 
distinguished aurists and laryngologists in America and Europe. 
Such examples have made a lasting impression on me, and with 
a broader and larger experience I feel competent to give them 
their full value aud to translate their bearings to those before 
whom I have the pleasure and honor of reading this paper. 
There is a most obstinate form of cough occasionally explained 
by hysteria, anaemia, a disordered stomach, fibroid changes in the 
lungs, puberty (as Sir Andrew Clarke would have us believe), 
which, I am sure, is simply dependent upon an enlarged lingual 
tonsil. 
Try all kinds of general treatment that you may, give change 
of air and habits, tone up the system by every sort of corroborant, 
and sometimes such a cough will defeat all your best directed 
efforts. Local treatment judiciously employed, will alone at times 
relieve persons thus affected. 
Such a case was under my care for several weeks last winter at 
St. Luke's Hospital, New York City. The patient was a young 
woman, single, and somewhat anaemic, and presumed to be hys- 
terical. From these standpoints all rational treatment was tried 
until it was proven to be utterly futile. The patient was then 
placed in my charge. Upon examination I found she had a 
very much enlarged lingual tonsil which pressed upon the an- 
terior surface of the epiglottis and lapped over a portion of its 
free margin. 
Active cauterization with the electro-cautery repeated several 
times at intervals of a few days, reduced materially the size of the 
tonsil and relieved the cough entirely. 9 
I would not have my hearers believe, however, that all enlarge- 
ments of the lingual tonsil can be thus cured. On the contrary 
in some cases that I have seen even after very thorough cauter- 
izations the tonsil has remained undiminished as to its increased 
size, or else it has been smaller for a time and afterwards has be- 
come, more or less rapidly, quite as large as it was at the beginning 
of local treatment. 
Finding this to be true, I have naturally searched for the cause. 
In some instances I have found the profession at fault, or, rather, 
the use of the voice adjoined to a profession which is especially 
trying to the vocal powers. In more than one instance the voca- 
tion was that of a nurse, in another a preacher, in a third a 
broker. 
Occasionally the profession itself did not seem unfavorable until 
upon close questioning, the patient showed that from necessity he, 
or she, was forced to make immoderate, or injudicious, use of the 
voice. This bad habit was frequently allied to a general con- 
dition decidedly poor in which anaemia and lowered nerve- 
nutrition were clearly integral factors in the case. Of course the 
treatment in these examples was directed as far as could be to the 
correction of the evident great defects in the mode of life. 
Occasionally I have discovered that an underlying rheumatic 
dyscrasia was alone at fault, and so evident has this been-not- 
ably in one of my cases reported in the New York Medical 
Record, last winter, that every time the joints became more or 
less painful the throat was relieved and the lingual tonsil was 
visibly smaller in size and less angry looking. In a patient under 
my care at the present time, a bachelor forty years of age, of ex- 
cellent general health, with, however, a rare outbreak of litluemia, 
owing to too rich diet, there have been at various times marked 
symptoms of throat irritation due obviously to the presence of an 
enlarged lingual tonsil. More than once the most annoying 
symptom was that of a recurrent, obstinate, paroxysmal cough 
with little expectoration of phlegm. In fact there were scarcely 
any sputa at all, but merely an unpleasant feeling of dryness 
localized at the base of the tongue, and the occasional raising of a 
small pellet of inspissated mucus. This dryness could be quite 
effectually soothed for a while by applications of' carbolic acid and 10 
glycerine (fifteen grains to the ounce). Unfortunately, this 
sensation soon returned, and nothing I could do would entirely 
relieve it. After a somewhat prolonged hot spell, with a close, 
muggy atmosphere, my patient had a very distressing attack of 
facial eczema. No sooner had the eruption fairly appeared around 
the angles of the mouth, and on the skin of the upper lip, than all 
the throat symptoms disappeared, and the patient had no longer 
any of the throat disturbances to which I referred a moment ago. 
Occasionally the phenomena are different from those already de- 
scribed, and the sensation of a foreign body constantly in the 
throat, with that of a band constricting it more or less tightly, is 
what the patient complains of. Every effort of swallowing is 
painful and difficult, and at night the choking feelings are such 
that these patients are either prevented from going to sleep, or if 
they do sleep for a few hours, they awaken with a start and in a 
state of terror difficult to control. Their breathing is obviously 
obstructed, their face congested, and large drops of perspiration 
stand out as beads upon the forehead, thus betraying their anxiety 
and physical distress. Steam inhalations impregnated with 
turpentine, or benzoin vapors will relieve such cases when noth- 
ing else will. Beware of attributing them to the existence of 
spasmodic asthma, or to that sort of dyspnoea and dread caused 
by a chronically diseased and laboring heart. Last spring I had 
under my care a young lady sent to me from the New York 
Hospital, who had gone without solid food during six weeks for 
fear lest she should choke to death if she made an attempt to 
swallow anything of firm, or semi-solid consistence. All my per- 
suasive efforts, all my simulated severity remained without effect 
for many weeks, and my patient grew weaker daily, and was the 
source of much solicitude to her family and friends. It is true 
that in this case there was a marked nervous element present, and 
yet antispasmodic drugs, although thoroughly tried, were not of 
the slightest benefit. The lingual tonsil itself was notably enlarged, 
and at one time lapped over the free border of the epiglottis in 
such a way as to considerably interfere with the movement of this 
organ during deglutition. 
I burned away this portion of the tonsil with the galvano- 
cautery, and hoped thus to give relief to my patient. Unfortu- 11 
nately I failed in my endeavor, and it was finally determined to 
try what vigorous outdoor exercise, especially riding on horseback, 
more attractive surroundings, and complete abandonment of local 
treatment, would do for her. The result is not at present known 
to me. I am of the opinion, howrever, in view of this and other 
instances of an analogous character met with, that many cases of 
so-called " globus hystericus," are unquestionably dependent upon 
the presence of the enlarged lingual tonsil. I am not at all sure 
that all these cases will be cured, or even benefited by rational local 
treatment. I am persuaded, however, that some sufferers must 
be thus treated in order to effect a cure. In view of these state- 
ments it should also be urged that in hysterical girls not only 
should we examine the condition of the throat to see if the lingual 
tonsil be enlarged, but also inquire closely into the condition of 
the uterus and its function. An anteverted or retroverted uterus 
with profuse or painful menstrual periods, is often, as we know, 
the source and pabulum, so to speak, of the hysterical and anaemic 
condition, and, incidentally, such conditions are likewise efficient 
factors in producing enlargement of the lingual tonsil. I think 
all present will therefore agree with me, that a wise specialism 
makes one extremely conservative and loth to interfere unduly, 
either medically or surgically, with apparent abnormal states of 
one organ, before the other organs and the general system have 
been brought under the closest scrutiny. As I become older, and 
I trust better versed in the practice of medicine,- nothing fills me 
with more wholesome regrets than the knowledge of the large 
numbers of persons who are victims of well meaning, but also 
very narrow and ignorant advice and doing. 
If the patients of these blind men fell into the ditch together 
with their counsellors there might be some slight compensation to 
intelligent observers, but when the former alone are the sufferers 
in having their pockets depleted and their bodies made more ailing, 
there is in truth no equivalent, ever so small, to be found. In 
some of the instances of enlarged lingual tonsils, we shall notice 
that the faucial tonsils are also increased in size, and there is more 
or less adenoid hypertrophy at the vault of the pharynx. In more 
numerous cases the fauces, pharynx, palate, and even the faucial 
tonsils themselves are in relatively very good condition, and unless 12 
we make use of the laryngeal mirror, or attach absolute credence 
to the symptoms referred to already, we should be prone to be 
skeptical as to the existence of the enlarged lingual tonsil. One 
glance, however, into the large reflecting laryngeal mirror is 
enough to do away immediately with all our doubts, as we shall 
see the glosso-epiglottic fossae wholly filled up with a large mass 
of adenoid tissue where normally, as we know, there are two quite 
considerable excavations. One of the errors of the day, as I 
believe, on the part of some of the throat specialists, even the 
most eminent, is to attribute too great importance to the nasal 
organ as a cause of laryngeal inflammations. This is so true, 
that at least one of the physicians to whom I refer appears to 
believe that we may safely ignore much treatment, either local or 
general, directed to the larynx, and that by sawing off any pro- 
jections which may exist from the nasal septum the larynx will 
right itself, the hoarse voice will become pure again, and painful 
deglutition an unconscious act. 
Speaking in this connection Bosworth writes as follows (Trans. 
Am. Clim. Assoc., 1884, p. 67): " Chronic catarrhal laryngitis, 
then, I believe to be really a symptom rather than a disease. It 
is one of the results and accompaniments of catarrhal inflam- 
mation of the nasal mucous membrane, rather than a morbid 
process commencing in the laryngeal cavityand upon page 68 
he writes : " In the past three years I do not recall a single case of 
chronic laryngitis which has not been cured. During this period 
I have entirely abandoned all local applications to the larynx, and 
have treated the nasal disorder which I have found to be present 
in every case." 
I cannot share such views and mainly for the reason that I see 
too many acute and subacute cases of laryngeal inflammation, in 
which this condition is the essential disease from which the 
patient suffers, and upon which all his painful symptoms depend. 
If we treat these patients solely with general remedies, we ob- 
tain, usually, poor and slow results. They must be treated 
locally, and after a large experience I am confident that astrin- 
gent applications and soothing sprays, notably of carbolic acid 
and the bicarbonate of soda, are most beneficial. Occasionally, 
however, both local and general treatment of the most rational 13 
kind will prove to be wholly ineffective and the patient will con- 
tinue to cough and expectorate indefinitely, or until we give him 
a radical change of air. If he be at the sea-shore, send him to 
the mountains; if he be in the interior where the air is dry, 
elevated, and bracing, let him have the moist and more soothing 
atmosphere of a healthful resort upon the coast. If he be in a 
large city or town, transport him into a more salubrious environ- 
ment such as either mountain or sea-air afford. 
With respect to change of locality, there is one consideration 
which should be borne in mind, that is the fact of the presence 
of malarial germs in many places in this country. If unfortu- 
nately our patient be already a sufferer from miasmatic poisoning, 
he will be more surely benefited, as a rule, by judicious anti- 
malarial medication, so far as the inflammation of his upper air- 
passages is concerned, than by any mere change of climate. 
There are, however, exceptions to this law, and I have occasion- 
ally known patients in whom medicines had become of very little 
service, where a change caused very rapid and marked amelio- 
ration of their condition. If our patient, thus affected, go to 
another malarial place, he will derive no benefit whatever from 
change. If he go to a relaxing sea-side resort, even if it be 
wholly free from malaria, he will not surely get rid of his catarrh, 
his cough, or his general throat irritation. I have been witness 
too frequently, during the past ten or twelve years, of instances 
in which patients have gone to the sea-shore with the anticipation 
of being thus benefited, and who have returned home much dis- 
appointed at a different result, not to attach great importance to 
my statement. I am not sure that sea-side places do ultimate 
harm to malarial patients. I am confident, however, that they 
bring out more prominently certain malarial manifestations, which 
previously had been latent or ignored. Among these symptoms 
those pertaining to the nasal passages and throat were particularly 
harassing. During the past summer at Newport, Rhode Island, 
important facts relating to this subject have become indelibly 
stamped in my mind. Thanks to the learned and courteous co- 
operation of my friend Dr. Siegfried, surgeon in the United States 
Navy, I have been able to observe in several cases hsematazbon 
malarise of different and interesting forms in the blood of those 14 
who had other and different ailments it is true, but who, also, 
were constant, or periodical sufferers from catarrh, pharyngitis, 
laryngitis, or some form of catarrhal inflammation of the upper 
air-tract. 
One subject which has been of very great interest to a large 
number of accurate and painstaking clinical observers has been 
that of the proper treatment of hay fever, or hay asthma. Of 
course these cases like other instances of disease, are not all 
similar, and the treatment which appears to be of great benefit at 
times, is wholly negative at others. Still in reflecting upon my 
own experience with this disease, I am confidently of the opinion 
that local treatment is more important than change of residence, 
and, further, that the peripheral nerves in the inflamed nasal 
mucous membrane are oftener a source of the sneezing and other 
painful symptoms of the disease than the great irritability, or 
sensitive condition of the nervous centres. 
I have read with much interest some of the contributions of 
Dr. Beverly Kinnear in regard to the remarkable curative effects 
obtained by him in the treatment of hay fever with the spinal 
ice-bag. I have not, I regret to say, been entirely convinced by 
his statements, either of the entire correctness of his theories or 
of the curative results obtained. 
Whilst it seems to me proper to make this statement in view 
of the great importance Dr. Kinnear attaches to his treatment 
with the ice-bag, I am happy to add that in conjunction with 
cauterization of the most sensitive areas in the nose by means of 
the galvano-cautery, or carbolic acid and glycerine, I believe very 
favorable results can be obtained in a large number of instances 
of an obstinate and most painful disease. 
There are many other topics that I would like to touch upon 
even lightly and thus have the benefit in the discussion which I 
trust will follow my reading of this paper, of your own important 
observations and study. Time and your already tried patience 
forbid me to continue. To sum up. What I desire to say and 
what I wish most clearly to emphasize is this: For the best 
treatment of inflammatory affections of the upper air-passages, 
the general practitioner and the specialist must really work 
together. You can scarcely separate them if the work accom- 15 
plished is to be wholly satisfactory. Therefore either the patient 
must have two physicians to care for him, or he must look to his 
family medical adviser for such a measure of knowledge in regard 
to laryngology and rhinology as to render him able and willing to 
treat inflammatory conditions of the upper air-passages according 
to the latest and most approved methods. There will always re- 
main, however, a certain number of patients wrho in view of special 
complications, or difficulties pertaining to their disease, will im- 
prove sooner if they are taken care of exclusively from the begin- 
ning of their trouble and throughout its duration, by the well- 
informed specialist. When a proper estimate is made of the 
greatest good to the greatest number in instances in which only 
one physician can be employed, I am confident that the verdict 
should be that the general physician with only a limited experi- 
ence in the treatment of nasal and throat diseases, will be a safer 
and wiser guide than the most skilful and best versed specialist. 
DISCUSSION. 
F. II. Bosworth, M.D. I have been much interested in 
Dr. Robinson's paper, and the admirable manner in which he has 
presented the subject. I do not recall a better presentation of the 
subject of the lingual tonsil. When he speaks of the influence 
of the general system on catarrhal diseases, I think that we are 
confronted with a certain vagueness in the expression "catarrh." 
The systemic influence upon diseases of the naso-pharynx I fully 
concede, for they are notably influenced by rheumatism, gout, 
and diseases of that kind, and especially by derangements of the 
digestive apparatus. When we come to diseases of the nasal 
cavity proper I am disposed to think that they are but in a very 
slight degree affected by constitutional conditions. This distinc- 
tion between the nose and the naso-pharynx I regard as very 
important, and Dr. Robinson has not sufficiently regarded it. 
E. L. Shurley, M.D. I too, fully, indorse what the writer of 
the paper has said. It has always seemed to me that this matter 
of nasal hypertrophy was a relative thing. Regarding bald heads 16 
we don't know how long it will be before bald heads will be 
normal I 
So that, for the purposes of this discussion, we might adopt the 
standard that those noses presenting hypertrophied turbinated 
bodies or deflected septa are normal, and become abnormal only 
as soon as they produce some subjective symptom or other of dis- 
comfort. It may be, that the man under observation is a chronic 
snuff-taker, with nasal mucous membrane in a state of continual 
irritation. Now, it is useless to burn such a person's nasal mucous 
membrane as long as the habit is indulged. Therefore it occurs 
to me, that unless the nasal passages present stenosis from chronic 
structural change, or from more recent inflammatory change, or a 
growth which results from such causes that surgical interference 
is not necessary. A few years ago I presented a paper to the 
American Laryngological Association on the result of, I think, 
about two hundred observations of the naso-pharynx and pharynx 
of persons met with in hospitals and elsewhere, who did not com- 
plain of any nasal, naso-pharyngeal, or pharyngeal disturbances, 
many of whom were affected with enlarged tonsils and various 
degrees of swelling and congestion of these mucous membranes. 
I know now of two persons who are very fine singers with greatly 
enlarged tonsils and who will not consent to have their tonsils cut. 
They have such immense tonsils that I am sure any one of us 
would advise such cutting. Therefore, as I said before, I think 
this is a relative matter. We have no standard which can be 
followed as to surgical treatment on a purely local basis.