SYSTEM OF DISEASES A U t a. OF THE 0 EAR, NOSE, AND THROAT. EDITED BY CHARLES H. BURNETT, A.M., M.D., in ' ’ ’ EMERITUS PROFESSOR OF OTOLOGV IN THE PHILADELPHIA POLYCLINIC; CLINICAL PROFESSOR OF OTOLOGY IN THE WOMAN’S MEDICAL COLLEGE OF PENNSYLVANIA; AURAL SURGEON TO THE PRESBYTERIAN HOSPITAL, ETC., PHILADEL- PHIA, PA. VOL. II. ILLUSTRATED. PHILADELPHIA: J. B. LIPPINCOTT COMPANY. London: 10 Henrietta Street, Covent Garden. 1 89 3. Copyright, 1893, BY J. B. Lippincott Company. Printed by J. B. Lippincott Company, Philadelphia, U.S.A. CONTENTS OF VOLUME II. xi. DISEASES OF THE NOSE AND NASO-PHARYNX. PAGE MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVI- TIES: PATHOLOGY, ETIOLOGY, PHYSIOLOGY, AND DIFFER- ENTIAL DIAGNOSIS. By Carl Seiler, M.D., Lecturer on Laryngology in the University of Pennsylvania ; Chief of the Throat Dispensary in the Uni- versity Hospital; Late Curator of the Pathological Society, etc., Philadelphia . 1 SURGICAL PROCEDURES IN DEFORMITIES AND NEOPLASTIC GROWTHS IN THE NOSE. By William Chapman Jaryis, M.D., Pro- fessor of Laryngology and Diseases of the Nose and Throat, New York Univer- sity Medical College; Consulting Physician to Out-Patient Department, Bellevue Hospital; Visiting Physician to Charity Hospital, etc., New York 39 HAY-FEVER. By Francke H. Bosworth, M.D., Professor of Throat Diseases in Bellevue Hospital Medical College, New York 66 NEUROSES OF THE NOSE AND NASO-PHARYNX. By Joseph A. White, A.M., M.D., Senior Surgeon to the Richmond Eye, Ear, Throat, and Nose Infirmary, Richmond, Virginia 90 DISEASES OF THE EYE DEPENDENT UPON DISEASES OF THE NOSE, AND REFLEX NASAL DISEASE DUE TO OCULAR MALA- DIES. By George M. Gould, A.M., M.D., Ophthalmologist to the Philadel- phia Hospital 149 SKIN DISEASES OF THE NOSE. By L. Duncan Bulkley, M.D., Professor of Dermatology and Syphilis, New York Post-Graduate Medical School and Hospital; Attending Physician to the New York Skin and Cancer Hospital, etc., New York 173 (CONTINUED.) 3?_A_III. DISEASES OF THE PHARYNX AND LARYNX. ANATOMY AND PHYSIOLOGY OF THE PHARYNX AND LARYNX. By Alexander W. MacCoy, M.D., Professor of Laryngology in the Philadel- phia Polyclinic and College for Graduates in Medicine; Fellow of the American Laryngological Association, etc., Philadelphia, Pennsylvania 192 III IV CONTENTS OF VOLUME II. PAGE VOCAL CULTURE AND HYGIENE. By S. Hartwell Chapman, A.M., M.D., Fellow of t*he American Laryngological Association; formerly Lecturer on Laryngology and Otology in Yale College, etc., etc., New Haven, Con- necticut 212 ACUTE PHARYNGITIS. By Max Thorner, A.M., M.D., Professor of Clinical Laryngology and Otology, Cincinnati College of Medicine and Surgery ; Laryn- gologist and Aurist, Jewish Hospital; Consulting Laryngologist, Ophthalmic Hospital, etc., Cincinnati, Ohio 250 ACUTE TONSILLITIS. By C. E. Bean, M.D., St. Paul, Minnesota 274 CHRONIC PHARYNGITIS. By E. Fletcher Ingals, M.D., Professorof Laryn- gology and Practice of Medicine in Rush Medical College ; Professor of Diseases of the Throat and Chest in Woman’s Medical College ; Professor of Laryngology and Rhinology in Chicago Polyclinic, and Laryngologist to the Presbyterian and St. Joseph’s Hospitals, etc., Chicago, Illinois 284 ACUTE LARYNGITIS. By Jacob D. Arnold, A.M., M.D., President and Pro- fessor of Laryngology, San Francisco Polyclinic and School for Post-Graduate Instruction; Consulting Surgeon, Children’s Hospital, etc., San Francisco, California 805 CROUP. By William Carr Glasgow, M.D., Professor of Practice of Medicine, Diseases of the Chest, and Laryngology, Missouri Medical College, St. Louis, Missouri 328 DIPHTHERIA. By J. Lewis Smith, M.D., Clinical Professor of Diseases of Children, Bellevue Hospital Medical College, etc., New York 343 THE SURGICAL TREATMENT OF CROUP AND DIPHTHERIA. By Charles B. Nancrkde, M.D., Professor of Surgery and of Clinical Surgery in the University of Michigan, Ann Arbor, Michigan 390 LUPOUS AND LEPROUS LARYNGITIS. By Ramon de la Sota y Lastra, M.D., Ph.D., LL.D., Professor of Surgical Pathology in the Medical School of Seville; Laryngologist and Dermatologist in the Polyclinic of the same ; Knight of the Royal Order of Carlos Tercero ; Corresponding Member of. the American Laryngological Association, etc.; Seville, Spain. Translated by David Cerna, M.D., Ph.D., Late Assistant in Physiology, Demonstrator of, and Lecturer on, Experimental Therapeutics in the University of Pennsylvania; Corresponding Fellow of the Sociedad Espanola de Higiene of Madrid, etc. ; Galveston, Texas . 412 CHRONIC LARYNGITIS, SIMPLE AND TRAUMATIC. By E. L. Shurly, M.D., Professor of Clinical Medicine and Laryngology in the Detroit College of Medicine; Chief of the Medical Staff of Harper Hospital, Laryngologist to St. Mary’s Hospital, etc., Detroit, Michigan 457 FOREIGN BODIES IN THE LARYNX AND TRACHEA, AND IN THE PHARYNX AND CESOPHAGUS. By John O. Roe, M.D., Rochester, New York, Fellow of the American Laryngological Association; Corresponding Member of the Societe Frangaise d’Otologie, de Laryngologie et de Rhinologie; Member of the British Medical Association, etc . 500 CHRONIC DISEASES OF THE TONSILS. By Charles H. Knight, M.D., Professor of Diseases of the Throat and Nose, New York Post-Graduate Medical School; Surgeon to the Manhattan Eye and Ear Hospital, Throat Department; etc., New York 571 CONTENTS OF VOLUME II. V PAGE THE PHARYNX AND LARYNX IN THE EXANTHEMATA AND OTHER FEBRILE AFFECTIONS. By Rufus P. Lincoln, M.D., Member of the New York Academy of Medicine, of the American Laryngo- logical Association, of the American Climatological Society, etc., New York City 622 NEUROSES OF THE LARYNX AND OF THE PHARYNX, AND DYS- PHAGIA. By W. Peyre Porcher, M.D., Lecturer on Laryngology and Rhinology and on Materia Medica and Therapeutics in the Charleston Medical School; One of the visiting Laryngologists to the City Hospital, etc., Charles- ton, South Carolina 669 DEFORMITIES AND MORBID GROWTHS OF THE PHARYNX AND THE LARYNX. By Lennox Browne, F.R.C.S. Ed., Senior Surgeon to the Central London Throat and Ear Hospital; Surgeon and Aural Surgeon to the Royal Society of Musicians; President of the British Laryngological and Rhinological Association, etc., London, England 709 TUBERCULOSIS AND SYPHILIS OF THE LARYNX. By J. Solis Cohen, A.M., M.D., Professor of Laryngology in Jefferson Medical College, etc., Philadelphia, Pa 792 LIST OF ILLUSTRATIONS TO VOLUME II. PAGE Left Nans with Hypertrophy of the Mucous Membrane (Zuckerkandl) 9 Right Nasal Chamber containing Two Large Polypi (Zuckerkandl) 9 Nasal Polypi with Slender Pedicles (Zuckerkandl) 10 Left Nasal Cavity with a Papilloma on the Inferior Turbinated Body (Zuckerkandl) 15 Transverse Section of Framework of Superior Maxilla, Anterior Segment. In the left antrum of Highmore is a large polypus (Zuckerkandl) 27 Outer Wall of Left Nostril (Seiler) 27 Synechia in Left Nasal Chamber (Zuckerkandl) 30 Transverse Section of the Framework of the Superior Maxilla, Anterior Segment showing Deviated Septum (Zuckerkandl) 37 Transverse Section through the Framework of the Superior Maxilla, Posterior Seg- ment showing Deformity 37 Contraction of the Maxillary Sinuses in Consequence of Excessive Outward Devia- tion of the External Nasal Walls (Zuckerkandl) 38 Sigmoid Deflection of the Septum, probably the Result of Fracture (Zuckerkandl) . 38 Oro-Pharynx and Soft Palate (Browne and Behnke) 192 Muscles of the Soft Palate and Pharynx (Gray and Browne) . « . . 193 Sectional View of the Pharynx (Lennox Browne) 195 Side View of Muscles of the Pharynx (Gray and Browne) 195 The Hyoid Bone, seen from above (Harrison Allen) 199 Front View of the Larynx: Thyroid Cartilage in Position (Lennox Browne) ... 199 Side View of the Larynx (Lennox Browne) 199 Side View of the Larynx, showing the Interior, the Right Plate of the Thyroid Car- tilage being removed (Lennox Browne) 200 The Cricoid Cartilage, the Arytenoid Cartilages, and the Cartilages of Santorini (Cornicula Laryngis) (Harrison Allen) 201 The Hyoid Bone and Larynx, with Ligaments, seen from in Front (Harrison Allen). 201 The Same, seen from the Side (Harrison Allen) 201 Side View of the Larynx, showing the Left Ventricle of Morgagni, Left Epiglottic Ligament, etc. (Lennox Browne) 202 View of the Larynx opened from Behind (Lennox Browne) . . .’ 203 The Rima Glottidis (Harrison Allen) 204 Side View of the Larynx, showing Right Crico-Thyroid Muscle (Lennox Browne) . 205 Muscles of the Larynx, seen from Behind (Lennox Browne) 205 Side View of the Larynx (Lennox Browne) • 205 The Larynx opened from Behind (Harrison Allen) 206 The Larynx, displaying the Intrinsic Muscles, after the Removal of One Side of the Thyroid Cartilage (Harrison Allen) ' 206 Arterial Supply of the Larynx, Posterior View, showing the Distribution of the Superior Laryngeal Artery (Bosworth) 207 Arterial Supply of the Larynx, Anterior View, showing the Distribution of the In- ferior Laryngeal Artery (Bosworth) 207 The Larynx in Gentle Breathing (Lennox Browne) 209 PLATES. VII VIII LIST OF ILLUSTRATIONS TO VOLUME II. PAGE The Larynx in Deep Breathing (Lennox Browne) 209 The Larynx in Tone-Production (Lennox Browne) 209 Lupus Yulgaris of the Palate and Fauces: Cicatrices, Disseminated Lupus Nodules, and Large and Small Tubercled Ridges, upon the Fauces, the Velum, and the Hard Palate (Chiari and Riehl) 418 Lupus Vulgaris of the Larynx: Tubercles and Ulcerations at the Base of the Tongue, and upon the Swollen, Crumpled Epiglottis : the Left Ventricular Band Thickened and Tubercled (Chiari and Riehl) . 418 Large, Thick, and Congested Epiglottis, drawn backward by Lepro-Tubercled Masses: Enlarged Arytenoids 443 Tumefied Epiglottis hanging over Glottis; Enlarged and Congested Ary-Epiglottic Folds and Ventricular Bands, covered with large and small Leprous Tubercles . 443 Leprous Tubercles on the Hard Palate and Velum (Leloir) 443 Enlarged and Thickened Epiglottis, with rounded edges curled inward, towards each other, the whole pale-grayish in color: on the upper margin were yellowish tubercles (Mackern) 443 Leprous Tubercles at Base of Tongue, on the Epiglottis, Left Vocal Cord, and Car- tilages of Wrisberg (Wagnier) 443 Leprous Distortion of Larynx (Lennox Browne) 443 Chronic Atrophic Laryngitis, showing Crusts adhering to Vocal Bands and Posterior Wall of Trachea (Ives) 475 Injury of Larynx from Contusion (J. H. Packard) 479 Scabbing-over of the Mucous Membrane after Application of Nitric Acid (Tiirck) . 480 Gun-Shot Wound of Larynx, Left Side (Daly) 480 Catarrhal Ulceration of Vocal Cords (Tiirck) 481 More Extensive Ulceration, probably Catarrhal (Tiirck) 481 Piece of Boiled Beef in the Larynx (Poulet) 507 A Buckle in the Larynx (Pemberton) 507 Dime in the Larynx (Ives) 507 Lamella of Bone in the Larynx (Morell Mackenzie) 507 Brass Watch-Ring in the Larynx (Lefferts) 507 Piece of Glass in the Larynx (Ransom) 507 Tooth-Plate lodged in the (Esophagus (Silver) 544 Four figures showing the Early Forms of Syphilis of the Larynx. The conditions represented in these four figures date from the fourth, the sixth, and the eighth week after infection (J. Schnitzler) 818 Redness and Swelling of the Vocal Bands; the left vocal band shows on its edge a dark-red spot which was sharply defined by a grayish-white line (J. Schnitzler) 818 Three figures showing the Varied Forms of Syphilitic Papules on the Vocal Bands. These small, gray-white, mostly round or oval infiltrations are so characteristic that if once seen they are never forgotten (J. Schnitzler) 818 Appearance of the Larynx Several Months after Infection. Irregular Ulcers on the Vocal Bands: Characteristic Appearance of Syphilis of the Larynx. Two illus- trations (J. Schnitzler) 818 Comparatively Circumscribed, but Deep, Syphilitic Ulceration on the Right Vocal Cord in Process of Healing (J. Schnitzler) 818 Complete Destruction of the Left Vocal Band, the Vocal Process alone intact. On the Left Ventricular Band Distinct Cicatrization. Cured after loss of entire left vocal hand (J. Schnitzler) 818 Characteristic, Irregular Ulcers on the Edges of both Vocal Cords; in addition a Round, almost Typical Ulcer on the Left Arytenoid Cartilage f J. Schnitzler) . 820 Irregular Ulcer on the Laryngeal Surface of the Epiglottis, Left Side, with beginning Ulceration on the Left Vocal Band and Left Arytenoid Cartilage (J. Schnitzler) 820 Ulcer on the Left Ventricular Band, with lardaceous, purulent covering (J. Schnitz- ler) 820 Intense Swelling of the Epiglottis: the latter is unrecognizable by reason of diffuse LIST OF ILLUSTRATIONS TO VOLUME II. IX PAGE infiltration. Entrance to the cavity of the larynx entirely occluded. On the left half of the epiglottis, a deep, irregular ulcer with lardaceous covering: a second, crater-like ulcer on the outer surface of the right arytenoid cartilage ex- tending to the ary-epiglottic fold (J. Schnitzler) 820 Advanced Syphilis of the Larynx. Characteristic ulcers following breaking down of gummous infiltration on the edges of the epiglottis and on the outer surface of the arytenoid cartilage. Dirty-gray, deep ulcers, with lardaceous covering and circumscribed by sharply-defined edges (J. Schnitzler) 820 The same Larynx after several weeks of Anti-Syphilitic Treatment. Cure of ulcers, with great loss of tissue. Characteristic cicatrices (J. Schnitzler) 820 Extensive and Profound Destruction of the Larynx, especially of the Epiglottis and Arytenoid Cartilage (J. Schnitzler) 820 Same Case, healed by Systematic Anti-Syphilitic Treatment (J. Schnitzler) .... 820 FIGURES. Transverse Section of Erectile Turbinated Tissue, X 500 (Seiler) 5 Section of the Cavernous or Erectile Tissue of the Middle and Lower Turbinated Bones, inflated and dried, X 2 (Bigelow) 6 Section of Nasal Cavities, showing Nerve-Supply. Spheno-Palatine Ganglion, seen on its Internal Surface (Sappey) 8 Cleft Middle Turbinated Bone (Woakes) 10 Section of Mucous Polypus (Seiler) 11 Fibrous Polypus of the Nose—View of the Growth as seen by Posterior Rhinoscopy (Mackenzie) 12 Tubular Adenoma (Gross) 13 Section of Angioma, X 300 (Seiler) 16 Syphilitic Ulcer of Nasal Mucous Membrane, slightly Diagrammatic, X 500 (Seiler) 21 Dilated Nostril, showing Anterior Hypertrophy (Seiler) 26 Rhinoscopic Image from a Case of Posterior Hypertrophy of Middle Turbinated Bone (Seiler) 27 Rhinoscopic Image in a Case of Cleft Palate with Posterior Hypertrophy 27 Transverse Section of Nasal Hypertrophy (Seiler) 20 Dilated Nostrils, showing Ecchondrosis of Septum 30 Posterior "View of Congenital Bony Occlusion of Left Posterior Nares 31 A Split Septum (Seiler) 38 Pathological Specimen of Posterior Hypertrophy, showing Snare-Loop in Position (Jarvis) 44 Nasal feraseur and Polypus Snare (Jarvis) 44 Removal of Posterior Turbinated Hypertrophies, with Rhinoscope and Tape-Holders in Position (Jarvis) 45 Transfixion-Needles (Jarvis) 45 Transfixion-Needle and Ecraseur adjusted for Operation (Jarvis) 47 Operating Nasal Speculum (Jarvis) 50 Septometer (Jarvis) 50 Haemostatic Clamp (Jarvis) 51 Small Septum Scissor-Punch (Jarvis) 52 Rongeur Septum Forceps (Jarvis) 52 C and C Electric Motor 53 Weber's Hand-Piece for Drills 54 Trephine Crown-Drill (Jarvis) 55 Antiseptic Crown-Drill (Jarvis) 55 Scissor Tubular Drill (Jarvis) 56 Deflection of Septum, before and after Operation (Jarvis) 56 X LIST OF ILLUSTRATIONS TO VOLUME II. PAGE Modified Steele’s Stellate Septum-Punch (Jarvis) 57 Nasal Clamp-Splint 57 Monogenetic Nasal Myxoma associated with Deflection of the Septum (Jarvis) ... 60 Small Spring Scissor-Punch 60 Ecraseur Tips for Adenoids 61 Cavernous Angioma (Jarvis) 62 Sarcoma of Nose and Superior Maxilla (J. Bryant and Jarvis) 63 Syphilitic Caries of the Nose and Mouth (Jarvis) 64 Congenital Nasal Atresia, before Operation (Jarvis) 65 “ “ “ after “ “ 65 Yocal Cords in Phonative Position 220 Diagram showing Action of Crico-Thyroid Muscle, Stretching of the Yocal Cords, and Altered Direction of Sound 222 Muscles and Cartilages concerned in Phonation 223 Three Diagrams representing Position of Yocal Cords in Different Registers (Behnke) 224 Nineteen Photographic Yiews of Laryngeal Images corresponding to Different Notes of the Musical Scale (French) 228, 229, 231, 232, 233 Diagram of Phonetic Arch formed by the Tongue and Soft Palate in Singing . . . 235 Four Diagrams showing Variations of the Phonetic Arch in the Singing of Different Notes (Browne and Behnke) 236 Diagrammatic Representation of a Musical Note in its Extent from the Larynx to the Lips 237 Six Diagrams representing the Varying Capacity of the Chest according to the Method of Inflation (Lennox Browne) 238 Inflammation confined to Epiglottis and Right Ventricular Band (Lennox Browne) . 312 (Edema of Epiglottis, “ Acute Miasmatic Epiglottitis” (Arnold) 313 “Rugae” of Inner Arytenoid Space simulating Ulceration in Simple Laryngeal Catarrh 316 General (Edema Laryngis from Burn 318 Subglottic (Edema (Cohen) 318 Lupoid Ulceration of Epiglottis, and Subglottic (Edema 319 Paresis of the Yocal Cords 320 Introducing-Instrument and Obturators 390 Gauge for Tubes at any Given Age 391 Gag used in Intubation 392 Extracting-Instrument 392 Golding-Bird’s Tracheal Dilator 398 Trousseau’s Tracheal Dilator 398 Fenestrated Obturator .' . 399 Tracheal Forceps used in Tracheotomy 400 Plug with Shield to keep Tracheotomy-Wound from Healing (Parker) 408 Chronic Laryngeal Catarrh, showing a Nodule on the Right Yocal Band from Ex- traordinary Hyperplasia at that Point (Burow) 470 Chronic Inflammation of the Vocal Bands, with Subglottic Swelling (Tiirck) . . . 470 Chronic Laryngeal Catarrh, showing Particular Swelling and Injection of the Left Yocal Band (Burow) 471 Chronic Laryngeal Catarrh, showing Swelling of Ventricular Bands (Burow) . . . 471 Chronic Laryngeal Catarrh, showing Secretion adhering to the Yocal Bands and at the Inter-Arytenoid Space (Burow) 471 Chronic Laryngeal Catarrh, with Aphonia from Interstitial Deposit (Burow) .... 471 (Edematous Laryngitis, showing the whole Mucous Membrane swollen, and particu- larly the Arytenoids and Posterior Wall of the Larynx (Burow) ....... 472 (Edematous Laryngitis, showing a more Chronic and Partial Involvement (Burow) . 472 (Edematous Laryngitis, showing Swelling mostly confined to the Epiglottis (Burow). 472 (Edema and Hypertrophy of the Ventricular Bands after Typhus Fever (Tiirck) . . 472 LIST OF ILLUSTRATIONS TO VOLUME II. XI PAGE Perichondritis Laryngis affecting principally the Left Arytenoid Cartilage (Burow) . 473 Pachydermia Laryngis (Bergengriin) . 473 Chorditis Yocalis Hypertrophica Inferior (Burow) 474 Chorditis Yocalis Hypertrophica Inferior, showing Great Diminution in Size of the Yocal Bands (Burow) 474 Laryngitis Hsemorrhagica (Burow) 474 Perichondritis of the Left Vocal Cord: Unopened Abscess (Tiirck) 482 The Same, after Opening of the Abscess (Tiirck) 482 Perichondritis Laryngis (Burow) 482 Laryngeal Appearance of Enchondroma (Tiirck) 482 Chorditis Yocalis Hypertrophica Inferior following Typhus Eever, showing Mem- branous Growth on Under Surface of the Vocal Bands (Burow) 485 Membranous Stenosis of the Larynx the Result of Typhoid Fever (Burow) .... 486 Membranous Stenosis of the Larynx, showing Effects of Treatment—Incision and Dilatation (Burow) 486 Shurly’s Face-Shield Inhaler 489 Tin Inhaler 490 Dry Inhaler 490 Shurly’s Powder-Blower 491 Puff-Darts, American Pattern (Wyeth): English Pattern lying in the Bronchus (Bruce) 504 Toy Locomotive in the Larynx (Johnston) 505 Piece of Bone lodged in the Larynx (F. W. Rockwell) 508 Bead in the Right Bronchus: two positions (Sprengel) 509 Bronchial Septum (S. D. Gross) 509 Cusco’s Forceps 523 Mackenzie’s Angular Forceps 523 Mackenzie’s Tube Forceps 524 A Coin in the Laryngeal Ventricle (Grazzi) 524 The Same, in the Grasp of the Instrument (Grazzi) 524 Piece of Bone in the Larynx : two positions (Whistler) 525 A Cockle-Burr in the Larynx (Thorner) 525 Trousseau’s Tracheal Dilator 529 Lahorde’s Dilator 530 Golding-Bird’s Double Retractor 530 Gross’s Tracheal Forceps 530 Cohen’s Shouldered Traction Forceps 530 Roe’s Tracheal Forceps 531 Large Open Pocket-Knife removed from the (Esophagus by (Esophagotomy, Natural Size (Gussenbauer) 536 Specimens of Irregular Fragments of Bone lodged in the (Esophagus, Natural Size (Poulet) 537 Tooth-Plate impacted in the (Esophagus during an Epileptic Seizure (MacCormac) . 539 Tooth-Plate (MacLean) 544 Pin perforating the (Esophageal Ganglion (Dagron) 547 Perforation of the (Esophagus and Trachea by Piece of Bone (Poulet) 547 Perforation of the (Esophagus and Aorta by a Five-Franc Piece (Poulet and Denon- villiers) 548 Duplay’s Resonator 553 Mackenzie’s (Esophagoscope: a, closed for insertion ; 5, opened after introduction . . 553 Fauvel’s Forceps, Antero-Posterior View 558 Fauvel’s Forceps, Lateral View 558 Moe’s Gum-Elastic Forceps 559 Dawson’s Flexible Forceps 559 Mathieu’s Alligator Forceps 559 Bond’s Forceps (modified by Roe) 559 XII LIST OF ILLUSTRATIONS TO VOLUME II. PAGE Petit’s Hook 560 Graefe’s Basket, Natural Size 560 Graefe’s Ring Coin-Catcher 560 Roe’s Flexible Spiral Lever Extractor: two positions 560 Gross’s Bristle Probang: two positions 561 Sanford’s Probang 561 Roe’s Dilating Extractor: two positions . 561 Bosworth’s Tonsil Snare 583 Wright’s Electric Amygdalotome 584 Electric Tonsil Snare (C. H. Knight) 584 Clendinnen’s Tonsil-Compressor 590 Mackenzie’s Tonsillotome 592 Bilateral Paralysis of Superior Laryngeal Nerve (Porcher) 685 Bilateral Recurrent Laryngeal Paralysis (Porcher) 686 Right Recurrent Laryngeal Paralysis: Position of Cords in Deep Inspiration (Porcher) 687 Bilateral Abductor Paralysis: Position of Cords in Deep Inspiration (Porcher) . . . 689 Unilateral Adductor Paralysis : Position of Cords in Attempted Phonation (Porcher) 692 Paralysis of the Arytenoideus Muscle (Porcher) 692 Paralysis of Right Internal Tensor (Porcher) 693 Delavan’s Alimentation-Bottle 707 Mackenzie’s (Esophageal Injector 708 Congenital Stenosis of the Pharynx (Lennox Browne) 711 Syphilitic Outgrowth from the Pharynx (Lennox Browne) 713 Congenital Pouch and Atresia of the Pharynx (Lennox Browne) 718 Pouch of the Pharynx in Advanced Life (Lennox Browne) 719 Microscopic Section of Lymphoma (Lennox Browne) 720 Papilloma of the Pharynx (Lennox Browne) 724 Section of Papilloma of Pharynx (Lennox Browne) 725 Spindle-Cell Sarcoma of the Pharynx (Lennox Browne) .... 729 Lympho-Sarcoma of Pharynx (Lennox Browne) 730 Lvmpho-Sarcoma of Pharynx and.(Esophagus (Lennox Browne) . . 730 Alveolar Epithelioma of the Pharynx : Microscopic Section (Lennox Browne) . . . 732 Prickle-Cell Epithelioma: Microscopic Section (Lennox Browne) . 733 Congenital Web of the Pharynx: two figures (Morell Mackenzie) 736 Congenital Papilloma of Larynx (Lennox Browne) 739 Recurrent Papillomata of Larynx of Congenital Origin (Lennox Browne) 739 Two Illustrations of Syphilitic Stenosis (Lennox Browne) 745 Cicatricial Stenosis before and after Treatment (Lennox Browne) 746 Hollow Laryngeal Dilator, with Cutting Blade (Lennox Browne) 747 Supra-Glottic Stenosis of Larynx due to Lupus (Lennox Browne) 748 Papillomata of the Larynx (Lennox Browne) 752 Single Papilloma of the Larynx with Syphilitic History (Lennox Browne) .... 753 Symmetrical Papillomata with Syphilitic History (Lennox Browne) 753 Papilloma of Vocal Cord in the Common Situation (Lennox Browne) 754 Histological Features of a Papilloma (Lennox Browne) 755 Fibroma situated on Under Surface of Right Vocal Cord (Lennox Browne) .... 756 Fibroma of Left Vocal Cord (Lennox Browne) 757 Myxoma of Right Vocal Cord: two figures (Lennox Browne) 758 Fibro-Myxoma of Larynx (Lennox Browne) 758 Mucous Growths of Larynx accompanying Papillomata (Lennox Browne) 758 Adenoma of the Larynx: three figures (Lennox Browne) . . 759 Thrombosed Angioma of the Larynx, showing Complete Section and Detail of Struc- ture : two figures (Lennox Browne) 761 Gibbs’s Laryngeal Snare 763 Voltolini’s Laryngeal Sponge-Probang 763 LIST OF ILLUSTRATIONS TO VOLUME II. XIII PAGE Dundas Grant’s Guarded Forceps 765 Three Illustrations of Cancer of the Larynx by Contiguity with the Pharynx (Lennox Browne) 774 Laryngoscopic Appearance of a Sarcoma (Lennox Browne) 779 Post-Mortem Appearance of the Same (Lennox Browne) 779 Sarcoma of the Tonsil (Lennox Browne) 780 Sarcoma of the Epiglottis and Larynx in the Same Case (Lennox Browne) 780 Sarcoma of the Larynx (Lennox Browne) 781 Epithelioma, Laryngoscopic View (Lennox Browne) 788 Epithelioma of Larynx, Left Wing of Thyroid, Left Half of Cricoid, and Left Arytenoid Cartilage, showing Extensive Area of New Growth (Lennox Browne) 790 Thickened Omega-Like and Ulcerated Epiglottis (J. Solis Cohen) 793 Progressive Ulceration of Epiglottis (J. Solis Cohen) 793 Destructive Ulceration of Epiglottis (J. Solis Cohen) 793 Initial Multiple Superficial Ulcerations of the Acuter Forms of Secondary Tuber- culosis (J. Solis Cohen) 796 Supra-Arytenoid Intumescence, beginning on the Left Side and Complete on the Right (J. Solis Cohen) 799 A Later Stage of Supra-Arytenoid Intumescence, with Thickenings in the Epiglottis and on the Vocal Bands (J. Solis Cohen) 799 Turban-Like Epiglottis of Tuberculosis (J. Solis Cohen) 800 Crescentically Swollen Epiglottis overhanging the Orifice of the Larynx (J. Solis Cohen) 800 Tuberculous Infiltration of Larynx, showing Lateral Destruction of Epiglottis from the Side (J. Solis Cohen) 800 Condylomatous Meso-Arytenoid Infiltration; Color Normal; Softening at Right Apex (J. Solis Cohen) 801 Acuminated Meso-Arytenoid Infiltration; Red Right Vocal Band; Condensation at Right Apex (J. Solis Cohen) 801 Ulcerated Vocal Bands and Left Ventricular Band; Solidification at Right Apex ; Cavity in Left Apex (J. Solis Cohen) 801 Abscess over Right Side of Internal Face of Cricoid Cartilage (J. Solis Cohen) . . . 802 Club-Shaped Uvula in Primary Tuberculosis of the Larynx. Palate involved (J. Solis Cohen) 805 Hypertrophic Glands simulating Tubercles (J. Solis Cohen) . 806 Schroetter’s Laryngeal Dilator 825 AUTHORS REFERRED TO IN VOLUME II. Abbe, 512, 542, 544, 564, 567. Abercrombie, 329. Abraham, 440, 441, 726. Abramson, 113, 135. Abulcasis, 3. Abutkoff, 537. Adams, 49, 537. Addenbrook, 528. Adelmann, 555, 563, 566. A2gina, Paul of, 2. Aetius, 2. Agnew, D. H., 505, 616. Aitken, 336, 642, 663. Albert, 58. Alderson, 599. Alexander, 538, 569. Alibert, 414. Allbutt, Clifford, 522, 554. Allen, Harrison, 37, 48, 131,155, 158, 165, 273, 463, 534, 574, 595, 596, 611. Althaus, 93. Alvaro, Mendez, 436, 439. Anderson, 545. Andral, 116. Andrews, 549. Andriessen, 510. Annandale, 529. Anstie, 132, 141. Anthoniesz, 537. Antonoff, 546. Appleyard, 502. Arantius, 3. Archambault, 411, 666. Aretaeus, 102. Aristotle, 102. Arning, 413. Arnold, 521. Arnot, 551. Arnozan, 139. Aronssohn, 92, 146, 504, 506, 514, 531. Arvispt Ti QQ Asch, 49, 493, 604, 664, 749, 761. Aschenbrandt, 98. Asclepiades, 396, 526. Ashhurst, John, 501, 504, 506, 516, 521, 535, 552, 553, 556, 565. Atkinson, 610. Atlee, 546. Aubrun, Sr., 380. Audebert, 478. Augagneur, 129, 159. Auspitz, 414. Avery, 519. Avicenna, 102. Baber, Cresswell, 110, 598, 617, 723. Babes’ 343, 443, 446, 448, 451, 453. Bach, 213. Baginsky, 346, 347, 360. Baker, H. B., 363. Balch, 535, 557. Bally, 545. Balme, 575, 576. Balujew, 535, 546, 567. Bannister, 505. Baptie, 158. Baraffio, 538, 556. Baratoux, 105, 114, 412, 421, 565. Baring, G., 480. Barker, 619. Barre, 593. Barth, B., 465. Barthez, 348, 396. Bartholini, 102. Bartholow, 255, 622, 633, 634, 654, 655. Bartlett, 520. Barton, Isaac, 461, 567. Baruch, 650. Bates, 170, 356. Battle, 535. Baud, 539, 563. Baudens, 575. Bauduy, J. K., Jr., 372. Baumgarten, 91, 343, 422, 607. Baxter, 154. Bayer, 597. Bazin, 414, 439, 542. Bean, 115, 475, 605, 610. Beard, Geo. M., 67, 68, 70, 73, 78, 79, 80, 83, 131. Beclard, 92. Bednar, 349. Beebe, 611. Beeston, 529. Begbie, 660. Begin, 537, 567. Behnke, 216, 218, 219, 224, 226, 227, 235, 239, 240. Behrend, 501. Belde, 654. Bell, 503, 527, 547, 743. Bender, Max, 413. Beneque, 565. Bennett, 644. Benno, 657. Benoit, 504. Benthal, 502. Bentlif, 515, 528. Berard, 507. Bereskin, 567. Bergengriin, 469, 473, 478. Berger, 130, 150, 152, 153, 154, 155, 156, 157, 164, 169. Bergeron, 459. Bergtnann, 416, 427, 430, 494, 529. Bergoni6, 49. Bergson, 115. Bernabei, 251. Bernard, Claude, 90, 98, 697. Bernardino, 582. Bernardo, 653. Bernutz, 635. Besnier, 186, 415, 421, 422. Bettman, 129, 130, 169. Beverley, 527. Bianchi, L., 341. Bierbaum, 662. Bierfreund, 537. Biermer, 115. Bigelow, 6, 99, 349. Bild, 354. Bilhaut, 355. Billington, 381, 623. Billroth, 556, 586, 644, 785. Bimar, 722. Binningerus, 66. Binz, 67, 87. Biondi, 318. Birch, 521. Birch-Hirschfeld, 311. Bird, 620. BischofF, 697. Bishop, 535, 697. Black, 428. Blackader, 637. Blackley, 67, 68, 69, 70, 72, 76, 83, 87. Blair, 576, 594. Blanc, 508, 526, 770. Blandin, 48, 49, 618. Blandon, 526. Blass, 647. Bloch, 140. Block, 117, 415. Blount-Dyer, 323. Blum, 502, 516. Bobbitt, 535, 557. Bobone, 108. Boch, 660. Boeck, 436, 439. Boecker, 106. Boerhaave, 3. Bohn, 638. Bolton, 49. Bond, 558, 559. Bonet, 519, 545. Bonheben, 19. Bonito, 598. Borelli, 582. Bostock, John, 66, 67. Bosworth, 4, 8, 9, 15, 22, 23, 24, 25, 32, 33, 34, 35, 37, 41, 43, 46, 48, 59, 61, 62, 63, 94, 95, 105, 109, 113, 117, 119, 121, 123, 134, 135, 194, 253, 255, 257, 260, 261, 263, 308, 323, XV XVI AUTHORS REFERRED TO IN VOLUME II. 458, 491, 513, 573, 583, 609, 670, 684, 688, 690, 772. Botallus, 66. Bottini, 611, 781, 785. Bouchard, 664. Boucheron, 462. Bouchut, 349, 390. Bouillon-Lagrange, 348. Boulard, 533. Boullochfi, 251. Bourdillat, 518, 519. Bourges, 346, 628. Boyer, 2, 32, 33. Brandeis, 486, 525. Braun, 480. Brebion, 114. Breda, 427. Bresgen, M., 129, 136, 139, 152, 159, 163, 164. Bretonneau, 349, 371. Briand, 662. Bricheteau, 378. Briddon, 502, 523. Brieger, 344, 345, 484. Brissard, 467. Broca, 555, 589. Brodie, 521. Bron, 32. Brooks, 89. Broussais, 506, 510, 513. Brown, Bedford, 649. Brown, C. Haig, 275. Brown, Graham, 387. Brown-S6quard, 119, 487. Browne, Lennox, 4, 49, 61, 93, 114, 129, 130, 170, 216, 235, 240, 253, 262, 274, 275, 311, 312, 315, 318, 332, 333, 337, 340, 412, 413, 417, 426, 431, 452, 459, 460, 467, 475, 479, 485, 489, 503, 576, 606, 607, 609, 613, 614, 615, 670, 673, 679, 680, 683, 778. Brownell, 514. Bruce, 502, 504, 513. Brugelmann, 136. Brunei, 528. Bruns, 721, 746, 761, 770, 791. Bryan, J. H., 254. Bryant, AV. S., 16, 63, 505, 515. Buchanan, 660. Buck, A. H., 137, 140. Buck, Gurdon, 660. Buckholtz, 387. Bucklin, 159, 160. Bull, 157, 538. Bullock, 508, 510. Bumstead, 600. Burckhardt, 15. Burger, H., 339, 340. Burnett, C. H„ 41, 101, 128. Burns, Allan, 515. Burow, 470, 471, 472, 473, 474, 482, 485, 486, 502. Busch, 546, 549. Busey, 623, 626. Bushe, 528. Bussard, 546. Butler, 590. Butlin, 512, 526, 527, 567, 613, 619, 620, 621, 770, 773, 791. Buttenberg, 546. Cadier, 135. Cadogan-Masterman, 375. Caesar, 501. Cagny, 356. Cahier, 568. Caille, 366, 377. Campana, 440, 452. Campbell, 415, 607, 711. Cant, 59, 566. Capart, 61, 256, 458, 587. Cardone, F., 269. Carion, Stellwag von, 165. Carlyle, 534, 538, 539. Carstens, J. H., 464. Cartay, 106, 108, 111, 135, 664. Cartier, M., 480. Casabianca, 17, 19. Castle, 547. Caswell, 528. Catti, 562. Cazenave, 86, 87, 89. Celsus, 2, 582. Cerchez, 508. Cerlot, 650. Cerutti, 93. Championniere, 140. Chantemesse, 628. Chapman, S. H., 466. Chappell, 502, 503, 579. Charcot, 94, 120, 341. Chassaignac, 575, 593, 662. Chauliac, Guy de, 3. Cheadle, 642, 666. Cheatham, 41, 89, 129, 159, 170. Cheever, 545, 554, 569, 616, 618, 619. Cheselden, 589. Chessman, 510, 513. Cheyne, 329. Chiari, 262, 412, 413, 417, 426, 469, 478, 652, 747. Chiolini, 611. Chomel, 655. Christian, 503. Christina, 511. Chrystie, 663. Clark, Andrew, 87,116,165, 170, 512, 531, 545. Clarke, E. W., 590. Claubry, Gauthier de, 542. Clendinnen, 590. Cline, 171. Cloquet, 96. Clutton, 552, 567. •Coats, 548. Coester, 384. Cohen, J. Solis, 4,11, 42, 49, 61, 108, 113, 141, 260, 270, 271, 274, 277, 282, 287, 312, 318, 322, 332, 337, 408, 458, 459, 460, 462, 463, 464, 467, 475, 480, 482, 483, 487, 489, 491, 492, 493, 494, 495, 504, 505, 506, 516, 521, 523, 541, 542, 544, 547, 551, 553, 565, 574, 579, 5S0, 597, 612, 618, 623, 635, 636, 639, 640, 643, 644, 646, 648, 649, 651, 654, 657, 663, 664, 665, 669, 683, 770, 785, 786. Cohen, S. Solis, 493. Cohnheim, 306, 311, 317, 415. Coit, 579. Coleman, S. C., 356, 357. Colles, 4, 548, 550. Collier, 504, 529. Collin, 549. Collins, F. H., 553, 647. Conner, 502, 528. Coomes, 461, 519. Cordemans, 568. Coriveaud, 134. Cornil, 414, 422, 439, 448, 602, 643. Couetoux, 129, 130. Coupard, 666. Coupland, 507. Courtenay, 542. Coyne, 639. Cozzolino, 138. Craiger, T. F., 631. Crawley, 523, 525. Cr6quy, 563, 564. Croker, G., 723. Croly, 614. Crooke, 279. Crossfield, 135. Cruveilhier, 99, 652, 712, 722. Cullen, 96. Cursehruann, 634. Curtis, 49, 55. Cusco, 523, 524. Cuvillier, 582. Czermak, 429. Czerny, 618. Da Costa, 514. D’Agnano, 95. Dagron, 547. Dailey, 520. Daly, 41,43, 67, 68, 70, 103, 139, 140, 141, 270, 384, 465, 480. Dana, C. L., 94. Danaher, 502, 511, 514, 516. Danielssen, 436, 439. Dantra, 537. D’Arcy, 510. Darwin, 212. Davaine, 600. Davidson, 510. Davies, 566. Davy, 531. Dawson, 502, 510, 558, 559. Day, 522. Deacon, 239. De Angelis, 513. Dearden, 560. Deaver, 564, 568. De Blois, 42, 579, 610. Debout, 510. De Budberg, 87. De Cassis, Vidal, 501, 506. Dechambre, 84. Decker, 598. De la Count, 508, 510, 513. Delafield, 475. De la Hale, Adam, 213. Delasiauve, 502, 514. De la Sota y Lastra, 502, 525, 535, 568, 608. Delavan, 16, 50, 59, 139, 194, 195, 461, 465, 481, 494, 576, 580, 588, 591, 604, 605, 606, 611, 643, 645, 647, 651, 709. Delewsky, 386. Delie, 599. De Mariqual, E., 348. Demarquay, 563. De Mees, 540. Demine, 24, 415. Denton, 556. De Rechter, 109. Desbrousses, 666. Deschamps, 102. De Schweinitz, 163, 164, 166. Desgranges, 519. Desir6, 582, 812. Despagnet, 129, 159, 160, 164. D’Espine, 348, 374. Dessault, 539. AUTHORS REFERRED TO IN VOLUME II. XVII Desvernine, 568, 742. Devergie, 414. Dieffenbach, 48. Dmochowski, 571, 605. Donaldson, 58,477,580,601,618. Donatus, 510. Dorr, 515. Doutrelepont, 414. Dove, 538. Dowling, 159. Downie, J. W., 586, 690. Dowse, 502. Dress, 135, 137, 140. Druitt, 591. Du Bois-Reymond, 224. Duchamp, 351. Duchenne, 701. Duclos, 116. Ducros, 115. Dufour, 742. Duhring, 428. Dumas, 387. Dumenil, 15. Dumez, 363. Duncan, 521, 742. Dunglison, 2. Dunn, J., 129, 130, 153, 160, 591. Duplay, 19, 553. Dupuy, 555. Dupuytren, 510, 565, 577, 578, 600, 734. Duret, 219. Durham, 4, 17, 401, 406, 517, 518, 520, 528, 532, 570. D’Urto, 526. Duval, 534. Dzondi, 4. Eales, 170. Edis, 759. Edwards, 502, 507, 641, 642. Egeberg, 568. Ehrlich, 416, 423, 427, 431, 448. Eichhorst, 268. Ekel, 515. Eldridge, 510. Elias, 501. Eliot, Llewellyn, 385, 726. Elliotson, 87, 154, 512, 516. Elsberg, 104, 114, 134, 135, 139, 341, 466, 470, 483, 494, 554, 745. Emminghaus, 642. Emrys-Jones, A., 154. Ensing, 110. Epler, 513. Eppinger, 310, 311. Erichsen, 16, 58, 59, 548. Esch, J. P., 373. Esmarch, 430. Espey, J. R., 377. Esquirol, 536. Eulenburg, 669. Evans, 556. Eve, 485, 546, 549. Fabricius ab Aquapendente, 3, 526. Fabry, 21. Fagge, Hilton, 331, 622, 623, 625, 636, 644, 654, 655, 656, 666, 668. Farlow, 591, 723. Farmer, 582. Farr, 330. Fauvel, 135, 426, 466, 519, 558, 666, 752, 764, 771, 772, 784. Fayrer, 19. Fehleisen, 268, 269, 644, 648. Felizet, 568. Fell, 521. Fenykovy, 109, 139. Ferber, 102, 131. Fer6, 108. Ferguson, 373, 380. Fernelius, 102. Ferrein, 219. Ferrier, 219. Ferrus, 540, 555. Festier, 712. Ficano, 501. Fick, 250. Fienzal, 162. Figueira, 532. Filipo, 440. Fincke, 135. Fingerhuth, 547. Fischer, 159, 318, 466, 567, 568, 569. Fitz, 549, 521. Fitzgerald, 611. Flatau, 136. Fleck, 387. Fleisher, 658. Flemming, 279. Flesh, 336. Fleury, 549, 550. Flint, 622, 631, 640, 644, 650, 651, 653, 660, 663. Fogg, 513. Follin, 18. Forchheimer, 271, 662. Fortuner, 545. Foster, 120, 528. Foulis, 786. Fountaine, 373. Fournier, 601. Fowler, George B., 384, 617. Fox, Colcot, 713. Fox, George H., 415, 421, 452. Fox, Kingston, 275. Fox, R. Kingston, 136. Frael, 416. Fraenkel, B., 105, 115, 116, 134, 138, 263, 316, 346, 416, 427, 462, 483, 597, 598, 652, 664, 773, 783, 793. Fraenkel, C., 344, 345. Fraenkel, E., 99, 103, 104, 113, 135, 597. Franco of Cologne, 213. Francotte, 356. Frank, Francois, 139. Frauke, F., 111. Frankhauser, 507. Franks, 546, 566, 612. Freeland, 536, 568. Freeman, 501. French, 226, 227, 234, 491, 512, 525. Frew, 541, 542, 568. Friedlander, 414, 423. Fritsche, 484. Froriep, 506. Fruitnight, 387. Fuller, 591. Fulton, 167. Furner, 568. Fiirst, 506. Gairdner, 598. Galen, 2, 102, 526. Galentine, C. B., 387. Gallardo, 617. Gamberini, 439, 440. Gant, 531. Garcia, 225. Garel, 465, 595. Gariel, 565. Garre, 412. Garrett, 218. Gassicourt, Cadet de, 374. Gaupp, 501. Gautier, 501, 508, 565, 597, 599. Gay, 403, 552, 568. Gee, 623. Gelsner, 386. Gennaro, 135, 137. Geoghegan, 502, 527. Gerasimow, 389. Gerdy, 9. Gerhardt, 269, 320, 356, 466, 484, 639. Germain, 552. Germonig, 650, 651. Gerster, 506, 551, 556. Gibb, 318, 446, 523, 635, 636, 648. Gibbes, 483, 485. Gibbs, 758, 760, 763. Gill, 336. Giommi, 568. Glandorf, 3. Glasgow, 131, 486, 503, 509, 650, 651, 759, 809. Gleitsmann, 316, 584, 586. Godet, 501. Goetze, 131. Golding-Bird, 398. Gooch, 357. , Goodall, 508. Goodhardt, 623, 632, 638, 641. Goodwillie, 48, 49, 55. Gordon, 67, 85, 128, 160. Gordone, 648. Gorecki, 619. Gottschalk, 91. Gottstein, 106, 328, 332, 339, 423, 446, 463, 470, 477, 484, 485, 608, 683, 747. Gouguenheim, 256, 465, 478, 539, 751, 802. Gourewitsch, 96. Gradle, 61, 128, 150. Graefe, 539, 540, 560, 563. Grancher, 363, 364, 367, 368, 375. Grant, Bey, 382. Grant, Dundas, 93, 333, 741, 753, 764, 765, 771, 784. Graves, R. J., 92, 110, 344. Gray, 341, 614. Grazzi, 95, 512, 524. Green, J. T., 488. Green, T. Henry, 475, 479, 485, 511, 512, 516. Gridley, 520. Griesinger, 655, 660. Griffith, 642. Groom, 511, 528. Gross, M., 459. Gross, S. D., 58, 478, 500, 503, 505, 508, 509, 510, 511, 513, 514, 517, 518, 519, 520, 521, 528, 561, 568, 649. Grossmann, 413. Grove, 239. Grubert, 568. Griider, 656. Griin, 510, 511. Griinfeldt, 19. Gruening, 41,129,164, 168, 599. Griinwald, 156. Gruhn, 165. XVIII AUTHORS REFERRED TO IN VOLUME II. Gruner, 4, 102. Grut, 165. Grynfeltt, 595. Gubler, 268. Guelton, 543. Guersant, 348, 396, 592. Guest, 508, 516. Guido of Arezzo, 213. Guillemeau, 586. Guinaud, 602. Gussenbauer, 536, 568. Guttmann, 265, 311, 346, 386, 651. Guye, 136. Guyon, 15, 501, 723. Habel, 556. Habgood, 530. Hack, 41, 75, 103, 104, 106, 108, 110, 114, 128, 130, 131, 135, 136, 137, 150, 156. Hadden, 502. Haeniseh, 115, 661. Hagendorn, 521. Hager, 514, 650. Hahn, 416, 427, 430, 431, 787, 788, 790. Haidenhain, 415. Hajek, 155. Hallepeau, 374. Haller, 93. Halstead, 539, 552, 568. Hamburger, 554. Hamilton, 93, 129, 130, 160, 169, 505. Hammond, 141. Hanford, 521. Hanot, 650, 652. Hansen, Armaner, 439, 440, 448. Hardaway, 638, 640, 641. Hardy, 414, 415, 440. Harrison, 514. Hartman, J., 474, 494. Hartmann, 103, 131, 156, 316. Haslund, 413. Hauff, 668. Havenith, 415. Hays, 541. Heath, 527, 539, 540, 645. Hebra, 185, 414, 608. Heim, 641. Heine, 746, 785. Heinze, 794, 795. Ileister, 3. Helbing, 263. Helferich, 387. Helmholtz, 67, 72, 87> 216, 545. Hemenway, 596, 597, 598. Henderson, 42. Hendrig, 159, 162. Henoch, 340, 346, 372, 375, 388, 638. Henry, F. P., 810. Herard, 110. Hermann, 307. Hernandez, 587, 590. Hernando, 436, 437, 439, 446. Hertz, 505, 662. Heryng, 105, 111, 114, 135, 300, 429, 495, 534, 574, 587, 595, 597, 745, 746, 811. Herzfeld, 99. Herzog, 73, 164, 466. Hess, 509. Heurteaux, 17. Heusser, 502, 506, 516. Hevin, 519, 533, 537, 545, 557, 570. Hewitt, 400. Heymann, 106. Hill, William, 136. Hillis, 443, 446. Hilton, 4, 59, 501. Hime, F. W., 427. Hinkel, 89, 110. Hinrichs, 525. Hippocrates, 2, 21, 58, 102. Hoang-Ty, 21. Hodenpyl, 572. Hodgkinson, 512. Hohlein, 711. Hoffmann, 122, 129, 567, 655. Holden, 221, 223, 507, 527, 670, 694. Holm, 413. Holmes, 494, 517, 518, 528, 563, 570, 580. Holt, 389, 722. Homans, 616. Home, Everard, 329, 711. Honman, A., 653. Hooper, 61. Hooper, 221, 465, 470. Hopmann, 14, 15, 19, 105, 138. Hopper, 479. Hopton, 527. Horsley, 219. Houston, 505, 506. Houtang, 717. Howard, 218. Hows, 531. Howse, 506. Hubert, 50. Hucbald, 213. Hue, 601. Hiirlin, 624. Huguier, 15. Ilulke, 512. Ilullah, 243. Hunt, James, 212. Hunt, Middlemas, 413, 414. Hutchinson, James H., 654, 660. Hutchinson, Jonathan, 414,415, 416, 420, 421, 422, 426, 738, 780. Hutinal, 628. Huxley, 221. Hyde, J. N., 634, 636. Ingals, 48, 129, 272, 318, 466, 487, 513, 583, 628, 645, 670, 691. Isambert, 443, 450, 457, 465, 466, 606, 793. Isch-AVall, 99. Isidore of Seville, 213. Israel, 427. Itard, 577. Ivanoff, 541. Ives, 507, 512. Jackson, Hughlings, 93, 94, 337. Jacob, 102. Jacobi, 134, 336, 349, 357, 372, 377, 382, 383, 387, 632. Jacquot, 659. J&kinovitcb, 601. Jakins, Percy, 774. Jalaguier, 568. Janssens, 363. Jarvis, 4, 15, 62, 458, 470, 495, 582, 583, 765, 770. Jawdynski, 566. Jean, 513. Jeauty, 155. Jelley, R., 521. Jenner, 336, 655, 657, 659. Jennings, 638. Jessop, 628. Jewett, 528. Joal, 113,131,135, 140,653,666. Johnson, George, 523, 534. Johnson, 11. A., 488, 742. Johnston, Samuel, 505, 522, 528, 604. Johnstone, 329. Jones, 557, 787. Jones, T. Arnalt, 653. Joynt, 629. Juhel-Renoy, 603. Justi, 501, 546. Jurasz, 48, 49, 263, 526. Jurist, 59. Kalindero, 442, 446, 451, 453. Kaposi, 185, 414, 415,416, 421, 441, 445, 446, 607, 636, 731. Karlenski, 502, 522. Kaurin, 439. Keiiner, 611. Keller, 806. Kellogg, 582. Kidd, 802. Killian, 155, 806. Kinnear, 75, 85. Kirby, 537. Kitchen, 580. Klebs, 310, 343, 344, 345, 346, 347, 348, 351, 356, 357, 358, 359, 360, 362, 371, 627, 628, 655, 810. Klein, 343, 356, 624. Knapp, 152. Knight, C. H., 43. Knight, F. I., 494, 604, 670, 679, 728. Koch, Paul, 466, 664. Koch, R., 414, 415, 416, 422, 423, 427, 430, 431, 434, 453, 454, 466, 511, 515, 607, 608, 664. Kbbner, 418, 448. Koehler, 513. Kolliker, 35, 322. Koenig, 416, 430, 566. Korner, 140. Kohler, 511, 557. Kohlrausch, 99. Kolopinski, 159. Korlovski, 563. Kratschmer, 99. Kraus, 786. Krause, 219, 300, 416, 427, 465, 606, 811. Krauss, 482. Krieger, 507, 511, 512, 513, 520, 521, 539, 540. Krishaber, 318, 339, 341, 507, 523, 581, 586, 773, 774. Kronlein, 568. Kiipper, 137. Kussmaul, 248. Kuster, 416, 430, 619. Labadie-Lagrave, 356. Labb6, 514, 647. Laborde, 513. Labus, 495. Lacretelle, 502. Laenneb, 115, 506. La Forge, 84. Lagen, 522. Lagrave, 351. Laidler, 532. LamartiniSre, 505. Lambron, 577. AUTHORS REFERRED TO IN VOLUME II. XIX Landgraf, 650, 655, 658. Lane, A., 480. Langenbeck, 538, 562, 565, 788. Langier, 479. Langmaid, 458, 459, 461, 464, 465, 467, 470, 470, 491. Lannois, 611. Lapeyre, 722. Laranza, 466, 666, 667. Larghi, 582. La Roche, 661. Lasegue, 110, 573. Lathrop, 487. Laurent, 563. Lavacherie, 545. Lavrand, 139. Law, G. E., 494. Lawrence, 356. Lax, 386. Lazarus, 100, 121. Lea, 566. Leber, 154. Lebert, 659. Lebouis, 510. Leclerc, L., 3. Lediard, 564, 617. Lee, Robert J., 109. Leeper, 538. Lefferts, 41, 43, 257, 316, 413, 418, 422, 480, 483, 508, 512, 520, 527, 566, 576, 588, 589, 608, 611, 670, 683, 746, 747, 749, 750, 751. Leflaive, 73. Legg, 93. Legouest, 34, 553. Lejars, 653. Leloir, 414, 422, 429, 436, 437, 438, 439, 443, 445, 448, 449, 452. Leinere, 58. Lennander, 644, 645. Lenoir, 521, 664. Leonard, C. H., 670, 695. Lepelletier, 506. Lermoyez, 73. Leroy, 563. Lesbros, 534, 543, 553, 569. Lescure, 510, 512. Lesser, 430. Levis, R., 590. Levret, 4. Levy, 430. Lewin, 646. Lewis, 278. Leyden, 427, 509, 520. Libermann, 666, 667. Lichtwitz, 100, 111, 134. Liebermeister, 328, 655, 656. Liegois, 599. Linares, 505. Lincoln, 631. Lindenbaum, 546. Line, W. II., 630. Little, 542. Littlejohn, 501. Littlewood, 728. Liveing, 642. Livon, 465, 467. Loder, 93. Loeffler, 343, 344, 345, 346, 347, 348, 351, 357, 358, 359, 360, 362, 371. 374, 627, 628. Loeri, 640, 642. Lowe, 103, 135. Lowenberg, 61, 161. Longuet, 104, 110. Loomis, 760. Louis, 349, 500, 510, 520, 521, 655, 657, 794. Lovadina, 549. Love, I. N., 387. Lovett, 410. Low, Bruce, 356. Lowndes, 34. Lublinski, 106, 111, 598, 605, 611, 657, 664, 665. Luc, 418. Lucae, 593. Lucas, 513, 620. Luchsinger, 96. Ludwig, 652. Liibning, 658. Lueddekens, 172. Lunn, 214, 218, 219, 221. Luschka, 195, 201, 218, 287. Lusk, 630. Luton, 565. Lyon, 502. Macalister, 718. MacCormac, 505, 539. MacCoy, 614. MacIntyre, 415, 615. Mackenzie, G. Hunter, 139, 766. Mackenzie, John N., 41, 43, 49, 50, 72, 73, 75, 86, 91, 96, 99, 100, 102, 104, 105, 106, 107, 108, 109, 110, 113, 115, 122, 128, 138, 139, 140, 253, 311, 458, 459, 460, 465, 493, 802. Mackenzie, Morel], 4, 9, 11, 12, 13, 15, 17, 18, 21, 23, 32, 37, 39, 41, 43, 59, 61, 72, 84, 85, 87, 88, 137, 159, 166, 172, 221, 263, 266, 273, 281, 316, 317, 318, 320, 413, 414, 418, 426, 430, 436, 437, 441, 443, 445, 446, 459, 462, 470, 473, 477, 490, 507, 523, 524, 526, 527, 533, 539, 542, 543, 549, 550, 553, 554, 556, 557, 563, 565, 579, 581, 583, 589, 591, 592, 593, 594, 599, 600, 606, 613, 626, 635, 636, 646, 647, 651, 652, 659, 667, 670, 683, 684, 688, 700, 707, 708, 713, 724, 736, 737, 738, 742, 744, 750, 751, 752, 753, 754, 758, 759, 760, 761, 764, 765, 768, 769, 770, 771, 773, 774, 777. Mackey, 428, 510. MacLean, 538, 541, 543, 544 553. Madelung, 737, 738, 783. Maisch, 386. Maisonneuve, 599. Maissurianz, 502. Major, 61, 139, 514, 515, 524, 541, 597, 670, 682, 742, 750, 751. Malbranc, 770. Mandl, 259, 315, 428, 435, 613. Manfredi, 460. Mann, 573. Manning, N. S., 631. Mantle, A., 466. Marais, H., 647. Marans, 665. Marcel, 140. Marckwort, 156. Marian, 495. Markoe, 562, 568. Marrow, 519. Marschka, 479. Marsh, 67, 78, 401, 532. Marston, 553. Martel, 507. Martin, 360, 502, 548. Martinache, 307. Marty, 413, 417, 421, 607. Maselli, 464. Masini, 129, 130, 160, 161, 164, 165, 441, 446, 448, 449. Mason, 11, 19, 515. Massei, 50, 135, 318, 413, 418, 428, 465, 502, 506, 541, 646, 647, 648, 649, 651, 652, 770. Massueci, 136. Mathieu, 4, 558, 559. Maxwell, 59, 129, 510. May, 102, 549. Mayo, 513. McArdle, 568. McBride, 135, 267, 341, 594. McCarthy, 591. McCullough, 83. McDonagh, 739. McFarlane, 568. McGaughey, 510. McGuire, 576. McKeown, 552. McLean, 512. McRuer, 58. McWheeney, 346. Mears, J. E., 505. Meigs, 623, 629, 633, 635, 638. Meltzer, 522. Meniere, 131. Menzel, 535, 556. Menzies, 355. Mprkol Merklen, 602, 650, 652, 712. Merrigan, 646. Mertens, 640. Meyer, E. 478. Meyer, L., 61, 131, 316, 469, 495, 528, 541, 545, 550, 577, 578. Michael, 416, 430. Michel, 47, 58, 553. Middeldorpf, 59, 86. Mignot, 557. Mikulicz, 554, 590, 618, 619. Miles, 171. Milsonneau, 465. Miller, 646, 658. Mitter, 537. Moe, 558, 559. Moldenhauer, 159. Mondi&re, 549. Monestier, 548. Monroe, 410. Montez, 515. Monti, 544, 545. Moore, 465, 491. Morehead, 85. Morelli, 770. Morgagni, 3. Morgan, C., 316, 540, 541, 542, 610, 719, 730, 759. Morgan, J. C., 480. Moritz, 431. Morrison, 416. Morse, 502. Moscati, 586. Moure, 49, 152, 252, 466, 467, 479, 587, 588, 759. Mouton, 534. Moxon, 750. Muller, Emile, 501. Muller, Johannes, 225. XX AUTHORS REFERRED TO IN VOLUME II. Muller, Paul, 110. Mules, 155. Mulhall, 459. Munk, 108, 219. Murchison, 654, 655, 659, 660, 661. Murrell, W., 108. Musehold, 138, 158. Mygind, 613, 620. Naseloff, 532, 570. Natier, 595. Neisser, 413, 448, 449, 607. Nelaton, 15. Netchaieff, 113. Netter, 653. Nettleship, 154. Neumann, 19, 20, 731. Newcomb, 597, 598. Newman, 484, 506, 510, 613, 769, 774, 783, 787. Nicati, 355. Nichols, 713. Nieden, 129, 152, 157, 161, 163, 172. Niemeyer, 331. Noquet, 577, 595. Norris, W. F., 162. North, 41, 140, 521. Northrup, 329, 361, 392, 394, 395. Notta, 93, 94. Nycamp, 597, 698. Oatman, 393. O’Dwver, 390, 408, 429, 522, 737*, 740, 744, 746. Oertel, 328, 349, 351, 388, 514, 523. Ogle, 93, 549. Olavide, 439. Oltuszewski, 596, 598. Onodi, 91. Opitz, 519. Oppert, 93. Orwin, 412, 717, 728. Osier, 540, 546, 624, 654, 655, 656, 657. Otto, 726. Otz, 510. Ouspenski, 576. Owen, Edmund, 716. Ozanam, 332. Packard, J. H., 479, 566. Padley, 522. Paget, 154, 534. Pallucci, 4. Palmer, 566. Palombieri, 137. Panas, 15. Paquelin, 590. Par6, Ambroise, 586. Park, 360, 641. Parker, Edward F., 93, 403, 408, 515, 576. Parrott, 349, 501, 506. Pasteur, 596. Pate, 511, 512. Paterson, 506, 547, 554, 642, 660. Paul, 537. Pavloff, 601. Payne, 475. P6an, 19. Peaslee, 501, 503. Pelletan, 510. Peltesohn, 134. Pemberton, 503, 506. Penny, 553. Pepper, Augustus J., 591, 633, 635, 638. Pepper, William, 623, 629, 660. Peris, 316, 415. Perrin, 503, 508. Peter, 647. Petit, 560. Pettit, 521. Peyer, 91, 108, 113, 140. Peyrot, 594. Pfeiffer, 414. Phillips, 351. Phoebus, 67, 72, 73. Pick, T. Pickering, 511, 648. Picqu<§, 501. Pieniaczek, 502. Pilate, 548, 643. Pilcher, L. S., 396. Pillot, 548. Pipping, 467. Pitts, 513. Plato, 102. Playfair, 630. Plenck, 186. Plieque, 508, 615. Pliny, 102. Plumert, 445, 446. Poirier, 775. Poland, 620. Polisius, 545. Politzer, 2581 Polo, 140. Poltauf, 415. Pond, E. P., 574. Ponfick, 156, 427. Poole, T. W., 119. Pope Sylvester, 213. Porai-Koschitz, 601. Portal, 102. Porter, 474, 627, 646, 726. Post, A. C., 48. Posthuma, 503. Postnikoff, 545. Potain, 578. Potter, 140. Poulet, 501, 502, 503, 507, 508, 513, 514, 515, 519, 521, 522, 528, 537, 538, 539, 540, 547, 548, 549, 554, 556, 557, 566. Powell, 527. Power, W. H., 357. Prat, 566. Predborski, A., 114, 751. Pressat, 93. Pr6vost, 93, 98. Pritchard, 506. Profeta, 439, 440. Prudden, 343, 346, 350, 360, 475. Puech, 576. Putzel, 670, 701. Pye, 568. Pynchon, 581. Quelmaltz, 47. Qu6nu, 532, 582. Quinart, 579. Quinlan, 130, 171. Rampoldi, 130. Ransom, 512, 523. Rauchfuss, 328. Raudnitz, 415. Raug6, 109, 726. Raulin, 424, 428. Ravenel, 520. Rayer, 414. Rayland, 501, 506. R6clus, 594. Reed, 641. Reeves, 564. Regiani, 531. Reid, 274. Reidlinus, 521. Reinard, W., 388, 389. Renard, 32. Renaudin, 544, 548. Rendu, 251, 576, 650, 653. Resieyes, 521. Rethi, 111, 471, 475. Retterer, 194, 197. Rewentaver, 385. Rheiner, 477. Rice, 414, 415, 417, 418, 477, 478, 495, 581, 589, 607. Richardson, 505, 567, 570. Richardson, B. W., 135. Richerand, 322. Richet, 15, 17, 568. Ricord, 590. Ricordeau, 589. Riehl, 412, 413, 415, 417, 747. Rilliet, 348. Ringer, Sydney, 108, 255, 643. Risley, S. D., 159. Ritter, 346. Rivington, 542, 546. Roberts, F. T., 539, 622, 623, 642, 655, 660, 661, 668. Roberts, J. B., 49. Robertson, 4, 59, 565, 713. Robin, 599. Robinson, Beverley, 42, 43, 48, 59, 61, 88, 89, 129, 259, 272, 273, 458, 462, 463, 464, 491, 662. Roche, 540. Rochester, 379. Rockwell, 512, 525. Roddick, 602. Roe, 15, 41, 48, 62, 82, 104, 117, 131, 139, 458, 476, 480, 489, 571, 588, 670, 679, 681, 682, 742. Roederer, 735. Roersch, 568. Rose, 384. Rokitansky, 310, 544, 611, 655. Rollet, 602. Romberg, 109, 132, 133. Rosenbach, 131, 513, 628, 658. Rosenberg, 606, 811. Rosenmiiller, 93. Rosenthal, 307, 416, 427. Ross, 669. Rossbach, 106, 372. Rostan, 115. Roth, 106. Rothholtz, 129. Rotter, 430. Rousseau, 96. Routh, 541. Roux, 343, 345, 356, 360, 375. Ruault, 106, 135, 443, 445, 446, 573, 575, 576, 577. Riihle, 252, 502, 507, 633, 635. Rukovitch, 658. Rumbold, 136, 159. Rushmore, 505, 510, 532. Ryland, 649. Sabatier, 58. Sadebeck, 598. Saenger, 22. Saint Ambrose, 213. Saint-Germain, 581, 594. Saint Gregory, 213. AUTHORS REFERRED TO IN VOLUME II. XXI Sajous, 9, 43, 73, 86, 467, 479, 495, 583, 594, 649. Salicet, William of, 3. Salkowski, 387. Sallinger, 134, 135. Salmuth, 102. Salter, 115. Sanders, 513. Sanderson, Burdon, 119, 311, 512. Sanford, 561. Sandwith, 663. Sands, 506, 591. Sanng, 352, 378, 387, 396, 398. Santwood, 420. Sappey, 8, 93. Sarycheff, 568. Saucerotte, 549. Savitzky, 543. Schadewaldt, 252, 523, 524. Schadle, 111. Schaeffer, Max, 15, 49, 104, 105, 106, 114, 115, 131, 156. Schech, 4, 13, 48, 59, 106, 111, 113, 121, 128, 134, 260, 261, 264. Schede, 416. Scheinmann, 111. Schenck, 504. Schenker, 385. Scherschewsky, 465. Schiffers, 466. Schimmelbusch, 430. Schirmer, 165. Schlemmer, 118. Schley, 433. Schmaltz, 105, 106, 110, 135. Schmidt, 316, 431, 525, 576. Schmidtborn, 166. Schinidt-Rimpler, 130, 156, 165. Schmiegelow, 108, 110, 117, 139. Schneider, 96, 135. Schnitzler, 104, 466, 475, 479, 483, 671, 770, 802. Schoetz, 495. Schreiber, 106, 141. Schroeder, 102, 258. Schrotter, 41, 315, 316, 317, 320, 413, 429, 461, 477, 485, 502, 503, 505, 508, 515, 562, 735, 736, 744, 745, 746. Schuler, Max, 422. Schuler, 593. Schuster, 656. Schwartz, 650, 652. Schwimmer, 607. Schwitzen, 731. Secehi, 137. Secretan, 638. Sedziak, 49. S6e, 186, 117, 458, 542, 546. Segond, 568. Seibert, 377. Seifert, 113, 128, 134, 598, 735, 770. Seiler, Carl, 4, 15, 42, 43, 48, 103, 110, 128, 139, 459, 464, 480, 491, 579, 580, 670, 694, 770, 794. Seiler, Emma, 224. Seiss, R. W., 164. Seitz, 307. Selby, 564. Semeleder, 321, 480, 647. Semon, Felix, 138, 214,219,227, 241, 265, 339, 482, 494, 508, 577, 652, 688, 689, 760, 767, 768, 770, 771, 774. Senator, 265, 650, 651, 652. Sendler, 528. Senenko, 506. Senert, 510. Sestier, 317, 652. Sevestre, 343, 346, 348. Shackelford, 510. Shann, 549. Shattock, 760, 770. Shaw, 576, 577. Sheppard, 510. Shoemaker, 543. Shurly, 318, 482. Sigel, 384. Silver, H. M., 544, 552, 553. Simanovski, 548. Simon, Jules, 343, 369, 373, 374, 381, 382, 384, 387, 646, 647. Simpson, 666, 667. Sims, Marion, 141. Sipe, 503. Siredey, 349. Sivers, 698. Skey, 534. Sklifosovski, 535, 568. Smith, A. A., 389. Smith, A. H., 43, 458, 474, 512. Smith, Charles, 367, 368. Smith, Gilbart, 733. Smith, J. L., 623, 626, 627, 628, 629, 630, 631, 632, 633, 640, 642, 660, 661. Smith, Priestley, 154, 158. Smith, S. S., 387. Smith, Thomas, 529, 556. Smolitschew, 502, 522. Snow, H. L., 387. Sokolowski, 571. Soltmann, 339. Sommerbrodt, 108, 110, 121, 131, 477. Sonnenburg, 265, 431, 652. Southam, 568. Sowers, 565. Spencer, 641. Spillmann, 4. Sprengel, 509. Squibb, E. R., 368, 376. Squire, B., 186, 662. Squires, Win., 329, 330. Stanski, 519. Starr, 638. Steavenson, 503. Steele, 49, 57. Steffen, 336, 338. Stein, Stanislaus von, 137. Steinbrtigge, 15. Sternberg. 353. Stevens, 549. Stewart, 537, 566. Stille, 386, 661. Stimson, 538. Stockton, 461. Stoerk, 4, 61, 116, 117, 264, 312, 315, 429. Stoessel, Hiero, 519. Stoffella, 639. Stohr, 279. Stoker, 48, 50, 138, 783. Stokes, 501, 508. Strasser, 510. Strassmann, 605. Strieker, 223. Stroem, 515, 538, 568. Stromeyer, 541. Striibing, 316, 317. Striimpel, 622, 630, 634, 644. 654, 655, 660. Strumpf, 383. Subbotic, 534, 566. Sutherland, 506. Sutton, Bland, 510, 726, 738. Svanson, 514, 527. Sykes, 502. Sylvius, 138. Syme, 563. Sympson, 539. Szadek, 600. Tappan, 381, 382. Tauber, 506, 770. Taylor, Frederic, 722. Taylor, L. H., 129, 160, 162, 445, 446, 601. Tchernaieff, 627. Terillon, 568. Terpander of Lesbos, 213. Thacher, 389. Thiersch, 430. Thin, 447, 448. Thomas, 486, 622, 623, 628, 629, 638, 640, 642. Thompson, 137, 509, 512, 538, 564. Thorburn, 617. Thorner, 272, 525, 542, 652, 670, 672, 742. Thrasher, 113. Thudichum, 4. Tigri, 349, 663. Tillaux, 398. Tissier, 802. Tobin, 568. Tobold, 322, 413, 429, 446. Todd, 643. Toison, 583, 584. Tornwaldt, 71, 106, 111, 131. Torrance, 563. Traube, 121. Trendelenburg, 351, 565, 787. Trifiletti, 109. Trolard, 534. Trousseau, 96, 115, 116, 122, 129, 161, 268, 270, 272, 344, 370, 371, 396, 398, 636, 643, 647, 657. Tiirck, 312, 316, 317, 318, 413, 470, 472, 473, 482, 700, 806. Turner, 355, 357. Tusa, 544. Tyler, 511. Tymowski, 484. Tyndall, 218, 219. Tyrmann, 154, 155, 157. Tyrtaeus, 213. Unna, 258, 448, 452. Urban, 430, 431. Ure, 17. Usiglio, 556. Valat, 581, 599. Valentine, 93. Valsalva, 3. Vanderpoel, 15, 597, 598. Van de Warker, 546. Van Helmont, 66, 96, 102. Vanlair, 132. Van Meck’ren, 9. Velpeau, 589, 619. Verdos, 577. Vergely, 633. Verneuil, 15, 17, 19, 40. Vialle, 271. Vidal, 186, 421. XXII AUTHORS REFERRED TO IN VOLUME II. Viennois, 19. Vierordt, 466. Vieusse, 502. Yigla, 545. Yilcoq, 664. Villar, 612, 721. Virchow, 35, 265, 306, 346, 423, 447, 448, 469, 477, 611, 651, 747, 772. Voelcker, 507. Volgnarius, 545. Volkmann, 23. Volland, 513. Voltolini, 2, 4, 49, 58, 59, 101, 103, 115, 525, 526, 763. Von Focke, 373. Von Hacker, 554. Von Hoffmann, 317. Von Klein, 695, 696. Von Troeltsch, 782. Von Wahl, 568. Vulpian, 307. Vysokovitch, 627. Wagner, Clinton, 474, 490, 589, 770. Wagner, R., 15, 42, 213, 269, 278, 572, 573, 576, 799. Wagnier, 445. Walker, 565. Wallace, James, 160, 169, 546. Walsham, 49. Walshe, 549. Walther, 502, 539, 540. Ward, 528. Warden, 91. Warren, J. M., 506, 510. Watson, P. H., 49, 163, 329, 679, 785. Watts, 542, 548. Waxham, 395. Weber, 116, 117. Weichselbaum, 664. Weigert, 328, 349. Weinlechner, 556. Weir, 503, 505, 512, 531, 535, 586. Weiss, 415, 494, 522. Weist, 517, 518. Weiszbarth, 513. Welch, 343, 622, 631, 634, 640, 644, 653, 660, 663. Welcher, 383. Welcker, 153. Wells, 528. Welsh, 660. Wendt, 258. Werner, P., 382, 587. Wetmore, 333. Wharton, 407, 408, 502, 513, 519, 528. Wheeler, F. T., 355, 527, 567. Whistler, 523, 525, 745. White, George, 534, 537, 545. White, Hale, 726. White, J. A., 129, 503, 523, 548. Whitehead, 787. Whittier, 381. Whyte, Robert, 102. Wight, 568. Wilde, 4. Wilkinson, 540. Willard, De Forest, 532. Wille, 111. Willis, 138. Wilson, 515, 536. Wing, 464. Wingrave, 612, 720. Winternitz, 502, 522. Witte, 512. Woakes, 4, 10, 43, 59, 98, 110, 112, 307, 308. Wolf, 446, 480. Wolfenden, 426, 613, 614, 616, 665, 722, 812. Wood, C. A., 154. Wood, George B., 359. Wray, 501. Wright, Jonathan, 48, 61, 256, 568, 583, 584. 604. Wunderlich, 647. Wurtz, 346, 628. Wurzer, 599. Wyeth, 502, 504, 528, 529. Wyman, 67, 73, 78, 80. Wyss, 660. Yearsley, 574. Yersin, 343, 345, 356, 360, 375. Zahn, 356. Zaufa), 58. Zawarakin, 572. Zeleneff, 601. Zeinan, 548. Ziegler, 415. Ziem, 96, 129, 130, 140, 153, 155, 156, 168, 169. Ziemssen, 248, 312, 322, 412, 413, 418, 426, 428, 459, 462, 477, 484, 512, 639, 640, 647, 654, 660, 661, 683, 685, 693, 771, 777. Zuckerkandl, 4, 8, 9, 13, 15, 37, 38, 92, 99. Zuelzer, 647. Zwaardemaker, H., 92, 93, 95. Zwillinger, 446. Zwinger, 515. SYSTEM OF DISEASES OF THE EAR, NOSE, AND THROAT. IP-A-IE^/T1 II. Diseases of the Nose and Naso-Pharynx. (CONTINUED.) MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES: PATHOLOGY, ETIOLOGY, PHYSIOLOGY, AND DIF- FERENTIAL DIAGNOSIS. BY CARL SEILER, M.D., Lecturer on Laryngology in the University of Pennsylvania; Chief of the Throat Dis- pensary in the University Hospital; Late Curator of the Pathological Society, etc., Philadelphia. INTRODUCTION. The subject of tumors and neoplasms in the nasal cavities is one of great interest, and at the same time a very difficult one to discuss intelli- gently in a short treatise, such as necessarily must be given in the following pages. The difficulty lies chiefly in the fact that true neoplasms may be, and frequently are, confounded with hyperplasias, hypertrophies, or deviations from the normal contours of the bony framework forming the nasal cavities. This difficulty must therefore be overcome by including these deformities, hypertrophies, hyperplasias, and even foreign bodies and rhinoliths, in the list of tumors, so as to be able to give a clear understanding and compre- hensive view of the differential diagnosis in the respective cases of nasal obstruction; because tumors and neoplasms situated in the nasal cavities must necessarily obstruct free nasal respiration by their very presence. 1 2 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. It is therefore reasonable to consider in detail other obstructions which are not tumors or neoplasms in the strict sense of the words; also to include the rare aggregation of calcareous matter around a nucleus formed by a foreign body as a neoplasm, or a new formation, which by its presence obstructs and cannot be expelled by the ordinary natural effort of forcible expiration. But the hardened excretions so often met with in atrophic rhinitis, although they obstruct, cannot be logically or reasonably included in the list, because their removal does not require surgical interference, but is accomplished sooner or later by the natural efforts of the patient. According to Dunglison, a neoplasm is “ a new formation or tissue, the product of morbid action in other words, it is a pathological aggregation of tissue-elements, either foreign to the tissue in which it occurs, or else a superfluous and superabundant accumulation of the same tissue-elements; and we term the latter an hypertrophy. A tumor, on the other hand, is defined by Boyer (Dunglison) as “ any preternatural eminence developed on any part of the body,” which means that a tumor is a pathological aggrega- tion of either like or unlike tissue-elements producing an elevation, and in this one characteristic—namely, elevation above the surface—consists the difference between neoplasm and tumor. The tumors, as defined above, which occur within the nasal cavities are divided, for the sake of convenience of description as well as clearness of understanding, into two large classes, considered from the stand-point of the clinician. These classes are first the benign tumors, wrhich, clinically speaking, do not produce death by metastasis, and secondly the cancerous tumors, which latter are again divided histologically into the connective- tissue, or sarcomatous, and the epithelial, or carcinomatous, tumors. HISTORY OP TUMORS. Perhaps the first mention of tumors made in medical literature is an account of several cases of nasal polypi by Hippocrates,1 who describes the method of removal which was adopted and advocated by Voltolini for the removal of tumors in the larynx,—viz., by quickly and forcibly drawing a piece of sponge attached to a string through the nasal cavities from behind forward. Celsus2 advocated their removal by actual cautery with a hot iron. Galen3 recommended astringent solutions or powders. Aetius4 also recognized them as tumors, and employed caustics. Paul of iEgina5 was the first to mention the necessity of dilating the nostril, which he accom- plished with the thumb and index-finger of the left hand, while he em- ployed a peculiarly-shaped scalpel with the right hand to cut the attach- 1 De Morbis, lib. ii., Littre’s ed., Paris, 1851, vol. vii. p. 51. 2 De Medicina, lib. vi. cap. viii. 3 De Comp. Pharm. sec. Locos, lib. iii. cap. iii. 4 Tetrabibl., ii. serm. ii. cap. lxxxix. 6 Lib. vi. cap. xxv. MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 3 ments of the tumors. Abulcasis1 used forceps to draw out the excrescences, after which he cut off the protruding portion and scraped the seat of origin of the tumor. Guy de Chauliac2 employed forceps and removed the tumors by evulsion, as general surgeons perform the operation at the present day. William of Salicet3 introduced the plan of strangulation of nasal growths by tying a ligature tightly around the pedicle. The channel of the nose was widened by means of sponge tents or serpentaria root. The tumor was then tied tightly with doubled silk as near the root as possible. The growth was extirpated by evulsion with forceps, and the stump destroyed by corro- sive applications or actual cautery. Arantius4 was not satisfied with knife- treatment. He also invented blunt forceps with which he tore away the growth, and always operated in a dark room, a round hole in the shutter only allowing the sunlight to fall on the patient’s nose. On a dull day, a lighted candle placed behind a glass flask full of water was the illuminating method. Fabricius ab Aquapendente5 claimed to be the originator of an instrument for the removal of tumors, which consisted of a pair of forceps, the cutting blades of which were deeply hollowed, so that when closed the instrument formed a kind of canula, through which a hot iron could be passed or powder blown. Fabricius declared that his instrument was designed to cut growths without the dangers attending the use of the spatha, or ancient scalpel. He may therefore be termed the inventor of the “ cutting forceps.” In 1628 Glandorp6 published an erudite treatise on tumors and nose affections, and Boerhaave7 subsequently propounded a theory that nasal polypi were formed by a prolongation of the lining membrane of the pituitary sinuses. He argued that the secretion in one of the cells, becoming from some cause or other too thick, does not escape properly from the cavity, which thus becomes filled up, till its lining membrane is protruded into the nasal fossa, where it is suspended as a membranous sac filled with fluid or semi-fluid contents. Heister8 also propounded the theory that nasal polypi were formed by the obstruction of one or more of the glands of the pituitary membrane, leading to the formation of a tumor. Morgagni9 quoted and approved Valsalva’s method of removing the 1 Lib. ii. cap. xxiv. (Chirurgie d’Abulcasis, traduite par le Dr. Lucien Leclerc), Paris, 1861, p. 93 et seq. 2 Le Guydon (Guy) en Francois, par Maitre Jean Camappe, Lyon, 1538, fol. 198. 3 Chirurgia Gulielmo de Saiiceto, in Ars Chirurgiea Guidonis Cauliaci, Venetiis, 1546, p. 308 4 De Tumoribus prater Naturam, Appendix to his Treatise De Humano Foetu, Yenetiis, 1587, p. 170 et seq. 5 Operationes Chirurgicae, cap. xxiv., in Opera Chirurgiea, Lugduni Batavorum, 1723, p. 438 et seq. 8 Tractatus de Polypo, Bremen, 1628, cap. vii. 7 Prelectiones ad Institutiones, cap. 8, 498. 8 General System of Surgery, English translation, London, 1743, pt. ii., p. 437 et seq. 9 De Sedibus et Causis Morborum, ed. sec., Patavii, 1765, Epist. xiv. sec. 19, 20. 4 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. lamella of bone on which the tumor grows, with the view of preventing recurrence. Levret,1 when he turned his attention to nasal growths, in- vented several ingenious instruments for applying and tightening ligatures. Pallucci2 was considered one of the most successful operators in this branch of surgery, and he essayed to improve upon Lev ret’s methods. In 1805 Robertson of Edinburgh published a drawing of an instrument for snaring nasal tumors, and upon this Wilde modelled his aural snare, which was later on modified by Hilton so that it might be used for the nose to better advantage. In later days interesting treatises on the subject have been pub- lished by Gruner,3 Dzondi,4 W. Colles,5 Mathieu,6 Thudichum,7 Durham,8 and Spillmann,9 and also valuable treatises by Zuckerkandl10 and Woakes.11 Since the general introduction of the rhinoscope, and the more modern and improved methods of examining the nasal cavities, the literature on intra-nasal neoplasms has multiplied to such an extent that but a few of the more important writers need be mentioned in this short sketch. First and foremost among the English are Sir Morell Mackenzie,12 Woakes,13 and Lennox Browne;14 in Germany, Voltolini,15 Schech,16 and Stoerk ;17 and in America, J. Solis Cohen,18 Bosworth,19 Jarvis,20 and Seiler,21 all of whom have embodied their contributions to the literature either in text-books on rhi- nology and laryngology or in extensive monographs. And the medical journals of the day are replete with more or less extended papers and descriptions of interesting cases of intra-nasal neoplasms, by various authors. GENERAL ETIOLOGY. The peculiar anatomical relationship of the parts, the still more peculiar histological structure of the soft tissues within the nasal cavities, and also the unusual distribution of glands and blood-vessels, together with the 1 Obs. sur la Cure radicale de plusieurs Polypes, Paris, 1771, 3d ed., p. 214 et seq. 2 Ratio facilis atque tuta Narium curandi Polypos, Vienna, 1763. 3 De Polypis in Cavo Narium obviis, Lipsiae, 1825. 4 Ergo Polypi Narium nequaquam extrahendi, Halae, 1830. 5 Nasal Polypi, Dublin Quart. Journ. of Med. Sci., November, 1848, p. 373 et seq. 6 Sur les Polypes muqueux des Arriere-narines, These de Paris. 1875. 7 On Polypus in the Nose, etc., London, 1869 ; 3d ed., 1877. 8 Holmes’s System of Surgery, vol. iv. 9 Diet. Encyclop. des Sciences Medicales, art. Nez. 10 Normale u. Pathol. Anatomie der Nasenhohle, Wien, 1882, p. 64 et seq. 11 Post-Nasal Catarrh, Am. ed., Philadelphia, 1867. 12 Diseases of the Throat and Nose, London, 1884. 13 Post-Nasal Catarrh, Am. ed., Philadelphia, 1884. 14 The Throat and its Diseases, London, 1878. 15 Die Galvanokaustik, Breslau, 1867. 16 Diseases of the Mouth, Throat, and Nose, Eng. ed., Edinburgh, 1886. 17 Wiener Mediciniscbe Wochenschrift, 1886. 18 Diseases of the Throat and Nasal Passages, New York, 1879, 2d ed. 19 Diseases of the Throat and Nose, New York, 1881. 20 Archives of Laryngology, vol. ii. 21 Diseases of the Throat and Nose, 3d ed., 1889. MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 5 physiological functions of the organ, must be recapitulated, in a few words. Such recapitulation is necessary in order to appreciate fully the special peculiarities of intra-nasal neoplasms,—the reason why some, which are most common in other parts of the respiratory tract, are seldom found in the nose, while on the other hand some, most commonly met with in the nose, are hardly ever seen in other parts of the body. For instance, there are but few cases of intra-nasal papillomata on record, while warty growths are the most common kind of neoplasms in the larynx. And, on the other hand, where, except occasionally in the vagina, do we meet with a mucoid polypug, which is the most common form of intra-nasal neoplasm? Let us first consider the peculiarities of the mucous membrane lining the nasal cavities, and recall the histological details by which it differs from mucous membranes in other parts of the body. A microscopical examination of a transverse section of some of the soft tissues of the nasal cavities, under a moderately high power,—about five hundred diameters,— presents a picture at variance with similar sections from other portions of the upper respiratory tract; and so striking is this difference that no skilled observer could hesitate a moment to pronounce the section to be from the interior of the nose. (Fig. 1.) Fig. 1. Transverse Section of Erectit.e Turbinated Tissue. X 500.—1,1, epithelial layer; 2, mucous glands; 3, capillary vessel; 4, 4, venous sinuses. In the first place, the epithelial layer, composed as it is of columnar epi- thelium, ciliated in most parts of the nasal cavities, but without cilia in the upper, or olfactory, region, is very much less deep here than elsewhere in the body. The contour of the upper surface of this epithelial layer, as well as of its base, is smooth, and papillae are met with only near the lower and external portion of the anterior nasal cavities,—viz., that portion of the mucous membrane which gradually merges into skin, through the inter- 6 MORBID GROWTHS AND DEFORMITIES OF THE NASAE CAVITIES. mediate integument, lining the vestibule of the nose. The basement mem- brane separating the epithelial layer from the submucosa is extremely thin, and so is the submucosa itself, being composed of but a scant mesh-work of connective-tissue fibres and a very delicate net-work of capillaries; unlike the submucosa of the trachea, for instance, or, still more strikingly, of the small intestines, in which localities both the epithelial layer and the sub- mucosa are very deep and give ample room for the excretory glands. In those portions of the nasal mucous membrane overlying the tur- binated bones, and also the lower portion of the cartilaginous plate of the Septum, we find a peculiar tissue immediately below the submucosa, and in no way separated from it by any membrane or sheath. This tissue is com- posed of a net-work of strands of connective-tissue fibres of both the white and yellow elastic varieties, the meshes of which net-work form large open spaces of variable shape and size, which are lined with endothelium, and in the living tissue are filled with venous blood, thus presenting a very similar picture to a section of the corpora cavernosa, or other erectile tissue, in other portions of the body, as first described by Bigelow. (Fig. 2.) Fig. 2. Section of the cavernous or erectile tissue of the middle and lower turbinated bones, in- flated and dried, X 2 diameters (Bigelow). The resemblance to the true erectile tissue is still further borne out bv the facts that the venous sinuses communicate directly with the arterioles, without the intervention of capillaries, and also that the capillary circula- tion of the connective-tissue framework is very scant. The physiological functions of the nasal organ are threefold, or, better expressed, consist of three ditferent and distinct functions which make the nose one of the most important organs of the human economy, and natu- rally any interference with these functions will have a most important pathological bearing upon the whole system; for when respiration, perhaps the most vital function of organic life, is abrogated even in a minor degree, all other functions of the system, in either plants or animals, will be inter- fered with, to a greater or lesser extent. The interchange of carbonic acid MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 7 and oxygen is alike necessary in plants and animals, and is more important than the supply of food, because life may be sustained for a number of days, or weeks even, without supplying new material for cell-growth, but if carbonic acid accumulates and oxygen is withheld but for a few minutes, life becomes extinct. Thus nasal neoplasms, as defined, by their presence more or less obstruct the nasal chambers, and thereby interfere with proper nasal respiration. To understand this clearly, let us in a few words recall the functions of the nose as a respiratory organ, as well as its other two functions,—viz., the accessory resonance to the voice, and the site of the organ of smell. The short description given above of the histological structure of the nasal mucous membrane, with its underlying turbinated erectile tissue, clearly indicates, what has been proved by experiment, that the air inspired in its passage through the nasal chambers must become warmed by its contact with the large expanse of tissue and its nearness to the venous sinuses, in a similar manner as the air of a room is raised in temperature by its passage between the coils of a steam radiator. The abundant mucilaginous secretion which continually sutfuses the mucous membrane gives off part of its moisture to the air passing through the nares, and thus it is saturated to the dew-point. And, finally, this very same secretion acts as a purifier, because those fine particles of dust or foreign matter floating in the air, which have passed through the sieve of the vibrissae, are engaged on the sticky surface of the mucous membrane, and the air thus passes through the pharynx and larynx into the trachea and lungs warmed, moistened, and filtered free from dust. The next function—of minor importance, however—is what is termed nasal resonance, and consists simply in the addition of vocal power by the reverberation of the air contained within the nasal cavities during the act of vocalization, in the same manner as the air contained in the cavity of a violin by its reverberation increases and modifies the sound given forth by the strings. Again, the air contained in the cavity must be in direct com- munication with the outer air, but not in direct communication with the string producing the vibration. In the violin the so-called / holes1 allow the air to communicate with the reverberations within the cavity, and the strings communicate their vibration to this cavity through the medium of the resonance-cover. In the nose the nostrils communicate with the outer air, and, the soft palate closing the posterior nares in vocalization, the vi- bration of the vocal cords is communicated to the air contained in the nasal cavities through the hard palate. If in either case the / holes of the violin or the nostrils are obstructed, the resonance is lost according to the degree of the obstruction. This fact gives the careful observer a valuable means of diagnosis in nasal obstruc- tions and neoplasms. 1 The f holes are openings in the resonance-cover or belly of stringed instruments, shaped like an italic /. 8 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. The third function of the nose, which is rather a negative one, is that its upper anterior portion is the seat of the sense of smell, inasmuch as the sensitive Abridge of the olfactory nerve are spread out in a fan shape over the upper portion of the septum and the upper third of the middle tur- binated bone opposite. (Fig. 3.) Whether we accept the old theory, that the olfactory nerve ends are excited by substantial particles floating in the air and given up to it by odoriferous substances, or the new theory, that the odoriferous substance throws the air into vi- brations, or waves, like those of sound, which by the excitation of the nerve-ends produce the perception of odor, is immaterial, for in either case odors will not be perceived if access of air to the olfactory region is prevented by obstructions due to neoplasms, hypertrophies, foreign bodies, etc. Fig. 3. Section of Nasal Cavities, showing Nerve-Supply. Spheno- palatine Ganglion, seen on its Internal Surface (Sappey).— 1. Terminal branches of the olfactory nerve; 2, external division of the ethmoidal branch of the nasal nerve; 3, spheno-palatine ganglion; 4, termination of the great palatine nerve; 5, posterior palatine nerve; 6, middle palatine nerve; 7, branch of the great palatine nerve supplying the lower turbinated bone; 8, branch from the spheno-palatine ganglion to the middle turbinated bone; 9, origin of the branch from this ganglion to the septum ; 10, Vidian nerve; 11, great superficial petrosal nerve; 12, carotid branch of the Vidian nerve communicating with the corresponding branch of the superior cervical ganglion; 13, carotid branch of the superior cervical ganglion. POLYPI. The most common form of intra-nasal neoplasms observed is that form usually termed polypus. Its very name, which is derived from the Greek, meaning “ many-footed,” and which has been applied to certain marine and fresh-water mollusks, indicates that the earliest observers, who gave the name to this neoplasm, were not familiar with either its histology or its etiology, and named it so merely from its resemblance to the translucent mollusk, and from its tendency to recur after apparent total removal. Clinically, as well as from a histological and pathological point of view, we must recognize three distinct varieties of this benign neoplasm. Al- though Zuckerkandl1 gives five different forms, yet I am in harmony with Bos worth when he says “ he [Zuckerkandl] goes beyond the field.” The explanation of this apparent discrepancy lies in the fact that Zuckerkandl 1 Op cit., p. 64 et seq. Fig. 4. Left Naris with Hypertro! hy of the Mucous Membrane (Zuckerkandl).—a, indentation in the lower turbinated body; b. lobulated tumors on the edges of the indentation; c, warty tumor on the inferior turbinated body. Pig. 5. Right Nasal Chamber containing Two Large Polypi (Zuckerkandl).—b, infundibulum; c, cyst of the mucous membrane. MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 9 derived his knowledge from pathological specimens post mortem, most of which had been for years preserved in alcohol, while Bosworth and others, among them the writer, arrived at their conclusions by clinical observations and microscopical examination of pathological specimens obtained by operations on living subjects. What Zuckerkandl terms “polypoese Wucherungen” (polypoid excrescences) are not in a living subject to be classed with or mistaken for any of the three varieties of polypi, but were, in all probability, the shrivelled and distorted masses of hypertrophied turbinated tissue as seen after death in a preserved specimen. Mucous Polypi.—The first variety of polypi to be considered is the ordinary mucous polypus so frequently met with, and so easily recognized by its peculiar and characteristic resemblance to a small oyster or mollusk. With the ordinary light employed in rhinoscopy, whether artificial or natu- ral, it is seen to present a glistening surface of a pearl-gray or grayish-pink color, and, if not subjected to pressure by the adjacent parts, is of the form of a pear. In many cases these neoplasms protrude/from the nostrils, or hang down into the post-nasal or naso-pharyngeal cavity, and have the peculiar property of absorbing moisture from the atmosphere, so that their bulk is increased and they protrude more in damp wreather than when the atmos- phere is dry. In other cases, of not as long standing, they will not be seen at the anterior or posterior orifices of the nasal cavities, but may, like other intra-nasal neoplasms, cause a swelling and lateral enlargement of the external nose. Very frequently they give rise to spontaneous epistaxis, as well as obstruction to nasal respiration, which, owing to the hygroscopic properties above mentioned, increases in damp weather; to loss of the sense of smell, in a greater or less degree, and to the accumulation of a viscid, muco-puru- lent, sometimes sanguineous discharge, which oozes from the nostrils, as it cannot be blown out, and frequently excoriates the skin by its acridity. The usual symptoms due to obstruction of nasal respiration—viz., dryness of the pharynx, irritability of the laryngeal mucous membrane, and want of nasal vocal resonance, making the voice sound what is erro- neously called nasal—are present to a greater or less extent in all cases. In the foregoing pages the different theories entertained by the older observers have been already indicated, and a few words will suffice to give the opinions of our modern rhinologists as to the origin and causation of these peculiar neoplasms. Mackenzie1 says that the etiology is quite un- known. Sajous2 attributes mucoid polypi to chronic inflammation of the Schneiderian membrane. Van Meek’ren3 quotes a case of polypi as caused by the introduction of a splinter of wood into the nasal mucous membrane, and Gerdy4 attributes their origin to fracture of the septum; while 1 Op. cit., p. 352. 2 Medical and Surgical Reporter, 1881. 3 Quoted by Morgagni, loc. cit. 4 Des Polypes et de leur Traitement, Paris, 1833. 10 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. Woakes1 gives us perhaps the most plausible theory of the causation and origin of nasal mucoid polypi, which the writer can endorse and fully accept, not only as a theory, but as a fact demonstrated by clinical as well as pathological observations. In a few words, his theory is that in a long-standing chronic nasal catarrh of the hypertrophic variety it frequently happens that the middle turbinated bone returns to its embryonic condition ; that is to say, it becomes cleft into two portions, the two sides being parallel with each other, and the split in the bone running from before backward. At first the inner aspects of these two portions of the bone are covered with the normal mucous membrane, which follows the cleaving and becomes thus invagi- nated in a similar way as skin is in a dermoid cyst. Gradually, by pressure cutting off the proper blood-supply, and owing to the retention and consequent putrefaction of the normal secre- tion, the mucous membrane within the cleft be- comes ulcerated and the bone denuded. The necrosis of the bone, however, does not, as is gen- erally the case, cause sequestration, but, owing to the peculiar cancellated structure of the turbinated bones, small spicules of bone are thrown out, and the natural process of repair by granulation, springing from the still unaffected portions of the mucous membrane, covers these spicules. The blood-supply not being sufficient, however, true mucous membrane is not formed, but in its stead a myxomatous structure accumulates around them, which by its gradual enlargement increases the space between the two portions of the middle turbinated bone to such au extent that finally these mucoid neoplasms come in contact with the air- current, whereby their surface becomes hardened, the pressure is somewhat relieved, and epithelium begins to grow on their surface. Of course the lower polypi, having more space to expand, rapidly en- large, while those in the upper portion of the cleft grow more slowly, but as they grow they also push (Fig. 6), by their expansion, the lower ones into the respiratory portion of the nasal chambers, and thus the obstruction of the nose is gradually increased until total occlusion is accomplished. The histological features presented by a section under the microscope are very simple, as we observe nothing but the epithelium on the surface, the large meshes of delicate connective-tissue fibres containing the mucus, and delicate capillaries in this net-work, without walls or endothelium. Near the base or pedicle of the polypus the blood-vessels are somewhat larger, and the connective-tissue fibres are collected in parallel strands which emanate from the periosteum of the spicules of bone. Occasionally Fig. 6. Cleft middle turbinated bone (Woakes). 1 Op. cit., p. 190 et seq. Fig 7. Several nasal polypi with slender pedicles (Zuckerkandl). MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 11 we meet with open spaces in the centre of a section, which are lined with mucous membrane carrying on its surface (Fig. 8) ciliated epithelium and containing mucous glands. The cause of the presence of these spaces in the centre of the neoplasm is uncertain, but they may be accounted for by a coalescence of two adjacent polypi surrounding in their union a portion of still healthy nasal mucous membrane. We also sometimes find clots of blood coagulated within the meshes of the connective-tissue net-work, due to a rupture of some of the blood-channels, causing an extra- vasation of blood into the myxo- matous tissue. These clots are, as a rule, found near the surface of the neoplasms, and the spon- taneous epistaxis noticed in many cases of nasal polypi is probably due to a rupture of the surround- ing membrane of the neoplasm, allowing the extravasated blood to ooze out into the nasal cavities. These mucoid polypi are always multiple, occurring in large numbers, and varying in size in either or both anterior nasal cavities. Cohen1 says that the masses after removal occupy a larger space than it would seem possible they could have occupied in the nose, and this may be accounted for by the fact that their not being subjected to pressure after removal allows them to swell to a much larger size by absorption of moisture from the atmosphere. According to Mackenzie,2 as well as to the observations of other rhi- nologists, mucoid polypi occur more frequently in men than in women, and the ages at which they have been observed range from twelve years up to seventy or eighty. But the largest number of cases have been observed between the ages of twenty and forty years. The youngest cases are recorded by Mason,3 who reports a case of a boy of twelve years, and by Mackenzie, that of a girl of sixteen. The latter author expresses his belief that all examples of cases of polypi of a younger age were cases of malig- nant fibromata, and not of mucoid polypi. The various methods adopted at different times and by different surgeons for the removal of these neoplasms have been indicated in the Fio. 8. Section of Mucous Polypus (Seiler).—1, epithelial layer; 2, infiltrated submucous layer; 3, mucous gland; 4, fibrous band; 5, venous sinus filled with blood; 6, myxomatous tissue; 7, transverse section of arteriole; 8, invagination of mucous membrane. 1 Op. cit. 2 Op. cit., p. 353. 3 Medical Society Proceedings, London, 1872-74, vol. i. p. 156 et seq. 12 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. foregoing historical sketch, and are described in detail in other portions of this work. But, as the description of the etiology as well as the histology so clearly leads to a conclusion, I cannot resist the temptation of pointing out the one feature in the treatment which has for its object the prevention of a return of the neoplasms after removal. This feature is the destruc- tion of the necrosed bone, the total removal of the spicules, and the per- sistent application of remedial agents to the denuded surfaces of the cleft middle turbinated bone, with a view to cause a reunion of the separated portions and a return to the normal adult form of this middle turbinated body. Fibroids.—The second variety, which, however, fortunately, is not nearly as common as the mucoid variety, is the fibroid or fibrous polypus. It presents on rhinoscopy, both anterior and posterior, a mass within the nasal cavities of usually a glistening white or sometimes pinkish color, with blood- vessels of considerable size ramifying over its surface. To the touch, with a probe, or the finger, if near enough to the orifice to be thus reached, it feels hard and resisting. The mucus which exudes from the nostril or nasal pharynx is of a viscid, transparent nature, not usually stained as is the case in the mucoid variety. If the growth has existed for a considerable time, it may hang down into the naso-pharynx (Fig. 9), protrude from the nostril, and, as is sometimes the case, invade the adjacent cavities of the nose, such as the antrum, the sphenoidal cells, etc. The subjective symptoms to which this form of polypus gives rise are somewhat different from those observed in the mucoid variety. Inasmuch as the mass is hard and unyielding and does not possess any hygroscopic properties, and furthermore as it occurs usually on one side only, and is of slow growth, all the symptoms come on gradually, one after the other. For this reason it is often impos- sible to determine with any degree of accuracy, from the clinical history, the commencement of the trouble. The first symptom, as a rule, is obstruc- tion to breathing in the affected side of the nose, which is followed by a gradually increasing diminution of nasal resonance. Supra-orbital and dental neuralgia are the next symptoms, which, like the nasal obstruction, are persistent and progressive. When the tumor has reached such a size that it completely fills the anterior nasal cavity, it exerts such an amount of pressure that it first causes a deviation of the cartilaginous plate of the septum, and, when that possibility of expansion has become exhausted, atrophy of the mucous membrane and necrosis of the lateral wall of the nasal chamber by press- Fig. 9. Fibrous Polypus of the Nose.—View of the growth as seen by posterior rhinoscopy (Mackenzie). MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 13 ure ensue, and the neoplasm makes its way into the adjacent cavities. If, on the other hand, the tumor expands backward, it gradually fills up the naso-pharyngeal cavity, depresses the soft palate, and finally makes its appearance in the fauces. Both the mucoid and fibroid polypi, as well as the cystic variety, may be and often are mistaken for other nasal obstructions, such as devia- tion of the septum, middle hypertrophies, foreign bodies, and so forth, when rhinoscopy alone is used as a means of diagnosis. Therefore in all these cases the probe, as well as the finger, should be employed to test the consistency and mobility of the tumor or obstruction, thus adding the sense of touch to that of sight, and enabling the observer to arrive at a definite conclusion as to the nature of the obstruction. Histologically, the fibroid variety differs greatly from the mucoid polypi, inasmuch as its structure consists of closely interwoven strands of white fibrous connective tissue, without any meshes, and without mere blood-channels, so that a solid mass of fibrous tissue is formed contain- ing occasional mucous glands, and large ramifying blood-vessels, the walls of which are frequently canaliculated, preventing their contraction when the vessel is cut. Schech1 mentions the fact that in some cases the glands are so numerous as to present an appearance, under the microscope, of a section of an adenoma. (Fig. 10.) As a rule, the fibroid polypus springs from the connective tissue of peri- osteum of the bony plate of the septum, and is attached to its bed by a pedicle of considerable thickness. Zuckerkandl2 quotes four- teen cases in which the neo- plasms had their origin on the edge of the semilunar hiatus, one case from the frontal bone, one from the sphenoid bone, and one from the ethmoid bone. Of course, as Mackenzie3 says, the histological structure, the thickness of the pedicle, and the firm attachment to the bed preclude the possibility of a spontaneous ex- pulsion of a fibroid polypus ; yet at the same time we find in many cases the neoplasm to be lobulated, and a localized constriction of the neck of one of these lobules may cause a sloughing off of one of these buds, which then may be blown out, and such cases have been recorded as instances of a spontaneous expulsion of fibroid polypi. Fig. 10. Tubular adenoma (Gross). 1 Op. cit. 3 Op. cit., pp. 362, 363. 2 Op. cit., pp. 64-84. 14 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. The prognosis is, of course, a bad one if the tumor is not removed early, because of its persistent growth and the already mentioned destruc- tion of the parts with which it is in contact, leading to necrosis of the bones and consequent septicaemia, as well as chronic meningitis. The external contour of the nose itself is also considerably changed by this pressure, and if the tumor has invaded the antrum the cheek-bone is bulged outward, and the pressure upon the floor of the orbit causes also a bulging of the eyeball. Cystic Polypi.—The third variety of nasal polypi is the so-called cystic variety, which, like the fibroid, is single, usually on one side only, but may occur together with the mucoid variety. The symptoms to which it gives rise are the same as those caused by the mucoid variety, and need not be further detailed. It is comparatively rare, the first case having been recorded by the author1 but a few years ago, and since then some twenty or thirty cases have been recorded in the current medical literature. This neoplasm is nothing more than a delicate membranous sac covered with the epithelium found in the nasal cavities and filled with a straw-colored, sometimes sanguineous, serous fluid, which escapes when the membrane is pricked, and sometimes spontaneously. But the sac rapidly fills again, and the relief from the obstruction to the nasal respiration is of short duration. It is somewhat difficult to understand the etiology of these cysts, but they are probably merely retention cysts due to the obstruction of one of the serous glands of the nasal mucous membrane. Their usual situation is at the posterior portion of the lower edge of the middle turbinated bones, and their size is generally small, but they may assume such proportions that they make their appearance, like the fibroid variety, at the anterior nasal orifices, or in the naso-pharynx. As they are attached by a narrow pedicle, their removal with the cold snare is a comparatively simple and easy procedure. PAPILLOMATA. The next form of benign growths formed in the nasal cavities, spring- ing as they do from the mucous membrane, are the papillomata, or warty growths. When we consider the histological structure of these growths, as well as of the mucous membrane of the nose, it seems but natural that this class of benign neoplasms must be quite rare, and the reports of the dif- ferent observers must be taken cum grano salis; because in most instances these neoplasms, even after removal, were not subjected to microscopical examination, so that, no doubt, many of the reported growths were not papillomata, but growths resembling them in outward appearance only. Hopmann2 met with fourteen cases in one hundred nasal growths, and describes two varieties,—viz., the epithelial or benign cauliflower excres- cence, and the soft papilloma. Among those removed by Hopmann was 1 Archives of Laryngology, 1882. 2 Virchow’s Archiv, Bd. xciii., 1883. Fig. 11. Left nasal cavity with a papilloma on the inferior turbinated body (Zuckerkandl). MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 15 one four centimetres long; and in several other cases the neoplasms were multiple. Mackenzie1 reports only five cases of undoubted intra-nasal papillomata, and in four of these polypi were present at the same time. Zuckerkandl2 reports only one case. (Fig. 11.) Schaeffer3 reports twenty papillomata out of one hundred and eighty-two nasal growths, and Bosworth4 only one in two hundred. Mackenzie gives as the site in his five cases the mucous membrane covering the lower and anterior portion of the septum ; in ZuckerkandFs case the tumor was found on the lower turbinated bone, and in Hopmann’s cases the neoplasms were also found springing from the lower border of the lower turbinated bone. The cause of the growth of this variety of neoplasms is, of course, some- what doubtful, but as papillomata of the mucous membrane in other por- tions of the body are, as a rule, due to localized irritation or inflammation, we by analogy must assign the same cause to intra-nasal papillomata, from whatever cause such localized inflammation may come. And the fact that the most frequent position of these neoplasms was found to be the lower and anterior portion of the septum and of the lower turbinated bone, scratching with the finger-nail to remove small scabs, or the introduction of the twisted corner of a handkerchief into the nostril for a similar purpose, which is so frequently done by patients, may have been the cause of the localized inflammation of the parts. Erectile tumors, or angiomata, are extremely rare, and the only cases recorded are by Verneuil,5 Wagner,6 Steinbriigge,7 Seiler,8 Richet,9 Roe,10 Jarvis,11 Vanderpoel,12 and Burckhardt.13 Roe, in a comprehensive essay on this rare form of intra-nasal neoplasm, also mentions cases reported by Nela- ton,14 Huguier,15 Panas,16 Guyon,17 Dumenil,18 a second case by Richet,19 and ERECTILE TUMORS. 1 Op. cit., vol. ii. p. 377. 3 Deutsche Medicinische Wochenschrift, 1882, No. 3. 4 The Nose and Naso-Pharynx, New York, 1889. 5 Annales des Maladies de l’Oreille, vol. i. p. 169. 8 Diseases of the Nose, New York, 1884, pp. 149, 150. 7 Zeitschrift fur Ohrenheilkunde, vol. viii. p. 110. 8 American Specialist, Philadelphia, 1881, vol. ii. p. 7. 9 Cited by Debrie, These de Paris, No. 5, 1882. 10 Transactions of the American Laryngological Association, 1885, p. 94. 11 International Journal of Antiseptics, vol. i. p. 1. 12 Cited by Jarvis, loc. cit. 13 Berieht iiber dieChirurgische Abtheilungdes Ludwigsspitals, Charlottenhilfe, 1884-85. 14 Cited by Boeuf, These de Paris, No. 69, 1857, pp. 21, 25. 15 Bulletin de la Societe de Chirurgie de Paris, 2e s5r., vol. i. p. 7. 16 Bulletin de la Societe Anatomique de Paris, 1872, vol. xlvii. p. 435. 17 Bulletin de la Societe de Chirurgie de Paris, 3e ser., vol. ii. p. 856. 2 Op. cit., p. 70. 18 Ibid., p. 339. 19 Loc. cit. 16 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. one by Delavan.1 But a careful examination of the clinical features of all these cases as reported leaves us but ten in all which were undoubtedly angiomata, and from which number our knowledge of this rare form of intra-nasal neoplasm is derived. They are round, dark, sessile tumors, with a regular smooth surface, growing to the size of a cherry-stone, and are seen to pulsate synchronously with the heart. The only clinical difference between a tumor of this kind and an hypertrophy of the turbinated tissue is this pulsation, and histologi- cally the difference consists in the fact that the meshes of the erectile tissue are in direct communication with one of the larger arterial branches, and are therefore not venous sinuses, such as we find in the turbinated tissue. (Fig. 12.) This fact is of importance in the choice of the method for the Fig. 12. Section of Angioma, X 300.—1,1, arterioles; 2, 2, connective-tissue strands, forming the meshes; 3, 3, sinuses filled with blood. removal of such a tumor, as the hemorrhage must necessarily be vastly greater after the removal of an erectile tumor than is the case after removal of an hypertrophy. CHONDROMATA AND OSTEOMATA. Chondromata as well as osteomata of the nose are of very rare occur- rence, and although they both spring from the same structures, and, patho- logically considered, are very closely related to each other, we must clinically consider them under separate heads, because of the ditference in consistency and the ditference in the rapidity of their growth. The chondromata or cartilaginous tumors are, as already mentioned, extremely rare, and the first case reported was one occurring in the practice of Erichsen.2 Bryant3 1 Archives of Laryngology, vol. iii. p. 174. 2 Lancet, 1864, vol. ii. p. 152. 8 Ibid., 1867, vol. ii. p. 225. MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 17 mentions two cases, and Ure1 and Durham2 are reported in Holmes’s Surgery as recording each one case. Richet,3 Heurteaux,4 and Verneuil5 also reported cases later on. Mackenzie6 states that these cartilaginous tumors occur at an age near puberty, when cell-development is most active, and also makes mention of the facts that in all the cases described the growth sprang from the carti- laginous plate of the septum, and that it is more common in the male than in the female. The clinical features of these neoplasms very closely resemble those noticed in cases of fibroid polypi, and the differential diagnosis between a chondroma and a fibroid is frequently only possible by carefully noticing the difference in the elasticity and mobility of the two tumors. While the fibroid polypus, although hard and resisting to the pressure of the point of the probe, gives slightly, owing to its pedunculated attachment, the chon- droma, being sessile, will not yield, and a peculiar gritty feel is imparted to the fingers holding the probe when the point of the latter is gently passed over the surface of the tumor. Another difference in the clinical features of the two is that, owing to the immobility of the chondroma, the discharge which oozes from the nostrils is generally fetid. This fetor is produced by decomposition of the mucus, owing to its retention. The external appearance on inspection with the rhinoscope shows a glistening white or pinkish tumor, with blood- vessels very much like the picture presented by a fibroid polypus. But the surface of the growth is not smooth and rounded, and resembles rather the pock-marks of a patient’s cheek who has recovered from a severe attack of small-pox. The histological features are those common to all chondromata,—viz., a solid mass of hyaline cartilage, which sometimes is seen to undergo cystic degeneration in the centre; or calcareous nodules may be found here and there, and finally centres of ossification may have started in various portions of the growth, more or less numerous according to the length of time it has existed. This mass of cartilage is surrounded by a thick sheath of white fibrous tissue, which in turn is covered by a thin mucous membrane devoid of glands. Like all other cartilaginous growths, the mass of the tumor is nourished by loops of capillaries dipping into the cartilage from the perichondrium. No cause can be assigned for these excrescences. All authorities agree,that the prognosis is favorable if the proper method for the early removal of such neoplasms is employed. 1 Holmes’s System of Surgery, London, 1870, 2d ed., iv. 319. * Ibid. 8 Casabianca, Des Affections de la Cloison des Fosses nasales, Paris, 1876, p. 59. 4 Bulletin de la Societe de Chirurgie, November 7, 1877. 6 Quoted by Spillmann, Dictionnaire Encyclopedique des Sciences Medicales, xiii. 184. 6 Op. cit, p. 379. 18 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. Osteomata, or osseous tumors, like cartilaginous tumors, are extremely rare. Very doubtful cases have been reported by ancient writers; but Follin1 seems to be the first one who gives a good description and makes a distinct differential diagnosis between osteomata and exostoses. These tumors do not spring from the osseous tissues of the nose, but are attached by a more or less slender pedicle to the mucous membrane of either the septum or the turbinated bodies. Clinically they present a smooth pinkish surface which may in places be eroded or ulcerated, which ulcers or ero- sions are then surrounded by areolas of dark and even purplish color, and, if of long standing, exfoliation of spicules of necrosed bone, together with the characteristic odor of decaying bone, may be noticed. As is the case with fibroid polypi and chondromata, so also does the slow but persistent growth of the hard, unyielding bony mass produce deflection of the septum, and erosion of the walls of the nasal cavities, by pressure, and consequent distortion of the nose and disfigurement of the face. The pressure being by an absolutely unyielding substance, the early symptoms, besides occlusion of the affected side, are first itching, then sharp, lancinating pains of the face and head, and later anaesthesia, and even paralysis, when the tumor has destroyed the nerves as well as the blood-vessels supplying that part of the face. To the touch of the probe it feels hard and unyielding, and the sharpest needle cannot penetrate into its substance, as in the case of exostoses, nor will it break off particles of gritty substance, as is the case with rhinoliths. Histologically two varieties of osteomata are recognized, the eburnized or solid form, and the cancellated variety, which latter usually presents a hollow space in the centre. The microscopical structure of these two varieties is identically the same as we see it in the two varieties of bone structure in the adult skeleton. It may happen that a bony tumor of the nasal cavity is covered with calcareous accretion, when the differential diagnosis between it and the rhinolith becomes almost impossible,—except that a rhinolith rarely, if ever, causes the neuralgic pain, or the erosion of the walls of the nasal cavities. The removal, of course, of these tumors, which may vary in size from that of a cherry-stone to that of a hen’s egg, can usually be accomplished through the natural openings by first severing the pedicle and then delivering the growth with forceps, either through the post-nasal cavity, or, if not too large, through the nostrils. The origin, Mackenzie2 suggests, might be from a spicule of bone extending either from the bony plate of the septum or from the turbinated bones, which spicule becomes broken or absorbed, leaving the tumor attached only to the mucous membrane. This explanation would make the neoplasm nothing more than a detached exostosis; but this, of course, is merely theory, and any attempt to explain the presence of these extremely rare growths would be futile. 1 Traite Elementaire de Pathologie externe, Paris, 1877, tom. iii. p. 839 et seq. 2 Op. cit., p. 383. MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 19 MALIGNANT NEOPLASMS. Malignant tumors in the nasal cavity are mentioned by ancient medical writers and by authors of the Middle Ages, but the differential diagnosis, owing to the absence of pathological data, renders many of the cases doubtful. The later records, however, show that malignant tumors of the nose are not of common occurrence; also that if they do occur they are usually primary, and that the sarcomata are much more common than carcinomata and epitheliomata. Thus, Fayrer,1 Viennois,2 Mason,3 Griinfeldt,4 Duplay,5 Hopmann,6 and others have published cases of sarcomata in the nose, and Verneuil7 and Pean8 mention each one case of carcinoma of the epitheliomatous type. Duplay9 reports a case of encephaloid and Neumann10 one of medullary carcinoma. From this review of the literature it would seem that the remarks made in regard to the peculiar histology of the nasal cavities and of the nasal mucous membrane are again verified in the case of malignant tumors, as they were in the case of non-malignant intra-nasal neoplasms,—viz., that the epithelial type of tumor would presumably be much less common than the connective-tissue type. The malignant tumors usually spring from the septum, although instances have been reported in which they had their origin from the turbinated bones and the floor of the nasal cavities. Like the fibroid polypi, they are generally on one side, and single. They are attached by a broad base, are soft to the touch, bleed readily, and at an advanced stage of their growth are prone to ulcerate. Their color varies from a light pink, through the different shades of red, to purple, and even black, if of the melanotic variety. The first appearance—which is, however, but rarely noticed—is that of a small pimple or flattened elevation of the mucous membrane. They grow more or less rapidly, and may assume enormous proportions. The clinical features to which they give rise are the same that we have noticed in the description of the symptoms produced by the fibroid polypi, with the exception that the discharge is of a greenish color, fetid, but without the characteristic odor of necrosed bone and the frequency of epistaxis. 1 Medical Times, July 4, 1868. 2 Lyon Medical, 1872, No. 18. 3 Medical Times, May 22, 1875. 4 Montpellier Medical, October and December, 1876. 5 Traite elem. de Pathologie externe, Paris, 1877, tom. iii. p. 846. 6 Virchow’s Archiv, Bd. xciii., 1883. 7 Bonheben, De l’Extirpation de la Glande et des Ganglions sous-maxillaires, These de Paris, 1873. 8 Quoted by Casabianca, Des Affections de la Cloison des Fosses nasales, Paris, 1876, p. 67 et. seq. 9 Op. cit., t. iii. p. 788. 10 Oesterreich. Zeitschr. f. praktiscbe Heilkunde, 1858, iv. 17. 20 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. As in other portions of the body, malignant tumors of the nose give rise to the peculiar, intermittent, lancinating pain so pathognomonic of cancer. In the later stages the glands of the neck become enlarged and hard, and metastasis may take place in other parts of the body. Cachexia soon ensues, and death supervenes usually within eighteen months from the time that the first symptom was noticed. The prognosis, of course, is extremely bad,—in fact, hopeless,—and surgical interference, unless early instituted, or when absolutely necessary for the comfort of the patient, is not indicated, as experience has proved that these neoplasms grow much more rapidly and cachexia sets in much earlier after attempts at removal of the growth. The differential diagnosis should not be difficult when the clinical history of the case, as well as the peculiarities of the neoplasm, are taken into consideration. For only osteomata, foreign bodies, and rhinoliths might be mistaken for cancerous growths; and the differential diagnosis in these cases is easily determined by the touch of the probe. The origin or cause is as doubtful and uncertain as it is with cancer in other parts of the body; and the assumption held by some that syphilitic ulceration should assume a cancerous form and produce either sarcoma or carcinoma is not substantiated by clinical experience. The only case in which there is some reason to believe that a medullary carcinoma was caused by syphilitic ulceration is that reported by Neumann;1 and even in that instance it is more likely that the cancer developed in the cicatricial tissue left after the idcer had healed than that it should have been caused by the ulceration itself. It is just as unlikely that sarcomata should develop from fibroid or mucoid polypi, or carcinomata from warty growths, because histologically it does not seem possible that an adult tissue, such as fibrous connective tissue, should return to the embryonic type of connective tissue, the spindle- and round cell, or that the full-grown, well-nourished, and hardened adult epithelial cell should assume the characteristics of its embryonic prototype. SYPHILIS. The neoplasms proper having been discussed in the foregoing pages, it remains now to consider the diseases of the nasal cavities which give rise to tumors and obstructions interfering with the proper normal physiological functions of the nasal organ. Syphilis, standing as it does on the border- line, by the production of gummatous tumors, which, like tubercles, may be looked upon as neoplasms, is the disease which is perhaps more common, more frequently observed, and more difficult to diagnose than any other, and for these reasons forms an apt connecting link between true neoplasms and mechanical obstructions of the nasal chambers not due to a localized neoplastic cell-growth. 1 Op cit., p. 17. MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 21 Syphilis of the nose, according to Mackenzie,1 is spoken of by the earliest Chinese medical writer, the emperor Hoang-Ty,2 who described syphilitic disease of the nasal cavities twenty-six hundred years before Christ. Many of the later writers of antiquity, such as Hippocrates3 and others, mention nasal stenosis due to syphilitic infection, and the standard as well as current medical literature of modern times is replete with accounts of cases in which tumors, swellings, and other obstructions of the nasal cavities, due to the specific virus, were observed. Inasmuch as the primary lesion of syphilis is extremely rare in the nose, and, like the so-called secondary lesions,—viz., the mucous patches and shallow ulcers (Fig. 13), Fig. 13. Syphilitic Ulcer of Nasal Mucous Membrane, slightly Diagrammatic, X 500.—1, epithelium; 2, pus of ulcer; 3, cloudy epithelium melting into pus; 4, pus invading healthy tissue; 5, 5, capillaries gorged with blood; 6, 6, venous sinuses; 7, racemose gland. —do not give rise to any obstruction which is noticeable, it is only the gum- matous tumor with which we have to deal. Gummata are usually seen on the cartilaginous and bony portion of the septum,—rarely on the turbinated bodies,—and on the floor of the nose. If in the latter situations they are usually unilateral, while if situated on the septum, and particularly if on the cartilaginous portion, they are generally found to be bilateral. They give rise to the subjective symptoms of nasal obstruction, accompanied by a serous discharge, loss of sense of smell, and pain in the cheek, eye, or forehead, which has the peculiarity of being most severe at night and very much ameliorated or entirely absent during the waking hours. When the tumor has existed for some time and ulcera- tion has set in, the discharge becomes thickened, muco-purulent, and san- guineous, and a slight fetor is perceived. On inspection with the rhinoscope, a sessile tumor is seen to project either from the wall of the septum or from the turbinated body, or, in rare 1 Op. cit., p. 390. 2 See Fabry, La Medecine chez les Chinois, Paris, 1863, p. 260 et seq. 3 Quoted by Mackenzie, op. cit., p.390. 22 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. instances, from the floor of the nose, into the lumen of the nasal chamber. Its surface is smooth, and usually considerably paler in color than the rest of the mucous membrane, although in some cases it may be deep red, or even purplish, in hue. To the touch of the probe it feels immovable, hard, and yet elastic; although its surface cannot be indented by pressure. The histology of these nasal gummatous growths has been particularly studied by Saenger,1 and perhaps most graphically described by Bosworth,2 who says,— “ The essential pathological lesion which constitutes a gummatous deposit is an infiltration of the mucous membrane with small round cells, or inflammatory corpuscles, which invade not only the epithelial layer, but also the mucosa proper and the deep layers of the membrane or periosteum, and even the bone-tissue itself. . . . “ The membrane is crowded, as it were, with these small round cells, which so far encroach upon the periglandular structures as to obliterate the glands, probably by pressure, thus resulting in their destruction and the exfoliation of their lining epithelium. In addition to this, the same process invades the vascular structures of the membrane, more especially the nutrient arteries, giving rise to an infiltration of the arterial coats, and particularly the inner, by which their calibre is markedly diminished, and finally completely obliterated, partly, perhaps, as the result of pressure from without, but in the main as the result of a genuine endarteritis obliterans which is set up by their presence. “ According to Saenger,3 we occasionally find in the deep layers of the membrane, in addition to the small round-cell infiltration, a certain number of spindle-cells deposited in or near the periosteal layer. Saenger further states that as the result of the obliteration of the arteries we have a damming back of the blood, which may give rise to a hypersemic condition of the tissues beyond, and that this is followed by localized extravasations of blood, and, as an occasional ultimate result, small cyst-formations.” This obstruction of the nutrient vessels, as it gradually proceeds from the centre to the periphery of the gummatous tumor, deprives the quasi- neoplasm of its nourishment, the cells undergo the usual retrograde meta- morphosis, due to want of nutrition, and an ulcer is formed, beginning in the centre and extending toward the periphery of the tumor, and if the ulcerative process is not arrested it will transgress the limits of the localized infiltration and invade the surrounding healthy tissue, whether it be mucous membrane, cartilage, or bone. But, as Bosworth4 observes, the syphilitic ulcer due to the breaking down of a gummatous deposit seems to respect anatomical limits, so that we never see an ulcer of this kind ex- tend either into the vestibule or into the pharynx proper; although, as fre- 1 Journal de Med. Prat, et Pharm., 1858-59, vol. xxvi. p. 425. 2 Op. cit., pp. 348-44. 3 Loc. cit., p. 425. 4 Op. cit., p. 344. MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 23 quently happens, all the bones, including the septum and turbinated bodies, may have been destroyed. Unlike the gumma in the pharynx or soft palate, or even in the oral cavity, which ulcerates within a few days of its appearance, the gumma in the nasal cavity frequently remains for weeks and even months; and the author recalls a case in his own practice in which the clinical history clearly indicated bilateral gummatous deposits of the nasal septum to have existed a year, without showing any signs of breaking down, and giving rise only to the usual subjective symptoms of obstruction, coryza, and nocturnal pains. This peculiarity may be accounted for by the fact that the gum- matous growth in the nose is protected from irritation first by the mucus covering its surface, and secondly by the absence of friction or pressure upon its surface, to which the gummata in the oral and pharyngeal cavities are continually subjected. Mackenzie1 speaks of condylomata as having been observed within the nasal cavities, but it is doubtful whether they were really intra-nasal, and it is more likely that they sprang from the skin of the vestibule. Gummatous tumors of the nasal cavities may be mistaken for deviation of the septum, or septal abscess, or hypertrophy of the turbinated tissue; but the absence of a depression on the opposite side of the septum, as well as the peculiar elasticity to the touch of the probe, will exclude deviation of the septum. The absence of fluctuation, and the usual history of the long-continued existence of the nasal obstruction, prevent mistaking the tumor for a septal abscess. The same difference exists in regard to hyper- trophy of the turbinated tissue, together with the most important symp- tom,—viz., nocturnal pain, which is never absent in a gummatous tumor of the nose. It may not be considered good surgery to remove a gummatous deposit by surgical means, yet, when a gummatous tumor encroaches upon the lumen of the nasal chambers to such an extent as to cause stenosis, and the patient’s general health has been so undermined by loss of sleep, owing to the nocturnal pains, Volkmann’s method of scraping out the deposit will be found not only admissible, but also more satisfactory than the slow process of absorbing the deposit by internal medication. Another advantage of this procedure is, that the surrounding tissue will be saved from the extension of the ulcerative process should the gumma break down before the antisyphilitics have had time to cause its absorption. Tubercular disease of the nasal mucous membrane is an exceedingly rare affection, and but twenty well-authenticated cases of intra-nasal tuberculosis are to be found, according to Bosworth,2 in medical literature. Mackenzie3 TUBERCULOSIS. 1 Op. cit., p. 396. 3 Op. cit., p. 401. 2 Op. cit., p. 373. 24 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. acknowledges never to have met with a single case, and the author must admit the same. Very little, therefore, can be said about this disease except what can be gleaned from those few cases recorded. The clinical features are a slight stenosis of the nasal chambers caused by a deposit of small tubercular nodes, varying in size from that of a bird- shot to that of a split pea, usually multiple, and in clusters, more com- monly situated on the septum than in any other portion of the nasal mucous membrane; and coexisting with these nodes, or subsequent to them, shallow ulcers of an irregular rounded outline, without an aureola, of a grayish-pink color, lighter in the centre and near the periphery, so that it often becomes difficult to define clearly the edges of the ulcer. The secretion is of a grayish-white color, viscid in substance, and slightly opa- lescent, through the admixture of cell-debris, but in no way resembles pus (Bosworth).1 Very little, if any, pain is caused by either the nodes or the ulcerations, and the latter are but slightly sensitive to the touch of the probe. The mucous membrane not involved in the morbid process is of the charac- teristic ashy grayish-pink color so frequently noticed in the mucous membrane of the larynx and pharynx when tubercular deposits are present in that portion of the upper respiratory tract. In all the cases reported, tubercular disease of the lungs and other por- tions of the body either preceded or coexisted with the tubercular deposit in the nose, and they all ran a protracted course. There is only one excep- tion, that reported by Demme,2 which ran a rapid course, terminating fatally within six months; yet, this case having been observed in a small child, it is somewhat doubtful whether tubercular deposit really existed in the nose. The microscopical examinations which were made by careful observers in a number of these cases showed the same picture and the same arrange- ment of histological elements that are so well known to pathologists as indicative of tubercle. The prognosis, of course, is almost hopeless, and the question of surgical interference for the removal of either the nodes or the ulcerations is one not to be discussed here: still, it would seem useless, and even cruel, to scrape, cut, or burn when there is so little, if any, inconvenience to the patient from this local tubercular deposit, and when the general symptoms so far overshadow the local ones. LUPUS. Like tuberculosis, lupus is extremely rare, and the author has not met with a single case of lupus deposit or lupoid ulceration within the nasal cavities proper; although lupus of the soft palate, and even of the 1 Op. cit., p. 374. 2 Berliner Klinische Wochenschrift, 1883, No. 15. p. 217. MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 25 upper pharynx, is by no means uncommon. To judge from the recorded cases of undoubted intra-nasal lupus, which Bos worth1 enumerates also as twenty, the subjective symptoms are mainly obstruction, muco-purulent discharge, fetor, and pain of a dull character extending into the cheek, eye, and forehead. On inspection, small, hard, but elastic tumors, multiple and arranged in clusters, are noticed more frequently on the septum than on the turbinated bodies or the floor of the nose, together with large masses of greenish or brownish dry scabs of hardened secretions, which when removed forcibly disclose a bleeding, ulcerated surface, with raised and indurated edges. These ulcerations are usually small and of an elongated oval shape at first, but have a tendency to run together and form large, irregular-shaped, crater-like excavations covered with a thick greenish- yellow pus, which easily becomes desiccated by the air-current, thus pro- ducing the masses of hardened scabs which are the chief cause of the nasal obstruction. Lupus of the skin of other portions of the body generally either coexists with the lesions in the nose, or soon follows the appearance of the intra- nasal deposit. As in the case of syphilis and of tuberculosis, so also in lupus, the microscopical appearance of the deposit of lupus within the nose does not differ from the histological arrangement of cell-elements seen in lupoid deposits in other portions of the body. The question of differential diagnosis of syphilis and tuberculosis was intentionally omitted in the description of those two affections, because the picture presented by a case of lupus of the nose had to be held up before the reader’s mind before the differential diagnosis of these three local mani- festations of general dyscrasias which are so much alike could be intelli- gently pointed out. It is often difficult to make a differential diagnosis between the local manifestations of these three different diseases when they are seen in more accessible portions of the upper air-passages, such as the pharynx, the larynx, and the soft palate, and this difficulty must necessarily be increased by the restricted view obtainable when the deposits occur within the nasal chambers. But, if we bear in mind the peculiarities of the subjective as well as objective symptoms, the consistency of the neoplasms, the character of the secretion upon the ulcers, and the clinical history of the case, we can generally arrive at a definite conclusion as to the nature of the disease by exclusion, even without the aid of a microscopical examination of a portion of the new growths. Thus, the syphilitic gumma is large, sessile, hard, yet elastic to the touch, and the mucous membrane covering it is of a reddish hue; while the tubercular node and the lupoid nodules are small rounded elevations, soft to the touch, multiple, and arranged in clusters. The mucous mem- brane in the tubercular deposit is always pale, while that in lupus appears 1 Op. cit., p. 376. 26 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. of a normal line. Nasal obstruction is produced within a short time and is of long duration when caused by a gumma. In tuberculosis there is little or no nasal obstruction, while in lupus the nasal stenosis, being due to the scabs covering the ulcerations, is intermittent, being relieved temporarily by the expulsion of these scabs. And, finally, when ulceration has set in, the syphilitic ulcer is of a rounded outline, with slightly-raised edges, with a zone of inflammation surrounding it, and covered with a yellowish-white, thick, and opaque layer of pus. The tubercular ulcer, on the other hand, is small, of irregular outline, without raised edges, no aureola around it, and covered with a thin grayish-white opalescent secretion : it does not easily bleed, and is not sensitive to the touch ; while the ulcer of lupus is covered with the hardened secretion, forming scabs of a green or brown color, which when removed reveal a crater-like excavation, the edges of which are raised above the surface of the surrounding mucous membrane, without aureola, but bleeding easily, and touching which gives rise to sharp pain. Its outline when small is elongated, but when large and caused by the coalescence of a number of smaller ulcerations it becomes irregular in contour. The clinical history generally reveals the pre-existence or coexistence of other manifestations characteristic of the general systemic disease. The prognosis of lupus in the nose seems to be the same as for lupus elsewhere, and the same may be said of the treatment. Hyperplasias of the nasal chambers, although they are not, strictly speaking, neoplasms, yet, because they produce the same symptoms, present the same appearances upon inspection, and give rise to the same reflexes, must be considered in this chap- ter,—the more so as they resem- ble so closely the true neoplasms that they are often mistaken for them, and their histological ele- ments show a similar arrangement under the microscope. Within the last fifteen years, since the introduction of the modern im- provements in rhinoscopy, these hyperplasias have received more and more attention, so that now the standard as well as current medical literature is so volumi- nous, and the individual writers are so numerous, that references to individual observers would be entirely beyond the scope of this chapter, and therefore the subject will be discussed HYPERPLASIAS. Fig. 14. Dilated nostril, showing anterior hypertrophy (Seiler). Fig. 15. Transverse Section of Framework of Superior Maxilla, Anterior Segment. In the Left Antrum of Highmore is a Large Polypus (Zuckerkandl).—a, polypus; b, ridge of infra-orbital canal; c, infra-orbital depression; d, depression of cheek-bone. Fig. 16. Outer Wall of Left Nostril (Seiler).—1, superior turbinated bone; 2, middle turbinated bone, with posterior hypertrophy; 3, section of hypertrophied pharyngeal tonsil; 4, inferior turbinated bone; 5, orifice of Eustachian tube. MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 27 in an entirely general way, based upon personal experience as well as upon the knowledge acquired through the writings of others. The first form of hyperplasias to be considered is that to which the name of hypertrophies has been applied. Two varieties of hypertrophies of the turbinated tissue are observed, which differ from each other chiefly in location, and but slightly in their clinical features, but not at all in their histological structure. These two varieties are the anterior and middle hypertrophies (Fig. 14), situated (Fig. 15) on the anterior aspects of the lower and middle turbinated bones, and the posterior hypertrophies (Fig. 16), which are found at the posterior ends of the lower and middle turbinated bones. (Fig. 17.) 4 On inspection of the nasal chambers we notice rounded sessile eminences projecting into the nasal cavity, of the color of the ordinary nasal mucous membrane in most cases. Sometimes they appear lighter in color, due to the fact that the mucous membrane itself has become anaemic by pressure upon its capillaries. In the case of the posterior variety of hypertrophies the tumors can be seen only with the rhinoscope (Fig. 18), and present a Fig. 17 Fig. 18. Rhinoscopic Image from a Case of Poste- rior Hypertrophy of Middle Turbinated Bone (Seiler). Rhinoscopic Image in a Case of Cleft Palate, with Posterior Hypertrophy.—1, 1, middle turbinated bone; 2, 2, hypertrophic tissue on vomer; 3, 3, posterior hypertrophies on lower turbinated bone; 4, 4, opening of Eu- stachian tube. raspberry-like surface of a grayish-white, reddish, or even purplish color, and, unlike the anterior variety, they are more or less pedunculated, pro- jecting into the posterior nasal chamber. The anterior hypertrophies when pressed upon with the probe can be indented, but immediately assume their rounded outline on removal of the pressure. The subjective symptoms to which these hyperplasias give rise are chiefly nasal obstruction to a greater or less degree, according to their size and location, which obstruction comes on so gradually that the patient is often unconscious that nasal respiration is materially interfered with. In the recumbent position the hypertrophies become larger, and the patients 28 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. frequently notice that that side of the nose which is undermost in lying becomes stenosed, and opens again when the body is turned to the other side. The ingestion of hot food or hot drinks, as well as emotional excite- ment, also has a tendency to increase the bulk of the hypertrophies, and consequently increases the nasal obstruction. The normal secretion of the nose is greatly diminished, and particularly is this true of its watery or serous element: so that accumulations of thick, glairy mucus occur in the posterior nasal chamber, which form the chief source of annoyance to the patient. In the case of anterior hypertrophies, particularly when situated on the lower turbinated bone, it is not uncommon to find a gradually-increasing indentation of the cartilaginous plate of the septum, and the consequent bulging on the opposite side amounting in many eases to deviation, and also do we find, not infrequently, below the point of impact of the hyper- trophy against the wall of the septum, a projection of the cartilaginous septum. When the hypertrophy is situated on the middle turbinated bone and presses against the bony portion of the septum, pains of a neuralgic char- acter over the eyes, high up in the forehead, or in the nape of the neck are frequently complained of, and these pains or headaches, which may be of an intermittent character, are not infrequently accompanied by nausea, and even vomiting, thus closely resembling sick headache or migraine. In other cases this condition gives rise to paroxysms of sneezing, especially in the mornings, or whenever an increase in the bulk of the hypertrophy takes place, and in those cases in which the hypertrophy is situated on both sides of the nasal chambers and is so large as to close the upper portion of the chambers the sense of smell is greatly diminished or entirely lost. If the posterior hypertrophies are very large, they not infrequently prevent the introduction of air into the Eustachian tubes, by pressure upon the lateral walls of the posterior nasal cavity, and thus dulness of hearing and tinnitus are produced. The pressure exerted by the hypertrophies upon the circulation within the nose, and the inability of the turbinated tissue to swell, and thus act as an overflow in cases of sudden capillary congestion of the skin of the nose and cheeks, give rise to the frequently-observed symptom of acne of the face and nose, particularly at the age of puberty, and in women during pregnancy, when the erectile tissues in other parts of the body are in a stage of greatest activity. There is no doubt that these hypertrophies of the erectile tissue in the nose are produced by irritation and consequent congestion of the mucous membrane, by repeated and frequent attacks of acute coryza, or by the impact upon the mucous membrane of irritating dust floating in the atmos- phere, or, finally, by irritating gases, insufficient oxygen, and nervous irri- tation. But it is impossible to say when the erectile tissue of the nose begins to be hypertrophied. MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 29 The histological structure of the anterior, middle, or posterior hyper- trophies is merely a superabundance of the connective-tissue net-work of the ordinary erectile tissue (Fig. 19), together with an increase in the size of the venous si- nuses, and a greater or less infiltration of in- flammatory corpuscles into the connective-tissue net-work and the mu- cous membrane proper. In regard to treat- ment a few words may not be out of place in this article calling at- tention to the fact that the anterior as well as middle hypertrophies are sessile, and as the connective-tissue strands are very much enlarged and thickened, and the venous sinuses of the erectile tissue distended with venous blood, little can be gained by the application of astringents, and surgical measures must be adopted for their removal. A very popular and eminently satisfactory method is cauterization with galvano-cautery; but it should be observed that unless the cautery knife is carried through the hypertrophied tissue down to the periosteum nothing is gained, because the small amount of tissue destroyed is near the surface, and the cicatrix following the healing of the burn does not tie down the bulging tissue as it will when adherent to the periosteum as a fixed point. It is also well to remember that when the mucous membrane of the nose is in a state of acute or subacute inflammation, and particularly in the peculiar anaemic condition following the so-called grippe, the galvano- cautery does not give satisfactory results. Fig. 19. 1, epithelial layer; 2, mucous follicle; 3, submucosa, showing inflammatory infiltration; 4, mucous glands; 5, venous sinuses filled with blood; 6, small branch of arteriole; 7, transverse section of arteriole. ECCHONDROSIS. In cases of hypertrophic rhinitis we often notice projections from the cartilaginous plate of the septum, situated, as a rule, on the anterior and lower portion. They are seen on inspection of the anterior nasal chambers to be mostly unilateral, and but rarely bilateral, forming projections of various shapes and sizes covered with mucous membrane, which is some- times excoriated on the highest point (Fig. 20), but otherwise of normal appearance. The shape may be a cone-like protuberance from the surface, or it may be like a ridge, running from below upward and backward in a slanting direction, or the most frequent shape may be that of an inverted shelf, sloping from below upward and presenting an almost straight surface running directly out from the wall of the septum and close to the floor of 30 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. the nose, leaving a space or tunnel through which frequently even a thin probe can be passed only with difficulty. Inasmuch as these ecchondroses are usually found in connection with anterior hypertrophies, they them- selves, perhaps, do not give rise to any distinct symptoms, but as they project into the cavity of the nose, already encroached upon bv the hypertrophied erectile tissue, they increase the stenosis. They also occasionally give lodgement to thickened secretion, which becoming dry forms small scabs tightly adhering to the mucous membrane and causing by their for- cible dislodgement the excoriations above mentioned. Histologically considered, they are nothing more than a localized hyperplasia of the cartilage cells of the septum, which may or may not undergo ossification. Their causation is undoubtedly due to localized congestion of the nutrient vessels of the cartilage, in most instances caused by the pressure of the hypertrophied tur- binated tissue, and in not a few instances the outline of the anterior hypertrophy can be traced in the shape of the ecchondrosis. Still other localized irritations, such as foreign bodies, rhino- liths, etc., may cause this peculiar condition, and in one instance the growth of an ecchondrosis on the lower and anterior portion of the septum was carefully watched. In this case the source of irritation was a habit of the patient to introduce the little finger into the nostril and press its tip against the wall of the septum, without, however, scratching the mucous membrane with the nail: this gentle and intermittent pressure caused a teat-like ecchondrosis to grow in the course of a few months. It is not likely that, on careful inspection of the anterior nares, either hypertrophies, both anterior and middle, or ecchondroses, could be mis- taken for any other of the numerous neoplasms met with in the nose, and also, as in the case of anterior hypertrophies, local applications of astringents or other drugs cannot be expected to remedy the difficulty. Surgical measures alone are of any avail. Fig. 20. Dilated Nostrils showing Ecciion- drosisof Septum.—1,1, middle turbinated bone; 2,2, lower turbinated bone; 3, edge of vestibule; 4, shelf-like projection from septum ; 5, 5, floor of nose. SYNECHIA. Synechise, or bridges connecting the turbinated bodies with the wall of the septum, are not infrequently met with in hypertrophic rhinitis. They are either cartilaginous or bony, and but rarely membranous. They are covered with normal mucous membrane, and may be situated in any por- tion of the anterior nasal chambers, thus dividing the cavity into two por- tions. If they are situated low down in the respiratory tract (Fig. 21)} Fig. 21 Synechia in Left Nasal Chamber.—a, asymmetrical lower nasal wall; c, spongy- and b, con- nective-tissue masses encroaching upon the cavity of the sinus; d, lower turbinate ; e, hamular process of the septum; / and g, the lower nasal gallery divided by synechia between the lower turbinate and the nasal floor; h. upper part of the lower nasal gallery; i, synechia between the middle turbinate and the septum; m, middle turbinate adherent to outer nasal wall; n, ostium maxillare; o, cells of ethmoid bone; t, meatus of the lachrymal duct (Zuckerkandl). MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 31 they act as a dam or obstruction to the air-current, causing the thickened secretion to lodge behind them until it becomes putrefied and causes the symptom of ozaena together with that of nasal stenosis. The usual cause of these bridges is the simultaneous excoriation of the mucous membrane of both the hypertrophy and the septum at the point of contact, which favors agglutination, and later the projection of a mass of cartilage cells into the erectile tissue. This excoriation of the mucous membrane may be, and usually is, due to the friction of the two surfaces against each other in the act of respiration at a time when the anterior hypertrophy has not as yet caused complete stenosis. They may, however, also be produced by surgical interference for the removal of nasal obstructions, when both the mucous membrane of the turbinated bodies and that of the septum opposite have been wounded. Congenital synechia in the shape of a bony bridge across the posterior nares is sometimes met with, but is of exceedingly rare occurrence (Fig. 22). A differential diagnosis can always readily be made by the sense of touch in passing two probes, one above and the other below the obstruction, and in that way the thickness, the density, and the extent of the bridge can be easily determined. The only con- dition which might be mistaken for a synechia is an uncurling of the lower turbinated bone so that it projects straight across the nasal chamber and comes in contact with the wall of the septum,—a condition which is, however, extremely rare. Fig. 22. Posterior View of Congenital Bony Occlusion of Left Posterior Naris.—a, septum; b, b, Eu- stachian tubes; c, normal posterior nasal opening; d, d, posterior naris divided into three openings; e, hamuiar process of the septum; /, inferior tur- binated body. Exostoses are bony projections from the bony framework of the nose, usually situated either on the floor of the nose near the margin of the vestibule or on the bony portion of the septum. When seen in the former position they spring from the superior maxillary bone, and are of extreme density ; they appear as rounded eminences projecting from below upward into the nasal cavity, and are covered with pale mucous membrane, which is frequently excoriated, due to the removal of the dry scabs which find lodgement behind them by the finger-nail of the patient. If situated on the bony plate of the septum they are usually near the middle of the plate, and, like the ecchondroses, which they closely resemble, are of various sizes and shapes. They are covered also with mucous membrane, but of normal color and appearance, and do not produce any particular symptoms by themselves. EXOSTOSES. 32 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. It is probable that, like the ecchondroses, these bony excrescences are due to localized congestion of the periosteum, and the consequent hyperplasia of bone-corpuscles due to hypernutrition. FOREIGN BODIES. Foreign bodies are not infrequently met with in the nasal cavity, and according to their situation and the length of time during which they have remained within the nose they give rise to a group of symptoms which often closely-resemble those produced by neoplasms. The dilferent foreign bodies are introduced into the nasal cavities through the nostrils, usually by children and insane persons, or through the naso-pharynx, in the act of vomiting or choking, or, thirdly, through the external integument, and finally by growth and development, as in the case of maggots. Of course the first class is the most common, and the instances met with by every physician are usually of so little import that in the general litera- ture and the text-books of medicine the subject is treated very lightly. At the same time, the specialist meets with cases which are much more grave and present features which are not usually seen in those cases in which the foreign body has remained within the nasal cavity but a short time. The articles which have been found as foreign bodies are of various kinds, such as shoe-buttons, pieces of wood, small pebbles, beads, beans, peas, allspice, paper, cotton, etc. Usually they are seen to lodge in the lower and anterior portion of the nasal cavity immediately beyond the vestibule, but they may also be found farther back in the lower meatus, being carried thither by the air-current in forcible inspiration or “ sniffing,” or they may even lodge in the middle meatus or be wedged in between the middle turbinated bone and the septum. The immediate symptoms are nasal obstruction and sneezing, whereby the foreign body in a majority of cases is spontaneously expelled. If this expulsion does not occur, the contact of the foreign body with the mucous membrane gives rise to an acute inflammation, which in no way differs in its symptoms from the ordinary acute coryza, but it does not spontaneously resolve itself within a few days, and persists for weeks and even months, until finally the mucous membrane becomes tolerant to the presence of the foreign body, and only the ordinary symptoms of chronic hypertrophic rhinitis may supervene. In this way alone can we explain the possibility of a foreign body being retained within the nasal cavity for years, as in instances recorded by Renard,1 Boyer,2 Bosworth,3 Mackenzie,4 and others, and in an interesting paper written on the subject by Bron.5 Generally, however, a foreign body very speedily gives rise to an ulcera- tive process of the mucous membrane, with pain in the forehead and cheek, 1 Journal de Medecine, t. xv. p. 525. 2 Traite des Maladies Cliirurgicales, Paris, 1846, t. v. p. 65. 3 Op. cit., p. 321 et seq. 4 Op cit., p. 432 et seq. 6 Gazette Medicale de Lyon, 1867, No. 36. MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 33 paroxysms of sneezing, and yellow or sanguineous discharge, sometimes mixed with white, cheesy, flocculent masses, which Bosworth1 believes to be cheesy degeneration of inspissated mucus and to be characteristic. The breath becomes extremely fetid, the sense of smell is lost, and the voice grows nasal. As the swelling of the mucous membrane extends to the other side of the nose and into the naso-pharynx, by obstruction of the orifices of the Eustachian tubes the hearing becomes affected. On inspection by aid of the proper instruments, the foreign body can usually not at first be seen, because it is covered with the muco-purulent discharge, and because the tumefaction of the turbinated tissue in front of the foreign body is so great as to obstruct the view. Only after thorough cleansing with an alkaline wash in the form of a spray, and the introduction of a pledget of cotton saturated with a four- per-cent. solution of cocaine, for the purpose of reducing temporarily the swelling of the turbinated tissue, can the foreign body be seen and its nature and location determined. But then it is not always possible to make a correct diagnosis, even with the aid of the probe, because hard substances, such as shoe-buttons, pebbles, etc., are often encrusted with calcareous deposit and may then be mistaken for rhinoliths ; while soft substances, more particularly seeds of plants, have become swollen and dis- torted, and may even sprout, so that they can easily be mistaken for polypi or malignant neoplasms. Boyer2 recites a curious case of a “ haricot” bean which shot out ten or twelve roots and produced the appearance of a polypus, for which it was in fact mistaken. As a rule, a history is not obtainable, and it is difficult to determine with any degree of accuracy how long the foreign body has remained within the nose, because there is either an unwillingness on the part of the patient to confess to having introduced a foreign body, or, in the case of children, absolute ignorance or forgetfulness, and it is often amusing to hear the earnest protestations of a fond mother that her child was never out of her sight, and could not possibly have put anything up its nose without her knowing it. And still more amusing is it to see her dismay, and even anger, when she is confronted with the actual cause of the trouble, the foreign body. The second class of foreign bodies which usually lodge in the posterior portion of the nasal cavity are, as a rule, composed of particles of food, and are thrown into the naso-pharyngeal cavity in the act of vomiting. Or they may be substances accidentally inhaled into the larynx and pro- pelled into the nose by the spasmodic cough due to the irritation of the laryngeal mucous membrane, and this accident is favored by partial or complete paralysis of the soft palate. The irritation produced by the presence of the foreign body causes sneezing, and forcible expiration through 1 Op. cit., p. 323. 2 Op. cit., p. 66. 34 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. the nose, and if the body is small enough, as is the case when cherry-stones, pieces of bone, or similar substances have been vomited into the post-nasal cavity, they are likely to be forced into the anterior nasal chamber from behind, and find lodgement in the same localities in which we generally see foreign bodies introduced wilfully through the nostrils. In these instances the same symptoms and appearances of the mucous membrane are observed as in the former type. On the other hand, when the foreign body thus introduced into the post-nasal cavity is too large to be propelled by the air-current into the anterior nasal chamber, it is not likely to remain very long in its abnormal position; although Lowndes1 records a case in which a metal ring was removed from the post-nasal cavity of a child fifteen months old, which was too large to pass through the nostrils, and must, therefore, have been swallowed and thrown up. Another case occurred some years ago in Baltimore, in which an undigested raw oyster had been vomited into the naso-pharyngeal cavity and was mistaken for a fibroid polypus. Gener- ally the “ hawking” as well as the efforts of the patient to dislodge a foreign body by introducing the finger behind the velum are sufficient to remove the offending substance, which is then expectorated. It sometimes, but rarely, happens that a tampon which had been in- troduced by the physician for the purpose of stopping epistaxis is wedged in so tightly that it is not dislodged together with the rest of the tampons, and may remain for a considerable length of time in situ. It becomes then discolored as well as covered by the secretions, and may very easily be mistaken for either a small fibroid polypus or a posterior hypertrophy. A case of this kind came under the notice of the author not long since, and the symptoms produced by this foreign body were those of nasal obstruction and scanty thickened secretion, together with headache, such as we see in ordinary chronic hypertrophic rhinitis. Bosworth2 mentions a unique case of foreign body retained in the naso-pharyngeal cavity for many years. In this case he removed a de- ciduous tooth from the nasal cavity of a gentleman aged thirty-seven years, which had been the cause of a purulent catarrh for twenty-five years. Sometimes it may happen that a foreign body is introduced into the nasal cavities, and retained there, through«the skin or the bones of the face, or even through the alveolar process of the superior maxillary bone : thus, spent musket-balls, shells, lead-pencils, points of knives or daggers, and even tooth-picks and needles, have been found within the nasal cavity. Lo- gon est 3 reports a case of a carpenter who was stabbed by a man in the nose with a pencil, the broken end of which was subsequently removed through the nares. In all these cases there is naturally an external wound or cicatrix which 1 British Medical Journal, September, 1867, p. 206. 2 Op. cit., p 321. 3 Traite de Chirurgie d’Armee, Paris, 1863, p. 383. MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 35 marks the entrance and the method of entering of the foreign body into the nasal cavities; but these instances are extremely rare, and more curious than instructive, particularly as the subjective symptoms do not differ from those produced by foreign bodies introduced either through the nostrils or through the posterior nares. A still more curious accident is the introduction of the eggs of the ordinary house-fly into the nostrils in Southern climates. These eggs are deposited by the fly while the victim is asleep, and they develop with re- markable rapidity into maggots, which crawling upward into the nasal cavi- ties give rise to the various symptoms already described, with the addition of formication, which is said to be so irritating that convulsions and death have occurred in a number of instances within a few hours after the devel- opment of the maggots. Some of the older writers mention cases in which earwigs, centipedes, and ascarides have been discovered as foreign bodies in the nose; but no such accident is to be found in modern medical literature. KHINOLITHS. Rhinoliths, Avhich are accumulations of the salts of the nasal secretion, are occasionally met with in the nasal cavities, and they act in a similar manner and give rise to the same symptoms as foreign bodies. They may be situated in any portion of the anterior nasal cavities, and some instances have been recorded in which they had penetrated into the soft tissues and were partly covered with mucous membrane. They are of various shapes and sizes, irregularly elongated, with a rough and often spiculated surface, varying in color from a light gray to brown, and even black. They are hard and brittle to the touch, and, when seen in situ, are covered by muco- purulent discharge or scabs of desiccated mucus, which must be removed by washing before a definite diagnosis can be made. It is not known defi- nitely what gives rise to the accretion of the salts forming the rhinolith, and the theory that a foreign body is invariably the exciting cause around which as a nucleus the calcareous material is deposited in layers is not always borne out by fact. Bosworth1 suggests that those cases in which a calcareous deposit is in the shape of a lamella or cast, having on its inner aspect the shape of a projecting portion of the nasal tissues, such as the pendent portion of turbi- nated bone, or a deflection or ecchondrosis of the septum, may be due to a calcareous degeneration of the mucous membrane, as described by Virchow2 and Kolliker.3 Instances are on record in which rhinoliths were found in both anterior nasal cavities, and in a number of other cases the calculus when broken showed a hollow centre. It is more probable that the nucleus is a dry scab of mucus, and the altered secretion in a case of atrophic rhinitis is 1 Op. cit., p. 328. 2 Cellular Pathologie, IY. Aul, Berlin, p. 453 and note. 3 Gewebelehre: Geruchsorgan. 36 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. more likely to undergo calcareous change than is the superabundant secre- tion from the actively-inflamed mucous membrane irritated by a foreign body. The suggestion made that the calcareous deposit in the shape of a rhinolith is due to a gouty diathesis is not borne out by clinical observa- tion, nor by an analysis of the recorded cases. A differential diagnosis, as already suggested, is easily made, because small portions of the surface can be broken off with the point of a needle, and this fact, together with the peculiar hard and metallic sound which is emitted when the calculus is tapped with the probe, at once distinguishes it from an osteoma, the only neoplasm for which it could possibly be mistaken. The literature on this subject does not date back very far, nor are the reports of cases very numerous, probably owing to the fact that most of them were published in various and, to the writer, often inaccessible medical journals of different countries. It is astonishing to what size these calculi will sometimes grow. The writer met with a case some time ago in which a rhinolith had obstructed the left nasal cavity for about ten years, giving rise to muco-purulent discharge, with occasional epistaxis, and a most horrible stench. At the suggestion of the patient’s wife, he at last sub- mitted to an operation under ether, and then it was discovered that the calcareous mass completely filled the lower portion of the left anterior nasal cavity, extending from the edge of the vestibule to the posterior edge of the vomer, three and a half inches in length, and in width, by actual measure- ment, it was three-quarters of an inch. Its thickness could not be ascer- tained, nor was it possible to determine its weight, because it was necessary to employ a lithotrite of considerable strength to break up the calcareous mass into small crumbs before it could be removed, and most of the pieces were lost in the copious hemorrhage. Only one portion was saved, and this was found to weigh forty-six grains when dry. The accumulation of scabs of desiccated mucus in some cases of atrophic rhinitis sometimes forms a solid mass, filling up the channel, so that stenosis of the nasal chambers, with all its concomitant symptoms, is produced. These masses can readily be distinguished by inspection, by the sense of touch, and by the clinical history, from neoplasms, foreign bodies, or rhino- liths,—particularly because they are spontaneously expelled periodically, only to reform within a short space of time. The writer has met with three instances of large pieces of necrosed bone lying loose in the nasal cavity, in which an ulcerative process had destroyed the bony walls as well as the septum, but had healed and left the detached pieces of bone to act as foreign bodies. In one case the portions of bone were so large that they had to be cut with bone-forceps before they could be removed, and in another case, owing to the fact that a dense cica- tricial tissue had agglutinated the edge of the velum to the posterior wall of the pharynx, the pieces could be removed only with great difficulty through the nostrils. All these cases occurred in young girls, and no family history of syphilis Fig. 23. Transverse Section of the Framework of the Superior Maxilla, Anterior Segment (Zucker- kandl).—a and b, pus-filled glandular follicles in the mucous membrane of the sinus; c, infra-orbital depression; d, deviated septum. Fig. 24. Transverse Section through the Framework of the Superior Maxilla, Posterior Segment (Zuckerkandl).—-The right maxillary antrum, a, is capacious; the left, 6, is contracted by the encroach- ment of the outer maxillary wall, c. Fig. 25. Contraction of the Maxillary Sinuses in consequence of Excessive Outward Deviation of the External Nasal Walls (Zuckerkandl).—a, nasal cavities; b, b, contracted maxillary sinuses; c, c, deviating outer nasal walls; d, infra-orbital nerve, to which one of the deviating walls extends. Fig. 26 Sigmoid Deflection of the Septum, probably the result of Fracture (Zuckerkandl). MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. 37 in the parents could be obtained; and because the personal history of the patients did not show any traces of acquired syphilitic infection, it is difficult to assign any plausible cause for the systemic dyscrasia giving rise to the self-limited ulcerative process. The deformities met with in the nose are either congenital or acquired, and the former class mostly consists in the absence of parts of the nasal cavities. Inasmuch as this article is devoted to neoplasms and their effect upon nasal respiration, it is unnecessary to consider any such deformities, and only those which might give rise to a mistake in the diagnosis will have to be mentioned. The most common form of such derangement of the nasal parts is deviation of the septum, which occurs either in the bony or in the cartilaginous plates, or it may be present in both at the same time. It is difficult to arrive at a definite origin of this deformity, and to call it either congenital or acquired, because the development of the vomer and the fusion of the turbinated bones are not completed until near the age of puberty (Zuckerkandl).1 Therefore the large number of de- viations of the bony septum found in dry skulls by Mackenzie,2 Allen,3 Zuckerkandl,4 and other observers can really not be considered as con- genital, but must be looked upon as the result of intra-nasal pressure, on one or the other side, during the period of development between birth and puberty. Bosworth5 combats the view expressed by the writer6 that hypertrophic rhinitis will cause deviation of the septum, and remarks that the reverse is true,—viz., that the deviation is either congenital or due to traumatism, and that the hypertrophic catarrh is caused by the deviation of the septum. However this may be, it is the clinical experience of many rhinologists that deviation of the cartilaginous portion of the septum, at least, is in most cases due to pressure on the opposite side. (Figs. 23, 24, and 25.) Various forms of deviation of this lower portion of the bridge are observed, the most common of which is a bulging of the cartilage until it occludes the nostrils, with a corresponding depression or concavity on the opposite side. There may be also in some cases a sigmoid flexure (Fig. 26) occluding one nostril low down and the other higher up. Another form is a bulging to one side, and a projection of the anterior margin of the car- tilaginous plate into the opposite nasal cavity, thus occluding both nasal chambers. Sometimes cases are met with in which the two plates of the cartilaginous portion have become separated, and the lower free edges flare DEFORMITIES 1 Op. cit., p. 100 et seq. 2 Op. cit., vol. ii. p. 424. 3 Loe. cit. 4 Op. cit., pp. 99, 100. 5 Op. cit., p. 293. 6 New York Medical Journal, February 18, 1888, p. 180. 38 MORBID GROWTHS AND DEFORMITIES OF THE NASAL CAVITIES. like the tail of a swallow, occluding both nostrils (Fig. 27). This variety is usually due to blows directly upon the bridge of the nose in a vertical line, thus forcibly separating the two plates. But this separation may also be caused by an accumulation of pus in Jacob- son’s organ, in which instances a small perfora- tion is generally seen. As a rule, these deviations produce little or no deformity of the external contour of the nose. If, however, the pressure due to hyper- trophic rhinitis, or polypus, or a foreign body, has begun in early childhood, and has been unilateral only, a leaning over towards the opposite side of both the cartilaginous and the bony plates of the septum occurs, and the nose becomes more and more crooked as the child grows older. The symptoms to which such a deformity gives rise are those of unilateral or bilateral nasal obstruction, and need not here be reiterated. The differential diagnosis is easy to the experienced rhinologist, because there is no new growth or abnormal condition in the nose for which deviation of the septum could possibly be mistaken, when the nasal cavities are carefully explored with the rhinoscope, the speculum, and the probe. Bony occlusions of the post-nasal orifices, which are usually congenital and are extremely rare, have already been mentioned in the foregoing pages, and the same is true of splitting of the middle turbinated bone, and also of the uncurling of the middle or lower turbinated bodies. As a last, but extremely rare, deformity, mention should be made of a bladder-like expansion of one of the turbinated bones, resembling a bony tumor in its contour, which as described by Zuckerkandl1 is, however, nothing but a thin shell of bone covered with mucous membrane and filled with air. Fig. 27. Split septum. 1 Op. cit., p. 44. SURGICAL PROCEDURES IN DEFORMI- TIES AND NEOPLASTIC GROWTHS IN THE NOSE. BY WILLIAM CHAPMAN JARVIS, M.D., Professor of Laryngology and Diseases of the Nose and Throat, New York University Medical College; Consulting Physician to Out-Patient Department, Bellevue Hospital; Visiting Physician to Charity Hospital, etc., New York. The successful practice of intra-nasal surgery largely depends upon the proper utilization of a form of applied mechanics derived from a practical knowledge of approved pathology and diagnosis. Through the introduc- tion of the wire ecraseur, as has been indicated by Sir Morell Mackenzie,1 it has been made to differ from general surgery in that it permits some relaxation of the rule under which surgeons were taught “ to cut through everything soft, to saw through everything hard, and to tie everything that bleeds.” In view of the importance most properly attached to antisepsis, an- esthesia, and hemorrhage, in the practice of nasal surgery, a preliminary consideration of these subjects is deemed desirable, in order to prevent unnecessary repetition. ANTISEPSIS. In dealing with the question of precautionary antisepsis, it must be borne in mind that injury to certain intra-nasal structures is more likely to be followed by the occurrence of septic symptoms than injury to other parts of the same cavity. Operations upon the septum, judging from the records of the subject, are particularly liable to be followed by sepsis. By an a priori method of reasoning, this accident may, perhaps, be attributed to the peculiarity of the septum, its cartilaginous or osseous character, as with joints, rendering it more susceptible to the absorption of morbific material, or to the character of the instruments employed; saws, multiple-knife drills, etc., being more efficient sepsis-carriers than hot or cold wire. The incandescent platinum wire is, of necessity, typically aseptic. The cold wire, though in a different manner, is likewise peculiarly aseptic in its action, from the practice of employing fresh loops, and because of the 1 Diseases of the Throat and Nose, 1884. 39 40 SURGICAL PROCEDURES IN DEFORMITIES crushing action serving as a ligature to shut off communication between the active absorbents and extraneous septic matters in the same manner that it prevents hemorrhage. The absolute absence of septic symptoms among patients operated upon in dispensary practice by means of the cold-wire ecraseur, which may not, in the hands of careless operators, have been properly sterilized for months at a time, affords convincing evidence upon this point. I am inclined to believe, furthermore, that certain post-operative mani- festations referred to, for instance, as surgical fever, etc., are in reality to be viewed as septic. Records of septicaemia supervening after the use of nasal tampons,1 etc., clearly indicate such a possibility and demonstrate the necessity of employing perfectly aseptic nasal plugs. The preceding remarks naturally imply the necessity of sterilizing both the instruments and the dressings employed in intra-nasal procedures, par- ticularly when these measures are directed against the septum. Surgical drills and saws should be boiled and burnished after each oper- ation, and bichloride of mercury dressings or other fitting substitutes should alone be allowed to remain in the nasal cavities for any length of time. Hemorrhage.—In the practice of all the ordinary intra-nasal procedures, the skilful and properly-equipped operator need never have occasion to contemplate seriously the occurrence of hemorrhage. Except in the treat- ment of pulsating angiomata and certain telangiectatic neoplasms, extraor- dinary precautions are rarely required. Surgical nasal hemorrhage, especially from the septum, is significant only as a temporary mask to the field of operation. The haemostatic action of cocaine has greatly reduced this inconvenience, and the Ecraseur and the haemostatic clamp, when conveniently utilized, have entirely abolished it. General Anaesthetics.—Of the general anaesthetics, ether, chloroform, and nitrous oxide, the last-mentioned, when possible, should receive the prefer- ence; chloroform, when used just short of its complete abolition of volun- tary movements, is next in choice. Ether is the least convenient of the three, by reason of its explosiveness when in proximity to the laryngo- scope. Cocaine, however, should render recourse to general anaesthetics comparatively rare. Local Anaesthesia.—With regard to the employment of local anaes- thetics, those having a topical action are, when feasible, to be given the preference. Of these, cocaine has certainly received by far the largest en- dorsement, as determined by common usage. It may be advantageously employed upon a pledget of cotton or sprayed into the nostril, or in both of these ways. Strong solutions, from twenty to thirty per cent., are more advantageously employed. Purified rhigolene, when properly employed with the cold-wire loop, invariably insures a painless and bloodless operation by reason of its 1 Verneuil, Tribune Medicale. 1887. AND NEOPLASTIC GROWTHS IN THE NOSE. 41 marvellous refrigerating action on the tissues. A certain amount of care and skill must be exercised in its employment. The surgical management of tiie more common intra-nasal pathological conditions may be conveniently considered under the following divisions, in the order of the frequency of their occurrence,—namely, hypertrophy of the turbinated tissues, deflection of the septum, neoplasms, and miscel- laneous conditions. Indications.—Removal of the turbinated bodies in a state of hyper- trophy is principally indicated for the relief of nasal stenosis and the immediate results, habitual mouth-breathing, rhinorrhcea, and excessive accumulation of nasal mucus; as well as of the more remote results, disease of the middle ear, obstruction of the lachrymal duct, naso-pharyngitis, laryngeal hypersemia, laryngitis, and secondary pulmonary disease. The removal of the turbinated tissues is also indicated for the relief or removal of various reflex neurotic conditions directly or indirectly traceable to these structures when in a state of irritative hypertrophy. The following reflex neuroses may occur in the nose,—viz.: sternutus, hyperesthesia, hay- fever (Daly,1 Mackenzie,2 Roe3), tinnitus aurium (Burnett4), pharyngeal or laryngeal irritation, direct or indirect, from habitual mouth-breathing, bronchitic asthma (Bosworth5), photophobia or asthenopia (Cheatham,6 Gruening7), cephalalgia, vertigo, gastralgia, and dyspepsia (Hack8), neuras- thenia (North9), and sexual neuroses (J. N. Mackenzie10). Historical and Critical.—The methods commonly employed for the per- manent removal of turbinated redundancies may be conveniently considered under two heads : reduction and excision. Reducing agents act either upon the principle of absorption, by shrink- age, or by gradual exfoliation. Chemical Caustics.—The caustic method is by far the most popular. It accomplishes the result by the exfoliation or superficial erosive action of the local sloughs generated by the repeated application of various caustics combined with a certain amount of cicatricial contraction. Promi- nent among these chemical agents may be mentioned London paste (M. Mackenzie), chromic and glacial acetic acid (Bosworth), nitric acid (Letferts), chloride of zinc and nitrate of silver (Schrotter). HYPERTROPHY OF THE TURBINATED TISSUES. 1 Archives of Laryngology, 1882. 2 Diseases of the Throat and Nose, 1884. 3 Medical Journal, 1883. 4 Philada. Medical News, 1884. 5 Medical Journal, 1886. 6 American Practitioner and News, 1887. 7 Medical Record, 1886. 8 Wiener Medicinische Wochenschrift, 1883. 9 Bosworth, Diseases of the Nose and Throat, 1889. 10 Medical Record, 1884. 42 SURGICAL PROCEDURES IN DEFORMITIES Electric Cautery.—The turbinated struetures may likewise be reduced by the application of the electric cautery. While the galvano-cautery, as a reducing agent, possesses the advantage of permanency in its effect, it is not entirely free from certain objections attending its use. This means, as gen- erally applied in the form of the incandescent platinum point, accomplishes the desired object through the extraordinary cicatricial contraction incident to the healing of the furrows burned into the obstructing turbinated tissues. The common forms of electric apparatus employed for this purpose are the plunge-battery and the storage-cell. Both accomplish this object in a satis- factory manner, the preference lying mainly in the matter of cell-construc- tion. The two most convenient forms of plunge-batteries known to me are those of Dr. Seiler, made by Fleming, of Philadelphia, and of Dr. Robinson, sold by Stammers, of New York. The thermo-cautery (Good- willie), utilized by means of the Paquelin apparatus, is seldom used. Storage-batteries, of which a large number of manifold form and make are obtainable, also constitute a convenient means for the supply of elec- tric power for galvano-cautery purposes. Though possessing a much greater degree of indestructibility and endurance than the gravity-cell, even these devices eventually become useless through corrosion of their plates. The only absolutely reliable and practically indestructible source of electrical supply is to be had in the employment of a properly-constructed rheostat connecting with the street-main of an electric-power depot. Lack of general availability is the only serious objection that can be urged against this method. While there is no doubt as to the ability of caustics effectually to reduce turbinated redundancies, it must be remembered that their employment requires great nicety of manipulation and perseverance on the part of both physician and patient, involving a large expenditure of time, and that their use is not devoid of painful secondary results, oedematous inflamma- tion and agglutination of the injured surfaces. Among other forms of reducing agents are the metallic sound (Wagner’s1), electrolysis,2 laminaria tents (Justi’s3), compressed sponge (Cohen4), hypodermic medication, ergo- tine (De Blois5), and carbolic acid (Henderson6). The metallic sounds accomplish the result by absorption and require “ weeks of treatment.” The ergotine injections act by “ curtailing blood- supply.” The carbolized injection acts by interstitial sloughing. It is clear that all these methods, whilst doubtless effectual to the full amount claimed by their respective advocates, are nevertheless open to the objection of temporizing with pathological conditions susceptible to prompt treatment 1 Diseases of the Nose, 1884. 2 Robinson, Nasal Catarrh, 1885. 5 Wiener Medicinische Wochenschrift, 1880. 4 Diseases of the Throat, etc., 1879. 5 Archives of Laryngology, 1883. 6 St. Louis Medical and Surgical Journal, 1886. AND NEOPLASTIC GROWTHS IN THE NOSE. 43 by the employment of more radical and satisfactory measures, by which they should be replaced whenever possible, even if only in deference to the maxim Ars long a, vita brevis. Methods of Excision.—Among the more important methods of excision are found the tearing away of the tissues by means of the forceps (Robinson1), eanula-scissors (A. H. Smith), scissors (Daly), nasal plough (Woakes2), hot-wire (Sajous3) and cold-wire ecraseur (Bosworth,4 Robinson, Seiler,5 Lefferts,6 J. N. Mackenzie,7 M. Mackenzie,8 Knight9). With regard to the forceps and scissors, it may be added that serious hemorrhage is likely to follow the extensive tearing of the turbinated tissues. The same objection holds against the knife-plough and scissors. The combined favorable experience of the more prominent operators has resulted in the almost universal adoption of the cold-wire Ecraseur as the best means for the removal of all varieties of turbinated hyper- trophies. Special Procedures.—The first operation devised by me for the removal of enlargements of the posterior turbinated bodies is based upon the peculiar form assumed by these structures in a state of hypertrophy.10 The posterior surfaces of these bones, especially of the inferior, show a peculiar constriction formed by the hypertrophied tissue extending back- ward into the upper pharynx. The extreme point of the growth is thus thrown beyond its base. This constriction forms a nidus for the retention of the ecraseur wire. (Fig. 1.) The ecraseur (Fig. 2, C) consists of a long and short canula, the latter of which glides over a screw-thread cut on the former, and about the size of a No. 3 sound, Eng-lish scale. A milled nut fitting this thread is intended to push the outer canula before it. Well-tempered steel wire (No. 5 piano gauge) is drawn through the large canula, and its ends are attached to the retention pins on the smaller one. As the outer canula cannot turn, there is no twisting of the wire loop formed. The Combined Mirror and Tongue-Depressor (Fig. 3).—A stout wire, after being made to divide and assume the form of a tongue-depressor, is crossed upon itself and then shaped into a pincette. Mirrors of different sizes are received between the pincette’s blades. These mirrors can be placed at any desirable angle with the shaft. The hinge-joint will permit the 1 Nasal Catarrh, 1885. 2 Post-Nasal Catarrh, 1884. 3 Diseases of the Nose, 1884. 4 Jarvis’s Operation, Medical Record, 1881. 5 Ibid. 6 Chronic Nasal Catarrh, 1886. 7 Reference Handbook of the Medical Sciences, vol. viii. 8 Diseases of the Nose, 1885. 9 Medical News, 1882. 10 Archives of Laryngology, 1881. 44 SURGICAL PROCEDURES IN DEFORMITIES mirror to be fixed at the most favorable angle for viewing the posterior nares, and at the same time will facilitate depression of the tongue. This instrument will sometimes be found a convenient one, as it enables Fig. 1. Pathological specimen of posterior hypertrophy, showing snare-loop in position. (From the author’s collection.) the operator to bring the posterior nares into view with one hand, leaving the other free for the manipulation of the 6craseur. The tape-holders (Fig. 3) are intended to obviate the unsatisfactory and disagreeable manipulation of tying the ends of the tape which pass around the soft palate in cases requiring this procedure. They are two Fig. 2. The author’s nasal (Scraseur and polypus snare. small Y-shaped spring-clips, so arranged that the tape passing through apertures in its blades is caught by a tooth-like projection and firmly held. Pressure on the spring releases the catch and sets the tape free. AND NEOPLASTIC GROWTHS IN THE NOSE. 45 The transfixion-needles (Fig. 4) need no special description. They are pointed like the ordinary glover’s needle. Four different sizes are made, Fig. 3. Removal of posterior turbinated hypertrophies, with author’s rhinoscope and tape-holders in position. running from one to four inches in length. Each number has a straight needle and three others of varying curves. They are all furnished with a light, convenient handle. In using the ecraseur pass the two ends of the wire through the canula, entering them at its distal extremity, and twist them round the retention pins. A loop is formed whose size depends, of course, upon that of the growth. Giving the wire loop a twist towards the side of the nose occupied by the growth, it is fixed by a turn of the nut and passed into the nostril. Holding the rhinoscopic mirror in one hand, the position of the wire loop in the posterior nares is carefully watched, whilst it is steadily advanced with the other hand until it is seen to encircle the growth. (Fig. 3.) In drawing the wire home the tissue is cleanly divided, and, if not too large to pass through the nares, it will generally be drawn out clinging to the snare. Fig. 4. Author’s transfixion-needles. 46 SURGICAL PROCEDURES IN DEFORMITIES Make traction very slowly, stopping at short intervals in order to prevent hemorrhage. An hour or more may sometimes be profitably consumed to insure a perfectly bloodless procedure. If the nostril is obstructed by a deviated septum, or narrowed by any other cause, it may be necessary to introduce the wire sheathed in the main canula, when, by projecting the loop within the naso-pharyngeal space, the growth can be readily snared. Long experience in the use of the ecraseur should enable the operator to engage posterior hypertrophies with ease and precision without having recourse to posterior rhinoscopy. A perfect knowledge of the exact location of the hypertrophies, and careful utilization of a cultivated sense of touch, are the important factors for the successful accomplishment of this procedure. Cocaine, if used, should be employed only after the hypertrophy has been engaged in the loop, since its contractile action upon the turbinated structures, when used at the start, may in some instances defeat the object of the operator by causing obliteration of the necessary pathological nidus already referred to. The hemorrhage resulting from the practice of this procedure is usually trifling, and sometimes nil, provided due caution is observed to make slow traction. Dr. Bos worth’s suggestion to leave the tissues undisturbed after their complete division, in order to avoid the occurrence of hemorrhage, may sometimes be found useful. On the other hand, I have known the hasty and careless employment of this method on the part of certain operators to be followed by alarming and persistent hemorrhage, which, upon investiga- tion, invariably proved to be due to a flagrant violation of the commonplace rules laid down for the successful performance of this operation. Soft, sessile hypertrophies occurring in any part of the nostril can be easily removed, as the wire readily sinks into the tissue and takes firm hold on the growth. Firm, non-pedunculated posterior hypertrophies require both Ecraseur and transfixion-needle. (Fig. 4.) In using the transfixion- needle, the amount of tissue requiring removal is carefully determined, and the point of the needle directed accordingly. The loop will be caught by the point of the needle projecting into the nostril (Fig. 5), and a few turns of the milled nut cause the wire to sever the transfixed tissue. In trans- fixing posterior hypertrophies the position of the needle’s point can be determined by means of the rhinoscopic mirror. Curved needles should be used in transfixing anterior hypertrophies in order to bring the needle’s point into view. A little practice will enable one to determine when com- plete transfixion has taken place, by the sense of touch, in cases where the needle’s point cannot be seen. Nasal hypertrophies of every size and description can be permanently abolished by the practice of this simple method. The discomfort caused in removing these growths will vary with the susceptibility of the patient to pain and the amount of care used in manipulating the ecraseur. Patients, as a rule, declare that they do not suffer. The rules just given for the employment of cocaine to prevent pain in AND NEOPLASTIC GROWTHS IN THE NOSE. 47 the removal of posterior hypertrophies apply in an equal, if not greater, degree when this analgesic is used in anterior forms of this growth. Unless markedly rugous, the retrac- tion is likely to render the hy- pertrophy difficult of seizure by means of the naked wire loop. This difficulty, how- ever, is obviated by the use of the transfixion-needle in con- junction with the wire loop, since the retracted tissue may be actually stripped from the turbinated bones without fear of evil consequences. A bloodless cocaine pro- cedure of this character does not mean certain immunity from secondary hemorrhage, against the occurrence of © which it is well to make ample provision. A pledget of cotton thrust into the nostril will generally suffice to con- trol any slight hemorrhage that may occur. It is not necessary to exercise much care to prevent bleeding from anterior hypertrophies, as the hemorrhage is but transient. Fig. 5. The author’s transfixion-needle and 6craseur adjusted for the performance of the operation. (From Dr. Sajous’s work on Diseases of the Nose and Throat.) The indications for the correction of the deviated septum are largely those mentioned under the head of turbinated hypertrophies, with the addi- tional feature of their agency as an especial cause in the development of catarrhal disease and nasal myxomata. Historical and Critical.—The first systematic presentation of the subject of deflection of the nasal septum, with its special treatment, appears to have been made by Quelmaltz1 in the eighteenth century. His suggestion to overcome the deformity by the employment of continual finger-pressure upon the tip of the nose has been advocated in more modern times (1876) by Michel. This method is obviously of doubtful efficacy and, for general purposes, useless, reminding the reader of the physical acts accomplished by posture among the dervishes, some of whom have been described as spending their lives contemplating the tip of the nose from eighty-four different postures.2 The somewhat ancient method of Chassaignac3 might perhaps be DEFORMITIES OF THE SEPTUM. 1 De narium earumque septi incurvatione, 1750. 2 Encyclopaedia Britannica, 1878. 3 Bulletin de la Societe de Chirurgie, 1851-52. 48 SURGICAL PROCEDURES IN DEFORMITIES properly cited as next in order of crudity. It consisted in paring off the cartilaginous projections piecemeal with a knife. The matter of hemorrhage must obviously interfere with the satisfactory completion of such a procedure, and I recall a case recited to me of an operator who was compelled to abandon the operation on this account, after etherizing his patient. The knife operation has been much improved by Dr. Ingals,1 who de- vised a special plan for combating the hemorrhage. The knife is also advocated by Stoker,2 Schech,3 Jurasz,4 and Dieffenbach.5 A modification of this method is reported by Dr. B. Robinson6 as having been employed by Dr. A. C. Post, consisting in dissecting away the nasal integument and ala nasi, exposing the septum, and removing it through the flaps. This is clearly an unnecessarily formidable method, and, judging from a case which recently applied to me for operation after this procedure had been unsuccessfully practised, it is not even reliable. Small low spurs upon the superior maxillary portion of the septum are removed by Dr. H. Allen7 by dissecting up the gingival aspect of the upper lip, and in this way ex- posing the vestibule and operating per os,—a rather severe procedure, it seems to me, for the correction of a very simple pathological condition. Saw.—From the knife to the saw—an amplified knife—is but a step. And here we meet with an operation which has become popular on account of its simplicity and the eminence of its propagators, Bosworth, and others. Dr. Bosworth8 credits Seiler with being one of the first to use the metacarpal saw; but Bosworth himself greatly improved the shape and cutting power of this device. The objectionable feature of hemorrhage exists with this device as with the knife, but to a smaller degree, by reason of the crushing power of the saw’s teeth. Roe9 has utilized a form of eccentric motion, imparted by an electric motor, to accomplish the saw motion. J. Wright10 perforates the septum longitudinally and saws between the openings. Chisels have been skilfully employed by Seiler.11 Blandin,12 supported by Goodwillie,13 used a punch, with which he perforated the deflected septum at the most prominent point upon its anterior aspect. With deep-seated deflected septa an anterior connection between the open and closed nostrils is to be obviously viewed 1 Transactions of the American Laryngological Association, 1882. 2 Deviations of the Nasal Septum, 1888. 3 Die Krankheiten der Mundhohle, des Rachens und der Nase, 1890. 4 Ueberdie Behandlung hochgradiger Verkrummungen der Nasenscheidewand, 1882. 5 Chirurgische Erfahrungen, 1834. 6 Nasal Catarrh, 1885. 7 Philadelphia Medical News, 1890. 8 Diseases of the Nose and Throat, 1889. 9 Transactions of the American Laryngological Association, 1888. 10 New York Medical Record, 1890. 11 Ibid., 1888. 12 Compendium de Chirurgie, tome iii. 13 Medical Gazette, 1880. AND NEOPLASTIC GROWTHS IN THE NOSE. 49 more as a psychical impression than as a real factor for the radical relief of nasal stenosis. Watson1 advocates the practice of Adams’s operation for the removal of extensive deformities of the nasal septum, which has for its object the breaking up of the osseo-cartilaginous septal framework by means of a specially-devised “ fraction-forceps.” Rendered plastic by this means, they are then retained in position by means of intra-nasal plugs or complicated external nasal splints. Jurasz2 has modified Adams’s forceps by making the blades serve the double purpose of a septoclast and an intra-nasal splint-plug. This operation is very severe and unreliable, and is now seldom em- ployed. A modification of Blandin’s operation has been advanced by Steele,3 who employed a stellate punch to obtain mobility of the deflected cartilaginous septum. J. N. Mackenzie credits Bolton,4 of Virginia, with being the original inventor. A more extended account of this device will be found under the head of special operations in treatment of the septum. Asch5 has devised an ingenious but extremely complicated substitute for Steele’s operation. Roberts6 employs pins to keep the fragments in posi- tion. The merits and demerits of the stellate punch procedure are ex- plained in a subsequent paragraph. Dr. J. Solis Cohen7 was among the first to recommend the employment of drills propelled by means of the surgical engine worked by a pedal. A description of the more convenient electric motor substituted by myself will be found under the proper head in the main body of the text. Goodwillie8 employs shielded “multiple knives.” Curtis9 utilizes the trephine. Properly-constructed nasal drills offer one of the very best means at our disposal for the exsection of the septum. Like the saw, they require especial oversight to prevent septic accidents. Lennox Browne,10 Voltolini,11 Schaeffer,12 and Walsham13 recom- mend the galvano-cautery, the sphere of which is limited, of course, by bone. So, too, does Sedziak.14 Electrolysis is employed by Moure and BergoniC15 It is to be viewed more in the light of a curious mechanico-therapeutical feat than in that 1 Diseases of the Nose, 1875. 2 Op. cit. 3 St. Louis Courier of Medicine, 1879. 4 Richmond Medical Journal, 1868. 5 Transactions of the American Laryngological Association, 1890. 6 Philadelphia Polyclinic, 1884. 7 Philadelphia Medical and Surgical Reporter, 1878. 8 Medical Gazette, 1880. 9 New York Medical Journal, 1887. 10 Diseases of the Throat, 1887. 11 Die Krankheiten der Nase, 1888. 12 Chirurgische Erfahrungen in der Rhinologie und Laryngologie, 1885. 13 Journal of Laryngology and Rhinology, 1890. 14 Ibid., 1891. 15 Ibid., 1890. 50 SURGICAL PROCEDURES IN DEFORMITIES of a valuable mode of treatment. Stoker1 and Hubert2 recommend lami- naria bougies and cotton tampons. Massei favors compressed air. John N. Mackenzie3 urges the removal of the inferior turbinated body as a substitute for excision of the septum, in certain cases. Delavan4 advises excision of the middle turbinate. Special Operations on the Septum.—The Ecraseur.—The ecraseu r em- ployed is the same device as Fig. 2, described under the head of turbinated bodies and recommended for the removal of these structures in a state of hypertrophy. Fig. 6. Author’s operating speculum. For opening the field of operation I employ my ring-drop nasal specu- lum (Fig. 6), since in my hands it has proved the best for painlessly and persistently dilating the nostrils. In the treatment of cartilaginous and soft structural deviations of the septum I at one time employed nothing more than my ecraseur with transfixion-needles. Instead of using the No. 5 piano wire originally recommended and introduced by me for the removal of turbinated hypertrophies, I employ Nos. 0 and 00 piano wires. The exclusion of the question of hemorrhage in operations by ecrasement is an additional recommendation for the employment of fine wires cutting like knives. The employment of the ecraseur for this purpose must be invariably combined with the use of my transfixion-needles. These needles (Fig. 4) have been already described. Fig. 7. Operation.—The amount of tissue requiring removal is generally esti- mated by comparing the redundance with the unaffected portion of the sep- tum. This having been carefully determined by means of the septometer Author’s septometer. 1 Deviations of the Nasal Septum, 1888. 2 Miinchener Medicinische Wochenschrift, 1886. 3 New England Medical Monthly, 1885. 4 New York Medical Journal, 1887. AND NEOPLASTIC GROWTHS IN THE NOSE. 51 (Fig. 7), the base of the cartilaginous projection or hypertrophied tissue is pierced with the transfixion-needle until the point reappears. The wire loop of the ecraseur is now passed over the point of the needle projecting into the nostril, and tightened around the transfixed tissue by forcing up the outer canula with a movement of the finger against the milled nut. A few turns of the milled nut cause the wire to sever the transfixed tissue. When the posterior surface of the deviated tissue is not well defined, it is advisable to use a curved needle in order to bring its point in view. A little practice will enable one to determine when complete transfixion has taken place, by the change in resistance appreciated by the touch in cases where the needle’s point cannot be seen. When the cartilaginous or thickened tissue is in contact with the outer wall of the nose, I make use of the No. 3 curved transfixion-needle (Fig. 4), which has its point at a right angle with the shaft. By succes- sively hooking and snaring otf pieces of the septum, it is possible to make an opening into the posterior nares. The patient practice of this method has enabled me to perforate even an im- perforate nostril without connecting the nasal cavities by an undesirable opening. The removal of cartilaginous and soft deviated tissues by ecrasement has been followed by most excellent results in my hands, and where there is plenty of time at the operator’s disposal it is to be pre- ferred for this purpose. This operation can, of course, be rendered painless and bloodless by the employment of my haemostatic clamp (Fig. 8) and cocaine whenever possible, and is probably the least painful and bloody of all the radical procedures when practised without these aids. Operations on the Septum with the Forceps.— It is often desirable to econo- mize time, and in order to do so I have devised instruments with which I have most satisfactorily accomplished this purpose. This brings me to an operation which I will, for convenience, term my scissors and forceps pro- cedure. These instruments are essentially for cutting, and consist of a fenes- trated cartilage-forceps, trimming-scissors, and transfixion-scissors. Their blades are made almost at a right angle, to enable the operator to obtain a clear view of the field. The cutting edges of the fenestrated forceps (Fig. 9) resemble somewhat, in shape and action, the ordinary ticket-punch. A ring on the fixed blade is intended to slip over the middle finger, and a knob on the free one is manipulated with the thumb. This arrangement enables one to seize and divide the cartilage with great facility. The trimming-scissors are con- venient for removing asperities remaining after the other instruments have been employed. The instrument is grasped like a pistol, firm pressure being exercised against its lateral margin by the index finger. The transfixion-scissors, as their name implies, possess needle-like Fig. 8. Author’s haemostatic clamp. 52 SURGICAL PROCEDURES IN DEFORMITIES points to facilitate piercing of the cartilage of the septum, and may lie ground to cut by either closing or opening the blades, their general form being similar to that of the preceding devices. Fig. 9. Author’s small septum seissor-punch. Thus far the instruments shown have applied only to cartilage and hypertrophied mucous membrane. Bone blunts or breaks their keen edges, and we may have to treat an osseo-cartilaginous deviation of the septum. The little instrument (Fig. 10), essentially a rongeur forceps, has, in my hands, most satisfactorily accomplished this result. Its two blades are hollowed to cut like the teeth of a rodent. The instrument has the proper nasal curve. A great advantage possessed by this bone-forceps is the control exercised Fig. 10. Author’s rongeur septum-forceps. over it by the operator. Each osseous projection can be plainly distin- guished over the edge of the upper blade and deliberately crushed away by the keen-edged cutting surfaces, and by a kind of gnawing process large sections of the bone are removed with rapidity and precision. All the methods thus far mentioned accomplish their purpose by removing the superfluous or deviated tissues or the turbinated structures opposite the deviated point. AND NEOPLASTIC GROWTHS IN THE NOSE. 53 My remarks concerning the employment of the haemostatic clamp to prevent pain and hemorrhage will, of course, apply in this procedure, when the deflected structures are located within easy reach. The foregoing procedures are particularly commendable on account of their combining the qualities of simplicity, portability, and availability. When rapidity and expedition are viewed as particularly desirable or of pre-eminent importance to either surgeon or subject, or to both, the surgical drill propelled by electricity is, unquestionably, the most satisfactory means at our disposal. The Surgical Drill.—A sufficient experience with the common treadle surgical engine, and particularly with an improved form of this apparatus invented and used by me during an extended period for intra-nasal opera- tions, has convinced me that the natural dread occasioned by the sight of the cumbersome and rapidly-revolving, noisy machinery constitutes a hinderance to the usefulness of the nasal drill. This sometimes serious objection, though mostly of a psychical nature, is effectively overcome by the employment of the electric motor. Concealed in its narrow shell suspended in mid-air, but few patients can form an idea of the great mechanical possibilities possessed by this apparently insignificant mechanism. I now employ the compact C and C electric sewing-machine motor. (Fig. 11.) Inasmuch as this instrument has proved in my hands the de- Fig. 11. C and C electric motor. sideratum sought for, I shall give it exclusive attention, referring to other motors for purposes of comparison only. There is absolutely no dead- point, a prevalent objection to electric motors, and the common annoy- ance of laboriously adjusting the armature at intervals during an operation is, by this device, relegated to the inconveniences of the past. The counter-electro-motive force generated by the motor running at eigh- teen hundred turns a minute, with an eighteen-ampere current in the field, 54 SURGICAL PROCEDURES IN DEFORMITIES is five volts. The revolutions can be carried as high as two thousand to the minute. Its extreme capacity equals one-eighth horse-power. A single quantity-cell supplies electro-motive force for any ordinary nasal operation ; two of these cells furnish an excess of power, even in operations including the densest portion of the vomer. My electro-motive force is de- rived from storage-cells, which a somewhat extended experience has induced me to view as the most powerful, reliable, and, in the long run, cheapest device obtainable for combined cautery, illuminating, and motor purposes. To facilitate the attachment of the flexible shaft, I have had constructed a metallic sleeve which slips over the journal-box of the motor. Within this sleeve is an angular rod soldered to the flexible cable, which slips in a groove cut into the centre of the axle of the armature. The free movement of this rod within the groove favors the flexion of the cable and permits the shafting to be quickly attached or withdrawn. The electric motor can be used either attached to a convenient table or suspended by wires from the ceiling. The wires running from the battery are interrupted before reaching the Fig. 12. Weber’s hand-piece for drills. motor and arranged upon a foot-board. The convenient cut-off thus formed is simply composed of a sheet of spring brass, which the pressure of the operator’s foot brings in contact with a button through which the electric current is conducted to the motor. The employment of small nasal drills, already referred to, I desire to lay particular stress upon as constituting a desirable digression from the routine course, heretofore pursued, of resorting to large and cumbersome AND NEOPLASTIC GROWTHS IN THE NOSE. 55 devices of the kind in operations upon the nose. To facilitate the practice of keeping the parts operated upon constantly in view, the dimensions of the drill must necessarily be made small. When large drills are employed, —the ingenious shielded multiple-knife of Dr. Goodwillie, for example,—a view of the field of operation is rendered difficult or impossible, and the operator is compelled to rely upon his acquired tactus eruditus, to the exclusion of his sense of sight. The long practice required to attain the necessary tactile proficiency to operate with precision, though blind to the exact behavior of the drill, it seems to me, must seriously interfere with the extensive adoption of large nasal drills in general practice. Furthermore, surgeons will naturally hesi- tate to permit keen-edged cutting instruments to revolve rapidly out of sight in close contiguity to the brain beneath the frail plate of the ethmoid. The extreme narrowness of the superior meatus makes it impossible satisfac- torily to employ shielded drills in this region. Contrary to the teachings of the advocates of the tactus eruditus, my rule is to direct the burrs ex- clusively by the sense of sight, and I adopt as a precaution the maxim, “ Never lose sight of the drill.” The hand-piece employed by me (Fig. 12) as a drill-holder, invented by Mr. Weber, has the great advantage of clutching the drills after the manner of a powerful chuck. It is my custom in operating with the drill to dilate the nostril gently by means of my operating nasal speculum, then, starting the motor by pressure of my foot upon the electric button, with a single sweep of the drill to sever the desired point d’appui. An antiseptic crown-drill (Fig. 13) propelled by the electric motor has, in my hands, proved a very useful device for cutting away septal ob- structions. A steel knife-blade located just below the serrated margin of the drill breaks up the osseous and cartilaginous core, and the resultant detritus is eventually discharged through a window cut in the side of the instrument. It is clear that this device enables one to obtain the advantages of the Fig. 13. Fid. 14 Author’s trephine crown-drill. Author’s antiseptic crown-drill. anterior action of the trephine without the objectionable features possessed by Dr. Curtis’s instrument, due to the retention of the excised core within the nostril or the drill itself. I have recently modified and improved this drill by simply surrounding the cutting facets by a knife-like ring, the edge of which may be either interrupted or unbroken, thus approximating more exactly the true type 56 SURGICAL PROCEDURES IN DEFORMITIES of crown-drills. (Fig. 14.) The simplicity and reduced size of this device obviously facilitate its manipulation in a narrow nostril and render thorough cleansing easier, without sacrificing any of the advantages of the first-mentioned drill. In the tubular scissors or nasal plane (Fig. 15) I have utilized a cutting device which has already been employed on other Fig. 15. Author’s scissor tubular-drill. parts of the body in various forms and for different purposes. It consists of a small cylinder within which rotates a delicate tube, the end of which can be discerned through the fenestra as shown in the figure. The inner tube, it will be observed, is set with a row of fine teeth. These teeth may be dispensed with. A useful feature of these drills will be recognized in the property they possess of removing bone and cartilage of the deflected septum without injury to the overlying mucous membrane. It is obvious that the preser- vation of the pituitary membrane in its entirety and integrity affords pro- tection to the wound and hastens the restoration of the injured tissues to their proper functions. It will be often found convenient to separate the mucous membrane and temporarily secure it to the roof of the nostril by means of cotton pledgets before cutting away the subjacent bone or cartilage. The tubular scissors or nasal plane I find particularly useful for levelling Fig. 16. Author’s case of deflection of septum, before and after operation any slight irregularities left after the use of either of the foregoing drills, and I believe that the finishing touches imparted by it in this mode of pro- cedure conduce to more rapid healing and better results. (Fig. 16.) The AND NEOPLASTIC GROWTHS IN THE NOSE. 57 rules for the use of cocaine and the haemostatic clamp apply, of course, with equal force in this class of operations upon the septum. Stellate Punch Procedure.—Although this, in the majority of instances, can be accomplished without perforating the septum narium or weakening the nasal supports, it is obvious that a certain class of cases, usually those presenting an extreme degree of deflection, may be followed by the above- Fig. 17. Author’s modified Steele’s stellate septum-punch. mentioned undesirable consequences. I have therefore occasionally made it a rule to resort to a different method in this class of cases. It consists in the employment of a modification of Steele’s stellate punch (Fig. 17) in conjunction with a peculiar nasal clamp or splint. The modification con- sists of a change in the form of the socket which permits the blades to be introduced singly and perfectly parallel with each other and at the same time securely jointed, and the excavation of the centre of the stellate knife, thereby avoid- ing the occurrence of sloughing from excessive mutilation, with consequent button-holing of the septum,—a common accident apparently ignored by certain operators. Another difficulty rests in the proper ap- proximation of the divided fragments, and just at this stage the bad results show them- selves. While observing the behavior of a case operated upon and afterwards treated bv the usual method (the nasal plug), I was con- vinced that just here the trouble arose. A hard foreign body within the nostril may produce intense irritation, profuse rhinorrhoea, high fever, and inflammation. Why, then, should we expect other than unfavorable re- sults from the practice of this method ? The nasal clamp-splint (Fig. 18) has, in my practice, relegated these incon- veniences to the history of the past. The septum, made sufficiently plastic by means of the punch, is simply held in place by a slight pressure ex- ercised over the cutaneous surfaces of the ala; nasi. No hard foreign Fig. 18. Nasal clamp-splint. 58 SURGICAL PROCEDURES IN DEFORMITIES substances disturb the equilibrium of the inner nares, and therefore the above undesirable consequences are avoided. The pressure of the splint can be nicely regulated by the patient by means of a delicate screw. Any tendency to loosen may be easily overcome by affixing adhesive plaster to the pressure-pads and then sticking it to the skin. It is some- times desirable to employ soft intra-nasal antiseptic plugs in conjunction with this clamp. NEOPLASMS. The more common forms of nasal neoplasms calling for surgical inter- ference are myxomata, myxo-fibromata, and adenoid enlargements in the naso-pharynx. These growths are notably benign in character. • Of more infrequent occurrence, yet usually benign in character, may be enumerated fibromata, papillomata, adenomata, angiomata, osteomata. Of the malignanat neoplasms, in order of frequency occur sarcomata and carcinomata. There may, in some instances, exist an intermingling of benign and malignant elements, as in cases of angio-sarcoma, lympho- sarcoma, etc. BENIGN NEOPLASMS. Myxomata.—Historical and Critical.—Prominent among the methods employed for the surgical treatment of nasal myxomata or gelatinous polypi may be noticed injection, galvano-cautery, galvano-puncture, and the more strictly surgical measures of evulsion, abscission, and eerasemcnt. Evulsion was first recommended by Hippocrates,1 who employed a sponge for this purpose. It has been practised in more modern times by McRuer2 and Voltolini.3 The finger-nail has been employed by some operators to carry out the same plan of treatment (Sabatier4). The forceps, through the endorsement of the late Dr. Gross,5 was rendered quite popular among a certain class of operators in this country, and has been advocated abroad by Erichsen6 and Albert.7 Zaufal’s criticism8 that it is “ a barbarous operation, unworthy of modern surgery,” though apparently severe, has been shown to be appropriate by the researches of Michel9 and Lem6r6.10 The practice of injecting caustic compounds has been recommended by Donaldson,11 who employed chromic acid carried into the substance of the growth by means of a pointed glass rod. 1 Mackenzie, Diseases of the Nose. 2 Holmes, System of Surgery, 1862. 3 Monatsschrift fur Ohrenheilkunde, 1882. 4 Medecine operatoire, 1824. 5 System of Surgery, 1882. 6 Science and Art of Surgery, 1860. 7 Lehrbuch der Chirurgie, 1881. 8 Die allgemeine Anwendbarkeit der kalten Drahtschlinge, 1878. 9 Die Krankheiten der Nasenhohle, 1876. 10 Les Accidents consecutifs a l’Arrachement, etc., 1877. 11 Archives of Laryngology, 1883. AND NEOPLASTIC GROWTHS IN THE NOSE. 59 Among other chemicals used for injection are found chloride of zinc (Erichsen1), tincture of the chloride of iron (Maxwell2), nitric and acetic acids, and Vienna paste. Caustic methods are seldom employed, on account of the pain, secondary putrefaction, and great expenditure of time required by this treatment. The electro-cautery, originally introduced by Middeldorpf,3 has been ad- vocated by Voltolini,4 M. Mackenzie,5 et alii. It is open to the objection of being a needlessly complicated and tedious procedure for the removal of conditions amenable to much simpler and speedier methods of treatment. The same criticism may be applied with still greater force to the procedures of electrolysis and galvano-puncture. The method of abscission has been employed by a number of prominent surgeons by means of various mechanical devices, conspicuous among which are M. Mackenzie’s6 nasal forceps, Woakes’s7 scissors, Cant’s grape-scissors, and snaring devices of Robertson,8 Hilton, et alii. The scissor devices have never become popular, by reason of the profuse hemorrhage occasioned by their action ; the snaring process, though provo- cative of less hemorrhage and consequently insuring greater precision, has been almost entirely superseded by the more accurate and bloodless method of ecrasement. The employment of the ecraseur for the removal of nasal myxomata was first urged by me in 1880. My method and instrument in its entirety or in its modified form is advocated by Bosworth,9 Robinson,10 M. Mackenzie,11 Delavan,12 Jurist, Woakes,13 Schech,14 et alii. Stated in general terms, I think it will be conceded that the treatment of myxomata must have for its object not merely the removal of the growth, but also the eradication of its base, the stalk of the polypus, and the removal of its apparent cause, the offending septal deformity. The first indication is always imperative; the last-mentioned course must depend upon the ex- igencies of the case, the character of the polypus, and the extent of the de- flection. In my experience nothing has accomplished the eradication of the base of the polypus with such satisfaction and certainty as the cold steel wire in a canulated ecraseur, reinforced by my rongeur forceps and nasal punch. 1 Science and Art of Surgery, 6th edition. 2 Medical Record, 1868. 3 Die Galvano-Kaustik, 1854. 4 Ibid., 1867. 5 Diseases of the Nose, 1884. 6 M. Mackenzie, op. cit. 6. 7 Robinson, Nasal Catarrh, 1885. 8 Edinburgh Medical and Surgical Journal, 1805. 9 Op. cit. 10 Nasal Catarrh, 1885. 11 Diseases of Throat and Nose, 1884. 12 Cyclopaedia of the Diseases of Children, 1889. 13 Nasal Polypus, 1887. 14 Die Krankheiten der Mundhohle, des Rachens und der Nase. Eng. Trans., 1886. 60 SURGICAL PROCEDURES IN DEFORMITIES Monogenetic (single-root) myxomata (Fig. 19) require the employment of the snare alone; polygenetic (many- rooted) myxomata may call for the com- bined use of both snare and punch. Inasmuch as the principle and con- struction of my 6craseur have already been noted, it will be necessary only to briefly explain its action upon the poly- pus. Fig. 2 exhibits the polypus snare. All that is required is that the loop, properly arranged in shape and size in accordance with the dimensions and loca- tion of the myxoma, be inserted over the polyp’s point of greatest curvature, and simple traction accomplishes the rest, for the steel loop with each turn of the trac- tion-bar advances steadily towards the base of the pear-shaped mass, not stopping till it reaches the very point of the growth’s attachment to the mucous membrane or bone itself, which it often tears away along with the polypus. Myxomata, varying in size from that of a millet-seed to that of an oyster, can with equal efficiency be grasped and removed by this accommodating little instrument. Much patience, however, must be exercised in the eradication of the diminutive polypi. In order to facilitate this procedure, I have frequently employed, in conjunction with the Scraseur, the delicate scissor- punch (Fig. 20), which effectually grasps and divides the clusters of diminu- tive polypi lying in the almost inaccessible recesses of the superior meatus. Several sizes and forms of this little instrument can be obtained, the smallest of which is not much wider than the lead of an ordinary pencil. This device, therefore, acts as a veritable searcher, seeking out the embryonic or glistening bead-like masses and cutting and dragging them from their basic attachment together with the mucous mem- brane which ushered them into life and maintained their growth. Fig. 19. A monogenetic nasal myxoma asso- ciated with deflection of the septum. The neoplasm could he partly swallowed hy the patient, a young man. It was removed en masse by means of author’s 6craseur. Fig. 20. Author’s small spring scissor-punch. AND NEOPLASTIC GKOWTHS IN THE NOSE. 61 As might naturally be inferred, the hemorrhage resulting from the cuts made by this instrument is insignificant, evidently for the reason that, like the action of the ecraseur wire, that of the scissor-punch is crushing in its effect. Adenoids.—The surgical treatment of adenoid growths in the post-nasal vault permits a large latitude in the character of the instrumental inter- ference on account of their markedly glandular and consequently slightly hemorrhagic nature. Consequently, we find a number of cutting and tearing devices recommended and employed for this purpose. These growths may be removed through the anterior nares, or, pref- erably, through the mouth and naso-pharynx. Reduction in the size of these obstructions has been accomplished by means of caustics, chromic acid, nitrate of silver (Ldwenberg), and electric cautery (B. Robinson). Chemical caustics are contra-indicated by reason of the difficulty in limiting their action, and the electro-cautery because of its tardy action. Of the more strictly surgical procedures, the use of the finger-nail and that of the artificial steel nail of Capart and L. Browne are good examples of the simplest measures. Next in order of simplicity come ring-knives (Meyer and Stork), blunt and sharp curettes (Bosworth and Mackenzie); also knife and tearing-forceps (Major, Gradle, Cohen, Ldwenberg, and Hooper). Whilst it is quite possible to seize and remove larger masses of these growths through the naso-pharynx by means of these various cut- ting and tearing devices, their employment may be and has been followed by serious hemorrhage (J. Wright) on account of the difficulty or impossi- bility of seizing the soft glandular structures without lacerating the firmer and more vascular basic tissues. The practice of ecrascment for the removal of these growths (Bosworth and Robinson) affords a perfectly safe, comparatively bloodless, and efficient method for excising adenoid enlargements in the vault of the pharynx. This may be accomplished through the anterior nares by introducing a re- duced wire loop and playing out the wire when it reaches the naso-pharynx, or, still better, through the mouth by means of my cup canula (Fig. 21 A), or the bent canula of my ecraseur, as suggested by Dr. Bosworth (Fig. 21 B). Fig. 21. A B Ecraseur tips for adenoids. Angiomata.—Angiomata, though of infrequent occurrence, demand recognition on account of the manner in which they have been known to resent ordinary surgical interference, profuse and even fatal hemorrhage having been reported to have resulted from their incautious excision. Pure pulsating angiomata should be distinguished from growths possessing angio- 62 SURGICAL PROCEDURES IN DEFORMITIES matous features,—e.g., telangiectatic polypus or angio-sarcoma. (Fig. 23.) Of the surgical measures adopted for their removal, external excision has proved fatal, the galvano-cautery uncertain, and interstitial injections of caustics extremely dangerous. It has been conclusively shown that the cold-wire ecraseur is the instru- ment best adapted for the removal of these growths.1 It is obvious that, on account of the great vascularity possessed by these neoplasms, great care must be exercised to accomplish their successful and safe removal. Of para- mount importance is the practice of slow traction, to secure firm clotting before permitting final division of the tumor. Sometimes the vascularity is so excessive that the greatest manipulative delicacy must be exercised in the adjustment of the wire loop, since even the momentary contact of the wire or instrument against the tumor may prove sufficient to cause profuse hemorrhage. It is safer to permit the excised tissues to remain undisturbed in the nostril for from twenty-four to forty-eight hours. Im- mediately after the adjustment of the wire loop around the growth it is sometimes advisable to pack the nostril hermetically with styptic cotton. The employment of eerasement with the cold wire, whenever possible, has invariably yielded excellent results in my hands. Even partial excision of these neoplasms is likely to be followed by their almost complete disappear- ance through post-operative shrinkage. Fig. 22 may serve to convey an idea of the appearance of these tumors. The patient, a negro, had suffered from the growth for more than seven years. The dimensions of this very vascular angioma were three by two by one and a half inches. Marked displacement of the osseous nasal framework had resulted from the great and prolonged intra-nasal pressure. The tumor was entirely eradi- cated by means of my Ecraseur. The rules just enunciated for the surgical treatment of non- malignant neoplasms apply with equal or slightly modified degree to that of the other forms already enumerated. Any variation that may exist in the management of these principally applies to that of fibromata and myxo-fibromata, and largely consists in the utilization of wire-placing devices to secure these tumors properly within the wire loop. Fig. 22. Cavernous angioma (author’s case). 1 Roe, Archives of Laryngology, 1892 ; Bosworth, Diseases of the Nose and Throat, 1889; Jarvis, International Journal of Surgery, 1888. AND NEOPLASTIC GROWTHS IN THE NOSE. 63 Of the malignant neoplasms, the sarcoma is more frequently found than the carcinoma. It is usually non-hemorrhagic in character, but may possess angiomatous features. The last-named attribute renders treatment both difficult and dangerous. Unlike pure angiomata, there is apt to be an in- crease rather than a decrease in the dimensions of the mass when consid- erable time has been allowed to elapse after its partial removal. The cold or hot wire is preferably employed in the treatment of these growths. Choice should be given to the cold over the incandescent wire. The pain resulting from the excision of sarcomata is not apt to prove severe, nor the hemorrhage great. They may be, consequently, excised with ease and rapidity by using the cold-wire ecraseur, and in fact more speedily than they can reform. When the base of the tumor has been reached and levelled, it may prove advisable to cauterize the root-structures with chromic acid to retard repullulation. The main difficulty lies in the adjustment of the wire loop about the neoplasm. The adoption of any one of the methods available for this purpose will depend upon the location and size of the neoplasm. Occasionally the combined practice of intra-nasal and extra-nasal sur- gery may be rendered necessary by reason of the extension of the growths into the accessory nasal fossae. Fig. 23, taken from a photograph, exhibits a patient from whom I removed a quantity of sarcomatous tissue and who was eventually cured by an external operation performed by Dr. Joseph Bryant. The operation consisted in the ligation of both common carotids and the subsequent exsection of a portion of the left superior maxilla. As a counterpart to this good result might be instanced a case of the kind now being treated by me upon strictly intra-nasal principles, in which partial ex- cision of the upper jaw has been followed by a regrowth of the tumor. That it is pos- sible to attain a favorable result through the employment of intra-nasal measures has been satisfactorily demonstrated by the history of a case of round-cell sarcoma of the vault of the pharynx, reported by Dr. Bosworth as cured by the use of my nasal Ecraseur.1 Carcinoma of the nasal passage is less frequently met with than sarcomatous disease. The surgical treatment of this condition and that of sarcoma are identical. MALIGNANT NEOPLASMS. Fig. 23. Dr. Joseph Bryant's and the author’s case of sarcoma; a portion of the supe- rior maxilla removed. 1 Medical Record, 1885. 64 SURGICAL PROCEDURES IN DEFORMITIES The tendency to return is probably greater than that usually manifested by sarcomata, but when subjected to surgical interference they exhibit slighter vascularity and less sensitiveness. MISCELLANEOUS CONDITIONS. Nasal Caries.—Conspicuous among the miscellaneous conditions re- quiring surgical treatment stands nasal caries. Necrosis of the osseous structures of the nose may occur as a result of syphilitic disease, and also from scrofula, traumatism, and inflammatory abscess in the accessory sinuses. This condition is most frequently met with as one of the tertiary manifestations of syphilitic disease, and conse- quently is especially amenable to surgical treatment. In the event of a sequestrum having formed, the necrotic mass may be seized and removed by the forceps. Firm carious formations may be some- times loosened en masse by judicious manipulation, or they may be scraped away by means of the curette. In the event of these means being without avail, recourse must be had to the surgical drill. Small revolving burrs afford the speediest and safest means for the accomplishment of this object. Care must be taken never to lose sight of the drill. Cutting must be continued until the friable necrosed bone is replaced by a firm vascular base. The detritus should be frequently swept away by means of coarse sprays and detergent douches, to facilitate inspection. Healing of the surgical wounds should be hastened by the employment of appropriate topical applications, —iodoform, vaseline, etc.,—used in conjunction with constitutional specific medication, large or increasing doses of iodide of potassium, and the like. Fig. 24 exhibits an example of extensive syphilitic caries which in- volved almost the entire nasal cavity and a portion of the superior maxilla. Meningitis resulted in this case, as in Trousseau’s fatal one, from extension of the nasal disease into the cranial cavity. Treatment of the patient in accordance with the rules just enumerated resulted in the complete cure of the syphilitic disease.1 A necrosed inferior turbinated bone and perforated osseous septum may be observed in the figure within the left nostril, also a small post-operative opening through the alveolar border connecting the nose with the mouth. The rules laid down for the treatment of syphilitic nasal caries apply, with the slight modifications due to situation and circumstance, to the surgical management of the other forms of this condition. Fig. 24. Author’s case of syphilitic caries of the nose and mouth. 1 Notes on a Case of Nasal Caries, Medical Register, February 2, 1889. AND NEOPLASTIC GROWTHS IN THE NOSE. 65 Congenital Nasal Atresia.—Congenital atresia of the nasal passages, though of comparatively infrequent occurrence, is a noteworthy condition by reason of the excellent results obtainable through surgical treatment. It may exist in the form of an anterior stenosis, posterior occlusion, or general obliteration of the nasal chambers.1 All of these varieties have come under my notice. The surgical drill cutting both forward and laterally (crown-drill and burr) affords by far the most efficient means for restoring the patency of the congenitally sealed nostrils. It may be necessary to divide membrane, plates of bone, or altered tur- binated structures. Figs. 25 and 26 exhibit a case of anterior congenital Fig. 25. Fig. 26. Author’s case of congenital nasal atresia, before operation. Author’s case of congenital nasal atresia, after operation. atresia before and after operation. The patient, a lad of nineteen years, was unable to use the nostril on account of the obstructive presence of a web of dense fibrous tissue which converted the nasal vestibule into a cup- shaped depression. Normal nasal respiration was restored by perforating the fibrous membrane by means of the surgical drill, as just explained, or more elaborately noted in the division devoted to deformities of the septum. Fracture of the nose, as commonly met with, may be treated in ac- cordance with the mechanical principles already indicated for the surgical management of the common deformity, displacement of the septum. Hcematoma, abscess and perforation of the septum require no surgical treatment worthy of special notice. Irregularity (asymmetry) of the turbinated bones and turbinated osseous shells may be removed by means of the wire ecraseur in the same manner as explained for the removal of hypertrophied turbinated tissues, or, where special indications exist, by the employment of the surgical drill. 1 Two Unique Cases of Congenital Occlusion of the Anterior Nares, New York Medi- cal Journal, November 2, 1887. HAY-FEVER. BY FRANCKE H. BOSWORTH, M.D., Professor of Throat Diseases in Bellevue Hospital Medical College, New York. This is a generic expression which we use as covering all those affec- tions of the nasal mucous membrane which are characterized by profuse watery discharges, with turgescence of the mucous membrane, not dependent upon inflammatory action, but rather upon a vaso-motor paresis of the blood-vessels which constitute the turbinated bodies. This vaso-motor control being abolished, the blood-vessels are dilated to such an extent that the serum escapes and pours through the mucous membrane into the nasal cavity, giving rise to nasal stenosis and intense irritation with formication. This term is generally used to designate that periodical form of the disease which occurs only during the autumnal months, in contradistinc- tion to the vernal fevers or rose-colds which occur in the early portion of the summer. It has received, however, such universal adoption, as covering all the forms of the periodical influenzas, that we use it here in its more generic sense. Definition.—We may define hay-fever, then, as an affection which is characterized by recurrent annual attacks of a more or less severe type of influenza, in which the mucous membrane of the nasal cavity becomes swollen and turgescent and pours out a large amount of watery serum, which in traversing the mucous membrane gives rise to intense irritation with formication. It recurs and terminates each year at fixed periods in the same indi- vidual, although the periods of invasion vary greatly in different indi- viduals. I believe it to be entirely dependent upon the presence in the atmosphere of the pollen of some one of the flowering plants. Moreover, different individuals are susceptible to the action of different pollens, which will explain the fact of the varying periodicity of the disease in individual cases. History.—The affection was first recognized by John Bostock,1 who suf- fered from the disease in his own person, although before his time instances had been observed by Botallus,2 Van Helmont,3 Binningerus,4 and others. 1 Medico-Cbirurgieal Transactions, vol. v. p. 161, 1819. 2 Commentarioli duo, alter de Medici, alter de Aegroti Munere, Lugduni, 1565, p. 23. 3 Asthma et Tussis, cap, x., Opera omnia, p. 344, Hafnias, 1707. 4 Obs. et Curat. Medicinas Centurise quinquae, Cent, secundo, Obs. lxxxvi. 66 HAY-FEVER. 67 Bostock, however, first recognized its periodicity, and gave an excellent description of the disease. He objected to the term “ hay-fever,” which already in his day had crept into use, owing to the fact that the attack in some instances seemed to have been brought on by the emanations of hay, contending that moist heat, sunshine, and dust were the prominent factors in exciting the exacerbation. Subsequently, Gordon1 deduced, from a careful study of his cases, the fact that the cause of the attacks was to be found in the emanations from flowering grasses, especially the Anthoxanthum odoratum, or sweet-scented vernal grass. In 1854, Phoebus made a colla- tion of one hundred and fifty-four cases, from the study of which he seems to have reached the conclusion that sunlight was the active cause of the attacks. Still later we find Helmholtz detailing to Binz,2 by letter, the history of his own sufferings from the disease, propounding the theory that the attacks were caused by certain vegetable spores which he discovered in the mucous discharge from his own nose. Curiously enough, the solutions of quinine which Helmholtz seems to have used successfully in his own case became an exceedingly popular and somewhat efficient remedy until his theory of vegetable spores was completely disproved by the remarkable series of experiments which were performed by Blackley,3 who demon- strated beyond question that the impact of the pollen of flowering plants on the mucous membrane of the upper air-tract was the true source of the symptoms which characterize an exacerbation of hay-fever. No account of this disease would be complete without reference, at least, to the admirable monographs of Wyman4 and Beard,5 as also that of Marsh,6 who first called special attention to the activity of the pollen of Ambrosia artemisicefolia, or common rag-weed, which prevails so extensively through the United States, and which is probably by far the most active of the pollens in America in producing the attacks. In 1882 a notable addition to our knowledge of the affection was made by Daly,7 who first called attention to a fact which I think has been since conclusively demon- strated, that in a diseased condition of the nasal cavities might be found an important factor in the production of the exacerbations of this disease. Etiology.—We find that the earlier investigators practically confined themselves to the study of the exacerbations, and various theories were broached until Bostock clearly demonstrated the activity of pollen in producing the attacks. In Beard’s investigations a new line of departure seems to have been taken, in that his deduction, which was based on an analysis of over two hundred cases, was that the disease was essentially 1 London Medical Gazette, vol. iv., 1829. 2 Virchow’s Archiv, February, 1869, p. 100. 3 Hay-Fever, London, 1873. 4 Autumnal Catarrh, New York, 1876. 5 Hay-Fever or Summer Catarrh, New York, 1876. 6 Transactions of the Medical Society of the State of New Jersey, 1877. 7 Archives of Laryngology, vol. iii. No. 2, p. 157. 68 IIAY-FEVER. a neurosis. His conclusion, I think, cannot be questioned. Daly’s further suggestion of a local morbid lesion in the nose adds a third factor to the causation of the disease. We thus find that there are three condi- tions necessary for the production of an attack of hay-fever: first, the presence of pollen in the atmosphere, as demonstrated by Blackley; second, the neurotic habit, as shown by Beard; and third, a local morbid condition of the nasal mucous membrane, as proved by Daly. I think this view must be accepted. Certainly my own experience, which has been a somewhat large one, warrants me in the belief that these three conditions are present in all cases, and that no individual in whom one or more of these conditions is absent is susceptible to an exacerbation of hay-fever; the first condition being the exciting cause of the exacerbation, while the other two are to be regarded as actively predisposing causes. The Presence of Pollen in the Atmosphere.—The pollen theory of hay- fever is a very old one, but we find its advocates failing to make a distinc- tion between the cause of the exacerbations and the peculiar systemic habit which renders individuals susceptible to the action of pollens. Of course, when we have established beyond question that the pollens of flowering plants are responsible for the peculiar symptoms which attend the disease, we have only determined the exciting cause of the exacerbations, without having arrived at any knowledge of the primary cause of the disease itself. That the exacerbations are excited by the presence of pollen in the atmos- phere cannot be questioned, in view of the admirable series of experiments which were made by Blackley,1 extending through a series of years from 1866 to 1878. These experiments were not only ingenious in their details, but so thoroughly conclusive that it seems wise in this connection to give a brief risume of the plan which Blackley pursued. As before stated, he was a sulferer from hay-fever: his annual attack came on about the 10th of June and usually terminated the 1st of August. The apparatus from which he obtained the most satisfactory results in his investigations con- sisted of a vertical plate of glass seven-eighths of an inch in diameter, which was covered by a hood and pivoted to an upright staff*. Surmount- ing the hood was a weather-vane, the object of which was to direct the face of the glass plate towards the prevailing wind-current. To the face of the glass plate there was affixed a microscope cover-glass one centimetre in diameter, which was covered with glycerin. In this manner any pollen which was floating in the atmosphere would be blown directly upon the plate by the wind-current, and adhere to the small slide prepared with glycerin. Blackley observed that from the last of May to the 7th of June the atmosphere contained pollen in small but increasing quantities: thus, on the 30th of May he was enabled to count twenty-five grains on his small disk, and at this time he commenced to suffer in his own person with a slight sense of irritation in the nasal mucous membrane. 1 Op. cit. HAY-FEVER. 69 From this time on the number of grains increased, until on the 8th of June he was able to count seventy-six grains upon the slide. On the 10th of June the number had increased to over two hundred and eighty, and at this time his catarrhal symptoms had increased to such an extent that he considered his annual visitation as having fully developed. Continuing his investigations, he found the number of pollen grains varying greatly according to certain atmospheric conditions, the largest number which he counted being on the 28th of June, when there were present eight hundred and eighty grains. He furthermore noticed that on a bright, sunny, dry day the atmosphere contained large quantities of pollen, whereas on rainy days the number of pollen grains deposited upon the glass plate was notably diminished, and that passing showers made but little dilference, whereas a rain continuing through twenty-four hours resulted in a very notable decrease in the number of pollen grains, as well as an amelioration of his individual symptoms. After the 28th of June he noticed a progressive decrease in the number of pollen grains which adhered to his disk, and by the 1st of August they had completely disappeared, and at the same date he experienced complete relief from the influenza. Of course these experiments are only conclusive with regard to Blackley’s own case of hay-fever; but he also made a number of investigations with regard to the annual attacks in other individuals, clearly establishing, I think, that the pollen of flowering plants is to be regarded as the active exciting cause of the exacerbations. Why the germinal principle of flowering plants should have this pecu- liar action in producing vascular dilatation in the nasal mucous membrane of certain individuals is rather curious. No explanation can be offered : we can only liken its action to that of cocaine, the single drug in our Pharma- copoeia which possesses the remarkable property of producing vascular contraction. Both these facts are simply established by clinical observa- tion. Thus, Blackley has clearly shown that a condition of the atmosphere which will deposit twenty-five grains of pollen upon a disk one centimetre in diameter in the course of twenty-four hours is practically innoxious to mucous membranes : increase the amount of pollen in the atmosphere until it deposits seventy-five grains in the course of twenty-four hours, and we have a condition which is irritating to the mucous membrane in certain individuals. When, however, the atmospheric condition is such that two hundred and eighty grains of pollen are deposited upon this disk in twenty- four hours, the result is that when certain individuals inhale such an atmos- phere through the nose, complete vascular dilatation ensues by the direct action of the pollen upon the mucous membrane. In exactly the same way a two-per-cent, solution of cocaine applied to this membrane produces such complete vascular contraction that the mem- brane becomes thoroughly exsanguinated in about fourteen minutes; in- crease the strength of the cocaine to a twenty-per-cent, solution, and the 70 HAY-FEVER. same phenomenon results in about four minutes. Here, also, there is a notable variation as regards individuals : although many are exempt from the action of pollens, none, as far as I know, are ever entirely exempt from this action of cocaine. We have spoken of pollen in general, without referring to any of the different varieties. As a matter of fact, in individuals possessing this peculiar susceptibility, the pollen of all flowering plants is to a certain extent active, but it varies notably in different plants. Those which we regard as especially active are the different varieties of meadow-grass, sweet- scented vernal grass, meadow-foxtail, golden-rod, etc. Indeed, Blackley in his experiments recognized these pollens as constituting from ninety to ninety-five per cent, of all those which he counted on his disks. In addi- tion to these, the pollen of roses, as well as of the cereals, wheat, rye, oats, Indian corn, etc., is known to be active in the production of the attacks. In America the rag-weed is probably the most active source of the. disease in its autumnal form, which is the prevailing type met with in this country. The patients occasionally complain that their symptoms are excited by various fruits, such as peaches, pears, plums, as well as the flowers and stalks of different vegetables. This is probably due to the fact that some one of the anemophilous pollens have found a lodgement upon their surface, rather than that there are any irritating emanations from these fruits or vegetables themselves. The Neurotic Habit.—The underlying systemic condition which renders individuals susceptible to the disease is undoubtedly neurotic. This has been very conclusively shown by Beard, who collated over two hundred cases by a somewhat extensive correspondence, and established the fact in the majority of the cases that the prevailing family tendency was in the direction of nervous affections, such as chorea, epilepsy, asthma, and other kindred disorders. Furthermore, it is a matter of constant observation that the disease runs in families. What the essential pathological lesion is which constitutes neurosis, in the very nature of the question is one difficult to determine. I am disposed to think, however, that if there is any pathological lesion in these cases it is found in the peculiar lack of vaso-motor control which characterizes the neurotic manifestations; thus, what in former days was called spinal irri- tation was due probably to a vaso-motor paresis of the blood-vessels of the spinal cord. In asthma the essential lesion is unquestionably a vaso-motor paresis of the blood-vessels of the bronchial mucous membrane, while in hay-fever the condition is due to a vaso-motor paresis of the blood-vessels of the nasal mucous membrane. The Local Morbid Condition of the Nasal Passages.—As before stated, this feature of hay-fever was first brought prominently to our attention by Daly,1 who reported cases which had been cured by treatment confined 1 Loc. cit. HAY-FEVER. 71 entirely to the correction of the diseased condition of the intra-nasal raucous membrane. A clinical fact was thus established which has been verified in such a large number of cases since as to compel our acceptance of the view that certainly in the very large majority of cases, and probably in all, a predisposing cause of the attack lies in a previously existing morbid con- dition of intra-nasal tissues. This, furthermore, must be one of an ob- structive character, which tends to produce in itself vascular dilatation. I have never seen a case of hay-fever occur in connection with an atrophic rhinitis or syphilitic disease of the nose which has resulted in destruction of tissue whereby the lumen of the passages was abnormally increased. In all cases which have come under my own observation the lesion has been obstructive in character. The method of its action is to a certain extent mechanical and easily appreciated. An obstructive lesion in the anterior portion of the nasal passages necessarily gives rise to a rarefaction of air immediately behind the point of stenosis with every act of inspiration. The immediate result of this perhaps is not apparent, but if long continued there ensues a some- what permanent dilatation of the blood-vessels, which is especially marked in the large venous sinuses which are found on the faces of the lower and middle turbinated bones,—namely, the turbinated bodies. This results in a permanent turgescence of the mucous membrane, whereby hyper-nutrition is established, and ultimately a true connective-tissue hypertrophy in the mucous membrane proper. This gives rise in ordinary cases simply to a hypertrophic rhinitis. In a patient of a neurotic habit—namely, one in whom vaso-motor control is somewhat weakened—the result is likely to be that the impact of a pollen-laden atmosphere on such a membrane will give rise to symptoms which constitute the exacerbation of hay-fever; certainly the conditions are established which favor the development of this disease. Nasal polypi are occasionally said to be active in the causation of this affection. This may be true in certain cases : I think, however, that in most instances the polyps are rather the direct result of the hay-fever; the essential feature of this latter disease being, that enormous quantities of serum escape from the blood-vessels and pour through the mucous mem- brane, especially of the upper portion of the nasal passages, whereby it becomes sodden, or water-soaked, as it were, and in this way myxomatous degeneration develops, which eventually assumes the form of small pedun- culated polypi. Tornwaldt,1 in his admirable series of observations on naso-pharyngeal catarrh, takes the ground that a diseased condition in the naso-pharynx may not only give rise to symptoms simulating nasal disease, but may also be the actively predisposing cause of asthma and hay-fever, in the same manner as a diseased condition of the nasal mucous membrane. I fully agree with the observation as far as the question of hay-fever is concerned. 1 Ueber die Bedeutung der Bursa pharyngea, Wiesbaden, 1885. 72 HAY-FEVER. In just what manner this operates I am unable to express a definite opinion; but basing my conclusions purely on clinical observation, I am fully of the opinion that a catarrhal condition of the mucous membrane lining the naso-pharynx should be reckoned among the possible local lesions in the upper air-tract which predispose to a periodical influenza. Among the curious features of hay-fever we should note the peculiar psychic influence, which acts occasionally to precipitate an exacerbation. It is only in this way that we can explain such remarkable instances as .John N. Mackenzie reports,1 in which an attack of rose-cold was brought on by means of an artificial rose. Morell Mackenzie also reports an instance in which a patient was seized with an attack of hay-fever by gazing upon a picture of a hay-fiekl. Patients often state that their annual attack occurs each year upon a fixed date. Now, it is impossible, with the varying character of our seasons in this country, that the plant which generates the pollen which is the exciting cause of the attack in these individuals should flower at exactly the same date each year. We can only explain these cases, then, by the peculiar state of anticipation which is established in the minds of these patients, by which they expect their attack on this fixed date, and which therefore serves to precipitate it, even though but a small amount of the pollen be present in the atmosphere at the time. This con- dition of mental anticipation is well illustrated in those eases of inter- mittent fever in which the chill occurs each alternate day at a given hour. It is not infrequently a successful experiment to turn back the clock for two or three hours, and in this manner postpone the chill by the same length of time. Phoebus, as we have seen, after a most elaborate investigation of the subject, arrived at the conclusion that sunlight was an active cause in producing the exacerbation. In the light of Blackley’s experiments this error is easily explained bv the fact that a hot, dry day is especially favorable for the dissemination of pollen, whereas rainy weather, while interfering with its dissemination, favors its development. In this way it becomes especially active where a hot, dry period follows immediately upon stormy weather. The minute organisms which Helmholtz’s microscope revealed to him as permeating the discharges from his nose during an attack of hay-fever were probably fragments of the mycelium-like threads which develop from the pollen cells under the influence of the heat and moisture of the nasal secretions, and which contained the minute fovilla of the pollen cells. The relief obtained by the quinine solution (a remedy which became so popular immediately after his investigations were published) must be at- tributed to psychical influence. The age at which the disease develops is usually in the earlier decades of life: thus, in the series of eighty cases observed by the writer,2 there 1 American Journal of the Medical Sciences, January, 1886. 2 Diseases of the Nose and Throat, vol. i. p. 208, New York, 1889. HAY-FEVER. 73 occurred between the ages of one and ten, nine cases; between the ages of ten and twenty, twenty-seven cases; between twenty and thirty, sixteen cases; between thirty and forty, twenty-one cases; between forty and fifty, three cases ; and over fifty, four cases. We thus find that the larger proportion of cases developed during the second decade of life. No age, however, seems to be exempt from its development: thus, I have seen it occur at the age of two, and have also had under treatment a patient in whom the disease first developed at the age of seventy-three. Wyman,1 in an analysis of the seventy-two cases on which he based his observations, found the disease occurring as follows: under ten years of age, eleven cases; between ten and twenty, fifteen ; between twenty and thirty, twenty-five; between thirty and forty, eight; between forty and fifty, eleven; and above fifty, two. This table differs somewhat from my own, but it should be stated that in my cases the date of the occurrence of the first attack is given, while Wyman simply reports the age of the patient at the time he came under observation. The fact observed by all writers, that the disease belongs essentially to the better-educated classes, and is rarely met with among laboring people, only emphasizes the view already stated that it is to be classed among the neuroses. The fact that it occurs more frequently in males than in females lends weight to the statement that a catarrhal affection of the upper air- tract is to be regarded as the actively predisposing cause, since men are much more exposed to those conditions which develop catarrhal disorders than women. Of my own cases, fifty-eight occurred in males and twenty- two in females; of Wyman’s cases, forty-seven were males and twenty-five females: of Beard’s2 two hundred cases, one hundred and thirty-three were males and sixty-seven females; while Phoebus found one hundred and fifty-four cases in males and but fifty in females. The influence of heredity is so well known that comment is unneces- sary. Sajous3 has observed cases which have developed after convalescence from one of the continued fevers or other diseases; while Leflaive4 and Lermoyez® believed that the gouty habit exercises a predisposing influence in producing the affection. Pathology.—The various names which are given the disease seem to suggest that the local morbid condition in the mucous membrane of the nose which characterizes the exacerbation is an inflammatory process: thus, Herzog6 designates it as rhinitis vaso-motoria; John Mackenzie,7 rhinitis vaso-motoria periodica; and others, rhinitis sympathetica, pruritic catarrh, 1 Autumnal Catarrh, p. 97, New York, 1876. 2 Op. cit., p. 43. 3 Diseases of the Nose and Throat, p. 178, Philadelphia, 1887. 4 Ehino-bronchite Annuelle, Paris, 1887. 5 Annales des Maladies de l’Oreille, March, 1888. 6 Allgemeine Med. Central-Zeitung, p. 1125, October 24, 1883. 7 New York Medical Record, July 19, 1884. 74 HAY-FEVER. rose-cold, etc. The term rhinitis certainly is a misnomer, if by this it is intended to convey the idea that the exacerbations are characterized by an inflammatory process in the nasal mucous membrane. The first stage of an inflammation is vaso-motor paresis, but inflammatory action is not estab- lished without the subsequent occurrence of the second and third stages, in which there are rupture of the blood-vessels, escape of leucocytes, and hyper- nutritive processes in the tissues beyond. In hay-fever the essential lesion consists in vaso-motor paresis, but it remains such throughout the whole attack, there being no further development of the later stages of inflam- mation. The attack comes on gradually, and develops with the progres- sive increase of the amount of pollen in the atmosphere, and subsides with the subsidence of this atmospheric condition ; but throughout its whole progress it is characterized by nothing other than simple dilatation of blood-vessels with the escape of serum. To understand this more properly involves a brief reference to the normal physiological function of the nasal mucous membrane in respiration, for I believe that the hay-fever exacerbation has practically to do alone with the respiratory function of the nose. In health the nasal membrane pours out from twelve to sixteen ounces of watery serum daily, which is diffused over the convex faces of the turbinated bodies, for the purpose of warming, moistening, and cleansing the inspired current of air as it passes into the lungs. This process of serous exosmosis is regulated by the exer- cise of a vaso-motor control from certain centres in the medulla. This con- trol furthermore is directed with an exceeding degree of nicety, in order to adjust it to the varying hygroscopic conditions of the atmosphere. The pollen of flowering plants possesses the curious property of producing prac- tically a paralysis of this vaso-motor control in certain individuals, whereby this function of serous exosmosis is unloosened, as it were, and the mem- brane pours out serum with great profuseness. The pollen itself is not irritating and does not excite inflammation. It is a mistake to suppose that the pain and sense of irritation which accompany the attack are the result of the impact of an irritating substance upon the membrane. The pain, on the other hand, is the result of the pressure on the terminal fila- ments of the nerves exercised by this flood of serum pouring through the meshes of the membrane. This paralyzing action of pollen, then, is to be regarded as one of the peculiar properties which it possesses; moreover, this action is mainly confined to those blood-vessels which are concerned in the respiratory process,—namely, the large venous sinuses which compose the turbinated bodies. The exacerbation of hay-fever, then, consists simply in a paralysis of the respiratory function of the nose, for if we carefully examine the mucous membrane we fail to discover that the blood-vessels which circulate in the mucous membrane proper are dilated or involved in any way in this vaso-motor paresis. This is confined entirely to the turbinated bodies. We thus find that the exacerbation is due entirely to peripheral causes, and that in this way we practically eliminate the necessity HAY-FEVER. 75 of the neurotic habit. The role that this latter plays in the affection is that under its influence the direct vaso-motor control which is exercised by the trigeminus and sympathetic nerves over the blood-vessels which make up the turbinated bodies is so far weakened by the systemic neurosis as to render them susceptible to the influence of pollen. This would seem to argue the possibility of there being some morbid lesion in the ganglionic centres. I do not think this necessarily follows, although the view was advocated by Kinnear,1 who describes two conditions, one of which consists in a hyper- semia and another in an anaemic condition of the central ganglia. John Mackenzie2 and Hack,3 on the other hand, seem to regard the central con- dition as a functional disturbance, the former describing it as a disordered functional activity of the nervous centres, while the latter regards it as a hyperaesthetic condition of the olfactory and fifth pair of nerves. Symptomatology.—As the season approaches for the annual attack or ex- acerbation, the patient experiences a sense of uneasiness about the nasal passages, with a slight disposition to sneeze. As the atmosphere becomes more fully surcharged with pollen, these symptoms increase and an intense itching or formication about the upper portion of the nasal cavity becomes a prominent feature, in connection with a profuse watery discharge, which necessitates the constant use of a handkerchief, or in aggravated cases the serum drips constantly from the nose. This is usually a perfectly clear and transparent fluid at the onset of the attack, but after a few days the mucous membrane itself, with its muciparous glands, is stimulated to such an extent that an excess of mucus is poured out, which gives the secretion a grayish or cloudy appearance. The turgescence of the membrane naturally causes a more or less complete stenosis of the nasal passages, which adds notably to the discomfort of the sufferer. The vaso-motor paresis is so complete that the blood-vessels are dilated to their fullest extent, and the turbinated bodies thus form loose, flabby sacs, as it were, which completely fill the nasal passages. This condition is especially noticeable in a certain hydrostatic character which the fluid which distends the vessels manifests. Thus, it shows a tendency to collect in the most dependent portion. If the patient lies on the side, the nasal meatus which is uppermost becomes opened, while the fluids collect in the parts below, or, if the patient lies on his back, the blood flows into the posterior portion of the turbinated bodies, causing complete occlusion of the posterior meatus of each side. After the attack has persisted for a day or so, a sharp, stinging pain, which the patient refers to the roof of the mouth, is experienced and be- comes a source of no little discomfort. This is probably due to the impact of the pollen upon the mucous membrane of the upper surface of the soft palate and also of the naso-pharynx. 1 Hay-Fever a Disease of Central Nervous Origin. New York Med. Record, p. 32, July 14, 1888. 3 Loc. cit. 3 Wiener Med. Wochenschrift, 1883, No. 14. 76 HAY-FEVER. When the attack is fully developed, the prominent symptoms consist in the profuse watery discharge, nasal stenosis, and the violent attacks of sneezing. The fluids which escape from the nose are somewhat irritating in quality, and not infrequently give rise to an irritation, or even eczema, of the muco-eutaneous junction, which may also extend to the lip. Suffu- sion of the eyes is a not infrequent accompaniment of the attack, and is in part the result of the sympathetic disturbance of the conjunctiva, but in the main is probably caused by the impact of the pollen upon the ocular membrane, causing vascular relaxation. In rare instances the same irrita- tion is experienced in the mucous membrane of the mouth and even of the ears. That these symptoms are due to pollen was conclusively demon- strated by Blackley’s1 experiments, who injected a drop of the infusion of the pollen of gladiolus into the eye, producing almost instantly intense con- gestion of the membrane, which was soon followed by oedema, with pain and photophobia. In the same way Blackley found the mucous membrane of the mouth susceptible to the same influence. The mucous membrane of the upper air-tract very soon shows evidence of mild inflammatory trouble, in many instances, which is to be attributed rather to the interference with the function of the nasal chambers than to the impact of the pollen. Thus, hoarseness, loss of voice, and cough may develop. This is especially liable to occur after the patient has suffered his annual attacks for a number of years. The distressing symptoms of the attack persist during the waking hours with little abatement, but at night there is a notable amelioration of the condition. This is probably due to the fact that the atmosphere of the sleeping-apartments is not so fully charged with pollen as that which is inhaled during the day. The onset of the attack is not infrequently marked by a feeling of gen- eral malaise, loss of appetite, and depression of spirits. These symptoms, moreover, characterize the whole course of the attack to a more or less well-marked extent. Aside from this we do not ordinarily meet with any evidences of general systemic disturbance. Thus, Blackley,2 in a series of observations with reference to the pulse and temperature, found no devia- tions from the normal. After the affection has persisted for a period varying from one to two weeks, in a certain proportion of cases, an attack of asthma sets in, marked by the symptoms which ordinarily characterize a paroxysm of spasmodic asthma. The asthmatic symptoms are confined to the night-time, as a rule, although the waking hours are characterized by a certain amount of shortness of breath, with what patients describe as “ wheezy” sensations. Asthma is not often observed with the first attack of hay-fever, but is liable to develop after the disease has persisted for a number of years. A certain clinical connection is thus clearly established between hay-fever and asthma. The question arises as to what the direct connection may be, and whether • Op. cit., p. 103. 2 Op. cit , p. 205. HAY-FEVER. 77 the asthmatic symptoms result from the impact of the pollen upon the bronchial mucous membrane in the same way that the hay-fever symptoms arise in the nasal mucous membrane. If this were true, I think that we should naturally expect the asthmatic symptoms to develop coincidently with the nasal symptoms. This very rarely occurs, and moreover, as we have seen, the asthma does not set in until the patient has suffered from a number of annual recurrences of the hay-fever. In writing on this subject some years since,1 I first advanced the theory that hay-fever and asthma were practically one and the same disease, the former consisting of a vaso-motor paresis of the blood-vessels coursing in the nasal mucous membrane, while the latter is a vaso-motor paresis of the vessels coursing in the bronchial mucous membrane. Furthermore, I argued that underlying an attack of asthma was the neurotic habit, in which there exists a special susceptibility to vaso-motor paresis in certain areas. Any- thing which tends to weaken vaso-motor control in any region of the body, in a patient with a neurotic habit, is to be regarded as an active predisposing cause of the development of the disease. There is an intimate and quick sympathy between the nasal mucous membrane and that of the bronchial tubes, established by the existence of the important respiratory apparatus which is constituted by the turbinated bodies. Anything which causes dila- tation of the blood-vessels of the nose tends to be followed by a similar condition in the bronchial mucous membrane. This latter is to an extent weakened, in that the impeded respiration which characterizes hypertrophic rhinitis tends to develop rarefaction of air in the passages below, and thereby vascular dilatation. We have then, in an attack of hay-fever, all the con- ditions present which should render a paroxysm of vaso-motor bronchitis or asthma especially liable to occur. There are nasal vascular dilata- tion, the intimate sympathy existing between the two regions, together with the neurotic habit. An attack of hay-fever, therefore, is especially liable to develop an attack of bronchial asthma, not from the impact of pollen on the bronchial mucous membrane, but purely as one of the conditions which may arise as a natural sequela of the disturbance in the nasal chambers. I do not say that the pollen exerts no influence upon the bronchial mucous membrane; it is probable that the atmosphere which reaches the bronchial passages is moderately surcharged. Most of the pollen-grains, however, are arrested in the passages above. The reason that the asthma does not set in immediately upon the onset of the hay-fever is found in the fact that the vaso-motor paresis in the parts below only occurs after the blood-vessels have been subjected to the weakening influence of the intra-nasal disease for a certain period of time. It is a somewhat notable fact that after a patient has suffered for a number of years with hay-fever in connection with asthma, the asth- matic attack comes on somewhat earlier each year, until finally its ad- 1 New York Medical Journal, April 24 and May 1, 1886. 78 HAY-FEVER. vent is coincident with the hay-fever symptoms. I have observed in a number of cases who were subjected annually to attacks of hay-fever with asthma, that the hay-fever symptoms gradually abated while the asthma became the prominent factor, and that finally, in certain instances, with each annual recurrence of the season the patients were seized with attacks of asthma in which the nasal symptoms were exceedingly mild in character. In still rarer instances I have observed cases in which patients who had suffered for a number of years from simple hay-asthma finally became vic- tims of the perennial form of disease, the attacks occurring at all seasons and without reference to the presence of pollen in the atmosphere. Course and Duration.—By far the most prevalent form of hay-fever which is met with in this country is that in which the annual attack commences in the latter part of August and lasts until cold weather. All forms of hay-fever terminate with the first frost, as we know, because the activity of all pollen is completely destroyed when the thermometer reaches the freezing-point. That form of the disease which commences in the latter part of August is usually designated as autumnal catarrh. The usual date assigned for its commencement is the 29th of August. Many patients assert that their annual attacks recur on exactly the same date and even at the same time of day. This, of course, as before stated, is only the result of mental anticipation. In patients in whom this mental condition does not exist, the recurrence of the exacerbation varies greatly in different years. I know of no reason why so large a number of cases should assume the autumnal form of the disease, other than the fact that at this period the pollen of ragweed is the cause of the attack. This weed, as we know, is widely dissembled, and grows with a luxuriance that is equalled by few other of the anemophilous plants. Its specific action in individual cases has been so clearly demonstrated by Wyman, Marsh, and others, that we must accept it as probably the most active of the causes of autumnal catarrh. Another variety of hay-fever is that which sets in about the 10th of June, and which is commonly designated as a rose-cold, from the fact that it seems to be excited by the action of the pollen of the different varieties of roses which flower at this season of the year. Beard1 seems to attach especial importance to the fact that he had demonstrated the existence of a third variety of the disease in which the attacks came on in September. I do not think any classification of these cases feasible, since the idiosyn- crasy which renders patients liable to the action of the pollen of the various flowering plants is peculiar iu each case to the individual himself, and hence while one patient is susceptible to the action of one pollen, another patient may be affected by a totally different pollen, and their annual attacks only come on when the atmosphere is permeated by the special 1 Op. cit., p. 49. HAY-FEVER. 79 pollen to which they are individually susceptible. I do not mean by this that every individual is susceptible to only a single pollen, for many are sus- ceptible to a number. Thus, we not infrequently meet with patients who not only suffer from rose-colds in the early summer but also from the autumnal form of the disease in August. The following analysis by Beard1 shows the great variation which is observed in the time of the annual recurrence. Thus, of the one hundred and ninety-eight cases which he collated, the onset of the disease occurred— Prom May 1 to May 10 in 2 cases. “ May 10 to May 31 “ 6 “ “ June 1 to June 10 “11 “ “ June 10 to June 30 “ 8 “ “ July 1 to July 10 “ 6 “ “ July 10 to July 20 . “ 6 “ “ July 20 to July 31 “ 7 “ “ August 1 to August 10 “ 7 “ “ August 10 to August 20 “81 “ “ August 20 to August 31 “54 “ “ September 1 to September 10 “ 7 “ “ September 10 to September 20 “ 1 case. “ September 20 to September 30 “ 2 cases. The following analysis of my own cases2 is more interesting, as showing the duration of the annual attacks. Thus,— From May 1 to frost 1 case. “ May 15-May 25 to July 1 3 cases. “ May 10 to August 1 ( 1 case. “ June 1 to July 1 2 cases. “ June 1 to July 14 . 1 case. “ June 1 to frost 5 cases. “ June 10 to July 4 4 “ “ June 10 to July 26 5 “ “ July 1 to September 1 1 case. “ July 10 to August 1 1 “ “ J uly 10 to September 1 1 “ “ July 25 to frost . . 4 cases. “ August 10 to August 27 to frost 51 “ A mere glance at these statistics demonstrates conclusively the futility of any attempt at a close classification of the various forms of hay-fever. Of course it is possible that by careful study and experimentation in each case it might be feasible to determine the definite source of the flowering pollen which was active in each individual case. It is probable, however, that by this means we might show that in certain cases but a single pollen was the active cause of the disease, while in others we would find patients suscep- tible to a very large number or group of pollens. Thus, in my own records 1 Op. cit., p. 50. 1 Diseases of the Nose and Throat, vol. i. p. 216, New York, 1889. 80 HAY-FEVER. I find a case who suffered from the attacks from the 1st of May until cold weather. The neurotic habit was very pronounced in this instance, and the patient was undoubtedly susceptible to a very large number of the various kinds of pollen. The statistics given above refer to the disease as we observe it in America, wherein the very large proportion of cases suffer from the autumnal form of the affection. In England the attacks usually set in during the months of May and June and rarely last longer than until September. The same is true of France and Germany and others of the Continental countries. Geographical Distribution of the Disease.—Wyman1 devotes a large proportion of his excellent treatise on the subject of autumnal catarrh to a consideration of the regions of country where the disease is especially preva- lent and those which are exempt. He seems to think that the affection confines itself mainly to the country east of the Mississippi River and between the thirty-fifth and forty-fifth parallels. In this region he found certain portions of the country which were exempt. These were Canada, the Adirondack Mountains, the Appalachian Range, and the elevated plateau throughout the centre of New York. He found that portion of the country which is west of the Mississippi River and south of the thirty- fifth parallel practically exempt from the disease, with the exception of certain limited districts in the neighborhood of Milledgeville, Georgia, Montgomery, Alabama, and Beaufort, North Carolina. Beard also, in his later investigations, seemed to think that the country west of the Mississippi River was exempt from the disease. These observations are entirely in- correct, for, with our increased knowledge of the affection, we learn that practically no portion of the United States is exempt, except certain elevated districts, such as the White Mountains, the Blue Ridge, the Adirondack region, and some high altitudes in the Western States. It is a long-recognized fact that patients suffering from hay-fever in the valleys find relief by spending their summers in the White Mountains or the Adirondacks. I think the only explanation of this is that the flora of the elevated regions differs materially from the flora of the valleys, and that the flowering plants whose pollen is the source of the exacerbations are not found above a certain altitude. It was claimed by Beard that hay- fever did not prevail west of the Mississippi River. He explained this on the ground of the lack of vegetation and the sparseness of the population. I think a better explanation would have been found in the rugged character of the inhabitants and the vigorous health which resulted from their frontier life. With the extension of civilization to this region, we find hay-fever becoming quite as prevalent as other forms of nervous diseases. Southern climates are to an extent exempt from the disease. We explain this, I take it, by the fact that in the semi-tropical region of the South 1 Op. cit. HAY-FEVER. 81 catarrhal diseases do not prevail, and hence one of the active predisposing causes of the affection is absent. For many years no region of the country has enjoyed a reputation so great as the White Mountains in affording relief to the disease. Curiously enough, with the increased facilities of communication and the establishing of a line of railroad through the mountains, this exemption has to an extent disappeared. It would be an interesting question to observe whether this might not be the result of the extension of the flora of the valleys into these elevated regions. Diagnosis.—The pronounced character of the symptoms, together with' the periodicity of the attack, and especially its prompt termination on the occurrence of the first frost, in the autumnal form of the disease, would seem to afford us clinical symptoms which would render a diagnosis com- paratively easy. Curiously enough, we not infrequently meet with cases in which the annual attack has recurred even for several years without the patient discovering the character of the disease from which he suffered. When once seen, however, such a failure of recognition need scarcely be made on the part of a physician. The only disease with which it need be mistaken, of course, is an ordinary acute rhinitis, but, as we have seen, hay-fever differs essentially from the ordinary cold in the head, in the fact that the latter is marked by several stages,—namely, first, a dry stage, lasting about twelve hours; second, a stage of serous discharge, lasting from two to three days; and third, a stage characterized by a profuse muco-purulent discharge which lasts from three to five days; the whole affection running its course in from five to ten days. In hay-fever, on the other hand, the discharge is a serous discharge from the onset, and is practically so during its whole course. There is never a muco-purulent discharge, although the serum may contain viscid mucus and a few epithe- lial cells, sufficient to render it very slightly opaque. Moreover, an acute rhinitis is not usually characterized by the violent and persistent attacks of sneezing which occur in hay-fever. An examination of the mucous membrane should always serve to estab- lish the existence of a morbid condition which is due purely to a vaso-motor paresis. The appearance of the membrane is characteristic, and resembles in no respect an inflammatory process. It is markedly swollen, giving rise to more or less complete occlusion of the nares, but is of a bluish-gray color, which in every respect differs from the appearance of the membrane in a state of acute inflammation, which, as we know, is of a bright red color. This is due to the fact, already noticed, that the vaso-motor paresis confines itself entirely to the venous sinuses which compose the turbinated bodies, the capillaries which course in the mucosa proper not being involved, and therefore the surface of the membrane shows no evidences of congestion. Moreover, the mucous membrane in hay-fever is covered with a thin, slightly viscid, watery serum, which gives it a glassy and semi-translucent aspect. 82 HAY-FEVER. The suffusion of the eyes, with photophobia, should also afford a certain amount of information, although this may occur in connection with an acute rhinitis. Prognosis.—Although the disease is one which entails no little discomfort and even suffering to the patient during the exacerbations, it does not seem to involve any special menace to the general health. The prognosis, there- fore, is not a grave one. The tendency to the development of a periodical asthma and eventually of a perennial asthma is one that should always be borne in mind. Of course the interesting question in this connection is as regards our ability to cure the disease. This, in late years, has been the subject of no little discussion. Occasionally the disease disappears spontaneously. This is especially noticeable, I think, in young children and in cases of rose-cold. This tendency, however, is not one, of course, that can be depended upon, and is manifested in but a small proportion of cases. That the disease can be cured cannot be questioned in view of the large number of cases reported by various observers. That all cases can be cured, as some claim, is very questionable. I doubt if any physician is -warranted in holding out an ab- solute promise of a cure in any given case. We can only assure our patients that probably a majority of cases are curable, and that much relief certainly can be afforded in the larger proportion of cases. I have had under my own personal care and treatment one hundred and twenty-one cases, in which the records are complete. In addition to these cases it is interesting to note that four patients came under treatment for some diseased condition of the upper air-passages, who reported that in pre- vious years they had suffered from annual attacks of hay-fever which seemed to have disappeared spontaneously. This will, perhaps, represent a fair pro- portion of instances in which a spontaneous cure may be looked for. Of the above cases the results of treatment were as follows: cured, fifty-one; relieved, forty-three; unrelieved, thirteen ; results unknown, fourteen. The above cases include not only cases of periodical vaso-motor rhinitis or hay- fever, but also several instances in which the symptoms were perennial, such as I have elsewhere described under the term “ nasal hydrorrhoea.” 1 Hoe2 has found even better results than these, since of forty-four cases under treatment thirty-six were cured\glthough he states that in sixteen of these thirty-six there was some return of the symptoms. **#he development of hay-asthma in connection with the attacks does not seem to influence unfavorably the prognosis. As before stated, this is not to be regarded as an evidence that the neurotic habit has more fully de- veloped in the individual, but is to be regarded merely as a sequela of the disease. That this does not seriously complicate the affection is well illus- trated in an analysis made by the writer3 of eighty cases of asthma. Thirty- 1 Diseases of the Nose and Throat, vol. i. p. 258. 2 American Journal of the Medical Sciences, September, 1888. 3 Tbid. IIAY-FEYER. 83 four of these were cases of hay-asthma, and of these eighteen were cured, fourteen relieved, one unrelieved, and one lost sight of,—a better result even than that given above in the one hundred and twenty-one cases of hay- fever. Age has an undoubted influence upon the prognosis, since the younger the patient the better is the promise of relief. Rose-cold would seem to belong more especially to the earlier period of life, and hence the prognosis, I think, should be regarded as somewhat more favorable than that of the autumnal form of the disease. At best, hay-fever is essentially a treacherous and somewhat fickle disease, and even in those cases which seem to offer a promise of the best results, as in patients in vigorous health, and in whom the local morbid lesion in the upper air-tract is pronounced, we are not in- frequently disappointed in our anticipations of good results from treatment. While, therefore, we are warranted in the expectation of affording com- plete relief in a fairly large proportion of cases, it is unsafe in any individual instance to give an absolutely favorable prognosis. As already noted, we have found three factors which we regard as essential in the production of an attack of hay-fever. The treatment of the disease, therefore, will consist in, first, measures for the correction of the neurotic habit; second, local treatment for the relief of such morbid conditions as may be found in the upper air-tract; and third, the treatment of the exacerbation. Constitutional Treatment.—Various internal remedies have been recom- mended for the relief of the disease, dating back to the time of its first recognition, which practically recognized the neurotic habit, although not avowedly. Among these are belladonna, zinc, arsenic, phosphorus, strychnia, hydrocyanic acid, valerian, asafoetida, musk, lobelia, amber, bromides and iodides, chloral, opium, hyoscyamus, quinine, and the various preparations of iron. The usual manner in which these were given was to commence their administration from ten days to two weeks before the annual attack was expected, and thus to bring the system thoroughly under their influence, in order that the local symptoms might be thus ameliorated. Blackley was a homoeopathic physician, and his experiments in the therapeutics of the disease seem to have been quite as thorough as those which were used in the study of its causation. He found the administration of the arsenite of potash and the arsenite of quinine attended with excellent results, but the greatest relief was afforded, in his experience, by the exhibition of the iodide of zinc in doses of one-two-hundredth of a grain. Beard1 and McCullough 2 both advocated the use of quinine, the latter stating that it has “ helped more cases than any other single remedy.” The use of the bromides does not seem to have been attended with any good results, although TREATMENT. 1 Op. cit., p. 158. 2 Remittent and Intermittent Diseases, London, 1828. 84 HAY-FEVER. in combination with chloral they are often rendered necessary to quiet ner- vous irritability and to produce sleep during the exacerbation. La Forge1 claims to have got excellent results from the administration of belladonna in connection with opium, while Dechambre2 found it equally efficient ad- ministered in connection with quinine. He advised that it be given in gradually-increasing doses until its physiological effect is obtained, when the amount is decreased. These results are to be attributed to the specific action of belladonna on the vaso-motor system of nerves, although the observa- tions were made before this feature of the disease was recognized. A better method, I think, than Dechambre’s, is to commence the administration of the drug about two weeks before the attack is expected and to continue it until the end of the period. Mackenzie3 believes that “ valerianate of zinc in combination with asafoetida is more valuable than any other drug.” He administers one grain of the zinc with two grains of compound asafoetida pill, commencing before the attack sets in, and at the end of two weeks doubles the dose. I regard belladonna as exercising a more specific and thorough control of the disease than any other drug, and next to this I am disposed to place reliance in the therapeutic value of some preparation of zinc. The following combination in my own experience has been attended with most excellent results : R Zinci phosphidi, gr. viij ; Extract, belladonnae, gr. x.—M. Fiat mass, in pil. no. xl. div. Sig.—One pill three times a day after eating. Impairment of general nutrition is not ordinarily observed in these cases. When this is noted, however, the administration of arsenic in com- bination with the above will be found efficacious, adding a single grain of the arsenious acid to the above prescription, thus administering it in doses of one-fortieth of a grain. The administration of these drugs should be commenced at least two weeks before the onset of the attack. Unfortunately, these patients do not often present themselves at that time. We are more liable to meet them during the exacerbation or immediately after it. If they are seen during the exacerbation, the above remedies should be administered in the same manner. If seen immediately after an attack, I see no reason why the beneficial action of these drugs on the nervous system should not be secured by a course of internal medication extending over from six weeks to two months. There are certain general remedies which I regard as of special value in the correction of the neurotic habit; these consist in the regulation of 1 Union Medicale, December 7, 1859. 2 Gazette Hebdom., p. 67, 1860. 3 Hay-Fever and Paroxysmal Sneezing, 4th ed , p. 66, London, 1877. HAY-FEVER. 85 the clothing and the habits of life. These have already been sufficiently discussed in the chapter on acute rhinitis, and need not be entered upon here. There is one measure, however, which I regard as of the greatest importance: this consists in the judicious use of cold water, especially as applied to the spine. A cold sponge-bath is not sufficient; what is espe- cially desired is the tonic effect produced on the spinal nerves by the sudden and decided shock of cold water on the back. This is excellently accom- plished by the use of the cold shower-bath. This, however, is not always well tolerated, while patients do tolerate the cold sponge to the spine. The plan is not a new one, for we hnd it recommended by Gordon1 as early as 1829, who especially emphasizes the value of cold water in the treatment of these cases. Kinnear2 also reports six cases of hay-fever in which excellent results were obtained by the daily application of ice-bags to the spine, the application being continued for from an hour to an hour and a half. In addition to the above measures, the sleeplessness and nervous irrita- bility which the attack entails will not infrequently necessitate the adminis- tration of anodynes to secure sleep. For this purpose opium is undoubtedly the most efficacious. Mackenzie3 finds the best effects from the use of the tincture, giving from five to seven drops twice daily. Morehead4 recom- mends the hypodermic administration of morphine, one-twentieth of a grain, in combination with one-two-hundredth of a grain of atropine, given twice daily; or, better still, one-twentieth of a grain of the tartrate of morphia gradually increased, as the attacks develop, to one-tenth of a grain. It is probably not safe to give as large a dose as this through any long period of time, and hence it will be wiser, perhaps, to resort to less dangerous anodynes, such as hyoscyamus, the bromides, or sulfonal. The Treatment of the Diseased Condition of the Upper Air-Passages.— The active discussion of the subject of hay-fever and its curability has been largely carried on by those who. have made a special study of diseases of the throat and upper air-passages, and I think it is fair to claim that the most successful results in affording relief from the disease have been attained by methods of treatment directed towards the removal of such morbid conditions as may be found in the nasal passages. If the results obtained by these observers can be relied on, it seems to me that a causative relation to catarrhal affections in the upper air-tract is clearly established, and in this point of view, therefore, becomes of special importance, in that we have here definite conditions which can be recognized on ocular inspec- tion, and definite indications for treatment. Moreover, we are enabled by ocular inspection to fully estimate the success which has attended our 1 London Medical Gazette, vol. iv. p. 266, 1829. 2 New York Medical Record, July 14, 1888, p. 32. 3 Op. oit., p. 66. * British Medical Journal, vol. ii. p. 18, 1886. 86 HAY-FEVER. measures. The treatment is not new, for as early as 1837, Cazenave1 recom- mended that the mucous membrane of the nose should be cauterized with nitrate of silver. This plan seems to have been attended with a certain amount of success until the galvano-cautery was introduced by Middel- dorpf,2 when the use of this device became a favorite procedure. These measures were used without any definite recognition of indications. Of course we do not treat hay-fever with caustics in this manner, but we occa- sionally find it necessary to resort to this measure for the removal of those morbid lesions in the nasal passages which predispose to the disease. These are hypertrophic rhinitis, deflections of the septum, nasal polypi, naso- pharyngeal catarrh, and indeed any obstructive lesion in the upper air-tract which tends to induce a turgescence of the blood-vessels in the nasal mucous membrane. The indications for treatment, therefore, are only made clear by a careful inspection of the parts and a recognition of such lesion as may exist. If nasal polypi or other tumors are discovered, they should be removed; if a deflection of the septum exists, the normal patency of the passage should be restored by its ablation; if hypertrophic rhinitis or chronic hypersemia of the nasal mucous membrane is found, this should be reduced by the judicious use of caustic applications. Briefly, the indications for local treatment are fully carried out in restoring the normal patency to the whole of the upper air-tract, thus enabling the process of respiration to go on in a perfectly normal manner and without entailing any diminution of air-pressure in any portion of the breathing passages. Sajous3 lays special stress on the superficial cauterization of the nasal mucous membrane, by which nutrition is altered. This seems rather obscure and fails to give us any definite clinical indication. In a later contribution4 the same writer emphasizes the necessity of confining the caustic applications to the sensitive areas in the nose, as previously described by John Mackenzie.5 The im- portance of these sensitive areas of John Mackenzie I have always regarded as being greatly overestimated. They are simply found in that portion of the nasal mucous membrane where the turbinated bodies are most highly developed. This unusually high development necessarily entails an unusu- ally rich nervous distribution for the regulation of functional activity. Those portions of the nasal mucous membrane, therefore, where the venous sinuses which form the turbinated bodies are more largely developed, are unusually sensitive. This sensitiveness is merely an adventitious feature, and does not carry with it any indications for treatment; they belong to health as well as to disease. The indications for treatment in hay-fever 1 Gazette Medicate, p. 31, 1837. 2 Die Galvano-Kaustik, Breslau, 1854. 3 Medical and Surgical Reporter, Philadelphia, December 22, 1883. 4 Diseases of the Nose and Throat, Philadelphia, 1886. 6 New York Medical Record, July 19, 1884; and American Journal of the Medical Sciences, July, 1883. HAY-FEVER. 87 are the control of turgescence, and not the destruction of tissue or the abolition of hyperaesthetic conditions. I am disposed to think that such success as has been obtained by cauterizing these sensitive areas has been simply from the reduction of turgescence accomplished in this way. Treatment of the Exacerbation.—In the earlier literature of hay-fever we find many observers recording with a certain degree of enthusiasm their success in controlling the local symptoms of the disease by means of certain topical applications. Thus, Elliotson1 claimed excellent results from the use of the chlorides in solution in connection with vaporous in- halations. Cazenave2 warmly advocated the irrigation of the parts with weak solutions of bichloride of mercury. Helmholtz’s original observa- tion of the efficacy of quinine was followed by a somewhat extended and successful use of this remedy, until De Bud berg3 showed conclusively that a solution of chlorate of potash was quite as efficacious, and Sir Andrew Clark4 even quite recently has claimed excellent results from the local ap- plication of a solution of quinine, carbolic acid, and bichloride of mercury in combination. Binz5 found salicylic acid efficient in controlling local symp- toms. I question if any of these remedies exercises any notable controlling influence on the local process. When the pollen theory was first demon- strated, the attempt was made to control the local manifestations in the air- tract by protecting the mucous membrane from the impact of the pollen. Thus, Blackley6 found notable relief from wearing a wire gauze respirator. Mackenzie7 advises that the nostrils be plugged with cotton wool. The discomfort attending these methods, with the failure to afford notable relief in most instances, scarcely warrants us in recommending patients to resort to them. No local remedy which has yet been introduced more clearly and directly carries out the indications in relieving the local manifestations of hay-fever than cocaine, since this drug not only produces insensibility in the mem- brane but reduces plethora, thus controlling the two essential conditions which characterize an exacerbation. The value of its action I regard as prac- tically in contracting blood-vessels, rather than in its anaesthetic properties. This remedy, I think, may be safely placed in the hands of patients for use by means of a spray, using a two-per-cent, solution, which is thoroughly effi- cacious in most of these cases. It is always to be borne in mind, however, that cocaine is liable to produce a constitutional effect, resulting in disturb- ance of the heart’s action, nervousness, and sleeplessness. Watching some- what carefully its action in this respect, and restricting its use as far as 1 London Medical Gazette, vol. viii. p. 411, 1831. 2 Loc. cit. 3 British Medical Journal, vol. ii. p. 18, 1881. * Ibid., June 11, 1887. 5 Deutsche Medicinische Wochenschrift, September 27, 1877. 6 Op. cit., p. 260. 7 Diseases of the Throat and Nose, Am. ed., vol. ii. p. 310, Philadelphia, 1880. 88 HAY-FEVER. possible, I see no reason why patients should not be afforded the very marked relief to local symptoms which it is able to give. Beverley Ilobinson1 asserts that after the turgescenee has been subdued by the local application of cocaine the relief is but temporary, and there follows a reaction in which the vascular dilatation is even greater than before. This certainly has not been my own experience. As before stated, relief follows very promptly upon the first application, but is not permanent and rarely lasts more than from half an hour to two hours, varying notably in different cases. In this manner the repetition of the application will be demanded at varying intervals, according to the relief afforded. The formula which I prefer is as follows: R Cocainse hydrochlorat., gr. xx ; Sodii bicarb., Acidi borici, aa gr. x ; Aquae, i.—M. We thus commence with a four-per-cent, solution, which is to be used by means of a small atomizer and applied as frequently as may be needed. The patient should be directed to gradually weaken this solution, carefully noting the amount of dilution, until the weakest solution is arrived at which will afford relief. In many cases I have found that a one-per-cent, or even a half-per-cent, solution acts quite as favorably as the stronger preparation. In many cases a still better method of using this drug con- sists in making a suspension of the cocaine solution in one of the petroleum oils, as follows: R Cocainse hydrochlorat., gr. x ; Aquae, q. s. M., fiat solutio. Adde albolene, f^i. This is to be used in one of the large atomizers adapted for the petro- leum oils. This not only affords the controlling action of cocaine in re- ducing turgescenee, but also coats the membrane with the albolene in such a way as notably to protect it from the impact of pollen. It has been asserted that the use of cocaine is dangerous in producing an enslaving habit. I have been a somewhat interested and careful observer of this subject, and while I am not ready to state that there is no cocaine habit, I unhesitatingly make the assertion that no case of so-called cocaine habit has come under my own observation in which I was not convinced that the drug was used in connection with either alcohol or opium; in other words, I have seen no case of pure cocaine habit. While I recognize a certain danger in the careless use of this drug, and would hesitate to prescribe it in any case without a careful watchfulness, I am disposed to think that its dangers are somewhat overestimated. Mackenzie2 recommends the use of gelatin bougies containing a tenth of a grain of cocaine combined with 2 New York Medical Record, October 17, 1885, p. 425. 2 Hay-Fever and Paroxysmal Sneezing, 4th ed., p. 02, London, 1877. HAY-FEVER. 89 the one-hundred-and-twentieth of a grain of atropine. These are to be inserted into the nasal passages and allowed to melt. I am disposed to think that most of the more distressing symptoms of the disease are the result of a turgescenee of the middle turbinated bodies rather than of the lower. Such an application as this, of course, would not thoroughly reach the parts. Robinson1 reports a number of cases in which cocaine failed entirely to give relief to hay-fever, and in which he obtained notable success from pencilling the mucous membrane with one part of carbolic acid in three parts of glycerin. One of his cases was completely cured, and two were notably relieved. Occasionally I have found excellent results from directing the patients to make use of a snuff composed of the following: R Cocainse hydrochlorat., gr. x ; Bismuthi subcarb., gi; Magnesii calc., sjij ; or: R Hydrarg. chloridi mitis, gr. v; Cocainse hydrochlorat., gr. x ; Sacch. lactis, giij ; If there is much nervous irritability, a small amount of morphine may be administered in a snuff, as follows : R Morphinae tartratis, gr. i; Cocainse hydrochlorat., gr. x ; Sulphuris flor., gss; Sacch. lactis, giij. Hinkle2 has obtained favorable results from the local application of anti- pyrin alone or in combination with cocaine; while Cheatham3 and Brooks4 have obtained equally good results from the internal administration of antipyrin, which would suggest that possibly Hinkle’s results may have depended upon the constitutional action of the drug. The eye-symptoms are occasionally so distressing in character as to require attention. Temporary relief, of course, will be afforded bv the application of cocaine. Here, however, a no stronger solution than one per cent, should be used. Cheatham5 makes the suggestion that eserine in the strength of one twelfth of a grain to the ounce should be added to the cocaine solution in order to prevent dilatation of the pupil. As a rule, however, the use of colored glasses, as first suggested by Cazenave,6 will be found to afford sufficient relief to this condition. 1 Loc. cit. 2 New York Medical Journal, October 20, 1888, p. 429. 3 Annual of the Universal Medical Sciences, vol. iii. p. 267, 1888. 4 British Medical Journal, May 19, 1888. 5 New York Medical Record, November 21, 1885, p. 567. 6 Loc. cit. NEUROSES OF THE NOSE AND NASO- PHARYNX. BY JOSEPH A. WHITE, A.M., M.D., Senior Surgeon to the Richmond Eye, Ear, Throat, and Nose Infirmary, Richmond, Virginia. Neuroses of the nose and naso-pharynx may be divided into neuroses of olfaction, or alterations of the sense of smell, and reflex nasal neuroses, which comprise a host of morbid phenomena, sensori-motor, vaso-motor, and trophic, which at times emanate from impressions made on the olfactory or the trigeminus and its sympathetic connections. PART I. NEUROSES OF OLFACTION. Neuroses of olfaction, or alterations of the sense of smell, may be divided into parosmia, or parosphresia, hyperosmia, or hyperosphresia, and anosmia, or anosphresia. PAROSMIA, OR PAROSPHRESIA. Parosmia, or parosphresia, is a perversion of the sense of smell, so that, whilst the special sense remains perfect for all odors, the individual is afflicted by imaginary odors. For its perfect action the sense of smell must have normal olfactory bulbs, healthy mucous membrane,—covering the superior turbinated, the upper half of the middle turbinated, and the upper three-fourths of the posterior part of the septum,—and free access of air with the odorous par- ticles to excite the nerve-filaments. Perversion of the sense of smell may result from any change in these •*Hcessary conditions for normal olfaction. Whilst it may be apparently mormal to all intents and purposes, one may be annoyed by imaginary odors, such as gas, petroleum, urine, etc., due probably to some pathological con- dition of the olfactory nerve or bulb or to some brain-lesion. That imaginary odors can be purely subjective is evidenced by such cases as Bernard’s,1 in which the autopsy revealed an absolute destruction of the olfactory nerves, although the patient had complained of unpleasant 90 1 Froriep’s Notizen, vol. xi. NEUROSES OF THE NOSE AND NASO-PHARYNX. 91 smells whilst living. Such subjective hallucinations are common among the insane. They are also met with in epilepsy, hysteria, syphilis, etc. I have once observed this symptom in a case of atrophic rhinitis, where objective odors could not be perceived. That it can result from simple catarrhal rhinitis, causing peripheral excitation, would appear from the fact that during the recent epidemic of “ la grippe” I saw cases of perverted olfaction where the patients were annoyed by unpleasant tastes and smells for days, such as the odor of carrion, stable manure, etc. Onodi1 records similar cases. This may be the result of altered nasal secretions from the catarrhal conditions which accompany “ la grippe,” but it can also be of central origin from the cerebral irritation so frequently observed during influenza. Over-stimulation of the nerve-endings by a powerful odor can also cause perverted olfaction (Warden).2 Hyperosmia, or hyperosphresia, is a hypersesthesia of olfaction, and sometimes follows exhausting diseases which impair the nerve-force and exaggerate all nervous impressions; or it may be due to local irritation of the olfactory bulbs, causing a hypersensitive condition; or it may be as- sociated with hysteria, hypochondria, or neurasthenia (Baumgarten).3 In hyperosmia odors that ordinarily are not noticeable will produce a most profound impression, and smells not perceptible to a healthy nasal organ will give great annoyance. Unpleasant odors are often retained for hours after the offending substance is removed. Abnormal function of the olfactory nerve is sometimes of reflex causa- tion, from troubles of the sexual organs, especially in women (Fever).4 I have met with a case where exaggerated sense of smell invariably developed at each menstrual period, but was accompanied by hypersemia and slight turgescence of the mucous lining of the nose. Such cases show the intimate relations between the nasal mucosa and the sexual organs by way of the sympathetic, a connection demonstrated by John N. Mackenzie5 in his remarkable essay on this subject. In the same connection Gottschalk6 reports a case of a lady thirty-six years of age who had both ovaries extirpated on account of uterine myoma : one year later the patient had entirely lost the sense of smell. There was no spinal irritation, and no assignable cause for the anosmia. Gottschalk believed there was a relation* between the artificial climacterium and the anosmia. HYPEROSMIA. 1 Monatsschrift fur Ohrenheilkunde, March, 1891. 2 Parosphresia and Parageusia, Journal of Laryngology and Rhinology, May, 1889. 3 Pester Med.-Chirurgische Presse, No. 9, 1889. 4 Miinchener Medicinische Wochenschrift, Nos. 8 and 4, 1889. 5 Irritation of the Sexual Apparatus as an Etiological Factor in the Production of Nasal Disease, American Journal of the Medical Sciences, April, 1884. 6 Deutsche Medicinische Wochenschrift, No. 26, 1891. 92 NEUROSES OF THE NOSE AND NASO-PHARYNX. ANOSMIA. Anosmia, or anosphresia, loss of smell partial or complete, is the more common and most important clinically of the alterations of this special sense. It can be congenital or acquired, but congenital anosmia is very rare. It is very frequently developed temporarily by acute catarrhal inflam- mation of the nasal passages, or a so-called cold in the head, and by any other change in the nasal passages that prevents free access of air to the upper nasal chambers. H. Zwaardemaker1 suggests a division into anosmia respiratoria and anosmia expiratoria, according as the smell-act is inspiratory or expiratory, —i.e., whether interference with reaching the olfactory fissure is in the anterior nasal passages, as for external odors, or in the choanse or post-nasal region, aA for odors accompanying the acts of eating and drinking; for perception of odors during expiration is not so limited as wTas supposed (Aronsohn).2 He also divides anosmia into anosmia essentialis and anosmia intra- cranialis, according as the nerve-endings of the olfactory cells or nerves themselves are pathologically altered, or the central olfactory apparatus in the brain is affected. Anosmia respiratoria is brought about by asymmetry of the nasal chambers, or by any obstruction to nasal ventilation. In deflections of the septum, exostosis, enchondroma, etc., it is often unilateral, and usually on the side of the convexity of the septum. In hypertrophy of the nmcosa when'present it is usually bilateral. In acute rhinitis, temporary and bi- lateral anosmia is frequent, as above mentioned. Polyps—which can also produce essential anosmia by pressure in the pars olfactoria—are among the common causes. Tumors of the pharynx and naso-pharynx also produce it. Paralysis of the alae nasi and absence of the external parts of the nose both impair or abolish the sense of smell, but in the latter instance it has been restored by the formation of an arti- ficial nose (Beclard, quoted by Zuckerkandl).3 Essential anosmia can be unilateral or bilateral, temporary or constant. It can be primary from the effects of irritating gases, as in the case of Althaus,4 of a physician who lost the sense of smell after the dissection of a gastric carcinoma, in which he suggests a capillary hemorrhage as the probable pathological alteration; or of strong and disagreeable odors (R. J. Graves).5 ♦ Excessive and repeated irritation, as in constant inhalation of tobacco- 1 Weekbl. van het Nederl. Tijdschr. voor Geneesk.,No. 9, 1889. 2 Arehiv fiir Anatomie und Physiologie, 1880. 3 Normale und Pathologische Anatomie der Nasenhohle, Wien, 1882. 4 Lecture on the Physiology and Pathology of the Olfactory Nerve, Lancet, May, 1881. 5 Dublin Journal of Medical and Chemical Science, 1834. NEUROSES OF THE NOSE AND NASO-PHARYNX. 93 smoke (more common in cigarette-smokers), has been known to impair the sense of smell (Edward F. Parker).1 Congenital anomalies of the olfactory epithelium and nerve-filaments, such as absence of the pigment, are some- times the cause (Dundas Grant).2 Injury by a blow (Legg),3 or traumatism of the nerve, by tearing at the ethmoid foramen from fracture of the base of the skull (Notta)4 or of the ethmoid plate (Ogle),5 causes anosmia. It has been produced temporarily by cocaine applications (Zwaardemaker).6 Usually it is secondary to chronic rhinitis, extending from the pars respiratoria to the pars olfactoria, and ending in atrophy; to a chronic pharyngitis, as in Lennox Browne’s7 case of anosmia, where no reason could be found beyond a chronic pharyngitis and relaxed uvula, and where abscission of the uvula resulted in a cure; to adenoids or polyps; to syphi- litic alteration of the nasal mucous membrane; and to excessive or dimin- ished secretion. Persons, e.g.} with dry mucous membrane can smell only in moist air. The effect of section or paresis of the fifth nerve on olfaction is in all probability due to the alteration in the secretions of the nasal mucous membrane. It can also result from morphine, atropine, mercurial poison- ing, etc. The inflammation of the olfactory nerve commencing in the terminal filaments, or ascending neuritis, is a rare but possible cause. Anosmia intracranialis can result primarily or secondarily. Primarily, from affections of the olfactory bulb and tract, as by wounds and tumors, when injury to sight may accompany the anosmia ; by degeneration, as in locomotor ataxia (Althaus) ;8 by general paralysis; by senile decay; by syphilis, which can produce descending olfactory neuritis; by functional paralysis; by congenital absence of the olfactory nerves (cases reported by Haller, Valentine, Rosenmuller, Cerutti, Pressat, and others quoted by Sappey); and possibly by non syphilitic olfactory neuritis. Secondarily, from injuries (Hamilton);9 hemorrhage (Hughlings Jackson,10 Ogle11); meningitis; abscess (Oppert);12 tumors (Loder);13 necrotic and atrophic processes (Provost).14 > 1 Anosmia from Tobacco-Poisoning, Philadelphia Medical News, September, 1890. 2 On Anosmia, British Association of Laryngology and Rhinology, 1888. 3 A Case of Anosmia following a Blow, London Lancet, 1873. 4 Recherches sur la Perte de l’Odorat, Arch. Gen. de Med., 1870. 5 Anosmia, or Cases illustrating the Physiology and Pathology of the Sense of Smell, Medico-Chirurgieal Transactions, London, 1870. 6 Cocaine Anosmia, Fortschritte der Medicin, No. 13, 1889. 7 Diseases of the Throat, London, 1887. 8 Loc. cit. 9 Transactions of the College of Physicians, Philadelphia, 1870, vol. iv. 10 London Hospital Reports, vol. i. p. 410. 11 Loc. cit. 12 Dissertatio Inaug. de Vitiis Nervorum Organicis, Berolini, 1815. 13 Observatio Tumoris Schirrhosi in Basi Cranii reperti, Jen., 1790. 14 Gazette Medicate de Paris, 1866. 94 NEUROSES OF TIIE NOSE AND NASO-PHARYNX. Unilateral anosmia has been met with in eases of aphasia, and Hugh- lings Jackson explains it by the passage of the external root of the olfactory past the island of Reil to the anterior part of the temporo-sphenoidal lobe. This cortical anosmia with aphasia, and sometimes with hemiplegia, is on the opposite side to the paralysis. The usual location of the pathological process is at the base of the brain, and in the anterior fossae, but the hippocampus, the thalamus, the posterior part of the internal capsule on the opposite side, and the pons are mentioned as having been the seat of disease that has affected the sense of smell, syphilis being the most frequent cause (C. L. Dana).1 Hemianosmia from alterations in the internal capsule is one of the symptoms of Charcot’s hysterical hemiansesthesia. Symptomatology.—The evidence of this defect is an inability to perceive odors, which is often spoken of as a loss of taste, the absence of flavor in eating being more apparent than the loss of smell. The relationship of the sense of smell and the sense of taste has been explained under the heading of anatomy and physiology, and there is no space to enter into its consideration here. But it is well known that the sensation of flavors is not gustatory, but olfactory, and that this deficiency is the means of recognizing anosmia in nearly all cases. Where there is an inability to perceive delicate odors and at the same time the perception of flavors is acute, there is only a partial loss of function of olfaction, usually due to nasal stenosis, or so-called anosmia respiratoria. Where there is anosmia essentialis or intraeranialis, unless in rare cases when it is unilateral, the sense of taste is correspondingly impaired. Prognosis.—When anosmia is due to obstructive lesions in the nose, to malarial influences, to syphilitic changes, a favorable opinion may be given, provided that such loss of the olfactory function has not persisted so long that atrophy or degenerative alterations in the nerve-endings or in the nerve itself have taken place. It is well known that any part of the economy which has been deprived of its functional activity for a long time will degenerate or atrophy, but it has never been and probably never will be definitely settled how long any function can be retained in a state of absolute inactivity. This uncertainty in some cases leaves the prognosis of many cases of anosmia doubtful. According to Bosworth,2 six or eight years of functional inactivity of the olfactory would result in the permanent loss of smell, from degenera- tion of the trunk or cerebral centres of the nerve. I have had two cases entirely cured by treatment of nasal disease, one in a lady who had lost the sense of smell for more than twenty years, and another where atrophic rhinitis had caused the same defect for more than ten years. Notta3 reports a cure after loss of smell for fifteen years from polypi. 1 New York Medical Journal, September, 1889. 2 Diseases of the Nose and Throat, New York, 1889. 3 Loc. cit. NEUROSES OF THE NOSE AND NASO-PHARYNX. 95 D’Agnano1 records the case of a man who had anosmia forty years in consequence of a blow from a stone upon the naso-frontal region. The local treatment of the deviation of the septum and polypi was followed by complete recovery of smell when free respiration was restored. These cases show the difference in functional activity in different indi- viduals. Even in intracranial lesions recovery is sometimes met with, especially when the loss of smell is due to hemorrhage. Diagnosis.—There is no difficulty about the diagnosis, but it is some- times important in relation to prognosis and treatment that a differentiation be made between anosmia respiratoria (symptomatic) and anosmia essen- tialis and intracranialis. A careful examination of the nose and naso-pharynx, and the presence or absence of any possible local causation for the loss of olfaction, will usually determine the question. In testing for anosmia, substances should be used that affect only the olfactory nerve, and not acrid or pungent odors that stimulate the branches of the fifth pair. Unilateral anosmia can be determined only by absolute occlusion of the other side, both back and front, when making the test. Zwaardemaker in an article in the London Lancet, January, 1887, has suggested a method of measuring the sense of smell clinically by an apparatus called the olfactor- meter, for a full explanation of which, from lack of space, I refer the reader to the article. Treatment.—In parosmia and hyperosmia internal treatment directed to improvement of the general nervous system should be instituted. If there is any nasal disease, cocaine locally has been suggested as useful (Grazzi).2 In anosmia due to nasal stenosis, or to secretory changes in the nasal mucous membrane, the removal of all obstructive lesions and the restora- tion of the nasal mucosa to its normal condition is the only treatment. In syphilitic changes, iodide of potassium internally, and galvanization of the olfactory nerve, will usually give good results. Strychnine and phosphoric acid in gradually increasing doses until physiological effects are produced is sometimes serviceable. Althaus3 suggests the use of strychnine, not only internally, but also by local insufflation in powder, commencing with one-twenty-fourth of a grain and gradually increasing the dose. Bosworth4 proposes stimulation of a defective olfaction by powerful odors, frequently changed during the same day, thus forcing the nerve into increased activity by its normal stimulation. Whilst considering olfaction, it would be well to call attention to the effects of odors at times in introducing a psychical element into the produc- tion of neurotic phenomena. 1 Bollettino delle Malattie dell’ Orecchio, etc., No. 5, 1890. 2 Parosmia e sua Cura, Bollettino delle Malattie dell’ Orecchio, etc., No. 1, 1887. 3 Loc. cit. 4 Loc cit. 96 NEUROSES OF THE NOSE AND NASO-PHARYNX. Certain odors, for example, in some individuals, whether from a peculiar mental association or from an unexplainable neurotic predisposition, have been known to produce such sympathetic reflexes as sneezing, cough, asthma, hemicrania, fainting, vomiting, and convulsions. The odors pro- ducing such effects may to the normal olfactory nerve be very pleasant, and may emanate from flowers or plants that please the eye as well as the sense of smell. Schneider1 speaks of a suffocative catarrh from the odor of roses. Van Helmont2 refers to the influence of perfumes in producing migraine, palpitation of the heart, and asthma. Cloquet3 also mentions the peculiar effects of certain odors. Cullen’s4 case of asthma from ipecacu- anha is well known. Trousseau5 speaks of asthma produced by the odor of violets. Ziem6 and others have reported similar cases. That the fifth pair has nothing to do with the production of these reflex disturbances has been proved by the experiments of Gourewitsch and Lueh- singer, who artificially caused respiratory neuroses after sections of the trigeminus and superior laryngeal. The explanation is to be found in disease or abnormal sensitiveness of the olfactory nerve filaments and bulbs, and a special irritability of the central nervous system, with a probable transferrence of the irritation from the olfactory to the pneumogastric through the nprve-centres, as the central connections of the olfactory are not yet clearly established. But the most important factor in their causa- tion is probably the psychical element, and if, as Rousseau says, olfaction is the sense of imagination, we can easily appreciate how it affects our emo- tions and brings about alterations in the cerebral centres. Sometimes the sight of the exciting cause, and the mental association thus brought about, may have as much to do with the vaso-motor changes as the effect of the odor. This fact is evidenced by the case of “ rose-cold” produced by the sight of an artificial rose reported by John N. Mackenzie.7 A case in point is the following: After the battle of Port Republic the wounded were taken into the house of the grandfather of one of my colleagues, now living in Richmond, Virginia. The honeysuckle was in full bloom, and its fragrance filled the air. My colleague’s aunt was so affected by the harrowing scenes attending the care of the mangled soldiers that she was overcome and fainted. From that day until she died, years after, the odor or sight of honeysuckle brought on an attack of syncope. Here undoubtedly the psychical element had as much to do with the vaso-motor disturbances as the impression made on the olfactory nerve by the odor of the flowers. 1 De Catarrhis, 1662. 3 Dissertation sur les Odeurs, Paris, 1815. 4 Institutes of Medicine, Edinburgh, vol. i., 1788. 5 Clinique Medicale de l’Hotel-Dieu de Paris, 3d ed., 1869, vol. ii. 6 Deutsche Medicinische Wot henschrift, No. 30, 1885. 7 American Journal of the Medical Sciences, January, 1886. 2 Op. Omnia, Francofurti, 1682. NEUROSES OF THE NOSE AND NASO-PHARYNX. 97 PART II. REFLEX NASAL NEUROSES. The peculiar relationship above mentioned of sundry reflex and neurotic manifestations to the nose has been a subject of much discussion in the last decade. The frequent controversies in medical assemblies, and the numerous contributions to current literature, have made it a familiar topic, and the vast accumulation of clinical evidence in support of the connection has compelled recognition of the importance of the nose as a factor in the production of various sensory, motor, vaso-motor, and trophic neuroses. But, whilst this fact has been demonstrated beyond cavil, there is a bewildering haze enveloping much of the subject. Enthusiasm has carried some observers too far, whilst others in their extreme conservatism have taken alarm from this fact, and, shutting their eyes to the plainest kind of evidence, have denied the existence of nasal neuroses at all. The nasal mucosa is only one of many points of origin of reflex effects, and, like all other probably sensitive areas, its influence has been as much over-estimated as the application of the phrase “ reflex” hag been abused; as, for example, the frequent use of the latter to designate functional nervous actions which arise simultaneously with sensory phenomena without any demonstration of their connection with peripheral irritation. Physiology.—For the production of a reflex action we must have an afferent sensory nerve, an efferent motor nerve, and between the roots of these two a system of nerve cells and fibres, the “ reflex centre,” connecting them in the spinal cord. These are the three necessary elements of the “ reflex arc.” The “ reflex centre” is often a complicated structure, with paths of different “ resistance,” which determine the form and extent of the reflex action, according to the source and intensity of the sensory im- pression. Not only may the sensory impulse cause a motor process, but it may pass to the brain and affect consciousness as a sensation. These reflex centres, or ganglia, are also more or less under the control of the cerebral centres (Gowers).1 Now, as the afferent fibrilke of each sympathetic ganglion are in reflex relationship with the efferent vaso-motor nerves furnished by it to the arteries, the brain and spinal cord, through their connection with the gan- glion, are capable of transforming afferent sensory impulses into efferent vaso-motor impulses; and any impulse thus transmitted which could inter- fere with the nerve-control of the arteries of any special area would bring about vascular changes in the region to which they are distributed. The medulla oblongata is the vaso-motor centre which controls the innervation of the blood-vessels; it is also the co-ordinating centre of all 1 Diseases of the Nervous System, vol. i. p. 10. 98 NEUROSES OF THE NOSE AND NASO-PHARYNX. reflex action necessary to the maintenance of life; and these physiological functions can be disturbed by the irritation of any sensory nerve of the body. The juxtaposition of the medulla with the spinal cord and all the nerve-ramifications, not only to organs of special sense, but also to the locomotive and organic systems, shows how far-reaching could be the results of any disturbance of its physiological functions. It is only through the basal ganglia that the body has any direct nervous communication with the cerebrum and cerebellum, but there is some uncer- tainty about the exact mode of this communication. The correlation of the cranial nerves is not thoroughly understood ; but, as far as we can make out by investigation, the sympathetic nerve-centres seem to possess a corre- lating nerve-function between near and distant organs (Edward Woakes).1 For example, giddiness and tinnitus aurium from indigestion are held to be due to vascular disturbances in the labyrinth, caused by reflected irri- tation from the stomach to the otic ganglion (Woakes). Irritation of the larynx and cough from foreign bodies in the ear, and earache from ulcera- tion of the larynx, are supposed to be caused by sympathetic irritation through the same ganglion. Whilst this may be so, there is an element of uncertainty in these ex- planations, because of the different results from physiological experiment. Claude Bernard found that tearing away the spheno-palatine ganglion caused a serous flow like that accompanying coryza. He also found sensibility to persist in the nasal mucous membrane after section of the naso-palatine branches of this ganglion. Prevost found that extirpation of the ganglion was not followed by any alterations either in nutrition or in vascularization of the nasal mucous membrane, and that, as stated by Bernard, the sensibility remained intact. Aschenbrandt2 found that extirpation of the ganglion produced a congestive condition, whilst irritation caused turgescence of the inferior turbinate and the vessels of the septum became injected. There is at first hypersemia, followed by a mucous and muco-purulent discharge. Prevost found also that galvanization of the ganglion produced a flow of mucus from the same side. He, moreover, observed that irritation of the superior cervical ganglion produced no result whatever. This was con- firmed by Aschenbrandt, who discovered no change in the nasal mucous membrane even after extirpation of the cervical sympathetic. These experiments show that the trigeminus is the nerve controlling the secretion, and possibly the nutrition, of the nose, but do not demonstrate that its ganglia are centres of reflex action. Nothing has yet been adduced to support this view, except theoretic reasoning. It is through the tri- geminus, however, that we are to look for the production of the so-called nasal reflexes, both physiological and pathological. It is among the most 1 Correlating Function of the Sympathetic Ganglia, Transactions of the International Medical Congress, London, 1881. 2 Monatsscbrift fur Ohrenheilkunde, No. 3, 1885. NEUROSES OF THE NOSE AND NASO-PHAEYNX. 99 important of the cranial nerves, because of the large territory it innervates, of its numerous anastomoses with the sympathetic (the ophthalmic ganglion, Meckel’s ganglion, and the cavernous plexus), and of the spread of its roots to the bulbar spinal apparatus, where it is connected with all the nerves that have their origin in the medulla oblongata. Its rich ganglipnic connections, and the important functions over which the trigeminus presides, make it extremely probable that any irritation, whether local or reflected, of its terminal ends in the nasal mucous mem- brane, or elsewhere, can produce various phenomena not only in the parts directly under control of the nerve and its branches, but also in parts innervated by any of its ganglionic connections. The peculiar construction of the intra-nasal tissues makes them exceed- ingly sensitive to irritation, not only applied locally, but reflected to them from other parts. The presence of vascular tissue analogous to similar tissue in the genital organs, the erectile character of which was first noticed by Cruveilhier,1 and to which Professor Bigelow,2 of Boston, gave the name of “ turbinated corpora cavernosa,” explains its excessive irritability. Kohlrausch3 (1853), Zuekerkandl,4 E. Fraenkel,5 John N. Mackenzie,6 Isch-Wall,7 L. Arviset,8 Herzfeld,9 and others, by further investigation and description of this tissue, have added to our knowledge. With few excep- tions, most writers of this day admit its erectile nature. According to Zuekerkandl, it is not limited to the turbinated bodies, but is found in all parts of the nasal mucosa except the olfactory fissure. This intra-nasal tissue, being obliged to adapt itself to constantly-changing thermal and atmospheric conditions, is provided with a regulating mechanism to correlate and control the glandular and vascular supply by the trigeminus, and especially 'by the branches of the spheno-palatine ganglion. The sen- sitiveness of this tissue is proved by its resentment of the slightest irrita- tion, whether direct or indirect, manifested by the physiological movements produced by such irritation. The most common and best-known of these reflexes are sneezing and lachrymation. Direct irritation of the mucous membrane of the nose can usually produce lachrymation and sneezing, with congestion and swelling of the erectile tissues followed by secretion. Kratschmer10 has shown that temporary arrest of the heart’s beats can be caused by irritation of the nose. 1 Traite d’Anatomie Descriptive, 1845, t. iv. p. 55. 2 Boston Medical and Surgical Journal, April 29, 1875. 3 Archiv fur Anatomie, Physiologie, etc., 1853. 4 Wiener Medicinische Wochenschrift, No. 38, 1884. 5 Deutsche Medicinische Wochenschrift, No. 18, 1884. 6 Historical Notes on the Discovery of the Nasal Erectile Tissue, Boston Medical and Surgical Journal, January, 1885, and loc. cit. 7 Le Progres Medical, September, 1887. 8 These, Lyon, August, 1887. 9 Ziiricher Centralblatt, No. 20, September 15, 1890. 10 Sitzungsberichte d. Akademie der Wissenschaften, Wien, 1870. 100 NEUROSES OF THE NOSE AND NASO-PHARYNX. Lazarus1 has produced increased pressure in the bronchi in the same way. As the pressure did not increase after cutting the vagi, it could come only from decreasing the lumen of the bronchi. These reflexes can also be pro- duced indirectly, as, for example, sneezing follows irritation of the retina by a strong light. Such phenomena differ somewhat in different individuals, as I have found by experiment made upon myself and others. If I irritate my intra-nasal tissues it takes some time to produce any reflex whatever, but the first to be manifested is lachrymation on the side irritated, followed by evident swelling of the corpora cavernosa and by a serous exudation: cough I cannot produce at all. On the contrary, if I sit in a warm room with my back to an open door or window, I will begin to sneeze almost before I am aware of the draught of cooler air. I have observed the same effect in others, whilst in some, artificial irritation of the nose will cause sneezing immediately, and in nearly all such individuals continuance of the irritation will cause cough. Hence I conclude that the sensitive areas localized by John N. Mac- kenzie 2 in the domain of the nasal branches of the spheno-palatine ganglion do not invariably exist, but are peculiar to certain individuals only. L. Lichtwitz3 also located similar irritable zones in the nasal spaces, but his subjects were cases suffering from nervous disorders, such as hysteria, etc. This spheno-palatine ganglion, which gives off branches to the nasal mucosa, is in direct connection with the Gasserian ganglion at the sensory root of the trigeminus, which is connected with the carotid plexus of the superior cervical ganglion of the sympathetic, and with the pneumogastric, the fibres of which are distributed to the larynx, lungs, heart, oesophagus, stomach, and intestines. We have also the otic, the ophthalmic, the maxil- lary, and the superior and inferior dentals, all united in common through the sympathetic, giving a rich field of nervous net-work in any part of which the transmission of any irritation sufficient to disturb its normal physiological function could produce neurotic phenomena. The patholog- ical reflex manifestations that have been supposed to emanate from periph- eral irritation of the nasal branches of this complex nervous communication are almost legion. The first to which attention was particularly directed was asthma; and following this observation came many other clinical reports of different neuroses, apparently dependent upon nasal disorder, and cured by the treatment of the nasal affection. They comprise sensory, motor, vaso-motor, and trophic neuroses of various organs, as follows: Of the eye, conjunctivitis, keratitis, phlyctenular ophthalmia, chemosis, glaucoma, asthenopia, muscse volitantes, etc. Of the ear, tinnitus, pain, 1 Archiv fur Anatomie und Physiologie, Hefte 1 und 2, 1891. 2 On Nasal Cough and the Existence of a Sensitive Reflex Area in the Nose, American Journal of the Medical Sciences, July, 1893. 3 Revue Mensuelle de Laryngologie, etc., December, 1886. NEUROSES OF THE NOSE AND NASO-PHARYNX. 101 itching of the external meatus, snapping noises (Burnett), spasmodic action of the tensor tympani, etc. Of the nose, spasmodic sneezing, hypersesthesia, hydrorrhcea, perversion or depreciation of the olfactory sense, epistaxis, erythema, acne of nose, cough, etc. Of the pharynx, parsesthesia, sensation of foreign body, neuralgia, dysphagia, and paresis of palate muscles. Of the mouth, herpes, salivation, and toothache. Of the larynx, aphonia, cough, and laryngeal spasm (croup). Of the bronchi, asthma and bronchitis. Of the gastro-intestinal tract, irritation, dyspepsia, etc. Of the skin, erythema, acne, herpes, urticaria, erysipelas, oedema, localized perspiration, etc. Of the heart and circulation, cardialgia, palpitation, symptoms closely resem- bling angina, and exophthalmic goitre. Of the muscles, rheumatic pains, spasmodic twitchings, convulsive movements choreiform in character, etc. Of the brain and nervous system, hemicrania, migraine, neuralgias of the trigeminus, epileptiform seizures, etc., loss of memory, inability to fix the attention (aprosexia), melancholia, neurasthenia, etc. Whilst the above neurotic manifestations accompanying or dependent upon irritation of the nose and naso-pharynx have been reported by numerous authors as the result of their clinical observation, it must be said that the connection between the supposed cause and the apparent effect has not been satisfactorily demonstrated in many instances, and there is no doubt that the enthusiastic rhinologist has been frequently led into the error of confounding cause and effect because of the coincident appearance of the two affections in the same subject. Because a patient has pathologi- cal alterations in the nasal fossae and at the same time is a victim of some respiratory or other neurosis, it does not follow that one is a sequence of the other. It is quite common to find asthma, bronchitis, etc., clinically associated with intra-nasal changes, without being dependent upon the latter, even where there may be a positive nasal reflex, such as cough, already manifested. In the last year, such a case presented itself to me in the person of one of my colleagues, who had had for some time a cough evidently due to some pathological condition in the nose, and which was much improved by the treatment of the latter. The subsequent advent of asthmatic attacks he was disposed to attribute to the same cause, because of the presence of an abnormality of the septum, with some turgescence of the turbinates in the left nostril; and, although he wished me to operate, I declined, on the ground that the asthma was due to other causes than nasal irritation, and the further developments in the case justified me in this conclusion. Historical Notice.—To Voltolini may justly be attributed the credit of awakening modern attention to the subject of nasal reflex neuroses, by his article “ Ueber die Anwendung der Galvano-Kaustik” (Wien, 1871), demonstrating that asthma often resulted from, and was cured by the re- moval of, nasal polyps. But the fact that respiratory and other neuroses were sometimes of nasal origin was known long before this accomplished rhinologist gave his clinical experience to the world. 102 NEUROSES OF THE NOSE AND NASO-PHARYNX. John N. Mackenzie1 has shown that this relationship was recognized almost from the earliest ages of medicine. His paper is sufficiently inter- esting to be quoted in full, if space permitted; but only a brief synopsis can be here presented. He has, with considerable labor and research, found references to the interdependence of the nose and various neuroses, such as asthma, syncope, epilepsy, periodic coryza, affections of the eye, ear, stomach, and skin, hoarseness, headache, vertigo, troubles of the sexual apparatus, etc., in the works of many authors in different ages. In the writings of Plato, Hippocrates, Aristotle, and Galen he has pointed out passages indicating at least a suspicion of the connection between the nose and certain neurotic phenomena. Many refer to the association of coryza with sneezing, migraine, asthma, etc. Ferber advanced the theory that these phenomena were the expres- sion of a neurosis of the trigeminus,—a view advocated by more recent writers. The possibility of some connection between irritation of the nose, or sneezing, and epileptiform seizures seems to have been considered for ages, as is gleaned from the writings of Aretseus, Pliny, Avicenna, Fernelius, Salmuth (1648), Van Helmont (1682), and others. Fernelius (1668) also speaks of hemicrania in connection with catarrh, and of a relation between suppression of urine and nasal catarrh. Van Helmont, as already stated, refers especially to the effects of odors in the production not only of epilepsy, but also of sneezing, vertigo, headache, cough, asthma, palpitation, and fainting. Johann Jacob Wepfer, in a work published in 1728, distinctly enunciates the relationship of hemicrania and other pathological phenomena to nasal inflammation and obstruction, and concludes that these neuroses are due to a turgescence of the myriad vessels of the spongy bodies (corpora spongiosa). Robert Whyte, in his work on nervous diseases, refers to fits being caused by the smell of musk, ambergris, etc. He also in this book (a fact over- looked by Mackenzie in his article) refers to the relationship of the nose and cough, and advises the inhalation through the nose of Hungary water and other volatile agents to check cough. The relationship of the stomach and coryza was discussed by Schroeder and May. Many of the older writers treat of the effects of odors, etc., on the nose in producing syncope, hemicrania, etc. Bartholini (1761), Gruner (1801), and others refer to the sympathy between the nose and the sexual organs. Deschamps ascribed hemicrania to disease of the frontal sinus, and Portal reported cases of pain, vertigo, and epileptiform convulsions in con- nection with diseases of the nasal membranes. These references to the nasal reflex show that the nose was recognized as a ready focus of peripheral irritation from which neurotic phenomena 1 The Pathological Nasal Reflex: a Historical Study, New York Medical Journal, August 20, 1887. NEUROSES OF THE NOSE AND NASO-PHARYNX. 103 could emanate long before Voltolini’s observations gave a positive and definite aspect to the question by the cure of his cases by intra-nasal treatment alone. His results were soon confirmed by a host of articles from different authors. Whilst most authors have dealt especially with the production of asthma by intra-nasal changes, some have called attention to other reflexes from the same causation. Fraenkel speaks of cough from nasal disease, Lowe, of epilepsy due to nasal irritation, Hartmann, of supra-orbital neuralgia, and Seiler, of conjunctivitis, as reflexes from the nose. Seiler1 also reports two cases of cough of similar origin. The paper of Dalv, of Pittsburg, on “ Hay-Fever and Nasal Catarrh,” presented to the American Laryngological Society in 1881 and published in the Archives of Laryngology in 1882, was a most valuable contribution to this subject, inasmuch as its author called the attention of the profession for the first time to the importance of intra-nasal irritation as a factor in the production of hay-fever. Of all publications on this subject Hack’s2 article and his subsequent publications attracted most wide-spread attention, because they were more general and more comprehensive in dealing with nasal reflexes. He reported cases of spasmodic sneezing, asthma, cough, supra-orbital and ciliary neuralgia, cephalalgia, pain and swelling of the eyelids, muse® volitantes, glottic spasm, and epilepsy, which he asserted, after the most careful clinical investigation, were due to pathological changes in the nasal tissues, and were cured by the destruction of the nasal irritability with the galvano-cautery. In this and subsequent articles3 he enunciated his theory of nasal re- flexes, which in the main was as follows, although he subsequently modified his views in some particulars : Following; irritations of the nasal mucous membrane from whatever © cause (whether extra-nasal, from atmospheric or thermal influences, or irritation of nerves of special sense, or of the skin; or intra-nasal, from polyps, spurs of the septum, adhesions, etc.), the erectile bodies become engorged, especially the anterior portion of the inferior turbinate. The resulting tension of the mucous membrane covering the cavernous bodies causes irritability of the sensitive nerve filaments of the mucosa, thus starting the train of reflex phenomena. He asserted that turgescence of the turbinates was the essential connect- ing link between the nasal irritation and the reflex manifestations, and 1 Archives of Laryngology, 1882. 2 Berliner Klinische Wochenschrift, xix., 1882. 3 Ueber die Entstehung von exudativen sogenannten rheumatischen Processen voe dor Nasenschleimhaut aus, Fortschritte der Medicin, No. 20, 1883; Ueber Reflex Neurosen die von der Nase ausgehen, Tageblatt der Versammlung Deutscher Naturforscher und Aerzte, Magdeburg, 1884; Ueber eine operative radical Behandlung bestimmter Formen von Migraine, Asthma, Heufieber, etc., Wiesbaden, 1884; and Erfahrungen auf dem Gebiete der Nasenkrankheiten, Wiesbaden, 1884. 104 NEUROSES OF THE NOSE AND NASO-PHARYNX. that, as inflammatory action interfered with engorgement of the cavernous tissue, the production of reflexes was in inverse ratio to the extent of the inflammation. The causes of this turgescence in the mucosa itself are due to reflex influences more or less distant. Hack’s are among the most valu- able articles in the literature of the nasal reflex, and his work gave a great incentive to the close study of the subject. In 1883 and 1884, in addition to Hack’s contributions, articles appeared from Elsberg 1 and others. Among these writers, whilst the majority agreed with Hack that the pathological condition of the intra-nasal tissues was the essential factor in the etiology of nasal reflexes, and that any accompanying neurasthenia was secondary to the nasal affection, there were some points of difference from his views. The investigation of E. Fraenkel seemed to prove that the turbinated hypertrophy was the result of a chronic inflammatory process (chronic rhinitis) which caused thickening of the mucosa over the turbinates, thus controverting Hack’s proposition above referred to in regard to inflammation. According to Fraenkel, Schnitzler, Schaeffer, and others, this chronic rhinitis was the starting-point of the nasal alterations which brought about reflexes. John N. Mackenzie, however, radically differed from these authors. His paper on nasal cough is an original production in its attempt to locate a special sensitive area in the nose, the artificial irritation of which could produce sneezing, lachrymation, cough, etc., this zone being more particularly confined to the middle turbinate and posterior portion of the inferior turbinate, and the septum opposite the part dominated by the spheno-palatine branches of the superior maxillary nerve. Mackenzie’s conclusions in regard to the reflex area were endorsed by Roe, Longuet,2 and others. Hack, on the contrary, in his earlier writings was inclined to limit the irritable zone to the anterior portion of the inferior turbinate, and thought that reflexes arising from stimulation of other portions of the nostril occurred secondarily through congestion of the erectile tissue of this locality. But, whilst Hack held that the point of greatest excitability was the terminal filaments of the nerves of the nasal mucosa, Mackenzie, in his scholarly article on “Coryza Vaso-Motoria Periodica,”3 and in subsequent publications,4 took the ground that reflexes arising from the irritation of this sensitive area (asthma, cough, etc.) are due to a certain excitability of the reflex or vaso-motor centres, but that such reflex phenomena cannot take place without engorgement of the turbinated tissue, the mainspring of the machinery that puts the pathological process in motion. The repeated irritation of the nasal erectile tissue, either from extraneous 1 Reflex and other Phenomena due to Nasal Disease, Archives of Laryngology, 1883. 2 L’Union Medieale, January, 1884. 3 American Journal of the Medical Sciences, July, 1884. 4 Rhinitis Sympathetica, Maryland Medical Journal, April 11, 1885. NEUROSES OF THE NOSE AND NASO PHARYNX. 105 influences or from internal causes, by keeping up constant vascular disturb- ances, can result in a hypersesthetic condition of the nerve-centres which will express itself in a paroxysm, the constant excitation of the centres by the peripheral irritation having so altered their reflex excitability that they respond more readily to reflex-producing impressions. This derange- ment of the nervous apparatus may also be due to inherited diatheses, such as gout, rheumatism, scrofula, herpes, etc., or to any general faulty condi- tion of the system, or to reflected irritation from other parts of the body, as from the gastro-intestinal or the genito-urinary organs. In individuals thus affected, whose nerve-centres are in a state of abnormal excitability, any increase of peripheral irritation would cause an explosion of some neurotic manifestation, and the respiratory tract, being more exposed to external influences than any other part of the economy, would naturally be more subject to vascular disturbances that could be the starting-point of such neuroses. For elaboration of Mackenzie’s views the reader is referred to his articles mentioned in this notice, as they are among the most valuable contributions to this subject. In my address1 before the American Medical Association, May, 1885, I took the ground that Mackenzie’s views in this particular were correct, for, as he says, “ it is a more comprehensive explanation of the varied phases assumed by these reflexes, to suppose a disordered functional condition of the nerve-centres as against organic alterations of the peripheral sensitive nerves, for upon this theory can be explained the occurrence of similar neuroses from irritation reflected from various parts of the body remote from the nasal passages.” But I was Inclined to differ from Mackenzie in the limitation of the reflex-producing power of the nasal mucosa to any special area, as from clinical experience I was familiar with reflex manifes- tations without engorgement or hypertrophy of the erectile tissue,—e.g., reflex cough accompanying atrophic rhinitis. Hopmann2 has reported a case of asthma, and Bosworth3 one of glottic spasm, as reflexes from the nose in the same disease. Subsequently Bara- toux4 and Heryng5 asserted that the special sensitive part of the nasal fossse was the septum, and that reflexes arose from irritation of the latter by the swollen nasal tissues, or any other cause that could stimulate the mucosa over the septum. B. Fraenkel,6 Schaeffer,7 Hopmann,8 Schmaltz,9 and 1 Journal of the American Medical Association, June 21, 1885. 2 Fifty-Seventh Reunion of German Naturalists and Physicians, 1884. 3 Archives of Laryngology, vol. iv. p. 289. 4 Revue Mensuelle de Laryngologie, etc., December, 1885. 5 Annales des Maladies de l’Oreille, du Larynx, etc., February and March, 1886. 6 Congres International, Copenhagen, 1884. 7 Chirurgische Erfahrungen in der Rhinologie, Wiesbaden, 1885. 8 Fifty-Eighth Reunion of German Naturalists and Physicians, September, 1885. 9 Berliner Klinische Wochenschrift, Nos. 29 and 32, 1885. 106 NEUROSES OF THE NOSE AND NASO-PHARYNX. others denied the necessity of engorgement of the turbinated tissues in the production of reflexes. Tornwaldt and others have shown that various reflexes, such as cough, headache, asthma, tinnitus aurium, etc., are produced by the presence of adenoid tissue at the vault of the pharynx and cured by its removal. From these opinions it would seem that all parts of the nasal mucosa are capable under certain conditions of exciting reflex neuroses, as main- tained by Roth.1 Accompanying or following the able contributions of Hack and Mackenzie on this subject were a host of publications from different authors who agree with these writers on some points and differ on others. Fraenkel,2 Schaeffer,3 Roth,4 Schmaltz,5 Schech,6 Boecker,7 Cartaz,8 and Ruault9 agree that reflex neuroses are due to a state of exci- tability of the sensitive fibres of the nasal mucosa, and that they can arise from any part of it without the intervention of turbinated engorgement. Rossbach,10 Lublinski,11 Heymann,12 and others consider a neurotic pre- disposition a sine qua non for the production of a reflex phenomenon by nasal irritation. Schreiber13 does not believe in nasal reflexes. He considers the turbi- nated engorgement accompanying certain neuroses as an accidental compli- cation, or a vaso-motor trouble due to the neurosis itself, and the favorable effects of cauterization as a piece of luck or an effect due to the revulsive action of the cautery. This view was held by Gottstein14 and a few others. These different views in regard to nasal reflex neuroses will be discussed when the etiology is considered. Classification.—It is a difficult matter to make a satisfactory classifica- tion of reflex nasal neuroses, because many of them are of a complex char- acter ; but the least unsatisfactory is probably a division into sensory, motor, vaso-motor, and trophic neuroses. For convenience we may also separate them into neuroses of the respiratory tract, and neuroses affecting other parts of the body. RESPIRATORY NEUROSES. We will deal first with neuroses of the respiratory tract, such as hyper- sesthesia, sneezing, cough, larvngo-spasm, aphonia, asthma, etc., or reflex 1 Wiener Medicinische Wochenschrift, Nos. 16 and 17, 1885. 2 Loc. cit. 3 Loc. cit. 4 Centrsilblatt fur die Gesammte Therapie, No. 21, 1887. 5 Loc. cit. 6 Die Krankheiten der Mundhohle, des Rachens und der Nase, 2d ed., Wien, 1888. 7 Deutsche Medicinische Wochenschrift, Nos. 26 and 27, 1886. 8 La France Medicate, Nos. 89 and 90, 1885. 9 Gazette des Hopitaux, December, 1887. 10 Die Nase in ihren Beziehungen zum iibrigen Korper, Jena, 1885. 11 Deutsche Medicinische Zeitung, No. 41, 1886. 12 Ibid., No. 66, 1886. 13 Berliner Klinische Wochenschrift, No. 33, 1885. 14 International Congress, Copenhagen, 1884. NEUROSES OF THE NOSE AND NASO-PHARYNX. 107 manifestations in the nose, naso-pliarynx, pharynx and mouth, larynx and bronehial tubes. Some authors, notably J. N. Maekenzie,1 divide these also into physio- logical and pathological reflexes. Under the former heading are comprised sudden and temporary engorgement of the nasal tissues, sneezing, increased secretion from the nose, lachrymation, and cough. Through any irritation of the nose by artificial means, or by dust or by sudden chilling of the surface, these reflexes can be developed in many, if not all, individuals. Even if they can be produced by artificial means, such as irritation with a probe, etc., I do not think they can all, particularly cough, be de- nominated physiological reflexes, because any prolonged irritation in the nasal passages by a probe or other artificial means will, if continued long enough, bring about a pathological condition of the intra-nasal circulation that would result in irritability of the nerve-filaments, just as would the presence of a foreign body or a chronic inflammation. If all these reflexes are produced very readily in some individuals and only after a considerable effort in others, it probably shows that the former class possess an irritable nose, ready to resent any unaccustomed inter- ference, and is in many cases an evidence of neurotic habit. This same reasoning holds good with the pharynx. Every one who is accustomed to examine the throat knows that in a healthy pharynx there is no trouble in using the tongue-depressor in the mouth or touching the pharynx with a probe. But frequently when the latter is pathologically altered a tongue-depressor will cause gagging, and the contact of a probe or foreign body in the throat, cough and retching. This is known as “ irritable throat,” and is hardly a physiological condition. Persons with special irritability of the nasal tissues are prone to functional disturbances, such as sneezing, swelling, secretion, etc., or the so-called physiological reflexes, which are also at times symptoms of a pathological state known as hypercesthesia. HYPERESTHESIA. If they are purely physiological, why is it that persons with the same condition of the nasal tissues, exposed to the same surroundings and the same presumable irritation, do not manifest the same phenomena ? I think the explanation lies in the difference in their nervous organization, a func- tional disturbance of the nerve-centres being present in some cases and not in others. A hyperaesthetic condition of the nasal mucous membrane can result from any irritation due to catarrhal inflammation or other local pathological alteration, or from central causes, or may be reflected irrita- tion from distant organs, as from troubles of the eye, the ear, or the respi- ratory, digestive, or genital apparatus. In mild cases there is a tendency to temporary obstruction of one or both nostrils from vaso-motor disturbances, 1 Reference Hand-Book of the Medical Sciences, vol. v. p. 222, 1887. 108 NEUROSES OF THE NOSE AND NASO-PHARYNX. especially when lying down. The nostrils on the side lain on will become somewhat stuffy, and if the patient turns over that side becomes clear and the other side obstructed. It is easy in such cases artificially to produce sneezing, flow of serum from the nose, and even cough. This tendency to vaso-motor alteration in the nose, sometimes attended by other symptoms of hypersesthesia, such as sneezing, etc., frequently accompanies the general nervous disturbances caused by the function of menstruation, and although occurring during a physiological epoch it is not necessarily a physiological phenomenon. It is more likely analogous to nervous coryza (Peyer),1 or to sympathetic rhinitis, so ably portrayed by John N. Mackenzie,2 the hypersesthesia of the nasal erectile tissue partici- pating in and sympathizing with the disturbances of the corresponding tissue in the sexual apparatus. Sneezing, which is the most common of nasal reflexes, is a symptom of hypersesthesia. The literature of nasal reflexes is filled with reports of cases of what may be called paroxysmal or spasmodic sneezing accompanying intra-nasal alterations, by Mackenzie,3 Hack,4 Sommerbrodt,5 Schmiegelow,6 Sidney Ringer, W. Murrell,7 and others. But paroxysms of sneezing so long continued or of such frequent occurrence as to endanger life, or similar paroxysms of constant repetition without any pathological alterations of the nasal fossa, are not common. Cartaz8 reports several cases of sneezing with sense of suffocation without any perceptible alteration of the nasal mucous membrane; Ch. Fer6,9 one case with constant paroxysms, sneezing thirty to forty times a minute, which he ascribed to hysteria; Bobone,10 a ease of a girl eight years old, recovering from some skin-trouble, who was seized with violent sneezing which at each attack continued until syncope resulted (in this case there was a swelling of the inferior turbinates, and flow of serum from the nose); Munk,11 a case cured by cocaine ; J. Solis Cohen,12 one case who suffered from uncontrollable attacks of sneezing with dyspnoea at any time of the year, the nasal spaces being perfectly normal (the attacks were accompanied by sensations of tickling in the nose, burning in the eyes, lachrymation, and STERNUTATION. 1 Loc. cit., also Munchener Medicinische Wochenschrift, Nos. 3 and 4, 1889. 2 Maryland Medical Journal, April 11, 1885. 3 Loc. cit. 4 Loc. cit. 5 Berliner Klinische Wochenschrift, Nos. 10 and 11, 1885. 6 Hospitals Tidende, March, 1885. 7 Remarks on Paroxysmal Sneezing, British Medical Journal, June, 1888. 8 La France Medicale, August, 1885. 9 Le Progres Medical, January, 1885. 10 Bollettino delle Malattie dell’ Orecchio, della Gola, etc., Anno IV., No. 4, p. 76. 11 Wiener Mediciuische Presse, No. 51, 1886. 12 A Case of Hysterical Sneezing, New York Medical Journal, January, 1887. NEUROSES OF THE NOSE AND NASO-PHARYNX. 109 flow of serum from the nose); Robert J. Lee,1 a singular case of sneezing and yawning caused by the drawing of a tooth; Fenykovy,2 a case of a girl twenty-two years old who had for seven years had violent attacks of sneezing every day, and who had perfectly normal nasal fossae and no other nervous manifestations; De Rechter,3 a case who sneezed thirty to forty times a minute repeated during days (there was pain on pressure over the left ovary); Rauge,4 four cases with itching, tickling, pain, etc., without any deviation from the normal conditions of the skin or nasal mucosa. Trifilletti5 and others have made similar observations. The cases here recorded as nasal reflexes without pathological alterations of the intra-nasal tissues are examples of hypersesthesia of the nose due to irritation trans- mitted to the sensory and trophic nasal nerves from other parts of the organism, more or less distant, and are evidences of a neurotic disposition, with impaired vitality of the central nervous system. In my own experience I have met eases who complained of attacks of sneezing coming on suddenly at any time, followed by pain in the bridge of the nose and over the eye, which they described as similar to the pain brought on by eating ice-cream too rapidly. Sometimes these attacks are preceded by a stuffy feeling about the nose, and end in a discharge of watery fluid; but these symptoms are not constant. In these eases a careful examination of the nose anteriorly or in the post-nasal space revealed no abnormality, not even engorgement. The attacks seem to come on without any apparent cause, and I have supposed the explanation to be in a highly irritable condition of the nasal mucosa, rendering it liable to resent the contact of the slightest dust or other atmospheric particles, and in a cor- responding irritability of the vaso-motor centres from lowered vitality. Where such conditions for the production of reflexes exist, the irritation may be transmitted from distant organs, as in Romberg’s6 case of sneezing during coitus. Hydrorrhceci, or a discharge of watery fluid from the nose, has been reported as secretory neurosis of the nose. Dr. Bos worth in his able work on Diseases of the Nose and Throat7 has collected eighteen cases of this trouble, and the reader is referred to them for the history, etc. When John N. Mackenzie8 published his paper on nasal cough in 1883, and directed attention to the great frequency of cough as a reflex from the COUGH. 1 Medical Press and Circular, January, 1888. 2 Coryza Spasmodica, Internationale Klinische Rundschau, No. 47, 1889. 3 Journal de Medecine, de Chirurgie et de Pharmacie, No. 4, 1889. 4 Lyon Medical, March, 1890. 5 Archivij Italiani di Laringologia, April, 1890. 6 Diseases of the Nervous System, Sydenham Society Transactions. 7 Vol. i., The Nose and Naso-Pharynx, p. 258. 8 American Journal of the Medical Sciences, July, 1883. 110 NEUROSES OF THE NOSE AND NASO PHARYNX. nose, which could be relieved by the treatment of the nasal affection, he marked a new era in the etiology of reflex or nervous cough. For, although others before him had recognized the connection between nasal diseases and cough, its importance had not received the consideration it merited. The mental anxiety caused by chronic cough to the sufferer and his friends, because of its possible significance in relation to pulmonary disease, makes it a subject of grave interest, and any elucidation of its etiology is an advance in regard to its treatment. Much has been written about hysterical, nervous, and convulsive cough. It has been traced to irritation of the intestinal tract, as from worms (R. J. Graves);1 to diseases of the genital apparatus, the so-called uterine cough (Paul Muller) ;2 to irritation of the ear from impaction of wax and other foreign bodies,—ear-cough; to irritation of the larynx; and to constitu- tional conditions, such as lithsemia (Whitehall Hinkel),3 etc.; but the most frequent cause of reflex cough is some pathological change in the naso- bronchial mucosa. This connection was referred to by Herard4 (quoted by Trousseau), who reported a case of hysterical cough which alternated with irregular spasms of sneezing; by Lasegue,5 whose case had constant cough accompanying a simple coryza, which disappeared with the cure of the cold; and by others without any comment on the causation. Hack6 reported a case of spasmodic cough caused by nasal polyp, and Seiler7 two cases dependent upon nasal disease, and cured by the treatment of the latter; but Mackenzie was the first to demonstrate the fact that cough was frequently dependent upon intra-nasal disease, and could be produced by artificial irritation, even when there was no apparent pathological alteration in the nasal tissues. As already stated, he was of the opinion that this result was due to the existence of specially sensitive areas in the nose (cough area), in the parts dominated by the nerve-filaments from the spheno-palatine ganglion, and that the physiological explanation of the phenomenon was found in the doctrine of correlated areas (Woakes),8 the reflex taking place through the vaso-dilator nerves from the superior cervical ganglion of the sympathetic. Longuet,9 Cresswell Baber,10 Schmaltz,11 Sommerbrodt,'2 Ensing,13 Schmiege- 1 Lessons of Clinical Medicine, 2d ed., London, 1863. 2 De la Toux Uterine, These, Paris, July, 1887. 3 Some Manifestations of Lithaemia in the Upper Air-Passages, Transactions of the American Laryngological Society, 1889. 4 L’Union Medicale, 1864 5 Memoire sur la Toux Hysterique, Archives Generales de Medecine, 1864. 6 Berliner Klinische Wochenschrift, No. 25, 1882. 7 Archives of Laryngology, etc., vol. iii. p. 240, 1882. 8 Loc. cit., and Diseases, Giddiness, and Noises in the Head, London, 1880. 9 L’Union Medicale, January, 1884. 10 British Medical Journal, November, 1884. 11 Loc. cit. 12 Berliner Klinische Wochenschrift, 1884. 13 Weekblad van het Nederlands. Tijdschrift voor Geneeskunde, No. 22, 1885. NEUROSES OF THE NOSE AND NASO-PHAEYNX. 111 low, Rethi,1 Cartaz,2 Wille,3 Schadewaldt,4 Heryng,5 Schech,6 Scheinmann,7 Tornwaldt,8 Lublinski, Lichtwitz,9 Schadle,10 and others reported cases of cough due to and cured by treatment of nasal diseases. Wille and Schadewaldt consider the cough a modification of the so-called physiological nasal reflex sneezing. According to them, the physiological reaction of the nasal mucosa from irritation is swelling, sneezing, secretion. In the patho- logical condition the swelling alone shows itself, there is coryza without sneezing, and the cough takes the place of the latter. It is frequently of extreme violence, resembling at times whooping-cough, and is due to irritation of the terminal filaments of the trigeminus. Nasal cough can be caused by simple coryza, hypertrophic rhinitis, spurs and deflection of the septum, polyps, hypertrophy of the cavernous tissue over the vomer, adenoid growths at the vault of the pharynx, etc. In my own experience I have seen a large number of cases of nasal cough, caused by almost every pathological condition in the nasal spaces that could cause a local irritation, although hypertrophy of the middle turbinate seems the most constant change and corresponds with the results of the investigation of Francis Franke.11 Simple vaso-motor changes in the nose also produce it. Whether the irritation is transmitted to the pneumogas- tric through its sympathetic ganglionic connections, or by the trigeminus through the basal ganglia (the bulbar theory of reflex production), is a matter for future investigation when we know more of the cranial and the sympathetic nerves. But the fact that cough is often thus reflexly pro- duced is of great clinical value in diagnosis. Its constant occurrence in the early stages of pulmonary disease makes it all-important that the physician should examine into the possibility of its being of reflex origin, and especially as emanating from the pharyngo- nasal spaces. I have seen cases whose life was a burden to them because of a cough which was supposed to be the advance-guard of phthisis, who were dragged from their homes every winter to Florida, Colorado, and other resorts for the phthisically disposed, who had to sacrifice home comforts, 1 Wiener Medicinische Presse, Nos. 37, 38, and 39, 1886. 2 Loc. cit. 3 Der Trigeminushusten, Deutsche Medicinische Wochenschrift, Nos. 16 and 17, 1885. 4 Die Trigeminus-Neurosen, Deutsche Medicinische Wochenschrift, Nos. 37 and 38, 1885. 5 Loc. cit. 6 Loc. cit. T Berliner Klinische Wochenschrift, Nos. 14, 15, 19, and 21, 1889. 8 Ueber die Bedeutung der Bursa pharyngea fur die Erkennung und Behandlung gewisser Nasenraehenraum-Krankheiten, Wiesbaden, 1885. 9 Neuroses d’Origine nasale et pharyngee, Annales des Maladies de l’Oreille, du Larynx, etc., December, 1889. 10 Cough in its Relations to Morbid States of the Nasal Passages, Journal of the Ameri- can Medical Association, March 1, 1890. 11 Archives de Physiologie, July, 1889. 112 NEUROSES OF THE NOSE AND NASO-PHARYNX. business, and everything else that makes life pleasant, to keep from dying, when the trouble was a simple reflex one. I have cases of this kind on my record-book, who were brought to me to see if the larynx was showing any signs of phthisis, and in whom an examination of the nose revealed the origin of the trouble. Sometimes a cough of years’ standing has been cured in a few days or weeks by the appropriate treatment of the nasal disease. In the last few months I have seen a lady who has had an annoying cough for three years, causing her great anxiety and alarming her family. In one wreek this three years’ cough was cured by the nasal treatment; and this is only one of many such. I doubt if to-day the importance of the relation is appreciated by most practitioners of medicine. Important as it is, it is only one of many causes, outside of pulmonary diseases, that can produce cough. But it is a frequent cause, and should not be overlooked in the elucidation of seemingly so grave a trouble and one so harassing to the sufferer. Every physician when a cough has proved intractable to ordinary treat- ment and he is satisfied that there is no pulmonary lesion, as far as the means of diagnosis enable him to determine, should examine the nasal spaces. If any pathological condition exists, if the intra-nasal tissues are irritable, there is a probability that the cough is of nasal origin. Sometimes the local application of a solution of cocaine will temporarily ameliorate the attack of coughing. Sometimes cough can be produced by artificial irritation of the intra-nasal tissues. In either case the diagnosis of “ nasal reflex cough” would be demonstrated. But even if the cocaine test fails, even if the cough cannot be produced by artificial irritation, it does not follow that it is independent of an existing pathological condition of the nose. I have seen cases where both these tests failed and yet the cough dis- appeared with the restoration of the normal symmetry of the nasal spaces. But the treatment should be directed not only to the local nasal trouble, but also to the improvement of the general nervous system (as well as other reflex phenomena), as without some functional alterations of the nerve-centres, whether of the sympathetic or of the basal ganglia, there could be no manifestation of reflex phenomena. PHARYNX AND MOUTH. Keflex effects of intra-nasal disease in the pharynx and mouth, reported by some writers, are hyperesthesia, paresthesia or imaginary foreign body, neuralgia, paresis of the palate, dysphagia, hiccough, salivation, etc. Pain in the pharynx and sensation of foreign body have been mentioned in several of the publications referred to in this article. Woakes1 endeavors to explain the paresis of the palate-muscles, so often 1 Nasal Polypus, etc., Philadelphia, 1887. NEUROSES OF THE NOSE AND NASO-PHARYNX. 113 associated with nasal catarrh, by vaso-motor paresis. He also suggests the same causation for what he calls paretic dysphagia. Schech1 and Seifert2 each report a case of spasmodic contraction of the palate, the faucial muscles also being involved in Seifert’s case, both caused by nasal disease. Seifert’s patient was cured by the treatment, Schech’s was not. CEsophagismus, another form of dysphagia, is reported by Netchaieff,3 by Joal,4 and by others. Joal observed nine cases cured bv treatment of the nasal affection. It is also reflexly produced by enlarged tonsils, bv dental caries, and by hypertrophy of the lingual tonsil. Hiccough of violent and distressing character has been reported as due to nasal disease by Abramson5 and others. Salivation has been reported as a nasal reflex neurosis by E. Fraenkel,6 Seifert,7 Bosworth,8 Peyer,9 Thrasher,10 and others. These cases are said to have been cured by the nasal treatment. The only manifestation I have seen of this affection is in a young lady who also suffers from asthma. In both affections, supposed to be dependent upon nasal disease (chronic rhinitis and adenoids), no benefit has been derived from any treat- ment. She has also consulted Dr. John N. Mackenzie, Dr. J. Solis Cohen, and others, and although every suggested method of treatment, local and general, has been carried out, both the salivation and the asthma continue to annoy her. Whilst the above-recorded observations of neuroses of the pharynx and mouth supposed to emanate from intra-nasal irritation can hardly be denominated respiratory neuroses, they are introduced here because the pharynx is an important part of the air-tract and is often secondarily the starting-point of respiratory vaso-motor disturbances. Cough and other reflex phenomena are often directly traceable to a diseased condition of the pharynx and mouth as well as the larynx, but in nearly every such case it will be found that there coexists more or less analogous trouble of the nasal cavities, which in all probability preceded it. This is especially true in the hyperesthesia accompanying simple congestive conditions of the pharynx and larynx in which there is excessive irritability, exhibited by a disposition to retch, cough, etc., from the slightest cause, by hoarseness from use of the voice, and sometimes by spasmodic contractions of the muscles of the pharynx and larynx, as mentioned above and in the following pages. 1 Klonische Krampfe des weichen Gaumens mit objectivem Ohr-Gerausch in Folge von nasaler Trigeminus-Neuralgie, Miinchener Medicinische Wochenschrift, No. 22, 1886. 2 Internationale Klinische Rundschau, No. 19, 1887. 3 Meditzinskoie Obozrenic, Nos. 9 and 10, 1888. 4 Congres Laryngologique Franqais, 1889. 5 Journal of Laryngology, No. 5, 1890. 8 Loc. cit. 7 Internationale Klinische Rundschau, No. 19, 1887. 8 Diseases of the Nose and Throat, New YQrk, 1889, p. 189. 9 Miinchener Medicinische Wochenschrift, Nos. 3 and 4, 1889. 10 Cincinnati Lancet Clinic, October 25, 1890. 114 NEUROSES OF THE NOSE AND NASO-PHARYNX. The vascular alterations in the mucous lining of the pharynx and larynx underlying these neurotic manifestations can be continuous with vaso-motor changes in the nasal spaces or reflexly dependent upon intra- nasal irritation. LARYNX. Aphonia dependent upon lesions of the nasal spaces is recorded by Brebion,1 Heryng,2 Baratoux,3 Max Schaeffer,4 A. Predborski,5 and others, and has been cured by the treatment of the nasal trouble. Hysterical aphonia is a well-known and troublesome affection to laryngologists, and its cure by psychical influences when local treatment of the larynx has failed has been often observed. Whether the cauterization of the nasal tissues effected a cure in this way by the revulsive action cannot be determined, as the-reports of such cases are rare, and the clinical data unsatisfactory. Laryngismus Stridulus.—The connection of glottic spasm and spasmodic croup with nasal and naso-pharyngeal diseases has been mentioned by Hack,6 Elsberg,7 and others. The amount of clinical testimony to the dependency of glottic spasm and spasmodic croup upon pathological altera- tions of the nose and naso-pharynx leaves no doubt about the relationship, and its importance cannot be overestimated. Coupard states that in fifty- six cases of adenoids forty-five had croup. Lennox Browne seems inclined to think that adenoids are almost in- variably present in spasmodic croup, and that their removal will result in a cure. I have found adenoids or other obstructive lesions of the nose in almost every case of laryngeal spasm I have seen. Enlarged tonsils will also produce the same effect. That neither adenoids nor any other obstructive lesions are necessarily present, but that it can be of a purely reflex character from intra-nasal irritation, a recent case in my experience proves. A boy six years of age who had been subject to croup was brought to me for treatment of enlarged tonsils and adenoids. The tonsils were shrunken by galvano-cautery appli- cations, and the adenoids were removed by the forceps. I had made a careful examination at his final visit, and after removing a small remnant of adenoid tissue I dismissed him from treatment. The use of the forceps caused some discomfort and irritation, followed by headache during the afternoon. The same night he had one of the most terrifying attacks of 1 Revue Mensuelle de Laryngologie, etc., December, 1885. 2 Annales des Maladies de 1’Oreille, etc., March, 1886. 3 Ibid. 4 Monatsschrift fur Ohrenheilkunde, No. 11, 1886. 5 Gazeta Lekarska, No. 30, 1886; Internationales Centralblatt fur Laryngologie, etc., vol. iii p. 394. 6 Loc. cit. 7 Reflex and other Phenomena due to Nasal Disease, Archives of Laryngology, 1883. NEUROSES OF THE NOSE AND NASO-PHARYNX. 115 croup in his experience, which I relieved, when I reached the house, by an application of a cocaine solution to the naso-pharynx. Since then he has had no recurrence of croup. ASTHMA. Bronchial Tubes.—That asthma was associated with intra-nasal disease was known long before Voltolini1 called attention to its connection with nasal polypi, but he was the first to cure his patient by the intra-nasal treatment. John N. Mackenzie2 has shown the early recognition of this relationship. Trousseau3 speaks of its frequently commencing with symp- toms of coryza, sneezing, discharge from the nose, etc. Ducros (quoted by Trousseau) thought asthma emanated from the pharynx, which he con- sidered the starting-point of all nervous manifestations, and he treated it by applications of liquid ammonia to the throat. Biermer4 considers the nasal fossae a frequent centre of irritation in reflex asthma. Following Voltolini’s paper appeared communications from Haenisch,5 M. Schaeffer,6 B. Fraenkel,7 and a host of later writers, and the mass of clinical evidence adduced by them in support of the theory of the produc- tion of asthma by nasal disease, and the large percentage of cures reported as resulting from the nasal treatment, should leave no doubt of its reflex dependency upon the nose in many cases. To enter into a consideration of the various theories advanced in regard to the causation of asthma would consume more space than the limits of this paper permit. Bergson8 was the first to regard asthma as a distinct disease. Before his day it was considered merely a symptom, the latter view being still retained by Rostan,9 Beau,10 and other later writers. Beau considered it a symptom of chronic catarrh of the small bronchi. Salter’s exhaustive work11 in 1860, in which he regards asthma as a nervous disease, the dyspnoea being due to reflex spasm of the bronchial tubes, and the essential patho- logical lesion residing in the nerve-centres, embodies the view adopted by the majority of more recent writers. Laennec12 had previously considered asthma a neurosis from functional 1 Ueber die Anwendung der Galvano-Kaustik, Wien, 1871. 2 Loc. cit. 3 Loc. cit., vol ii. p. 441. * Ueber Bronchiale Astlima, Volkmann’s Klinische Vortrage, 1870. 5 Loc. cit. 6 Deutsche Medicinische Wochenschrift, 1879. 7 Vorhandlungen d. Berliner Medicinische Gesellschaft, 1882. 8 Kecherches sur 1’Asthme, 1852. 9 De l’Asthme, Gazette dcs Hopitaux, No. 31, 1856. 10 Traite clinique et experimental d’Auscultation appliquee a l’Etude des Maladies du Cceur et du Poumon, Paris, 1856. 11 On Asthma, its Pathology and Treatment, London, 1860. 12 Traite d’Auscultation, 2e ed., tome i. p. 78. 116 NEUROSES OF THE NOSE AND NASO-PHARYNX. or organic alterations in the nerve-centres producing bronchial spasm, and Andral1 supported this view. Duclos2 considered it a neurosis dependent upon the herpetic diathesis, and the dyspnoea due to obstruction from eczematous eruption in the bron- chial mucous membrane. See3 thought asthma a neurosis of the vagus from irritability of the respiratory centres manifested by cramp of all the respiratory muscles. Trousseau4 regards it as a neurosis of the respiratory apparatus with bronchial spasm, but argues that the spasm is not dependent upon any in- flammatory action, as persons subject to asthma have been known to have capillary bronchitis or broncho-pneumonia without a sign of asthma showing during the attacks. He deemed the essential lesion to be some alteration in the cerebro-spinal axis or respiratory centres. In 1872 Weber5 first considered the possible influence of the sympa- thetic. He regarded asthma as a vaso-motor disturbance, the vaso-motor alterations being followed by such dilatation of the blood-vessels as to prevent the passage of air through the bronchial tubes, and thus bring about dyspnoea. That hypersemia and swelling of the mucous membrane took place was confirmed by Stoerk. This theory has been accepted by a number of later writers, some of whom reject entirely the spasmodic element in the production of asthma. Fraenkel attributes it to the propagation of a catarrhal congestion which causes swelling of the mucous membrane of the bronchial tubes and diminishes their calibre, somewhat similar to the vaso-motor tumefaction above mentioned. Sir Andrew Clark6 adopts the theory of local vascular disturbance in the bronchi, and thinks the paroxysm due to sudden swelling of the mucous lining of the bronchial mucous membrane, like the turgescence of the nasal mucosa in hay-fever, some peripheral irritation starting the train of symp- toms through diseased nerve-centres. Schlemmer7 argues that there are no physiological or clinical objections to the admission of both vaso-motor paresis and bronchial spasm. Schmidtborn8 regards asthma as the result of spasm of the pulmonary arteries, by which the “ suction-power” of the lung is diminished and less blood flows into the aorta, and he refers to the emptiness of the surface- vessels and the pale cyanotic appearance in support of this view. The increased action of the respiratory muscles is explained by the lack 1 Clinique Medicale, Paris, 1829. 2 Bulletin General de Therapeutique, April, 1861. 3 Dictionnaire de Medecine et de Chirurgie, 1865. 4 Loc. cit., 1869. 5 Tageblatt der 45ten Naturforscher-Yersammlung zu Leipzig, p. 169, 1872. 6 American Journal of the Medical Sciences, January, 1886. 7 L’Union Medicale, February, 1887. 8 Ueber Asthma Nervosum, Volkmann’s Klinische Vortrage, p. 328, 1890. NEUROSES OF THE NOSE AND NASO PHARYNX. 117 of oxygen, and the overloading of the blood with carbonic acid from this insufficient blood-supply to the larger vessels and consequent loss of nerve- control over the muscles. Block1 discusses Schmidtborn’s theory, and, whilst he considers that it has some grounds to recommend it, he rejects it because it is not altogether satisfactory. Schmiegelow,2 agreeing with See, regards asthma as a bulbar neurosis, by which is meant a reflex hyperexcitability of the respiratory centre, which can accompany the neurotic disposition, or can result from anything that tends to weaken the system or lower the vitality; and the par- oxysm of dyspnoea can be originated in any irritation transmitted to the medulla oblongata by any sensory nerve. Bosworth3 adopts the vaso- motor theory of Weber and Stoerk, as Roe and others have done, and rejects completely the idea of reflex spasm of the bronchial muscles. According to Bosworth, the pathological change which occurs in a par- oxysm is a dilatation of the blood-vessels of the bronchial mucous membrane from vaso-motor paresis, which differs from inflammation inasmuch as it is the first stage of inflammation only, and has no tendency to proceed further. Muscular spasm plays no part in the production of an attack, as the dyspnoea both expiratory and inspiratory is explained by the narrowing of the bron- chial tubes from vaso-motor paresis. This is followed later by exudation, decrease of the tumefaction, and cessation of the paroxysm. Etiology.—Whether vaso-motor paresis, muscular cramp, or both com- bined, are the essential pathological conditions of the bronchial tubes in asthma, the question for us to consider is, what pathological alterations in the nose can reflexly bring about an asthmatic paroxysm, and how is the irritation transmitted from the nose to the bronchial tubes? The anatomical relations of the nasal spaces and lower respiratory tract, the absolute dependence of the latter upon the former, and the close con- nection between the nerve-supply of these two areas, make it easy to under- stand how a pathological alteration in the nasal spaces might bring about more or less disturbance along and in the lower respiratory region. If asthma is due to disorder of the nerve-centres, as all authors more or less regard it, if it can develop in consequence of irritation of distant parts of the organism,—the skin or sexual organs, for example, according to some authors,—if it can come from simple psychic causes, as is admitted by others, how much more probable that irritation of the nasal spaces from vascular or other pathological alterations could produce a similar result! The exposure of the nose, which is the gate-way of the respiratory tract, to external influences of all kinds, makes it the most likely focus of irrita- tion in the production of respiratory neuroses. Although experiment has repeatedly failed to produce asthma by arti- 1 Yolkmann’s Klinische Vortrage, No. 344, 1890. 2 Stagerup’s Forlag, 94, S. 1889, Copenhagen. 3 Diseases of the Throat, 1889. 118 NEUROSES OF THE NOSE AND NASO-PHARYNX. ficial irritation of the normal nasal tissues, probably because the want of predisposition in the central nervous system was lacking, the clinical ex- perience of an army of competent observers over the whole civilized world has proved beyond doubt that asthma has at times its origin in pathological changes in the nose, if the cure of the affection by treatment of the nose is any demonstration of this fact. The suppression of the peripheral irritation in the nose by cauterization or otherwise can put an end to the paroxysm, but does not do away with the accompanying alteration of the central nervous system, which is the main factor in the production of the reflex phenomena. Without this central functional disturbance, there could be no manifestation of a respira- tory or other neurosis, and unless the normal resistance to the transmitted irritation is restored any return of the latter would bring about another paroxysm. Is the transmission of this peripheral impression by way of the sensory nerve-filaments along the branches of the trigeminus to the basal ganglia, and is the impression there transformed and reflected to the nerve of the part affected ? or is it by means of the sympathetic connections of the fifth pair that the external impression is conveyed to the point of reflex manifes- tation? Is the dyspnoea due to direct reflex irritability of the pneumogastric causing cramp of the respiratory muscles, or is it due to reflex disturbances of the circulation in the part affected,—vaso-motor changes,—or to both ? When considering these questions, we must recollect that in dealing with nervous manifestations of all kinds we have nothing positive except the clinical observations; the physiological and pathological laws governing them being more or less uncertain because of our limited knowledge of the nervous system. I quite agree with Schlemmer1 that there are no known physiological laws that conflict with admitting both vaso-motor paresis and spasm of the bronchial muscles, but I do not propose to argue whether the transmission of the sensory impression to the nerve-centres is by the tri- geminus or its sympathetic connections. I think that if the cerebral centres are functionally altered in any way their resistance is lowered, and their controlling power over nerve-force can be easily perverted by impressions brought to them through any of the nervous channels. As the medulla oblongata controls both respiration and vaso-motion, the sensory impression transmitted to it from the nose or elsewhere may be projected outward as a perversion of nerve-action in the pneumogastric or in the vaso-motor system. If a neurotic condition of the medullary ganglia exists, it is probable that a similar physiological alteration is coincident in the dependent sympa- thetic ganglia. It does not follow that all these ganglia are uniformly affected. Some may be more so than others, and the perverted nerve-action or vaso-motor disturbance projected outward will be manifested in the areas 1 Loo cit- NEUROSES OF THE NOSE AND NASO-PHARYNX. 119 dominated by the ganglia most affected or offering least resistance to the reflected impressions. Vaso-motor disturbances in the nose, whether from intra-nasal irritation, or brought about by the influence of distant organs, may, as Bosworth says, cause the same condition in the respiratory tract. But to do so there must be predisposition of both the medullary and the sympathetic ganglia to receive and transmit the reflected impression, and it will be most manifested where the perversion of functional activity is greatest. That vaso motor paresis attends the asthmatic paroxysm is almost uni- versally admitted, and Bosworth considers it, with its resulting changes, the sole pathological condition, and believes that the dyspnoea is due to it alone, the secondary hypenemia and dilatation of the blood-vessels causing the obstruction. But this does not necessarily exclude spasm of the bron- chial muscles, because the muscular cramp might be the result of the vessel- disturbances. In this light I regard vaso-motor alterations as the least unsatisfactory way of explaining all reflex phenomena, because they are all manifestations of perverted function, probably due to temporary interference with nutri- tion from reflex vessel-disturbances. The cramp of the bronchial muscles may result from the vaso-motor palsy, if certain physiological phenomena of muscular action have any application here. If the pneumogastric is cut, rejection of food takes place because the oesophagus contracts when deprived of its nervous influence. Dr. Burdon Sanderson says the muscular fibres of the bronchial tubes are in the same condition as the oesophagus and stomach after section of the vagi,—i.e., contracted or in a state of spasm. Brown-Sequard says that after section of the cervical sympathetic the blood-vessels are paralyzed and the blood-vessels are dilated : he does not say that the arteries are dilated, and does not state whether the result in hyper- semia is arterial or venous. Other phenomena are contraction of the eye- muscles, of the muscles of the angle of the mouth, and of the erectile muscles of the ear. It is always contraction that is spoken of from this deprivation of nerve-control, and not relaxation. Corresponding results have been had from section of other nerves. Now, unless this equally applies to the mus- cular tissue of the arteries when their nerve-control is diminished by vaso- motor paresis, we should have contraction of one set and relaxation of another set of muscles from the same causation,—which seems to be a physi- ological contradiction.1 If the arterial muscles contract, the arteries are emptied or partially so, and the hypersemia is venous. If vaso-motor paresis resulted in primary dilatation of the arteries, we should have the same condition as in inflam- matory action, and it would hardly stop short of other symptoms of in- flammation. 1 See T. W. Poole, Transactions of the Ninth International Medical Congress, vol. iii. 120 NEUROSES OF THE NOSE AND NASO-PHARYNX. But, as Charcot1 says, “this hypergemia, however intense or prolonged it may be, never lias the effect, save under exceptional circumstances, of determining by itself the development of inflammatory action.” Physiological experiment has shown that if the heart is opened imme- diately after the medulla and spinal cord are destroyed, it beats with regu- larity, but is empty, and all the intestinal veins are full; the blood being emptied from the arterial system into the veins. The same thing occurs in death. Now, is it irrational to apply these facts to the explanation of vaso- motor paresis, and suppose that the immediate effect of this interference with their nerve-control is contraction or constriction of the arteries of the area involved, with consequent overloading of the veins and venous hyperaemia? Such constriction is usually explained by the action of the vaso-motor constrictor nerve-fibres, whilst dilatation when present calls for an antagonistic set of nerve-fibres, the vaso-dilator nerves. Will not the loss of control over the nerves regulating the action of the arterial coats explain both phenomena ? Why cannot the dilatation be secondary to con- tinued venous hyperaemia and stasis, from the blood’s being pumped through vessels which have temporarily become like veins with their contractile energy suspended ? Instead of paralysis from over-distention, over-disten- tion from paralysis ensues. Why must we, as Foster2 says, “imagine a muscular fibre as subject to the action of two opposing forces, the one elongating, relaxing, or dilating, the other shortening, contracting, constricting, etc.,’2 if there is a way to get rid of this antagonism ? The supposition that the inherent contractile energy of the arterial muscular coat is regulated by the nerve-impulses transmitted to the vaso- motor centres (the brain and spinal cord), and that any interference with this governing function will at once release this contractile force, causing constriction at first, followed later by dilatation, is not irrational. This of course supposes that dilatation follows constriction and excludes primary dilatation. Foster, however, again says, “ we have as much right to sup- pose relaxation to be the necessary antecedent of contraction as to suppose contraction to be the necessary antecedent of relaxation.” There is no doubt about the right to “imagine” or “suppose,” but these quotations from an established text-book on physiology show how uncertain are many of its generally-accepted teachings, and also that speculation in regard to physiological questions is legitimate. Whether the vaso-dilator nerve fibres are demonstrable or not, physiologists teach that irritation of the cer- vical sympathetic causes contraction of muscles and constriction of arteries, and that no vaso-dilator impulses follow such irritation. It is also taught that vaso-motor changes in the condition of the minute arteries—changes, i.e., of any particular vascular area—have very decided effects on the cir- culation, and these effects may be both local and general. 1 Lectures on the Nervous System, pp. 90, 91. 2 Physiology, Philadelphia, 1891. NEUROSES OF THE NOSE AND NASO PHARYNX. 121 If the normal action of any organ or part of the organism is dependent to some extent upon the integrity of its circulation, and if vaso-motor impulses result in vascular disturbances of any area or organ, the function of the part must be thereby altered or interfered with. The impairment of nerve-control over the arteries in vaso-motor paresis, involving the vasa nervorum, produces changes in the arterial supply of the nerves with distention of their veins, and consequent interference with the sensory- or motor-nerve function of the part affected. In asthma, the vaso-motor alterations, unless limited to the mucous lining of the bronchi, can impair the innervation and circulation of the muscular tissue supplied by the branches of the vagi (of which the vasa nervorum come from the external carotid, and the vaso-motor supply from the superior cervical ganglion), with accompanying perverted muscular action. Sommerbrodt has shown that we can have vaso-motor changes in the bronchial mucosa without asthma,—i.e., dyspnoea from obstruction without the typical asthmatic symptoms. Moreover, vaso-motor paresis limited to the bronchial mucous membrane would not account for the spasmodic contractions of the intercostal and other muscles giving rise to the peculiar jerks so often seen in asthmatic cases. That the ganglia of the spinal nerves are frequently involved through their sympathetic connection is shown by the points (pointes apophysaires) tender to pressure in the lower cervical and upper dorsal regions of the spine so often seen in'nervous asthma. Therefore from this point of view there is no need for Dr. Bosworth and others to bar spasm in the production of the paroxysm, as both the vascular disturbances in the bronchial mucous membrane and the spasm of the bronchial muscles might depend upon the same sympathetic influences. That there is spasmodic contraction of the bronchial muscles during the paroxysm, most authorities admit, and that it can be brought about by irritation of the vagus is proved by the experiments of Lazarus1 and others. But the explanation of this phenomenon has been very various, and sometimes seemingly absurd. To attribute it, as Traube, Schech, and others have done, to extraordi- nary activity of the respiratory centres from the stimulation due to excess of carbonic acid in the blood, seems an untenable proposition. In other words, deficient oxygenation or deprivation of the normal nutrition increases functional activity of the respiratory centres. Does any one suppose that bad blood and poor hygienic surroundings could give increased physical strength and intellectual activity ? No one doubts that such a causation might induce muscular spasm in the bronchi or elsewhere, but it could only be on the hypothesis of impaired vitality of the nerve-centres, the ganglia of which are involved in the same functional alteration, with perversion of muscular action. 1 Experiinentelle Untersuchungen zur Lehre yon Asthma Bronchiale, Deutsche Medicinische Wochenschrift, 27, 1891. 122 NEUROSES OF THE NOSE AND NASO-PHARYNX. Whilst impaired nerve-vitality can result from vaso-motor paresis, per- version of the nerve-tissues, or a neurotic condition, is the essential factor underlying the manifestation of any reflex neurosis, and the ready develop- ment of vaso-motor disturbances from nasal or other peripheral irritation is a symptom of this tendency. Such irritability of the nerve-centres and reflex sub-centres can come from acquired or inherited causes that would bring about susceptibility to perverted function. Gout and rheumatism or the uric acid diathesis is in a large number of cases the basis of the nervous irritability. The connection between asthma and gout or rheumatism has been spoken of by different authors. Trousseau1 has observed cessation of attacks of asthma coincident with the advent of rheumatism, and no return of it until the symptoms of the latter had subsided. He made the same observation in regard to urticaria, which is one of the manifestations of the uric acid diathesis. John N. Mackenzie2 also dwells on this connection, and he makes refer- ence to Hoffmann (1760) and others as having mentioned it in the last century. It may have its basis in chronic affections or abuse of the sexual organs, causing general impairment of the nervous system. Syphilis, inherited or acquired, may lower the vitality of the nerve- centres. Any cause whatever that can vitiate the tone of the nervous system will predispose any individual to a ready response to irritation, and easy manifestation of reflex phenomena. What the nature of the change in the nerve-centres and reflex sub- centres may be is unknown, and the term “ neurasthenia,” so frequently applied to the most marked cases of nervous derangement without dis- coverable organic lesion, is used to cover this lack of knowledge, and has no definite meaning. It is like many other terms used in medicine for the same purpose, such as “ amaurosis,” “ idiosyncrasy,” etc., and is simply a confession of our ignorance. That there must be of necessity a pathological condition of the nerve-centres controlling sensation, motion, and vaso-motion to permit perverted functional manifestations from peripheral causes, is as obvious as that there must be inherent alterations of the psychical centres in perversion of the mental functions. This may be curable or incurable, and even when absolutely incurable may be so modified that with the removal of the peripheral irritation the reflex manifestation of functional perversion will cease. That nervous asthma can come from nasal irritation has been denied by some writers who regard the cures from intra-nasal treatment as merely the effects of revulsives which would have acted equally well if applied else- where. Whilst the mass of clinical evidence to the contrary is too great to 1 Loc. cit. 2 Reference Hand-Book of the Medical Sciences, 1887, vol. v. p. 238. NEUROSES OF THE NOSE AND NASO-PHARYNX. 123 warrant such an assumption, it does not justify the conclusions of those who look to the nose for the source of all asthmatic attacks. The exaggera- tion of the importance of nasal disease as the principal, if not the sole, factor in the etiology of asthma and other nasal reflexes, into which the enthusiasm of some authors has led them, is calculated to discredit a valuable clinical observation. It is not the sole, and I doubt if we can prove it to be the most frequent, cause. Admitting the alteration of the nerve-centres with predisposition to nervous disturbance in the bronchial region, we can easily see that other forms of peripheral irritation besides nasal could bring about the asthmatic paroxysm. Cardiac trouble, renal disease, malarial influences, gastric and intestinal disturbances, irritation of the cervical sympathetic by enlarged glands and growths, and chronic bronchitis, are important consid- erations in the etiology of the disease. Its connection with the skin, with sexual irritation, and with rheumatism and gout, already referred to, is to be kept in mind. Psychical causes can bring about an attack without the intervention of the nose, by direct vaso-motor influences through altered nerve-centres. We can have asthma without any sign of intra-nasal lesion or intra-nasal irritability, and we can have intra-nasal pathological condi- tions of all kinds without any development of asthma. Again, we can have asthma and decided lesions of the nasal spaces in the same individual, and there may be no etiological connection between them. But, whilst this is true, the nose should always be investigated as a possible factor in the causation, and any abnormality should be treated, whether the connection can be proved or not. Pathology.—Nasal obstruction of any kind can bring about dyspnoea, especially in sleep, but it usually lacks the essential attributes of the true asthmatic paroxysm. It is often seen in children with rhinitis, adenoids, and other nasal obstruction. The pathological conditions in the nasal mucous membrane that may induce an asthmatic paroxysm may be either inflammatory or non-inflammatory in character. Chronic rhinitis is essen- tially an inflammatory process, and the resulting hypertrophy of the tur- binated tissues a hyperplasia due to the inflammatory action. But the resulting vaso-motor disturbances are not due to the latter, for vaso-motor paresis differs materially from the first stage of inflammation, although Bosworth argues that they are identical, but to the local irritation set up by the resulting hyperplastic tissue. This local irritation, which is of itself a mild form of nerve-paresis, results not only from inflammatory changes in the nose, but from turges- cence of the erectile tissues caused by transmitted vaso-motor alterations from distant points of the economy,—e.g., the eye, stomach, liver, intes- tines, sexual organs, skin, etc.,—or from a diseased ganglion itself, or from any pathological lesion in the intra-nasal spaces, such as deflections, out- growths, and spurs of the septum, from polypi and other morbid growths, from adenoid tissue in the naso-pharynx, and from atrophic rhinitis with accumulation of crusts and secretions. 124 NEUROSES OF THE NOSE AND NASO-PHARYNX. Any of these conditions can irritate the terminal filaments of the trigeminus, the olfactory, and the sympathetic distributed in the nasal mucous membrane and cause reflex vaso motor changes in the nose and in other areas controlled by their nervous and ganglionic connections, and more especially in the respiratory tract, because of its more intimate connection with the nasal spaces. This irritation transmitted to depraved vaso-motor centres will be manifested by vaso-motor alterations in the area controlled by the ganglion which has become more impaired. In the respiratory neuroses the transmission will be by way of Meckel’s ganglion and the superior cervical ganglion, the latter of which controls the vaso-motion of the vagi. Whether a sensory impression transmitted to a reflex centre is primarily transformed into a vaso-motor impulse by the local reflex centre, or whether this is done secondarily by the medulla oblongata, in which resides the central control of all respiratory and vaso-motor impulses, is a matter for speculation, because, as said before, of our vague and uncertain knowledge of the sympathetic system. Symptomatology.—The symptoms of nasal asthma do not materially differ from those of any other form of nervous asthma, and, as these are familiar to all physicians and are found in all text-books on medicine, I shall not recount them here. But the terrible picture presented by the victim of a violent paroxysm, once seen, is never forgotten, and creates alarm even among those most familiar with it. Diagnosis.—Whether an attack of asthma is of nasal origin can be determined in some cases by the cocaine test,—viz., the arrest or the amelioration of the paroxysm by amesthetizing the mucous membrane of the nasal spaces with cocaine, which I have seen at times to be very effica- cious. When this test fails, the exclusion of cardiac, renal, and gastro- intestinal disorders would still indicate the probability of a nasal causation. The thorough inspection of the nasal spaces by anterior and posterior rhi- noscopy, and the discovery of polyps, enlarged turbinates, adenoids, or abnormalities of the septum, would greatly strengthen this probability. Even without marked pathological changes in the nose the causation might be in a decided hyperesthesia of the intra-nasal tissues, readily manifested by the production of sneezing, cough, etc., when irritated by a probe. It is in such cases that psychical causes exert most decided influ- ences. It is useless to consider the differential diagnosis of a typical asthmatic paroxysm and the dyspnoea of cardiac disease, pulmonary oedema, glottic spasm, laryngeal or tracheal obstructions, or hydrothorax, as no physician would be likely to confound them. The difference, however, between nervous asthma and the asthmatic attacks in chronic bronchitis should be taken into consideration: in the former no rales precede the attack or follow its complete subsidence; whilst in chronic bronchitis, auscultation of the chest will discover moist rales both before and after the paroxysm of dyspnoea, which occurs usually NEUROSES OF THE NOSE AND NASO-PHARYNX. 125 at night and is probably due to obstruction of the bronchial tubes by secre- tion. Such attacks are frequently the result of taking cold and grafting an acute attack of bronchitis on the already chronic disease of the bronchial mucous membrane. In nervous asthma the paroxysm, whilst most common at night, quite often appears just as suddenly during the day, and the ac- companying auscultatory signs are dry, sibilant, sonorous rales, a whistling and blowing like the sounds from a distant gale of wind, which appear as suddenly as the attack, are present all through it, change into moist rales when exudation into the tubes takes place, and as soon as they are clear again there is a complete disappearance of all auscultatory signs. This is not the case in chronic bronchitis. Prognosis.—The probability of curing a case of asthma originating in nasal irritation will depend very much upon the general condition of the patient and the length of time the attacks have been manifested. I doubt if asthma ever kills any one, but the existence of a chronic asthmatic is so miserable that this assurance is no consolation, as without the hope of cure life is hardly worth living. The prognosis is the more favorable the shorter time the disease has existed and the less the nerve-centres are impaired, and grows more and more unfavorable according to the duration of the causation and the frequency of the attacks. Whether cases of any long duration are ever radically cured by the local treatment is questionable, notwithstanding the seemingly favorable reports of Bosworth and others. If these cases are all followed out, most of them will be found to have in time lost the temporary improvement, and relapsed more or less, requiring constant changes of climate, etc., to avoid recurrence of attacks. This is especially true of those who fail to keep up constitutional treatment for a long time. Treatment.—Treatment should be directed first to removing the periph- eral irritation, secondly to improving the condition of the nerve-centres, and thirdly to controlling the paroxysm during an attack. As the first two points will be considered under treatment of nasal reflexes in general, I will here confine myself to the management of the paroxysm. This should be both local and constitutional. The local treatment is by applications to the nasal spaces to diminish temporarily their irritability, and by inhalations moist or dry to improve the condition of the bronchial mucous membrane. The constitutional treatment is by stimulants, alteratives, anaesthetics, and narcotics. Whether the irritability of the nasal mucous membrane is due to a simple hyperaesthesia, or to a turgescence of the corpora cavernosa, or to the presence of morbid growths or other pathological formations, the best remedy for allaying this irritability is cocaine, which acts as a stimu- lant to the nervi vasorum, restoring the control over vaso-motion and doing away with the venous hyperaemia. It can be best applied by an atomizer, a few drops of a four-per-cent, solution being sprayed into each nostril every five or ten minutes until the parts are thoroughly anaes- thetized. Unless some decided diminution in the violence of the paroxysm 126 NEUROSES OF THE NOSE AND NASO-PHARYNX. follows this application, it should not be continued, as it would be pro- ductive of more harm than good, its prolonged use being sometimes fol- lowed by a relaxation of the intra-nasal tissues. When the tissues are contracted under the cocaine application, I am in the habit of spraying the nose with a mixture composed of Menthol, Gum camphor, aa gr. xxx ; Liquid cosmoline, gi, which assists the action of cocaine and prolongs its effects. Of inhalations, possibly stramonium (the leaves being ordinarily used) is the best, and if mixed with saltpetre we get the combined effects of each. The mixture can be burned in a plate and the fumes inhaled. This combination of the two remedies is the basis of most of the so- called asthma cures sold in the drug-stores, and used quite extensively with more or less relief. Other ingredients in these preparations are belladonna, hyoscyamus, lobelia inflata, pulverized aniseed, ordinary tea, etc., any or all of which may be tried, as cases differ in their susceptibility to the in- fluence of different drugs, and all seem after a while to lose their effect, requiring a change in the remedy. Inhalations of pyridine sometimes prove very valuable in controlling the dyspnoea, and it is more efficient when combined with ethyl iodide (or hydriodic ether). A drachm of pyridine and a half-drachm of hydriodic ether can be placed in a saucer, under a croup-tent, or some substitute, and the patient allowed to inhale the volatile fumes for half an hour. In violent paroxysms, chloroform inhalation may be resorted to. In- ternal remedies should be directed to subduing the perverted action of the cerebral centres on the one hand, and improving vaso-motor control on the other. The former is accomplished by the use of remedies known as cere- bral sedatives, such as opium, chloral, paraldehyde, and bromides, which not only act as sedatives to the nerve-centres, but by deoxidizing the blood retard the chemical process in the muscles which generates contractile energy, and thus reduce tendency to spasm. The latter can be done in two ways, by administration of so-called excito-motors, such as belladonna and hyoscyamus, which act by stimulating the sympathetic ganglia and thereby restore nerve-control over vaso-motion, and by motor-depressants, such as quebracho, grindelia robusta, pilocarpine, etc., which reduce the contractile energy of muscular tissue, by lessening the functional activity of the motor nerves. Opium or its active principle morphine is the most reliable of the cerebral sedatives, but in many cases it cannot be used at all, because of the peculiar susceptibility of some persons to its influence. Chloral and bromide of potassium, in combination, are often more satis- factory. All these drugs prove most efficacious in small doses frequently repeated. Paraldehyde in my hands has been of great service. I have seen a most violent paroxysm promptly relieved by the administration of NEUROSES OF THE NOSE AND NASO-PHARYNX. 127 one drachm in a single dose. Occasionally I have had to give a second dose of the same amount, but less than a drachm will usually fail to pro- duce a satisfactory effect. I use it only at night to enable the patient to lie down and sleep. Sulphate of atropine is sometimes valuable during the paroxysm. Quebracho and grindelia robusta control to a great extent the dyspnoea of asthma, and are useful in all forms of dyspnoea. The trouble about all these agents is that, although very satisfactory in most cases for a while, they seem after a time to lose their effect, so that we have to ring the changes in their administration, using one when another fails. Iodide of potassium is one of the most reliable remedies in treating asthma in the intervals between the attacks, and is sometimes a valuable adjunct continued during the paroxysm. The application of ice to the spine over the upper part of the dorsal division often proves serviceable, especially when there is tenderness to pressure about the seventh cervical and upper dorsal vertebrae. I have seen also violent thumping of this region with the hand or fist give great relief, especially in cases with convulsive movements of the intercostal and thoracic muscles. Electricity in the form of the continuous current has sometimes a happy effect. When the paroxysm subsides spontaneously, or is relieved by the measures above suggested, the removal of the source of irritation in the nose may be attempted, and the constitutional treatment instituted to prevent a recurrence. One of the most important means of preventing a recurrence of the paroxysm, and frequently of aborting it during its height, is a change of location or climate. What altitude suits an asthmatic best, whether high altitudes or the sea-level, is a question difficult to answer. Much has been written on the “climatic treatment of asthma” (see Transactions of the American Climatological Association), but without solving the problem. Sometimes the slightest change of location will accomplish the result. I have seen cases moved only a mile or two outside the city during the paroxysm, and it ceased. I have among my patients some who never have an attack at any of the Atlantic sea-shore resorts, and others who have an attack whenever they visit such places, and must at once go to the mountains, where they enjoy perfect immunity from the trouble. I know one who has a paroxysm of asthma every time she changes her location, and prepares for the attack as a matter of course. These facts show that each individual is a law unto him- or herself, and each case requires different management. They show also that both the etiology and the treatment of asthma are open fields for future investigation. The intimate relations between the ear and the nose by direct communi- cation and the dependency of ear-diseases upon nasal troubles are not points for consideration in this paper; but there are at times reflex phenomena developed in the ear without any discoverable symptoms of local disease REFLEXES OUTSIDE THE RESPIRATORY TRACT. 128 NEUROSES OF THE NOSE AND NASO-PHARYXX. that have been referred to intra-nasal irritation. I have seen earache and tinnitus aurium, without any inflammation or alteration in hearing, from asymmetry of the nasal chambers. Dr. C. H. Burnett1 has reported an interesting case of peculiar noises and audible contractions of the tensor tympani from nasal troubles. Schech,2 Seifert, and others have recorded similar observations. John N. Mackenzie3 has described a peculiar con- dition coming on periodically, similar to hay-fever, in which there was intolerable itching, swelling, and secretion of the external meatus. These reflex phenomena are probably due to vaso-motor alterations through the medium of the otic ganglion, as it is from the ganglion the ear receives its vaso-motor and trophic supply, and are similar to the swollen and congested condition of the auricle seen after section of the cervical sympathetic. The direct anatomical connection between the eye and the nose makes it easy to understand how diseases could spread from one organ to the other; and since Bresgen4 first called attention to the fact that catarrhal conjunc- tivitis was often dependent upon nasal catarrh, much has been written upon the interdependence of diseases of the two organs. As this article, however, deals only with nasal reflex phenomena, the reader is referred to another part of this work for the consideration of the connection between the eye and the nose, outside of this reflex relationship. Hack5 called special attention to the reflex influence of the nose upon the eye, mentioning a case of scintillating scotoma due to the turgesccnce of the inferior turbinate, and explained it according to his theory of reflex production given in this article. Lachrymation may be of reflex origin from vaso-motor changes in the nose, and is often produced artificially by irritation of the nasal tissues. Conjunctival irritability with congestion about the eyes and lids may be a reflex disturbance from intra-nasal changes, and will resist all treatment until the nasal trouble is cured. In my address before the American Medical Association, in 1885, at New Orleans, I referred to a case of reflex conjunctivitis which rebelled against all treatment until I had cured the nasal trouble. Seiler,6 Gradle,7 N. R. Gordon,8 and others, also speak of this connection. (Edema of the lids due to intra-nasal changes is referred to by many authors, and in a case treated by me since I have been writing this paper EYE. 1 Medical News, July 26, 1884. 2 Miincbener Medicinische Presse, No. 22, 1886. 3 American Journal of the Medical Sciences, Februarj’’, 1887. 4 Der cbronische Nasen- und Rachen-Catarrh, 1881, B. i. 6 Erfahrungen aus dem Gebiete der Nasenkrankheiten, Wiesbaden, 1884. 6 Reflex Conjunctivitis, Archives of Laryngology, vol. iii., 1883. 7 Periodic Conjunctivitis, American Journal of the Medical Sciences, April, 1886. 8 Chronic Conjunctivitis caused by Nasal Disease, American Rhinological Society, 1886. NEUROSES OF THE NOSE AND NASO-PHARYNX. 129 an oedema which was quite disfiguring, and had been present some weeks, was shown to be dependent upon turgescence of the erectile tissue of the middle turbinates and septum opposite, by its complete disappearance in one hour when the swollen tissues were contracted by cocaine. Its reap- pearance when the effect of the cocaine subsided, and its final cure within a week by cauterization of the hypertrophic tissues, was conclusive demon- stration. Asthenopia, intolerance of light, retinal hypersesthesia, muscse volitantes, pain in eyeballs, contraction of visual fields, redness of eyelids, muscular twitching of lids, blepharospasm, phlyctenular ophthalmia, trophic changes of the cornea, etc., have been recorded by numbers of writers. Most of the reflex troubles of the eye from nasal irritation mentioned by these writers are vascular, secretory, and trophic disturbances that could depend upon vaso-motor alterations, whether emanating from a similar alteration in the nose of local or of distant origin, or from pathological changes causing irritation of the nasal branches of the trigeminus. These pathological conditions were polyps, chronic rhinitis, hypertrophy of the turbinates, spurs and outgrowths from the septum, adenoids, rhinoliths, etc. Blepharospasm and twitchings of the eyelids, mentioned by Bettman, Hamilton, and others,1 are of the nature of choreic manifestations, such 1 M. Bresgen (Zur Entwickelung von Refractions- und Stellungs-Anomalien des Auges in Folge von Nasenerkrankungen, Deutsche Medicinische Wochenschrift, 1884); Hoffmann (Zusammenhang von Nasen und Augenaffectionen, Deutsche Medicinische Wochenschrift, No. 25, 1885); Gruening (Reflex Ocular Symptoms in Nasal Affections, New York Med- ical Record, January 30, 1886); Masini (Dei Rapporti fra alcune Malattie del Naso con alcune Malattie degli Occhi, Bollettino di Oculistica, Nos. 1 and 10, 1885 and 1886); Beverley Robinson (Reflex Ocular Symptoms in Nasal Disease, New York Medical Record, April 3, 1886) ; Ziem (Intra-oculare Erkrankungen hei Nasenleiden, Berliner Klinische Wochenschrift, xxxviii., 1887) ; Bettman (Ocular Troubles of Nasal Origin, Journal of the American Medical Association., May, 1887); Gradle (Ocular Symptoms due to Nasal Affections, Archives of Ophthalmology, xvi., 1887); Neiden (The Connection between Diseases of the Eye and the Nose, Archives of Ophthalmology, xvi., 1887); J. A. White (Eye Troubles of Reflex and Neurotic Origin, North Carolina State Medical Society, 1887, Virginia Medical Monthly, October, 1887); Rothholtz (Ueber die Beziehungen von Augen- Erkrankungen und Nasen-Affectionen, Deutsche Medicinische Wochenschrift, lii., 1887); L. H. Taylor (Ocular Troubles as influenced by Nasal Disease, Journal of the American Medical Association, November, 1888); Lennox Browne (Reflex Association of Diseases of the Eye and Nose, British Medical Journal, May, 1887); W. Cheatham (Nasal Reflexes as a Cause of Disease of the Eye, American Practitioner and News, 1887); V. Augagneur (Pathologie et Traitement de la Kerato-Conjunctivite phlyctenulee, Revue Medicale de l'Est, October, 1888); E. Fletcher Ingals (Hypertrophic Rhinitis with Ocular Troubles, etc., American Rhinological Society, October, 1889); Maxwell (Chronic Nasal Catarrh as a Reflex Cause of Accommodative Asthenopia, Ophthalmic Review, vol. vii. p. 305); Despagnet (Rapport entre les Maladies des Yeux et du Nez, Societe franqaise d’Ophthal- mologie, Paris, August, 1889); T. K. Hamilton (Ocular Symptoms due to Disease of the Nasal Cavities, Transactions of the Intercolonial Medical Congress of Australasia, 1889); A. Trousseau (Troubles oculaires d’Origine nasale, Bulletin Medical, April, 1889); John Dunn (Adenoids of the Naso-Pharynx in Children, etc., Virginia Medical Monthly, September, 1891); Couetoux (De la Kerato-conjunctivite d’Origine rhino-pharyngienne, Annales d’Oculistique, December, 1891). 130 NEUROSES OF THE NOSE AND NASO-PHARYNX. as convulsive tic, etc., claimed by some authors to be due to nasal irri- tation. F. J. Quinlan1 has reported a case of continued instead of interrupted muscular spasm in a patient with strabismus following fracture of the nose, cured by the operation for restoring the symmetry of the nasal chambers. Ziem2 has reported three cases of iritis following suppuration of the nose, and cured by the treatment of the latter and hypodermic injections of pilocarpine. The connection of that obstinate and annoying eye-disease phlyctenular ophthalmia with nasal affections seems to be twofold, both by the continuity of the mucous surfaces and by reflex action in as far as the intra-nasal irritation from chronic rhinitis and adenoid tissue causes reflex vaso-motor and trophic changes in the conjunctiva and cornea. Couetoux and Dunn in their papers emphasize the importance of the association of this disease with adenoids of the naso-pharynx; and my experience is quite in accord with theirs, that an examination of the children subject to it will reveal the presence of these growths, which must be removed to insure a speedy recovery. Such reflex phenomena as muscae volitantes, cloudy vision, contraction of the visual field, as reported by Hack, Hamilton, Masini, Browne, Bett- man, Ziem,3 and others, should lead us to look to the nose as a possible starting-point of the ocular disturbance known as glaucoma, inasmuch as its etiology is still involved in some obscurity, and every possible cause is worthy of consideration. Lennox Browne’s case of a woman attacked by glaucoma who was rapidly cured by the removal of nasal polyps demon- strated this. Rampoldi4 also speaks of the connection between glaucoma and nasal disease. Not only have these reflex manifestations in the organ of vision been cured by the treatment of the nasal affection, but similar troubles have been artificially produced by operation in the nasal spaces. Berger,5 Ziem,6 and Schmidt-Rimpler7 report cases of contraction of the visual field and amblyopia following galvano-cautery operations and removal of polypi. Similar ocular troubles have been recorded again and again as reflexes in connection Avith diseases of the teeth, irritation of the cervical branches of the sympathetic, diseases of the digestive tract, disturbances of the sexual organs, and in hysteria, as I have elsewhere shown.8 These reflex manifestations are sensory, motor, and trophic in an area 1 Case of Convergent Squint, New York Medical Record, May, 1891. 2 Iritis bei Eiterung der Nase und ihrer Nebenhohlen, Centralblatt fur Praktische Augenheilkunde, December, 1887. 3 Wiener Klinische Woehenschrift, No. 12, 1889. 4 Clinique Ophtbalmologique de la Faculte de Pavie, Milano, 1884. 5 Archiv fur Augenheilkunde, vol. xvii. p. 293. 6 Centralblatt fur Augenheilkunde, vol. xi. p. 131. 7 Klinisches Monatsblatt fur Augenheilkunde, October, 1887. 8 Virginia Medical Monthly, October, 1887. NEUROSES OF THE NOSE AND NASO-PHARYNX. 131 controlled by the trigeminus and the sympathetic, and are due to vascular disturbances in the domain of the branches of the ophthalmic ganglion caused by transmission of the peripheral irritation in the nasal spaces to this ganglion and its connections, vaso-motor paresis being the principal pathological alteration underlying the production of these phenomena. MIGRAINE, CONGESTIVE HEADACHES, NEURALGIA (SUPRA-ORBITAL AND TIC DOULOUREUX). The connection of the nose with head-pains of various kinds, whether attended with gastric disturbances or not, has been recorded by many writers. Migraine, or sick headache, first denominated a neurosis by Dr. George M. Beard, has been cured by intra-nasal treatment in at least sixty to seventy per cent, of over three hundred cases reported by Hack,1 Sommerbrodt,2 Goetze,3 Schaeffer,4 Rosenbach, and others. Rudolph Ferber 5 in advance of any of these authors had referred to the connection between intra-nasal disease and migraine. So-called congestive headaches have been repeatedly associated with abnormal conditions of the nasal passages and cured by the relief of the nasal troubles. Meyer called attention to the cephalalgias often accom- panying adenoids. Tornwaldt6 also lays stress upon the point. Meniere7 reports a case of headache of two years’ standing cured by cauterization and removal of adenoids. Hack speaks of headache as a turbinated engorgement. Harrison Allen,8 Glasgow,9 and Roe10 treat fully of this relationship. Joal11 calls attention to the irritability of the nasal erectile tissues accompanying the headaches frequently encountered in young persons of both sexes approach- ing manhood and womanhood, and concludes that they are caused by intra- nasal changes which occur in sympathy with the irritation of the sexual apparatus so often manifested at the advent of puberty. Neuralgias of the branches of the trigeminus have been reported by numerous observers as dependent upon nasal and naso-pharyngeal affection, —Hartmann,12 Hack,13 Schaeffer,14 Sommerbrodt,15 and others. 1 Loc. cit. 2 Loc. cit. 8 Loc. cit. 4 Deutsche Medicinische Wochenschrift, No. 23, 1884. 5 Der Niese-Krampf u. deren Beziehung zur Migraine, zum Bronchial Asthma u. zum Heufieber, Archiv d. Heilkunde, lOter Jahrg., Leipzig, 1869, p. 586. 6 Loc. cit. 7 Revue Mensuelle de Laryngologie, July, 1888. 8 Medical News, March, 1886. 9 Transactions of the American Laryngological Society, May, 1887. 10 Medical Review, August, 1888. 11 Revue Mensuelle de Laryngologie, etc., July, 1888. 12 Loc. cit. 13 Loc. cit. 15 Loc. cit. 14 Loc. cit. 132 NEUROSES OF THE NOSE AND NASO-PHARYNX. The pathological alterations that cause reflex neuralgias are adenoids, turbinated hypertrophy, especially of the middle and posterior parts of the inferior turbinate, spurs from the septum, and intra-nasal synechise. In my experience, hypertrophy of the middle turbinate is the most common cause of nasal reflex neuralgias and headaches, as of cough. Every one knows that neuralgia can result from nasal obstruction, as frontal headaches are quite common with colds in the head. These reflex manifestations of pain, neuralgia, etc., may be explained on the hypothesis of a local irritation’s bringing about limited vaso-motor changes in persons of neurotic disposition on the one hand, or on that of a long continuance of this irritation extending to, and eventually involving, healthy nerve-centres, on the other hand. Pain is usually described as an exaltation of the ordinary function of sensation, a hyperaesthesia, or excess of sensory function, but it is probably more correct to speak of it as a perturbation of the ordinary function. It is well known that frequently in acutely-inflamed parts the tactile perception is blunted, which would not be the case if pain or neuralgia were a hyperaesthesia (Vanlair).1 Any cause that can interfere with the proper performance of the sensory machinery will alter the nerve-function and cause pain. Any injury or peripheral irritation can cause local pain by interfering with the normal function of the peripheral sensory nerves at the seat of injury or irritation, but to produce reflex manifestations this irritation must be transmitted to the ganglionic connections of the part. This reflex will be vaso-motor, sensory, or motor, according to the mode and direction of this transmission. Neuralgia or pain will be reflexly produced if the irritation is trans- mitted to the posterior root of any spinal nerve, provided this root is func- tionally altered. It does not appear rational to say that it may be in a state of “ exaltation” or in a condition of “ increased functional activity.” It must, on the contrary, be in such a condition that it cannot properly perform its ordinary functions. Its functional activity is decreased, not increased. Whether this lowered vitality is due to acquired disease or inherited diathesis that causes func- tional derangement of the nervous system, or to vaso-motor disturbance, makes no essential difference. In all the subjects of constant neuralgias the probable alteration of the posterior root of the nerve, in the domain of which the neuralgia develops, is a condition of atrophy more or less pro- nounced (Anstie). There is at first vaso-motor paresis, followed by non-inflammatory atrophy. As the fifth pair resembles a spinal nerve in having two roots, these remarks are applicable to trigeminal neuralgias. In a case of Rom- 1 Journal de Medecine de Bruxelles, 1865. NEUROSES OF THE NOSE AND NASO-PHARYNX. 133 berg’s1 with trigeminal neuralgia there was found almost complete destruc- tion of the Gasserian ganglion from pressure of an internal carotid aneurism which caused atrophic softening. Reflex neuralgia may depend on three causes,—local disease or irritation of the peripheral ends of the sensory nerves, alteration of the nerve-centres, and morbid conduction of the nerve-trunks. Anatomical changes in the nerve-terminals and branches are rare, and inflammation or neuritis is exceedingly uncommon. We can have pain from morbid action in the sensory root of the nerve without any peripheral irritation; or a peripheral irritation that would evoke no response in a perfect state of health can produce neuralgia when the nerve-centres are functionally altered. As post-mortem examination has seldom revealed any discoverable pathological alterations in the nerve- trunks or sensory nerve-centres of individuals who were victims of obsti- nate neuralgias, we must infer that the perversion of sensory function was due to alterations of nutrition from vaso-motor disturbances. If peripheral irritation is reflexly transmitted as a vascular disturbance to any part affected, it results in alterations of the circulation of that area, affecting more or less the nutrition of the nerves, with consequent perver- sion of their normal function. If the reflex impression involves the pos- terior root of the nerve, the resulting alteration of the sensory function is expressed by pain. Therefore reflex neuralgias of the trigeminus from intra-nasal irritation by pathological alterations of the nasal spaces, or by secretory and irritative changes, may primarily be due to vaso-motor paresis more or less pronounced. In subjects with morbid conditions of the nerve- trunks and with already lowered vitality of the sensory nerve-centres the local vaso-motor changes, the immediate result of the lowered vitality, can readily involve a greater or lesser area controlled by the nerves subjected to abnormal irritation. But if the centres are healthy, the local vaso-motor paresis could only involve the nerve-trunks after a long continuance of the peripheral irritation, the length of time that such effect could be brought about depending on the greater or less perfection of the centres, and their corresponding resistance to implication in the pathological process. This explains why the same abnormalities in the nasal passages produce neu- ralgias in some individuals and not in others, and may also explain the different expressions the neuralgias assume in different individuals, the conduction of the nerve-trunks, and the healthy resistance of the ganglionic connections and nerve-centres, being as varied as muscular strength, powers of endurance, or intellectual capacity. Probably chorea (the so-called delirium of the sensori-motor ganglia) and choreiform convulsions have been the least observed of all the reflexes CHOREA. 1 Disease of the Nervous System, Syd. Soc. Trans., vol. i. 134 NEUROSES OF THE NOSE AND NASO-PHARYNX. supposed to be connected with nasal troubles. Cases of chorea partial or general have been reported by Elsberg,1 B. Fraenkel,2 Jacobi,3 J. L. Sal- linger,4 Bosworth,5 Coriveaud,6 Lichtwitz,7 Peltesohn,8 and the author.9 Jacobi has seen a dozen cases of complete chorea cured by nasal treat- ment alone. The only case I have seen thus cured was a partial chorea, reported in my paper read before the North Carolina Medical Society. Fraenkel’s, Liclitwitz’s, and Peltesohn’s were cases of so-called “con- vulsive tic,” a species of chorea with rapid contractions of a few muscles limited to one side of the face. I have included these under chorea, because these partial convulsions have been known to develop into general chorea. Schech’s 10 and Seifert’s11 cases of spasmodic contraction of the palatal and faucial muscles, already referred to, were a species of chorea limited to these muscles. These choreiform convulsions have been found associated with rhino- pharyngitis, deflections of the septum, tonsillar hypertrophy, adenoids, etc. Their cure by the nasal treatment is the clinical evidence of their relation- ship with the nose, and we have no other evidence to prove that general eclampsia can result from intestinal irritation, or that local convulsions can come from local irritation. Dr. Bosworth12 says that no satisfactory con- nection has been shown between chorea and nasal disease, and he attributes the cure by nasal treatment to the building up of the general health by im- proving respiration and digestion on the one hand and removing a focus of peripheral irritation in a neurotic individual on the other. This applies equally to all reflex manifestations, of whatever nature. They can occur only in neurotic individuals, and must either be due to long-continued peripheral irritation or proceed from a diseased ganglion or nerve-centre whose functional perversion may be awakened by external influences that in a normal condition of the nervous system would produce no effect. We are dealing with theory merely when attempting to explain any reflex phe- nomena, and the only question is which theory is most rational in regard to chorea. That of vaso motor alterations, vaso-motor palsy, seems most gen- erally applicable, on the supposition that the vascular changes bring about muscular contraction and muscular spasm, or perverted muscular action. 1 Archives of Laryngology, vol. iv. p. 1883. 2 Berliner Klinische Wochenschrift, No. 28, 1884. 3 Partial and sometimes General Chorea Minor from Naso-Pharyngeal Reflex, Ameri- can Journal of the Medical Sciences, April, 1886; and Nasal-Reflex Chorea, New York Medical Record, May, 1890. * Polyclinic, Philadelphia, June, 1887. 5 Deformities of the Nasal Septum, New York Medical Record, January, 1887. 8 Journal de Medecine et de Chirurgie Pratiques, March, 1888. 7 Loc. cit. 8 Berliner Klinische Wochenschrift, No. 32, 1891. 9 The Nose: its Criminal Aspect, etc., North Carolina Medical Society, 1888. 10 Munchener Medicinische Wochenschrift, No. 12, 1886. 11 Internationale Klinische Rundschau, No. 19, 1887. 12 New York Medical Record, May 17, 1890. NEUROSES OF THE NOSE AND NASO-PHARYNX. 135 Troubles of sensation, troubles of sight, troubles of innervation in the appa- ratus of organic life, palpitation of the heart (ansemic bruit), vertigo, noises in the ears, etc., which sometimes accompany chorea, are effects elsewhere seen of vaso-motor paresis. The fact that the paralysis which is sometimes present during and which usually precedes the convulsions is always most pronounced in the part where the convulsive movements are greatest, seems to indicate that the contractions of the muscles are due to lack of nerve-control over them, which might result from impairment of nerve-nutrition caused by vaso- motor paresis. There is not an excitation of nerve-force, an explosion of nerve-energy, as so often stated, but a depreciation of nerve-force, or a loss of the nerve- control which regulates the contractions of muscles. These contractions are similar to the unconscious movements of the drowning, which Dr. B. W. Richardson1 says are simply the result of the action of muscles from which the controlling power of the nerve-centres has been removed. Epilepsy.—Epilepsy due to nasal troubles has been reported by Hack,2 Loewe,3 Elsberg,4 Schmaltz,5 Fincke,6 A. Cartaz,7 Sallinger,8 McBride,9 Heryng,10 Bosworth,11 Dress,12 Crossfield,13 Schneider,14 Abramson,15 the author,16 and others. Schneider reports six cases in his own experience, all cured by treatment of the nose, being dependent upon the irritation caused by polyps, exostoses, hyperplasia, angioma, etc. Similar cases re- corded were from similar and other intra-nasal changes. Vertigo from nasal irritation has been reported by quite a number of authors, Hack,17 four cases, Heryng,18 three cases, E. Fraenkel,19 two cases, Gennaro,20 Joal,21 nine cases, of which Fauvel supplied three, Cadier one, and Ruault one. Schmaltz,22 Massei,23 and others also report similar cases. EPILEPSY, VERTIGO, APROSEXIA, ETC. 1 Braithwaite’s Ketrospect, July, 1891, p. 255. 2 Loc. cit. 3 Loc. cit., Allgemein. Med. Central Zeitung, No. 76, 1882. 4 Loc. cit. 6 Deutsche Medicinische Wochenschrift, No. 4, 1885. 7 La France Medicate, Nos. 89 and 90, 1885. 8 Loc. cit. 9 New York Medical Kecord, vol. xxix. p. 137. 10 Loc. cit. 12 American Bhinological Society, 1887. 13 American Medical Association, Meeting of 1889. 14 Berliner Klinische Wochenschrift, No. 37, 1889. 13 Loc. cit. 17 Berliner Klinische Wochenschrift. 18 Loc. cit. 20 Archivij Ital. di Laringol., October, 1886. 6 Loc. cit. 11 Loc. cit. 16 Loc. cit. 19 Loc. cit. 21 Le Vertige Nasal, Bevue Mensuelle de Laryngologie, etc., July, 1887. 22 Loc. cit. 23 Patologia e Terapia della Faringe, delle Fosse Nasale, etc., Milan, 1890. 136 NEUROSES OF THE NOSE AND NASO-PHARYNX. The authors attempt to explain these as a reflex phenomenon from the nose, the intra-nasal changes by way of Meckel’s ganglion causing localized vaso-motor alterations and anaemia in the brain. Whilst this may be so, it is not worth while to go out of the way for such an explanation, when in all probability these cases belong to the cate- gory of “aural vertigo,” the same intra-nasal changes being capable of causing sufficient pathological conditions of the Eustachian tube, drum- cavity, etc., to bring about vertigo from alterations in the aural circulation. Aprosexia.—Another nasal reflex dependent upon the connection be- tween the nose and the brain, which Guye1 has called aprosexia, being inability to fix the attention, loss of memory, etc., has been treated of, not only by this author,2 but also by R. Hingston Fox,3 Brugelmann,4 Mas- succi,5 Rumbold,6 William Hill,7 M. Bresgen,8 and others. Melancholia and other mental troubles have been also referred to as occasionally dependent upon nasal irritation causing intra-cranial circula- tory disturbances by reflex vaso-motor changes. Such troubles, especially epilepsy from nasal disease, were supposed by Hack to be partially explained by a direct communication between the nasal passage and the subdural and subarachnoid spaces. Flatau’s9 investigations into the lymphatics of the nose, the subarach- noid space, and the meninges confirm the close relationship of the nose and brain through the lymphatic channels. The intimate connection between the intra-nasal and the intra-cranial circulation might also help to explain the ready transmission of changes in the nasal circulation to the brain with resulting vaso-motor paresis and anaemia, but the only demonstration of the relationship between the nose and these cerebral symptoms is a clinical one. There is no question about the improvement effected in the mental condition of many children by removing adenoids and relieving nasal obstruction from whatever cause, but we can only theorize in regard to the explanation of the phenomenon. STOMACH. That the stomach and the nose have both a direct and a reflex relationship is evident: direct, because the mucosa of the nose is continuous with that of the pharynx, oesophagus, and stomach, and nasal secretions often pass into the stomach involuntarily, and can under certain circumstances produce gastric disturbances,—even vomiting; reflex, because the innervation of 1 Keflex Neuroses of Nasal Origin, British Medical Journal, July, 1887. 2 British Medical Journal, September, 1890. 3 Lancet, May, 1888. 4 Therapeutische Monatshefte, ii., 1889. 6 Lassegna Critica Internazionale, January, 1889. 6 American Khinological Association, September, 1888- 7 British Medical Journal, September, 1889. 8 Monatsschrift fur die Gesammte Sprachheilkunde, July, 1891. 9 Deutsche Medicinische Wochenschrift, No. 41, 1890. NEUROSES OF THE NOSE AND NASO-PHARYNX. 137 the stomach is by the pneumogastric, and if nasal changes can cause reflex manifestations in one part of its distribution they might do so in another. Gastralgia, indigestion, flatulency, vomiting, etc., have been recorded as produced by intra-nasal changes. Mackenzie (see his historical notice), Gennaro,1 Dress, Secchi, Buck,2 and others have called attention to this connection. On the other hand, a stuffy sensation about the nose has been observed by some authors as a sequela of indigestion or of overloading the stomach. Whilst I have never met with any cases of reflex troubles of the stomach that could be traced to intra-nasal disease, I have no doubt that such pathological conditions could be an etiological factor in digestive dis- turbances, because of an analogous case that fell under my observation some time back. A lady who suffered from repeated headaches due to defective convergence of the eyes, amounting at times to diplopia, was also a victim of such aggravated dyspepsia that she could eat very little, and only of a very limited bill of fare. Tenotomy of both external recti was performed, with resulting perfect convergence and complete disappearance of the head- aches. Curious, however, to relate, from the same date all signs of dys- pepsia or indigestion disappeared, and she could eat without discomfort anything put before her. In this case in all probability the general nervous disturbance from the strain of the eye-muscles had caused the digestive troubles, and, as patho- logical changes in the nose can bring about similar neurotic conditions from the peripheral irritation, it is not improbable that indigestion might thus result either from the reflex irritation of the pneumogastric or from the general neurotic disturbance. HEART. The manifestation of heart-disturbance from nasal irritation has been referred to incidentally by several authors, but especially by Hack,3 Kupper,4 Stanislaus von Stein,5 Thompson,6 and Palombieri.7 In Stein’s cases there was a sensation of heaviness, retraction, and pain, palpitation, vertigo, difficulty of breathing, and prseeordial weight, and the cure was effected by cauterization of the swollen inferior turbinated. GRAVES’S DISEASE. Graves’s disease, or exophthalmic goitre, is also a circulatory disturbance that has been reported as sometimes due to the reflex influence of nasal irritation by Hack,8 who treated a case of exophthalmic goitre associated 1 Archivij Ital. di Laringol., October 15, 1886. 2 New York Medical Record, August 18, 1888. 4 Deutsche Medicinische Wochenschrift, No. 51, 1884. 5 Monatssehrift fur Ohrenheilkunde, 1889. 6 Cincinnati Lancet Clinic, August, 1890. 7 Gazetta degli Ospit., August, 1890. 8 Deutsche Medicinische Wochenschrift, No. 25, 1886. 3 Loc. cit. 138 NEUROSES OF THE NOSE AND NASO-PHARYNX. with chronic rhinitis, and as the rhinitis improved the goitre diminished, the tachycardia vanished, and sight returned. Felix Semon,1 on the contrary, had this disease develop in one of his patients after an operation for nasal polypus who had no signs of it pre- viously. B. Fraenkel2 and Hopmann3 both report cases cured by the nasal treatment. Hopmann’s case had atrophic rhino-pharyngitis. In Fraenkel’s case electricity failed, and afterwards the nasal treatment succeeded. George Stoker4 presented a case to the Medical Society of London, November 25, 1888, in which he had effected a cure by cauteriza- tion of the middle turbinates after every other treatment had failed, and also related another similar case with like result. The pathologic condition in the nose was simple hypertrophic rhinitis. Musehold5 reports a case similar to the above of a woman who at the menopause manifested sundry nervous troubles, headache, palpitation of the heart, and pain in the cardiac region, followed by slow development of goitre and visual disturbance in the right eye, but very little exophthalmos. Examination of the nose showed hyperplasia of the inferior turbinate. Its removal was followed immediately by disappearance of the head- ache, three days later of the eye-troubles, and in seven days the nervous symptoms about the heart were gone. The goitre slowly and gradually disappeared after the nasal trouble was cured. Cozzolino also reports a case. These circulatory neuroses which have been demonstrated clinically to be connected with intra-nasal irritation may be due to the resulting vaso- motor changes, as they are all symptoms that can arise from temporary or continued disturbances of the blood-vessels diminishing the arterial supply consequent upon vaso-motor paresis, the area involved depending on the ganglion or reflex centre most affected. In this connection we might consider the possibility of that inexplain- able affection “ angina pectoris” without organic heart trouble being at times of the same causation, as it is usually denominated a vaso-motor neurosis, and has been known to have developed from pivoting a tooth,— i.e., from peripheral irritation of a branch of the trigeminus. SKIN DISEASES OF THE NOSE AND FACE. The relation between the intra-nasal tissues and the cutaneous surface of the nose and contiguous parts of the face has been recognized since the days of Willis and Sylvius, according to John N. Mackenzie.6 1 British Medical Journal, April, 1887. 2 Berliner Klinische Wochenschrift, No. 6, 1888. 3 Ibid., No. 42, 1888. 4 British Medical Journal, December 1, 1888. 5 Deutsche Medicinische Wochenschrift, February 4, 1892. 6 Loc. cit., American Journal of the Medical Sciences. NEUROSES OF THE NOSE AND NASO PHARYNX. 139 Bresgen,1 Elsberg,2 Schmiegelow,3 G. Hunter Mackenzie,4 and Lavrands have reported cases of erythema and erysipelas due to chronic rhinitis. Fenykovy6 tries to make out a connection between urticaria and nasal disease; Arnozan7 reports three cases of erythema and acne accompanying intra-nasal affections and cured by the treatment of the latter. Seiler8 adds a contribution to the clinical connection between intra-nasal and skin affections. Major9 (of Montreal) records four cases demonstrating this relationship. In the discussion of Major’s paper, Roe, Mackenzie, and Daly, whilst agreeing that erythema resulted from intra-nasal lesions, were not disposed to admit the connection of the latter affections with erysipelas. Delavan, how- ever, agreed with the author. I have seen erysipelas of the face follow the removal of polyps and the too energetic use of the galvano-cautery, and therefore am of the opinion that it could result from intra-nasal lesions, but that it was more probably the result of direct infection through arteritis via the naso-lobar artery and vein, first described by Fran§ois Frank,10 than of reflex action. The production of erythema, acne, etc., reflexly through vaso-motor alterations is easier to explain physiologically. The rubicund nose is a reproach and an annoyance to the unfortunate possessor, whether he is convivially inclined or not, and if it is dependent upon intra-nasal lesions causing vaso-motor changes in the cutaneous circulation it is a loop- hole of escape from this disfiguring affliction. As a case in point, I will relate the following. A few months ago one of my patients, a young man of most correct habits, who rarely indulged in stimulants of any kind, called on me for relief from a distressing tin- nitus aurium. His nose had unfortunately that peculiar red appearance so often supposed to be indicative of over-indulgence in drink. In looking for the cause of the noises in the ear I discovered a large spur growing from the left side of the septum and apparently united to the turbinated tissues opposite. After thoroughly anaesthetizing the nose with cocaine I used a probe to decide whether it had become adherent to the turbinate, and observed that the nose became redder from the irritation caused by the probe. Experimentally I continued the manipulation until the redness extended from the end of the nose to the bridge and up to the forehead above the frontal sinus. With the cessation of the artificial irritation the redness gradually subsided. The removal of the spur resulted in an absolute disappearance of the nasal erythema that had been present for several years. These reflexes of the skin can be explained only by vessel-disturbances resulting from the intra-nasal irritation. 1 Loc. cit. 2 Loc. cit. 3 Loc. cit. 4 Loc. cit. 5 Societe Scientifique Medicals de Lille, 1891. 6 Wiener Medicinische Presse, 1884. * Association Scientifique Franqaise, Toulouse, 1887. 8 Journal of the American Medical Association, November 5, 1887. 9 Transactions of the American Laryngological Association, May, 1889. 10 These Inaugurate, Paris, 1875. 140 NEUROSES OF THE NOSE AND NASO-PHARYNX. The importance of the connection between the nose and the sexual organs, whilst referred to previously, was first clearly established by John N. Mackenzie1 in an article referred to. Several other writers have since called attention to the same relationship. Ziem,2 Dress,3 Bloch,4 and Korner5 endeavor to prove a connection between adenoids and other forms of nasal obstruction and incontinence of urine, which they state was cured by treatment of the nasal trouble, but the explanation of this connection is not satisfactory. The sympathetic relations between the nose and the genital organs has been demonstrated again and again in the manifestations of local nasal reflex phenomena, such as sneezing, dyspnoea, epistaxis, etc., from irritation of the sexual apparatus, whether in periods of physiological activity or from dis- ease, by Mackenzie,6 Championniere,7 Buck,8 Joal,9 Peyer,10 and others. The special causes of reflexes of the nose and respiratory tract emanating from the genital organs are excessive abuse of their physiological function, the disturbances attending the advent of puberty, pregnancy, the menopause, chronic affections of the uterus and ovaries, and all the abnormalities of menstruation. SEXUAL ORGANS. NEURASTHENIA AND HYSTERIA The relationship of so-called neurasthenia, hysteria, and allied condi- tions of the nervous system to nasal disease is a mooted question. The statement that the general perturbation of the nervous system represented by these terms is at times a reflex disturbance from intra-nasal disease opens up to the nose and rhinologists a territory long since pre-empted by the uterus and gynaecologists. This invasion of a “staked claim” has been made by Dr. Polo,11 Dr. North,12 Dr. Daly,13 Dr. Potter,14 Dr. Marcel,15 of Bucharest, and others. Dr. Polo’s case of a girl with hysterical attacks was cured by cauter- izing the turbinates. Marcel’s case, who had convulsive movements, loss of consciousness, etc., for seven years, was cured by the removal of polypi. 1 Loc. cit. 2 Allgemeine Mediciniscbe Zeitung, No. 64, 1885. 3 Loc. cit. 5 Muncbener Medicinische Wochenschrift, July, 1890. 6 Loc. cit. 7 La Pratique Medicate, July, 1888. 8 New York Medical Record, August 18, 1888. 9 Revue Mensuelle de Laryngologie, etc., p. 74, 1888. 10 Ibid., December, 1889. 11 Gazette Medicate de Nantes, September, 1887. 12 American Rhinological Society, September, 1888. 13 Transactions of the American Laryngological Society, 1889. 14 Buffalo Medical and Surgical Journal, 1891. 15 Tenth International Congress, Berlin, 1890, 4 Loc. cit. NEUROSES OF THE NOSE AND NASO-PHARYNX. 141 The hysterical aura, instead of starting from the ovary and mounting to the epigastrium, etc., began with a pricking in the left nostril, passing with painful sensation to the forehead and then to the neck, with a feeling of strangulation. Dr. Daly’s cases suffered with insomnia, indigestion, mental irritability, etc., or symptoms of a general nervous disturbance, and were benefited by the nasal treatment. In 1888 I reported to the North Carolina Medical Society1 a peculiar case of hysterical manifestations, ending in a cataleptic condition, in the wife of a physician who had been the rounds to find relief for her. Anstie, Marion Sims, Hammond, and others were consulted. Each attributed her condition to a different causation. Her husband consulted me as to the possibility of intra-nasal irritation having anything to do with the symptoms. To bar all psychical element, he told her he wanted me to see if she had any nasal catarrh, as she complained of a stuffy feeling about the nose. Curious to relate, the moment a probe was passed into the nasal passages an attack was developed, and she remained unconscious for hours. Even the irritation from a spray to the nostrils brought on an attack. The nasal treatment resulted in great amelioration of all the symptoms, and to this day, four years after, the improvement has continued. Such cases as these only show that the possibilities of peripheral irrita- tion in certain conditions of the nervous system, whether in the nose or elsewhere, are almost illimitable; but it is well to confine ourselves within proper limits in attempting to prove a definite connection between the nervous manifestation and the existence of pathological changes in the nasal spaces. Dr. J. Solis Cohen sounded a note of timely warning in his article “Look beyond the Nose/’2 and the rhinologist should not be led into the conclusions of a narrow specialism in considering this question. Even when the nervous phenomena are thus seemingly benefited by removing abnormalities from the nose, or by cauterizing swollen nasal tissues, we cannot with certainty say that the same result might not have come from revulsives elsewhere applied, or that the effect was not psychical. Schreiber,3 for example, in a discussion on this subject, in 1885, reported cough cured by cauterizing the neck, and epilepsy and hysteria, without any discoverable deviation from the normal condition in the nose, cured by cauterizing the nasal tissues. Such observations have also been made by others. That a certain irritability of the nervous system exists in a number of cases, due to functional alterations of the nerve-centres from different causes, inherited or acquired, such as lithsemia, e.g., in which any hind of peripheral 1 Loc. cit. * New York Medical Journal, September 27, 1890. 3 Berliner Klinische Wochenschrift, No. 33, 1885. 142 NEUROSES OF THE NOSE AND NASO-PIIARYNX. irritation will make manifest this latent depreciation of nerve-function in various ways, has been already stated. That these manifestations can originate in the irritable nose has been made sufficiently evident; but that the central nervous disease or so-called “ neurasthenia” is primarily the result of such nasal irritations I do not think can be demonstrated. The modification or disappearance of the nervous expressions of such a neurotic condition from suppressing the intra-nasal irritability does not prove that the central disease is due to the latter. That this neurotic state can coexist with pathological alterations of the intra-nasal tissues without any objective symptom of it, has been demonstrated by Dr. Chappel1 and others, who have observed different expressions of this irritability of the nerve-centres, manifested as the result of intra-nasal operations, even pro- found nervous prostration and cataleptic conditions, similar to the case I have mentioned. That the pathological state of the nervous system did not originate from the operation, goes without saying, but the local irritation set up by the latter manifested symptoms of the latent conditions through the transmis- sion to nerve-centres functionally perverted and ready for the development of reflexes. In the one class of cases the intra-nasal lesion was sufficient to make manifest the latent perversion of function, in the other the additional irrita- tion from the operations was the straw that broke the camel’s back. It was simply a difference in the degree of internal resistance, or a difference in the extent of central disease. This is the basis of all reflex neuroses, whether from the nose or from other parts of the organism. To claim that the central disease or neurotic state is caused by the peripheral irritation, whether idio- pathic or traumatic, is to make local applications and surgical intervention everything, and to do away with the necessity of constitutional treatment, which is really the foundation of rational therapeutics in the management of nasal reflex neuroses. Etiology of Nasal Reflex Neuroses in General.—From the facts and theories here presented it can be seen that the various neuroses mentioned are simply expressions of perverted nerve-function of different areas of the cerebro-spinal and sympathetic systems, dependent upon many different causes, and that they can be awakened by the irritation of any sensory nerve. If the location of the peripheral irritation is in the nose, we are dealing with “ nasal reflex neuroses.” This irritation is transmitted by the sensory filaments of the trigeminus affected to their respective ganglia, where if it meets with healthy resistance and normal nerve-control no neurotic mani- festation follows. A continuance of the irritation, however, may eventually bring about disturbance in a healthy ganglion resulting in a reflex vaso- motor impulse in the area whose vessels are controlled by that ganglion. 1 New York Medical Record. 1890. NEUROSES OF THE NOSE AND NASO-PHARYNX. 143 The afferent sensory impression is transformed into an efferent vaso-motor projection. If the normal nerve-control of the ganglion and other ganglia in correlation with it is already impaired from such causes as have been mentioned, the impression will be reflexly transmitted from ganglia to ganglia, and will produce vessel-disturbances where it meets the least healthy resistance, or in the area controlled by the ganglion whose physio- logical functions are most impaired. If the role of the sympathetic ganglia is control of vaso-motion, any interference with it would result in more or less pronounced circulatory alterations which could bring about perversion of function in the part affected. To hold that such an effect is due to unhealthy nerve-action is rational; to attribute it to increased physiological activity, or to an “ explo- sion” of stored-up nerve-force, as seems to be the teaching of some physi- ologists, appears illogical, because in no unhealthy state can there be any increase of physiological activity. When a function is physiologically altered or perverted, we have a pathological condition, and in all pathological conditions there is disease more or less pronounced. It may not be demonstrable anatomically, but it is there all the same. Circulatory disturbances, vascular changes, can produce more rapid results than any other pathological state. How rapidly circulatory disturbances from emotional influences manifest themselves in immediate syncope, sometimes in the strongest man, the effect of a mental impression on the vaso-motor centres controlling the heart’s action and the arterial supply of the whole body ! and in this condition there is general impairment of nerve-control, often accompanied by convulsive movements. Why cannot vaso-motor disturbances limited to a circumscribed region produce a corresponding impairment of nerve-function in this area, with resulting perverted nerve-action, the exciting cause being a limited periph- eral irritation instead of a general emotional influence? Whilst I admit that this theory of vaso-motor paresis being the main pathological condi- tion in the production of reflexes has objections, I think it the most accept- able explanation, if the perversion of nerve-function or loss of nerve-control, partial or complete, can be due to alterations of the local circulation. The immediate result of vaso-motor paresis is contraction of the nerve- arteries (vaso-constriction) and venous hypersemia, with temporary inter- ference with the circulation. Pain, muscular spasm, and secretory disturb- ances make up the whole category of these reflexes, and are all manifesta- tions of perverted action of nerves controlling sensation, motion, and vaso-motion. If alterations of their circulation are brought about, their nutrition is impaired and their physiological functions are perverted. An apparently similar exhibition of functional disturbances may be brought about by direct irritation of a sensory or motor nerve from injury, inflammation, etc., or by indirect irritation whether by electricity or other cause; but this disturbance is due to increased functional activity of the 144 NEUROSES OF THE NOSE AND NASO PHARYNX. branches and trunk of the nerve immediately affected, quite a different tiling from a perversion of function by a reflected impression through its sympa- thetic connections. In the one case it is increase of function accompanied by active or arterial hypersemia, in the other it is perverted action with passive or venous hypersemia, and wherever there is venous hypersemia there is inter- ference with nutrition. In the former the disturbance is local at the seat of irritation, in the latter it is at a distant point in the area of the ganglion offering least resistance to the transmitted impression. This impression can be started by any cause in the naso-pharvngeal mucosa that would set up local irritation of the sensory filaments of the trigeminus, and possibly of the sympathetic filaments as well. A reflex vaso-motor alteration anywhere in the naso-bronchial mucous membrane can from the resulting disturbances establish secondary foci of irritation. Hence we may conclude that every part of the respiratory tract may be primarily or secondarily the starting-point of the peripheral irritation, the nasal spaces, however, and especially the region of the middle turbinate, the posterior portion of the inferior turbinate, and the septum opposite, being the area most frequently involved. Diagnosis.—The diagnosis of “ nasal reflex neuroses” is at times very difficult. The test by cocaine anaesthesia in many cases may determine the dependency of the neurotic phenomena upon intra-nasal irritation, but in others this must be done by the exclusion of other probable causes. The examination of the nose may reveal sufficient deviations from its normal condition to make it the possible source of the peripheral irritation, but this would not confirm the diagnosis. As already said in regard to asthma, there may be pathological states of the nose accompanying neurotic manifestations without any etiological con- nection between them, and there may be neurotic phenomena dependent upon nasal irritability without the slightest demonstrable abnormality on the intra-nasal tissues. In these latter cases the excessive irritability usually due to slight vaso-motor changes in the nasal mucosa can often be demonstrated by artificial stimulation with the probe in the reproduction of the reflex, and this test should be always made use of. Its failure, however, does not bar the possibility of a nasal causation, as structural changes may have taken place from long-continued disease that would interfere with a successful demonstration by this means. Prognosis.—The prognosis in nearly all cases where the nasal causa- tion can be demonstrated is good. But no fixed rule can be laid down in this regard, as we have to take into consideration the peculiarities of each case. The nature of the pathological lesions originating the peripheral irritation, the extent of the secondary alterations in the respiratory tract or other areas affected, the kind of disturbance in the central nervous system, and the length of time it has existed, are all to be regarded in giving an NEUROSES OF THE NOSE AND NASO-PHARYNX. 145 opinion. The younger the patient, the shorter the time the nervous phe- nomena have lasted, and the less the nervous system is involved, the more favorable the prognosis. Treatment.—The treatment is both local and constitutional. In the simpler forms of reflexes due primarily to irritation of the naso-bronchial tract, with but slight functional perversion of the sympathetic nerve-centres, itself due probably to continued peripheral irritation, local treatment alone may effect a cure. A cough, an asthmatic paroxysm, a neuralgia of the trigeminus, or other reflex phenomenon traceable to nasal disease, either known or unsus- pected, can be radically cured by doing away with the source of irritation in the nasal spaces, provided the accompanying central disturbance, which results in these perversions of nerve-function, is principally due to the impression made by continued transmission of the peripheral irritation to hypersensitive nerve-centres. The transmission of the irritation being cut off by its suppression at the periphery, the nerve-centres are allowed to rest, the perversion of func- tion ceases, nerve-control is restored, and the reflex phenomena disappear. The removal of a nasal polyp, the shrinkage of an enlarged turbinate, the cauterization of peripheral nerve-filaments, etc., will bring about, under these circumstances, seemingly magical results. But if this functional alteration of the nerve-centres from peripheral irritation, whether from the nose or from distant organs, has existed a long time, if the perversion of nerve-action is due to central changes from inherited or acquired disease, lowering the resistance of the ganglia and making them ever ready to respond to the slightest irritation in a mani- festation of reflex phenomena, local treatment alone will not prove effi- cacious. The groundwork of rational therapeutics will then be in such consti- tutional remedies as will restore tone to the nerve-centres, increase their control over nerve-action, and prevent a ready perversion of function. This is all the more important inasmuch as we may safely conclude that the irritation which brings about perverted functional manifestations in an area dominated by this or that ganglion may start in the ganglion itself, if already diseased, from causes the most remote and unexpected. When nasal disease accompanies such reflex phenomena, it is surely rational to use proper measures to restore the nose to its normal condition, even when the connection between them cannot be proved, as it is a focus of possible peripheral irritation. Its restoration to proper symmetry, by the resulting improvement in respiration and better oxygenation of the blood, assists in the main object of the constitutional treatment, the toning up of the nerve-centres. The local treatment is therefore to do away with all intra-nasal irritation, whether due to pathological formations or to simple vascular alterations. The treat- ment of and operations for all pathological formations, such as polyps, 146 NEUROSES OF THE NOSE AND NASO-PHARYNX. growths, deflections of and cartilaginous and osseous projections from the septum, turbinated hypertrophies, adenoids, etc., will be found described in another part of this work. Their removal is essential to a successful treat- ment of “ nasal reflex neuroses.” But it is equally essential to get rid of all intra-nasal irritability, whether accompanied by pathological formation or not. This may be limited to a circumscribed area or areas, and, whilst they vary occasionally in my experience, the middle turbinated tissue and the septum opposite constitute the area most commonly involved. I have carefully observed hundreds of cases of supposed nasal reflex neuroses, and in a very large majority of them, even when other marked pathological alterations are lacking, the middle turbinate will by anterior rhinoscopy be found approximating so closely to the septum that a very fine probe cannot be passed between the two. Apply my palate retractor (described under the heading of “ methods of examination”), and a puffy appearance of the mucosa over the vomer will be observed which cannot be seen by anterior rhinoscopy nor by the ordinary methods of posterior examination. Both the approximation of the middle turbinate to the septum and the puffiness over the vomer are abnormal; and such abnormalities should be corrected. Accompanying them there is sometimes turgescence of the inferior turbinates, but not obstructive swelling. If there is any irrita- bility it must be done away with. The application of chromic, nitric, or trichloracetic acid, or the galvano-cautery, will accomplish these ends. The galvano-cautery is the best agent, because more thoroughly under the control of the surgeon. A skilful operator can so regulate it that he can get any effect he wishes, great or small, superficial or deep, if he has appropriate apparatus, and this can be done in the posterior as easily as in the anterior nares, provided the palate-retractor is used. This treatment is sometimes followed by a temporary aggravation of the symptoms, which, however, gradually subside and may entirely dis- appear. But such a result would in all probability be only a temporary improvement unless proper constitutional treatment were substituted. That intra-nasal operations, however, are not unattended by some risks, even of aggravating or producing reflexes, and that great care and a judi- cious selection of cases for such work are necessary, seems to be proved by the reports of different writers. Betlii,1 Aronsolm,2 Semon,3 Rosenberg,4 Laurent,5 Treitel,6 Lermoyez,7 report the development of asthma, laryngo- 1 Internationale Klinische Rundschau. Nos. 51 and 52, 1889. 2 Deutsche Medicinische Wochensehrift, No. 17, 1889. 3 Loc. cit. 4 Berliner Klinische Wochensehrift, No. 2, 1889. 5 Annales des Maladies de l’Oreille, etc., July, 1890. 6 Berliner Klinische Wochensehrift, Nos. 16 and 17, 1890. 7 Annales des Maladies de l’Oreille, etc., February, 1891. NEUROSES OF THE NOSE AND NASO-PHARYNX. 147 spasm, amblyopia, neuralgia, Graves’s disease, etc., from intra-nasal cauteri- zation, and this of itself demonstrates that intra-nasal irritation can bring about reflex phenomena. But it also teaches that operative measures are to be instituted only after the closest investigation into the condition of irrita- bility of the nasal mucosa, and a careful consideration of the peculiarities of the individual. These unfortunate sequelae of cauterization were prob- ably due to a too energetic use of the acid or galvano-cautery, for which there is hardly any necessity, as there is no demand for such destruction of the tissues as would result from this method of operating. Suppression of the peripheral irritation by superficial cauterization that will involve only the peripheral filaments of the sensory nerves and the superficial net-work of blood-vessels is all that is required in my experi- ence, and if one application of the cautery does not prove sufficient it can be repeated; quite as reliable a procedure, and an infinitely safer one. This local treatment, however, whilst of great importance, is only secondary to the constitutional management of such cases, which should be continued for a long time to insure permanent benefit. The alteration of the nerve-centres is the result of a chronic process, and should be accord- ingly treated. Any existing dyscrasia should receive appropriate consideration; syphilis and lithsemia especially should be looked for, and their effects neutralized. Any existing gastric and intestinal troubles should be corrected. Diseases of the genito-urinary organs calculated to keep up the lack of nerve-control in the sympathetic and cerebral centres must have proper attention. The whole object of treatment is to restore tone to nerve-centres of lowered vitality which through impoverishment of nutrition have lost their control over the nerves in the area dominated by them, and exhibit in consequence the perversion of their normal functions known as reflex neuroses. We wish, then, to improve their nutrition, do away with vaso-motor paresis, and restore nerve-control. As the object is to improve nerve-force and not to lessen it, stimulants in moderation will be very useful. Arsenic, mercury in tonic doses, strychnine, phosphorus, pilocarpine, zinc, quinine, etc., are the remedies I am in the habit of using. Arsenic can be employed in the form of either Fowler’s or Donovan’s solution, the latter probably the better, and it should be continued until its constitutional effects are produced, when it can be intermitted awhile and then resumed. A valuable prescription in these cases is the following: R Strychninse sulph., gr. v ; Pilocarpin. muriat., gr-. vii; Hydrarg. bichlorid., gr. iv.—M. Ft. pil. no. c. Sig.—One after each meal. This is usually continued for at least three or four months, and the improve- ment in many cases is rapid and continuous. It fulfils the indications given 148 NEUROSES OF THE NOSE AND NASO-PHARYNX. above in speaking of the treatment of the asthmatic paroxysm, for the application of drugs in such cases. Dr. John N. Mackenzie specially recommends the following combination: R Zinci phosphid., gr. T*5; Quin, sulph., gr. ii; Ext. nuc. vomic., gr. Ft. pil. no. i. To be taken before meals. Of course the treatment must be varied to suit the indications of each case, as every individual is a law unto himself, and the observant physician will be guided accordingly. DISEASES OF THE EYE DEPENDENT UPON DISEASES OF THE NOSE, AND REFLEX NASAL DISEASE DUE TO OCULAR MALADIES. BY GEOKGE M. GOULD, A.M., M.D., Ophthalmologist to the Philadelphia Hospital. Unless very well bred, close neighbors are apt to develop considerable friction in their domestic relations, and this is especially true if the bound- aries of their respective lots are not well determined. Besides this, if a house-drain from one empty in the middle of the other’s garden, good- fellowship is almost certain to be disturbed. The bearing of this homely rule as to the relations of the eye and the nose is evident. And yet it may be confidently questioned if the practical attention to it in the daily practice of the rhinologist and the ophthalmologist is nearly so routine as is either etiologically justifiable or therapeutically desirable. Judging from the text-books and from current literature, it would appear that the specialist is very prone to think of the organ he is especially and for the time interested in apart from its relations to other organs. The rhinologist thinks only of the nasal cavities, the ophthalmologist only of the eye, whereas the cause of disease as well as the effects may lie in the adjacent organ. It is a matter of the commonest knowledge, of course, that an important canal forms a direct means of intercommunication between the two structures, the fact of a common blood-supply to many parts is known, and the knowl- edge of the possibilities and of the multiplicity of forms of reflex neuroses is slowly becoming a prerequisite of diagnostic skill. The difficulty lies in practically acting upon and utilizing the vague knowledge we have. It is frequently observed that a bright light produces in many people violent sneezing. I had a patient in whom pressure upon the inner canthus of the eye aroused an immediate sneezing-fit. The lachrymation and other ocular phenomena coincident with measles, a common cold, etc., should keep us alert to suspect more serious and deep-seated pathological inter- dependencies of the two organs. It is needless even to recapitulate the anatomical bases of these rela- tions : the mucous membrane of the nose, continuous through the lachry- mal excretory apparatus with the conjunctiva, forms the readiest means for 149 150 DISEASES OF THE EYE DEPENDENT UPON the transfer from one to the other of morbific material; the anterior eth- moidal artery, a branch of the ophthalmic, the capillary supply of the sac and duct, and the anastomoses of the veins from each, all show that vaso- motor disturbance in one part may be felt in the other; and the common supply by the trigeminus and other related ganglia shows the mechanism of neurotic associated or anomalous function. Many attempts have been made to particularize the exact types of dis- ease in either structure that are the effects of disorder in the other. Among the earliest investigators to attempt this, as well as to call attention to the fact of the pathological relations themselves, was Hack, in a monograph on the operative radical cure of migraine, asthma, hay-fever, etc., and of cer- tain ocular complaints. He traces to congestion of the cavernous spaces and the consequent nasal obstruction or stenosis, ocular effects such as con- junctival congestion, swelling of the lids, epiphora, lachrymation, photo- phobia, etc. Hypertrophy of the nasal mucous membrane, polypi, rhinitis, deviation of the septum, and the like, also induce similar or particular forms of ocular affections. Berger1 finds in chronic hypertrophic rhinitis the chief source of ocular troubles, which he divides into five classes: 1, pain, smarting, or burning of the lids or globe, with injection; 2, photophobia; 3, lachrymation; 4, narrowing of the palpebral opening from blepharospasm ; 5, ciliary and conjunctival congestion. Probably the most systematic attempt to particularize the specific groups of these affections and define certain effects in the eyes as due to peculiar nasal anomalies is that of Gradle,2 who thus groups the symptoms of the eye: 1. Lachrymation without primary lesion of the tear-passages or of the eye, and due to some chronic abnormality of the nasal passages. 2. Fulness of the lids and itching, possibly with lachrymation and more or less pain in the eyes, and with asthenopia especially marked in one eye. Patients with these symptoms aggravated have also a refraction or muscular anomaly. In both classes of cases there coexists irritability of the vessels of the nose and of the mucous membrane of the anterior and sometimes of the middle turbinated bone, the submucous cavernous tissue being permanently enlarged. A large majority depend upon what the author terms “ irri- table nose,”—i.e., liability to sudden engorgement of the blood-vessels from slight causes, with sneezing and a watery discharge. The primary lesion is often polypi, but more commonly it is catarrhal inflammation. 3. Periodic discomfort and itching of the lids, allied to hay-fever, co- existing with conjunctival lesions, at first of follicular enlargement, but finally of the formation of large flat yellowish follicular granules, which disappear in the winter. 1 Journal de Medecine de Paris, February 28, 1892. 2 Archives of Ophthalmology, xvi., New York, 1887. DISEASES OF THE NOSE. 151 4. Photophobia, with or without pain in the eyes, these being often bloodshot, with little nasal annoyance, but decided itching. 5. Injection of the pericorneal vessels, together with varying degrees of the above symptoms, chronic and persistent. 6. Acute congestion of the lids, with irritable nose, erysipelatoid in character, subject to recurrence, lasting from two to six days. 7. Sudden oedema of the lids, without congestion, the attack lasting a few hours. In the present state of science the attempt to trace such sharp etiological and symptomatological groups seems premature, and must lead to a refinement and multiplication of divisions and symptoms savoring not a little of Hahnemannian casuistry. We must be content patiently to gather facts and slowly to systematize from them before any enduring framework of certain science can be established. Hence the present paper will attempt no finished system-building, but will content itself with little more than a mere enumeration and epitomization of the observations that have been put on record. It is evident that all the facts to be considered fall naturally into two large groups : I. Those starting in pathological conditions of the nose (or adjacent structures commonly included in the rhinological study) and re- sulting in ocular disease. II. Those commencing in the eye and ending in the nose. The methods of the communication or causation of these morbid condi- tions yield in each class the subordinate groups into which all fall,—some- what as follows: 1. The pathological condition may result from congenital or developmental abnormalism. 2. The intermediation may be purely mechanical. 3. The lachrymal excretory apparatus may serve simply as the passage-way for the transfer of morbific material from one organ to the other. 4. The morbid condition may be transferred by direct continuity and extension of tissue, of the mucous membrane, the skin, muscles, ves- sels, periosteum, or bone. 5. The relation may be established by neurotic reflex. The consideration of the last group, the highly important and interest- ing class of nasal reflexes ending in ocular diseases, is presented by another writer in this work. It is my duty to review the four other groups, including those reflex phenomena starting in the eye and ending in the nose. In passing, it may be said that it is often impossible to distinguish clearly between symptoms that might be classed as nasal reflexes or as due to vascular or other influences. Many that have been considered reflex are doubtfully so. A number of such cases are reported by Lieven,1 but in these instances the channel whereby the ocular affections become secondary to nasal abnormalities is chiefly neurotic in character. Parenthetically allu- 1 Deutsche Medicinische Wochenschrift, December 1, 1892. 152 DISEASES OF THE EYE DEPENDENT UPON sion may be made to a method of differential diagnosis often service- able in such cases. This consists in the application of cocaine to the nasal cavities. If the ocular symptoms cease, the lesson is obvious,—though even here some fallacy may be hidden, owing to the action of cocaine upon the capillaries and their congestion, with distant effects not entirely neu- rotic. Practically, of course, the distinction is of little moment, and the excellent procedure is allied in usefulness to that too little employed by physicians, consisting in the paralysis of the accommodation to differentiate between headache and other reflexes, whether due to ocular or to other causes. In reviewing the literature at command, one is struck by the fact that in the vast majority of cases the nose is the point of departure of the morbid process; the eye more seldom setting up disease in the nose,—the excretory lachrymal apparatus, of course, being considered in its entirety as an ocular structure. In conjunctivitis, even of the purulent varieties, the primary affection of the eye does not infect the nasal cavities. The greater sensi- tiveness of the eye to pathogenic micro-organisms is a noteworthy fact. The nasal mucous membrane is not for them so favorable a breeding- ground. Bresgen1 speaks of this, noting that in primary acute conjuncti- vitis the nose is seldom affected, whilst in acute coryza the eye is affected. He cites Moauro as having found in two cases trachomatous granulations in the adenoid tissue of the lachrymal canals. The diphtheritic membrane but rarely forms on the eyes, whilst croup and erysipelas do not extend from one structure to the other, nor does tuberculosis of the conjunctiva. Knapp2 has described a case of lupus of the nasal fossae propagated towards the lachrymal canal and producing symptoms of dacryocystitis. On the other hand, Bresgen says syphilitic coryza never extends to the conjunctiva. I.—PATHOLOGICAL CONDITIONS OF THE NOSE SECONDARILY AFFECTING THE EYE. CONGENITAL OR DEVELOPMENTAL ANOMALIES OF THE NOSE OR ADJACENT STRUCTURES INJURIOUSLY AFFECTING THE EYE. Berger3 reviews the congenital malformations of bones forming the pneumatic spaces surrounding the orbit and their influence on the form and functions of the eye. The distance between the eyes may thus be sub- normal, with consequent insufficiency of the internal recti, or divergent strabismus. If the ethmoid is abnormally large, corneal astigmatism may result from the abnormal insertion and function of the recti muscles. If the anterior ethmoid cells are over-developed, they may occasion stenosis of the osseous naso-lachrymal canal. Reference is made to Nieden, who ob- served congenital narrowness of this canal, with epiphora, etc., in several 1 Journal de Medecine de Paris, February 28, 1892. 2 New York Academy of Medicine, January 20, 1890. 8 Journal de Medecine de Paris, February 21 and 28, 1892. DISEASES OF THE NOSE. 153 members of one family. Over-development of the sphenoid is in the same way charged with producing congenital optic atrophy, and the charge has been proved by post-mortem examination. Berger further discusses the relation of discoloration of the optic nerve with or without diminution of the visual acuteness, etc., and of complete atrophy, as due to compression of the optic nerve in the optic canal. The atrophy termed “ Leber’s disease” arising in persons from eighteen to twenty years of age he considers due to the fact that at this age the growth of the sphenoid bone ceases. The irregular development of other bones of the base of the skull, exercising compression on dilferent parts of the nervous system, would explain other symptoms of Leber’s disease. Ziem1 contends that when the nasal cavity and the ethmoidal cells are developed asymmetrically, and the distances of both orbits from the median line are unequal, it follows when the eyes converge towards the median line that the performance of adduction differs for each rectus internus muscle, and this may lead to asthenopia and finally to strabismus. Ziem further states that as the breadth of the floor of the orbit is in proportion to the distance of the lateral and median walls of the maxillary cavity, asymmetry of the orbit must be brought about by asymmetry of the maxillary cavities. Welcker found this proportion actually present in twenty-one out of thirty- seven skulls which showed oblique direction of the nose. Ziem demon- strates the frequency of astigmatism with asymmetry of the face and orbit in chronic obstruction of the nose on one side. Dunn2 says that it is in the highest degree probable that continuous nasal obstruction in early childhood delays the development of the orbital plate of the ethmoid bone, as well as of the rest of the ethmoid bone, it being an integral part of this bone, and, if so, the orbit is necessarily pre- vented from developing properly. He finds in this the explanation of the fact that the majority of children who have suffered from nasal obstruction, and from post-nasal adenoids as the chief cause of this condition, are far-sighted, to a degree higher than can be explained by inheritance. The eyeball being in the orbit is influenced in its development within certain limits, though the laws of inheritance stamp their plan upon it while it is in embryo, by the development of the orbit. And here, again, in the faulty development of the orbit is to be found the explanation of some of those sporadic cases of astigmatism with which one meets,—certain cases not inherited, and which cannot be explained by influence of previous inflammatory conditions of the cornea, etc. He cites a case in support of this view. 1 Monatsschrift fur Ohrenheilkunde, 1883, Nos. 2, 3, 4, 5. s Virginia Medical Monthly, September, 1889. 154 DISEASES OF THE EYE DEPENDENT UPON DISEASES OF THE SPHENOID, ETHMOID, THE FRONTAL SINUS, ANTRUM OF HIGHMORE, ETC. An important work in relation to this department is that of Berger and Tyrmann1 on the diseases of the sphenoidal and ethmoidal sinuses and their relation to diseases of the eye. Our allotment of space permits hardly more than an allusion to their extended studies and conclusions. Caries and necrosis of the sphenoid may be attended by sudden unilateral blind- ness from perineuritis of the optic nerve in the optic canal; thrombosis of the cavernous sinus and of the ophthalmic vein from thrombosis of the venous sinus of the sella turcica. Injuries of the sphenoid may result in continuous leaking of the cerebro-spinal fluid ; injury of the internal carotid within the cavernous sinus, with consequent pulsatile exophthalmos; injury of the optic nerve, with blindness by prolongation of the fissure to the canal; injury to the second and third branches of the trigeminal, with anaesthesia of the parts they supply. Caries of the ethmoid may be fol- lowed by orbital abscess or emphysema, and traumata of the ethmoid by leaking of the cerebro-spinal fluid, orbital emphysema, nasal hemorrhage, etc. In this connection may be mentioned the case of A. Emrys-Jones,2 in which atrophy of the optic nerves was associated with the dropping of fluid from the nostril. Seven cases of a similar nature are on record,—viz., one by Elliotson,3 one by Baxter,4 one by Paget,5 one by Nettleship,6 two by Priestley Smith,7 and one by Leber.8 Leber, whose case is the last put on record before that of Emrys-Jones, analyzes those previously published, and comes to the conclusion that the fluid was cerebro-spinal, and probably the product of a vascular organ especially adapted for secretion, as the choroid plexus of the ventricles. Brain-symp- toms were present to some extent in six cases out of eight; and in some a distinct connection could be traced between the headaches, giddiness, etc., and the stoppage of fluid. Atrophy of the optic disk was present in all the cases that were examined; in several instances it followed optic neuritis. In the case of Jones the atrophy does not seem to have followed neuritis. It developed very slowly, and, although complete in the right eye, it made slow progress in the left. The coincidence Avas noted that the optic nerve that was the most atrophic was always on the same side as that of the most copious discharge. Wood9 gives the details of two cases of nasal hydrorrhcea, the first 1 Die Krankheiten der Keilbeinhoble, etc., 1886. 2 Ophthalmological Review, vol. vii., 1888. 3 Medical Times and Gazette, 1857. 4 Brain, 1882. 6 Transactions of the Clinical Society, 1878. 6 Ophthalmological Review, 1883. 7 Ibid. 8 Abstract in Ophthalmological Review, 1883. 9 New York Medical Journal, September 6, 1890. DISEASES OF THE NOSE. 155 associated with reddened conjunctiva, epiphora, asthenopia, amblyopia, and photophobia. The discharges occurred daily, usually in the morning, and lasted from three to four hours. Sneezing and formication were sometimes symptoms. The discharge from the nose was watery at first, but just before stopping for the day became opalescent and thicker. That from the eyes was like tears. There were deep excavations and pallor of the disks, with yellowish-white bands partially about the depression. Con- tinued nasal treatment (snaring portions of the middle turbinated) and internal medication gave much relief, especially of the subnormal vision. In the second case a prominent symptom was excessive sneezing. The nasal discharge had existed ten years. The ocular symptoms were in this case much less pronounced. Removal of polypi was followed by complete cure of all symptonis. The author discusses the theory of Mules as to the etiology of this affection, viz., that the coexistence of optic atrophy and hydrorrhoea from eye and nose is a coincidence, and inclines to think both conditions de- pendent upon a vaso-motor paresis. In a private letter Dr. Harrison Allen, of Philadelphia, cites an unre- ported case in which necrosis existed at the os planum over the posterior ethmoid cells, associating in an intimate manner a lesion of these cells with the connective tissue of the orbit. Panas1 says that inflammations of the frontal sinus commonly appear at the border of the orbit, and are not by any means always dependent upon nasal affections. The chief diagnostic indication is violent frontal and supra-orbital neuralgia. The author describes the best operative methods for trephining and treating the sinus. Empyema of the antrum of Highmore may, in passing, be mentioned as sometimes resulting in serious ocular complications. These may come about as results of reflex neurosis, or of pressure, even of invasion of the orbit, but usually by the transfer of purulent material through the nose and the lachrymal duct. In addition to the natural sequeke, such as lachrymo- nasal disease, conjunctivitis, etc., there have been mentioned iritis, panoph- thalmitis, and orbital abscess. Jeauty in his Bordeaux thesis (March, 1891) has recapitulated the histories of twenty-two reported cases of High- morian empyema, and Hajek2 gives the details of twenty-nine observed cases. Ziem3 says that Killian and others have expressed the opinion that a narrowing of the visual field with amblyopia accompanied by a purulent secretion of the nose pointed rather to a disease of the ethmoidal sinuses, whereas formerly these symptoms were grouped under those of purulent diseases of the antrum of Highmore. In Berger and Tyrmann’s monograph 1 Le Progres Medical, May 10, 1890. 2 Internationale Klinische Rundschau, October 23, 1892. 8 Berliner Klinische Wochenschrift, 1888, vol. xxv. pp. 747-51. 156 DISEASES OF THE EYE DEPENDENT UPON on the subject, no connection is found to exist between the presence of pus in the antrum of Highmore and the narrowing of the visual field. Ziem admits that in formation of pus in the maxillary sinus, as well as in the sphenoidal sinuses and the accessory cavities of the nose, a narrowing of the visual field may result, and he quotes a case to that effect. He does not believe that a reflex from the tumefied nasal mucous membrane or a marked irritation of the special reflex organs which, according to Hack, are located in the mu- cous membrane of the nose, enters into the question, but it is not improb- able that the tumefaction of the antrum of Highmore produces a temporal neuralgia, and also a stimulation of the vaso-motors of the choroid and ciliary body. He quotes a remarkable observation made by Marckwort1 of a case of glaucoma resulting from a prolonged application of cocaine to the nasal mucous membrane. He believes that acute congestion preceded by a venous stasis of the ciliary plexus was the cause of the glaucoma. He regards the case as analogous to cases of eye-trouble following applications of the galvano-cautery. He has observed a series of glaucomata in which a very marked coexisting purulent rhinorrhoea was noted. In several cases of this kind iridectomy performed by himself and other very experienced practitioners to overcome the glaucomatous process was ineffectual. Griinwald2 is unable to confirm Ziem’s contention that empyema of the antrum produces limitation of the field of vision. He has never found it so in his cases. Schmidt-Rimpler3 suggests that the supposed contraction of the field is due td a natural mistake in making the perimetrical diagnosis. Griinwald has never found any objective ocular symptoms due to the nasal trouble, although he has frequently heard patients complain of asthenopic difficulties coincident with the nasal disease, and he explains the fact as arising from hypersemia and irritability of the eyes due indirectly to the excess of blood and to the morbid conditions of adjacent parts, and increased by the direct influence of continued accommodation and ocular work. He also speaks of psychic causes as well as the physiological ones, and he uses the terms “ psychic asthenopia” and “ psychic contraction of the visual fields.” Schaeffer and Hartmann, as quoted by Berger,4 have described cases of orbital abscess following coryza. The suppurative inflammation of the ethmoidal cells served as the method of communication between the coryza and the orbital abscess. Ponfick5 had a case of meningitis following nasal disease in which there was a solution of continuity in the bony walls between the sphenoidal sinus and the cranial cavity. A similar explanation is used by Berger to account for a subacute attack of retro-bulbar neuritis. 1 Knapp u. Schweigger’s Archiv, 1887, B. xvii. S. 452. 2 Die Lehre von Naseneiterungen, etc., 1893. 3 Deutsche Medicinische Wochenschrift, No. 24, 1892. * Journal de Medecine de Paris, February 28, 1892. 5 Centralblatt fur die Medicinische Wissenschaft, No. 3, 1882. DISEASES OF THE NOSE. 157 Berger1 says that the limitation of the field of vision, sometimes met with in the course of nasal disease, may be caused by an affection of the optic nerve propagated by direct continuity of tissue from the nose to neighbor- ing cavities. MECHANICALLY-CAUSED ABNORMALITY OF THE EYES STARTING IN THE NOSE, OR IN COMMUNICATING AND ADJACENT STRUCT- URES. These, for the sake of systematic completeness, may be incidentally mentioned in passing, though they readily suggest themselves to the mind of the ophthalmic surgeon. No operator, for example, would perform a cataract or other major operation upon the eye if the patient were subject to paroxysms of sneezing or coughing whereby the post-operative healing processes would be greatly endangered. All have seen instances of capil- lary hemorrhage, subconjunctival or even retinal, produced or increased by these effects of such irritability of the respiratory passages. I had a patient with what was perhaps a unique illustration of mechanical effect. Blowing the nose had forced the air so violently through the duct that the mucous membrane of the sac had ruptured, and the skin was dissected up from the side of the nose and orbital border near the inner canthus, and formed there a large tense bulla or atmospheric tumor. Berger and Tyrmann2 discuss the symptoms of sphenoidal and eth- moidal tumors that augment the cavities of the sinuses, causing atrophy of the walls and compression or invasion of the orbits, compression (with blindness) of the optic nerve, expression of the eyeball, etc. Bull3 also discusses the symptoms and treatment of tumors of the orbit secondary or consecutive to tumors of the neighboring bony cavities. It is hardly necessary to mention the occurrence of intra-nasal tumors, hypertrophies, polypi, traumata, etc., which by pressure close the nasal out- let or lumen of the canal, the sac, or, in rare cases, directly or mediately act on the eyeballs themselves, even pushing them aside so as to produce the deformity known as frog-face. Nieden4 reports several such cases: 1. Polypi of the upper part of the nasal cavity perforating first into the left and afterwards into the right orbit; exophthalmos of both eyes; death with cerebral symptoms. 2. Myxo-sarcoma of the mucosa of the superior nasal sinus, rupture of the ethmoid plate, extension into the cranial cavity, and from there to the base of the brain and into both orbits; neuro-retinitis, double exophthalmos, blindness, death in coma; post-mortem examination. 3. Chronic empyema of the right frontal sinus and ethmoid labyrinth ; rup- ture into the right orbit; dislocation of the eyeball outward; direct com- munication of the abscess with the nasal antrum. 1 Journal de Medecine de Paris, February 21, 1892. 2 Die Krankheiten der Keilbeinhohle, etc., 1886. 3 New York Medical Journal, December 19, 1891. 4 Archiv fur Augenheilkunde, vol. xvi., 1885-86. 158 DISEASES OF THE EYE DEPENDENT UPON Priestley Smith1 describes a case in which a morbid growth in the nasal cavity was the cause of blindness in both eyes. Removal of the growth, a tumor of some kind, from the back of the nose, was followed by restoration of normal vision in one eye. On account of the fact that the optic disks presented no inflammatory or other changes long after one eye was com- pletely blind, it is thought that pressure was the direct cause of the blindness. Baptie2 reports a case in which injection of a nasal polyp by another surgeon (doubt therefore existing as to what was injected) probably resulted in inflammation of the lid and parts adjacent to the eye, something like herpes frontalis, together with iritis and optic atrophy. In another case a huge rhinolith of the left nostril culminated in a profuse purulent discharge from the nasal side of the left orbit, and destruction of the left eyeball. Nasal tumors may, of course, press on the tear-duct or occlude its intra- nasal orifice and thus cause epiphora and all the phenomena of lachrymal obstruction. Harrison Allen3 says that the anterior end of the middle turbinated bone, either by displacement of the bone or by hyperplasia of the mucous membrane, may make injurious pressure upon the lachrymal bone and thereby create a congested state of the lachrymal tube which will lead to obstruction. He reports two cases of this condition in which the lachrymal abscess and epiphora were cured by operation upon the local nasal abnor- mality. One does not know where to classify cases of exophthalmic goitre like that reported by Musehold,4 cured by removal of hyperplastic growth of the inferior turbinated bone. He considers the phenomenon to be that of a vaso dilator neurosis. Reports of five similar cures are epitomized by Musehold. OCULAR DISEASES CAUSED BY THE TRANSFER OF PATHOGENIC MATERIAL FROM THE NOSE TO THE EYE BY WAY OF THE LACH- RYMAL CANAL. I suspect that this fact is of far more importance than has heretofore been supposed. All ophthalmologists have doubtless had cases in which suppurative inflammation of a single eye, as, for example, in gonorrhoeal ophthalmia or ophthalmia neonatorum, despite the most rigid isolation and protection of the healthy fellow-eye, was followed by infection of this latter. It seems strange that such facts had not long ago directed attention to the nose as the half-way-house, and to the duct leading to the conjunctiva as the further route, of the morbific germs. The caution is wisely emphasized to keep the patient’s fingers away from the eyes, and in a dozen ways prevent inoculation of the eye by other contact-met hods. But nose-picking is far 1 Ophthalmic Review, vol. ii., 1883. 2 Canada Medical Record, October, 1892. 3 Proceedings of the Philadelphia County Medical Society, vol. xi., 1890. 4 Deutsche Medicinische Wochenschrift, February 4, 1892. DISEASES OF THE NOSE. 159 more common than eye-rubbing, so that it becomes probable that even the primary infection may have first reached the eyes by the nose. Mackenzie1 merely mentions purulent nasal catarrh intercurrent with purulent oph- thalmia, and (p. 296) speaks of patients with gonorrhoea as having infected the nostrils. Despagnet2 also alludes to the fact. The suggestion cannot be amiss that antisepsis of the nasal cavities and prophylactic cautions should form part of the routine prevention and treatment of eye-diseases in patients with gonorrhoeal disease. Nasal disease with copious mucous or muco-purulent nasal discharge, coexisting with suppurative conjunctivitis, is suggestive that the latter is dependent upon the former malady. A number of authors have noted the synchronous or consequent dis- eases of the eye in nasal disease with ozaena as a prominent symptom. It is, of course, impossible to say how often such nasal conditions may pro- duce dacryocystitis and other diseases of the lachrymal excretory passages. Fischer3 traces to this cause several cases of glaucoma, two of papillitis, several each of iritis and of hypopyon-keratitis, and many of trachoma and chronic conjunctivitis. In a private letter Dr. S. I). Risley, of Philadelphia, writes me, “ It has often seemed probable that the recurring attacks of inflammation of the cornea and conjunctiva of young children sustained an important relation to disease of the nose and upper pharynx, so constantly present in the neglected children that crowd our clinics. In making this suggestion I am not unmindful of the large group of obviously strumous children in whom all the mucous membranes are subject to disease as a part of the common expression of their malnutrition.” Among the first to emphasize the causal relation of nasal catarrh to conjunctival catarrh was Bresgen,4 who says that the ocular sequence will not disappear without treatment of the primary nasal disease. Similar observations have been made by Moldenhauer,5 Rumbold,6 Cheatham,7 Augagneur,8 Bucklin9 (with details of four cases of trachoma, opacity of the cornea, etc.), Kolipinski19 (with details of nineteen cases of conjunctival inflammations, phlyctenular ulcers of the cornea, etc., cured by nasal treat- ment alone), Hendrix,11 Dowling12 (details of three cases), and many others. 1 Diseases of the Throat and Nose, p. 295. 2 Recueil d'Ophthalmologie, September, 1889. 3 Zusammenhang von Augen- und Nasen-Krankheiten, New-Yorker Mcdizinische Presse. 4 Der chronische Nasen- und Rachen-Catarrh, 1881, Band i., and later, Grundzuge einer Pathologie, etc., 1884. 5 Die Krankheiten der Nasenhoblen, etc., Leipzig, 1887. 6 St. Louis Medical and Surgical Journal, 1886. 7 American Practitioner and News, April 2, 1887. 8 Revue Medicale de l’Est, October, 1888. 9 Medical and Surgical Reporter, May 18, 1889. 10 Medical News, xlv., September 27, 1884. 11 St. Louis Medical and Surgical Journal, January, 1886. 12 Cincinnati Lancet Clinic, xxiii., 1889. 160 DISEASES OF THE EYE DEPENDENT UPON Dunn 1 says, “ In the vast majority of cases of children suffering from phlyctenular troubles there will be found a coincident rhinitis, and behind this unhealthy adenoid vegetations/’ In a private letter Dr. James Wallace, of Philadelphia, gives it as his opinion that phlyctenular conjunctivitis may be the result of acrid dis- charge forced into the eye by sneezing or blowing the nose. “ I have seen phlyctenular disease yield to nasal treatment when local treatment of the eyes was of no avail.” Hamilton2 found in one hundred and six cases of post-nasal growths that eye-diseases coexisted in fifty-one : in twenty-two there was catarrhal, in seven follicular, and in sixteen granular conjunctivitis, and in six there was blepharitis. Gordon3 argues that there is a special form of conjunctival disease dependent upon chronic inflammation of the intra-nasal tissues. The pal- pebral conjunctiva is thickened and rough, with tarsal complications, photo- phobia, lachrymation, etc. The diagnosis is confirmed by the coexistence of chronic rhinitis with hypertrophy of the nasal mucous membrane, and the discharge of a thin, watery mucus. Illustrative cases are detailed. Masini4 contends that atrophic rhinitis may be the cause of a selero- tizing or atrophic disease of the conjunctiva. He adduces two cases in which treatment of the nasal difficulty gave relief to the ocular sequence. Dr. Lewis H. Taylor5 describes cases of granular lids with pannus, etc., not improved by local treatment, coexisting with enlargement of the lower turbinated bones, atrophy of the nasal mucous membrane, occluded passages, etc. Cauterization of the turbinated bones and local treatment resulted in improvement of the ocular condition. Bucklin6 contends that rebellious trachoma is often dependent upon disease of the nasal passages, and inclines to accept the theory that the obstructed nasal passages retain the original infectious matter uninfluenced by local ocular treatment, and there is thus constant reinfection of the con- junctiva through the lachrymal duct. Several cases are described which, after long treatment of the lid and corneal trouble, were relieved by cure of the nasal obstruction. Despagnet7 says that in old cases of cured trachoma, often subacute attacks of keratitis, etc., are lighted up without apparent cause, but that on the morbid nasal mucous membrane may be found microbes identical with those found in granular conjunctivitis, and that inoculation experiments with them result in the production of granulations like those of the con- junctiva in man. 1 Virginia Medical Monthly, September, 1891. 2 Transactions of the Intercollegiate Medical Congress of Australasia, 1889, ii. 779. 3 Journal of the American Medical Association, v., 1885. 4 Bollettino di Oculistica, viii. 11, 12. 5 Journal of the American Medical Association, November 17, 1888. 6 New York Medical Times, May, 1887. 7 Recueil d’Ophthalmologie, September, 1889. DISEASES OF THE NOSE. 161 Trousseau1 has had eleven cases of grave ulceration of the cornea that he believed dependent upon atrophic rhinitis or simple ozsena, without any apparent alteration of the lachrymal ducts. The causal relation is con- sidered certain because of the existence of a special coccus (Loewenberg) in the secretions of ozaena, which, through the intact lachrymal ducts, attacks any incipient ulceration of the cornea. With disinfection of the nose the corneal ulcers proceed to a cure under the usual treatment. Nieden2 says, “ We see still further the fact admitted by all ophthalmic surgeons, that another form of infectious disease, 'phlyctenular keratitis, almost invariably has its origin in a disease of the nose. Here we see in the preliminary stage more or less swelling, redness, increased secretion, and the formation of ulcers around the edges of the nostrils. The upper lip participates in the process of infiltration and begins to swell. The nose, too, as a whole tumefies, becomes red, the thickening of the mucous mem- brane extends well into the posterior portion of the nose, and hemorrhage follows even a gentle touch with the probe. The margins of the nostrils are covered with dry, hard crusts, which, when removed, reveal a more or less deep, excoriated, ulcerated, and bleeding surface. . . . The trouble with the eyes can only be permanently and certainly relieved when simultaneously the pathological condition of the diseased mucous membrane of the nose has been treated and restored to its normal state.” “ There is no doubt,” says Nieden further, “ that the products of ozaena exercise a directly noxious influence upon affections of the cornea, for we invariably expect suppurating ulcers with the characteristic infectious symptoms from extension of the disease whenever ozsena is present in cases of traumatism even of the epithelium of the cornea, and this even when there has never been any blennorrhoea of the lachrymal sac, which of itself is quite sufficient to excite the infection.” Masini3 also contends that corneal disease may result from ozsena. The corneal difficulty consists in ulceration of the limbus proceeding rapidly towards a grave termination, and upon this ordinary treatment of the eye is without result; but it is immediately cured by the appropriate nasal treatment. He also describes another kind of keratitis, a sort of paren- chymatous affection of the cornea dependent upon ozsena. It begins with slight lachrymation with increasing photophobia, a bluish circle surrounding the cornea, accompanied by ciliary pain, and whitish spots in the cornea, somewhat resembling interstitial keratitis. Treatment of the ozsena cuts the corneal difficulty short. The author cites the case of a child who for three and a half years endured without inconvenience the presence of a pebble in the right nostril; a fetid purulent discharge resulting, the child complained of violent pain in the right nostril, with lachrymation and conjunctival 1 Archives d’Ophthalmologie, ix., 1889. 2 Arehiv fur Augenheilkunde, Bd. xvi., 1885-86. 3 Bollettino di Oculistica, viii. 11 and 12. 162 DISEASES OF THE EYE DEPENDENT UPON congestion, photophobia, photopsia, etc. With the removal of the foreign body from the nostril all these symptoms disappeared. Dr. Lewis H. Taylor1 describes a case of chronic disease of the cornea and conjunctiva that had existed for thirty years, unimproved by local treat- ment. He found the mucous membrane over the turbinated bones swollen, and an offensive yellowish discharge, with occlusion of the nares. Local treatment of the nasal disease speedily ended the ocular complications. In a private letter Professor William F. Norris, of Philadelphia, says that he has had frequent cases of nasal disease causing purulent inflammation of the lachrymal duct. Hendrix2 reports the case of a young lady with tinnitus, blind in the right eye from conjunctival and corneal disease, the other staphylomatous, myopic, and nebulous. The mucous membrane of the right naris and the right middle turbinated was highly congested, causing interference with respiration, and the pharynx was congested and granular. Local treatment of the naso-pharynx, the author avers, brought to the right eye, which had been blind, ability to read large print, and entirely cured the staphyloma, myopia, and nebulous cornea of the left eye. DISEASES OF THE LACHRYMAL EXCRETORY APPARATUS. The chief symptom of disease of the lachrymo-nasal canal is excess of tears in the eye, followed or complicated by epiphora, lachrymal conjunc- tivitis, dacryocystitis, etc. It is evident that these symptoms and the single condition underlying them—stenosis or occlusion of some part of the drainage-system—may be primarily due either to ocular or to nasal disease. The ocular causes will be considered later. They are compara- tively infrequent and unimportant, the nose being usually the fons et origo mali. On the part of this organ the difficulty may be due—1, to mechanical obstruction of the intra-nasal end of the lachrymal canal; or, 2, the disease of the duct and sac may be the result of morbific material passing from the nares; or, 3, it may be due to an extension from the nose, by simple con- tinuity of tissue, of inflammatory or morbid processes. The effects upon the eye from lachrymal obstruction are too varied to mention, and may be found in detail in the best ophthalmological works. The healing of intercurrent diseases of the eye is hindered or rendered impossible by this cause, and positive production of multiform disease of the conjunctiva or cornea is frequent. Thus, Fieuzal3 reports seven eases of multiple corneal ulcers associated with constriction of the lachrymal ducts or obliteration of the puncta. All were cured by measures directed against the lachrymal troubles. The importance of general syphilitic disease and its treatment is em- 1 Journal of the American Medical Association, November 17, 1888. 2 St. Louis Medical and Surgical Journal, January, 1886, p. 20. * Gazette des Hopitaux, xlv., 1872. DISEASES OF THE NOSE. 163 phasized by Watson,1 who had a case of unilateral obstruction of the duct, with ozsena, due to syphilitic rhinitis, and from a study of this and similar cases he thinks that the constitutional treatment of lachrymal obstructions is quite as important as the mechanical measures, and that the condition of the whole tract of mucous membrane from the conjunctiva to the nostrils is at fault in the worst forms of rtiucocele; that the obstruction, in fact, depends rather upon a uniform narrowing of the whole extent of the series of channels, than upon a stricture limited to one or two points. When there is a strongly-marked syphilitic or scrofulous swelling of the mucous tract, it will be very difficult to overcome the epiphora, or to heal up the fistulse of an abscess, without very careful attention to constitutional treatment. De Schweinitz2 also had a case similar to that of Watson, from which he concludes that local treatment without general medication is ineffectual. Bresgen,3 as quoted by Nieden,4 regards the connection between the stricture of the lachrymal duct and diseases of the nasal mucous membrane as so close that he declares that every lachrymating patient, even when he first visits an ophthalmic surgeon, ought to be immediately referred to a rhinologist for a scientific examination, and for eventual treatment of the nose. Nieden5 says that in coexisting nose- and eye-affections two different categories of processes are concerned,—namely, those that extend by way of the naso-lachrymal canal, and those in which, the nerves of the mucous membrane of the nose being irritated, the eye and its surroundings sympa- thize by reflex action. In about one-half of the cases of lachrymation the cause lies in the visual organ and its appendages, and depends upon the avenues of deflection of the tears,—namely, through the canaliculi, the lachrymal sac, and the orifice of the naso-lachrymal duct; whereas in the other half of the cases the epiphora is due to affections located in the canal —stenosis, stricture, or an inflammatory swelling of the membrane, par- ticularly at the nasal opening. In the large majority of the former cases the stenosis is located at the entrance of the lachrymal sac, and is com- plicated with ectasy of the sac, whereas in stenosis of the duct or of the nasal orifice abnormal dilatation and muco-purulent collection in the lachrymal sac are more rarely encountered. According to Nieden, hered- itary influences are to be considered in these affections of the deviations of the tears, i.e., an anomaly of the nasal framework common to parents and children, with a dependent modification of the calibre of the naso-lachrymal duct. As far as the relation existing between ozsena and disturbance in the 1 Medical Times and Gazette, London, 1878, i. 58. * Transactions of the Philadelphia County Medical Society, 1892. 3 Grundziige einer Pathologie und Therapie der Nase, etc., 1884. 4 Archiv fur Augenheilkunde, Bd. xvi., 1885-86. 5 Ueber den Zusammenhang von Augen- und Nasenaaffectionen, Archiv fur Augen- heilkunde, Bd. xvi. S. 381. 164 DISEASES OP THE EYE DEPENDENT UPON deflection of tears is concerned, Nieden suspects, relying upon sixty-seven cases he has observed, that the chronic inflammation of the Schneiderian membrane may be the cause of the lachrymation, but that the formation of the chronic rhinitis is brought about principally by the absence of the lachrymal fluid, the secretion of the mucous membrane of the nose thus more readily becoming dried and decomposed. He also says that catarrhs of the mucous membrane of the nose complicating trachoma occur only when the mucous membrane of the naso-lachrymal duct participates, and in the cavity of the sac a focus is established for microbic infection. However rare it may be, it is doubtless more frequently the case than is usually supposed that occlusion of the intra-nasal orifice of the lachrymal duct by local anomaly or disease too often fails to be recognized, and that many obstinate eases of dacryocystic disease have been treated in vain from the ocular side, when the nasal speculum would have revealed the primary source of the mischief. At a meeting of the Philadelphia County Medical Society Dr. R. W. Seiss1 spoke of having seen a number of cases in which unskilled use of the nasal cautery had closed the mouth of the duct; and at the same meeting Dr. De Schweinitz reported a case of local closure pre- senting an impassable barrier to the outflow of tears, though permeable by the fluids used in a syringe. Bresgen2 speaks of this cause of duct-obstruc- tion ; also Masini,3 Despagnet,4 Berger,5 and Gruening.6 Bresgen7 and Herzog were among the first to show the nasal origin of diseases of the lachrymal duct and sac. Bresgen says that stricture of the naso-lachrymal eanal may be treated unsuccessfully for months and even years with the sound, whereas proper treatment, frequently only two weeks in duration, of the chronic rhinitis which always exists with closure of the lachrymal duct, removes the long-existing so-ealled stricture as if by magic, restores the naso-lachrymal duct to its proper functions, and assists in rapidly healing inveterate inflammations of the conjunctiva. Herzog’s8 opinion is that a certain reciprocity exists between the mucous membrane of the conjunctiva and that of the nose, by way of the naso-lachrymal duct. According to his experience, certain eye-aflections, “particularly those due to scrofula,” recover much more rapidly when at the same time k suitable treatment of the chronic catarrh of the nose is instituted. So far as the accessory cavities of the nose are concerned, it is frequently observed that diseases of these cavities may extend to the “ ways of deflection of the tears.” An empyema of the antrum of Highmore may 1 Transactions of the Philadelphia County Medical Society, 1892. 2 Grundziige einer Pathologie, etc., Wien und Leipzig, 1884. 3 Bollettino di Oculistica, viii. 1. 4 Recueil d’Ophthalmologie, September, 1889. 5 Journal de Medecine de Paris, February 21, 1892. 6 New York Medical Record, January 30, 1886. 7 Deutsche Medicinische Wochenschrift, 1884, Bd. x., S. 133. 8 Mittheilungen des Yereins der Aerzte in Steiermark, 1884, S. 19. DISEASES OF THE NOSE. 165 rupture into the naso-lachrymal duct, and empyema of the frontal sinus into the lachrymal sac. Hydrops of these cavities is followed by com- pression of the naso-lachrymal canal or of the lachrymal sac. Tumors, likewise, originating in the neighborhood of the naso-iachrymal canal, may compress this duct; malignant tumors may perforate it. Gruhn reports that in the cases examined during two years the affec- tions of the naso-lachrymal canal were frequently accompanied by a muco- purulent secretion. Strictures were frequently found at the nasal orifice of the naso-lachrymal canal; on introducing the sound the naked bone could be felt. He reports thirty-eight cases of patients with dacryocysto- blennorrhoea associated with atrophic rhinitis and pharyngitis, deflection of the nasal septum, the presence of spurs, and hypertrophy of the turbinated bones. In nineteen cases fetid atrophic rhinitis was present; in eight cases atrophic rhinitis without fetor; in six cases atrophic rhinitis without fetor, combined with hypertrophic rhinitis; in four cases hypertrophic rhinitis. He regards the affections of the nose as the primary trouble in all prob- ability, and the disease of the lachrymal duct as the complication. Hansen Grut1 gives as the most frequent cause of blennorrhoea of the lachrymal sac a recurring coryza which obstructs the flow of tears through the duct, gradually dilating the lachrymal sac and rendering the secretion septic; all other causes are relatively rare. Organic strictures are much more frequently the sequelae than the cause of blennorrhoea. Sooner or later acute dacryocystitis is established, and the author believes that this latter condition can be caused only by a chronic blennorrhoea of the lach- rymal sac. Harrison Allen,2 a most scientific observer, concludes that lachrymal obstruction and chronic nasal catarrh are not infrequently associated. The duct is obstructed in two classes of cases only,—namely, in chronic nasal catarrh in which there are submucous infiltrations and atrophies, and in cases in which the bony walls of the nasal chambers are attacked either by osteitis or by necrosis. He reports twenty-three cases in which the lach- rymal duct was obstructed, with coincident chronic nasal catarrh. One of these patients had an offensive discharge from the right nostril, and obstruc- tion of the lachrymal duct of the same side. The patient declared that the discharge from the lachrymal sac often had an offensive odor,—the odor, indeed, of the nasal discharge itself. It was never purulent, however, and exhibited the appearance usual in lachrymal disease. Schmidt-Ilimpler,3 Stellwag von Carion,4 Schirmer,5 Masini,6 Clark,7 1 Michel’s Jahresbericht, 1885, S. 480. 2 Philadelphia Medical News, February 6, 1886. 3 Augenheilkunde und Ophthalmoscopie, 1886. 4 Diseases of the Eye (English translation), p. 421. 5 Erkrankungen d. Thriinenorgane, Graefe und Saemisch’s Handhuch, Bd. vii. 6 Bollettino di Oculistica, viii. 7 Columbus Medical Journal, vii., August, 1888. 166 DISEASES OF THE EYE DEPENDENT UPON Mackenzie,1 De Schweinitz,2 and many others have also discussed this re- lation. Treatment of Lachrymal Obstruction.—There is considerable difference of opinion as to the proper method of treatment in cases of epiphora. Of course when the symptoms are due to evident eversion of the puncta, or failure in their normal apposition with the globe, the result of ectro- pion, blepharitis, conjunctivitis, or traumatism, this anomaly must be cor- rected. Sometimes the puncta are congenitally absent, or closed, some- times occluded by foreign bodies, as a lash, chalky concretions, or polypi. It hardly needs present allusion to the fact that if there is any reason to suspect nasal disease, if there is a history of rhinitis or of intra-nasal operations, etc., the primary indications are for a thorough examination of the nares and naso-pharynx, with a view of ascertaining if the intra-nasal orifice of the duct is patent, if diseased secretions are being transferred by the duct to the sac, etc., or if diseased processes are extended by con- tinuity of tissue from the nose to the drainage-mechanism of the eye. Exception must also be made of reflex lachrymation, the primary source of the irritation being in the nose or elsewhere, and the phenomenon being due to hypersecretion rather than to subnormal excretory function. Even when the intra-nasal disease may be the primary point of departure of the morbid processes culminating in stenosis or occlusion of the lachrymo-nasal canal, it will often be found that treatment of the nasal conditions alone, without the supplement of treatment from the ocular end of the system, will not entirely or speedily cure the dacryocystic or conjunctival sequela?. In pathology the effect does not always cease with disappearance of the cause. Chronic congestion has set up chronic organic changes, the lumen of the canal has been narrowed or closed by the results of inflammation, fibroid adhesions or proliferations, etc. Then, too, it is frequently impos- sible to tell in the beginning what changes have taken place, how far the symptoms are due to functional causes alone, or how far they are organic. It may be admitted that generally the ophthalmic surgeon proceeds at once to radical and operative methods when a patient presents with dacryo- cystitis. I have contended3 that in all cases a tentative or palliative treat- ment should be instituted before destroying the physiological function of the puncta (with their sphincter fibres), and especially before jamming a rigid rod of metal down into the inflamed or at least narrowed canal, with its delicate lining of mucous membrane, and thus crushing the latter between the metal and the bony walls of the duct. I have been moved to empha- size this preliminary treatment by the success attending a little manipula- tive device consisting in the following procedure. The retained secretions of the sac having been emptied by pressure, and the eye cleansed of the same, let the patient lie down, or cant his head backward and to one 1 Diseases of the Throat and Nose, p. 313. 2 Transactions of the Philadelphia County.Medical Society, 1892. 3 New York Medical Journal. DISEASES OF THE NOSE. 167 side, so that the inner canthus of the affected eye shall form the bottom of a depression that will hold an antiseptic and astringent solution. The proportions of the solution I use are as follows : R Acidi borici, gr. x ; Sodii chloridi, gr. iii; Zinci chloridi, gr. i; Aquae destillatae, f^i. I have this made in large quantity, doubly filtered after long settling, and deeply tinted with blue pyoktanin. With the inner canthus and the puncta submerged with this solution, I again empty the sac by pressure with the little finger from below and towards the eye, then slowly relaxing the pressure the resiliency of the walls of the canaliculi and sac will suck in the antiseptic solution and bring it in contact with the parts before filled with unhealthy secretions. Again pressure is made from the eye towards the duct, so as to drive the solution down into the duct. This little manipulation several times repeated at one sitting, and with two or three daily sittings, will, according to my experi- ence, speedily cure a large number of cases. It has the excellent merits of avoiding surgical operations, and of being easily carried out by the patient or by his friends at home. In some cases it is inefficient, and when proved to be so I insert the sharp point of the iris scissors into the punctum and snip it open by a stroke perpendicularly downward towards the palpebral fold, one-sixteenth to one-eighth of an inch long. The opening into the canali- culus is thus enlarged, and a larger influx of the irrigation-solution is allowed to enter. But when this or some other palliative method proves ineffectual, organic stricture is present, and it must be treated by surgical or radical measures. These, with their operative details, are given in extenso in every good book on diseases of the eye. My personal experience again leads me to advise conservatism. I should first try simple slitting of the canaliculus, and repeated irrigation, before probing the duct. The custom of ramming the canaliculus knife down into the duct seems to me in the beginning, if not always, simply barbarous. The same word I would also apply to the use of large probes and the act of driving them into the duct with any great force. Certainly only the smallest probes should be used at first, and the entrance effected more by the light tactus eruditus than by muscular force. The varying diameters of the bony canals, and the deflections from the normal either in direction or in straightness, prove anatomically the wisdom of caution. Fulton1 reports a case of severe orbital cellulitis consequent upon the passage of a No. 4 Bowman’s probe into the duct in suppurative disease of the sac, with a fistulous opening upon the cheek. Flushing and forced irrigation of the duct are sometimes, though rarely, I 1 Archives of Ophthalmology, xiv., 1885. 168 DISEASES OF THE EYE DEPENDENT UPON think, advisable, by means of a delicate canula inserted at various depths, and by a syringe with a nozzle to fit into the canula. OCULAR DISEASES OF INDIRECT NASAL ORIGIN AND DOUBTFUL METHOD OF TRANSMISSION. There exist in medical literature, and every ophthalmologist has seen illustrative cases, many instances of functional troubles of the eye which were connected with nasal disease, but in which the exact method of intermedia- tion was indeterminable. One case seems more certainly neurotic, another due more to vascular anomaly,—venous stasis or congestion passed by extension to the ocular system,—whilst in some cases both factors are at work. The practical doubt as to etiology is experienced in the present literary endeavor tentatively to classify and group all such diseases into some convenient order until, with more exact knowledge, they shall fall into their places with scientific accuracy and systematization. I append resumes of some of the more noteworthy of such cases as have fallen under my observation : Ziem1 effected permanent cures of lachrymation, blepharospasm, per- sistent and recurring inflammations of the conjunctiva and cornea, etc., in a number of cases, by removing adenoid growths in the naso-pharynx, hypertrophied tonsils, etc., after the patient had resisted local treatment of the eyes for weeks. He believes that the relation existing between the diseases is not due to a reflex irritation, but to interference with the circu- lation in the cavernous plexuses of the nasal mucous membrane. The venous stases are brought about by deficient aspiration, and this is caused by neoplasmata weighing down and interfering with the muscles of the palate and pharynx. Such stases, if they extend to the flexible elastic organ of the eye, the ciliary body, might explain the appearance of asthe- nopia in chronic tonsillitis. Lachrymation and its consequences he con- siders as sometimes due to deficient aspiration of the tears, which is one of the factors in their deflection, in the cases where adhesions exist in the region of the organs of the pharynx. He commends thorough examina- tion of the entire naso-pharynx in all cases that, owing to their chronic and relapsing character, are generally considered of a scrofulous nature. Ziem 2 also records a case of intense congestion of lid and eyeball due to complete obstruction of the nasal cavities by a tumor. Gruening3 asks whether, if in a considerable number of cases showing in bold relief the ocular symptoms of lachrymation, photophobia, and in- creased vascularity, local and general treatment prove ineffective, whilst nasal treatment (anti-catarrhal) is effective, the a posteriori argument is not con- clusive. A few illustrative cases are cited of the large number observed. Others are given where immense hypertrophic swelling of the corpora 1 Augsburger Me