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NASO-PHARYNGEAL
CATAERH.
BY
MARTIN   F.  CWOMES,  M. D.,
Professor of Physiology, Ophthalmology, and Otology in the Kentucky School of
   Medicine ; member of the American Medical Association, of the Kentucky
      State Medical Society, and of the Council of the Polytechnic Society
          of Kentucky; Visiting Surgeon to the Eye and Ear Depart-
             ment of the Louisville City Hospital; Surgeon to the
                   Louisville Eye and Ear Infirmary, etc
»
LOUISVILLE,  KY.          "« V-  ]^ "
BRADLEY & GILBERT, PUBLISHERS.

                       1880. 
wv
 C7T5n
Entered according to act of Congress, in the Year 1880, by

         MARTIN F. COOMES,
In the Office of the Librarian of Congress, at Washington.
  ELECTROTYPED BY
ROBERT ROWELL,
  LOUISVILLE, KY. 
CONTENTS.
 ANATOMY.                                                        PAGB.
  Osseous boundaries of nasal cavities—agger nasi—nerves—mucous glands—
      openings communicating with the pharynx—relations of the tonsil—blood
      supply of the tonsil—Bowman's  glands— pigment  of  the  Schneiderian
      membrane—the true olfactory fibres—the organs of Jacobson.....9 to 29

 EXAMINATION OF THE PHARYNX.
  The finger as  a tongue depressor—the palate elevator—tongue depressors-
      artificial illumination—rhinoscopic mirror in  position (Fig 5)—instruments
      used in anterior rhinoscopy—mirrors—catarrhal syringe and its uses—
      mode of applying atomized fluids.—dangers of the nasal douche—dangers
      of insufflation—detection of vegetative growths in the pharynx .  . . 29 to 49

 LOCAL  MEDICATION.
  Variations in the strength of cleansing solutions—peculiar therapeutic prop-
      erties of the bromide of  potassium — warm water—quack nostrums—
      dangers of the nitrate of silver—white sugar............50 to 60

 CONSTITUTIONAL  MEDICATION.
  Mode of administering quinine—establishment  of  iodinism—muriate of am-
      monia in glandular enlargement—cod-liver oil and iron........61 to 63

 CLIMATE.
  Effect of climate on hay fever—mountainous districts............   64

CATARRH.
  Definition of the word catarrh—divisions of catarrh—first medical description
      of catarrh—chronological order of the return of influenza—epidemic of
      1873.................................64 to 66

ACUTE SPORADIC CATARRH.
  Pain across the upper third of the nose—temperature—nasal secretions and
      epistaxis—facial neuralgia—quinine in the treatment of acute sporadic
      catarrh...............................66 to 78 
4
CONTENTS.
CHRONIC MOIST CATARRH.                                 page.
  Alteration in the voice,—peculiar expression of countenance—snoring, causes
     of—sense of weight across the upper third of the nose—anosmia—cough-
     audition—tinnitus aurium—pain—epistaxis—appearances presented  by
     the membrane—eczematous cases—ozena—prognosis of muco-purulent
     and purulent catarrh........................78 to 102

CHRONIC DRY  CATARRH.
  Dry atrophic  rhinitis—sleeping with the mouth  open—tobacco smoking—
     nasal respiration as a means  of alleviation—proliferous rhinitis—appear-
     ance of the membrane—tinnitus aurium—anosmia—impairment of nasal
     respiration—voice—epistaxis....................103 to in

CAUSES OF  CATARRH.
  Contagion — snuffles — syphilitic  coryza — atmospheric  causes — " catching
     cold "—ozone—acrid gases—odor and  pollen of  flowers—tobacco smok-
     ing—exanthems..........................in to 112

INFUSORIAL  CATARRH.
  Secretions of infusorial catarrh—spasm of the glottis—name of the disease .
                                                                122 to 141

SYPHILITIC PHARYNGITIS  AND RHINITIS.
  Mucous patches—painful deglutition—elevation of temperature .... 141 to 152

CATARRHAL  AND  PURULENT  INFLAMMATIONS OF THE
     DRUM  CAVITY.
  Acute aural catarrh mistaken for brain lesions—febrile symptoms—caution in
     the use of atropia with children—bulging of the drum membrane . 153 to 160 
TO
   PROFESSOR DUDLEY  S. REYNOLDS,  M. D.,

As a token  of my appreciation of his high professional
     attainments, and his love of truth and justice;

                       AND TO

         COLONEL BENNETT H. YOUNG,

In recognition of his benevolence and generosity in assist-
     ing to  maintain  the  Louisville  Eye and Ear
         Infirmary, and many other institutions
                  devoted to charity,

     THIS LITTLE VOLUME  IS MOST AFFECTIONATELY
                    INSCRIBED BY
THE AUTHOR. 
 
PREFACE.
   At the  request  of numerous friends I reluctantly
undertook to write a practical treatise on Nasopharyn-
geal Catarrh, for the use of general  practitioners of
medicine.  The task is at once difficult and of uncertain
value.   I may have  satisfied the demand of a few friends
who urged me to the work, and fallen far short of the
requirements of that large class of general practitioners
who, being remote  from metropolitan cities  and from
specialism,  do not care to  undertake the management
of a class of diseases so commonly regarded as neces-
sary evils supposed  to be irremediable.
   For the illustrative cuts I am indebted to Messrs. G.
Tieman & Co.,  and  Shepard & Dudley, of  New York;
Simon N. Jones and Adolph  Fisher, of Louisville.
   For much assistance and some  good advice, I am in-
debted to my publishers, Messrs. Bradley & Gilbert.
  To avoid perplexing difficulties in  making foot-note
references, and the  misuse of quotation marks, I take
this method of informing the reader that free use has
been made of  the  text of  Gray's  Anatomy, Frey's
Histology and  Histo-Chemistry of Man, Spencer Wat-
son's Treatise on the Nose, Holden's  Manual of Anat-
omy, beside those duly accredited in  my text.

                       MARTIN F.  COOMES,
                    145 West Chestnut Street, Louisville, Ky.
  May 30, 1880. 
 
NASO-PHARYNGEAL  CATARRH.
                  ANATOMY.

  The nose is the more anterior and prominent part of
the organ of the sense of  smell.  It  is of triangular
form, directed  vertically downward, and projects from
the center of the face, immediately above the upper
lip.   Its summit or root is connected directly with the
forehead.  Its  inferior part, the base, presents two elip-
tical orifices, the nostrils, separated from each other by
an antero-posterior septum, the columna.  The margins
of these orifices are  provided  with a number of stiff
hairs  or vibrissae, which arrest the  passage of foreign
substances carried with the  current of  air intended for
respiration.  The lateral surfaces  of the nose form,  by
their union, the dorsum, the direction  of which varies
considerably in different individuals.  The dorsum ter-
minates below in a rounded eminence,  the lobe of the
nose.   The nose is composed of a frame-work of bones
and cartilages, the latter being slightly acted upon by
certain muscles.   It  is covered externally by integu-
ment, internally by  mucous  membrane.   The nasal
fossae are two  irregular cavities, situated in the middle
of the face, and extending from before  backward.
  The following are the osseous boundaries of the
cavities: externally, each is bounded by the nasal, su-
                                          (9) 
10
ANATOMY.
 perior maxillary, ethmoid, lachrymal, inferior spongy,
 palate bones, and  pterygoid  plates of the sphenoid;
 above by the cribriform  plate of the ethmoid  in  the
 center, by the frontal and nasal bones in front; poste-
 riorly by the body of the sphenoid and part  of  the
 palate bone; inferiorly by the palate.  The vomer and
 perpendicular plates of the ethmoid form the partition
 wall between the two fossa.  The lower portion of  the
 lateral and anterior walls are composed principally of a
 cartilaginous frame-work  which  is moved by muscles,
 thus permitting of a certain amount of contraction and
 expansion of the cavities  in this region.   The mucous
 membrane covering the middle turbinated bone is pro-
 longed into an elevation anteriorly, described by Meyer
 as the agger nasi.
  Its direction is nearly parallel with the dorsal ridge
 of the nose,  moving  forward  and  downward, until it
 reaches very nearly the anterior aperture of the nostril.
  This agger nasi approaches  very  near to a thickened
 portion  of the septum, and a very slight lateral com-
 pression, as  by the  action of  the compressor naris
 muscle,  brings them into  actual contact, thus forming
 two  distinct  and separate channels — an  upper one,
 passing  toward  and along the  olfactory region, the
 olfactory channel, and a  lower,  the respiratory chan-
 nel.
  The nasal  fossae communicate with the pharynx by
means of two oval openings about seven-eighths of an
inch  in length and one-half an inch in diameter.   These
openings are  known as the posterior nares.
  The furrows or depressions on  the  outer wall of 
ANATOMY.
II
each  sinus formed by the projecting turbinated bones
are termed the meatuses..  They are three in number,
the superior, middle, and inferior.
   Each  fossa  communicates with  four  sinuses — the
frontal, above,  opening with  the anterior  ethmoidal
cells into the middle meatus through the infundibulum;
the  sphenoidal,  behind,  opening  into  the  superior
meatus; the maxillary or antrum Highmorianum, open-
ing indirectly into the middle meatus, at the lower part
of  the infundibulum;  and  the posterior  ethmoidal,
opening into the superior meatus.
   Each  fossa  also communicates  with the  conjuncti-
val sac by a  continuation of  the mucous  membrane
of the inferior meatus through the  nasal duct, lachry-
mal sac, and the  canaliculi and puncta lacrymalia.
   The mucous membrane  lining the nasal fossae is in-
timately adherent to the periosteum, or  perichondrium,
over which it lies.  It is continuous externally with the
skin through the anterior nares, and with the mucous
membrane of the  pharynx through the posterior nares.
   From the  nasal  fossae its  continuity may  be  traced
with the conjunctiva through the nasal duct and lachry-
mal canals ;  with the lining membrane of the tympanum
and mastoid cells, through the Eustachian tubes,  and
with the  frontal, ethmoidal, <and sphenoidal sinuses,
and the antrum maxillare, through the several openings
of the meatuses.
  The mucous membrane is thickest  and  most  vas-
cular over the turbinated bones.  It is  also thick over
the septum;  but in the intervals  between the spongy
bones and on the floor of the nasal fossa it is very thin. 
 12                    ANATOMY.

 Where it lines the various sinuses and the antrum max-
 illare it is thin and pale.
  The surface of the  membrane  is  covered with  a
 layer of tessellated  epithelium at the upper part of
 the nasal fossae  corresponding with the distribution of
 the olfactory nerve, but is  ciliated throughout the  rest
 of its extent, excepting near the aperture of the nares.
 This membrane is also provided with a nearly continu-
 ous  layer of  branched mucous  glands, the  ducts  of
 which open upon its surface.   They are most numerous
 at the middle and back parts  of the nasal fossae,  and
 largest at the lower and back part of the septum.
  Owing to the  great thickness of this membrane,  the
 nasal fossae are much narrower, and the turbinated bones,
 especially the lower ones, appear larger and more prom-
 inent than in the skeleton.   From  the  same circum-
 stance, also, the various apertures communicating with
 the meatuses are either narrowed or completely closed.
  In the superior meatus the  aperture of communica-
 tion with the posterior ethmoidal cells is considerably
 diminished in size, and  the  spheno-palatine foramen
 completely covered  in.  In the middle  meatus,  the
 opening of the infundibulum  is partially hidden by a
projecting fold of mucous  membrane, and the  orifice
of the antrum is contracted to a small circular aperture
much narrower than in the  skeleton.
  In the inferior meatus, the orifice of the nasal duct is
partially hidden  by either a single  or double valvular
mucous fold, and the anterior palatine canal either com-
pletely closed in, or a tubular cul-de-sac of mucous
membrane is continued a short distance into it. 
ANATOMY.
13
  In  the  roof, the opening leading to the sphenoidal
sinus  is narrowed, and  the apertures in the cribriform
plate  of the ethmoid completely closed in.
  The arteries of the nasal fossae are the  anterior and
the posterior  ethmoidal,  from the ophthalmic, which
supply the ethmoidal cells, frontal sinuses, and roof of
the nose;  the  spheno-palatine, from the internal max-
illary, which supplies the mucous membrane  covering
the spongy bones, the  meatuses  and septum;  and the
alveolar branch of the  internal maxillary, which  sup-
plies the lining membrane of the  antrum.
  The ramifications  of  these vessels  form  a  close
plexiform  net-work  beneath  and  in the  substance of
the mucous membrane.  The veins of  the nasal fossae
form a close net-work beneath the mucous  membrane.
They pass, some  with  the  veins accompanying the
spheno-palatine artery,  through  the   spheno-palatine
foramen, and others, through the  alveolar branch, join
the facial vein; some  accompany the  ethmoidal arte-
ries and terminate in the ophthalmic vein ; and, lastly, a
few communicate with  the veins in the interior  of the
skull, through the foramina in  the cribriform  plate of
the ethmoid bone and the foramen caecum.
  The nerves are the olfactory, the nasal branch of the
ophthalmic, filaments from the anterior dental branch
of the superior maxillary, the Vidian, naso-palatine,
descending, anterior  palatine,  and  spheno-palatine
branches of Meckel's ganglion.   The olfactory, the spe-
cial nerve, is distributed  over the  upper third  of the
septum, and over the surface of the superior and middle
spongy bones.   The nasal branch of the  ophthalmic 
14
ANATOMY.
distributes  filaments to the upper and the  anterior part
of the septum and  outer wall of the nasal fossae.   Fil-
aments from the anterior dental branch of the superior
maxillary supply the  inferior meatus and inferior tur-
binated bone.  The Vidian nerve supplies  the  upper
and back part of the septum and superior spongy bone;
and the upper anterior nasal branches from the spheno-
palatine  ganglion have a similar  distribution.   The
naso-palatine nerve  supplies the middle of the septum.
The larger or anterior palatine nerve supplies the middle
and lower spongy bones.
  Soft Palate.—This movable prolongation of the roof
of the mouth is attached to the posterior border of the
hard palate.  It  constitutes an imperfect  partition be-
tween  the  mouth and the posterior nares.  Its  upper
or nasal surface  is convex, and  continuous with the
floor of the nose; its  lower surface is concave, in adap-
tation to the back of the tongue,  and is marked in the
middle by a white line, indicating its original formation
by two lateral halves.
  When the soft palate  is at rest it hangs obliquely
downwards and  backwards;  but, in swallowing, it  is
raised to the horizontal position by the levatores palati,
comes into apposition with the back of the pharynx,
and thus prevents the food from returning through the
nose.
  A perpendicular section through the soft palate shows
that the great bulk of it is made  up of mucous glands,
which lie  thick  on its  under  surface.   Above  these
glands we  come  upon the aponeurosis  of the palate;
still higher, upon the fibres of the  levator palati; and 
ANATOMY.
15
 lastly, upon the nasal mucous membrane.   The  soft
 palate is supplied with blood by the descending palatine
 branch of the internal maxillary, and  the  ascending
 palatine branch of  the external maxillary.   Its nerves
 are derived from the second division of the fifth pair.
   Uvula.—The uvula projects from the middle of the
 soft palate, and gives the free edge of it the appearance
 of a  double arch.   It contains a number of mucous
 glands  and a little  muscle, "the  azygos uvulae."   Its
 length varies  in  different individuals, and in the same
 person  at  different times,  according to the state of its
 muscles.   It occasionally  becomes  permanently elon-
 gated and causes considerable  irritation,  a sense  of
 tickling in the throat, and harassing cough.
  Arches of the Palate.—The soft palate is continued
 into the tongue and pharynx by two folds of mucous
 membrane  on each side,   enclosing muscular fibres.
 These are the anterior and posterior  half  arches  or
 pillars of the  palate.   The interior arch describes a
 curve from the base  of the  uvula to the side of the
 tongue.  It is well seen when the tongue  is extruded.
 The posterior  arch, commencing at the  side  of  the
 uvula, curves  along the free margin of  the palate, and
 terminates on the side  of the pharynx.   The posterior
 arches,  when the  tongue   is  depressed,  can be seen
 through the span of the anterior.
  Pharynx.—The term "pharynx" is applied to that
 part of the alimentary canal which receives the food
after it has been masticated, and propels it downward
 into  the oesophagus.  It is a funnel-shaped, muscular
bag.  Its upper part is attached to the basilar process 
i6
ANATOMY.
of the occipital bone; from thence it  extends perpen-
dicularly as low as the cricoid cartilage.  The pharynx is
connected behind to the bodies of the cervical vertebrae
by  loose cellular  tissue which  never contains  fat.
Parallel with and close to its sides are the internal carotid
arteries.  Its dimensions are not  equal  throughout.
Its  breadth at  the upper part is just  equal to that of
the posterior openings of the  nose;  for here it is  only
required to transmit the air inspired through  the nose;
but it becomes  much wider in  the  situation  where it
transmits the food—that is, at the back of the mouth;
thence it gradually contracts to the  oesophagus.   The
pharynx may be compared to a funnel communicating
in front,  by wide apertures, with the nose, the mouth,
and the  larynx; while the  oesophagus represents the
tube leading from its  lower end.  On each side, and
parallel with the  floor of the inferior meatus, and  one-
fourth to one-half an inch in front of the posterior wall
will be found the faucial orifices of the Eustachian tubes.
Small glands surround the  orifice of each tube.  They
are similar in nature and function to the glands beneath
the  mucous membrane of the mouth, the palate, and
the  pharynx; and serve the purpose  of supplying an
aqueous  saline fluid, which, by mixing freely with the
mucous,  keeps the surface washed clean.
  Constrictor Muscles of the Pharynx.—They are
three  in  number, and  arranged so that they  overlap
each other, i. e., the inferior overlaps  the middle, and
the middle the superior.  They have the same attach-
ments  on both  sides of the body, and the fibres from
the  right and left meet, and are inserted together into 
ANATOMY.
17
 the mesial line, the insertion being marked by a white
 longitudinal line called the raphe.   The inferior con-
 strictor arises from the side of the cricoid and thyroid
 cartilages.  Its fibres expand  over the lower part of
 the pharynx.   The superior fibres  ascend; the middle
 run  transversely;  the inferior descend, and are identi-
 fied with the oesophagus.   Beneath its lower border the
 recurrent laryngeal nerve enters the larynx.  The mid-
 dle constrictor arises from the upper edge of the greater
 cornu  of  the  os-hyoides, from its  lesser cornu, and a
 part of the stylo-hyoid ligament.  Its fibres take differ-
 ent directions, so that with those of the opposite mus-
 cle they form a lozenge. The lower end of the lozenge is
 covered by the inferior constrictor;  the upper  angle
 ascends nearly to the basilar process of the occiput, and
 terminates upon the pharyngeal aponeurosis.
   The external surface of the muscle is covered at  its
 origin  by  the hyo-glossus.  The  superior constrictor
 arises from the hamular process of the sphenoid bone;
 from the pterygo-maxillary ligament (which connects it
 with the buccinator); from the  mylo-hyoid ridge of the
 lower jaw, and from the side of the tongue.   The fibres
 pass inward to the  mesial line;   some of  them  are
 inserted through the medium of the pharyngeal apon-
 eurosis into the basilar process.   The upper border
 of the superior constrictor presents on either side a free
 semi-lunar edge with its concavity upward, so that  be-
 tween  it and the base  of the skull a space  is left in
which  the muscle is deficient.   Here the pharynx is
strengthened  and  walled in by its own aponeurosis.
The  space is called the "sinus of Morgagni," and  in
                         2 
i8
ANATOMY.
it, with a little dissection, we get at the muscles which
raise and tighten the soft palate,  i. e., the levator palati,
the tensor palati.   The  fibres  of the stylo-pharyngeus
pass in between the superior and middle constrictors,
and expand on the side of the pharynx;  some of them
mingle with  those  of the  constrictors, but most of
them are inserted into the posterior margin of the thy-
roid cartilage.
  Pharyngeal Aponeurosis.—The pharyngeal aponeu-
rosis intervenes between the mucous membrane  and the
muscles of the pharynx.   It is  attached to the basilar
process of the occiput, and to the points of the  petrous
portions  of  the  temporal  bones.   It maintains the
strength  and integrity  of  the  pharynx at its upper
part, where  the  muscular fibres are deficient; but it
gradually diminishes in thickness as it descends, and is
finally  lost  in the walls of  the oesophagus.
  There are seven openings into the pharynx, viz.:  I.
The posterior openings of the nares.  2.  On each side,
near the inferior turbinated bones, are the openings
of the  Eustachian tubes;  below the nares is the soft
palate, with  the  uvula.   3.  Below the soft palate is
the  communication with the mouth, called the "isth-
mus faucium."   On each  side of this are two  folds of
mucous membrane, constituting the anterior and poste-
rior half arches of the  palate;  between them  are the
tonsils.  Below the  isthmus faucium is  the epiglottis,
which  is connected to the base  of the tongue by three
folds of mucous membrane.  4.  Below the epiglottis is
the aperture of the larynx.  5.  Lastly,  is the  opening
into the oesophagus.  All these  parts are lined by mu- 
ANATOMY.
19
cous membrane,  common to the entire  tract of the
respiratory passages and  the alimentary canal.   But
this membrane presents characteristic differences in the
different parts of these channels, according as they are
intended  as passages for air  or  food.   The mucous
membrane of the pharynx above the velum palati, being
intended  to transmit air  only, is very delicate in  its
texture, and lined by ciliated  epithelium like the rest
of the  air passages.   But opposite the fauces the mu-
cous membrane in every respect resembles that of the
mouth, and is  provided  with squamous epithelium.
At the back of the larynx  the membrane is corrugated,
to allow  the expansion of the  pharynx during the
passage of the food.
  Arches of the  Palate Continued.—The tonsils are
situated on each side, between the arches.   Now, what
are  the uses of these arches?  They are chiefly con-
cerned  in the mechanism of deglutition.   The anterior
(enclosing the  " palato-glossi" muscles) contract so as
to prevent the food from coming back into the mouth;
the  posterior side curtains co-operate  in preventing
the food from passing into the nose.  True, in vomiting,
food does sometimes escape through the  nostrils, but
one  can not wonder at this, considering  the violence
with which it is driven into the pharynx.
  Muscles of  the Soft Palate.—The muscles of the
soft  palate lie  immediately under the  mucous  mem-
brane.   There are four pairs, viz.: the levatores palati,
the  circumflex  or tensores  palati,  the  palato-glossi,
and  palato-pharyngei; the  azygos uvulae is single.
  Levator Palati.—This muscle arises from the petrous 
20
ANATOMY.
portion of the temporal bone, and  from the cartilage
of the Eustachian tube.  Its fibres spread out, and are
inserted along the upper surface of the soft palate.  Its
action is to raise the palate so as to make it  horizontal
in deglutition.
  Circumflexus or Tensor Palati.—This muscle is sit-
uated  between the internal pterygoid muscle  and the
internal pterygoid plate of the sphenoid bone.   It arises
from the scaphoid fossa, and  from the Eustachian tube.
Thence it descends perpendicularly, ends in a tendon
which turns round the hamular  process, and expands
into a broad  aponeurosis, which is connected  to its
fellow of the opposite  side, and is also  attached to the
horizontal plate of the palate bone.   It gives strength
to the  soft palate.   A synovial membrane facilitates the
play of the tendon round the hamular process.  Its
action is to draw down and tighten the soft palate.
  Azygos  or  Levator Uvulae.—This  consists of one
or sometimes two thin bundles  of muscular fibre, which
arise from the aponeurosis of the palate, and  descend
along the uvula, nearly down to its extremity.
  Palato - glossus  and  Palato-pharyngeus.—These
muscles  are contained within  the  arches of  the soft
palate.  The palato-glossus,  within  the interior arch,
proceeds from the anterior  surface of the soft palate to
the side of the tongue, and is  lost in the stylo-glossus
muscle.  The palato-pharyngeus, within the posterior
arch,  proceeds from the  posterior border of the palate
to the side  of the pharynx  and  mixes with the fibres of
the constrictor and the stylo-pharyngeus.
  These muscles,  and the relations they bear to sur- 
ANATOMY.
21
rounding parts, should be particularly noticed, as the
surgeon may have to divide them in the operation of
staphylorraphy.  Sir William Ferguson has shown that
in cleft-palate the fissure is separated by the levatores-
palati  and palato-pharyngei muscles;  which  offer an
impediment to the  parts healing after they are brought
together.  He recommends the division of these  mus-
cles as a necessary proceeding.   The  flaps are  thus
relaxed, and readily retained in position.   The pillars
should  be divided  just below  the tonsils  with a  pair
of blunt-pointed scissors.
  To divide  the levator palati, Mr. Pollock places the
flap upon the stretch, and passes a double-edged  knife
through the  soft palate, on the inner side of the  ham-
ular process, and above the line  of the levator-palati.
The handle  is  now raised and depressed,  a sweeping
cut being made along the  posterior surface of the soft
palate.
  Tonsils.—The tonsils consist of an aggregation of
muciparous glands.  They are situated at the entrance
of the fauces, between the arches of the palate.  Their
use is to lubricate the fauces during the passage of the
food.  The orifices  of their ducts, visible on the surface,
give the  tonsil an appearance  like the  shell of  an
almond; hence, as well as from their oval figure,  they
are called "amygdalae."   These  openings lead into
small cells in  the  substance  of  the  tonsil,  lined  by
mucous membrane; and into  these numerous smaller
ducts pour their secretion.   The fluid,  viscid and trans-
parent in  the healthy state, is apt  to become white and
opaque in inflammatory affections of the  tonsils,  and 
22
MINUTE ANATOMY.
occasionally accumulates in the superficial  cell, giving"
rise  to  the deceptive  appearance of a small ulcer, or
even a slough.
  Concerning the relations of the tonsil, remember that
it  lies close  to  the  inner  side of the internal carotid
artery.  It is only separated from the great vessel by
the superior constrictor and the aponeuris of the phar-
ynx ; therefore, in it the point of the instrument should
never be directed outward, but inward toward the mesial
line.   The tonsils are  supplied with blood by the ton-
sillar branch  of the external maxillary artery.
             MINUTE  ANATOMY.

  The organ endowed with the sense of smell con-
sists,  as is well  known,  of  the two  nasal  fossae  and
accessory cavities,  in  the lining memorane of which
the branches of  the olfactory nerves  are distributed.
Besides being a  sensatory apparatus,  this  also serves
as a passage for an important part of the great high-
way to the respiratory system.   The whole nasal mem-
brane does not participate in the perception of odors.
  It is  only the upper portions of  the  two greater
cavities which preside over the reception of this par-
ticular kind of impressions; the  other parts are either
accessories in the  process, or  merely endowed with
ordinary sensation  through  twigs  of the  trigemini.
That portion of the organ designed for the perception 
MINUTE  ANATOMY.
23
 of odors corresponds to the distribution of the olfactory
 nerves.   It  consists generally of the membrane cover-
 ing  the  upper part of the septum, the superior and a
 portion of the middle turbinated bones.   It is remark-
 able  for its  yellowish  or brownish tint, better seen in
 the  mature  than in the  newly-born animal, and but
 slightly pronounced in man.  It is further liable to vary
 in extent in different individuals, especially of the hu-
 man  species.  To this tract  the appropriate  name of
 regio olfactoria  has  been  given (Todd and Bowman).
 The  older name  of Schneiderian membrane may  be
 retained for the remainder of the mucous surface not
 endowed with perceptive power.
   In the  anterior nares strong hairs  are to be found,
 known as vibrissas, designed to prevent  the  entrance
 of foreign bodies.   Internally, the coating of  flattened
 epithelial cells  extends for a certain distance from  the
 entrance,  and then  gradually gives way  to a slightly
 laminated, ciliated species, already alluded to, which
 extends from thence throughout all the cavities of the
 organ.  Here also we find beaker-cells, except in  the
 regio olfactoria.   (Schultze.)
  The Schneiderian membrane, which is very vascu-
 lar in the  greater cavities, differs much  in structure in
 particular  localities.  In  the accessory cavities  it is
 thinner, and so intimately connected  with the surface
 of the bone, that its sub-mucous tissue plays  the  part
 of periosteum to the latter.   In the nasal fossae proper,
the mucosa attains, on  the contrary, a much greater
thickness.   Here  it is richly supplied  with racemose
glands, which occur very sparsely in the adjacent  cav- 
24
MINUTE ANATOMY.
ities.   It presents, also,  in this region, a dense  plexi-
form arrangement of blood vessels, especially of  veins,
to which is due the great  tendency of the nose to bleed.
The mode of termination of the sentient nerves of the
nose is still unkown.
  The regio olfactoria  offers for our consideration a
very remarkable  and extremely delicate tissue, whose
constituents are  particularly liable to suffer  from de-
composition.    For our  present acquaintance with its
nature we are indebted to Schultze, and before him, for
many points, to Eckard and Ecker.  Apart from  differ-
ence of color, it  may be distinguished  from the  sur-
rounding membrane by  its  greater thickness and dis-
similarity in the species of glands it contains, as well as
in not possessing ciliated epithelium.  The glands in
question have been  named  by Kcelliker after  their dis-
coverer, Bowman. They belong to the tubular species,
and remind one of the follicles of Lieberkuhn.  In the
central  portion of  the  regio  olfactoria they present
themselves in great  number, becoming more scattered
toward the periphery, and finally disappearing.   Their
form  is that of an elongated  tube,„somewhat twisted
below,  and of varying  calibre,  generally narrowing
greatly at the mouth.   Internally, they are lined with
rather large gland cells,  containing usually a consider-
able quantity of  small yellow or brown pigment  mole-
cules,  which fact explains,  to a  certain  extent,  the
peculiar tinge of  the olfactory region.
  These glands of Bowman, whose existence was for-
merly denied, are to  be  found in  all  lower mammalia,
and are not  absent  in  man, although they  take the 
MINUTE ANATOMY.
25
form here of a kind of transition to ordinary racemose
glands.  {Frey, Schultze.)
  The secretion  of Bowman's glands,  as regards its
composition and physiological significance, has not yet
been made the subject of investigation.
  Thus we find the olfactory region in the lower mam-
mals and the human infant.   (Schultze.)   In the  adult,
also, spots quite destitute of cilia are to be found, which
vary, however, considerably in extent.   But under cer-
tain circumstances the whole regio olfactoria has been
observed  to  be clothed  with  ciliated columnar cells.
(Gegenbaur,  Ley dig,  and  H.  Muller,  Weckler, Luschka,
Henle,  Ecklers.)
  When we take into consideration the  varying  acuity
of the sense of smell  in  different individuals,  and  that
frequently recurring catarrh  may induce changes of
structure, this need not surprise us.
  At  the border  of the  regio  olfactoria the  ordinary
ciliated epithelium gradually terminates,  giving place to
a no longer laminated covering of long cylindrical cells.
These  dwindle down  below  into  thread-like  parcels,
which  descend  into the  subjacent  connective-tissue,
where  they become  widened  again, and,  undergoing
division, unite with  one another.  In this way a  net-
work of fibres, or rather of more or less homogeneous
bands, is formed.   Between these cylindrical elements
there remain naturally interstices, which serve for the
reception of another species  of cell.  The occurrence
of particles  of yellowish  or brown  pigment, either in
the  upper broader portion of  the columnar  cells, or
deeper down below their nuclei, is peculiar;  these 
26                MINUTE ANATOMY.
granules may not  unfrequently be seen  also  in  the
widened portions  of the  process.   The former is  the
case in man and many of the mammalia.  Like  the
contents of the glands of Bowman, these caloused par-
ticles communicate  to  the locality in  which they are
situated a peculiar tint.
  Between  these  decidedly epithelial  elements (and,
moreover, in all vertebrate animals,) a second species
of cell presents  itself, different in  shape and composi-
tion and nervous nature.   These cells consist of a fusi-
form body,  situated deeper down, however, than  the
bodies of the first kind, containing a vesicular nucleus
and finely granular contents.   From both poles of each
of these nervous structures, as  they are held  to  be,
these olfactory cells, a  process is  given in opposite
directions.   The descending is of extreme delicacy,
and liable to undergo early decomposition.   At inter-
vals it is studded with  minute varicosities, recalling to
mind these very  fine nerve tubes.   The ascending pro-
cess is, on the other hand,  thicker and  less knotted,
presenting a more or less smooth  outline.  It has the
form of a slender cylinder or rod, 0.0018 or 0.0009 mm-
in diameter, reminding us of one  of the elements  of
the retina.   These  rods  mount up  between the col-
umnar epithelial  cells  to  the surface  of the  mucous
membrane, terminating here in various ways.   In  the
frog and allied amphibiae (in which they may be easily
seen), they are surmounted at their free extremities by
delicate hairs of considerable length, in a certain num-
ber of which ciliary motion  has been observed, while
others, generally the longest, remain quite stiff.   These 
MINUTE ANATOMY.
27
two  kinds of olfactory filaments appear  to  be linked
together by intermediate forms.
  In other amphibia and in birds, very similar, and, in
certain cases, even  longer hairs  are to be found, either
in large  numbers or single (Schidtze);  none have been
observed  among the  fishes.   In man, and the rest of
the mammalia, we may seek in vain for these paradoxi-
cal  cilia.   Here we  observe  small appendages, from
0.0023 to 0.0045 mm-  m length, seated on the extrem-
ities of each rod, and projecting beyond the  ends of
the columnar cells.
  In order to better understand the  nature  of  these
remarkable olfactory cells, we must now make ourselves
acquainted with the  arrangement of the branches of
the first cerebral  nerve.   The  nerves  of  scent  take
their origin  from peculiar masses in the lower surface
of the olfactory lobes in  the  form of bundles of pale
fibres.   A few dark-edge  fibres, which have  been met
with by Remak and  Sclmltze  in the  olfactory nerves,
are  probably  derived from  anastomosis   with   the
trigeminus.
  The true olfactory fibres are pale elements, 0.0045 to
O.0074 mm.  in  thickness, enclosed within a  nucleated
sheath.   The contents of  the  latter are not constituted
by a single  axis cylinder, however, but, as  was found
by Schultze,  by a bundle of extremely delicate varicose
primitive  fibrillae, 0.0023  to 0.0002 mm. in  diameter,
presenting a secondary nucleus.  Similar fibres are to
be found in  the  grey matter of  the bulbus olfactorius.
(Walter,  Sclmltze.)
  In the mucous membrane of the regio olfactoria sev- 
28
MINUTE  ANATOMY.
eral other bundles may be recognized.   These  spring
at acute angles from branches of the olfactory  twigs,
and give origin in their further course to the true (com-
plex) nerve tubes.  The latter are for a short distance
enclosed  within  their nucleated sheaths, until,  event-
ually, the delicate varicose fibrillae of the interior stream
out free into the  tissues around.  (Schidtze.)
  The mode  in  which these filaments ultimately ter-
minate is not yet fully ascertained;  it seems, however,
extremely probable that the varicose fibrillae are  con-
tinuous with the descending fibres of the olfactory cells;
so  that these bodies, with  their narrow  rods, may be
looked upon as the terminal structures of the olfactory
nerve.  The fact, however,  can not be concealed  that
the most recent observations by Exner on the structure
of these parts have pointed to other conclusions.   Ac-
cording to him there is no sharp line of distinction be-
tween the two species of elements of the regio olfactoria,
the olfactory, and columnar epithelial cells.   They are,
he says, connected by intermediate forms.
  Beneath  these cells,  there exists a  (sub-epithelial)
band-work of protoplasm, whose interstices  are filled
with  nuclei.   Into  this  (in man)  thin net-work  the
ramifications of both kinds  of cells  sink from  above,
and become fused.  From  below,  also,  the  olfactory
fibres ascend into it.   Thus we have in it an interme-
diate  nervous plate.  The  course  of development of
the olfactory organs in the embryo, although followed
up in  its broader  outlines, has not been minutely inves-
tigated.
  Remarks.—(i.) In many of the  mammalia we meet 
EXAMINATION  OF THE PHARYNX.         29
with peculiar structures, known as the organs of Jacob-
son.   These consist of tubes, with cartilaginous walls,
and are situated in the substance of the palate; they
open  into the duct  of  Stenson.   In  these is contained
branches of  the olfactory nerves.   In their texture
they resemble the regio olfactoria.  (C. Balogh.)   (2.)
Bowman's glands may  be  made out with  comparative
ease.   (3.)  The delicate  fibrillae which spring  from
the inferior end of  the  olfactory cells, and those which
are derived from  the  spreading out  of the olfactory
nerves, resemble each other in every respect.  But the
difficulties  connected with the investigation in  this
direction have hitherto rendered it  impossible to dem-
onstrate a direct transition of one into the other.
  EXAMINATION  OF  THE PHARYNX.

  The walls of the pharynx are to be examined by direct
inspection, and  by reflected light.  In order to make
a direct inspection it is necessary that the tongue should
be depressed.  Many persons are able to depress their
tongues  by voluntary effort.   This is done by open-
ing the  mouth very wide and taking a full  inspiration.
When the patient is unable  to  accomplish this  suffi-
ciently, the  tongue may be  depressed by the  index
finger.  The  finger should be  well  wrapped  with a
napkin or handkerchief, as  a matter of cleanliness and
protection.  (See Fig.  1.) A neglect of this precaution 
30          EXAMINATION OF THE PHARYNX,
might prove  disastrous to the observer by rendering
him liable to  contract  syphilis by inoculation, as this
disease is frequently  met  with  in  connection  with
Shepard & Dudley, N.Y.     Fig. I.
catarrh of the nose and pharynx.  In the event of an
objection on the part of the patient, or a reluctance on
the part of the operator, a tongue depressor maybe used, 
EXAMINATION OF THE PHARYNX.         31
 such as is represented  in  Figs. Nos.  2 and 3.  The
 handle of an ordinary spoon is an excellent substitute
 for  the depressor.  Tongue  de-
 pressors are objectionable,  and I
 rarely use  one, unless  it is in a
 case where the patient objects, or
 some  specific   manifestation  is
 present.   Children  often  refuse
 to permit the instrument to  enter
 the mouth, when the finger is  not
 objected to.  Adults refuse upon
 the  grounds that the instrument
 is common property, and there-
 fore is used in  the mouths of in-
 dividuals that  are probably con-
 taminated with some disease that'
 might be transmissible.   The  ob-
 jections are well taken, as a fail-
 ure  to  thoroughly cleanse these
 instruments might easily occur  on
 account of the rough surface that
 is usually  placed next to the
 tongue.
  By direct inspection the walls
 of the  pharynx that are below
the level of the soft palate  may
be very thoroughly  examined if
the tongue is kept well out of the
way.   In some instances the epi-
glottis may be seen.  In this way
 Tobold has been able on one occasion to see the action
 
 32          EXAMINATION OF THE PHARYNX.

 of the lips  of the glottis, and to recognize  a morbid
 growth upon the left vocal cord.  The posterior wall
 and  a portion of the lateral walls are usually very well
 shown, and likewise the arches and tonsils.
  A  more  extended examination  may be  made by
 lifting the soft palate  gently up.  This may be done
 with a palate elevator, or in the  absence of that instru-
 ment a stout flexible probe of sufficient length may be
 curved at the end and used for the purpose.
  To make a thorough  examination of  the  superior
 portion.of the pharynx, and  in  some instances certain
                        of the  inferior portions,  it is
                        necessary to use the reflecting
                        mirrors, or, in other words, to
                        practice pharyngoscopy.  The
                        steps in superior pharyngosco-
                        py are the same as those of pos-
                        terior rhinoscopy.   The  mir-
                        rors to be used for this purpose
                        are of two kinds:  First, a large
                        one (Fig. 4), from two and a
                        half to three inches  in diame-
                        ter,  perforated in the center,
                        and attached to a band which
                        is to fit around the head, so as
                        to give the manipulator the
         Fig. 4.          free use of both hands.   (See
 Fig 1.)  There should be a ball and socket joint, so as
 to permit the  free  movement of the mirror, in order
 that the light may be shifted from one point to another
with  perfect ease.   The focal distance of  this  glass
 
EXAMINATION OF  THE PHARYNX.          33
 should be about eight inches.   The small glasses should
 be attached to long handles with flexible metallic shanks,
 in order that the  angle  may be changed at will.  The
 size of these mirrors  is a  matter that should not be
 overlooked.  They should be small enough not  to im-
 pinge upon  the adjacent structures, as a mere  touch
 is often sufficient to cause severe retching, which mate-
 rially interferes with the examination.  The most con-
 venient size is about one-fourth  of an inch in diameter.
   Artificial illumination will be necessary as a rule,  on
 account of the uncertainty of  the sunlight  and  the
 inconvenience  of getting in a suitable position  at  all
 times to make  use of it. An argand  burner attached
 to a gas jet serves an excellent purpose, or the ordinary
 burner attached to a rack movement is sufficient.   The
 student's lamp  is preferable  to gas, because the flame is
 more steady and regular.  A condenser may be attached
 to the lamp or  gas  jet, but the light is  equally as good
 without, and is  much easier managed when coming from
 the  surface of  an  ordinary  chimney than from the sur-
 face of a convex lens, which throws the rays  of light
 out in a pencil.  In the absence of any of these conve-
 niences, the common lamp that is used about dwellings
 or a tallow-candle will suffice.
  To make a posterior rhinoscopic examination the fol-
 lowing steps must  be taken, in the order named:
   1. The patient must sit erect and face the observer,
 as in Fig.  I.
  2. The light  should be placed on a line with the ear,
and about twelve inches  from the head.  It makes  no
material difference upon  which side the light is placed;
                         3 
34          EXAMINATION OF THE PHARYNX.

this  is to be  arranged to suit the convenience of the
observer.
  3.  Seated in front of  the patient, with the  reflector
properly adjusted, so that  the right or left eye, as the
observer may  choose to use, looks through the perfora-
tion  in the center of the mirror.
  4.  Place the patient's head in  such a position as to
have him look you directly in the  face, then direct him
to open his mouth and breathe through the nose.   Use
the  smallest size mirror, which should be held over a
flame before introducing until it feels pleasantly warm
to the cheek, not hot.  The object in warming the mir-
ror is to  prevent its becoming misty by the moisture
of the throat.   Allow the patient's tongue  to remain
quiet, in its natural position.
   5. The small mirror should be placed  either in the
right or left hand, as suits the convenience of the oper-
ator, and then introduced into the patient's mouth with
the  reflecting surface upward, and  passed carefully in
behind  the soft  palate,  taking the  precaution not to
touch the base of the tongue or  the posterior wall of
the  pharynx.    The reflecting surface of  the mirror
should be about in the position represented by Fig. 5,
although it will  frequently  be necessary to vary the
position  from that represented in the cut, on account
of anatomical  peculiarities, and many other causes, that
will  manifest  themselves to  the observer.   When the
mirror  is  in  position,  direct the  patient to breathe
through the nostrils quietly, and as a rule a view of the
posterior nares may be obtained with but little difficulty.
  The  structures  brought  into   view  by  posterior 
EXAMINATION  OF THE PHARYNX.          35
rhinoscopy are the posterior surfaces of the soft palate
and uvula; the membrane covering the posterior and a
portion of the lateral surface of the septum, and that
covering the posterior portion of the turbinated bones;
the roof of the pharynx and the  superior part  of its
posterior  and lateral walls; the openings  of the  Eus-
tachian tubes,  and the posterior portion of the nasal
meatuses.
  It will  be  necessary to  change the position of the
mirror in  order to get a view of all the structures, as 
$6         EXAMINATION  OF THE PHARYNX.
 they can not all be included in one image.  By revers-
 ing the surface of the mirror inferior pharyngoscopy
 can be practiced.  This is done in the same manner as
 laryngoscopy.   It enables the observer to determine
 the condition of  the  walls of the pharynx down  to
 the larynx, and that organ also, if necessary,  and the
 membrane at the  base of the pillars  of the fauces and
 tongue.
   Anterior Rhinoscopy.—The  light  for this may be
 direct or reflected.   In using direct light it is necessary
                    to incline the patient's head back-
                   f ward,  so as to  allow the light to
                    pass  directly into the  anterior
                    nares.   Good sunlight is prefer*
                    able to any other in  making this
                    kind of an exami-
                    nation,  although
                    artificial light may
                    be used.  It is ne-
                    cessary that  the
                    nostrils should be
                    dilated in order to
                    obtain  a   good
                    view.  There are
                    a number  of in-
                    struments    used
                    for  this purpose.
                    The author  has
devised an instrument  (Fig. 6) with a screw arrange-
ment,  graduating the  amount of pressure, and at the
same time  rendering the instrument sufficiently small
Fig. 6.
Fig. 7. 
EXAMINATION  OF THE PHARYNX.
37
 for its introduction  into the nostrils of children as well
 as  adults.  Frankel's speculum (Fig. 7) works in a
 manner similar  to  the  above-mentioned  instrument,
 with the exception  that when  it is introduced it is
 adjusted by a screw, which must be loosened  before
 removal or its withdrawal will be painful.   Slight press-
 ure  on the blades of the author's instrument permits
 of its easy removal without  interfering with the screw.
   Dr. Elsburg's trivalve nasal  speculum (Fig. 8)  is a
 serviceable instrument,  but  is not  so  convenient as
 either of the former.  In the absence
 of  a nasal speculum,  an  ordinary
 aural speculum will answer for a sim-
 ple examination.  In the absence of
 a  speculum of any kind, the head
 may be thrown back, the  lobe of the
 nose elevated, and the nostril pulled
 open by means of a bent probe, hair
 pin, or ordinary piece of wire.  A
 good light, with this  manipulation,
 will  usually afford a fair view.  Any
 one  of these  instruments  may be
 used with direct  or  reflected light.
 In  using reflected  light the  head
 mirror is to be used as in posterior      Fig- 8.
 rhinoscopy.
  The structures to  be observed by anterior inspection
 are the lateral walls of  the anterior nares,  the  mem-
 brane covering  the  septum, anterior portion of  the
 turbinated bones,  and floor of the nares and  the agger-
nasi.   The anterior  portion of  the  septum is rarely
 
38
CATARRHAL SYRINGE.
 found in the center of the nose, and in consequence of
 that fact the cavities of each side are not  of equal di-
 mensions.   Any portion  of the  septum  may be  dis-
 placed, but it  occurs most  frequently in the anterior
 region.  The turbinated bones are occasionally distorted
 and bent out of their proper position.   When this is
 the case the cavities are disproportioned.   The distor-
 tion may be sufficient to prevent a perfect examination.
 It often interferes with the introduction  of the Eus-
 tachian catheter, and in many cases with the passage
 of atomized fluids.
  There are various modes and  devices for throwing
 fluids  into the nasal and pharyngeal cavities.  For in-
 jecting the naso-pharyngeal space the catarrhal or post-
 nasal syringe is the best instrument  of the kind in use.
 It is made  of hard  rubber, with a bulbous extremity,
 which is perforated by numerous small openings,  so
 arranged as to allow the fluid to escape in all directions.
  The manner in which the syringe should be intro-
 duced, emptied, and withdrawn is a  matter that  should
 receive special  attention.  First  of  all, it is necessary
 to have light sufficient to get a fair view of the velum
 palati  and  fauces.  The patient's head should be con-
 trolled by one hand and the syringe  carefully passed in
 behind the velum palati.   As soon as the instrument is
 in proper position, it should be emptied and instantly
 withdrawn.  The instrument should never move in the
 hand, and  in order to withdraw it properly it is neces-
sary to invert the hand.   If  manipulated in  this man-
 ner,  there  is no danger of  abrading the surfaces  or
inflicting pain.    It  should  be  remembered that the 
CATARRHAL SYRINGE.
39
patient's tongue must not be pulled out of the mouth
while washing  the nose and pharynx with this instru-
ment.   If the tongue is pulled  out, the larynx is drawn
forward, and the epiglottis prevented from closing that
aperture,  and  at  the same  time places  it  in such  a
position as to receive any fluid that  may fall from the
region of the uvula or posterior nares.
  The cases that are  best adapted to  its  use are those
that are confined to the pharynx  and lower portion of
the nose,  and those that are free from crusts of inspis-
sated mucus.   Where the secretions  are very dry and
adherent to the membrane, one application of liquid by
the syringe does  not  always cleanse the surface, and it
may be necessary to  introduce it a number of times to
accomplish the desired result.  Frequent introductions
of the instrument at a single sitting are often.objected
to by the patient.  Children sometimes shrink from the
use of the syringe on account of its having to be used
through the mouth,  but  after  a few applications  they
usually submit without any trouble.
  The question may be asked, is there any danger of
flooding the drum cavity with the  catarrhal syringe ?  I
have heard of but two cases ; one of these was undoubt-
edly due to the ignorance of the physician, who made
the patient put his tongue  out while he injected the
pharynx.   The patient strangled,  and the result was
that both drum cavities were filled with  liquid, which
set  up a  violent  acute suppurative otitis media,  that
resulted in perforation of both drum membranes.   The
other was a case in which the anterior nares were com-
pletely  closed  with inspissated mucus and  prevented 
40
ATOMIZERS.
escape through the proper channel.   The prompt use
of the catheter prevented any thing more  serious than
severe pain for a few minutes.  When the nose is in a
condition to permit the passage of liquid, the instrument,
if properly used, is free from harm in every respect.
  Atomizers.—Richardson's and similar anaesthesia ap-
paratuses (Fig. 9) are about the best hand instruments
Fig. 9.    Shepard & Dudley, N.Y.
in use.   Their complicated  structure  renders  them
somewhat objectionable.   The double bulb attached to
them gives a decided advantage, enabling the operator
to use  either an intermittent or continuous spray.
               rThe Holmes Boston Perfumer (Fig. 10)
             is a  very excellent  little  instrument as
             long  as it  remains  in  perfect working
             order.   Unfortunately, its tubing is made
             of metal, and the use of any  saline or
             acid solution  soon corrodes it,  unless it is
             thoroughly cleaned each time it is used.
   Fig. 10.      In  1878  I devised an  instrument for
atomizing fluids, which is represented by Fig.  11.   The
instrument consists  of a  receiver  with a capacity for
four  gallons,  with  a  stop-cock at the top and bottom,
and  a  force-pump connected with the  receiver by a 
ATOMIZERS.
41
piece of rubber hose.  Attached to the stop-cock at
the top of the receiver is a piece  of hose for attaching
the atomizer.   The advantages of this mode of cleans-
ing and medicating are numerous; it economizes time
and labor; it  is ma-
nipulated with more
ease than any other
instrument used for
such purposes. The
powerful force with
which the spray can
be  thrown  renders
it far superior to any £»
form  of  nebulizer,
because the  strong
current of air car-
ries  the  fluid into;:
every recess and in-
sures thorough ap-
plication.  The de-
gree  of  comminu-
tion that can be produced with this instrument gives it
an advantage  over all others, because it enables us to
use agents that would otherwise be exceedingly difficult
of application and distressingly painful.
  Steam  Atomizers. — Atomizers  of  this kind  are
impracticable, even for office use, on account of having
to keep them  constantly running to avoid the delay in
raising  steam, so to speak; and, moreover, the instru-
ment is unwieldy, and can not be manipulated with the
ease  of the air instruments.
 
42
INHALERS.
  The instrument  represented by Fig. 12 is one of the
best in use.   It is manufactured by G. Tieman &  Co.,
New York.   These instruments are  better adapted  to
the treatment of laryngeal affections, and to disinfect-
ing purposes.  If  it is desirable to use warm  fluids  in
the naso-pharynx,  it can be done by heating them to a
                       Fig.  12.

temperature of  1400 Fahr., and  using with  the  air
instrument.
  Fig.  13  represents  an instrument  devised  by Dr.
Lewin, of Berlin, for generating the vapor of the chlo-
ride of ammonium, and applying it in the nascent state.
"The bottoms of two bottles,  through the corks of
which a tube passes all the way down, are covered with
an ounce or so of strong muriatic acid and caustic water
of ammonia, respectively; a second tube, passing from
just below the corks of each of these bottles, is carried 
INHALERS.
43
down to the  bottom of third or wash bottle, half filled
with water.   A third tube from just below the cork of
this  bottle  communi-
cates with  a nozzle to
be placed  in the nos-
tril.   As  the  vapors
from the  generating
bottles  are driven to-
gether  into the wash
bottle   they unite  to
form vapor of the chlo-
ride   of  ammonium,
which becomes washed
before it escapes from
the apparatus."
  In this apparatus it
was  intended that the
patient should  inhale
the  vapor  by  the
mouth and pass it out
by expiration through         Fig. 13.  shepard & Dudley.
the  nose;  or else  inspire for a short period  through
each nostril alternately.  It is much better to pass a
current of air from a special reservoir, or from the hand
ball  compressor that  is  used with the ordinary spray
producers,  and force  the current of  air and vapor  on
through into the passages.   The small pocket instru-
ments sold in drug stores are not so efficient as Lewin's
instrument, and evolve too strong a vapor.
  In throwing atomized fluids in the  nose, care should
be taken not to direct the current upward at more than
 
44
NASAL DOUCHE.
 an angle of 45 degrees, because the current passing in,
 directed upward at a greater angle than this, will  come
 directly and  forcibly  in  contact with the membrane
 covering  the  upper portion of  the  middle  and the
 superior turbinated bones, and produce such an amount
 of irritation as to cause violent sneezing, with conges-
 tion of the membrane and  sense  of fullness about the
 frontal cells.
   It is  best to direct  the spray into the  nose through
 the  inferior meatus and  parallel with the floor.  In
 spraying the nose the  patient should sit or  stand erect,
 with the chin  slightly elevated, so as to allow the fluid
 to flow  back into the pharynx.  The patient should be
 directed to hold the breath, or to respire  gently, and
 refrain from swallowing while the fluid is in the cavities
 of the nose and pharynx, as the act of deglutition at
 this time  is apt to produce strangulation by a part of
 the fluid  trickling into the pharynx, thus  causing the
 patient  to experience the unpleasant effects of strang-
 ling  and  occasionally  forcing a small quantity of the
 liquid into the tympanic  cavity or into the Eustachian
 tube, producing more or less pain.
  But a few years ago Dr. Weber, of Halle, introduced
 the nasal douche,  an instrument for cleansing the cav-
ities  of  the nose by forcing  a stream  of fluid through
 them.   The instrument is simple,  consisting of a vessel
with the capacity of about one quart,  with  a stop-cock
at the bottom  for the attachment of a small  hose, about
three feet in length.  The vessel being filled with fluid,
is elevated above the head  a short distance,  so  as to
permit of pressure sufficient to force the  fluid through 
NASAL DOUCHE.
45
the nose.  The amount of force is  regulated by ele-
vating or lowering the vessel.
  Of all the methods resorted to for cleansing and med-
icating the nasal cavities, there is none more popular
than the douche.  Its popularity is to be accounted for
in several ways.  First of all, at the time  of its intro-
duction the profession were sadly in need of something
to meet  the demand, which the douche is claimed  to
fill.  Secondly,  the  simplicity of the instrument, and
the apparent ease with which  it is managed.  Thirdly,
its extreme  cheapness.
  Considering these facts, and that there was no instru-
ment but the ordinary syringe that  could be used by
the patients, it is not at all surprising that the douche
shou«ld at once become a popular instrument.
  Giving Dr. Weber all due credit for his discovery,  or
rather his application  of hydrostatics, I feel confident
that the profession  and humanity at large would be
better off without the nasal douche than with it.  There
can be no doubt but what the douche is a prolific source
of acute inflammation of the tympanic cavity, notwith-
standing the fact  that some  of its advocates claim to
have  used it in thousands  of cases without a single
mishap.  Ample evidence from the  best authority can
be obtained to show that it is not an infrequent occur-
rence for the drum cavity to be flooded accidentally by
the use of this  instrument.   The accidents are, in the
majority of instances, followed by violent acute inflam-
mation, which in most all cases results in suppuration.
I have seen numerous instances in which the douche
has unquestionably produced acute otitis  media,  and 
46
INSUFFLATION OR SNUFFING.
this is the experience of every gentleman working in
this special line.  The collection  of cases to be found
in St. John Roosa's work on the ear is sufficient evidence
to convince the most incredulous of its evil results.
                      Insufflation or Snuffing.—This
                    is practiced to a great extent by all
                    classes, and  especially while bath-
                    ing the face.   In some instances it
                    is done to cleanse the nose, and in
                    others to  medicate the passages.
                    Physicians frequently recommend
                    their patients to "snuff" salt water
                    for the  purpose of curing  catarrh.
                    The insufflation  of liquids is  cer-
                    tainly an  inefficient  method  of
                    cleansing, because it is an utter im-
                    possibility to reach the entire  sur-
                    face of the diseased membrane.
                      tit  is  not an  infrequent occur-
                    rence  for  the drum cavity to be
                    flooded  by snuffing fluid  into the
                    nasal passages.  A number of such
                    cases have come under my observa-
                    tion, the majority of which resulted
                    in inflammation  of the tympanic
                    cavity, and several  terminating in
                    suppuration.
       Fig. 14.         The  insufflation of  powders  is
occasionally beneficial, especially  where the disease  is
confined to the middle and inferior cavities of the nose.
Insufflation may be  practiced by the doctor or patient.
 
PROBES AND MOPS.
47
 It is  most usually done by the  latter, in the ordinary
 way of snuffing, which is quite sufficient.
   In the event that it  is desirable to blow powder into
 the nose and pharynx, it may be done by means of an
 insufflator, such as is  represented in  Fig. 14.   In the
 absence  of  an instrument which  has been  especially
 devised for the purpose, a simple tube  of  any kind
 attached to an air bag may be used; or, what  is still
 more  simple, attach  the tube to a small rubber hose,
 and in this way blow the powder into the nose or throat
 as may be desired.
   Probes,  Mops,  etc.—In  many instances a suitable
 probe well wrapped with cotton wool serves as a valuable
 adjunct  in  the  removal of inspissated secretions from
 the nose and pharynx.   The probe should be just suffi-
 ciently covered to protect the  soft parts, unless it  is
 desirable to swab out the cavities, as in cases where the
 bones have been lost and the patient is  unable to remove
 the  secretions by forcibly expiring through  the nose;
 then it is well to have as much cotton on the probe as
 the nostril will admit.   If the probe is  used unprotected
 it should be  done with good illumination,  otherwise
 there  is danger of injuring the membrane.   Mops or
 swabs should not  be used for applying medicaments,
 unless the disease is  confined to  a circumscribed spot,
as in cases of ulceration.
   The plan of saturating  a  sponge with a forty grain
solution  of the nitrate of silver, or saturated solution
of the sulphate of copper, and  thrusting it  into the
cavities of the nose and pharynx, tearing the membrane
in its passage in and out, is barbarous, to say the least 
48      DIGITAL EXPLORATION OF THE PHARYNX.

of it, and the  individual who presumes for an instant
that the cavities of the nose can be thoroughly cleansed
or medicated by  this method, simply expresses  his
ignorance of the anatomy of the parts with which he
is dealing.
  Digital Exploration of the Pharynx.—The superior
portions of the pharynx  and the posterior surface of
the soft palate and uvula may be explored by passing
the index finger through the mouth  and carrying it up
into the pharyngeal vault.   This method will frequently
enable us to determine the presence  of enlarged glands
that are sometimes found on the posterior surface of the
soft  palate,  tumors,  and  vegetative  growths.   The
practice is rather an unpleasant one, but is of exceed-
ingly great value  in  many instances.    Dr. Guije, of
Amsterdam,  practices this  method  very extensively,
and  recommends  that  the  vegetations and enlarged
gland-like substances be scraped off with the finger nail.
  It  occurs to me that there  should be considerable
discretion  used in  practicing this method, as laceration
of the membrane in the region of the  Eustachian orifices
would be likely to  produce cicatrization and contraction
or closure of these openings, thus materially impairing
the hearing.   A spoon-shaped  scoop has been recom-
mended by Justi, but the  danger attending the use of
such an instrument is so great, and the pain it produces
is so severe, that few may  be found who will be willing
to use it, and fewer still who would submit to its use.
  The following blank is one which  I have adopted in
recording  clinical notes.   It insures  accuracy and  sys-
tem,  and saves an immense amount of labor: 
FORM FOR  CLINICAL RECORD.
49
No...... Name.............................. Age...... Sex......... Color
Date...........................18......  Residence............................
Occupation..............................Duration of Disease ............
General Health.................................................................
Specific Taint  ...................................................................
Pinnae..............................................................................
	
	
n............................	o..................
w	
	
	
	
	
	
	
	
Pain ............
Tinnitus........
Meatus Ext....
Memb. Tymp.
Audition.......
Tub. Eustach.
Tymp. Cav. ...
Cerumen Imptd__
Morbid Growths...
Foreign Bodies in..
Aspergillus..........
Furuncles ...........
Septum Norum inclines toward.................................
Condition of     f R ..............................................
Nasal Passages... \ L ...............................................
Character of     f R ..............................................
Nasal Secretion.. \ L..............................................
Sense of Smell....................................Epistaxis ......
Frontal Headache...................................................
Condition of  Pharynx.............................................
Tonsils.................................................................
Soft Palate.........................................Uvula...........
Epiglottis.............................................................
Larynx.............................................Chords.........
Trachea ...............................................................
Cough..............................................Expectoration.
Local Complications.......
Injury .........................
Probable Cause.............
Has been Treated .........
Constitutional Treatment.
Local Treatment.................................................

Condition at the time of Discharge or when last seen.

REMARKS:' ....................................................
4 
50
LOCAL MEDICATION.
            LOCAL  MEDICATION.

   This is one of the important features to be considered,
for much of the success in establishing a cure is due to
local medication.  The first  consideration  is that  of
cleansing the diseased membrane.   To do  this  it is
necessary to employ agents that  possess the  power of
dissolving the secretions.
   At the head of this  list we may place the muriate of
ammonia, and next the bromide of potassium, then the
chloride  of sodium, and lastly the bi-carbonate of soda.
The solvent powers of these agents may be estimated in
the order in which they are mentioned.   The ammonia
and potash salts are very nearly the same as regards their
solvent properties; but the potash, being a local anaes-
thetic, is preferable in  some instances, especially when
the disease is confined principally to the pharynx, and
where there is considerable irritation and cough accom-
panying  it. The solvent power of the chloride of sodium
is  not so great as that of the former agents, but it is an
excellent substitute.   Variations in the strength of the
solutions of these salts modify their action materially, and
the same solution is productive of different effects upon
different  persons, and  even upon the same individual.
Saturated solutions of ammonia or potash salts applied
in  any manner are  exceedingly painful, and  when ap-
plied with the post nasal syringe is much more so than
when applied with an atomizer.   The greater the com-
minution of the fluid, the less severe the pain.    It is
not an infrequent occurrence to meet with an  individual 
LOCAL MEDICATION.
51
who has been tolerating a drachm solution with comfort
to suddenly rebel against it on account of the  intense
pain caused by its application.  They occasionally be-
come so sensitive as to be unable to tolerate a stronger
solution than five grains to the ounce of water.  I have
seen cases in which a ten-grain solution of the ammonia
or potash applied with the spray to the nose caused the
most intense pain for a short  time, which was followed
by a dull,  heavy frontal  headache,  with  a  sense of
weight  across the upper third of the nose.  In  such
cases the solution should be discontinued and a milder
one used in its stead.  In those cases where the mem-
brane is extremely sensitive it is best  to be  governed
by the  sensations of the patients in the application of
all medicaments,  and especially cleansing agents.  The
application  should  be sufficiently strong  to produce
only a slight smarting pain in  the nose.
  The  bromide  of  potassium  deserves  more than  a
casual  notice, inasmuch as it  possesses peculiar prop-
erties,  which  make  it an  important adjunct in many
instances, especially in rendering the walls of the phar-
ynx and soft palate insensible,  which enables us to make
rhinoscopic examinations that would  otherwise  be im-
possible.   In cases  of tonsilitis and  pharyngitis,  it is
valuable as a wash.   An ounce to the  pint or quart of
water,  to be used as a gargle every hour or so, is one
of the  most efficient agents that can be employed.  It
cleanses the parts and at the  same time  renders them
pliant,  and produces a cooling sensation  which is  very
grateful.  In cases of acute catarrh, when the discharge
is profuse, with or without frequent sneezing, weak solu- 
52
LOCAL MEDICATION.
 tions of the bromide of potassium,  from  five to ten
 grains to the ounce of camphor water, applied with the
 atomizer  every hour, is  a  very  efficient and grateful
 application, and if persisted in will arrest or cut short
 the disease.
   The bi-carbonate of soda is particularly adapted to
 those cases where the anterior nares is in an eczematous
 condition.   It  is a very mild application,  and at the
 same time possesses  sufficient solvent  power to meet
 all reasonable  demands in most cases.   It  not  only
 serves as a cleansing  agent, but also  acts as a curative
 agent  upon the same principle as the akaline  baths ap-
 plied to other portions of the body for similar affections.
   Simple  warm water applied to  the membrane by
 means of the post-nasal syringe or the atomizer, if per-
 sisted in, will in some cases be sufficient to  remove the
 morbid secretions, especially when  they are not in-
 crusted, but it will  always  irritate the membrane by
 removing  the normal saline ingredients of  the mucus.
 The warm  water  of  itself possesses  the  power of
 dissolving  or softening  the  secretions,  and in  this
 way they may be  detached and  removed;  and it also
 acts mechanically  by washing away the secretions by
 main force.  It may be well to  call attention to the
 value of hot water in certain cases where the membrane
 is greatly thickened,  with or without profuse secretion,
 and  particularly where the  disease  is acute and the
 membrane  inclined to be dry.   The hot water,  con-
 taining a minute portion of  chloride of  sodium, should
be applied by means of the atomizer, and  a constant
spray kept up for  four or five  minutes  at a time, this 
LOCAL MEDICATION.
53
to be  repeated  every three or four hours during the
day.  The temperature at which  the water is tolerated
in some cases is almost  incredible.   I have known sev-
eral instances in  which the  Schneiderian  membrane
would tolerate water at a temperature that could not be
borne by the hand of the patient.   In one instance the
water was so hot  as to  be  painful from the instant it
came in  contact with the hand, yet  it was  passed into
the nose with perfect comfort.  By frequent applications
of hot water to  the membrane  in  such cases as just
mentioned, the swelling is reduced, and respiration ren-
dered  easy and  comfortable  in a comparatively  short
time.
   Errhines.—Errhines are those  agents which provoke
sneezing, and at the same time increase the secretion
of the Schneiderian membrane.  In the true sense of
the  word,  any thing that  will provoke sneezing and
increase  the nasal  secretion may  be  considered an
errhine.   Many of the quack nostrums and proprietary
medicines, especially the snuffs,  are composed princi-
pally of irritating agents.  One of these packages recently
came under my observation  which was composed en-
tirely  of  common salt.   Among  the  most  valuable
may be mentioned  one  composed of white sugar and
pulverized  cubebs,  in   the  proportion of  one  part
of  the latter  to  eight of  the former,  to  be used as
a snuff.  The insufflation of the sugar alone is exceed-
ingly valuable in many instances.   It is of  most value
in those cases where the  membrane is studded  with
neoplasms, and  in  those cases where  the  dryness  is
extreme.   The sugar alone, or  in combination  with 
54               LOCAL MEDICATION.

cubebs, should be used immediately after the  parts
have been thoroughly cleansed by some one of the
salines.  The sugar acts as a stimulant, increasing the
flow of the secretions if applied to a healthy nose, and
frequently producing a considerable amount  of conges-
tion;  not enough, however,  to produce  headache or
any unpleasant effects.
  Astringents, Antiseptics, and  Soothing Applica-
tions.— Powdered tannin  is recommended  by  some
authors, but experience teaches that it is inadmissible
in the  form of powder, unless it be for the purpose of
arresting hemorrhage.  Insufflation of pure tannin  is
extremely painful, and produces violent congestion of
the Schneiderian  membrane and pain in the region of
the frontal cells, with more or less  headache.
  Tannic Acid,  in combination with carbolic acid in
solution, is one of the most valuable local agents that
is employed in the treatment of catarrh of the nose and
pharynx.   They  may be used in the strength of from
two to fifteen grains each to the ounce of water,  to be
applied with a spray  producer.   In this combination
we have both an astringent and a soothing application,
the local anaesthetic properties of the carbolic acid  being
admirably manifested.  If there is considerable relaxa-
tion of the  membrane, it  is probably best  to use the
tannin in excess of the carbolic acid.
  In  cases of acute catarrh, where there is excessive
rhinorrhcea, the  solution  should  be weak, not  more
than two grains of tannic acid nor more than five of the
carbolic acid to the ounce of water.
  Carbolic Acid  in full strength is useful in cases where 
LOCAL MEDICATION.
55
 it is desirable to use a caustic, as in the destruction of
 nasal  polypi or cauterization of an ulcer.  This is pre-
 ferred to most caustics, because it is almost free from
 pain,  and does not produce such an extensive slough as
 the solid  silver and many other agents  that might  be
 mentioned.   It may be applied every second or third
 day without fear.  The application  is  best made  by
 means of a probe and cotton wool; the wool should be
 wrapped closely around the probe, so that it will not
 take up a superfluous amount  of the acid.  In making
 any caustic application it is important that it should be
 done  under the guidance  of a good light, so that the
 healthy  structures may not suffer.
   Nitrate of Silver.—This agent is probably used more
 extensively than any other in the treatment of catarrh.
 It is difficult to understand why this is so, unless it be
 from habit,  for I am confident that  the  results  are not
 such as should induce its advocates to adhere to it  so
 closely.   It  possesses no  specific properties of value,
 and its  most earnest advocates will  tell you that its
 application will not cure a case of catarrh.  Weak solu-
 tions (five grains to the ounce) are painful,  to say nothing
 of the  forty and sixty grain solutions that are employed
 so frequently.  The pain induced by the  latter solution
 is extremely severe, and usually lasts from twelve to
 twenty-four hours; in many instances the patient being
 compelled to take  the bed.
  It should  be remembered that the  most efficient
cleansing agents are such as are capable of neutralizing
the silver;  hence it is  impossible  to determine how
much effect will be obtained from  a solution of silver 
56
LOCAL MEDICATION.
unless the  parts are thoroughly freed from  saline mat-
ters before the silver is applied.  It is to be  regretted
that an agent which is in such general use as the nitrate
of silver should not possess some positive value.
  If it is  used at all,  it  should not be  used strong
enough to destroy or abrade the membrane; and to be
certain that it  does not injure the membrane,  it would
seem advisable not to use more than twenty grains to
the ounce of water, to be applied with a spray producer.
A solution of this strength  is  sufficient  to  produce
intense pain and discomfort for ten or twelve  hours
after its application.  It is certain that its value is over-
estimated in the treatment of catarrhal affections.  I
have seen no  benefit from its use, therefore decline to
recommend it.
  Sulphate of Copper is not to be  recommended  as a
local  application to the nasal mucous membrane, as
solutions of any  strength are painful, and  almost  val-
ueless.
  Hydrate of Chloral, in solution,  in the% strength of
from three to ten grains to  the  ounce of water,  serves
an  admirable  purpose  in those cases  of  rhinitis  and
pharyngitis accompanied by erosions or ulcerations of
the mucous surfaces.   The  chloral  acts as  a stimulant
and antiseptic, and produces  a marked change in  this
class of cases.  It also acts as a deodorizer, and serves
a valuable purpose in cases of caries and necrosis.   It
may be used in combination with carbolic acid.
  Disinfectants.—At the head of this list stands La-
barraque's solution of chlorinated  soda;  it is safe to
say that there  is  no other  agent that  will  so com- 
LOCAL MEDICATION.
57
pletely destroy an odor as this.   If the  solution is to
be used with an  atomizer, from ten to  thirty drops
of it to the  ounce of water  is  quite  sufficient.   In
many  instances the half-drachm  solution applied as
a spray will  produce  considerable pain,  and after a
time excoriate the parts about the anterior nares.  If
the solution is to be used with the post-nasal syringe, a
drachm  or a drachm and  a half to the pint of water
will be sufficiently strong.
  Permanganate of Potassa.—A solution of this salt,
from five to fifteen grains to the ounce of water, is an
excellent disinfectant.   Its powers in this respect are
inferior to those  of the chlorinated soda, but  in the
absence of that agent it may be  substituted.  If a very
strong solution  of the permanganate  of potassa be
thrown into the nasal cavities with the spray producer
or post-nasal syringe, it will produce severe and constant
pain  in the nose  and frontal  region for several  hours.
The pain may be relieved by spraying the parts thor-
oughly with water as warm as can be borne.
   Iodine.—This  agent proves  a valuable adjunct in
those  cases where there is an  eczematous condition of
the  membrane.   Equal parts  of the tincture and gly-
cerine may be used with the atomizer.   In cases where
the  membrane is ulcerated,  as  in cases of syphilitic
rhinitis, the  above is an excellent application, acting,
in all probability, as  a stimulant to the ulcer and the
adjacent  parts.   If the drug  is to be applied  with a
mop or brush, a solution of from one half to two drachms
to the ounce of glycerine, with a sufficient quantity of
the  iodide of potassium to insure its solution, is suffi- 
58
LOCAL MEDICATION.
ciently strong.  In fact, the application  of a  solution
containing more  than a half drachm of the iodine to
the ounce of glycerine should  be confined to the ante-
rior nares and region of the pharynx, never reaching
the regio olfactoria  under any circumstances, as  such
solutions will be sure to  produce violent congestion of
the adjacent structures, and is  almost certain to be fol-
lowed by severe  pain, with frontal headache.   I  have
yet to see the least benefit from any application that will
produce  prolonged and constant pain in  the frontal
region.   An alcoholic solution of iodine may be used in
the same manner as the strong  glycerine solutions.  It
may vary from five to twenty  grains to the ounce of
alcohol.
  Glycerine.—This  agent is  to be  recommended in
catarrh only as a vehicle for other drugs, as its affinity
for water is so great that its application is followed by
a sense of dryness and warmth in the course of two or
three hours.   It is particularly valuable in making solu-
tions of tannic acid.   Theoretically, it would  meet the
demand in those  cases where the membrane is excess-
ively dry; but, practically, it is a failure.
  Bi-chloride  of  Mercury.—Weak  solutions of  this
salt, in combination with  a sufficient quantity of the
muriate  of ammonia  to insure  its solution,  may be
used as a local application in  the form  of a  spray in
those cases where there is excessive dryness, and particu-
larly in those cases where the membrane is considerably
thickened as the result of an increase in the connective
tissue.  From  one-fourth to one grain of the  bi-chloride,
with thirty grains of the muriate  to the ounce  of water, 
LOCAL MEDICATION.
59
is  as  strong as it is  advisable to use the mercury.  It
should be applied once a day, or once every other day.
   Chloride of Zinc.—This salt may be used in solution,
in  the form of spray, in from one to thirty grains to the
ounce of water.   In those  cases where there  is a ten-
dency to eczema in the region of the anterior nares,
with  great  dryness, the strong solution  proves  very
beneficial,  and sometimes will  give relief when other
agents have failed.
   Yellow Oxide of Mercury.—In those cases of eczema
which are  inclined to  be  moist, with a  tendency  to
spread from the  nose to the lips and face,  an  ointment
composed  of  twenty grains of  this salt and half  an
ounce of glycamil  (glycerole of starch), applied twice
a day, is one of the most valuable applications.  There
is  no  other agent that proves of such universal benefit.
It  is  less irritating than red  oxide, and  is  therefore
preferable to that salt.
   The yellow oxide combined with white sugar, in the
proportion of five grains of the former to two hundred
and forty of the latter,  makes  an excellent application
in  chronic cases where there is a tendency to inspissation
of the accumulating secretions within the cavities of the
nose.   The two agents  should be rubbed well together
and used as a snuff three or four times a day.
   Salicylic Acid.—My experience with this agent has
not been extensive, but it is favorable.   It may be used
in  combination  with  the sulphate of morphia in the
following proportions:  Salicylic acid,  three grains;
sulphate of morphia, one grain; rose water, one ounce;
with  a  sufficient  quantity of bi-carbonate  of soda  to 
6o
LOCAL MEDICATION.
insure solution of the acid.  This,  applied every hour
with  the  atomizer,  usually gives marked relief,  and
by  the time the third  or fourth application  is made
the patients usually express themselves as feeling com-
fortable and free from any desire to sneeze.   The uni-
form  results  obtained from  this drug,  as  prescribed
above, is indicative of its value in  the acute  form of
catarrh, and entitle it to a more extensive trial.
  Nascent  Chloride of  Ammonium.—The nascent
chloride  of ammonium,  generated  by Lewin's appa-
ratus, is beneficial and more pleasant than the solutions
of  that salt, but  the  unwieldiness of the apparatus
renders it impracticable for general use,  and,  likewise
for office work.   The nascent chloride has no advantage
over the solutions, and, in fact, is  not so convenient,
because the strength can not be varied.
  Cubebs may be beneficially used in two ways, viz.:
By  smoking in a pipe in the same manner that tobacco
is smoked, and exhale the  smoke  through the nose.
This proves very grateful in cases where  there  is a
sense of heat, with dryness of  the  nose  and pharynx.
The powdered berry may be snuffed by itself, or it may
be used in combination with sugar. 
CONSTITUTIONAL MEDICATION.
6l
        CONSTITUTIONAL MEDICATION.

  The demand for constitutional medication can not be
said to  be  general, although it is more frequently de-
manded than has generally been supposed.  There can
be no doubt that quinine is frequently demanded in the
treatment of  naso-pharyngeal catarrh, just  in the  same
manner that it is demanded in other diseases where^ma-
larial complications arise.   In those cases where  there
are neoplastic  deposits in  the  submucous structures
quinine hastens their removal, and without it they are
inclined to remain indefinitely.  It frequently happens
during the course of a case of catarrh, without any as-
signable cause,  the membrane which has inclined  to be
rather  excessively moist,  suddenly becomes dry, hot,
and painful, with a sense of weight across the upper third
of the  nose, and a dull, heavy headache.   These symp-
toms are usually developed in a few hours; the patient
having felt comparatively comfortable for days previous
to this  sudden attack.  In those cases no amount of
local medication will give relief from the constant pain
in the  nose and the dull  headache; but  full doses of
quinine internally are always sure to abate these symp-
toms.    It is best given at bed-time, say fifteen to twenty
grains for an adult, and a proportionate dose for younger
persons.  It  may not be  generally known to the  pro-
fession that a large dose at bed-time is less unpleasant
and more effective than when taken in  broken doses
of three or five grains every few hours.   The  large
dose may be given  during the day if the  patient will
assume the recumbent position and keep it. 
62
CONSTITUTIONAL MEDICATION.
   Chlorate of Potassa.—This drug is useful in cases of
a strumous taint.  It should be given in full doses three
times a day, largely diluted with water.   It is especially
beneficial in those cases where the tonsils are hypertro-
phied, and where the face is rough and full of pimples.
It is necessary to continue its  administration for a con-
siderable length of time in order to obtain any marked
benefit from its use.
   Iodide  of Potassium.—This is one of the most val-
uable agents we have.  In addition to its defibrinizing
properties,  its peculiar action on  the  nasal  mucous
membrane renders it an invaluable remedy, and one for
which  there is no  substitute.   The physiological  action
of the iodide  is first manifested by an increase  in the
flow of tears  and saliva, and also  an  increase  of the
secretions  from the membrane  lining  the  nose  and
pharynx.   In  those  cases of  catarrh where  the  mem-
brane  is habitually dry, and also in  those where there
is a thickened  condition of the membrane from  an in-
crease  in the   connective tissue  element, this  salt is
particularly valuable.  It should be given in full  doses,
commencing with ten  grains  after  each meal and at
bed-time.   The dose should  be  increased five  grains
each day,  until iodinism is  produced.   The patient
should be kept under its influence sufficiently to main-
tain a  moist condition  of the  membrane. This treat-
ment should be kept up for a considerable  length of
time to obtain  good results.  If given with glycerine and
syrup it will be less  likely to  irritate the stomach than
when given in water.
  There is another class of cases that the iodide of po- 
CONSTITUTIONAL MEDICATION.          6$
tassium seems to have a decided effect upon, viz.: those
acute cases that come on suddenly and violently, and
are  attended  with  frequent  sneezing,  difficult nasal
respiration, with an  oppressed feeling  about the chest;
excessive lacrymation, and a free flow of glairy, tough
mucous from the nose. The membrane is usually very
much tumefied,  and nasal respiration  is rendered diffi-
cult and,  sometimes,  impossible.   In those cases  the
iodide should be administered in full doses, and pushed
until the effects of the  drug  have  been manifested,
either by the abatement  of the symptoms or by  the
establishment of  iodinism.   In connection with  the
internal  use of  the iodide,  hot water,  containing  a
minute quantity  of chloride  of  sodium,  should be
used freely with  the  atomizer.  The hot  application
may be  followed  by some soothing anodyne,  as  the
solution of salicylic acid and morphia.   All local appli.
cation in these  cases are  most  beneficial when applied
hot as they can  be borne.
  Muriate  of Ammonia.—This agent is found to be
useful in  many instances, and may be given in cases
where there is glandular  enlargement or an engorged
state of the lymphatic system.   Its use must be con-
tinued for some  time to obtain  its effects.
  In addition to the use  of the above-mentioned con-
stitutional  remedies, cod-liver  oil,  with iron and the
bitter tonics, may be administered with benefit. 
64
CLIMATE—CATARRH.
                   CLIMATE.

  Climatic influence proves  exceedingly  beneficial in
many cases of acute catarrh, especially in the periodical
form of the disease.   It  is a well-known fact  that the
so-called hay fever, which is  nothing but  an acute
catarrh and which usually resists all therapeutic agents,
yields readily to a change  of atmosphere.   The same
locality does not prove beneficial to all who have the
disease; the atmosphere  of the sea coast giving relief
to some, others not being benefited  by it.  The same
is true with  regard to mountainous districts  and  the
coast of inland seas.
                   CATARRH.

  The ancients  considered  catarrh a simple flux, and
not an inflammation.  The French apply the term to
an  inflammation of any mucous structure, and  this
application is generally accepted by the profession,
although  in  a general  way  it is considered an  in-
flammation of the membrane lining the air  passages,
particularly that  of  the nose and larynx.  With the
laity,  the word catarrh is used to express the presence
of an inflammation of the membrane  lining the nose
and pharynx; and it is  this form of the disease that
will be considered in this volume. 
ACUTE EPIDEMIC  CATARRH.
65
   Catarrh  may be  separated into two grand divisions,
acute and  chronic; each of these may be subdivided,
the former into sporadic and epidemic,  the  latter into
dry and moist.   Epidemic catarrh was not particularly
noticed by physicians before the sixteenth century.  It
was first designated as influenza by the Italians.  There
was no medical description of epidemic catarrh before
the year 1510.   The epidemic of that year, according
to history, was confined to Malta, Sicily, Spain, Italy,
Germany,  France,  and  Britain.   Short  says that  "it
attacked at once and  raged over all Europe, not miss-
ing a family and scarce a person."  In 1557 an epidemic
of the  same  nature prevailed  in different  countries.
Fonseca says that in this year "it infested Asia, thence
came to Constantinople, and having  spread itself  all
over Europe afterward  attacked  America,  its  course
being westerly."  Mercatus asserts that  before the be-
ginning of  the autumn of 1557 it attacked all parts of
Spain at once, so that the greatest part  of the popula-
tion  were  seized with  it almost on the same day.
Riverius, in an account of this epidemic, says that the
disease was fatal to many in a small town near Madrid,
Mantua Carpentaria.
  According to the investigations of Gluge the follow-
ing is the chronological order of the return of influenza:
Fourteenth century,  1323, 1326;  Fifteenth  century,
1410, 1411, 1414; Sixteenth century,  1510, 1557, 1562,
1574, 1580, and 1593; Seventeenth century, 1658, 1669,
1675, 1693; Eighteenth century, 1708, 1712, 1729, 1732,
1733, 1742, 1743, 1761,  1762, and 1775; Nineteenth
century,  1800,  1803, 1831, 1833; and to these  maybe
                          5 
66
ACUTE SPORADIC CATARRH.
added  1857, 1843, and 1873.  The epidemic of  1873
was  an exceedingly mild one,  commencing in  New
York and traveling slowly in a southwestern and south-
erly direction.   It was commonly called the epizootic.
The  lower  animals, especially the equine species, suf-
fered severely, although it  rarely proved fatal.  The
symptoms weft  much the same in these animals as in
man.   There was generally more or  less cough, with
excessive lachrymation, and in the early stages a free
flow  of watery mucous from the nostrils, which became
muco-purulent as the disease advanced.  The hair of the
diseased animals became rough  and fell out,  and they
seemed to be void of all energy.  The cold  punished
them very severely, much more so than when in health.
During this epidemic, which was in the main confined
to the  lower animals,  there was  an unusual amount of
acute catarrh among the human species, but it was not,
in most cases here in Louisville, considered  a  matter
of any consequence,  and  medical advice was  rarely
sought.
  The  disease did not differ materially from ordinary
acute sporadic catarrh.
  Acute  inflammations  of the  membrane lining the
naso-pharyngeal space may be  classified in  the same
manner as  those of the conjunctival  membrane, viz.:
catarrhal, muco-purulent, and purulent.  The  character
of the secretions serve  to distinguish them  one from
the other, the symptoms differing but  little, if any; so
little, indeed, that for all  practical purposes  the three
diseases may be considered  as one, and the secretions
of each representing  a particular stage of the disease. 
ACUTE  SPORADIC  CATARRH.           67
The most important point is, that the former disease,
or stage, as you may please to call it, is not contagious,
while the two latter are, in consequence of pus cells in
the secreted matter. True catarrhal rhinitis may assume
either of the other forms of the acute disease.  In fact,
it is an infrequent thing to see a case of muco-purulent
or purulent rhinitis that has not been  preceded by a
true catarrhal inflammation.
  Symptoms.—An attack of acute coryza  is  usually
ushered  in by well-marked symptoms, which  are pre-
ceded by a feeling of general  malaise, accompanied by
stiffness about the joints,  and dull, aching pains in the
back and  extremities, chilly sensations, mental  incapac-
ity, etc.   The intensity of these symptoms vary consid-
erably;  in some instances  they are  so  mild as to be
overlooked by the patient, in others so  severe as to
disable them to such an extent that they are  obliged to
confine themselves to the bed.
  Following immediately after these  symptoms, or oc-
curring simultaneously with them,  there is a sense of
warmth and dryness, which in many cases is  so mild as
to create  little or no inconvenience, while in others it
becomes  painful and produces a dull, heavy sensation
in the region  of  the  frontal  cells.  There  is  always
more or  less  sneezing, accompanied  by an  excessive
flow of thin,  watery mucus,  which  contains  a small
amount of the chloride of sodium,  and, according to
Donders  and  Shonbein,  also some ammonia.   There
is usually congestion of  the conjunctival membrane,
with  excessive  lachrymation, and a stuffy  sensation
in the nose,  as though   the  passages  were plugged 
68
ACUTE SPORADIC CATARRH.
 with cotton wool or  entirely closed.   A sense  of
 weight, with pain across the upper third of the nose, is
 a frequent concomitant.   Nasal respiration is usually
 impaired.   The impairment may be  so  slight as to be
 scarcely noticed, or the passages may be closed, mak-
 ing  respiration  through  the nose  impossible.   This
 symptom is always better marked in children than in
 adults: and in young infants interferes with nursing,
 and  makes them exceedingly fretful.   There is always
 a desire to snuffle and draw the secretions back into the
 pharynx.  This is frequently due to  relaxation of the
 membrane.  Accompanying these symptoms there is
 an elevated temperature which reaches 1000 to ioi° F.,
 and  remains at that for twenty-four to forty-eight hours,
 and  sometimes even a greater length  of time than this.
 If the inflammatory process should  extend back into
 the  pharyngeal  vault, there  may be  some disturbance
 in the ears.  The invasion of the ears is usually accom-
 panied by slight deafness, with or without tinitus aurium.
 If the inflammation should assume an active character
 and  extend along  the  course of  the Eustachian tube
 and  into the tympanic cavity the  pain will be severe;
 in short, the symptoms  of an acute  salpingitis and
 acute otitis media will present themselves.
  If the pharyngeal box should be invaded in its entire
 extent, its  walls,  especially the lateral  ones, in  the
 region of the isthmus  faucium, will present a rugged ap-
 pearance, the  veins being invisible on account of the
 loss  of transparency in the membrane.
  There is usually slight pain  when the act  of deg-
lutition is  attempted.  The cervical lymphatics  are 
ACUTE SPORADIC  CATARRH.
69
occasionally involved,  and become swollen and very
tender.
   The rhinoscopic appearances in a case of uncom-
plicated catarrh  are not at  all times the same.  The
difference  in the  appearances of the membrane may
depend upon numerous causes; as,  for  instance, the
severity of the attack,  and the stage of the disease at
which the  observation is made, will have  very much to
do with modifying the appearance presented.   As a
rule,  the surface of the membrane is very red, differing
materially  from  the beautiful pink hue  of the  under-
lying  structure seen in the  normally  transparent con-
dition.   There  is generally a moderate amount  of
relaxation  and swelling of the  membrane throughout
the whole  naso-pharyngeal tract; the tumefaction oc-
casionally  becomes excessive; and again, in other  in-
stances, it  is scarcely perceptible.  If the cavities are
examined  in the  early stages the membrane  will  be
found bathed in  a clear watery mucus, which becomes
viscid later on, and, finally, on the third or fourth day,
if an  examination  is made,  the structures are  found
covered with  muco-pus,  unless the disease has been
arrested, when the secretions will be  more scanty than
in the first stage, and more tenacious.   There is  rarely
any considerable epistaxis, and when present is usually
due to the violent expiratory  efforts made  in attempting
to cleanse the nose, or to congestion of the membrane.
The anosmia accompanying acute nasal catarrh is tempo-
rary,  the sense of smell being perfectly restored when
the disease disappears.    Anosmia is frequently obstruc-
tive,  due to accumulation of the secretions or to  swell- 
70
ACUTE SPORADIC CATARRH.
ing and relaxation of  the  membrane.   The voice is
usually changed, and has a nasal sound, such as may
be produced by closing the nostrils with the thumb and
finger.  This  is due  to partial or complete closure  of
the nares.   If the soft  palate is involved the voice will
also be changed.
  The  following  are the microscopical  appearances
of the secretions.  The  mucous secretion always shows
white blood (pus) corpuscles, besides the so-called mu-
cous  corpuscles, sometimes red blood corpuscles and
epithelium.   A large number of little  bodies, recently
so much spoken of and called micrococci, may gener-
ally be seen covering the cells.   In  accordance  with
this general theory of inflammation, Hueter regards these
micrococci as the true  source of irritation in coryza.
In addition to the above, the secretions sometimes con-
tain accidentally formed ingredients, which float on the
inspired air,  and are thus  mingled with the fluids  in
the nose.   The number of pus  corpuscles  is  vari-
able.   They usually increase with the  duration  of the
disease, until,  owing to the  greater power which these
cells possess of refracting light,  they give the entire
mass that  turbid, opaque appearance characteristic of
what we call muco-purulent or purulent secretions. On
close  observation, a  stage,  even though quite short,
will appear toward  the  end of a coryza, during which
the fluid effused will at least be entitled to the name of
muco-purulent.   (Ziemssen's  Cyclopedia of  Practical
Medicine,  vol. iv., page  124.)
  Complications.—The inflammation  occasionally ex-
tends  to the  larynx,  lachrymal  passages, and ears. 
ACUTE  SPORADIC  CATARRH.
n
There is frequently excoriation of the skin covering the
upper lip and immediate vicinity of the nostrils.  The
integument  covering the  nose occasionally becomes
swollen and glistening, and more or less painful to the
touch.  I have seen a case of facial neuralgia that was
undoubtedly due to the  presence of  an aggravated
nasal catarrh.  It was  in  the person  of a lady about
thirty years  of age,  who was suffering with a chronic
form of catarrh, and had frequent attacks of the acute
disease.  The acute attacks were always  sure to be ac-
companied by the most severe  facial  neuralgia,  which
disappeared when the attack subsided.   "Such  neural-
gias of the fifth pair, dependent on nasal catarrh, have
been described by Duchek, Oppenheimer, Rollet, and
others."   (Ziemssen's  Cyclopedia of  Practical  Medi-
cine, vol.  iv., page 126.)
  Course.—The  course  of  acute catarrh is usually uni-
form and very rapid, the first stage lasting from twenty-
four to forty-eight hours; at this period the irritation is
less, and if recovery takes place without the secretions
becoming purulent they are materially reduced in quan-
tity and are  not  so watery and acrid in their character.
On the other hand, if the disease should continue to
run its course,  the  secretions will be more turbid and
tenacious, and by the end  of the third, and,  in  many
instances,  on the second  day,  the discharge  will be
purulent when  the disease may be said to be  in the
second stage, the duration  of which may be from two
to five days, if it  does not become chronic.
  Prognosis.—The prognosis of acute catarrh is always
favorable,  the  majority  of cases ending in recovery 
72
ACUTE SPORADIC  CATARRH.
without treatment.   Those cases that do not terminate
in recovery become  sub-acute  or  chronic.  All cases
recover with  proper treatment.   This latter statement
is contrary to the opinions of many writers, but I have
known  no disease  more tractable,  and shall presently
introduce a  few illustrative  cases.  I  am persuaded
naso-pharyngeal catarrh is just as  curable as the ordi-
nary form of intermittent fever.  On the other hand, I
have never known a death from catarrh.
  Treatment.—The treatment of acute catarrh  should
be both local and constitutional.  If the bowels are con-
stipated  they should be freely moved by the  use of
some saline;  this is especially indicated where there is a
marked febrile  disturbance, with a fullness about the
head.  In addition to this a hot foot-bath at bed-time,
with ten  grains of  Dover's powder, frequently gives
great relief, and seems to mitigate the disease, if not to
arrest it altogether.   Opium internally is said to possess
the power of cutting the disease short.   I am not pre-
pared to say whether there is any truth in this state-
ment or not.   Atropia  in doses of  T|(j of a grain may
be used with marked benefit.
  Many agents are recommended as local applications,
and in the selection of a suitable agent for this purpose
it should  always be borne in mind  that the membrane
is usually tender and irritable; and  in consequence of
that fact such  agents as will  tend to soothe the mem-
brane and allay this extreme sensitiveness are the ones
that should be applied.   Among the  most efficient
local agents are the bromide of potassium and carbolic
acid; the former being preferable in all ordinary forms 
ACUTE SPORADIC CATARRH.
73
of the acute disease, the latter in cases of erosions from
tuberculous or syphilitic taints.
   In malarial districts, the indications for quinine should
not be overlooked,  as its use is frequently demanded.


              Case I.—Acute  Catarrh.

   Miss T----, aged 28 years,  called  on me March  9,
1877, and gave the  following history:   About the 20th
of the  previous  month she was exposed to some very
inclement weather,  and in a few hours afterward was
seized with a violent attack of sneezing,  accompanied
by excessive lachrymation  and a free flow  of watery
mucus  from the  nose.   This state of  things lasted for
three or four days,  when the symptoms became modi-
fied but  continued to  be very annoying.  From the
date of the attack  up to  the time  of her visit on the
9th, nasal respiration had been very much embarrassed.
An examination of the  nose showed that the membrane
Covering the septum and  inferior turbinated bones was
congested  and  swollen.  There was  almost constant
expectoration of tenacious mucus.
  The treatment consisted in the application of a solu-
tion of one-half  drachm  of the muriate of ammonia
in  four ounces  of water,  which was followed  by a
solution composed  of five grains of carbolic acid, two
grains  of  the  sulphate  of morphia,  three drachms of
glycerine, and fourteen drachms of rose water.  These
agents were applied three times a day with the atom-
izer, the  latter  solution being  used immediately after 
74
ACUTE SPORADIC  CATARRH.
the former.   The patient  improved rapidly,  and was
entirely relieved in three weeks.


Case II.—Chronic Moist Catarrh, accompanied by frequent
  attacks of the Acute form of the disease, attended with
  severe Facial Neuralgia.

  Mrs. R. H----, aged  34, was  brought to me by  a
medical friend  in January, 1878, when the following
history was  obtained:   The patient had been  suffering
with chronic catarrh for a considerable time.   She said
that she had frequent attacks of acute coryza,  and that
they were always attended with the  most severe facial
neuralgia, which  continued until the  acute stage of the
catarrh abated; but only to be renewed each time the
acute disease manifested itself.   There was a great sense
of weight across the upper third of the nose, which was
much swollen.   The nasal  mucous membrane  was con-
gested and  relaxed to  an  extent sufficient to  render
nasal  respiration  difficult,  and  at  times impossible.
There was an excessive flow of clear, watery mucus from
the nose.   The drum membranes were  congested, and
there was an occasional pain in the region of  the tym-
panum.   Most of the agents that are usually employed
to relieve neuralgia had received a  trial  and  failed to
produce the desired result.  The patient's general health
was not at all good.   The appetite was insufficient, and
sleep did not refresh as it should.  Tonics and good diet
were  recommeded, with proper out-door  exercise.
The patient was not heard from again. 
              ACUTE  SPORADIC  CATARRH.            75

Case III. — Acute Catarrh, invading the right tympanic
                       cavity.

  In  January, 1880,  Dr. M----, aged 29, called,  and
stated that he had been up the greater part of two or
three nights previous to  the attack, and that he  had
slept in a room without any fire, which was contrary to
his usual custom.   Examination showed the nasal mem-
brane to be very much swollen  and bathed in a watery
mucus.   Nasal respiration was  impossible.   The mem-
brane was exceedingly irritable and tender, and sneezing
was frequent.  There was considerable pain in the right
ear for six or eight hours before I saw him.  The drum
membrane  was very  much  congested, and  presented
almost a scarlet hue.  The patient was unable to inflate
the  tympanum.   The hearing was  considerably  im-
paired.
  Treatment:  The nasal  cavities were sprayed every
three hours with a solution of forty grains of the  bro-
mide  of potassium  in four ounces of camphor water.
The  tympanum  was  inflated through the Eustachian
catheter.  The drum cavity  contained a  considerable
quantity of mucus, which was forced out  by the coun-
ter current of air.  The removal of the mucus relieved
the pain at  once, and there was no further disturbance
in the ear.   The application of the bromide was kept
up for six days, when all  evidences of the disease  had
passed away. 
76
ACUTE SPORADIC CATARRH.
       Case IV.—Acute Catarrh, with Dysphonia.

   Miss H----, aged 19 years, a member of an amateur
theatrical club, consulted me in the winter of 1877, an^
stated that, on the  evening previous to her visit, she
had experienced a chilly sensation, which was followed
by fever and slight headache;  during the  night  there
was a free flow of watery mucus from the nose.   She
experienced also, in the latter part of the night, a feel-
ing of warmth about the larynx,  which was soon fol-
lowed by hoarseness.   The Schneiderian  membrane
was found to be very much congested, and covered with
mucus; nasal  respiration  was embarrassed; and  there
was a fullness  of the blood vessels of the pharynx.
The  vocal chords  were  congested and  considerably
relaxed.  The  patient was very anxious to be relieved
of the hoarseness, as she had, on the following  even-
ing, an engagement to fulfill which  demanded a clear
voice.
   Treatment: I commenced by spraying the larynx with
fifteen minims of  Monsel's solution of  the per-sulphate
of iron in an ounce of water.  This application  gave
marked relief at once,  enabling the patient to speak in
an  ordinary tone  of voice.  She was directed to spray
the larynx every two or three  hours with  a five-grain
solution of tannic and carbolic acids.   In the intervals
a troche containing five grains of the bromide of potas-
sium was used every two hours.   The nose was sprayed
with a ten-grain solution of the bromide of potassium.
The hoarseness was sufficiently relieved to  enable the
patient to fulfill a  successful engagement for a public 
ACUTE SPORADIC CATARRH.
77
performance.  In five days all catarrhal  symptoms had
disappeared and she remained well.


  Case V. —Acute Catarrh, invading both  drum cavities.

  Edward  C----,  aged  7 years, was brought to me
February 14, 1878.   On  the night of the 12th he suf-
fered with severe pain in the left ear, which was relieved
some time  during  the following day.   The  13th,  at
night, he had  intense pain in the right ear, which con-
tinued until he reached my office the next day.   The
hearing was very much impaired on both sides.  There
was an excessive flow of  mucus from the nose, and fre-
quent sneezing.   The left external auditory canal was
full of muco-pus, and the drum membrane on that side
was perforated near the center.  The right drum mem-
brane was bulged, and presented an opaque appearance.
The nasal mucous membrane, and that lining the phar-
ynx, were  congested and relaxed.   The tonsils  were
slightly enlarged.
  Treatment:  The patient was unruly,  and would not
submit to the use of the Eustachian catheter.   Politzer's
method was employed and both drum cavities inflated.
The inflation of the right side ruptured the drum mem-
brane of that ear,  and a quantity  of muco - purulent
matter escaped.  The rent closed in twenty-four hours,
and there was no further trouble with that ear.   The left
ear was cleansed two or three times a day, and a solution
of fifteen grains of  carbolic acid and ten grains of the
sulphate  of zinc to two ounces of water was dropped 
78
CHRONIC MOIST CATARRH.
into it each time after cleansing.  The nose was sprayed
several  times  a day with a ten-grain solution of the
bromide of potassium.  On the fifth day the catarrhal
symptoms had entirely disappeared, the left drum mem-
brane had healed, and the only remaining  evidences of
the disease was the congestion of the membrana tym-
panae.
      CHRONIC  MOIST  CATARRH.

  Chronic  moist catarrh may exist  in two forms,  the
first of  which is accompanied by symptoms similar to
those of the second, but more mild in character.   The
first may be termed muco-purulent  rhinitis, and  the
second purulent rhinitis.  The following are the symp-
toms of the former:
  Symptoms.—The  resonant quality of the voice is
not  lost in all cases of catarrh, as asserted by some.
Indeed, not even in  the majority of cases of chronic
catarrh do  we find the voice materially altered.  There
is a mistaken idea about this particular symptom, be-
cause there can be  no  doubt there are more cases  of
chronic  catarrh unaccompanied by a change in the voice
than otherwise.   In those cases where there is an alter-
ation in the voice, it is usually of a peculiar nature, the
patient being unable to pronounce the consonant n and
m distinctly.   The  defect in these  cases is  due to  an
obstruction in the nose  or pharynx, or faulty action of 
CHRONIC MOIST CATARRH.
79
the soft palate.  The obstruction may be caused by a
thickened  membrane, by vegetations on the posterior
wall of the soft  palate, by an accumulation of  secre-
tions  in the passages of the nose, or on the posterior
wall of the soft palate.
  Nasal respiration  is impaired  in  most  cases.   The
patient breathes  with the  mouth  open, and  snuffles
when  an attempt is  made  at respiration through the
nares.   It  is  asserted by some  authors that patients
suffering with nasal catarrh present  a peculiar express-
ion of countenance, due to the fact that they have to
breathe through the mouth.  Obstruction of the nasal
passages compels the patient to breathe through the
mouth; but  this does  not necessarily  render  the ex-
pression stupid; and can not be  considered as a symp-
tom of the disease.   Snoring is not met with more fre-
quently  in individuals suffering  with chronic  catarrh
than other persons.   In  a  recent work  on the throat,
Mr. Lenox Browne says:  "Unless  the tonsils  are en-
larged the patient does not snore; this act of  snoring
being,  according to Michel, due to obstructions of both
fauces  and  nares, which  causes the inspired air to be
rarefied, and to produce a flapping up and down of the
epiglottis.   According to our knowledge  of anatomy
and physiology, snoring does not  in any manner depend
upon the movements of the epiglottis; but is produced
by the current of air passing over a  relaxed palate and
uvula.   The palate may be relaxed while respiration is
carried on  through the mouth or nose,  or when it is
effected  through  both  of these  cavities at the  same
time:  hence the act of snoring may accompany  respi- 
8o
CHRONIC MOIST CATARRH.
ration at any time when the palate  is relaxed;  and, to
convince one's self of the fact, it is only necessary to
relax the palate and breathe forcibly through the mouth
or nose.   Enlargement  of the  tonsils  may produce
snoring, when it would  not otherwise exist; but  the
inspired air is not  rarefied to an extent sufficient to
produce flapping  of the epiglottis as stated by Michel.
Enlarged tonsils necessarily lessen the  passage;  and in
both inspiration and expiration the air is forced through
a constricted orifice, which is bounded  above by  the
soft palate and uvula, and with these structures relaxed
it is easy to understand  why patients with enlarged
tonsils should snore.
  The cephalalgia which frequently accompanies
chronic  nasal catarrh  is generally confined to the fron-
tal region,  rarely extending beyond.   The pain expe-
rienced  in connection with the headache  which accom-
panies chronic catarrh is not acute; there is a sense of
tension  and fullness, which is increased  by violent ex-
ertion, and especially when the stooping  posture is
assumed.   There is frequently great sense of weight
across the  upper third of  the nose.  This sensation
may be produced by grasping the  nose across the upper
third and pressing backward with  considerable force.
This symptom, I believe, has not been  mentioned by
previous writers.  The frequency  with  which frontal
headache occurs in chronic catarrh is not so great as we
are  led  to  believe it  to be.   Observation leads to  the
conclusion  that it is not a  constant symptom in most
cases, and that it occurs more frequently  in those cases
where the secretions become inspissated and impacted. 
CHRONIC MOIST CATARRH.
81
 This so-called headache, which is not a typical cepha-
 lalgia, is brought about by a congested condition of the
 vessels of  the membrane lining the superior portion of
 the nasal  cavities.   It is an easy matter to understand
 how the  vessels of the  membrane  lining the  above
 cavities may be kept in  state of congestion, when it is
 remembered the least amount of tough mucus blown
 forward into the apices of the funnel-shaped cavities of
 the nose  must  remain until decomposition takes place
 before  it  can be removed.   Remembering these facts,
 it is not at all surprising that the accumulated secretions
 in the superior cavities of the nose should produce con-
 stant irritation and swelling.   Hence  the headache.
   Anosmia.—This often accompanies both  acute  and
 chronic rhinitis.  In the acute form it is usually due to
 obstructions (a)  of the cavities from accumulated secre-
 tions, or (b) to  swelling of the membrane  and conse-
 quent closure of the nasal passages.   The chronic forms
 arise (c) hypertrophy of the nasal membrane, (d) from
 ulcerative action, (e) from atrophy.
   The loss of the sense  of smell,  or its impairment,
 does not occur  in all  cases.   Very severe  cases  occur
 without the sense  of  smell being the least impaired.
 The prognosis in  regard to the sense of smell should
 always be  guarded, especially where  there is reason to
 believe  that the anosmia is due to  a change  in  the
 structure of the membrane.
   Cough  rarely exists as a  symptom of any form  of
chronic nasal catarrh.  Frequent hawking is one of the
characteristic features of the disease.  The presence of
tenacious mucus on the posterior wall of the pharynx,
                         6 
82
CHRONIC MOIST CATARRH.
or on the posterior surface of the soft palate or uvula,
is accompanied with a desire to  remove the  offending
substance; hence the frequent hawking.  In many cases
the  secretion is so profuse  as to necessitate frequent
efforts to remove it.   This is one of the most annoying
features of the disease.   It is particularly so with the
more refined class of individuals.   It is not an  uncom-
mon thing to hear a patient remark that the only object
in ridding himself of the disease is to avoid the constant
hawking when in society.
  Hearing.—Audition  may  or may  not  be impaired.
If the disease extends to the Eustachian tubes, hearing
will be more or less affected.   The amount of the defect
will  depend  upon circumstances.  If the Eustachian
tubes and tympanic cavities become  involved in the in-
flammatory  process, the  hearing  is  likely to become
very much impaired.
  Tinnitus aurium is a distressing and almost constant
symptom  of narrowing of the  faucial  orifice  of the
Eustachian tube.   Indeed, some of the most  stubborn
cases of tinnitus are met with in this form of catarrh,
and nothing will relieve the symptom short of restora-
tion  of the patency of the Eustachian orifice.
  Pain.—Acute pain is rarely present in any case of
chronic catarrh, unless the ears become involved.  There
is most always a feeling of  discomfort.   It may  be a
fullness about the frontal region, or a burning, hot sen-
sation in the  region of the posterior nares, or a sense
of dryness in the nose.   There is frequently a '' stuffy
sensation " complained of in the nares.   In the morn-
ing, when patients first arise, the secretions are likely 
CHRONIC  MOIST  CATARRH.
83
to be  dry, and at  this time it  is not unusual  to hear
them  complain of  soreness in the region of the poste-
rior nares and soft palate.   This soreness passes  off
after breakfast, or after taking a drink of water or other
fluid.  The moisture and motion of the parts usually
removes or makes the secretions pliant, thus relieving
the pain.  Occasionally there is pain in the ear and the
region immediately along  the  course  of  the  styloid
group of muscles.   This  is complained of more partic-
ularly when deglutition or yawning  occurs.  The pain
is frequently  complained of when  the tympanum  is
not  inflamed.   In  such  cases it  seems to be purely
reflex in character.
  Epistaxis.—Profuse epistaxis can  not be said to be
of frequent occurrence in nasal  catarrh, while capillary
oozing may occur in almost any case.  In  cases where
the nares are  in an eczematous condition, hemorrhages
occur most frequently.  Indeed,  there are certain classes
which might be styled as  hemorrhagic cases.  In those
cases the secretion is scant, and the membrane is usually
glazed, dry,   and fissured or cracked.  The slightest
touch  is  sufficient,  in such cases, to produce  hemor-
rhage.  The bleeding is  not profuse, and the blood  is
of a watery or serous character.  The hemorrhage  is
usually from  the anterior nares.   It  is  stated by some
that "epistaxis  is  a well  known  and  troublesome
symptom."   This seems  to be contrary to  the general
opinion,  and  I am  not  prepared to concur with the
statement, as  clinical experience does not  afford suffi-
cient proof to sustain it. 
84
CHRONIC MOIST CATARRH.
  The appearance presented by the membrane is of
the utmost importance, as it  affords an index which is
indispensable in making a thorough diagnosis.  In order
to be able to recognize the various changes that are
brought  about in the membrane by disease, it is abso-
lutely necessary to be thoroughly conversant with its
appearance in a healthy state.   No amount of reading
will enable any one to obtain a sufficient knowledge on
this point.  Nothing but clinical experience affords an
opportunity of studying the membrane in its various
conditions.  The membrane, when not covered by se-
cretions,  usually presents an engorged appearance; the
individual blood vessels  are  not traceable,  although
they may be discernable in some cases.   In the major-
ity of instances the surface is a bright, dusky red,  and
not pink, as in health.  In many cases it  is impossible
to distinguish  an individual blood vessel.   This condi-
tion  of affairs is induced  by a uniform turgescence of
the whole capillary system  of blood  vessels  in  the
structure.  The  membrane in such cases is not usually
relaxed in the nasal cavities and posterior wall  of the
pharynx; but, on  the contrary, it seems to be rather
tense, while in the region of the faucial orifices of the
Eustachian tubes it is frequently observed to be in a
lax state.  In other  cases, and at other times  during
the course of the  disease, the membrane presents a
spongy appearance, and bleeds on the slightest  provo-
cation.   As a rule the  secretions are rather scanty in
these bleeding cases;  at all events they are not profuse.
  There  is another class of  cases  in  which there  is
extreme  relaxation, so much  as to render nasal respira- 
CHRONIC MOIST CATARRH.
85
tion impossible.   The  greatest amount of  relaxation
occurs in the membrane covering the inferior turbinated
bones  and the anterior  portion of the  septum.  The
redundant structures may be mistaken for a polypus,
and in some cases a correct diagnosis will be difficult to
make  unless the proper  light and instruments are at
hand.   In these cases the secretions are usually profuse,
and composed  almost  exclusively of tenacious mucus.
The membrane is inclined to be pale, which  is a pecu-
liarity  that characterizes this one phase of the disease.
In  cases of long standing it is not uncommon to find
the greater portion of the surface of the membrane
covered with inspissated secretions.   Nasal respiration
in these  cases  is always very much interfered with, in
many  instances necessitating respiration through  the
mouth.  When the crusts  are removed there may be
slight  hemorrhage, which is generally due to the rup-
ture of some small vessel  by the instrument  used  in
propelling the fluid  into the cavities, or by the forcible
removal of the accumulation,  which produces a breach
of continuity in the surface of the membrane.  Again,
the hemorrhage may result from  capillary congestion,
which  is brought about by the application of the cleans-
ing solution.   It is not an unfrequent occurrence to see
considerable  epistaxis  follow the application  of strong
solutions  of the muriate  of ammonia or the bromide
of potassium.
  There is another class  of cases that might be very
properly  called the eczematous cases.  This  class is
met with more frequently in children  of strumous dia-
thesis; in fact, it  seems to be confined almost exclu- 
86
CHRONIC  MOIST  CATARRH.
sively  to  such subjects.   The  eczematous  crusts are
found  more  frequently in the  region  of the  anterior
nares,  and usually form on the inner surface  of the alae
and  anterior portion of the  septum.  They are also  #
found on the membrane covering the lower  portion of
the inferior turbinated bones, and rarely met with else-
where.  These crusts are formed principally by the
exudation  of a  sero-san-guinolent  fluid, which  dries
very rapidly, and becomes exceedingly hard, and they
adhere  to the  membrane so  closely as   to  render
removal very difficult and  painful.   It *is not an infre-
quent  occurrence to find the anterior nares completely
occluded by these crusts.   Hardened  secretions may
be mistaken for carious  or necrosed bone.  This  is the
class of cases which are frequently  complicated with
severe  frontal headache, loss of  smell, and foeted odor.
The odor which is  present in cases of  chronic catarrh
may proceed from three  sources, viz. :  from  decompos-
ing secretions, from ulceration  of the  soft  parts, and
from diseased bone.  When an offensive odor is emitted
from the  nose it is termed  ozena.   It is thought  by
many  that unless there is destruction of the osseous
tissues connected with  the naso-pharyngeal space, or
those within  its  cavities, that there will be  no ozena;
such is a mistaken idea,  for it may result, as  stated
above,  from  destruction  of the  soft parts, decomposi-
tion of secretions, or accumulation of blood.   In some
instances the membrane  covering the posterior wall of
the pharynx presents a regular thickened appearance,
and is constantly bathed in tenacious mucus or muco-pus.
In those cases there is a  continual desire to expectorate. 
CHRONIC  MOIST  CATARRH.
87
  The second form of chronic moist catarrh differs but
little from the first, except that there is an aggravation
of all the symptoms that are present in the former, and
occasionally a new one added.  The secretions are com-
posed  almost entirely  of pus, and  present a creamy,
yellowish,  or greenish appearance.   The headache  is
always more severe  and constant than in the former.
An offensive odor is frequently met with in those cases
where the secretions become  inspissated and  remain  in
the cavities.   The osseous and cartilaginous  structures
are occasionally invaded.  The soft structures are also
implicated in some  cases, and may be involved when
the osseous tissues remain in perfect condition.
  The causes of these two forms are the same, usually
being  the  result of neglected acute disease,  polypus,
foreign bodies in the  passages, etc.   The  purulent
form,  as before  stated, may be the  result  of  conta-
gion.   The  prognosis  of muco-purulent  and purulent
naso-pharyngeal catarrh is favorable to a certain extent
if the  proper plan of treatment is instituted and carried
out.    It is favorable as  regards the arrest of the inflam-
matory process; but it is not possible to restore the
impaired functions and form of the organ.


Case VI.—Chronic Moist Catarrh, with great relaxation
  of the nasal mucous  membrane, and  invasion of the
  tympanic cavities.

  Mr.  J----, aged 17 years, was brought to me by his
father  December  26, 1878, who stated that his son had 
88
CHRONIC MOIST CATARRH.
great difficulty in breathing through the nose, and that
he was constantly spitting and hawking.  There was
occasional  pain  in the region of each drum cavity.
The  membrani tympanse were slightly congested  along
the  course of the handle  of the  malleous, and  there
was  more or less tinnitus in both ears.   The watch was
heard at thirty-six inches on both sides.  The sense of
smell was  impaired.   The membrane covering the in-
ferior turbinated  bones and  the anterior part of the
septum was thickened and relaxed to an extent  suffi-
cient to render nasal respiration impossible.   The  secre-
tion  was muco-purulent in character.
   Treatment: Saturated solutions of the bromide of po-
tassium were used for four or five weeks without any
benefit.  I then removed as much of the relaxed  mem-
brane from each side  as could be included within the
range of an ordinary pair of angular scissors at one cut.
Profuse hemorrhage followed, which  was  arrested by
the application of Monsel's solution of the per-sulphate
of iron.  After  the  lapse  of several  days,  when the
parts had healed, the bromide solution was again applied
with the atomizer as before, and was followed by a solu-
tion of three grains  each of carbolic acid and hydrate
of chloral  to the ounce of  water.   Nasal  respiration
was  perfectly free after the excision  of the  redundant
membrane.  The local applications were continued until
May, 1878, when  all symptoms of the disease had dis-
appeared, with the sense of smell completely restored. 
CHRONIC MOIST CATARRH.
89
           Case VII.—Chronic Moist Catarrh.

   G. D. P----, aged 38, white,  a railroad engineer,
 consulted  me  January 14, 1875,  stating that he  had
 catarrh of  the nose and pharynx.   Examination  of
 these organs verified his statement.    The membrane
 covering the inferior turbinated bones, and that  in the
 region of the posterior nares and  faucial orifices of the
 Eustachian tubes, was very much relaxed and bathed
 in a thick muco-purulent secretion.  Expectoration was
 profuse; and the constant hawking rendered the patient
 disagreeable to himself and his associates.  The disease
 had existed about four months, being very much  worse
 at some times than  others.   His general health was
 excellent.
   Treatment:  The treatment consisted in having  the
 parts thoroughly cleansed two or three times a day with
 a solution  of one  drachm of the  muriate of ammonia
 to the  ounce of water.   Soothing astringents were  ap-
 plied immediately after the  parts were cleansed.  At
 the end of six weeks the patient was well.


 Case VIII.—Chronic Moist Catarrh, with chronic suppu-
                  rative otitis media.

  L. B. S----, aged  11  years, was brought to me by
her mother on the 10th of March, 1878.  At the age
of two years she had an attack of  scarlatina, which  left
her with catarrh  and suppuration of  both  tympanic
cavities.  The right drum membrane was perforated in 
9o
CHRONIC MOIST CATARRH.
the  center and the left in the posterior portion.   The
mucous  membrane of both tympanic cavities was in-
flamed  and  discharging a  muco-purulent  secretion.
The audition was sufficient to enable the patient to hear
ordinary conversation across a medium-sized room.  The
nasal cavities were full of decomposing secretions, which
emitted a very offensive odor.   When the cavities were
cleansed several small  abrasions were found in the sur-
face of the membrane.   The sense of smell was consid-
erably improved by the removal  of the  decomposing
secretions, thus  showing that  the  impairment was  ob-
structive.  The  ears  could  be  inflated by Valsalva's
method.   The tonsils were enlarged and interfered with
respiration when they were acutely inflamed.
   Treatment: The tonsils were scarified, or, more cor-
rectly speaking,  they were sliced to  a depth  sufficient
to cause  free sloughing,  after which they were very
much reduced in  size and  caused no further inconve-
nience.   The ears were syringed out once in twenty-four
hours, and sometimes  oftener, with a weak solution of
the bicarbonate  of soda; and  after they were cleansed
a solution of fifteen  grains of  carbolic  acid and  ten
grains of the  sulphate of zinc to two ounces  of water
was  dropped into each ear.  The nose was  cleansed
with a solution  of the chloride of sodium, and  after-
ward sprayed with a  solution  of  three grains of  the
hydrate  of chloral and three  of carbolic  acid to  the
ounce of water.  This treatment was continued until
the following  November, when the catarrh had disap-
peared and the ears ceased to suppurate.  The hearing
was much improved. 
CHRONIC MOIST CATARRH.
91
Case  IX. — Chronic  Moist  Catarrh, with dacryocystitis
                and lachrymal fistula.

  Mrs.  M----,  aged 45, consulted  me  on March 3,
1877,  and stated that five years previous she contracted
an acute catarrh,  which became chronic.   The voice
was very much impaired, and the sense of smell almost
completely destroyed.   The nose was  full of decom-
posing  secretions, and  not only was  the  pharyngeal
walls covered with inspissated mucus and pus, but there
was a solid mass of decomposing secretions occupying
nearly the whole upper part of the pharynx.   It  pro-
jected down sufficiently to be seen through the mouth.
The  odor emitted  from the  nose and  pharynx  was
offensive and nauseating.  No amount of spraying and
syringing would remove the mass from  the pharynx.
After some difficulty it was detached by  means  of a
stout  iron probe.   The patient was unable to remove it
after it was detached, and it had to be drawn  out with
a pair of forceps.   There was no complication save that
of dacryo-cystitis,  with lachrymal fistula.
   Treatment: The canaliculus was slit up, and the stric-
ture,  which was located  in the nasal duct,  was dilated
with Bowman's probes  until the  canal was restored to
its natural size.   In the meantime the lachrymal sac was
syringed out with  a solution of carbolic  acid  and sul-
phate of zinc, ten grains of the  former and five  of the
latter to the ounce of water.  In six weeks the fistulous
opening closed, and the inflammation  of the  sac  sub-
sided.  The  nose and  pharynx were cleansed with a
saturated solution of the muriate of ammonia, which 
92
CHRONIC MOIST CATARRH.
was followed by soothing  applications.  The posterior
walls  of the  pharynx were touched with a two-drachm
solution of iodine crystals*  every third  day for two
weeks, when its use was discontinued.  The cleansing
and soothing applications were continued until Septem-
ber, 1877, when the patient was discharged cured.


     Case X.—Chronic Moist Catarrh, with ozena.

  Miss C----, aged 18, white, called on me in Februa-
ry, 1875, and stated that she had suffered with catarrh
for five years.  The nasal  cavities and the superior part
of the pharynx was  almost filled with decomposing
secretions, which were of  a semi-solid consistence, and
emitted an exceedingly offensive odor.  The sense of
smell was very much impaired; but this was due to the
passages being obstructed by the  secretions, for when
the nose was  clean the sense of smell was perfect.  The
irritation produced by the secretions accumulating  in
the pharynx was so intense that it kept the patient con-
stantly hawking and  spitting.   The frontal headache
was very  severe and almost  constant.   The removal
of the inspissated secretions was  frequently attended
with considerable hemorrhage.   There was no diseased
bone to be detected.  The patient had been under the
care of a number of practitioners, most of whom had
ordered solutions of the nitrate of  silver or sulphate of
zinc to be applied by means of an ordinary syringe.
  Treatment: The treatment in this case was difficult on
               * See section  on Therapeutics. 
               CHRONIC MOIST CATARRH.             93

account of the passages being narrow, thus favoring the
retention  of the secretions.   It was necessary for me
to cleanse the nose  once a day for three weeks, as the
patient was unable to do so by any amount of washing
and spraying.   The principal  cleansing agents were
strong solutions of the muriate of ammonia and chlo-
ride of sodium.  The strength of the solution was
varied,  from  a  drachm  to the ounce,  to  saturation.
Applications were made with the post-nasal syringe and
atomizer.   It was frequently necessary to remove  the
crusts by means of a probe.   Solutions of carbolic acid,
permanganate of potassa, hydrate  of chloral, and  La-
barraque's solution were  used with a view of destroy-
ing the offensive odor.  At the beginning of the fourth
week the offensive odor had disappeared and the patient
could keep the nose clean from day to day, and by the
end of the fifth week her condition was such as to only
necessitate coming to the office once in four days.  The
treatment was continued until the following June, when
the patient  was discharged cured, with the sense  of
smell perfect.  In addition to the local treatment, cod-
liver oil and iron were administered internally.


Case XI.—Chronic Moist Catarrh,  with great relaxation
                  of the  membrane.

  Mr. T----, aged 55, white, was admitted into the Eye
and Ear Department  of  the  Louisville City Hospital
March I, 1877.  The  patient stated that he had been
afflicted with catarrh of the nose for fifteen years, and 
94
CHRONIC MOIST  CATARRH.
that it had recently become very much worse, and that
nasal  respiration was so embarrassed as to prevent his
sleeping more than three  hours  in the  twenty-four.
The discharge of glairy mucus from the  nostrils was
abundant.   The  frontal  headache  was constant and
severe.   The voice was altered, having a peculiar nasal
sound.  The membrane lining  the cavities of the nose
and pharynx was considerably thickened and relaxed.
There was occasional closure of the Eustachian tubes,
which produced temporary deafness.  The patient was
pale and anaemic, with no appetite.
   Treatment: First of all, good diet, such as beefsteak,
eggs,  milk, and such vegetables as his cravings might
call for.   In  addition to the diet he was allowed a lib-
eral amount of good whisky, with  iron and quinine as a
tonic.   The local  medication consisted in the applica-
tion of  a solution of equal parts of a saturated solution
of the muriate of ammonia and a solution of five grains
each of carbolic and tannic  acids to the ounce of water.
The medicine  was applied principally with  the post-
nasal  syringe.   Under this treatment the patient im-
proved  so rapidly that by the 7th  of April he was able
to sleep six or eight hours in succession.   His  general
health improved, and  he was discharged cured in the
following June.

Case  XII.—Chronic Moist Catarrh, with frequent attacks
   of the acute form  of  the disease,  accompanied by severe
   bronchial irritation.

   Mrs.  ----consulted  me  on  the  28th of  February, 
CHRONIC MOIST CATARRH.
95
1878, stating that she had been afflicted with catarrh of
the nose and pharynx for nearly twenty years, and that
she frequently had violent attacks of the acute disease,
which often lasted for a week and even longer, and that
during these attacks she was unable to sleep until almost
exhausted.  The right drum membrane was slightly
opaque;  audition in both  ears was unimpaired.  The
Schneiderian membrane was congested and  relaxed to
such  an  extent  as  to  prevent nasal respiration.  The
secretions were  composed  almost entirely of tenacious
mucus.   Expectoration was profuse;  the  pharyngeal
walls presented  marked evidences of the lavish use of
caustics.   The fauces,  larynx, and bronchial tract were
exceedingly irritable, a full inspiration being  quite suffi-
cient to  induce  a paroxysm  of  coughing,  which  was
usually very severe.  The  epiglottis was slightly con-
gested.   The patient  experienced a feeling of oppres-
sion about  the  chest,  and said that it was difficult for
her to take  a full inspiration.  The expectorated mucus
was  so tough and ropy as to  render  its removal from
the pharynx very difficult.
   Treatment:  The  patient  informed  me  that she  had
taken  almost every conceivable  drug with  a view of
relieving herself of her present  ailment.  The iodide
of potassium was suggested.  She at once stated that
she  had taken that drug in five-grain doses  for several
days on different occasions without any apparent bene-
fit.   Notwithstanding  her  assertions  in  regard to  the
iodide, it was ordered in  ten-grain  doses  every four
hours, with directions to double the quantity each  day
until some  evidences  of its  effects were manifested. 
96
CHRONIC MOIST CATARRH.
The local  medication consisted in the application of a
solution of one hundred and eighty grains of the muriate
of ammonia  to two drachms of glycerine and six of
water, which was followed by a solution of three grains
of tannic acid and two of carbolic acid to the ounce of
rose water.   The applications were made with an atom-
izer.   March 4th, the oppressive feeling about the chest
had  disappeared, nasal respiration was re-established,
and the secretions had become thin and watery.    Ex-
pectoration was easy, and the quantity of mucus very
much lessened.  On the 7th of March all acute symp-
toms had  subsided, and  the  patient was  comfortable
aside from  the chronic catarrh which still existed.  The
iodide was  reduced to twenty grains per diem, and  con-
tinued in  that dose until  about  the middle  of April,
when it was  withdrawn.   The local applications were
not materially changed, except that the bromide of po-
tassium was  substituted for the  muriate  of ammonia
toward  the latter  part  of June, and  continued until
August, 1879, when the patient was discharged cured.


Case  XIII.—Chronic Moist Catarrh, invading both  tym-
                   panic cavities.

  Miss N----, aged 13  years, was brought  to me in
March,  1876, by a medical friend, who stated that  she
had  been  suffering from  catarrh for several  months.
The  drum  membranes were  congested and  slightly
opaque.  At times there was  considerable  pain in  the
ears.   Hearing was impaired to such an extent that the 
CHRONIC MOIST CATARRH.
97
patient  was unable  to  perceive the sound  of a watch
unless the instrument was in contact  with the ears.
Nasal respiration was difficult, and at times impossible.
The sense of smell  was impaired.   The Schneiderian
membrane was inflamed, relaxed, and bathed in muco-
pus.  There was some  swelling and tenderness across
the upper third of the nose, with slight  frontal head-
ache at  times.
   Treatment: The drum cavities were inflated by means
of the Eustachian catheter and air-bag, and a quantity
of mucus blown out with  counter currents  of air.   It
was  necessary to repeat this  operation several  times;
but finally the  hearing was  completely restored and
there was no further trouble  with  the ears.  It was
necessary for the patient to visit the office three times
a week  for two months.  At these visits I cleansed her
nose and pharynx with a solution of the muriate of am-
monia in  the proportion of one ounce to eight ounces
of water.   The  solution was  usually applied with the
post-nasal  syringe, and if this failed to  remove  all the
secretions the atomizer was used until the nasopharyn-
geal cavities were thoroughly clean.  After cleaning,
the cavities were sprayed with a solution of five grains
each of  carbolic and tannic acids to the ounce of water.
In the  intervals  between  the  visits to the  office, the
patient  used the above agents three times a day with
an atomizer.  The treatment  was  kept  up until the
following  November,  when the patient was  discharged
cured.                    7 
98
CHRONIC MOIST CATARRH.
Case  XIV. — Chronic Moist  Catarrh, with suppurative
                    otitis media.

  Mr. T. A----,  aged 18, white,  brass  finisher, con-
sulted  me  May 19, 1877, and stated that for the last
eighteen months  he had been very much annoyed by
an offensive discharge from the nose  and  pharynx.  In
February, 1877, he placed himself under the care of a
general practitioner, who sought  the advice  of a spe-
cialist, and, according to  the directions of the consult-
ing physician, the doctor proceeded to inject the nose
and pharynx with a caustic solution, using the catarrhal
syringe, and being ignorant of the manner in which the
instrument should  be manipulated,  the patient was
ordered to hold the tongue out of the mouth while the
solution was thrown into the pharynx, and the  result
of this procedure  was strangulation and flooding of the
drum cavities, which  produced the most excruciating
pain for several hours, and terminated with perforation
of the drum membranes.   At the time I first saw him
there was a profuse discharge of pus from both ears,
with a perforation of each drum membrane.   The nasal
cavities were filled with decomposing secretions,  which
emitted an offensive  odor.   The  sense  of smell was
slightly impaired.   The hearing equaled the watch in
contact.
   Treatment: The treatment consisted in cleansing the
ears once each day  by the use of  the Eustachian cath-
eter and air-bag, and blowing a solution of carbolic acid
and  sulphate of zinc into the drum  cavities.  In less
than six weeks the perforated drum membranes had 
CHRONIC MOIST CATARRH.
99
closed, and in a short  time the hearing was quite re-
stored.  The  catarrh was treated with muriate of am-
monia, followed by soothing astringents and deodorizers.
The treatment was kept  up  until November, 1877,
when  the patient was discharged cured.


          Case XV.—Chronic Moist Catarrh.

   Mr.  N. F----, aged 30 years, consulted me in March,
1877,  and  stated that for four years he  had been very
much  annoyed with  the  sensation  of a foreign body
substance in the region  of the posterior nares and  pos-
terior surface of the soft palate, and that he was  obliged
to make  frequent  and  violent efforts by hawking to
remove it.   There was a feeling of warmth and dryness
in the  pharynx.  The sense of smell was perfect.   The
membrane lining the nose and pharynx was glazed; the
secretions were of a muco-purulent character.  The pa-
tient had frequent acute  attacks of the disease, which
usually subsided in two  or three days.
   Treatment:  A  solution of one hundred and eighty
grains  of the muriate of ammonia to the ounce of water
was applied two or three times a day with the atomizer
for six weeks.  At this time the membrane was ex-
ceedingly sensitive and the strong solution was withheld,
and a  solution of thirty grains of the muriate to the
ounce  of water was used until the following November,
when the patient  was discharged cured. 
100
CHRONIC MOIST  CATARRH.
          Case XVI.—Eczematous Rhinitis.

  Mattie F----, aged 9 years,  was brought to  me in
the month  of May,  1875,  by her father,  who  stated
that for three months crusts had been  accumulating
about the nostrils and  lips, so as to frequently interfere
with nasal respiration; and that their removal was diffi-
cult and painful.   The  membrane  lining the inferior
portions of the nasal cavities was very much congested
and swollen.   The  secretions, save those which were in
the region of  the anterior nares, were scanty, and com-
posed principally of tenacious  mucus.   The general
appearance of the  patient was  that of a strumous in-
dividual.
  Treatment:  The treatment consisted in the local ap-
plication of a  solution of carbolic  acid of five grains to
the ounce  of water.   This was thrown into the nose
two or three times a day with the atomizer.   The crusts
were removed once a day and the open surface touched
with a half-drachm  solution of iodine.*  In addition to
the local medication, the iodide  of potassium was freely
administered internally.   Under this plan of treatment
the disease rapidly disappeared,  and she was discharged
cured on the first of the following July.


          Case XVII.—Eczematous  Rhinitis.

  Miss  R----, aged 7  years, was brought to me by her
mother  August 11,  1877.  Her  general health was ap.
               * Vide section on Therapeutics. 
CHRONIC MOIST CATARRH.
IOI
parently good, notwithstanding  she had  recently had
several  attacks of intermittent fever.   She had several
small flecks around  the margin  of each cornea, just
within  the  occular  conjunctiva.  The  tonsils  were
slightly  enlarged,  and the  nasal  mucous  membrane
thickened.   The region of  the anterior nares and  the
upper lip were covered with eczematous  crusts, which
so obstructed  the  passages  as to interfere very mater-
ially with nasal respiration.  The  pharyngeal  mucous
membrane was congested, with a quantity of brownish
looking muco-pus deposited upon its surface.
   Treatment:   The  treatment consisted in  the free
administration  of quinine  internally to break up  the
malarial paroxysms,  which occurred every few  days.
A solution of  the sulphate of atropia of one grain to
the ounce  of  water was instilled into  the  eyes three
times  a day.   The  nose and  pharynx were sprayed
three times a day with a solution  of fifteen grains of
the bromide of potassium to an  ounce  of water.  She
was discharged, cured, August 29,  1877.


         Case XVIII.—Eczematous Rhinitis.

   Jane McD----, age  12 years, was admitted to  the
Louisville  Eye and   Ear  Infirmary April  12,  1878,
suffering with  phlyctenular keratitis and eczematous
rhinitis.  There were a  few small vesicles  at  the
juncture of the cornea and sclerotica, with considerable
lachrymation and photophobia. The Schneiderian mem.
brane was inflamed and inclined to bleed upon  slight 
102
CHRONIC MOIST CATARRH.
provocation.   There was little or no secretion from the
nose, and no unusual amount of expectoration.  The
nostrils were almost or quite  occluded  by eczematous
crusts, which extended down on  the lip  to considerable
distance.
   Treatment: Quinine was administered internally, and
a solution of atropia dropped  in the eyes two or  three
times a day.  The crusts were softened  with a solution
of the bicarbonate of  soda and removed once a day,
and the open surface anointed with a salve of ten grains
of the yellow oxide of mercury to the  half an ounce
of glycamil.   At the end  of  six weeks she was dis-
charged cured.
  She had another attack in September of 1879, which
was not so  severe as the  first,  and which was cured  by
a similar plan of treatment.

  It  will  be seen that two of  the three cases reported
under  this head were  complicated with malaria and
phlyctenular  ophthalmia.   These   two  complications
are frequent in  this locality.   It is thought by  some
observers that phlyctenular ophthalmia is produced by
this  peculiar form of catarrh; and  there can be  little
doubt but that such is the case. 
CHRONIC DRY CATARRH.
103
        CHRONIC  DRY CATARRH.

   Dry catarrh may be subdivided into dry atrophic and
proliferous.  The dry form is not a catarrhal inflamma-
tion,  as defined by  most  authors,  the  characteristic
feature, the increased secretion, being absent.
   Dry Atrophic.—In dry atrophic inflammation of the
Schneiderian and pharyngeal mucous  membrane, the
nasal cavities are  usually  free and  capacious, unless
there should be  some malformation of the bony or car-
tilaginous  structure.   Nasal respiration is perfect, the
membrane is pale, and seems to be drawn closely over
the irregularities of the cavities,  and  is entirely free
from any secretion whatever.  There  is frequently a few
dry, mealy-looking scales  about  the  anterior nares.
When the  disease invades  the pharynx, the membrane
covering its  posterior wall  presents a dry, glazed, and
attenuated appearance,  and  seems to  be  very  thin.
There is always a sense of dryness, which  is exceed-
ingly annoying when the membrane  covering the pos-
terior surface of the  soft palate and  posterior nares is
involved.   The  pathological change is just the opposite
in this form of the disease  to what  it is in  proliferous
rhinitis.  The etiology of this peculiar form of naso-
pharyngeal disease is a matter about which there is but
little  known.  It is supposed by some to be the result
of sleeping with the mouth open.  This may possibly
assist in bringing about the disease by inducing dryness
of the fauces and Schneiderian membrane.   The  inju-
dicious  use of  caustics  probably  has  much to do in 
104
CHRONIC DRY CATARRH.
establishing this abnormal condition.  The most com-
mon  form of caustic application  is that which results
from  the smoking of tobacco.   It  is well  known that
tobacco  contains a large amount of nitrate of potash,
which, being oxydized by the burning,  is rapidly con-
verted into the caustic form.
   Treatment: These cases may be palliated, but a per-
manent cure is not to be expected.   The local applica-
tion of stimulating agents, such as iodine  in combination
with  glycerine and iodide of potassium,  and persistent
nasal  respiration both day and night, are  about the most
efficient  means of alleviating the deplorable state.  If
there is  any difficulty about keeping up  constant  nasal
respiration it may be done by wearing a mask  over the
mouth.   This will usually be necessary at night.
  Proliferous  Rhinitis. — In proliferous rhinitis the
membrane is considerably thickened, and is of a  pale,
pinkish hue in the anterior portion of the nasal  cavi-
ties, causing  it to  resemble the integument in color.
There is  almost an entire absence of the normal secre-
tions ; the membrane presenting a velvety appearance.
The thickening in these cases is due to  an increase in
the connective tissue cells.   What it is that induces the
increase in the cell element of the connective tissue in
this locality is to be conjectured.   It may be due to
local  inflammatory action, or mal-nutrition from other
causes, as a deranged circulatory or lymphatic system.
I am inclined  to believe that the  change is  brought
about by constant irritation of the vaso-motor nerves in
the affected locality.  The irritation  of these nerves
would undoubtedly invite  an extra amount of blood, 
CHRONIC DRY CATARRH.
105
which would tend to increase the bulk of the structures
just in the same  manner that any other tissue may be-
come hypertrophied by an increase in its circulation.
The inflammation sooner or later extends to the phar-
ynx, thence to the Eustachian tubes, and, lastly, to the
tympanic cavities.   The  tympanum  and  Eustachian
tubes may escape for a considerable time; they gener-
ally become  involved,  but the invasion is  so gradual
that the patient is not  aware of the affliction until con-
siderable damage has been done.
  Tinnitus aurium is one of the earliest signs of the
invasion  of the tympanum in these cases, and  should
always receive the proper consideration in this connec-
tion.  While tinnitus aurium of itself is not significant
of the presence of any special malady, it is always well
to determine its cause  if possible, for it is often due to
narrowing of the faucial orifices of  the tube.
  Impairment  of the  hearing  usually  accompanies or
follows  the tinnitus.   The drum membranes may  be
depressed or  opaque.   The defect in the  hearing is
usually  slight at  first, and if allowed  to  continue the
patient  becomes  gradually worse  until the  power  of
audition is practically lost.  Suppuration of the middle
ear rarely occurs in  connection with dry catarrh, and
there is little or no pain  accompanying the ear compli-
cations.
  Anosmia  is  usually present  in this form  of disease.
It may be due to organic changes in the olfactory mem-
brane, or it may be caused by the thickened membrane
obstructing  the passages  and preventing  odors from
coming in  contact with  the regio olfactoria.  Nasal 
106            CHRONIC DRY CATARRH.
respiration is usually more or less impaired.   The voice
is  changed  when  the membrane is  much thickened.
The frontal  headache, which is frequently met with in
other forms  of catarrh, is ordinarily absent in this form
of the disease.
  Epistaxis, so common in other forms  of  rhinitis, is
rarely met with in the so-called dry catarrh.
  The prognosis of this form of rhinitis should always
be  guarded.   If the disease  is taken in its  incipiency
there is a fair chance  of arresting it, and preventing ex-
tension to other  organs; but if the  Eustachian tubes
and tympanic cavities are involved, it is doubtful if we
can do more than  arrest  its progress and keep the dis-
ease in abeyance.
   Treatment: This is an affection that in all probability
is  more  or  less influenced  by the so-called strumous
diathesis, and therefore demands special attention.  The
iodide of potassium is possibly the most valuable agent
we have in  the treatment of hypertrophy, whether it
be in  the nasal membrane or other tissues of the body.
It  seems to  possess  a peculiar influence  on  the thick-
ened membrane.   It should be given freely until symp-
toms  of iodinism are manifest, and then withheld a few
days  and repeated again, and the patient  kept  on the
verge of iodinism for weeks at a time.   The bi-chloride
of mercury may be given in small doses,  but it is not
so  efficient  as  the iodide.  The muriate  of ammonia
proves beneficial in some instances, and should  not be
lost sight of in the course of treatment.   Local appli-
cations  must be of a stimulating nature,  such as satu-
rated solutions of the muriate of ammonia, bromide of 
CHRONIC DRY CATARRH.
107
potassium, solutions  of  iodine, etc.   (See  section on
Therapeutics.)   Caustics should never be applied under
any circumstances, as  harm  must  necessarily result
from their use.


  Case XIX.—Dry Atrophic Rhinitis and Pharyngitis.

  John S----, carpenter, was  admitted into the Louis-
ville City Hospital December  17, 1878.  His  general
health was good, and the only inconvenience which he
experienced was an excessive dryness  in the nose and
pharynx.  The Schneiderian membrane was perfectly
dry and glazed, and very much attenuated.  The  vocal
chords were  congested.
  Treatment: The walls of the pharynx were touched
once a day with a solution of one drachm of iodine  to
the ounce of glycerine.  In addition to this, the nose
and pharynx  were sprayed twice a day with a saturated
solution of the  muriate  of ammonia.   Respiration was
carried on through the  mouth as much as possible.
After a trial of three months the patient was discharged,
without improvement.


  Case XX.—Diy Atrophic Rhinitis and Pharyngitis.

  Susan J----,  aged 41, colored, cook  and washer-
woman, consulted me in March, 1877, anc* said that for
several years she had  suffered with a dry throat, which
frequently kept her from sleeping.  The pharynx was 
io8
CHRONIC DRY  CATARRH.
as dry as the palm of the  hand, and the membrane at-
tenuated.   The nasal mucous membrane was also dis-
eased to an extent sufficient to completely destroy the
sense of smell.  The membrane here, as in the phar-
ynx, was dry  and attenuated, and free from secretion
of any kind whatever.
   Treatment: The  treatment  in this case consisted  in
the application of the iodine solution as in Case XIX,
with the addition of almost every conceivable  agent
that was thought to have any special tendency to in-
crease the activity of the mucous follicles.  There was
considerable improvement at times,  but it was not per-
manent.  This woman  had been an  inveterate pipe-
smoker for twenty years, which no  doubt had much to
do with the production of the disease.


Case XXI.—Chronic Proliferous Rhinitis,  invading both
                  tympanic cavities.

  James R----, aged 14 years,  was brought to  me  in
March,  1876, by his father, who stated that the boy's
hearing had been  failing for two years. There was oc-
casional pain in the region  of the drum cavities.  The
hearing on the right side equaled the watch in contact;
on the left side the sound of the watch  could  not be
perceived at all."   The membrane lining  the nose was
thickened,  and free from any secretion whatever.  The
posterior wall  of the pharynx was  studded with neo-
plasms.  The tonsils were very much enlarged;  and the
Eustachian tubes were both closed.   The drum  mem- 
CHRONIC DRY CATARRH.
IO9
 branes were slightly depressed, and there was conges-
 tion along the course of the handle of the malleus on
 both sides.   There was considerable tenderness about
 the faucial orifices  of  the Eustachian tubes.
   Treatment:  The tonsils  were sliced  sufficiently to
 produce free sloughing, which reduced the size of the
 glands very materially,  and  enabled  the patient to
 breathe  with  much  more  comfort than  previously.
 The Eustachian tube  on the right side was catheter-
 ized twice a week,  and a single drop of a solution of
 the bi-chloride of mercury, one grain to the  ounce of
 water, was blown into the tube and drum cavity.  The
 cavities of the left side  of the nose were  so  distorted
 as to  prevent the  introduction of a catheter, and the
 ear on that side was inflated by Politzer's method.  The
 nose and pharynx were sprayed twice a day with a sat-
 urated solution of the muriate of ammonia.   The iodide
 of potassium was  given internally in full doses.   The
 above  plan  of treatment  was kept up for about four
 months.   There was a decided improvement  in all the
 symptoms.  The hearing in the right equaled ■£$,  and
 in the  left ■s%.   The patient become dissatisfied because
 the improvement was not more rapid, and discontinued
 the treatment.


 Case XXII.—Chronic Proliferous Rhinitis, invading both
                  tympanic cavities.

  Mr.  D----consulted me in  June, 1877,  and stated
that he had been annoyed more or less for fifteen years 
no
CHRONIC DRY CATARRH.
with tinnitus aurium, which at times was distressing.
He  was  not  certain,  but  thought  his  hearing had
been failing for ten years.   The watch could only be
heard when in contact with the ears.  The membrane
lining the nose and pharynx was very much thickened,
and  at  times was inclined to be  moist.   Respiration
through the nose was difficult, and the voice had a pe-
culiar nasal sound.  The membrane in the region of
the faucial orifices  of the Eustachian tubes was thick-
ened to such an extent  as to nearly close them.   The
drum membranes were opaque and depressed.
   Treatment: The tympanic  cavities were inflated by
the catheter and air-bag.   This was repeated on several
occasions, but without the slightest benefit.  A single
drop of a solution  of one grain of the bi-chloride of
mercury to  the ounce of water was  thrown into the
drum cavities  every fourth day for three weeks.   The
nose was sprayed twice a day with a saturated solution
of the  muriate of ammonia.   The catheterization was
discontinued at the end of the third week, and the am-
monia  solution at the end of the  sixth week.   There
was not the slightest improvement, and, feeling satisfied
that the patient was not to be benefited, I advised him
to discontinue treatment.


Case XXIII.—Chronic Proliferous Rhinitis, invading the
                    drum cavities.

  Mr. W----called on  me in May, 1877, and  stated
that  for two years  he had  been  gradually losing his 
CAUSES.
Ill
hearing.   There was no pain in either ear.   The hear-
ing on the right side  equaled /g, and on the  left  3V
The drum membranes  were  opaque and  depressed.
The Schneiderian membrane was  thickened  and pale,
presenting more  the appearance  of integument than
mucous membrane.   The Eustachian tubes were closed,
but could be easily inflated.
   Treatment: The nose was sprayed every  third day
with a saturated  solution of the muriate of  ammonia.
In the intervals a solution of  sixty grains of the bro-
mide  of  potassium to the ounce  of water was used
three times a day with the atomizer.   This  treatment
was kept up for two months, at the end of which time
the hearing equaled \%  in both ears.  The patient con-
cluded that  his hearing was sufficiently restored, and
discontinued the treatment.  He has retained  all that
was gained by the treatment,  never having  suffered a
relapse.
          CAUSES  OF  CATARRH.

  The causes are numerous, among the most common
are contagion, trauma, atmospheric influences, germs,
irritants (rose perfume), inhalation of acrid gases.
  Contagion.—"Among the  laity it is regarded as an
incontrovertible  fact that a cold in the head may be
communicated from  one person to another, both by 
112
CAUSES.
direct contact with the secretion (as in using the same
handkerchief, etc.), as well  as  by mere approximation
of the diseased organ to the  healthy one—in the  act
of kissing, for instance."   It  can  not be denied that
there is a great deal of evidence in favor of the theory
of contagion, and yet a sufficient amount of positive
proof has not been collected to establish  it as fact, and
therefore to declare it as such would be unwarrantable.
But, nevertheless,  I am quite certain that naso-pharyn- <
geal catarrh,  in an  advanced stage,  is  a contagious
disease.  It is a well-known fact that the Schneiderian
membrane can be inoculated  by placing pus  cells on
its surface.  This,  however, is  a fact that most practi-
tioners  can testify to, having,  in the course  of their
practice, met with cases of gonorrhceal  rhinitis  which
were unmistakably the result of contagion.   It may be
claimed that  gonorrhceal virus  possesses  some specific
properties  which  render  it more infectious than the
secretions  of a purulent rhinitis arising from atmos-
pheric causes.  It  is impossible to determine the differ-
ence between specific and non-specific urethritis; and,
likewise, it is just as impossible to determine the differ-
ence between gonorrhceal conjunctivitis and the puru-
lent conjunctivitis  resulting from atmospheric causes or
ordinary traumatic injuries, followed by suppuration.
The same is true of purulent rhinitis.   Many attempts
have been made to demonstrate the contagiousness of
catarrh  by inoculating the nasal  mucous membrane
with. secretions taken from the noses of individuals
suffering from catarrh in its various stages. The results
so far have been negative;  but I think that the causes 
CAUSES.
"3
 of failure are to be accounted for in many ways, as they
 are numerous and difficult to avoid.  First of all, there
 can  be no doubt but that  the activity or virulence of
 the  secretions in cases of gonorrhoeal  conjunctivitis or
 rhinitis depend to  a great extent,  if not altogether,
 upon the number of pus cells and their condition at the
 time of inoculation.  I do not believe that there is any
 difference in the activity of pus cells when they arrive
 at maturity, unless they possess some specific property
 aside from  that of the cell found in cases of ordinary
 inflammation;  it matters not whether they are taken
 from the urethra, vagina,  conjunctiva,  or  Schneiderian
 membrane.   And,  furthermore, it must  be conceded
 that there is a period during the course of all suppura-
 tive  diseases in which the  contagious element is partic-
 ularly active.   The time at which this activity is mani-
 fested can not be positively determined, but it is fair to
 presume that it occurs when the greatest number of pus
 cells  are  being  eliminated,  as these  bodies,  or the
 "granular matter"  resulting from their degeneration,
 are known to contain the propagating germs or parti-
 cles.  Taking the above view of the matter, failure to
 inoculate may depend upon the condition of the secre-
 tions at the  time of their transfer, or upon the quantity
 placed on the membrane.   In addition to these, the
locality upon which infectious pus is placed would have
a great deal to do with its producing the desired result;
because the membrane lining the anterior nares and the
inferior meatus is much less sensitive than that covering
the middle and superior turbinated bones, therefore pus
cells coming in contact with the membrane of the former
                          8 
H4
CAUSES.
locality would not be so apt to reproduce themselves
as if they were deposited in the superior cavities of the
nose.  Again, the secretions of the nasal mucous mem-
brane may be so profuse as to  wash the infectious ma-
terial off, or the  membrane may be so dry as to render
it inert, and it remains upon the thin crust of inspissated
mucous until the whole is removed from the cavity.
  There can be no doubt but that many cases of acute
catarrh  which are met with in new-born  children are
the result of contagion, the membrane having become
contaminated by the vaginal secretions  of the mother
during birth.  An allusion is made to this by Herm.
Weber, in  Ziemssen's Cyclopedia, vol.  iv., page  119:
"A well-developed boy,  whom they were not able to
wash until some three hours after his birth, and whose
mother, during the last weeks of pregnancy, had shown
an abundant vaginal leucorrhcea, soon developed a yel-
low discharge from his  nose, and inflammation of the
left eye, with secretion  of pus.  In the same way, on
closer examination, it will be  found  that by far the
larger proportion of cases  of coryza neonatorum aris-
ing within the same period as  the ophthalmia of that
age, and sometimes associated with it, is to be attributed
not to taking cold immediately after  birth,  nor to a
peculiar susceptibility of  the mucous membrane, but to
an infection in the vagina of the mother.  At least in
almost all cases of coryza  neonatorum  that I have  in-
vestigated I have been  able to show the existence of
lucorrhcea in the mother."
  The  snuffles which is  said to be  pathognomonic of
inherited syphilis in the infant is doubtless  in  many 
CAUSES.
H5
instances due to coryza, instead of any hereditary taint.
I am inclined to believe that  snuffles, as spoken of in
this relation,  is  in  no way connected with  syphilis.
There is nothing  peculiar about  the secretion  that
would serve to distinguish it from  that  of  ordinary
coryza.  The membrane in many cases where  the snuf-
fles is present does not show any evidences that would
lead us to believe that the affection was anything more
than common catarrhal inflammation.   I have  not seen
a case of syphilitic  coryza  in  which there was not a
breech of continuity in the Schneiderian membrane, or
an involvement of the bony or cartilaginous structures.
  The following is a description of syphilitic coryza of
infants as found in the recent work of Dr. J. Solis Cohen;
  "Much  more  frequently, however, the disease is
manifested in the form of fibrinous coryza, which, in
accordance with  the  opinion  of  Diday and others, is
probably due to  the  development  of mucous patches
upon the mucous membrane of the nose.   The earliest
evidences of the disease is then some impediment to
free nasal respiration and consequent embarrassment in
nursing; the symptoms  being similar at first to those
of ordinary coryza.  After a short time a thin serous
liquid  drips  from the nose,  soon becoming thicker,
purulent, and somewhat  sanguinolent.  The lips some-
times become excoriated by the acridity of the discharge.
The nasal passages become more and more occluded,
and as this condition increases, the child, while suckling,
is forced to take  rapid respirations through the nose;
this dries up portions of  the secretions  into crusts,
which  are discharged from time to time, with  more or 
n6
CAUSES.
less  hemorrhage.    Finally,  these  crusts accumulate
more rapidly  than  they can be  discharged, and com-
plete obstruction of the nose ensues.  When this is the
case, great difficulty is experienced in nourishing the
child, because it is unable to breathe while at the nip-
ple.   It  seizes the breast  eagerly, but is compelled to
drop it almost  immediately, and thus rendered cross
and fretful.  As the disease progresses specific pustules,
fissures, and ulcers become developed upon the alae of
the  nose  and  upon  the lips, and at the angles of the
mouth, and extend outward upon the cheek  along the
natural  fissures  of the skin.   In this  manner, some-
times,  peculiar  striated  appearances  are  produced,
which, according to Prof. Trousseau, are characteristic
of syphilis, and are true  mucous crusts, though  not
exactly of the same aspect as  in  the adult;  their size
being  smaller the  greater  their distance  from  the
mucous membrane of  the  lips; their edges are finely
fringed and blackened by the adherence of coagulated
blood; and they have gristly  and bleeding bottoms,
more or  less  bright  red  in  color.  Prof. Trousseau
states that they often  leave indelible  cicatrices  after
recovery,  and  that he  has seen young men and young
women  still carrying  these scars-stigmata, the nature
of which they did  not  suspect.
   "As the disease of the nasal  passages progresses,
ulceration takes place in the structures of the nose also,
often destroying the  cartilages and the  bones,  frag-
ments  of which are thrown off with the crusts.   In
this  way the  septum  often  becomes perforated, and
sometimes the nose flattened.   Some cases of so-called 
CAUSES.
117
scrofulous perforation of the septum in the adult are
of  infantile specific origin.  Sometimes the general
system is  poisoned by the exhalations  of  the decom-
posing secretions  in  the nose, and  death ensues  in
consequence.  This syphilitic coryza  is sometimes the
only manifestation  of  hereditary syphilis, and, accord-
ing  to Trousseau,  the earliest  sign  of  the disease  in
almost every instance."
  The flow  of bloody  yellowish serum referred  to  in
the above description, and the crust that  accumulate
in the region of the anterior nares, may accumulate  in
cases  of  simple  eczema, and  frequently extend  to a
considerable distance into the nasal cavities and invade
a considerable amount of tissues  in the adjacent vicinity.
  Atmospheric Causes.—The idea of a vitiated atmos-
phere being the cause of acute catarrh is not at all new.
Most of the literature pertaining  to  this subject con-
tains  statements, if not positive assertions,  which lead
the reader to infer that the  profession have generally
supposed one of the prime causes of this disease to be
due either to a contamination of the atmosphere,  or  to
the sudden  lowering or  elevation  of  its temperature.
Whether or  not sudden changes in the temperature  of
the surrounding atmosphere are capable of producing
acute  inflammation of the  Schneiderian membrane  is
more than the writer is able to say; but it is an evident
fact that sudden changes in the temperature are usually
followed by an increase of  catarrhal affections, and
particularly of  the nose and larynx.   We know by
experience that the inspiration of air at  a very low
temperature  produces an unpleasant  sensation in the 
120
CAUSES.
 pervades the air in thunder storms.   Ozone has remark-
 able purifying properties.   It has also the effect, when
 breathed  in  large quantities,  of irritating the mucous
 membrane of the air passages.  While M. Schonbein
 was engaged in  examining its  chemical relations,  he
 found that the  inhalation of strongly ozonized air pro-
 duced a painful affection of his chest, a sort of asthma,
 with violent  cough, which obliged him to discontinue
 for a time his  investigations.   Reflecting on this  cir-
 cumstance, he began to suspect that certain  catarrhal
 disorders might be caused by atmospheric ozone.   He
 got several physicians at Basle to compare their lists of
 catarrhal patients with his tables of atmosphero-ozono-
 metric observations; and he and they were struck by
 the occurrence of an unusual number of catarrhal cases
 on the days or during the periods when M. Schonbein's
 test  papers showed that ozone was unusually abundant
 in the air."
  The observations of Schonbein and  his colleagues,
 notwithstanding the fact that they were limited, carry
 with them a great deal  of weight  in  support of  the
 theory that ozone is an active agent in the production
 of acute catarrh.
  No one has  ever undertaken to push the  investiga-
 tions of Schonbein, and they stand to-day just in  the
 same condition as when he ceased his labors.   Attempts
have been made to  refute his  arguments in relation to
the ozone theory, but they have been unsuccessful.
  The  inhalation of dust  and irritants produce catarrh
occasionally,  and tend to aggravate  it  very materially
where  the disease  already exists.  The inhalation  of 
CAUSES.
121
 acrid  gases, as the  fumes of  chlorine,  bromine, and
 kindred agents, produce great  irritation of the Schnei-
 derian membrane, and frequently an  acute rhinitis re-
 sults from  it.  The  odor of certain flowers, as the Da-
 mascus and other roses.  The probabilities are that the
 pollen of the flower  acts as the irritant in those cases.
 Dr.  C. M. Sebastian, of Martin, Tenn., reports,  in the
 August, 1879,  number of the Medical Herald, the his-
 tory of an interesting case in which he has succeeded
 for  three years in warding off periodical attacks  that
 had occurred annually for twenty-one  years.  He com-
 pelled the patient to  keep his face covered with a thick
 vail  during the period at which the  disease  recurred.
 This is very strong evidence  that in  this  instance the
 irritant must have  been in the shape of  pollen or bearded
 spores, as suggested  by Dr. Sebastian in his paper.  I
 have tried this plan in a case after the  disease  had man-
 ifested itself, but the patient was not faithful in carrying
 out the treatment, and the results were not so gratifying;
 nevertheless the sufferer said that  she  was benefited by
 the use of the vail.
  Tobacco smoking is a more common cause of inflam-
 mation of the  membrane lining the  nose  and pharynx
 than it is generally thought to be.   Cigarette smoking
 is possibly more  injurious than  cigar or pipe smoking,
because the  smoke is frequently exhaled through  the
nose, thus bringing hot fumes directly in contact with
the delicate membrane, and thereby creating a greater
amount of irritation.   Mr. Lenoxe Browne, in his  ex-
cellent work on the throat, in  speaking  of the causes
of chronic laryngitis,  says:   "In the opinion  of  the 
120
CAUSES.
pervades the air in thunder storms.   Ozone has remark-
able purifying properties.  It has also the effect, when
breathed in  large quantities,  of irritating the mucous
membrane  of the air passages.   While M. Schonbein
was  engaged in  examining its  chemical relations,  he
found that  the  inhalation of  strongly ozonized air pro-
duced a painful affection of his chest, a sort of asthma,
with violent  cough,  which obliged him to discontinue
for a time  his  investigations.   Reflecting on this  cir-
cumstance, he began to  suspect that certain  catarrhal
disorders might be caused by atmospheric ozone.   He
got several physicians at Basle to compare their lists of
catarrhal patients with his tables of atmosphero-ozono-
metric observations; and he and they were struck by
the occurrence of an unusual number of catarrhal cases
on the days or during the periods when M. Schonbein's
test  papers showed that ozone was unusually abundant
in the air."
  The observations  of Schonbein and  his colleagues,
notwithstanding the  fact that they were limited, carry
with them  a great  deal of weight  in  support of  the
theory that ozone is an active agent in the  production
of acute catarrh.
  No one has  ever undertaken  to push the investiga-
tions of Schonbein,  and they stand to-day just in  the
same condition as when he ceased his labors.   Attempts
have been made to refute his  arguments in relation to
the ozone theory, but they have been unsuccessful.
  The  inhalation  of  dust and irritants produce catarrh
occasionally,  and  tend to aggravate  it  very materially
where  the  disease already exists.  The  inhalation  of 
CAUSES.
121
 acrid gases, as the  fumes of  chlorine,  bromine, and
 kindred agents, produce great  irritation of the Schnei-
 derian  membrane, and frequently an  acute rhinitis re-
 sults from  it.  The  odor of certain flowers, as the Da-
 mascus and other roses.  The probabilities are that the
 pollen of the flower  acts as the irritant in those cases.
 Dr.  C.  M. Sebastian, of Martin, Tenn., reports,  in the
 August, 1879,  number of the Medical Herald, the his-
 tory of an interesting case in which he has succeeded
 for  three years in warding off periodical attacks  that
 had occurred annually for twenty-one  years.  He com-
 pelled the patient to  keep his face covered with a thick
 vail  during the period at which the disease  recurred.
 This is very strong evidence  that in this  instance the
 irritant must have been in the shape of pollen or bearded
 spores,  as  suggested  by Dr. Sebastian in his paper.  I
 have tried this plan in a case after the  disease  had man-
 ifested itself, but the patient was not faithful in carrying
 out the treatment, and the results were not so gratifying;
 nevertheless the sufferer said that she  was benefited by
 the use of the vail.
  Tobacco smoking is a more common cause of inflam-
 mation  of the  membrane lining the  nose  and pharynx
 than it  is generally thought to be.   Cigarette smoking
 is possibly more  injurious than  cigar or pipe smoking,
because  the smoke is frequently exhaled through  the
nose, thus bringing hot fumes directly in contact with
the delicate membrane, and thereby creating a greater
amount of irritation.   Mr. Lenoxe Browne, in his ex-
cellent work on the throat, in speaking of the causes
of chronic laryngitis,  says:   "In the opinion  of  the 
122              INFUSORIAL CATARRH.

author, however, the use  of  tobacco has but  a very
slightly obnoxious  effect on the larynx, though  it un-
doubtedly tends to  induce chronic pharyngeal  inflam-
mation, especially when  accompanied by frequent ex-
pectoration. "  Many of the exanthems are accompanied
or initiated in with acute coryza, which is, to all intents
and purposes, a  genuine catarrh.   It may therefore be
called an exanthematous catarrh, in contradistinction to
other forms  of  the disease.  The material difference
between this  and other forms of catarrh of the nose and
pharynx is, that it is more violent, and generally invades
the entire membrane lining the naso-pharyngeal space,
and is more apt to extend to the middle ear.
          INFUSORIAL  CATARRH.

  The discovery of parasites in the nasal secretions  of
patients suffering with acute catarrh was first  made by
Dr. J.  H. Salisbury, of Cleveland, Ohio.   Dr.  Ephraim
Cutter, of Boston, Mass.; Prof.  Paulus  F.  Reinsch,  of
Erlangen; and Mr. F.  N. Daykin, a student of Dr.
Salisbury's, have found the parasite in the  nasal secre-
tions.  These four observers have seen  about  1,100
cases.  They prove in various ways, as will be seen  in
their reports (which I have considered worthy  of repro-
duction in this article), that there is a parasite present in 
INFUSORIAL CATARRH.
123
many cases of acute catarrh.  First, they demonstrate
its presence by the use of the microscope;  secondly,
the application of most any of the ordinary parasiticides
kills the animal and gives immediate relief to the patient.
Personal experience does not enable me to speak upon
this subject;  nevertheless these  gentlemen  have cer-
tainly opened a new field for investigation, which ought
to induce others to continue the search.  If this can be
established, it opens a new field for the general practi-
tioner, who may just as well administer upon  the estate
of the parasite without the trouble of examining his
person with illuminating or other instruments.
   Dr. Cutter  says  (Virginia Medical  Monthly for No-
vember, 1878):
   "The general practitioner is very familiar with a kind
of epidemic influenza that runs through whole families
and neighborhoods.  It is not asserted that all catarrhs
and influenzas are caused by rhizopods (root-footed pro-
toplasmic animals), but it  is desired to submit  some
positive evidence that sometimes they have been caused
by them;  that when the rhizopods are destroyed, either
by self-limitation or by parasiticides, the influenzas dis-
appear  (when uncomplicated).   It  has seemed to me
that Dr. Salisbury has in this  discovery given  us an
example of pure science in medicine, as I regard the
discovery of a cause of a disease, its removal, and there-
by the cure, as an exhibition of the highest skill in our
profession.
   "First  Testimony.—This is the original  paper pub-
lished by the discoverer in Hallier's Zeitschrift, Jena,
January, 1873, page 7,  as follows: 
124
INFUSORIAL CATARRH.
 " ' Infusorial Catarrh and Asthma.—By J. H. Salisbury,
               B. N. S., A. M., M. D.

   "'This is  purely a  parasitic disease, arising from a
peculiar animalcule organism (asthmatos ciliaris, Salisb.)
armed upon one  side with cilia.
   " 'This organism assumes a great variety of shapes
and sizes during the different phases of its  existence.
                        Fig. i.
                             St,
ASTHMATOS CILIA-
     RIS.  (S.)

  Photo-engraving from
drawing   executed  by
Mrs. Jerome Thompson,
the celebrated head pain-
ter, of New York.
In the same case, by watching carefully its development
and  metamorphoses  under the microscope, it may be
seen to transform itself into all the different forms rep-
resented in figures i to  17.   The  most usual  shape 
INFUSORIAL CATARRH.
125
seems to be spherical or oval, as seen in figures 1 to 8.
These frequently send out a long proboscis,  at the end
of which  is a dilated and elongated cilium, as  repre-
sented at 14,  15, 16, and 17.   This proboscis may be
in the center of  the mass of cilia, as at 15 and 16, or at
one side, as at 14 and 17.  It may be drawn  in, leaving
a nipple-like elevation, as at  10, or may disappear en-
tirely, leaving the  organism  oval  (8) or  spherical (6).
The proboscis often only partially disappears, or is only
partially drawn in,  while a constriction  occurs in the
form, as represented at 13 and 14.  It may  be simply
a large dilated cilium,  as at 17 and  18, or the cell walls
may go  out forming a more or less sharp protuberance,
as at  15; or the  walls may go still further out, forming
a more  or less fusiform  organism, as at 16.   The  cilia
are simple extensions of the cell-wall, are hollow, and
communicate with  the  cell cavity,  and can  be  dilated
and elongated at the pleasure of the animal.   The par-
asite consists of a simple sac, armed upon one side with
cilia, and enclosing one or more large nuclei, and many
smaller  germules of various sizes, as seen in the figures.
The young are  dveloped within the parent cell, and,
when mature, are discharged at the end of the organism
opposite the cilia, as seen at  18.  The parent becomes
quite large before  delivery,  and as the young one is
discharged, the  parent cell  becomes shrunken  and
shriveled  for a  time.    The  aperture soon,  however,
closes;  the wrinkled,  shriveled condition of the sac
walls  disappear, and the parent moves about again—
fresh, plump, and lively as ever. The cilia are in active
motion  during the  greater part of the life existence of 
126             INFUSORIAL CATARRH.

the animal, and  produce a most aggravating irritation
of the mucous surfaces they infest.  The young organ-
isms (i to 6) have a rolling, rocking, vibrating motion
from  side to side, making about one-third of a revolu-
tion on the  transverse axis at each oscillation.   The
more mature cells either vibrate  slightly  or  have a
tremulous motion, their cilia not moving at all,  as at 5,
but vibrate in different directions.
   " 'Symptoms.—After once obtaining a foothold on the
mucous surfaces  of the respiratory tract they multiply
rapidly.  At  first they attack  the  mucous surfaces of
the eye and nose, producing sensitiveness  of the parts,
which results in  a free  secretion  of tears,  and  thin
mucus, uncomfortable, and often intense paroxysms of
sneezing.   The  organisms  gradually travel from   the
nasal  surfaces down  into  the  fauces, larynx, trachea,
and larger and smaller bronchi.   As soon as they reach
the fauces there is a  burning heat  and irritation in the
parts  that excite  severe coughing.   This tendency to
cough constantly increases as they  and the irritation
gradually travel further and  further down  the air-pass-
ages.   When the larger bronchi  are  reached, a heavy,
hot, feverish pain is  felt in the parts they invade, ac-
companied by more or less flushes of heat and fever.
These symptoms  ordinarily and very naturally suggest
to the physician "catarrhal fever," under which head
the disease is usually placed, especially when occurring
during the winter and  spring.  This  stage is accompa-
nied by most intense paroxysms of coughing,  which
are frequently long and most painful, especially in the
morning. 
INFUSORIAL CATARRH.
127
   "'If the  parasite makes its  way  into  the smaller
bronchi and air-cells, asthmatic symptoms of a distress-
ing character often supervene, and the sufferings, already
almost unendurable, are much intensified.
   " 'The disease may continue a long time if the para-
site is not destroyed,  though  after a period, longer or
shorter, according to temperament  and constitution and
state of the health of the patient, the irritation assumes
a chronic form, and the sufferings gradually grow less
and less  until they disappear.  In irritable,  sensitive
constitutions,  the irritation  in  the fauces, larynx, phar-
ynx, and  bronchi becomes so great that the parts spas-
modically close  in attempts to swallow or to inhale air
charged with anything which excites the inflamed parts.
   " ' I have no  doubt, from what I have seen, but that
death may have  occasionally occurred  in the  acute
stage  of this disease from spasms  of the pharynx and
epiglottis.*
   " (Secretio?ts.—The cells of mucus first secreted from
the surfaces invaded are large  and  round, not differing
materially from  those  in health.   Soon, however, they
begin to  be  shrunken and  jagged, and  in  a  few days
many of them assume the appearance and character of
pus cells  (muco-pus).  The amount of  secretion dis-
charged from  the air-passages at  any one time is small;
yet the presence of  this small quantity creates so much
irritation that it is very difficult,  during the acute stage
of the attack, to  keep,  for any length  of time, from
coughing  and sneezing.  The secretion is thin, clear,
   * Probably it  is  the cause  of whooping cough occurring for the
eecond time.—E. C. 
128
INFUSORIAL CATARRH.
and watery at first, and  small in quantity, soon becom-
ing thicker and more turbid.   The cough is short and
somewhat painful, and the invaded surfaces feel irritated
and  hot.  The cough raises but a  small quantity of
sputa at each time, and  relieves the irritation and itch-
ing but for a few moments.
  " 'Whenever the parasites are developing rapidly on
the velum palati, most intense  paroxysms of coughing
are excited, which are long and persistent, painful, and
sometimes are accompanied by severe spasms of the
epiglottis  (whooping  cough).   Often  an irritation and
itching will be felt on one side of the throat only, ex-
citing constant desire to cough.  In  such  cases, the
irritation will always be on the side on which the nasal
passage is closed.   Under such circumstances inhaling
remedies through the mouth very often  fails to check
the coughing for but a few moments only.  By clearing
the closed nasal passage, and inhaling through it, the
coughing  and irritation  is soon checked.   The  rea-
son for this is, that the parasites are developing rapidly
on the posterior surface  of the wing  of the palate, on
the side of the nasal passage, and are constantly work-
ing down  into the larynx and pharynx on that side.
   '''Asthmatic Symptoms. —When  the parasites reach
the smaller bronchi and air-cells, especially in irritable
and sensitive constitutions, asthmatic  symptoms begin
to show themselves, and often become distressing and
almost unendurable.   Any excitement in the circulation
aggravates the symptoms.  The evening and night air
always increase the sufferings.
   " 'Season of Invasion.—This  disease is more common 
INFUSORIAL CATARRH.
I29
 from July to November in this climate than at any other
 season of the year,  though it may occur at any season.
 When it occurs during the  latter part of the summer
 and in early autumn, it is usually called "hay fever" or
 "hay asthma," and sometimes  "malarial asthma," of
 which class it is one form only.   During the winter it
 is frequently called "catarrhal fever," and with  very
 good reason, as the disease is always accompanied with
 fever and chilly sensations.   The face is usually flushed,
 head hot, and  pulse rapid, especially during the  acute
 stage.  How long the disease would continue  if left to
 itself I do not know, as I have never let a case run long
 without the use of  remedies  to destroy the cause.*
   " 'Contagion.—This disease belongs to those that may
 be transmitted from one  individual  to  another, though
 the transmission  is  not very readily accomplished.   In
 working very closely over about  sixty cases of the dis-
 ease, examining the sputa  under the microscope for
 many hours together in  each instance, and in several
 severe attacks devoting days to the examination, I have
 taken  the disease  only six  times  myself, and in two
 instances have transmitted  it to my  family.   I  have
 usually begun to feel symptoms of the presence of the
 parasite in from four to eight days after commencing to
 treat a case.   In all of my late cases I should state that
 I have taken the precaution to inhale a  solution of crys-
 tallized carbolic acid, one drachm to the pint of water,
 every two or three  hours, and to take twenty drops of
 tinctura ferri chloridi in a tumbler of water two hours
   * The writer found himself to get well  without treatment in a week
or ten days.—E. C.
                         9 
130             INFUSORIAL CATARRH.
 after each meal.  This course has  lately protected  me
 from taking the disease.*
   "'Name of Disease.—I  have given this disease  the
 name that stands at  the head of this paper.  It has been
 given after carefully studying for over six years, with
 great interest, the  symptoms and  peculiarities of  the
 complaint.   During that time I have treated about sixty
 cases of  "infusorial catarrh" and  asthma (now, Janu-
 ary,  1878, about  1,000), and made over one hundred
 drawings of the  parasite,,eighteen  of which are given
 in the accompanying plate, f
   " 'Treatment.—All means  ordinarily used for colds
 and  coughs are  worse  than  useless  in  this disease.
 While they tend to  get the system out of order,  they
 do not retard the development  and progress  of  the
 cause.  The only remedies that do any good  are  such
 as either destroy or retard the growth and reproductive-
 ness  of  the  parasite.    Fortunately,  we  have  many
 agents belonging to this class, among which are carbolic
 acid, tinctura ferri chloridi, sulphate of quinia, sulphuric
 acid, sulphurous acid, nitric acid, hydrochloric acid, etc.,
 all of which  remedies should be in  solution with suffi-
 cient water, so that  they can be  inhaled  without pro-
 ducing irritation.   The inhalation should be made freely,
 and  as often as every hour or two.  In addition to  in-
 haling, I  give two grains of  sulphate  of quinia every
 four hours, and twenty drops tinctura ferri chloridi in a
glass of water, morning, noon, and  evening.  It is sur-
   * It is almost as contagious as measles in my experience.—E. C.
   t Naming always belongs to the discoverer.  Some seem to forget
this.—E. C. 
INFUSORIAL CATARRH.
131
prising how much  a single  thorough  inhalation  will
relieve a suffering patient.   If the sputa is examined
before  the  first  inhalation, and then again after it, a
remarkable difference will be  observed in the condition
of  the parasites.  Before  inhalation,  they are  all in
active motion; after it, if  thoroughly done, they  will
nearly all be found dead or motionless.  Occasionally
one will be seen that has either not been reached at all,
or has not received a sufficient dose to destroy life.  As
they develope in the follicles as well as  as on the plain
surfaces of the air-passages, it will be seen that frequent
inhalations  must be  resorted to,  or the parasites  will
soon  be as numerous as  ever.  By keeping up  the in-
haling at short  intervals  and  inhaling thoroughly,  the
parasites  have no  chance  to  get very  numerous,  and
soon the  follicles become permeated with  the inhaled
materials and the cause is  entirely  destroyed.  The
sufferings of the  patient  are much  relieved, or  almost
disappear in a short time after entering thoroughly on
the treatment.   In  fact,  they are almost entirely gone
in a few minutes  after taking the first inhalation.  This
shows conclusively that the parasite is the cause of  the
disease.*
   " 'Asthmatos Ciliaris (Salisbury).—I have  taken  the
liberty to give this  little parasite a name which, per-
haps, a more extended acquaintance may deprive it of.
It may be found  to  be  one  of the many  forms, that are
already described, that inhabit stagnant and running waters,
and under certain conditions fermenting organic matters.
The name here suggested will, however, answer present
   * This the writer unqualifiedly indorses.—E. C. 
132
INFUSORIAL CATARRH.
purposes.  The generic title is indicative of one form of
disease it causes, while its specific name is suggested
from the cilia with which it is armed.  The figures from
I to 18 represent the different forms  and shapes the
parasite  assumes during the different phases of its ex-
istence.  They are magnified from  300-500 diameters.
Fig. 18 represents the mode in which  the parasite re-
produces and discharges its young.  The young animal
grows within the parent cell, and when mature, is dis-
charged at the posterior part  of the organism.   In fig-
ures 7, 8, 14,  15,  16, and 17,  are  seen  the young cells
inside the parent cell.   After the  young is discharged,
the  parent  soon begins to assume a more  plump ap-
pearance, the opening closes up, the wrinkled,  shriv-
eled condition passes away,  the  cilia  become active,
and  the organism soon assumes the freshness, activity,
and  vigor it had previous to parturition.'
   "Second Testimony.—1877, June 20, the writer,  while
visiting Dr.  Salisbury, at Cleveland, Ohio, expressed a
desire to  see the parasite just described, if possible.
This day Dr. Salisbury stated that he felt some of the
symptoms, and that he  might have the disease.  He
spoke doubtfully, and would not be positive until after
a physical exploration should reveal the actual presence
of the animal.  He then spat up some glairy, tenacious
mucus from  his pharynx, in which small, whitish patches
appeared.   Some of these  were deposited upon a glass
slide and covered with a  suitable cover.  The  object
was placed under a microscope two-inch eye-piece and one-
fifth objective of superlative excellence.  It was a Spencer.
Apartment lighted by one window open to the northeast. 
INFUSORIAL CATARRH.
133
  "The first observation  showed a dead protoplasm,
globar,  with motionless feet or roots on the part, like
figure 5.
  "The second observation of another specimen  of ex-
pectoration showed several young ones of globar  shape,
with beautiful  cilia, whose length equaled the diameter
of the body of the animals.  One displayed a marked
rocking movement of rotation on its own center of one-
third of a circle, with a graceful  waving of the cilia.
  " Another specimen was observed where the wave
and rotation were less, but the  ciliary movement was
by a longer sweep to the right and left.   They were of
the size of a common  mucus corpuscle.  A few speci-
mens only were in the sputa  examined.  Sometimes,
the doctor said, the field is crowded with them.
  "June  21.—An examination  of the  sputa from Dr.
S.'s throat showed a dead parasite as large  as a dozen
of those of yesterday's examination.  It was distended
with many young protoplasms.  The writer then studied
the field and detected five other specimens of the small
size in a single field of the microscope.   They all were
actively swaying to and fro with graceful  ciliary move-
ments that  continued for a  long time.  I  asked Dr.
Salisbury  if he thought the disease would be found in
the East.   The  reply was in the affirmative.   'It  is
very common  everywhere, and it is only necessary to look
it up.'
  "After having thus unmistakably demonstrated the
presence  of the  parasite in  his oral  excretions, the
doctor then  partook freely of salicin, carbolic acid, and
quinine.  He was very much relieved of his hoarseness, 
134
INFUSORIAL CATARRH.
cough, suffused eyes, and discomfort, and only the next
day (June 22), on examination, a  few  parasites were
found, but none alive.
  "Third Testimony.—Mr. F.  N. Daykin,  a medical
student in Dr. Salisbury's office, thus wrote:
  "'Cleveland,  O., Sept. 1, 1877.  Dr. Cutter: Dear
Sir—Yours of July 8th was received and should have
been  answered, but was  mislaid while  I was studying
"infusorial catarrh," an  account of which I shall give
you.   On Sunday morning  (no date) there was a slight
irritation of the mucous  membrane of my nose, but it
could not be distinguished from a very mild cold, which
I supposed it was.   The irritation increased constantly,
and  on Monday morning the eyes also were inflamed
and sensitive to light.  At 10 a. m., used carbolic acid
solution with a nasal douche, which gave relief for half
an hour.   In the afternoon, the throat became sore and
a headache came on, both of which  continued through
the night.  On Tuesday morning,  the  headache con-
tinued, the eyes  were very sensitive and watery, and
the inflammation  of the nose  and throat was  worse.
After using salt and water  as a douche,  I came over to
the office and discovered the infusoria under the micro-
scope.  From that time I  used carbolic acid solution
about once  an hour until  evening,  and felt much re-
lieved.   Wednesday  morning my eyes  were natural,
throat only slightly sore, and nose  much better.  Car-
bolic solution continued until evening, when the irrita-
tion was hardly noticeable.  By Thursday morning the
infusoria had  reached  the  bronchial tubes  and  caused
some coughing, but no expectoration.  Nose and throat
• 
INFUSORIAL CATARRH.
135
but slightly sore.   Inhaled  carbolic  acid solution with
atomizer, which removed all irritation, but I began to
feel languid and tired.  Friday continued carbolic acid
and noticed some improvement, and by Saturday morn-
ing the irritation was all gone, though it was three or
four days  before the tired feeling  ceased and  I  felt
naturally.
   "'The  solution  used was about  half a drachm of
crystals of carbolic acid to the  pint  of water,  and half
an ounce  of glycerine, warm, as it  feels pleasantly in
the douche.  For the atomizer, one  drachm of acid to
one pint of water.
   " 'I had a nice time looking at the  animal, and saw
all  the forms,  but would have  liked to have photo-
graphed it  also.   Yours truly,     F.  H. Daykin.'"

  The specimens in Fig. 2 were drawn by  Prof. Paulus
F. Reinsch, of Erlangen,  who,  with Dr. Cutter, exam-
ined a number of specimens: 
I36               INFUSORIAL CATARRH.

                         Fig. 2.
ASTHMATOS  CILIARIS. Hatfield's case.  Drawn by Prof. Reinsch
   from life.
   1. Mature specimen.  2-4.  Young do.   5, 6, II, 14, 15. More
mature specimens.  13. In division.  7. Young cell inside near pro-
cesses.  8. Do.  moved to center.  9. Do. moved to upper part just
before escaping. 10.  The escaped young individual with moving cilia.
12. A specimen resembling Actinophrys sol.

  The following extract and cut are taken from a second
paper  of Dr.  Cutter's,  which appeared in  the April
number of the Virginia Medical Monthly of  1879:
   "In  the November (1878) number of this Journal  I
reported  the testimony  that I  had  on  this  subject.
Since that time the matter has assumed a grave aspect.
I ave  had hone  case to die; another case, with  asth-
matic  symptoms, is  expected to die; and have heard 
INFUSORIAL CATARRH.
137
of several other cases in the hands of my contempora-
ries  that  I have  every reason to believe were similar
cases that were also fatal.  I do not, then, write in the
interest of pure science alone, but for the sake of suf-
fering humanity, of which we ourselves are a part, and
with which we suffer or enjoy.
   "As a  clinical observer, I find that thousands, if not
millions, of our people are or have been suffering with
contagious  'colds.'  Some  get well  of themselves;
others are severe  cases;  some die.   I  believe that the
asthmatos ciliaris  is the cause, and  I think I have the
right to submit the evidence on which I base my belief,
with the  hope that the matter will receive that study
which, it seems to me, it deserves.   As it is, I can only
call  respectfully for  a  consideration of the  following
testimonies, not included in my former report,  above
referred to.
   "1. Dr. G. B. Harriman, my associate in micrology,
has exposed slides, covered with  glycerine,  in the  air
of infected districts,  and  tells  me that  he has caught
forms floating in the air identical with the asthmatos.
   "2. Dr. J. H.  Salisbury writes, January  14,  1879:
'Frequently I have found the  ashmatos ciliaris in the
mucous secretion  of the eyelids and nose before the
disease  has yet extended to the throat.  In fact, the
parasites almost always attack the  membranes of the
eyes and  nose first—unless it be in persons who habit-
ually breathe with the mouth open.'
   "3. (Condensed from the Boston Journal of Chem-
istry, November, 1878): W. Martin Living, of Arling-
ton Street, Cambridge, Mass.,  said  his one-and-a-half 
138
INFUSORIAL CATARRH.
year old child had  the  croup or lung fever.  I found
neither, but there was a severe harassing cough, copious
discharges  from the eyes and nose, flushed face, fever
systemic,  breathing free,  pulse  regular.   The  nasal
excretion contained an abundance of the living, moving,
rocking, and  still  forms of  the  so-called asthmatos
ciliaris.
  "The  passive inhalation of the nascent chloride of
ammonium (by means of an apparatus of the writer,
made by Codman & Shurtleff, of Boston) was given to
the child.  Some of the excretion was placed on  the
stage of a Tolle's stand with a one-sixteenth inch objec-
tive eye-piece for a condenser, and  exhibited the phases
shown in the cut.   Four persons saw the genesis. 
INFUSORIAL CATARRH.
!39
   "May 29, 1878, 10:40 a. m.  It gradually separated
 itself, as in the cut, until 11:23 a.  m., it got out of the
 field.  The gubernaculum then parted in the  middle.
 That part connected with the parent was drawn into its
 body, and that connected with the new individual was
 drawn into it.  After these changes occurred, Professor
 Reinsch came in.  He  said it was new to him, and de-
 sired to study the process further on  new specimens
 from the child.  It was seen at 8 p. m.   We studied the
 excretion for one  hour and found only one specimen.
 It was alive and had forty feet.   The child in the mean-
 time had been relieved and was playing about the room,
 though it was  late.   It was cured.   Next day further
 examination revealed only one specimen.  It was dead.
 The search was strict and very careful and disappointing.
   "The clinical lesson  I derived from this was  that the
 nascent chloride had killed the parasites.
   "4.  September  24, 1878,  1:05 p. m., a specimen from
 my own nasal excretion had its feet downwards on the
 lower surface of its oval body.   From the nearest  end,
 a  gubernaculum  extended  straight,  about twice the
 length of the body, with a young individual at the end;
 at 1:11 p. m., it turned  over, so that the feet were up-
 wards;  at 1:14 p. m., gubernaculum drawn up into two
 curves like the letter W; at 1:15  p.  m., into one large
 U curve; at 1:20 p. m., gubernaculum  straight  and in-
clined  at an angle of  135 degrees to the axis of the
body; at  1:23 p. m., while the straight gubernaculum
still  kept the angle,  the feet  began to disappear.  I
thought them drawing in; at 1:24  p. m., gubernaculum
the same;  feet now on the under side  once more;  at 
140
INFUSORIAL CATARRH.
1:25 P. M.,  gubernaculum now forms  an angle of 45
degrees with the body, which  moves towards the gub-
ernaculum;  at 1:26 p. m., new individual almost touched
the body; gubernaculum  curled like a crozier; at 1:30
p. m., body vertical; gubernaculum  elevated in a large
curve; at 1:35  p. m., gubernaculum thrown backwards
and  more  elevated.   A round  nucleolar body now
formed within."
  In closing his  paper Dr. Cutter offers the following:
  "Resume. — 1.  Testimony has  been submitted that
there is a parasitic animal, of a protozoic type, that is
found in the  secretions of the  respiratory tract  of per-
sons suffering from influenza, colds, catarrhs, and asth-
mas.   Dr. Salisbury, the discoverer, has observed over
1,000 cases.  Mr. Daykin reports one case.  Professor
Reinsch  reports two  cases in  one  individual.  The
writer  has observed about  100 cases.
  "2.  It is supposed to  be the  cause of the  disease
named because,  (a), It is infectious;  (b), Parasiticides
kill the animals; (c), With this  killing, comes instant
relief to the  symptoms of the disease; (d), Because it
is found, when it has been  carefully looked for, in this
class of cases, and not in other catarrhs.
  " [It is not claimed that all influenzae, colds, etc., are
caused by the animal in question.]
  "3.  The writer tries to connect the protoza with the
actinophryina found  in drinking water, because, (a), Dr.
Salisbury suggested  the idea; (b),  The  actinophryina
are morphologically identical;  (c), Similar forms have
nowhere else been found in nature, except in salt water;
(d),  Thousands  are  daily swallowed  in the drinking 
SYPHILITIC PHARYNGITIS AND RHINITIS.     I4I
water; (e), At the present time  they are abundant in
the water, and the disease abounds."
 SYPHILITIC  PHARYNGITIS  AND RHINITIS.

  The frequency with which syphilitic affections of the
nose  and pharynx occur make it  necessary that  they
should  be mentioned with  other diseases  of these or-
gans.   We shall consider the disease only in its second-
ary and tertiary forms, as primary manifestations rarely
present themselves in these localities.
  Symptoms.—The  first manifestations of syphilis in
the pharynx frequently escape the observation of the
physician on account of their  apparent insignificance.
However, if the  pharynx should be inspected at the
commencement of an attack of secondary syphilis, the
anterior surface of the  soft palate,  and possibly of the
pillars of the fauces, will be  found congested.  The
congestion may be confined to a single small spot, on
either side,  but  it usually appears in a  symmetrical
manner.  This condition may remain for a few days if
nothing is done to  arrest the progress  of the disease,
when the surface of the congested area gradually as-
sumes a grayish  color, which is supposed by some to
be characteristic  of the  specific nature of the disease.
These patches may appear on the tonsils, tongue,  and, 
 142     SYPHILITIC PHARYNGITIS  AND RHINITIS.

 in fact, on any part  of the surface of the membrane
 lining the nose, pharynx, or mouth.   They occur most
 frequently upon the velum, arches, tonsils,  and tongue,
and  rarely appear upon the  posterior wall  of the phar-
ynx, but often invade its lateral walls.   Occasionally
the orifice of the Eustachian  tubes become involved,
and the hearing will be more or  less impaired.
  The so-called mucous patches may remain almost
indefinitely without any material change in  appearance,
other than the gradual increase  in size;  and if proper
and  persistent  treatment is enforced they usually dis-
appear without further destruction  of tissue than the
superficial portions of the mucous membrane, while,  if
they are neglected, and even in some instances where
they are not, the deeper structures  become rapidly in-
volved,  and  ulceration and  sloughing ensue in a very
short time.   If the pharynx is examined at this time,
the site of the so-called mucous patches  will now be
occupied by an ulcer, the surface of which is covered
with thick creamy pus.  The edges of the ulcer are
ragged,  and the membrane for a considerable distance
out from it presents an angry scarlet hue, showing that
the inflammatory process is  going on actively.   If the
velum and uvula are involved to an  extent  sufficient to
interfere with the movements of these organs, the voice
will be materially changed.   Deglutition will usually be
painful,  and in some cases almost impossible.
  The history of the  case,  and the  existence  of other
symptoms, as the peculiar cutaneous eruption, enlarged
lymphatics in the sub-occipital region, will  confirm the
diagnosis. 
         SYPHILITIC PHARYNGITIS AND RHINITIS.     143

   These manifestations are frequently accompanied by
an elevation of temperature;  especially is the tempera-
ture increased  if  the attack is violent.
   If the nose is invaded the  attack may be so gradual
as to  escape the patient's notice;  the only subjective
symptom  being  that of  any ordinary catarrh.  The
catarrh becomes worse, and very soon tenderness in the
region  of  the  posterior nares, or in some part of the
cavity, will be noticed by the patient, and the secretions
become  offensive and occasionally  tinged with blood.
The appearances presented by the membrane are simi-
lar to those described as occurring in the pharynx at
the corresponding stages.  If the  periosteum or the
perichondrium  be affected there is  usually a dull, heavy,
aching pain in the nose, which is more severe at night.
When the bones are carious and necrosed, the sensation
received through a probe is the same as that  produced
by diseased bone in other localities.
   Prognosis.—The prognosis of syphilitic pharyngitis
and rhinitis  is favorable in most  cases as regards life,
but the symmetry of the parts can  not always be pre-
served, even with the  most  judicious  management.
The structures likely to be  destroyed are the velum
palati, uvula, spongy bones, and septum.
   Treatment: The treatment  in this, as in other forms
of syphilis, is in  the main constitutional.  The selec-
tion  of agents for internal  administration should  be
made with  great  care, as much harm may result  from
the use of improper drugs.   It is safe to say that  all
debilitating agents are  injurious.   The most effective
remedy is the iodide  of potassium.   It should  be ad- 
 144     SYPHILITIC PHARYNGITIS  AND RHINITIS.

ministered internally in full doses until some perceptible
impression is  made upon the disease, or until iodinism
is produced.   The patient should be kept on the verge
of iodinism until the local manifestations have subsided.
In addition to the iodide, cod-liver oil, iron, and quinine
should  be administered.  Good, nutritious diet is  an
important adjunct.  Cleanliness of  the ulcerated sur-
faces must be insisted upon; and the same agents that
are used in cases of  catarrh for cleansing purposes may
be resorted to with benefit.  After thorough cleansing,
stimulant applications  should be made with  spray  or
otherwise, as  may be  indicated.   Solutions  of odine
crystals, half drachm to a  drachm to the ounce  of gly-
cerine, or solutions of similar stimulating character, usu-
ally prove most efficient.   Caustic applications are not
indicated.  The external manifestations of syphilis are
but evidence of a constitutional dyscrasia, and no amount
of cauterization can be of any benefit; on the contrary,
may prove detrimental to the chances of recovery.


Case XXIV.—Syphilitic  Pharyngitis and  Laryngitis,
  terminating in recovery, with preservation of the func-
  tions of all the organs involved.

  Mr. G----,  aged 21,  white,  clerk,  consulted me May
26, 1879, and said that  several months previous he had
contracted syphilis,  and that the primary sore  healed
up after a considerable time had elapsed, and that there
had been no secondary  manifestations until within three
or four days  preceding his visit to me.  There was a 
         SYPHILITIC PHARYNGITIS AND RHINITIS.      145

gray-colored spot in the roof of the mouth, on the left
of the median line, about three-fourths of an inch in
diameter.  There were several small ones on the tongue,
tonsils, and arches of the soft palate.  The vocal chords
were  of  a dusky, red  color, and  the  voice was harsh
and rough.  The  epiglottis was also  very  much con-
gested.
   Treatment:  The iodide of  potassium  was  ordered
in full doses every four hours,  until  iodinism was
produced.  Then the dose was lessened, and the patient
kept  constantly  under  its  influence.  The  mucous
patches in the mouth were touched once  a day with  a
solution of thirty grains of iodine  crystals to the ounce
of glycerine.  July 2, 1879, the vocal chords were almost
normal in color, the epiglottis was but  little congested,
and the  mucous patches were all closed except one
about the size of a split pea.   The patient was ordered
to continue the iodide  in moderate doses.  I saw him
the first of November,  1879, and there  was no breach to
be seen  anywhere in  the mouth  or pharynx,  and the
larynx presented a healthy appearance.


Case XXV.—Syphilitic Pharyngitis, with partial destruc-
   tion of a portion of  the soft palate  and uvula, with
  permanent alteration in the voice.

   Susan C----, aged 24,  white, was admitted  into the
Louisville City Hospital in the spring of 1878.  At the
time she  was suffering with secondary syphilis, which
had invaded the throat.  The pharynx was inflamed,
                         10 
I46     SYPHILITIC PHARYNGITIS  AND RHINITIS.

with several small ulcers on the surface of its walls.
The soft palate had a small ulcer on its anterior surface,
to the left of the median line.  There was  a purulent
discharge from the nose; but no visible breach in the
Schneiderian membrane.  The sense of smell was im-
paired to a limited extent.
   Treatment:  The  ulcers were  touched  with a  half-
drachm  solution of iodine (see section on Therapeutics,
Page 57) once a day.   The iodide of potassium was
freely administered internally.   Under this  treatment
the disease was arrested and the throat was  apparently
almost  well.  The patient  left the  hospital and re-
mained  absent for about six  weeks, at the end of which
time she returned in a much worse condition than when
first admitted.  There was a large ulcer on the anterior
surface of the palate at  the site of the former one; the
uvula was also extensively  ulcerated.  No amount of
local or constitutional medication seemed to  have the
least influence  over the  disease.  The ulceration  con-
tinued  until  the  soft palate  was completely divided
diagonally downwards  and  outwards to the left; and
the uvula cut almost into about one-fourth  of an  inch
from its lower extremity.   After  this the  ulcerative
process  abated, and there was no further destruction of
tissue.   The iodide of potassium was pushed to its full
extent, and  the ulcers healed in a comparatively short
time, leaving a cleft in the left side  of the  palate and
the end  of the uvula hanging by a mere shred. 
SYPHILITIC PHARYNGITIS AND RHINITIS.     147
Case XXVI.—Syphilitic  Pharyngitis and Rhinitis,  with
         loss of the vomer and turbinated bones.

  Charles S----, aged 44, an  inmate of the  Louisville
City Hospital, was  sent  to me May 24, 1879, to nave
his  nose examined.   He stated that he had contracted
syphilis in the early part of 1869, and that the disease
manifested itself by the  presence of a single sore on
the genitals.  The primary lesion soon disappeared, and
there was no further disturbance  until February,  1878,
at which time the pharynx  and  larynx were invaded.
He was  then admitted to the hospital,  and remained
there for a time and  improved considerably.  He left
and did  not  return  for several months.   In  the mean-
time the disease had made rapid progress;  the struc-
tures of the pharynx had become  invaded and the
patient's general health was much impaired.   The ears
were  both inflamed; one was suppurating,  the  other
was painful, with the drum cavity full of fluid.
  Treatment: Tonics and the iodide of potassium were
administered internally, with nutritious diet.   The drum
cavities were cleaned out by  the catheter and air-bag,
and a solution of ten grains of  carbolic acid to the
ounce of water was blown into them.  Stimulant appli-
cations were made to the ulcers in the pharynx.  This
plan of treatment was continued for several weeks, with
some improvement, particularly in the ears  and  phar-
ynx.  The general health did  not improve, but, on the
contrary,  he continued to fail, and finally complained
of pain in the left lung, which was examined  and found
to have a tubercular deposit in its apex.  In July,  1879, 
I48     SYPHILITIC PHARYNGITIS AND RHINITIS.

the bones of the nose began to drop out, and by Decem-
ber, 1879, they were all removed.  After the bones were
removed the  membrane healed up, and the foetid odor
was no longer present.   The loss of the bony structures
of the nose caused it to sink down and become very
much flattened.  The voice was necessarily changed.


Case XXVII. — Syphilitic Rhinitis, with loss of the vomer.

   Mrs. K----, aged 39, white.  In the spring of 1875
she consulted a physician in  regard to her nose.  Pie
ascertained that she had  contracted syphilis from  her
husband about  one year pseviously.  He prescribed
for her, giving the bichloride of mercury and the  iodide
of potassium  in  combination.   This treatment  was
kept  up for  eighteen months,  with  little or no im-
provement.   In December,  1876,  the vomer was lost.
October  17, 1877, the  patient was sent  to me by her
attending physician.  At this time the membrane lining
the nasal cavities was  inflamed and  thickened; there
were  small abrasions at several  points, which were in-
clined to bleed at  the slightest touch.  There  was  a
dull,  aching  pain in the region of the superior  turbin-
ated bones, which was more severe at  night than  during
the day.   The anosmia was almost complete, and had
been so for several  months.
    Treatment: The constitutional treatment  consisted in
the administration of large doses of the iodide of potas-
sium with bitter tonics.  Cleansing  applications were
made three times a day, and followed by a solution of 
         SYPHILITIC PHARYNGITIS AND RHINITIS.      149

ten grains of hydrate of chloral, two drachms of glyce-
rine, and six  drachms  of water.  In a  short time the
nocturnal pain in the nose disappeared and the offensive
odor was very much lessened.  The iodide was  kept
up for a year,  during which time the patient was almost
constantly under its influence.  The local  medication
was  not varied.   In November, 1878, the patient was
free from all pain and inconvenience, and there was no
active  change going on in the region of the nose and
pharynx.  She was now discharged, with orders to con-
tinue the iodide in moderate doses for several months.


Case XXVIII. — Syphilitic Pharyngitis and Laryngitis,
   terminating in recovery, with complete restoration  of func-
   tion in all the diseased organs.

   Louis S----,  aged 23,  white, occupation baker, ap-
peared  at the  clinic of  the Kentucky School of Medi-
cine March 3, 1877.  In  August,  1876,  he  contracted
syphilis.  The initial sore healed  readily.  He stated
that about three or four months after the primary sore
had gotten well, an eruption made its appearance on the
surface  of the body and face, and that his throat  became
involved about the same time.  The vocal chords were
congested; there was an  abrasion  on each  tonsil;  the
uvula was inflamed and  oedematous; and  deglutition
was exceedingly painful.   The face was covered with
syphilitic eruption,  and there was a small  ulcer on one
of the lower eyelids.
   Treatment:  The end of the uvula was cut off; and a 
 150     SYPHILITIC PHARYNGITIS AND RHINITIS.

gargle of half an ounce of the bromide of potassium to
the pint of water was used three or four times a day.
The iodide of potassium was administered internally in
full doses after each meal and at bed time.  The acute
symptoms abated in the course  of a  few days; but,
despite all efforts, the disease continued until the poste-
rior wall  of the pharynx was invaded and a considerable
portion of the soft structures destroyed.  When the
disease became  chronic, a solution of  one drachm of
iodine crystals to the ounce  of glycerine was applied
once a day.   The iodide was increased until its physio-
logic  effects  were  manifested, and  the  patient  kept
almost constantly on the verge of iodinism.   Under
this line of treatment he was cured in four months,
without the impairment of any function.


 Case XXIX.—Syphilitic  Pharyngitis, Laryngitis,  and
                      Rhinitis.

  William H----, aged 27 years.   In February, 1878,
contracted a venereal ulcer, and at once placed himself
under the care of a physician.  The  sore healed in  a
short time.  On the 23d of  May he was admitted into
the hospital.  At that time  the  inguinal  lymphatics
were enlarged, without tenderness.  There was exten-
sive ulceration of the lateral walls of the  pharynx, the
vocal chords and epiglottis were inflamed, and  degluti-
tion painful.  His general health was very much reduced.
The debilitated condition, in all probability, was brought
about by the excessive use of mercury. 
         SYPHILITIC PHARYNGITIS AND RHINITIS.      15 I

   Treatment: Iodide of potassium was given, beginning
with ten-grain doses, after each  meal and at bed-time.
The local medication consisted of cleansing fluids, such
as fifteen grains of bromide of potassium,  or muriate
of ammonia, to the ounce  of water, or equal parts  of
whisky and water, applied  with a  spray apparatus.
After cleansing the ulcers, they were touched daily with
a solution of iodine crystals, one drachm to the ounce
of glycerine.   The dose of the iodide was gradually in-
creased to thirty grains.   Under this treatment the man
improved rapidly, and left the hospital in August almost
well.   In November he returned decidedly worse than
at his first admission.   The vocal chords and epiglottis
were in a state of ulceration.   There was a large ulcer
in the base  of the tongue, extending on to the epiglot-
tis and entirely around its free border.   There was also
an ulcer about one  inch in diameter on the  posterior
wall of  the  pharynx.   The lining of the nose, the face,
and scalp were full of syphilitic ulcers; in short, he was
a complete wreck, scarcely able to  swallow the most
bland fluid.   The  iodide  of potassium was  given  as
before.   The local treatment did not differ materially
from that practiced in his first attack.   He  was dis-
charged cured in August, 1879.


           Case  XXX.—Syphilitic Rhinitis.

  Mary W----, aged  26, white, consulted me April 2,
1880, and stated that her nose had been sore  for three
weeks.  There was a  ragged ulcer on the left side of 
152     SYPHILITIC PHARYNGITIS AND  RHINITIS.

the septum, near  the floor of the nose, running hori.
zontally backward.  Its vertical diameter varied from a
fourth to half an inch; the horizontal diameter was fully
an inch.   The cartilaginous and osseous structures were
not invaded.   There was a simple abrasion on the cor-
responding surface of the right side.
  Treatment:  The iodide  of potassium was adminis-
tered in ten-grain doses after each meal and at bed-time,
until  its physiological effects were manifested.   The
patient was kept just short  of iodinism for six weeks,
at the end  of which time the ulcer and abrasion had
entirely closed.  The local medication consisted  in the
application of a solution of iodine crystals,  one drachm
to the ounce  of  glycerine.   The  iodine was applied
every third day.
f 
INFLAMMATIONS  OF THE DRUM CAVITY.     153
CATARRHAL  AND  PURULENT  INFLAMMA-
        TIONS OF THE DRUM CAVITY.
   Catarrhal  and  purulent diseases  of the  tympanic
cavities are of such frequent occurrence in connection
with naso-pharyngeal catarrh that a work like this would
be incomplete without  a brief notice of the subject.
About two-thirds  of  all the cases of acquired deafness
result from catarrhal inflammation of the drum cavities,
the remainder occurring as the sequelae of the exan-
thems and other causes,  as traumatic injuries, etc.
   Considering that the ear is an organ of special sense,
and that the disease or diseases which are most destruc-
tive to its organism and functions  are, in the  majority
of instances, curable, we ought certainly resort to any
reasonable means  to prevent so sad an affliction.
   Catarrhal inflammation  of the tympanic cavity most
usually occurs as a  secondary  affection, by extension
from the nose and pharynx.
   The symptoms of acute aural catarrh, or what is termed
"earache,"  are so characteristic that they point directly
to the  seat  of the disease in adults, while in children,
who are unable to speak, the diagnosis is often difficult.
Pain is the most prominent symptom.   It is almost in-
tolerable, and often so severe as to cause adults to shriek
and tremble.   In children the  affection  is  frequently
mistaken  for  some  brain  lesion.   There  is  always a
sense of fullness  about the ear,  with tinitis  aurium. 
154     INFLAMMATIONS OF THE DRUM  CAVITY.

There is usually some heat about the external auditory
canal, with more  or less vascularity of the membrana
tympani.  The congestion may be so  great as to pre-
vent the recognition of a single vessel, the membrana
tympani presenting almost a scarlet hue.  This is typi-
cal, and may vary  from the scarlet hue to a simple
blush.   If the disease has  progressed  a few hours,  the
membrana tympani  is often found bulging outward into
the external auditory canal, presenting the appearance
of a little bleb, with a  number of small arteries cours-
ing over its surface.  This bulging of  the drum  mem-
brane is caused by  an  accumulation of mucus within
the tympanic cavity, which, by  the undue  pressure that
it exercises upon the delicate nerves supplying the tym-
panum,  is one of the prime causes of the intense pain.
Hearing is more or less  impaired in  all cases.   The
closure  of the Eustachian tubes accounts for the accu-
mulation of mucus within the tympanum.
  Febrile symptoms are present in many cases.   They
are usually more marked in children than in adults.
  The causes of acute aural catarrh are numerous.  In-
flammations of any kind  that  affect  the pharyngeal
cavity are  liable and do frequently extend to the tym-
panum by continuity of surface.   This  is the manner in
which the majority of inflammations  of the tympanum
occur.   It is  a rare thing for a  catarrhal  inflammation
to originate within the drum cavity.  It usually invades
that organ by extension.  The  same is true of the ex-
anthematous  inflammations, which are  also among the
common  causes  of acute  otitis  media.   The  nasal
douche, as used in  the treatment of nasal catarrh,  fre- 
        INFLAMMATIONS OF THE DRUM CAVITY.      155

quently excites the already inflamed surface and causes
the inflammation to extend  up the Eustachian tube to
the middle ear.  The prognosis of acute catarrhal otitis
media is generally very favorable where the proper plan
of treatment is  pursued.   If there  has been an accu-
mulation of mucus in the tympanum,  and relief is not
obtained within  the first forty-eight to sixty hours after
the attack, ulceration and perforation of the membrana
tympani is almost  certain to  occur, and it is no longer
catarrhal otitis, but muco-purulent.   When this occurs
the prognosis is not so favorable, as there is a possibil-
ity of the drum membrane remaining perforated or thick-
ened, and the power of hearing more or less impaired.
  This form demands the immediate attention of some
one skilled in the treatment of aural affections; but like
most other disease of the ear, it is too often neglected.
The local  treatment for the  relief of pain should con-
sist  in the constant application of  warm water to the
ear.   This is best  done by means of a piece of rubber
tubing,  with one end  placed in the external auditory
canal, and the  other  attached to  a vessel filled  with
warm water,  and elevated above the level of the  ear.
With this arrangement a continual stream can pass  into
the external  canal.   Leeches to the tragus is certainly
a means of obtaining relief  equal to any.  A solution
composed of two grains of the sulphate of atropia and
six of the sulphate of  morphia to the ounce of water is
one of the very best medicated lotions for the relief of
pain in the middle ear.   It should be used with caution
on  small  children,  as  it  may be absorbed and produce
poisonous effects.   If  there is perforation of the mem- 
 I56        MUCO-PURULENT OTITIS MEDIA.

brana tympani it should not be used.   Paracentesis of
the drum membrane is demanded where the bulging of
the drum and head  is so great as to threaten perfora-
tion.  This should not be done  until  the  Eustachian
catheter  and air-bag  have been  sufficiently tried.   In
many cases the  current of air that is  passed  through
the catheter opens the closed tubes, forces  the mucus
out, and gives  prompt relief by thus evacuating the
drum cavity.  If necessary,  opiates may be given  by
the mouth or hypodermically for the relief of pain.
  In the absence of the air-bag or catheter, if the pa-
tient be  an adult, relief may  be occasionally obtained
by practicing Valsalva's method of inflating the drum
cavity.   Spontaneous rupture of the drum  membrane
is dangerous, because it is more extensive than is nec-
essary.   When  it is  desirable to perforate  the  mem-
brane in  cases  of acute catarrhal  inflammation,  the
opening  may  be made in the most prominent part of
the protrusion.  A small, sharp-pointed knife or a cat-
aract needle will suffice to open the membrane.
  The next of these—muco-purulent  otitis media—is
simply a  combination of the catarrhal and purulent form
of the disease, being too severe on the one hand to be
considered catarrhal,  and not violent  enough  on the
other to be characterized as  strictly purulent.   The
causes are the same as those of catarrhal  otitis  media,
or it is better considered one of the results of that form
of the disease.  The pathological  changes  of the two
are quite different.   In the former there is  no disinte-
gration  of tissue—simply a hypersecretion  of mucus;
while in the latter the disintegration of connective  and 
MUCO-PURULENT OTITIS MEDIA.         157
other tissues  is well marked.   There  is generally  an
absence of febrile symptoms, because the fever is always
irritative, unless there is some complication, and as soon
as the tympanum  is evacuated the source of irritation
is removed and the fever subsides in eight or ten hours.
  The membrana tympani does not always undergo de-
structive changes  sufficient  to  cause  perforation.   In
cases of this kind the contents of the tympanum pass
out  through  the  Eustachian  tube.   The  subjective
symptoms  are the same as those  of  catarrhal otitis
media, but in  a more aggravated form.  The objective
symptoms are different.   When perforation of the mem-
brana tympani is  threatened by ulceration, as it most
usually is, the  surface of the drum  head presents a
"boggy, sodden, or swelled appearance."  The prog-
nosis is  less favorable in this  than catarrhal, because
of the destruction of tissue.  The drum  membrane is
more liable to become thickened and remain so,  and, in
consequence of  this, audition is more or less impaired.
The treatment of  this form  should be  the same  as that
of catarrhal until  perforation takes place.  The most
important point to be considered is thorough cleanli-
ness.  For this purpose the catheter and air-bag  are the
most efficient.   The syringe can do no more than assist
in cleansing the external auditory canal.  The probe
and  cotton wool will  answer the place  of the syringe,
and  is much more  easily managed.
  The medicaments to be  used in cases of this kind
need not be numerous.   A solution composed  of car-
bolic and tannic  acids, each  five grains to the ounce  of
water,  is certainly  one among the best agents that can 
158
PURULENT OTITIS MEDIA.
 be applied  in this form of the disease.  Four or  five
 drops should be blown  into the tympanum, by means
 of the catheter and air-bag, once in twenty-four hours.
 Solutions of sulphate of zinc, sulphate of copper,  and
 nitrate of silver, from one to three  grains to the ounce
 of water, may be used in the same way as the solution
 of carbolic  and  tannic acids.   The strength of any of
 these may be increased as the disease advances.
   In purulent otitis media, which is a still more violent
 form of the disease than either of the above, the disin-
 tegration of tissue is very rapid.  The membrana tym-
 pani soon melts away and the lining membrane of  the
 whole drum cavity becomes more or less involved, and
 if the disease is  not  checked  it invades the deeper
 structures of the tympanic walls and may reach the in-
 ternal ear and brain.   In the majority of cases it may
 be considered an advance  of  the  muco-purulent,  or,
 more properly,  one of  its results.   I believe I may
 safely say that this is the  case  in most  all instances
 where it  is not due to  some  traumatic  injury.  The
 symptoms are much the same as those of the muco-
 purulent form of the disease, until  perforation of  the
 drum membrane occurs.
   The discharge is more profuse and strictly purulent.
The febrile  symptoms are  usually about  the same as
those occurring in the muco-purulent form.  They may
or may not continue after perforation of the drum mem-
brane.   If the disease  continues to invade  the deeper
structures of the tympanic walls  and make its way to
the brain, the febrile symptoms will continue in a more
or less aggravated form. 
PURULENT OTITIS MEDIA.            159
   The prognosis is rendered less favorable in proportion
to the amount of destruction that takes place within the
tympanum  and  its walls.   Where  the treatment  is
prompt, energetic, and conducted in  the proper man-
ner, its  termination  is most always  favorable.   Any
neglect renders the disease liable to  become  chronic.
Then its cure is much more difficult.
   The local treatment is the same  as that of muco-puru-
lent otitis media.   It may be necessary to use constitu-
tional  remedies.   At all events  the  bowels and skin
should be kept in good condition, and the patient take
plenty of good diet.  In  our Southern country it  is
necessary to keep on the look-out for malarial compli-
cations.  If they should occur, administer quinine freely.
   Lastly, for consideration, is a form of otitis  media
that has been termed "dry catarrh," and is  known as a
proliferous or non-suppurative inflammation.  The dis-
ease is very insidious in its attack, coming on, in many
cases,  seemingly  without  any  cause  whatever.   It  is
frequently produced by extension  from the  pharyngeal
cavity by continuity of surface.  It is thought that bad
hygienic surroundings, with the want of proper food,
has something to do with  producing it.   Syphilis and
phthisis  pulmonalis  are  supposed to be  among the
causes of this affection.
  The pathological changes which  take place are varied.
In some cases there is simply a thickening of the mem-
brane lining the drum cavity and  the tympanal orifices
of the Eustachian tubes; in others there are bands of
adhesion formed, stretching across from one part  of the
tympanic  cavity  to another,  with anchylosis of  the 
i6o
PURULENT OTITIS MEDIA.
ossiculae auditus.   There may be hyperostosis of the
petrous bone, fatty degeneration of the tensor tympani
muscle,  and thickening of  the membrana tympani.
The symptoms are fullness about the external auditory
canal;  loss of hearing, which  comes so gradually; ver-
tigo is present  in many cases, but is not characteristic
of the disease.   There is one  peculiarity about persons
affected with it, and that  is many of them hear much
better when in a rapidly moving railway coach, or in
the midst of some similar noise, than persons whose
hearing is perfect.
  The  treatment of this form of otitis is both local and
constitutional.  Persons of  a strumous diathesis  are
often benefited by the use of the  iodide  of potassium
and other alteratives of a similar nature.   Constitutional
medication does but little good where the disease is due
to some  local cause: as in cases where it extends from
the pharynx.  Where there is congestion present, with
slight pain, the application of a leech to the tragus may
be of benefit in many cases.
  The  medicated  fluids that  may be used with  the
catheter  and air-bag  are  numerous.   Any of  the  fol-
lowing may  be applied: Corrosive sublimate, half grain
to the  ounce of water; sulphate of zinc, from one  to
three grains to the ounce of water; sulphate of copper,
the same strength  as the zinc; nitrate of silver, one
grain to  the ounce of water; iodine,  half grain, with
five grains of the iodide of potassium to the ounce  of
water.   These should be alternated,  and the treatment
kept up for several months. 
INDEX.
                                                            PAGE.
Acute epidemic catarrh...................65
Acute sporadic catarrh....................66
Anatomy..........................   9
Anterior rhinoscopy.....................36
Antiseptics.........................54
Anosmia..........................81
Arteries of the nasal fossae..................   13
Arches of the palate.....................'5
Arches of the palate continued................19
Astringents.........................54
Asthmatic symptoms of  infusorial catarrh............128
Asthmatos ciliaris......................X3J
Atomizers..........................4°
Atmospheric causes of catarrh................117
Azygos or levator uvulre...................2°

Bi-carbonate of soda................• • • • 5°-52
Bi-chloride of mercury....................58
Boston perfumer.......................4°
Bromide of potassium...................50-51

Carbolic acid........................54
Catarrhal syringe......................3^
Catarrh...........................64
Catarrhal and purulent  inflammations of the drum cavity.....153
Causes of acute aural catarrh.................*54
Causes of catarrh......................II{
Cephalalgia of catarrh....................8o
Chloride of zinc.......................59
Chlorate of potassa.....................6?-
Chronic moist catarrh....................?8
Chronic dry catarrh.....................io3
                                II 
162
INDEX.
                                                             PAGE.
Circumflexus or tensor palati.................20
Cleansing agents......................5°
Climate...........................64
Constrictor muscles of the pharynx..............16
Constitutional medication...................61
Complications of acute sporadic catarrh............7°
Contagion.........................*1'
Contagion of infusorial catarrh................129
Cough...........................81
Coomes' spray apparatus...................4°

Digital exploration of the  pharynx..............48
Disinfectants ........................5^
Dry atrophic rhinitis.................,  . .  . 103

Epistaxis..........................83
Errhines..........................53
Examination of the pharynx.................29

Form for clinical record...................49

Glycerine..........................58

Hard rubber spray producer.................4°
Hearing affected......................82
Holmes' Boston perfumer...................4°
Hydrate of chloral......................56

Illumination........................33
Insufflation or snuffing....................46
Infusorial catarrh......................122
Iodine...........................57
Iodide of potassium.....................62

Levator palati........................19
Lewin's inhaler.......................42
Local medication......................5° 
INDEX.
163
                                                              PAGE.
Microscopical appearances of the nasal secretions in cases of acute
    sporadic catarrh.....................70
Minute anatomy.......................22
Mirrors...........................32
Muscles of the soft palate...................19
Muriate of ammonia....................5°~63
Muco-purulent otitis media..................156
Nasal douche........................44
Nerves...........................13
Nitrate of silver........................55

Openings communicating with the pharynx...........18

Palato-glossus and palato-pharyngeus muscles..........20
Pain............................8z
Permanganate of potassa...................57
Pharynx..........................*5
Pharyngeal aponeurosis...................18
Position in examination....................3°
Probes and mops......................47
Prognosis of acute sporadic catarrh..............7'
Proliferous rhinitis......................104
Proliferous otitis media..............•.....159
Prognosis of syphilitic pharyngitis and rhinitis.........143
Prognosis of acute aural catarrh................155
Prognosis of purulent otitis media...............*59
Purulent otitis media.....................158

Regio-olfactoria.......................24
Rhinoscopic examination...................33
Rhinoscopic appearances in acute sporadic catarrh........69
Rhinoscopic appearances in chronic moist catarrh........84
Richardson's spray......................4°

Salicylic acid........................59
Schneiderian membrane...........    .......23
Secretions of infusorial catarrh................i27 
164
INDEX.
                                                             PAGE.
Season of invasion of infusorial catarrh............128
Sinus of  Morgagni......................17
Soft palate   ........................14
Sprays...........................40
Steam atomizers.......................41
Structures observed by anterior rhinoscopy...........37
Structures observed by posterior rhinoscopy...........34
Sulphate of copper.....................56
Symptoms of acute catarrh..................67
Symptoms of chronic moist catarrh..............78
Symptoms of infusorial catarrh................126
Syphilitic pharyngitis and rhinitis...............141
Symptoms of syphilitic pharyngitis and rhinitis.........141
Symptoms of acute aural catarrh...............153
Symptoms of muco-purulent otitis media............157
Symptoms of purulent otitis media..............158
Symptoms of proliferous otitis media..............160

Tinnitus  aurium.......................82
Tobacco  smoking......................121
Tongue depressors......................  31
Tonsils...........................21
Treatment of acute sporadic catarrh..............72
Treatment of chronic moist catarrh.  (See Climcal Cases from VI
    to XIII).......................87-101
Treatment of dry atrophic rhinitis...............104
Treatment of proliferous rhinitis...............106
Treatment of infusorial catarrh................130
Treatment of syphilitic pharyngitis and rhinitis.........143
Treatment of acute aural catarrh...............155
Treatment of muco-purulent otitis media............157
Treatment of purulent otitis media..............159
Treatment of proliferous otitis media.............160

Uvula...........................15
Yellow oxide of mercury
59 
INDEX.
I65
                INDEX  TO CLINICAL CASES.
                      Acute  Sporadic  Catarrh.
                           PAGE.                             PAGE.
Case I...........73   Case IV..........76
Case II..........74   Case V..........77
Case III..........75

                       Chronic Moist  Catarrh.
Case VI..........87   Case XIII.........96
Case VII.........89   Case XIV.........98
Case VIII.........89   Case XV.........99
Case IX..........91   Case XVI.........100
Case X..........92   Case XVII........100
Case XI..........93   Case XVIII........101
Case XII..........94
                       Chronic Dry Catarrh.
Case XIX.........107   Case XXII.........109
Case XX..........107   Case XXIII........no
Case XXI.........108
                Syphilitic Pharyngitis and Rhinitis.
Case XXIV.........144   Case XXVIII........149
Case XXV.........145   Case XXIX.........150
Case XXVI........147   Case XXX.........151
Case XXVII........148

                INDEX  TO  ILLUSTRATIONS.
Fig. 1...........3°   Fig.  8..........37
Fig. 2...........31   Fig.  9..........40
Fig. 3...........31   Fig.  10..........40
Fig. 4..........32   Fig.  11..........41
Fig. 5...........35   Fig.  12..........42
Fig. 6...........36   Fig.  13..........43
Fig. 7...........36   Fig. 14..........48
Cuts illustrating rhizopods, as described by section on Infusorial
    Catarrh....................124, 136, 138 
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                   CHEMISTRY.

Attfield...............................................Cloth, $2 50;  Sheep, $3 00
Fowne."...............................................Cloth,  2 75;  Sheep,  3 25
Witthaus' Essentials..........................................................  1 00
Tyson's Examination of Urine............................................  1 25


 MATERIA MEDICA  AND THERAPEUTICS.

Bartholow............................................Cloth, $5 00;  Sheep, $6 00
"Wood.......................,..........................Cloth,  6 00;  Sheep,  6 50
Kinger.............................................................................  4 50
Farquharson.....................................................................  2 25
Kiley..............................................................................  3 00
National Dispensatory...........................Cloth, $6 75;  Sheep,  7 50
United States Dispensatory .......................................Sheep,  7 50 
CLINICAL MEDICINE.
Flint ..................................................Cloth, $4 50;  Sheep, S5 50
Tanner....................................................................Cloth,  1 50
Bennett...............................................Cloth, $6 00;  Sheep,  7 00


            PRACTICE OF MEDICINE.

Flint..................................................Cloth, $6 00;  Sheep, S7 00
Bristowe..............................................Cloth,  5 00;  Sheep,  6 00
Robert................................................Cloth,  5 00;  Sheep,  6 00
Niemeyer, 2 vols..................................Cloth,  9 00;  Sheep, 11 00
Aitkin, 2 vols., best edition.........................................Sheep, 14 00
Fothergill's Hand-book of Treatment...................................  4 00
Hartshorne's Essentials.................Cloth, S2 63;  Half  Bound,  2 88


                        SURGERY.

Erichsen............................................Cloth, S8 50; Sheep, $10 50
Ashhurst............................................Cloth, GOO; Sheep,   7 00
Bryant...............................................Cloth, G 00; Sheep,   7 00
Gross...................................................................Sheep,  15 00
Stimson's Manual of Operative Surgery............'...........Cloth,   2 50
Heath's Manual.......................................................Cloth,   2 00


                      OBSTETRICS.

Playfair...............................................Cloth, $4 00; Sheep, $5 00
Leishman ............................................Cloth, 4 50; Sheep,  5 50
Cazeaux.............................................Cloth, 6 00; Sheep,  7 00
Roberts' Student's Guide............................................Cloth,  2 00
Barnes' Manual.................................................................  1 25


               PHYSICAL  DIAGNOSIS.

Loomis ........................................................................... $3 00
Da Costa  ............................................Cloth, $6 00; Sheep,   7 00

              DISEASES  OF WOMEN.

Thomas...............................................Cloth, $5 00;  Sheep, $6 00
Emmet...............................................Cloth, 5 00; Sheep,   6 00
Barnes...........................................Cloth, 4 50; Sheep,   5 50
Goodeli;..................................................................Cloth,  3 00
Duncan...........................................................................   1 50

                       CHILDREN.
Smith
Cloth, S4 50;  Sheep, $5 50 
    DISEASES OF SPECIAL ORGANS, Etc.

Coomes on Naso-Pharyngeal Catarrh...........................Cloth, $2 00
Burnett on the Ear...............................Cloth, S4 50; Sheep,  5 50
Browne on the Throat...............................................Cloth,  5 00
Cohen on the Throat.............................Cloth,  5 50; Sheep,  6 25
Flint on the Heart.....................................................Cloth,  4 00
Fothergill on the Heart.............................................Cloth,  3 50
Habershon on the Alimentary Canal.............................Cloth,  3 50
Allingham on the Rectum  .........................................Cloth,  3 00
Van Buren on  the Rectum.........................................Cloth,  1 50
Bumstead on Venereal Diseases .............. Cloth, 4 75; Sheep,  5 75
Van Buren & Key's Genito-Urinary Organs, Cloth, 5 00; Sheep,  6 00
Cutaneousand Venereal Memoranda.............................Cloth,  1 00
Stellwag on the Eye...............................Cloth,  5 00; Sheep,  6 00
Landott on the Eye.................................................„. Cloth,  3 00
Nettleship on the Eye ..............................................Cloth,  2 00
Ophthalmic and Optic Memoranda................................Cloth,  1 00
Murchison on the Liver..............................................Cloth,  5 50
Headland's  Action of Medicines..................................Cloth,  3 00
Loomis on Fevers.....................................................Cloth,  4 00
Hartshorne's Conspectus...........................................Cloth,  4 25
Neill and Smith's Compendium...................................Cloth,  4 00
                    DICTIONARIES.

Dunglison's Lexicon..............................Cloth, $6 50; Sheep, $7 50
Thomas'  Pronouncing..........................Cloth,  3 25; Sheep,  3 75
Hoblyn ...............................................Cloth,  150; Sheep,  2 00
Woods' Vest Pocket Lexicon ....................Roan, 75c; Tucks,  1 00
                  MISCELLANEOUS.

Parrish's Pharmacy ..............................Cloth, $5 50; Sheep. $6  50
Griffith's Formulary..............................Cloth,  4 50; Sheep,  5  50
Holden's Manual of Dissection....................................Cloth,  5  00
Cleveland's Dissector..................................................Cloth,  1  25
Wythe's Dose Book...........................Cloth,  1 00; Tucks,  1  25
Stewart's Pocket Therapeutics and Dose Book.......................  1  00
Leonard's Vest Pocket Dose Book..............Cloth, 75c; Paper,    50
Gerrish's Prescription Writing....................................Cloth,    50
Flint's Percussion and Auscultation.............................Cloth,    50
Fresenius' Manual of Qualitative Chemical Analysis......Cloth,  3  50
Holden's Medical and Surgical Landmarks....................Cloth,    90
Code of Medical Ethics.............................................Cloth,    40
Leonard's Code of Medical Ethics ..............................Paper,    25
Field's Origin and Insertion of Muscles .......................Paper,    10
Billroth's Surgical Pathology..................Cloth,  5 00; Sheep,  6  00
Cornil and Ranvier's Pathological Histology,Cloth, 5 50; Sheep,  6  50 
 
 
 
 
 

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