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DISEASES
THE NASAL CAVITY
                           2. Hi
             AND THE

    VAULT OF THE PHARYNX.
     translated from the german of

Dr. Carl Michel, of Cologne on the Rhine,
     WITH AN INTRODUCTION BY


E. L. SHURLY, M. U., and C. C. YEMANS, M. D.,


       OF DETROIT. MICHIGAN.
'4min
FIRST AMERICAN EDITION.
XreRs:/'
     DETROIT, MICHIGAN;

C. Jung, 2 50 Randolph Street,

        1877. 
wv
 hA{i23*
Entered according to Act of Congress in the year 1877, by C. Jung, in the
                Librarian of Congress, at Washington.
O. S. GuiiLEY's Steam Presses, Detroit. 
INTRODUCTION TO  AMERICAN EDITION.
   Monographs by distinguished specialists, wrought out by large
experience, develop many facts in pathology, diagnosis and treatment,
important for both the general practitioner and the specialist to know.
   This monograph by Dr. Michel is by no means an exception, and is
a valuable contribution to the literature concerning our most common
diseases in this northern latitude.
   We have carefully read this work of Dr. Michel in the original,
and also the translation of Mr. C. Jung, of this city.
   The translator has faithfully  done his  work, and  we think the
treatise has sufficient merit to recommend itself to the profession in
America.
   Dr. Michel has contributed much to our knowledge of pathology.
   His treatment has both novelty and success in its favor, especially
his treatment of Catarrh, Ozcena and Nasal Polyps.
   Certainly his removal of polyps by aid of the  galvano-cautery is
preferable to our method of removal by forceps
   Tearing a polyp from its attachment is a very painful operation,
having  often unpleasant consequeuces as  well as failure in curing
the patient.
   The anatomy is faithfully and carefully stated.
   We hope all who read the within will  have the pleasure to gain
some  knowledge,  which  will be helpful  in combating some  of the
most common and obstinate diseases, with which we  meet in every
day practice.
                                       C. C. YEMANS, M.D.
                                       E. L.  SHURLY, M. D.
  Detroit, Mich., Sept., 1877. 
 
PREFACE.
   When  I took up my abode here in Cologne, about six
years ago, it was my intention to confine myself exclusively
to diseases of the chest and the  throat.  But gradually this
field expanded, and I was induced to include the  nares, the
vault of the pharynx,  and  the organs of hearing.  I was
thus compelled to include one after another, because of their
close relations.
   The difficulties, which I had  to overcome, were not small,
and I was in a measure  obliged to be my own  teacher;  but
I was soon rewarded with extraordinary success in  healing
{Heilerfolge).  Soon I gathered  a large amount of material;
and I was also able to make a number of new discoveries,
regarding the knowledge and treatment of diseases in  the
nasal cavity and pharyngeal  vault.  To report these  is  the
object ot the following pages.
                               DR.  CARL MICHEL.
    Cologne ox the Rhein, February i, 1876. 
 
INTRODUCTION.
   It cannot be gainsaid, that heretofore the nasal cavity has been
treated with a disregard, to say the  least, which is  so much the
more strange in the face of the fact, hat it furnishes the natural
medium for respiration; that it serve  in one of the most import-
ant functions — breathing; that it is mdispensible  for  a pleasant
voice; that it is the organ of one ot our senses — of smell.
   In the text books the chaptei ok nasal diseases is soon hurried
over.  In  all,  the same  common presentations  of  " Epistaxis,
Nasal Polyps, Malignant Tumors, Bad Distortions (grobe Zerstoer-
ungen), and Injuries of the Exterior Frame," are crowded together
on a  few pages. Pathological anatomy, it seems, is seldom attended
to except accidentally, or else the  nature of ozcena for instance
would have been  explained long ago; and the incorrect views con-
cerning it would have been exposed.
   In practice it  is not at all customary  to  examine the cavity—
although the speculum is much easier to handle than the laryngo-
scope and the pharyngoscope.  Generally the point of the nares
is raised somewhat, and then the vague pronunciations are uttered :
" high up in the nares," or " deep down in  the nares."  It cannot
be wondered at, therefore, that the diagnosis  and therapeutics of
nasal diseases are in a mixed condition (im  Argen liegen—lie in
wickedness);  that scrofulous ulcers are still playing a  large role ;
that  the nasal douche, snuff water, and bathing in  salt water were
in many cases applied in  vain  or with but little  relief, and was
quite inadequate  in comparison with the inconvenience the patient
had  to go through.  Even Voltolini in his book, " the Application
of Galvano-caustic in the  Pharynx, Pharyngeal  head, and  the
Nasal Cavity, to which I owe my first impulse to  treat nasal dis-
eases, after describing the operation of nasal polyps, confines him-
self  to the remark,  that  on  the anterior end of  the  interior
turbinated bone a round tumor, having  the form of a pear, was
often to be seen in the exterior opening of  the nares.
   Schroetter in his laryngoscopic reports speaks in a few  words
of the treatment  of  ozcena, of chronic catarrh,  of  polyps, and 
8                      INTRODUCTION.
 Zaufal has described anomalies in the development of the turbi-
 nated bones, in the " Aerztlichen Correspondenzblatt, Prag, 1874."
    Besides this, I am not aware, that anyone has ever described
 the  nasal  diseases as  comprehensively and precisely  as  I have
 tried to do in this book; nor  has  there  ever  before  been such
 observation on  living subjects, and such results reached thereby,
 as I have described in the chapters on " Chronic Catarrh, Ozcena,
 Syphilis in the Nasal Cavity.'"'  In the chapter on  " Tumors " of
 the nasal cavity, I think, there is  also to  be found  so much pro-
 gress as to the diagnosis and therapeutics, that I had occasion to
 treat of the subject anew.
    I may also be allowed to mention, that since  Semeleder and
 Voltolini have  spoken of the nasal examination anteriorly, noth-
 ing has been published  in this regard;  and in comparison with
 what has  been  said by these  men, thus eminent  in the field of
 pharyngoscopic investigation, I  think my  directions for examining
 the  cavity will  be found more systematic and complete.  The
 number of diseased nasal cavities, which  I  have  examined in
 about four years,  is about  450; if I add 94 patients  who were
 troubled with hypertrophied pharyngeal  tonsils, and whose nares
 were also carefully inspected  and those, whose nares were found
 to be healthy, with an  affection of the throat,  I can say,  that I
 have at least examined  850  different  nasal  cavities  with  the
 speculum, aided by the  calcium light.
   The experience thus made, and the knowledge thus gained, I
 have tried  to record in the most condensed form. It was therefore
 also  necessary to confine the data of patients to  but a few cases,
 of the very great number which I have recorded.
   Nor did I deem it necessary  to add  an anatomy of the nose,
 because I could  have produced nothing  new, but  could at best
 have given a new version of what is already found in other works.
   But if  thus the book has  become  insignificant in size, I hope
 nevertheless,  that no blame or unfavorable prejudice will  be
 caused thereby.
   As to the  diseases of the pharyngeal vault, my observations in
part  corroborate those of Voltolini, Meyer,  Wendt,  but for  the
greater part they supplement  them, as I  show, that the pharyn-
geal  tonsil appears very  often hypertrophied in a moderate degree
 [mittlerem  Grade),  and  mention  the symptoms  {die  klinischen
Zeichen), and give direction for diagnosis with the rhinoscope, and 
INTRODUCTION.
9
for a treatment, by which the tumor  can be removed easily  and
without danger, even by those who have  not had much  practice
before.
   It would be better to apply the term rhinoscopy to examina-
tion with the speculum, whilst pharyngoscopy might describe that
with the mouth mirror.
   To the diseases of the pharyngeal  vault  some  observations
have been added concerning  the consequences upon the entire
organism, the voice, and the  speech,  which grows  out of the
obstruction  of the nares, and also its relation to hard hearing.
   Among the remedies the galvano-caustery takes the first place.
Whoever  will apply the same with a careful use of the speculum,
will  find  that it is  the  most  agreeable to the patients, and the
surest and quickest as to results. To show that I am not preju-
diced in favor of it, I  freely  confess,  that I would prefer an-
other  treatment, which had the same merits.   For as long as a
stream sufficiently strong for caustic purposes cannot be produced
in a dry way, inconveniences and disagreeable circumstances will
always be connected with the application of the galvano-caustery.
The instruments which I use are those recommended by Voltolini;
where I found it best to modify them, I have mentioned this in
due  time.   The battery is that of Middeldorf.
   Several times in the year I pour about  a  small teaspoonfull
quicksilver  into the  glass cylinders.  As the  battery works, the
quicksilver  rises on the walls of the cylinders; and if  thus the
battery is cleaned  immediately after  taking it apart, it takes but a
few moments—the quicksilver being rubbed off makes them shine
instantly.  But if there is a black spot, which yields slowly, the
cloth for washing  it is made wet  in  saltpetre or concentrated
sulphuric acid, then this spot will also yield by rubbing the cloth
over it a few times.  But it is necessary  to wash the acid  off with
water in order that it does not corrode.
   It is not necessary therefore to have a tray for the amalgama-
tion of the zinc-cylinder.  The charcoals are always covered with
water.  I always use the same cells (Tonzellen), though  the  bat-
tery  is used four or five times a day.  They are neither made wet
nor dry, as  formerly was thought necessary previous to every use
of them.
   If the acids were  not  too old, the current remained evenly
strong for about three hours, a fact  which I have always noticed.
        2 
10
INTRODUCTION.
After I had once become familiar with the batteries, which I have
constructed more than a thousand times—I use the galvano-caustery
also in the mouth and in the throat—it has never failed me, with-
out my being able to find the cause of failure and to remove it.
    The rules for direction may be given in a few words:
    If the acids are fresh *—have not been  used too often, if the
zinc cylinders are well amalgamated, greasy, shining, not  opaque,
blind, then the source  of the  current is  opened.  But if, never-
theless, the platinum glows not or but slowly, and the platinum is
made thinner with the hammer or the file, in case it were somewhat
thick, then the trouble must  be looked for in the  conducting.
Either the rings, which  contain the charcoals are not clean at the
inside, or the conducting wires  proceeding  from  them and  the
zinc contents (Zinkelementen)  are not clean, there  is too  much
quicksilver in the vessels, or the wires do not  come into  contact
with it, or the anterior vessels covered with copper are  soiled, or
this is the case with the exchange-pane ( Wechselscheibe).   Also the
shells {Huelsen) for the reception of  the conducting  wires  on the
exterior of the box,  or the pivots may be in a  state  of oxidation,
and thus incapable to conduct, the  surface on  the handle coming
in contact with them, is oxidized through much  use, or the con-
ducting wires touch somewhere.  Of the exchange-pans I always
use the one giving the strongest current—the pillar.

  * I renew the nitric acid after the batteries have been used from three to six times,
according as they have been used for a longer or shorter time.  It  must be  clear,  not
dark, blackish-green.  If it is relatively or entirely fresh, the conductors in  order and
the current not as it should be, the glowing heat weak, I pour about a teaspoonful of
concentrated sulphuric acid into the  cylinders (glasbehaelter)  and thus renew the
mixture of sulphuric acid. 
        EXAMINATION
                      --OF THE--

MSAL  CAVITY ANTERIORLY.
   I always use the speculum of Charrier, modified by Voltolini,
by which the nares are much widened.*   It is better than that by
Frankel, because being funnel-shaped  and  semi-cylindrical, it
catches up and  concentrates  the rays  of light.  My source of
light is generally the calcium lamp of Bruns.  The considerable
brightness of its light  makes examination  and operation easier
than the common  pharyngeal lamp, which, however, is also quite
useful.
   But  that sunlight is best calculated for a minute distinction of
colors, is self-evident.  The patient to be examined sits with his
head in the  common position.  If now light  i§ thrown into the
cavity  through the speculum by means of the  reflector, then the
eye falls in the first place on the anterior end  of the inferior tur-
binated bone at the  entrance of the bony cavity.  As the head is
gradually lowered toward the front, the inferior turbinated  bone
is inspected along the septum to the end of its choana.  A more
or less broad ray of  light falls in between the latter and the septum
upon the posterior wall of the pharyngeal vault.
   In swallowing, or in  giving  a sound, the   movements of the
latter are plainly to be seen, and a part of the  soft palate and the
inferior  end of the Eustachian tubes are often  to be  seen much
elevated.
   The free border of the inferior turbinated bone on an average
remains \ to § of a centimeter from the nasal floor.   The inferior
meatus  is completely  open to  view.  Sometimes  one can see
through under the posterior end of the turbinated bone into the
pharyngeal vault, but in most cases the crevice between it and the
nasal floor is too small for this.
*In this country QoodwiUie's is the best.—C. C. Y. 
12
EXAMINATION ANTERIORLY.
    The nasal floor, sometimes a little hollow from one side to the
 other, and always sloping posteriorly, is best illuminated with the
 head strongly bent forward.
    On the convex (superior)  surface of the  turbinated  bone
 isolated uneven spots are seen, which are caused by the roughened
 condition of the bone.   It can be inspected very well to the pos-
 terior part, where  the middle  meatus is too narrow and the turbi-
 nated bone descends too abruptly.
    As the head is bent backward,  the  concave (inferior) surface
 and the free border of the middle turbinated bone comes in sight.
 If the latter is to be inspected to its anterior end, then  it will be
 necessary to bring the head  completely into  the  neck.   It will
 then also be noticed, that this one  is a  few  centimeters  shorter
 than the inferior turbinated bone, that  it  appears  much  farther
 back of the anterior opening of the nares than the former.
    The turbinated bones (the  third being very small, and as a
 rule not  visible anteriorly,) are sometimes  flattened,  level; or
 again they have a  distinct shell form and spring  in  wide  arches
 from the side wall, in which case the concave  surface is broader
 and can be completely illumined.
    In the posterior part of the nasal cavity, especially in narrow
 nares, the border lines  of the turbinated bones run  across  each
 other on account of the middle turbinated  bone, which in extend-
 ing from before backwards, curves decidedly inwards.   In young
 persons the middle turbinated bone, hanging in its anterior portion
 perpendicularly over the nasal floor, appears to originate from the
 roof instead of the side wall of the nasal cavity.
   Directly over the anterior end of the middle  turbinated bone
 the rounded acute angled roof of the nasal cavity  is to be seen,
 but generally only  the anterior part of it; because, as a rule, only
 a small crevice remains free between the middle turbinated bone
 and the septum;
   In a few cases,  where the patients were  suffering  from  ozcena,
 and had very wide cavities, in which the third turbinated  bonesi
 sitting posteriorly upon the middle ones, were also largely  devel-
 oped, I could clearly inspect the roof of the nasal cavity from the
 front to the choanes.
   In  these cases I saw about i£ to 2 cm. above  the  choanum
(generally on the left side) a round hole, or a crevice,  through
which the probe passed into a cavity, which could be nothing else
but the cavity of the sphenoid  bone.   The roof of the  cartila-
ginous nose of course lies free before one's eyes. 
EXAMINATION ANTERIORLY.
13
   The septum is open to inspection nearly in its  entire extent,
except the small part pertaining to the superior meatus, and gen-
erally the border of the choanes, which can only  be illuminated
in broad nasal passages.  It is, as is well known, often bent, in the
cartilaginous part as well as in the bony one, and in accordance
with this concavity, or the number and size of bone projections
or edges from the septum, or the crista nasala on the nasal  floor,
one nasal passage is narrower than  the  other, and can be  less
completely inspected.
   The color of the mucous membrane is  rose-red, in spots  yel-
lowish, on account of  the bones  and cartilage shining through.
If one inspects closely, he  finds,  that the red color is brought
about by numberless point-like plexi, which are very close to  one
another.
   Anteriorly on the septum a small light red blood vessel  can
often be traced  to  the nasal floor.  The concave surface of the
middle turbinated bone, which can be seen in most cases, always
has the light color of  the bone showing through.
   The mucous  membrane is  smooth and shining, lies more or
less closely attached to the nasal floor, the septum, and the mid-
dle turbinated  bone, which fact is demonstrated  by an examina-
tion  with the probe.  In  the same way the middle turbinated bone
is felt to be unyielding, bony; and  also, that  the  inferior  turbi-
nated bone on the convex (superior) surface, especially toward the
free  border, is more elastic, so that  one has to press it in more
deeply in order to  feel   the bone (in consequence of the greater
abundance of blood vessels in the submucous connective tissue.—
Kohlrausch).  The nearer one gets to the posterior end, the softer
it is  to the touch.
   The probing is felt very keenly, where the  mucous membrane
is sound,  not  loosened  or thickened.  During an examination
with the probe  it sometimes happens, that even  strong, healthy
men  suddenly  become  pale, unwell, and  half fainting.   Some-
times cough ensues. 
H
EXAMINATION POSTERIORLY.
EXAMINATION OF THE  CHOANAE-OPEN1NG OF THE
   NASAL, CAVITY AND THE PHARYNGEAL VAULT.
   With the rhinoscope, by which the posterior ends of the turbi-
nated bones  can be  distinguished  as  much as is necessary, the
examination of the nasal passages can  and  must be  completed.
Formerly I was accustomed to use  the  little  round  mirror  with
long handle, which  has been recommended by Vollolini.   It is
about ii to i% cm. in diameter, made of thick glass,  which has a
clear white (not a green) appearance on the  edge.   The handle
is  nearly in  the position of a right angle to the surface of the
mirror.
   Lately I have used the  rhinoscope, which  I  have especially
recommended for the study of the  Eustachian orifice, with  good
result.   First it is brought into the pharynx, then its surface is
arranged by pressure on an attached lever, so as to be  in the  right
position.   Let the space between  the  base  of  the  tongue  and
uvula be ever so small, there will be no gagging caused by touch-
ing these  parts, or by  pressure on  the tongue, which is further
prevented by the handle remaining stationary, while  the position
of the mirror is being changed.   The circumstance, that the  sur-
face of the mirror (i-J cm. in diameter)  can thus  be  placed quite
at a right angle, makes it possible for the entire posterior surface
of the soft  palate and the posterior ends of the inferior turbinated
bones of the nares often to be completely inspected, which other-
wise could  only be accomplished in exceptional  cases, where the
pharyngeal space is very wide.
   The patient  must open his mouth very wide, show his teeth,
push back his lips, keep his tongue in the mouth, breathe quietly,
and if possible not think of the examination.
   In  front  of the  uvula the tongue is held  down  with the
spatula,—sometimes it offers so little  resistance, that it can be
held down  with the unmovable handle  of the  mirror—and the
mirror is conducted past the  uvula at  its side,  or below in the
same manner, if the space is large enough, close  to  the posterior
pharyngeal  wall.  Touching the parts is to be avoided, but  espe-
cially the borders of the posterior palatal arches, which if touched
instantly produce gagging.
   As far as I know, it has been hitherto recommended by  every
one, that the image of the septum is  first  of all  to be found.  I 
EXAMINATION POSTERIORLY.
15
deem it easier, and more systematic, however, to begin with the
posterior wall of the pharynx, and from  there to examine the
pharyngeal vault.  {Cavumpharyngeal nasal.)
   If the surface of the mirror is at an obtuse angle (approaching
the right angle) to the posterior wall, then the latter appears  in
the mirror as a rose-red, damp-shining  surface.  The  more the
position of the surface of the mirror approaches an  obtuse angle
to the pharynx, the higher the eye ascends on the posterior wall.
Soon it is noticed, that the  surface  grows uneven, and one sees
either small shallow  depressions or small hole like  oval  or round
recesses, or smaller or broader open furrows not very deep.  They
mark the side of the pharyngeal  tonsil.  In the  normal condition
of this glandular bed (Druesenlager) the unevenness of the arch,
caused by it, is thus insignificant  and indistinct to the eye, while
the surroundings of  these recesses are elevated so little, the two  or
three longitudinal  edges  causing these furrows, are  thus low
that one has to look sharp in order to distinguish them.
   A little movement of the mirror toward the  right or  the left
brings to view  the place, where  the posterior meets  the lateral
wall.  Here is the fossa of Rosenmueller  with the anterior  border
thereof, the Eustachian tube, which is sometimes  connected with
the bottom of the fossa,  or  the  posterior wall, i. e.,  the lateral
part thereof, the pharyngeal  tonsil, by short bridges  of  mucous
membrane.  If now the handle of the mirror is lowered but very
little, the eye glides over the projection of the  Eustachian tube
into the yellow-white orifice of the same.
    Again the surface of the mirror is brought into the horizontal
position.   Once more the posterior wall  of  the pharyngeal head
{Schlundkopf) is  seen.   As the  handle  is now more  and more
lowered,  and the surface of the  mirror is thereby more and more
brought into a position parallel to the long axis  of the pharyngeal
vault, the eye  will  follow in the first place the pharyngeal tonsil
to the pharyngeal roof, when a clear white spot  appears,  which is
the alae vomeris, and finally the one or the other choane—in large
mirrors both the choanae—come to view.
    Brightly illumined and first to be seen is of course the superior
elliptical arch.   Below farther toward the front, within the  nasal
cavity, the  superior turbinated bone as a light edge, bordering
quite closely to the  septum.   Below it (the  sup. turb. bone) and
separated from it by a  half dark shade—the superior meatus—
a roundish object comes  to sight.  It is smooth on  its surface, 
i6
EXAMINATION POSTERIORLY.
of yellow-red  or gray-reddish color; it  is  the posterior  part of
the middle  turbinated  bone.   It  lies nearer the side wall and
farther from the septum.   It can be followed up with  the eye for
a distance into the nasal cavity, into which it projects quite freely,
as the middle meatus has the  greatest width here.
   By a further  lowering of the handle the inferior border of the
middle meatus, and the inferior turbinated  bone come to  sight.
Generally the superior half of its posterior end can be seen.  It
is of round  knob-like shape, light-gray  and smooth,  or  a little
rugged on its surface, and approaches the septum closer than the
middle turbinated bone.
   The inferior  half of it, as also  the  floor of the nasal cavity,
are mostly invisible; because  the  soft palate, which appears as a
pale  surface, strongly convex in  its centre,  through the base  of
the uvula, covers them curtain-like from one end  to  the other.
But in deep pharyngeal cavities, where it is possible to bring  the
mirror more nearly opposite these  parts, the posterior  end of the
inferior turbinated bone can be illuminated in its  whole extent,
and also the posterior part of the nasal  floor.  With the movable
mirror one can always  succeed in  this, where the  soft palate is
lax,  and the  pharynx  is  not too  narrow.   The septum, which
superiorly on the pharyngeal  roof  divides fork-like (alae vomeris,
for the reception of the rostrum sphenoidale), otherwise appears as
a sharp edge, placed perpendicularly in the centre of the entrance
to the nasal cavity.
   An elevator for the uvula is not necessary, as the little mirror
can be conducted past every uvula at its side.  The palate-hook,
with  which the uvula is forcibly pulled down, has but a  limited
use.   The posterior surface of the soft palate (richly supplied by
the glasso-pharyngeal and vagus nerves) is generally  very irritable,
and thus spasms of the superior pharyngeal muscle can easily be
induced by reflex action, through which  the cavity is annualarily
closed to such a degree, that only around the hook a  little light
can be thrown up, and thus only the centre of the pharyngeal roof
can be inspected.  If the  uvula rises  even at the least pressure
upon the tongue, or by a simple opening of the mouth, and  the
pharynx  is  of small dimensions, as for  instance  with children,
then the examination is often very  tiresome.  The  mirror has to
be held patiently in  front of  the  posterior  wall  until the  uvula
sinks down; then the favorable moment is to be quickly improved. 
EXAMINATION POSTERIORLY.
17
If the  patient says "on" {Voltolini),  or  knows how to breathe
strongly, chiefly exhaling through the nares, with his mouth  wide
open, then the uvula  falls for  a short time,  and the  light can
ascend.
   A strong tendency to gagging, which comes as quick as light-
ning, if the tongue is barely touched with the spatula, or even if
the mouth  is opened, is  one of the most disagreeable hindrances.
But this can be removed  with  a certainty in a few days, if the
patient will several times daily press down the tongue from twenty
to thirty times with the handle of a spoon, so deep  that  he can
see the uvula and a part of the posterior wall of  the  pharynx in
the mirror.  If gagging ensues, let him lay aside the spoon, wait
a few minutes, until the feeling of  nausea is past,  and then  try it
again.
   From the foregoing it will be seen, that generally of the entire
nasal cavity only the roof and the  convex surface of the middle
turbinated bones—viz , the superior meatus—for a distance of 2
to 2% cm.  cannot be brought to view.
   But if these parts  are  affected by  ever  so  small' a tumor, it
must hang down, and thus be seen.   A tumor at all worth looking
after, will cause so much swelling in the  surrounding  parts, that
it can be brought to light, and distinguished either with  the specu-
lum or the rhinoscope.
   I believe  that  I have shown by  this presentation, that the
nasal cavity can be as  completely illuminated  and inspected as
any other cavity of the body, and as much as  may be  absolutely
requisite for medical treatment.
3 
i8
ACUTE  CATARRH.
DISEASES  OF THE NASAL CAVITY.
                  I. ACUTE CATARRH.

   The origin of acute catarrh, if we except infectious diseases,
is mostly to be referred to a sudden cooling off of the hot  skin,
especially the feet (which after vigorous exercise  are  perhaps
placed on a cold floor) or of  the  back.   Between the shoulders
and hips, where the clothes are not very tightly attached to the
body, and where evaporation  of heat can take place easiest, and
quickest,  the  cold  is felt  very  soon.   A  disagreeable  shudder
comes over one,  and immediately a sharp tickling is felt anteriorly
in the nares,  followed by violent sneezing   One or  both nares
become impassible to the air; a watery mucus collects unceas-
ingly therein, which can hardly be managed, and calls  for con-
tinued use of the pocket-handkerchief.  After  a few days, the
secretion becomes thicker and yellow, and after about  fourteen
days it nearly ceases, when the nasal cavity is again open.
   Often it amounts only to a repeated  sneezing, a quickly pass-
ing obstruction, and  a somewhat increased watery secretion, viz.,
during a longer stay  in a cold room, sitting near a  window not
airtight, or stepping on a cold floor afier one has arisen, or during
the night, when an arm is taken out from under the  cover, and  is
for a time exposed to the  cold air of the room.  Whether the
cooling off that has taken place  on  different parts of the body,
brings the blood contents of  the nasal mucous  membrane  under
an increased  pressure, or whether the capillaries expand, and the
trigeminus nerves are irritated thereby* {Mordhorst), or whether
the tickling is a concomitant  sensation  and brought  about in a
reflex way, with  the sneezing, expansion of the vessels, swelling
of the inferior turbinated bone, and  the mucous  membrane, and
the suddenly increased secretion, I am not prepared to say.
   If  the  side-cavities  are  more strongly  affected,  it will be
marked by more or less violent headache, pressure over  the eyes,
&c.   But it is not necessary to tarry v/ith these sufficiently known
* Ursachen, Vorbeugung, Behandlung der Lungenschwindsucht.—Berlin, 1874. 
ACUTE  CATARRH.
!9
phenomena, which are frequently  accompanied by other catarrhs
and fever.
   The inspection with the speculum shows especially the inferior
turbinated  bone  much hypertrophied, and  that  it lies close to
the nasal floor as well as to the septum.   Its mucous membrane
is smooth and vivid red;  that of the septum  and the nasal floor
is also found to be spongy, and raised in the anterior  part  of the
cavity, which only can be  seen.  Of the middle turbinated bone,
nothing at all, or only a very small part of its anterior end is to
be seen.
   With the rhinoscope the posterior ends of the turbinated bones
are found to be adcematous, swollen, gray or gray-reddish.   The
inferior often project  out of the  choane.  The septum  is also
often evenly thickened, intensely red, or grayish-red.  In cases of
violent, acute catarrh, the turbinated bones and the septum touch
each other.   The entire pharyngeal head  is intensely reddened ;
the openings of  the Eustachian tubes are frequently narrowed by
swelling, their yellow-white color having given  place to a more
rose-red one.  Vascular branches  of considerable size are some-
times seen to go  there from  the  velum.   The pharyngeal tonsil
appears all over darkly reddened,  and is  in  consequence  of the
swelling more distinctly to be recognized.
   The therapeutics pertaining  to acute  catarrh, has established
in general, that it cannot be checked;  hence  it  has  to run  its
course.  The  mixtures   of carbolic acid, solution of ammonia,
hypermanganate of potassium highly diluted with water, and used
as " snuff-water," free  the nares  momentarily; but I cannot say
from  experience, that the course  of the catarrh  becomes  really
shortened thereby.
   The immediate influence  of these remedies  may  perhaps be
looked upon  as  not so much disinfecting, as astringent, by con-
tracting the  vessels, through which the diminution of the swelling
on the inferior turbinated  bone and the mucous membrane, the
opening of the cavity, and the  decrease   in  the  profuse  watery
secretion are brought about.   P. Niemeyer recommends  warm
baths, followed by a cold  douche.
   If the stage of muco-purulent secretion does  not  stop  other-
wise, then insufflations of  nitrate of  silver one part to  twenty of
talc, which  is done by means of a  strong glass pipette, one end of
which is cut out shovel-like—so that the  powder may  be easily 
20
ACUTE  CATARRH.
taken up—while the other end is curved, so  that  the  insufflation
can be accomplished from through the mouth.
   Over the shovel-formed end of the pipette the end of a rubber
tube about one foot long is drawn, after  about  r to i£ cm. of the
pipette has been filled  with powder.  Then the  tongue  is  held
down with a tongue-depressor;  the curved end  of the pipette is
introduced behind the uvula, and then upward, until certainly no
resistance is felt, which indicates, that the opening of the insufflator
is now above the narrow arch, formed by the soft  palate ;md the
superior pharyngeal muscle.  A little shifting to  the right  or the
left points the opening to  the choane of that  side.  And now, if
one suddenly blows strongly into the tube, a little cloud of powder
is immediately thereafter seen to come out of, one  or both nares.
   The rhinoscope shows the posterior  ends of the turbinated
bones, which are especially  vascular,  more or  less  completely
covered with powder.   Through the speculum  it can be seen, that
the septum, the inferior and middle turbinated  bones  are  also
covered, but not so densely.
   Some patients are immediately after  affected  with headache,
flowing of tears, redness of eyes, pain over one or both eyes, and
sneezing.  But these  phenomena  last only a few minutes in this
disagreeable degree, unless the  powder used has  been too strong.
   According as they are  borne,  one to three  insufflations are
made successively.  One or two repetitions on the second or third
day will suffice, and the mucus  will no  longer be  thick, yellow,
but clear,  transparent, normal.
   Insufflations from the anterior  do not work  so quickly and
successfully.   They are accomplished with a straight glass pipette,
that  can be exchanged for a goose-quill, which is also cut out like
a shovel, on one end.   The opening is brought  into  one  of the
nares, while  the  pipe  is held  in  horizontal position (not higher
posteriorly), in order not to throw the powder  directly against the
roof of the  nares and  the middle turbinated bone, where the
olfactory  and ethmoidal nerves branch  out, and  where it might
therefore  cause violent headache, lasting for hours.
   After  the insufflation the septum, the convex surface of the
inferior, and the concave surface of the middle turbinated bones,
also a  part of the pharyngeal roof may be  seen covered  with
powder.  If a region is to be reached especially, this can easily
be accomplished by a little movement of the opening to the  right,
the left, upward, or downward. 
ACUTE  CATARRH.
21
   I prefer the application of medicine in the  form of powder,
because it can be easily accomplished, because the powder sticks
better, works  with  more energy, and  because the brush  soon
loses its liquid by hitting against the walls of  the nasal cavity—or
in case of application from the mouth—the  superior pharyngeal
muscle and the soft palate may have pressed it out, long before it
reaches the choanes.
   Where the side cavities participate in  a marked  degree, cold
cloths are to be applied to the forehead and  nose, leeches at the
entrance of the nares and at the root of the  nose, cathartics, and, in
short, an antiphlogistic treatment will prove most serviceable.
   I have repeatedly seen cases, where according to my impres-
sion the muco-purulent stage in those cavities  alone had lasted
for months.   The patients complained, that aside from  the mod-
erate  obstruction in the nares, yellow cream-like  mucus would
loosen itself in great abundance at times, and run  down into the
throat, and  that an uncommonly bad, stale odor, connected with
it, would give notice of the fact.
   Examination would show first of all, that  the  inferior turbi-
nated  bone was  normal, but  the  middle, i.  e„ its mucous mem-
brane, was hyperaemic  in a high degree, and  swollen, that it was
lying close to the septum throughout, with the middle meatus
much reduced in the middle.  In touching the mucous membrane
with the probe, I noticed, that it was considerably raised from the
underlying bone.
   In one case I could, after pushing aside the intensely reddened
mucous membrane  coming out from  under the anterior  end  of
the left middle turbinated bone, see yellow mucus dropping down
profusely.  The patient complained  frequently of pain on the left
side of  the forehead, which would diminish after  a  sudden dis-
charge of yellow secretion.  No doubt, he suffered from purulent
inflamation of the left  frontal sinus.   Strong solutions of chlorate
of potassium (from  two to three tablespoons to one liter  of water)
applied twice a day [vid. art. ozcena], in  connection with insuf-
flations, which of course did not reach the  sinuses themselves, but
only the anterior wall of the ethmoid cavity, and the middle tur-
binated bone, but could  nevertheless exert a  beneficial influence,
and thus perfected  a cure in a short  time.
   Some persons came who complained of having  to sneeze vio-
lently for some time, the sneezing accompanied by a profuse watery
secretion ;  and that once a day, or once or twice a week, without any 
22
CHRONIC  CATARRH.
known cause, in awaking, or arising, or at the moment of stepping
from the room into  the open air, or vice versa, this would happen ;
that only very little  or no obstruction was  connected with it, that
yellow mucus would not be discharged at all, and that  the catarrh
would often pass away within a few hours or a day without coming
to this stage.
   In examining the nasal cavity, I could not find any abnormality
whatever,  and believe that the ailment was caused by excessive
sensitiveness of the  skin.  I have tried to overcome  this by  an
ablution of the whole body in cold water every morning, which
would toughen it.
                 II. CHRONIC CATARRH.
   In  German it  is generally  called Stockschnupfen [permanent
snuffles], by which is  designated an obstruction of the nares of
long standing, sometimes more moderate, sometimes more violent,
accompanied by  an uncommon  production of mucus, and by
nasal speech.  The latter immediately reveals the affection, and it
is often very disagreeable to be obliged to listen for any length of
time to one  who is  troubled  with it;  often it  stamps  the
patient with the appearance of imbecility.   The color of his face
is pale and sallow in a high degree; his  appearance is older than
corresponds to his real age.  The  obstruction is  often acutely
increased  with sneezing, and  large  masses of tough, purulent
mucous secretion  have forcibly to be blown out, which  are  barely
removed when it accumulates  again.  The restless  sleep, the
choking and tormenting every morning, as the mucus, gathered in
the pharyngeal vault is being removed—combine to make chronic
catarrh a very annoying affection.
   Sometimes the  excessive  production  of mucus  is  a more
prominent symptom than the obstruction.   This is  partly  owing
to the fact that the concerned nares are so large, that even consider-
able swelling can  take place therein, without serious  obstruction.
   On the other hand, with anaemic persons, having  a pale dry
skin, the obstruction (with an ever  present tendency for acute
catarrh) is  a more prominent symptom.  Nasal speech of course
being modified by the degree of obstruction.
   A strong, sharp, disagreeable odor, as in  ozcena  is  not  found,
but sometimes a weak sweetish, stale one. 
CHRONIC  CATARRH.
23
   Very often the sense of smell  is disturbed, but it generally
returns  in the  course of treatment in a very satisfactory  degree,
even after it had been absent for years.   The number of patients
having chronic catarrh with hypertrophy, treated by me, is 81; 54
of them were males, and 27 females, aged from 8 to 50 years.

                         EXAMINATION.
   In well marked cases the speculum  in  the  first place  shows,
that the anterior end of the inferior  turbinated bone  is swollen.
This  swelling  often  changes  under one's  eyes.  It  sometimes
passes away transiently  after bleeding, especially on the posterior
end of  the inferior turbinated bone, after cauterization or rubbing
with the probe [in consequence of  a  contraction of the vascular
tissue].  Sometimes it  also  diminishes during the inspection of
the cavity, evidently because the vascular tissue is incited  to con-
traction in a reflex way, by the expansion of  the nasal  wings.
    It is therefore  only a symptom,  the treatment of which alone
has  no  influence  on the condition of the entire situation.  An
extended swelling is very seldom  noticed  here.   The surface is
mostly  smooth, and of a gray, pale color.
    A closer inspection shows, that  the entire turbinated  bone is
swollen; that it lies for the greater part of its extent close to the
septum.  The view through the nares into  the pharyngeal vault is
more or less  prevented.   The convex surface is  also  smooth
bluish  pale,  not  reddened.  One  has to press deeply into it, in
order to get to the underlying bone, and as soon as the  probe is
removed, the depression ceases.
    On  the inferior (concave) surface in older cases a white granular
mass is seen, which has the appearance of  frogs' spawn.    Anteri-
orly it generally fills only the space between  the  turbinated bone
and the nasal  floor; but  posteriorly  it is  present  in  such  large
masses, that  it  comes  out  from under the  turbinated bone and
reaches to  the septum.  Thus the  greatest part of the  inferior
meatus becomes impassable.   With the probe this mass feels soft,
is moveable from  one side to the other, and nearly insensible.
    The middle turbinated bone has also a white-grayish,  mouldy
appearance on its concave surface.  On its  border, especially on
the  anterior end, the  thickened mucous membrane  has  become
lowered, is abnormally  long,  has  a  crestlike  form, and can be
moved hither and thither; it is often spongy and  raised  up from
its underlayer over the  entire concave surface, which  fact can be
plainly ascertained by the probe. 
24
CHRONIC  CATARRH.
   Sensation is everywhere much diminished.
   On the  septum I  have found  only once in connection  with
chronic catarrh several crestlike, thick, tough tumors opposite the
anterior end of the inferior turbinated bone.
   The  posterior ends  of the  turbinated  bones appear  in  the.
rhinoscope light gray, rough,  and swollen, especially those  of  the
inferior turbinated bones, which often project out of the choanes,
resting upon the uvula, and sometimes cover a part of the  Eusta-
chian orifice.   They  touch each other  in  front of the septum,
leaving only the superior part  of it  open  to  view.  In  one case,
the first I treated,  the posterior ends of  the  inferior  turbinated
bones were changed into gray tumors, nearly as thick as a thumb.
Sometimes also the septum  is found to  be swollen, rugged, and
whitish-gray.
   In  the great majority of cases, the  nasal floor was  found
smooth and healthy.  But now  and  then half round elevations
were found at the anterior entrance  of the cavity.
   All these changes may be  found  in one nasal cavity in a  degree
corresponding to the degree of the affection, or only the inferior or
the middle turbinated bones, or only the posterior ends on  one or
both sides are changed.  The widest  cavities as a rule are most
extensively diseased.  Where bone-projections  from the septum,
or incurvations of it obstruct  the cavity, extended swelling cannot
take  place,  as on this  account a wide-spread  thickening  of  the
mucous membrane, the sub-mucous and glandular tissue, is checked
posteriorly.
   Sometimes the obstructed side is found to be quite healthy, or
only the  posterior ends of the turbinated  bones are diseased in a
small degree.
   In several  cases the septum was the principal seat of chronic
catarrh.   The  turbinated bones were  found to  be in a. more or
less  normal condition.   But  the  septum  was very extensively
roughened and granulated.   In narrow nares a considerable ob-
struction may be brought about through irritation or  swelling of
the septum.
   In one case (the patient a boy  eight  years old) I  found on
both sides of the septum on the anterior part,  opposite the ends
of the inferior turbinated bones, granulations high enough to be
removed  with  the loop.   Some elevations were also found  on the
anterior  part  of the  left inferior  turbinated  bone."   After  the 
                      CHRONIC  CATARRH.                  25

 operation a white-yellow, deep  spot, somewhat rough—the bare
 cartilage—was to be noticed on  the septum.
    In five other cases I saw the  septum perforated three times on
 the boundary between the cartilaginous and  the  bony part of it
 close to the nasal floor.   At first the opening, about f to 1 cm. in
 dimension, was hidden from the eye  by the  granulations.  Evi-
 dently a chondritis or a perichondritis  was  lying at the bottom of
 these excesses.
    In many cases chronic catarrh of the pharynx, or hypertrophy
 of the  palatal or  pharyngeal  tonsils  was  also  present, or some
 small soft polyps on the middle turbinated  bone.

                          TREATMENT.
    It is a well known fact, that  therapeutic remedies have been
 hitherto quite powerless against chronic catarrh.  In  the  estima-
 tion  of many  laymen chronic  catarrh is  still  incurable. Nie-
 meyer says:  " Chronic catarrh of the  nares  is a very  obstinate
 disease, which not seldom mocks at  every treatment, and often
 lasts  with changing intensity for  many years."
    In the nasal douche of Weber a remedy giving the  best results
 was thought to have been found  against the diseases of the nasal
 cavity.   But the  expectations  have  not   been  realized.   Lucae
 expresses himself pertinently on this subject  in an article  "On a
 new  connection  between  nasal  and  ear  diseases."*  He says :
 " If I speak of healing,  I  mean of course only, that I have by
 this treatment (nasal  douche) succeeded in  a short time—through
 a diminution of the secretion and a reduction  of the  swelling, in
 removing the complete  obstruction  of the nares, and thus also
 cured the affection of the ear, resulting from  it.  But in  saying
 this,  I  am  not  to  be understood to mean, that chronic catarrh
 itself  was completely  removed  in this time  (the time  of a few
 weeks).   Forit is well known, that the several  remedies, including
 the douche of  lV?br>\ are often without avail."
    Where only hypersemia or simple swelling of the mucous mem-
 brane subsists, where chronic catarrh is  still of late date and
 cannot really as yet be called chronic, one  may perhaps succeed
 with the nasal douche, or the syringe, which I prefer (see ozcena),
in perfecting a cure.  And this too, according  to  my  experience
in a few weeks, if in the morning and in the  evening a liter of

            * Archiv fuer Ohrenheilkunde, IV Band, iii Heft, 1869.
       4 
26
CHRONIC  CATARRH.
water is forced through the nares, in which one to two tablespoons
full of chlorate of potassium  has been  dissolved.   But  insuffla-
tions of nitrate of silver i: 10-8-6 parts of talc, act much quicker,
and they are applied alternately one day anteriorly, the other day
from through the mouth.   Skillful  persons  can  accomplish  this
themselves by means of the bent pipette.  On the concave surface
of the inferior turbinated bone some  cauterization  may be  done
with nitrate of silver in substance in order to  accelerate healing,
when the mucous membrane  is spongy and swollen.
   Schroetter reports, * that he has cured old catarrh {Stockschnup-
fen) in one to two months.   He applies cauterization with nitrate
of silver in subtance, which  has  already  been recommended  by
Niemeyer.   He {Schroetter) says, that  with  his covered  caustic-
holder he very easily succeeds in covering the involved  turbinated
bones, as also the septum with a white scurf for a larger or smaller
distance.   But first of all it is  to be noticed,  that the caustic-
holder, being straight—not knee-formed—cannot be used under
the guidance of the eye, with the speculum, which Schroetter does
not seem to use at all.   But  in most cases the  mucous  membrane
of the nasal cavity is only diseased in  spots, as has already been
described.   (On wide-spread  affections see page  32.)  But the
more the healthy mucous membrane is touched by the cauteriza-
tion  on the middle  turbinated bone, the  more intense headache
ensues; or  if on the  inferior, toothache follows.   The  patients
are sometimes affected so much, that  they have to  be in bed  for
hours.
   After every cauterization the posterior ends of the  turbinated
bones are  much smaller, if the  caustic  has been  well  applied.
But on the next day they are swollen again.
    In the first cases, which were treated  by  me, I  had to apply
very many cauterizations—in part with the aid of the rhinoscope,
as only the  posterior ends of the turbinated bones were affected—'
before the  nares remained open and a cure was perfected.
    Since I have become familiar with the galvano-cautery, I have
found it a remedy by which  every chronic catarrh  can be surely
and entirely cured in a few operations and with much less pain.
    I  have therefore since then wholly dispensed with cauterization
in such cases ; but I believe, without  having tried it, that lunar-
caustic alone, without  being  accompanied by other remedies, will
* Laryngologische Mittheilungen of 1870, 1871 and 1872. 
                      CHRONIC CATARRH.                   27

 not suffice to cure old hypertrophy of the mucous membrane, and
 such tumors as are described in the following pages.
    At  first  I  confined  myself chiefly  to the use of the galvano-
 cautery alone, but soon I learned that this treatment was too slow
 in cases of much swelling on  the  inferior  turbinated  bone.   I
 therefore continued to shorten it much by the use of the loop-
 ecraseur.
    The loop is arranged  squarely  and made  about  1  cm. wide,
 conducted over the nasal floor, under the turbinated bone, pushed
 up until a solid resistance—the bony frame—prevents  its going
 further;  then the loop  is  drawn  together.   If the person  is
 spansemic or young, not more than  fifteen  years old, the current
 can work uninterruptedly, the loop being at the same time drawn
 together closer.  After a few seconds a tumor  about 1 to i| cm.
 long and also as thick, is seen hanging in the loop.  In most cases
 it has precisely the appearance of a pale red raspberry, and con-
 sists of soft kernels, which can be pushed widely apart.   After it
 has been lying in spirits for a time, it has the appearance of a
 caterpillar.   Spread out, it appears  lined with  furrows crosswise.
 Once I removed a tumor, consisting of  six flat  berries, of the size
 of a pea, put together like a  bunch of grapes.
    The surface of the wound is smooth and of compact consist-
 ence.   The pain, which is moderate, ceases immediately  after the
 removal of the instrument.  The hemorrhage  is also small, and
 soon stops either by itself, or after about a liter of cold water has
 been forced through and upon the  nose with the syringe.  (See
 ozcena.)
    As the swelling of  the anterior end  of  the  turbinated bone is
 removed, and the inferior meatus anteriorly opened, the tumors,
 which are still present and which are generally  largest as  we come
 into the posterior part of the nares, can now be  seen easily, and
 under complete guidance of the eye, they  can  be removed with
 the loop.
   If the patient is plethoric, it is better to take a  thicker wire
 (No. 2 or 3) to check  the current several  times, especially after a
 fresh  filling of the batteries, in order to seperate the  parts  more
 slowly.  This is  done to prevent   copious  hemorrhage, which,
 although it can soon be checked in the above described  manner,
is nevertheless  very inconvenient and time-taking.  (On the con-
cave surface of the inferior turbinated bone a narrow blood canal
runs longitudinally.—Luschka). 
28
CHRONIC  CATARRH.
    Great care must be  taken in this, that the tubes, which soon
get hot. are kept free in the cavity and touch nowhere, or else the
healthy parts, especially at the entrance, will be burned—which
will make  the  otherwise very painless  operation, as long as it is
confined to the diseased  parts,—a very  irritating one, and cause
much pain not only during  but also long after the operation.
    I generally  remove  but three or four pieces at one sitting.  If
two large pieces have been removed, I do not attempt to remove
any more;  partly because the patients feel somewhat indisposed
(affected in their heads),  while the cavity is often obstructed in a
measure by blood and  swelling of its walls, and  partly because  I
desire to avoid a too strong reaction.
    I have therefore never seen any bad consequences from  the
operation.  Only a few patients have been on  the next or second
day after the operation taken with fever, dull headache, and rest
less sleep in a mild degree.  It is therefore advisable, to make the
first sitting short, in order to see first,  whether the patient is espe-
cially irritable and sensitive or not,—that is, whether he endures
the operation well.  Generally patients  are  able directly to go
about their business,—always  going  home on  the  same day, if
they have come from a distance,—and manage the after-treatment
themselves, by injecting  every morning and  evening a  liter of
water,  containing  a  solution of chlorate of potassium,  into  the
nares, in order  to remove the mucus, which accumulates  in large
quantities.   Moreover  I give  them  this  advice, that  if fever,
pressure in the head,  or general  indisposition  should  ensue, to
keep quiet, abstain  from work,  eat  but little, drink a  glass of
mineral water (Bitterwasser), and if necessary apply a cold poul-
tice to the  face and forehead for a few hours.
    The continuance of the operation  depends somewhat on how
much has been done at the first sitting, and how the patient  has
borne it.  Operative procedure  may  be  resumed  on the  third,
fourth, fifth or tenth day.  Inflammatory swelling must  have dis-
appeared in order that the  diseased  parts can  be  distinguished
from the healthy, so that the latter shall not be  also removed by
the loop.
    In every consecutive  operation the inferior meatus will be seen
more open, unless  a new acute  catarrh  interferes and it has been
neglected to  tell the patient not to come in  such  a case, as the
nares will be too much  obstructed and hyperaemic  In the second 
CHRONIC  CATARRH.
29
or fourth sitting the posterior end of the turbinated bone will be
seen anteriorly.
   But  here,  on the posterior  ends of the inferior turbinated
bones, where the parts are more  vascular, the loop must be made
to glow  very slowly, by a frequent  interruption of the current, in
order to prevent a copious hemorrhage.   Or the galvano-cautery
is to be  applied instead.  The galvano-cautery has  a  broad, thin
armature of  platinum, formed like  the  plate of  a knife.  The
tubes run parallel, at the sides of each other, and are bent knee-
formed.  When  first  applied  to  the concerned  spot, it must be
cold; and again after it has  been glowing for a  few moments, it
may be  somewhat cooled off by checking  the  current.  Through
hissing and bubbling the cavity is densely filled with steam, which
the patient can  remove  by a sudden, strong expiration through
the nares, thus making it light again.  He feels no pain  until the
plate reaches the  healthy  parts.   As  the  pain  increases  and
becomes more unbearable, he says, "stop !" and the operation is
finished at this spot.
   In this way I always destroy the rugged elevations on the
convex  surface of the inferior turbinated bone.   The burner is
pushed  through between the septum and  turbinated bone, and
pressed against  the latter;  then  the  current is  let on  until the
patient  reports that pain is coming.   With the rhinoscope  it  can
now be  more definitely ascertained how much still remains to be
done, and whether the burner must be brought further up toward
the exterior part of the surface.
   The more plethoric the individual, the  more  frequently the
current  has to be checked.   With the loop arranged horizontally,
I remove only thin tumors from the posterior ends of the inferior
turbinated bones, especially when the patients  are anaemic.  I am
also  careful in such cases to push the loop only a very little toward
the  exterior, i. e.,  toward the side wall,  for  fear  that not only
hypertrophied mucous membrane, &c, but even  a part of the end
of the turbinated bone  itself might be pressed into it, and thus,
not only a copious hemorrhage, but also other even  more serious
accidents might  be caused thereby.   This is to be feared so much
the more, as there is an  abundance of nerves on this spot, and the
space between it and the openings of the  Eustachian tubes is very
small indeed.
   If there are bone-projections from the septum, or incurvations
of it in the way of operating on the posterior end of the turbinated 
30
CHRONIC  CATARRH.
 bone, then I generally conduct the instrument, which is strongly
 bent towards the front, through  the mouth, with  the aid  of the
 rhinoscope, to the tumor on  the  turbinated bone.   However,  as
 one can only succeed in this  where  there is considerable  space,
 he may be obliged to have recourse to the following treatment.
    In the first place the burner  (with  the tubes  running by the
 side of  each other)  is pushed  through  the  inferior  or middle
 meatus into the  pharyngeal vault.   Then by the aid of the rhino-
 scope, it is applied to the tumor, to which it is  closely pressed and
 held there by the right hand, whilst the left lays aside the mirror.
 The handle, which had been removed, is now  applied to the ends
 of the  conducting wires, and by interruptions heat is  produced.
 Soon the platinum will cleave to the tumor, and can now lie there
 for a time.  It must  be removed very slowly and carefully, if we
 desire to avoid hemorrhage.  Caution of course demands a very
 prudent management,  with the aid of the rhinoscope in  the appli-
 cation of this method, which Vollolini also applied in the pharyn-
 geal vault.   After the inferior turbinated bone has been completely
 cleaned, it often  appears larger, and springs in a wide arch from
 the side wall.   It now presents a broad  concave surface, which
 can be inspected from the anterior to the posterior.
    The middle turbinated bone is treated by drawing shallow lines
 over the surface  of the spongy mucous membrane with the burner.
 As before, the sensation of the patient furnishes the best  guide.
 But if the swelling has anywhere  grown into a somewhat defined
 tumor, a small mucous polyp, which is most frequently  the case
 on the anterior end,  then  the loop of course will be most service-
 able.
    In some cases the tumefaction  on the middle turbinated bone
 has not yet arrived at this  stage, where it can be removed with
 the loop.  Then the  galvano-cautery  has  to be used from the
 beginning.   It  is  slowly  pushed  through  under  the  turbinated
 bone to the posterior end;  then  it  is  pressed somewhat upward,
 when the current is let on and the instrument is slowly drawn out.
 In this way the  galvano-cautery is two or three times successively
 drawn over the concave surface.
    But in these  cases a treatment  with bluestone  in substance is
'best adapted.  The  end of the knee-formed probe is dipped into
 melted bluestone, which is then rubbed over the inferior surface
 of the  turbinated bone.   If this  is done with caution and the
 healthy spots are carefully  avoided, especially  on the septum and 
CHRONIC  CATARRH.
31
the turbinated bone, then  the  patient feels  but  very little pain.
But some sneezing and more or less watery secretion will follow.
   The cauterization can take place two  or  three  times  a  week,
no matter whether the  concerned parts  are  not  quite  healed as
yet, but still yellow, in  a state of inflammation.   It must be done
from ten to twelve times, whilst the galvano-cautery has only to
be applied two or three times in intervals of from ten to twelve
days.
   The cure  is  recognized by the fact, that the  copious muco-
purulent secretion has  ceased and  the  obstruction  is completely
removed.   Inspection shows, that the meatuses are open, that the
mucous membrane is smooth and adheres closely all over.
    In the rhinoscope it is to be seen, that the ends of the  turbi-
nated bones are within the choanes, and do neither touch  one
another nor the septum.
    A few cases came to my notice  which were  accompanied by
real spasms of sneezing.   The patients  complained of having to
sneeze from twenty to  fifty times, soon after  leaving the bed in the
morning, until they  were  quite exhausted, and  watery  secretion
would copiously flow in connection with  it.
    In one of  the cases I found the inferior turbinated bone lying
close  to the  septum.   The  cavity was thus wholly obstructed
and inspection thereby prevented as in acute catarrh.
    The  rhinoscope could not be  employed  on account  of the
great tendency to choking.
    As the galvano-cautery had never  yet  failed me, I  tried its
merits also here.   I gently conducted it under the turbinated bone
into the pharyngeal vault.   Then, making it hot, I slowly drew it
out again.   This slight cauterization I repeated two to three times.
    After a few days of profuse yellow mucous secretion the nares
were open and I could now see that the middle turbinated bones were
entirely normal and that the inferior ones were  healthy up to the
posterior part.  Here were scattered around the free border and
the concave surface a number of light, smooth kernel-like tumors
having the size of a pea.
    They were the cause of the daily spasms of sneezing, for after
they had been destroyed (in about five sittings),  these phenomena
were  completely stopped.  After  about one and  a half years  a
small  relapse had ensued, which  was  however removed by the
same means.
    With another patient, H. G., of Duisburg, with equally  tor- 
32
CHRONIC  CATARRH.
turing spasms  of  sneezing, which  immediately followed on  his
getting out of bed and  placing  his  feet on  the  floor, the nares
were  entirely open  and healthy.   On  the  anterior ends of the
middle  turbinated bones there  were about a dozen such kernel-
shaped  tumors.  Some  of them  being rather  more than  little
mucous polyps.
   On the next day after the first operation, the sneezing was not
so violent, and after the  second, it disappeared entirely.
   After  about  a  year's time a weak relapse, a few little tumors
had again appeared, against which the galvano-cautery was applied
but once.  As to the question when he should  come  again, the
patient was answered, that he must  come as  soon as tickling or
sneezing returned again.  A year and  a half has since  elapsed,
but I have not heard  from  him, no doubt because  the  affection
has not returned.
   Another case was that of a lady  of about thirty-six years of
age.   Her nervous condition would  easily lead one to think that
the spasms of sneezing  were hysteric.   After  the  little polyps,
which were on the  anterior  end of the left middle turbinated bone,
had been  removed, the spasms did not return.
   But  the  condition just  described,  can  also  be  caused  by
chronic  inflammation, or a swelling of the mucous membrane on
the anterior end of the septum, which is then found to be wrinkled
and spongy.
   Once I found the  entire  mucous  membrane of the nasal  cavity
seriously affected.   The  patient was  a  lady, thirty-six years old.
She had been afflicted with  chronic  catarrh ever since she  was a
child.  At first sight  I thought that the red tumor at the entrance
of the left nares—quite granular  on its surface—was of  inde-
pendent growth.  But with  the  probe  I found  that the  lining
(Bekleidung—i. e.,  the mucous membrane^  on  the anterior  end
of the middle turbinated bone was  thus much  affected.  In the
right nares at the same place was a  similar tumor, only somewhat
smaller.
   With  the  rhinoscope I  found, that the  choanes were  much
diminished in size.   The ends of the turbinated  bones projected
out of them as grayish-white  uneven rolls as thick  as  a finger.
The septum in its entire height was  changed into a thick, pale,
rugged bunch.
   In the course of treatment the entire mucous membrane, with
the exception of the  floor, was found to be much thickened raised 
DEFORMITIES.
33
up, covered with pointed rugged crests, which were too small to
be removed .with the loop.
   Hence the galvano-cautery was  applied.  Sixteen operations
were necessary, each lasting one-half to one and a half  hours, to
remove this  extraordinary  hypertrophy of  mucous  membrane,
glands and sub-mucous tissue; to  free  the turbinated bones  of
their monstrous shape; to make the lining  of the cavity smooth
all over, and  to  bring  about again a  patulous condition  of the
nasal cavity through to the pharyngeal vault.
   And thus  not only all the  difficulties against which help had
been sought in vain,  disappeared, but also the exterior cartilagin-
ous nose was diminished in size by degrees   Its form became
natural and the entire face received a more  healthy and  youthful
appearance.
   Thus chronic nasal catarrh of old date has its origin  either in
hypertrophy of the  mucous membrane, tumefaction on  the  con-
cave surface of the  inferior turbinated bone, or on its  posterior
end (in which the  sub-mucous tissue participates more  or less),
or the  mucous membrane of the middle turbinated bone, becoming
spongy, hypertrophied, or formation of polyps, beginning on the
anterior end,  free border or posterior end.
   The septum is less often the seat of chronic catarrh in  conse-
quence of cartilaginous inflammation.  Very  seldom is a chronic
inflammation  or a swelling of the entire nasal  mucous membrane
the cause of chronic catarrh.   The nasal floor almost never par-
ticipates.
     III.  DEFORMITIES IN THE NASAL CAVITY.
   Frequently  persons  have  come  to  me, who complained  of
having chronic  catarrh.  But examination revealed the fact, that
the obstruction  was caused  by a deformity of the walls of the
nasal cavity.
   Triangular projections are most frequently noticed on the bony
septum: sometimes anteriorly, sometimes  in  the centre, or again
on both sides of the free border.  They have thin pointed ends,
directed towards the inferior turbinated bone.  Often they project
freely into the meatus between the middle and inferior turbinated
       5 
34
DEFORMITIES.
bones.  Sometimes a projection  extends over a large part of the
septum, as an oblique edge from below upwards, and from before
backwards.  Thick, triangular edge-like bone-projections are also
often seen close to the nasal floor, extending  for some distance,
and  seem to proceed  from the crista nasala opposite  the  ante-
rior end of the inferior turbinated bone.
   An abnormality,  which not very seldom occurs, is the angular
bending in of the septum, by which on the one  side a deep hori-
zontal furrow is drawn along the entire wall.   On  the other side
of the wall, the nasal cavity is obstructed in a high degree through
the knee-formed projection  of the  wall into  it.  It is doubtful
whether a blow on the nose, or a fall, could thus injure only  the
bony septum,—break it, and bring  about a dislocation  of the
broken parts in this  manner.
   The cartilaginous part of the septum is more largely exposed to
external violence, and can be more easily injured.  Thus the very
frequent  deformities, which are noticed  even  exteriorly by  the
inclined position of the nose, may mostly have been brought about
in this manner.
   The anterior part of one side is often enlarged in this manner
to the detriment of the other.   And  then, at times, when sudden
strong inhalations are made, the air in the nares is quickly diluted
and the exterior air presses the nasal wing against the convex side
of the bent cartilage, and the entrance of air  is  thus hindered at
a time when it is most needed.
   At the entrance to the bony portion of the nares, a pale, move-
able  projection  is sometimes found near the nasal floor.   It is  the
inferior part of  the cartilaginous septum, which has been discon-
nected from the bony one, and has been dislocated from the grove
of the vomer.
   This condition  gives rise to the same disturbance  of breathing.
I  also observed it once in a case  of extraordinary   thin  and
relaxed nasal wings.
   The bone-projections at the anterior entrance I have  repeat-
edly  diminished, where it  was desired, with the galvano cautery
to such a degree,  that  the  entrance of air  (breathing) was no
longer much retarded.
   Those cases, where evidently a partial  luxation  of the carti-
laginous  septum had taken place, were too old, to encourage one
to a trial of bringing them back again into the grove  of the bony
septum.  Where the cartilaginous septum  in  young  persons was 
OZCENA.
35
bent, I advised them to press the cartilage daily from fifty to one
hundred times toward the other side, so as to straighten it; and
also to put on the nose-squeezer during the night, of which men-
tion has been made in the catalogues.  But as to the result I am
not prepared to speak as yet.
   Deformities of the turbinated bones, as has been  already  ob-
served, are often brought about by projections from the septum.
Sometimes the middle turbinated bone on the one side is of mon-
strous  dimensions, while its mucous membrane,  adhering very
closely, shows that the bony structure gives it this shape.  On the
other side the turbinated bones are of smaller  dimensions, while
the cavity is  obstructed  by the  septum  projecting into it.  the
superior part of the septum especially being  bent  in.    In ozcena
the anterior end of the middle  turbinated bone (i. e., its mucous
membrane) is often found to have  grown adherent to the septum.
    In  the normal condition there is but a  small cleft between
these.   But in a condition of swelling they soon touch each other,
which, if the epithelium is knocked off, easily gives rise to  a growing
together, by which they may be united in small spots  or over a
larger area.  Thus no doubt the bridges of mucous membrane, so
frequently observed between the turbinated bones and the septum
are brought about in this way.  Three times I have seen tough
strings,  about  \ cm. wide, spread out between the  anterior end of
the inferior turbinated bone and the septum.   Also once between
the posterior end of the  same and  the septum.  It could not be
ascertained, whether they were congenital or acquired. One patient
said, that  the bridge, which he  could feel  with  his index-finger,
had  formed  after  an  operation  on  some polyps with forceps.
These strings  were cut through in  a  moment with the galvano-
cautery, as they were in the way of operating, and then destroyed.
                        IV. OZOZNA.
   The Greek name " ozaina " has ever signified an odorous nose
(Stinknase), an odorous ulcer in the nares.  An indescribable offen-
sive, sharp odor of the breath,  and occasional obstruction by dried
purulent secretion, are the most prominent symptoms.
   When the obstruction is removed, yellow-green  scales, large
slices or thick gray or nut  colored stopples, of cadaverous odor
can  be  brought out, through  the nares, or  the  mouth; which is 
3^                        OZCENA.
often however not  accomplished without much useless  chocking
and blowing of the nose.  On an average one  succeeds in this
about once in  2—3 days, and then only partially.
   Until they have succeeded in this  the  patients often  suffer
vertigo and  aching  of  the head.   Often they also experience a
painful  pressure over the eyes; while the voice  has a somewhat
nasal tone.
   The patients often complain of a dryness in the throat, a want
of ease in swallowing.   The sense of smell generally  suffers, and
may be entirely wanting.
   Of  the 85 cases observed by me, 44 were females.   This ratio
impugnes the opinion of Voltolini^ that this sad disease was almost
entirely confined to women.—The youngest was 7, the oldest 45—
50 years of age.
   With the older patients  the  phenomena were generally more
moderate than with the younger.   But all stated, that the affection
had commenced (that they had known of it), when they were very
young.
   They themselves had been weakly, or came from parents, who
were more or  less  diseased.  Some of  them had suffered with
swelling of the lymphatic glands, inflammation of the eyes of long
duration, and  had shown a great tendency  for  contracting cold.
The patients—even in  cases  of moderate degree—do not have a
youthful, healthy appearance, corresponding to their real age; but
appear sallow and unhealthy.   On the  forehead and  around the
eyes, signs of dissatisfaction are often noticed.  In  cases of a
higher degree  of severity the color of  the  face  seems gray and
yellow; and the features  are  pale and lax.  The  nose is  often
swollen in the  cartilaginous part, but seldom reddened.  The pale
skin of  the nasal root and glabella is often moderately swollen.
   It is easily  explained, why with some of the patients a feeling of
oppression predominates;  for they perceive,  that their  breath  is
avoided by everyone.
   By means of the speculum the nares are found to be  unusually
large.    In the  posterior  part  the  inferior and middle turbinated
bones,  the roof, the pharyngeal roof, and the posterior wall of the
pharyngeal vault, which can be well  illuminated, are seen to be
covered with large  scales of yellow-green color, or some glots of
nut-color.   On the  middle  turbinated  bone a  yellow, watery
cream-like mucus is generally observed; which also has a penetrat-
ing bad odor 
OZCENA.
37
   The anterior  part  of the cavity is  mostly free, unless the
patient's avocation requires him  to bend his head forward.  (This
fact  is  to be  explained  hereafter.)  After the mass of mucus—
which  cleaves like mortar on the  walls—has  been loosened by
means of  the syringe, and blown out, or removed with the knee-
formed forceps, it is  observed, that the cavity is  thus  large, be-
cause the  inferior turbinated  bone is very narrow and thin ;  often
running like a thin edge, about \ cm. high, along  the  sidewall.
Posteriorly  it is  often flattened  out so thin, that its end is  more
like  a part of a skeleton.  It also appears shortened.
   The inferior  and middle  meatus being in consequence con-
spicuously broad.  The Eustachian orifice, and also the entire half
of the pharyngeal vault,  as determined by the respective choane,
can  thus be easily illuminated.  The movements of the soft palate
can  also be well  observed.  The observations I have thus  made,
have been  published  in an article, bearing  the  following  title:
" The Relation of the Eustachiau orifice to the soft palate, as  ob-
served on a living subject through the nares."
    Anteriorly the middle turbinated bone  is often for some dis-
tance  adherent  to the septum  (has  grown to it), or is only con-
nected with it by bridges of mucous membrane.   The superior
turbinated bone and the whole nasal roof can be seen only in  ex-
ceptional  cases.
    The mucous membrane adheres closely all over.   Only on the
anterior end of the middle turbinated bone it is sometimes moder-
ately swollen.  Sometimes, but not always, it has  a  rough, wrink-
led  appearance on the septum and middle turbinated bone, which
is perhaps brought about through swelling of  the glandulae, and
the  knocking off of the epithelium.  Some small  elevations are
also seen  sometimes on the inferior turbinated bone; which often
has  a  pale color; whilst the middle  turbinated bone is  generally
more  reddened.   When  the  septum  presents a  velvety, uneven
 surface, hyperaemia  is present.  The intensively red color, which is
 seen immediately after the scales have been removed, on the spots,
 which they occupied, soon passes away.   In  some  places, as for
 instance on the nasal floor, the mucous membrane has  a shining,
 smooth, rose-red appearance.
     But in not a  solitary instance have I seen  purulent defects of
 the  mucous membrane in connection with this affection, and only
 in one case bone-necrosis; which has been reported in the case of 
38
OZCENA.
H., in an article :  " New observations," etc.  Berlin Klin. Wochen-
schrift. No. 41, 1875.
    Among the 85 patients,  treated by  me, and  suffering  with
ozcena,  there were none affected with syphilis,  or  who had  ever
suffered with it.   This discovery will show conclusively, the cur-
rent opinion, hitherto held—namely  that  the principal cause of
ozcena was to  be  found in a process of ulceration of the mucous
membrane and the bones, from which this odorous secretion origi-
nated—to be eroneous.  Cases, where such  a process  is present,
must be very rare. I have not yet found any. In the convocation
of naturalists ( Wisbaden, 1873) I remarked, that according to my
observation, no ulcers were to be found in connection with ozcena;
that the scales had always been  taken as such by mistake.
    The unanimous contradiction met with then, would  no doubt
not be offered  again.   For  not  only  have my views, as then  ex-
pressed, been confirmed by a great number of cases, observed by
myself since that  time, but  also by Professor Zaufal; who says,
that he has found no ulcers  in  about 20 cases,  which he has  ex-
amined.  He also thinks, that where ulcers had been diagnosed,
it was done by mistake.
    I found the affection always  on both sides, except in one case.
The patient  was a man. 45  years  of age, who  had always been
weak, and had suffered much with cough and expectoration.   He
had been afflicted with this loathsome malady from childhood.
The septum was bent to the left.  The inferior turbinated bone
was very small—lying along the sidewall like a  small edge.   For
the first  time  I found here  the middle turbinated bone  almost
gone.   Only the third part of it, toward the  posterior end, could
yet be distinguished.  The entire roof was bare, as also the anterior
wall of the sphenoid  cavity, which had an opening on the right.
    The left nares was very much obstructed by the convex septum
projecting into it.   The inferior  and middle turbinated bones were
completely normal.   The mucous membrane somewhat wrinkled,
and uneven.   But there were no scales and no odoriferous mucus
present.
    His child, 8 years old, had  already suffered with ozcena for
about three  years and a half.  The cavities of the child's  nose
were very wide; the turbinated  bones having their  normal form,
but small. 
OZCENA.
39
                 DISCUSSION OF THE SYMPTOMS.

    In looking at the secretion, one finds, that it has a yellow-green
appearance.  Often  some  plugs  of pasty consistance, dirty gray
color, and horrible odor are taken  out.  The liquid  secretion is
yellowish-white, purulent, opaque;  sometimes aerated.  It cleaves
very tenaciously, and has a sharply unpleasant odor.
    The  first question, to be asked, is:  Where does this mass of
purulent mucus originate ?
    The glands of the  nasal mucous membrane have  the form of
grapes.   According to Luschka the mucous membrane is i^—3 mm.
thick.   In the  olfactory  region  {regio olfactoria)  the  glands are
smaller,  but are strongly drawn out  in  their length.  To  this
region the greatest part of the septum belongs, as also the superior
part of  the  nasal cavity,  reaching to  the  border of the middle
turbinated bone.  In  the respiratory region (regio respiratoria),
which is formed by the middle and inferior meatus, and which is
the broadest part of the cavity, the  glands  are much  larger,  and
are present in great number.—Luschka.
    The mucous membrane of the nasal cavity presents an exten-
sive surface, and is well adapted to  produce large masses of mucus.
In  ozcena we see the  mucous membrane affected only in a very
slight degree.   The scales may irritate and incite the healthy parts
of it to increased  secretion ; but  it is not swollen, spongy, and
thickened, as it is found to be, after it has been for years in a state
of chronic inflammation.  It adheres closely to its underlayer; it is
not in a state of hypertrophy.  For the most part it is  smooth,
shining on  its  surface, and in some places  not even reddened.
Its condition does not at all correspond to the quality and quan-
tity of the extraordinary nasal mucus  produced.   Moreover it is
to be noted, that the inferior turbinated bone, the  part, which has
the greatest quantity of blood, and which constitutes  the greatest
part of the respiratory region, is found to be in a state of atrophy.
While—there can be no doubt—that, as it  passes  away, a great
number of mucous glands are destroyed  also.
    But  the  facts, through which I was  first  led,  to look for the
main source of secretion—not in  the principal nasal cavities—but
somewhere else, are as follows:  After the mucous membrane had
all over resumed its normal condition—had a normal  appearance
—in consequence of the treatment instituted; there was neverthe-
less a yellow liquid mucus found daily in the pocket-handkerchiefs 
4o
OZCENA.
of the patients; and some scales were also noticed in the water,
used for injection.  Again, if the syringe had not been used, and
if  no injections had been made for a few days, the posterior ends
of the middle and inferior turbinated bones, the septum, and  the
head of the pharynx were again seen to be covered more  or less
with a layer of dried secretion and scales.
   On the  posterior end of  the  inferior  turbinated  bone, I had
often  noticed a yellow covering, having the appearance of an
ulcer.   But after injections had  been used (for which often i—2
liter of  water were used, on account of  the adhesive character of
the cream-like fluid secretion),  the  mucous membrane  appeared
again clean and pale-red, even where the scales  had  been.   The
most minute inspection, with  sun- and calcium-light, could  find
neither  ulceration, nor inflammation.  It was  found to be neither
rough nor swollen.
   I was therefore forced to conclude, that  the  purulent mucus
came from  one of the  side-cavities of the nasal cavity.
   The largest one is  the  cavity  of Highmore; the opening of
which is in the middle meatus, somewhat below the centre of the
middle  turbinated bone, on the sidewall  of the nasal cavity.   On
this spot I  have never seen any  mucus  or scales  anywhere  as a
rule on  the surface of the  inferior turbinated  bone below  this
opening.
   Aside from this it is  to  be noted, that  the  opening of this
cavity is about 3 cm. above the floor of the  same.   A discharge
could therefore not take place until the cavity was thus  far filled
with mucus.  But all the symptoms—such as toothache,  swelling
and reddening of the  face, which would necessarily be connected
with the filling up of so large a  cavity with purulent mucus,  are
entirely wanting in ozcena.   It seems  to  me therefore, that  the
maxillary cavities as a rule are not concerned in  ozcena.
    The frontal sinuses have their  openings  under  the  anterior
ends of the middle turbinated bones.  But in the anterior part of
the nares on the sidewall, or anywhere else, scales are very seldom
found;  and as it  can not be possible, that this very  tenacious
mucus  could flow off posteriorly—in  consequence  of  the de-
cided  sloping—without  leaving a trace  behind,  by which its
source could be discovered.   And as also  a yellow mucus is  very
seldom found flowing below the inferior turbinated bone, I believe,
I  can  offer the following proposition:  viz.,  that, as  a rule,  the 
OZCENA.
41
frontal sinuses are not at all, or not conspicuously affected in con-
nection with the malady under consideration.
   Perhaps in cases, where a swelling is noticed on the skin over
the nasal root, or on the glabella, they may  be more concerned;
but I have never as yet paid any particular attention to their con-
nection.—I have studied these parts on about 25 skulls, a part of
which were macerated,  while  the  others  had been preserved in
spirits.
   As to the cavities of the septum, T found large openings upon the
posterior ends of the middle turbinated bone.   1, 2, or 3 through
which the probe passed into the posterior and central  cells  of it.
A hole over the centre of  the free  border, through which the
probe entered into the anterior cell, was not so large.
    The opening of the sphenoidal cavity  was in  every case seen to
be 1—2 cm. above the border of  the choane,  and opposite the
posterior end of the middle turbinated bone.  There was but one
opening, and this mostly on the left side ; never at  the bottom of
the cavity, but always on its  roof
   The discharge of  mucus is hindered thereby, but it is acceler-
ated  by bending the head forward.   It is  further aided by the
circumstance, that the lining {Bekleidung—here  its mucous mem-
brane) of the cavity,  when in a state of inflammation,  is swollen;
and thus the bottom of it is brought nearer the  cleft-like or round
opening.
   The openings of the cells of the septum  were  all  found  low
down at the bottom.  These cavities are the largest next to those
of the maxillary.
   If  mucus is discharged from the cavities just spoken of—the
septum and  the sphenoidal cavities—while  the head is  in the
ordinary position, then  the mucus  thus discharged, must  run to
the posterior  end of  the middle  turbinated  bone,   whence it
drops down to the inferior turbinated  bone,  the nasal floor, and
the soft palate.   If the patient is  lying on  his back,  it  covers
especially  the  pharyngeal roof; lying on his  side, the septum.
Repeatedly I saw, in cases of ozcena,  in  patients with very wide
cavities, a yellow plug hanging out of  the opening of the  sphen-
oidal cavity on the left  side.
   Therefore  the reasons I have for believing, that ozcena chiefly
consists in purulent  inflammation  of  the side-cavities especially
those  of  the septum  and  the  sphenoid bone, are  now, in short,
given  as follows: 
42
OZNCEA.
    1.  The inadequate pathological proof  in the nasal cavity.
    2.  The manner in which the secretion  spreads in the posterior
 part of the cavity and on the pharyngeal roof; and its appearance
 there even after the nasal cavity has been healed.
    3.  The intense odor of the  purulent secretion  even in  its
 semifluid condition, showing that it comes from a cavity favorable
 to its decomposition.   For mucus, which is produced on an open,
 free surface, does not give an offensive odor.
    4.  The extraordinary obstinacy of the disease, which could
 not exist, if the mucous membrane of the nares  was  the cause of
 it; because in ozcena the mucous membrane of the nares is especi-
 ally easy to be treated throughout its extent.
    It might be supposed, that not only the  membranous  lining of
 these cavities was chronically inflamed, but  that also bone-necrosis
 was present.   There may be  indeed  some  little straps  of bone,
 dividing the cavities into pigeonhole-like partitions, which do also
 perish.  But an extended bone-necrosis, on the  superior wall for
 instance, would cause brain-phenomena; and on  the exterior  wall
 of the cavities of the septum  it  would cause disturbance of sight
 to a greater or lesser degree.  But all these phenomena are gener-
 ally wanting in ozcena.
   But the decisive word will have to be spoken  by pathological-
 anatomical investigation.  Yet I confidently hope  to see my ob-
 servations confirmed in every essential point.
   The complaint sometimes  made, of pressure over the eyes,  of
 dizzines, of heavy dull headache, might without  difficulty find an
 explanation in the fact, that the cavities, in  consequence of an ob-
 struction to their openings, are filled to excess.
   The second  prominent symptom of the disease under con-
 sideration is, the bad odor.
   It originates in this, namely, that the  purulent mucus, already
 odorous in its  semifluid, i. e. relatively fresh condition, is subject
to further decomposition, as the nasal cavity can be but  insuf-
ficiently emptied by the  blowing of the nose.  The secretion  has
therefore to remain in  it for days, thus accumulating  in large
masses.
   The proof, that the bad odor is  thus  brought about, and not
otherwise, is to be found in the  fact, that it  passes  away, as soOn
as the cavity is completely cleaned by methodical injections;  and
that it also stays away as long as the removal of  the exudation  is
regularly performed. 
OZCENA.
43
    Why the secretion can not be removed by simply  blowing the
nose, without the aid of injections, is partly owing to  its adhesive
nature;  but more than this to the  circumstance, that the  nasal
cavity is very much enlarged, and the air, forced through it, has
more of a chance to pass by—to escape.   Zaufalbelieves, that the
abnormal enlargement of the  cavity is brought  about by a  rudi-
mentary growth of the inferior turbinated bone.  And that in con -
sequence of the stagnation  of the  secretion putrefaction  takes
place; that ozcena  is not  so much a disease  sui  generis, as a
symptom of stagnated or putrefied secretion in the nares.
    My view of  the nature of ozcena I have  tried to substantiate
above, and here I would only add, that to me the diminutive size
of  the  inferior  turbinated  bone  seems  to be less an  hereditary
phenomenon than a consequence of the  disease.
    According to Kohlrausch the veins of the inferior turbinated
bone consist in a really cavernous network {Netzwerk), which ex-
tends as a layer about 4 mm.  thick, between  the periosteum and
the mucous membrane.  (Luschka.—"Anat. of the Head.")
    This vascular submucous  tissue  is either entirely wanting, or
substantially reduced in ozcena patients.   For the  inferior  turbi-
nated bone feels hard, and is not at all or but very little elastic, ac-
cording to the degree of atrophy.  It has lost  its faculty  to  swell.
It does not swell after cauterization, nor are ozcena patients subject
to acute catarrh, after having contracted cold, or a  complete ob-
struction of the nares like healthy persons.
    My theory of the process is as follows: Originally the patient
as a child was  subject to a more or less  violent catarrh  of the
nasal cavity  and  its side-cavities.  But  as  his  constitution was
weak, lax and scrofulous, the  tendency to overcome  the affection
was not sufficiently strong, and it  therefore remained.  In conse-
quence of this chronic  catarrh, which  was often acutely aggra-
vated—an expansion of the submucous  tissue—ensued, and the
subsequent contraction of it brought about an erosion  of the sub-
mucous vascular tissue.
    The sallow  appearance of ozcena patients  may  be brought
about by the loss of so much purulent secretion, containing albu-
men ; and the infection of the air inhaled through the nares.
    Sometimes, no doubt, the appetite is also diminished on account
of the feeling of nausea, brought about by the mucus cleaving  to
the posterior surface of the soft palate and the pharyngeal vault. 
44
OZCENA.
The mucus,  by  being  swallowed, may also produce  stomach-
catarrh.
   Dryness in the throat is in many cases described as very trouble-
some.  In examining  the throat, the posterior wall is found dry,
smooth and shining, as if it were covered with a thin transparent
cover of  varnish.  But the mucous  membrane is  not thickened,
swollen, roughened, or reddened ; but on the  contrary is found to
be pale and thin.  The posterior surface of the  uvula also has a
dry  appearance.  This condition  has been  described  as " dry
catarrh ", but I have  never found it in  connection with healthy
nares, and do not look at it  as an independent form of throat-
disease, but  as  an affection, which is very often  found in con-
nection with ozcena.
   With  other  patients,  having their nares obstructed in a great
degree—which is very seldom the case in connection with ozcena,
and then only for a  short time—by  polyps, chronic  catarrh, or
hypertrophy  of  the pharyngeal tonsil, and who were  obliged  to
breathe through the mouth exclusively, I have never found this
wall dry.  They only  complained  of  dryness  in the throat after
fast running,  or during the night, after they had  slept  for several
hours.
   The obstruction of the nares then can  not be the cause—at
least not  the  main  cause—of  this phenomenon; nor is it to be
supposed, that the mucus found here  (on the walls of the  pharynx)
comes down from out  of the nares.  For  it is not purulent, yel-
low, but light-gray and  transparent,  covering the walls like  an
even layer of glue.  The facts in the case seem to me to be these :
The normal watery mucus  is  secreted in very small  quantities;
hence, as soon as it has come out of the glands to the surface  it
dries.  Thus we find the cause  in a defective action of the mucous
glands.
   Below the region of the root of the tongue  the wall is moist,
evidently because in swallowing, it is  constantly besmeared by the
tongue, and also on the pharyngeal roof, and  the superior part of
the posterior wall, because the great number of glands aid the
pharyngeal tonsil  in  as  far as it  has not also been subject to
atrophy.   I look at this dryness or defective, insufficient action of
the mucous glands as  a result of the atrophied state of the pharyn
geal mucous membrane.  And I am strengthened in this belief by
the observation already made, viz., that I have never found hyper-
trophy in connection with ozcena, either of  the uvula,  the palatal 
OZCENA.
45
tonsils, or the mucous membrane and pharyngeal glands (chronic
pharyngeal catarrh), or the pharyngeal tonsil.
   As to the trouble in swallowing—dysphagia—it is,  no doubt,
caused by the dryness, as also by an accumulation of the secretion,
and crust formation on the posterior surface of the uvula and the
posterior pharyngeal wall.  Some patients complain  especially of
dysphagia, and  of a sensation as if  a foreign  body was  in the
throat, &c They complain of obstruction by mucus (Verschleimung)
in the throat.   And as the mucus is loosened  through the acts of
mastication and  swallowing—they  complain,  that thick knots of
yellow-green mucus often fall  down into  the  throat from above>
while they are taking their  meals.
   They generally point to the region of the hyoid bone to show
the seat of affection.  Not a few have in consequence of this been
treated  by  different physicians for throat  disease.   They were
astonished to learn that their throat  was perfectly  healthy; but
that instead their nares were diseased.
    Finally there remains for discussion the partial or entire loss of
smell.  According to Vierordt there are branches of  the  olfactory
nerve on both sides reaching through holes of the septum into the
nasal cavity, distributed in  a  double row.   The  exterior row
spreads on the interior wall of the labyrinth of the vomer and the
superior and middle turbinated  bone.   The interior row spreads
on the superior and anterior part of the nasal septum.   Thus the
exterior row in part spreads over a region, which is covered with
a thick and  chronically inflamed mucous membrane.   This fact
alone explains  sufficiently, why the ends or the nerves can not be
reached, can not be touched by odor, the specific means of their
irritation.
    The taste was never  found  to be  diminished in  a  perceptible
degree. Nor was it but seldom found that an ozcena patient suffered
at the  same time  with deafness.  Progressive hard hearing was
found in one case.  In several cases I found purulent inflammation
of the tympanum in connection with  ozcena.

                          TREATMENT.
    The first thing in order is to get rid of the bad odor, to remove
 the secretion.
    The nasal douche does not  suffice  for  this, as  I have  had a
 chance to learn from a great number of patients who had in vain
 used salt water, solution of alum, &c, for a long time. 
46
OZCENA.
    A complete cleaning can be perfected by means of the syringe,
which I would especially  recommend ;  it can  be bought  of the
trussmakers, where it is known as '' the english  spray "  (englische
Spritze).  It consists of a  bulb with a  valve-like  apparatus in its
interior; has  a tube on  each of its  ends, about 1-5- to 2  feet in
length.
    One end, made heavy by means of  lead, is put into a vessel,
containing water;  the  other end, the tube of  which is a little
longer, and has a little  pipe of horn attached, is pushed  into the
nares.  Then it is brought into a horizontal position and gently  laid
to  the  septum.   After  the  air has  been removed, by  a  few
compressions of the bulb, and it has been  filled  with  water, the
full bulb, held in the hand, is about half emptied by a short com-
pression;  then a pause  ensues to  let the water  flow  out of the
other nares.  An uninterrupted pumping—forcing  of water  into
the nares and  the pharyngeal vault—calls for an  incessant strain-
ing of the uvula (lavaterpalati), in order to keep the mouth shut
off from the pharyngeal vault.  If its  strength fails only for one
moment, the openings of the  Eustachian tubes, which are closed
by the raised  uvula, become freely open, and thus the water would
have free access to the  tympanum, and  much  pain  and  even in-
flammation might ensue.
    An act of swallowing, whilst the nasal cavity  is full of  water
also very much aids the water in entering the tympanum (Mittel-
ohr).  As  I have observed in my mirror-pictures, that  in  swallow-
ing the Eustachian orifices are widely opened.
    A sudden pressing out  of  the entire bulb of the  syringe then,
is, aside from the violent, painful dashing of the water against the
walls, also inadmissible  for the reason, that the  water, not being
able to flow off fast enough, and therefore, under strong  pressure
in the pharyngeal vault, might overcome the strength of the parts,
which close the Eustachian  tubes, and thus  enter  forcibly  the
tympanum.  Some few patients came  to  me  and complained of
having had pain in one or  the other ear during the time of or after
the injections.  But when  I requested them to show me how they
had used the  syringe, I learned, that they had emptied the bulb
too suddenly  and too strongly.  They  had not  followed my  in-
structions.
    The syringe has the following merits over the nasal douche:
    1.   The force required to drive the water into the  nares, can
easily be determined by the feeling of  the  hand, and by a little 
OZCENA.
47
shifting now and then, whereby the point of the tube is  directed
to a different part of the wall, the  cavity can be easily and surely
cleaned; however tenaciously the  scales and the mucus, still in a
liquid condition, may cling.
    2.   On a  journey, or away from home,  it can be used without
attracting much attention.   On the contrary the nasal douche has
the following disadvantages : First, It provides too weak a stream,
it only softens, but does not  carry off; on which account it requires
much more time, unless the  sticky  secretion is to be removed only
in part;  Second,  Its application  is more  difficult,  because  two
vessels are required, and one of them must stand  in an  elevated
position.
    Those, who have used the nasal douche  for months without any
result, are best able to acknowledge the merits and  reliability of
the syringe.
    According to the degree  of affection and the mass of mucus
accumulated, i, 2 or 3 liters of water is forced through the nares in
the morning  and  evening, sometimes also  in the  afternoon.  In
winter the water is made warm ; in summer this is not necessary.
    If after this syringing the nares  are completely open, respiration
unobstructed; the palate feeling free; and the air, expired through
the nares, devoid of odor—it is evident,  that the  cavity is well
cleaned.
    Now the cleaning of the side-cavities will be taken up.
    If a larger quantity of  water  is thrown  into the nares, than
happens by half emptying the bulb, then one may see a stream of
water coming out of the other nares immediately  after.   Then a
little pause ensues,  when again as  much more water comes out as
at the first time.   As soon  as the first water has flowed off,  the
patient lets the point of the  tube  in his nares  slip out and shuts
up both nares with his thumb and  indexfinger,  at the  same time
bending his head  strongly forward, and keeping it down quite low
for a few minutes.  Thereby the water is forced to enter the side-
cavities—the openings of which  have been freed of mucus—
especially the cavities of the sphenoid and  the septum.  A pain-
ful  feeling in the  head above the eyes, and the  slow dropping
down of water from the nares shows, that this has taken place.
    I add to the water 1, 2 or 3 tablespoons full  of chlorate of
potassium, which  has  previously been dissolved in hot water.
    The roughened, wrinkled spots on the  inferior  and middle
turbinated bones  I cauterize once  a  week with the galvano- 
48
OZCENA.
cautery,  or  with  nitrate  of silver, or with potassium causticum in
substance.   The galvano-cautery has to  be applied very slightly,
as no hypertrophied submucous vascular  tissue is  present.  An
incautious  application therefore  might  instantly  cause violent
toothache.   On the septum, as in the nares in  general, I deem  it
advisable to cauterize only in spots, because  otherwise it causes
very easily too much  and  too  severe pain and  affection  in the
head.  The bluestone-wire must also be applied lightly and super-
ficially, especially on the anterior part of the  septum, to prevent
a tearing of vessels or other serious consequences.  In one of the
first cases, treated by me, a very disagreeable  accident happened
after cauterization on this spot.
    Formerly I prescribed  and  tried insufflations  of  nitrate of
silver, sulphate of zinc (i: 10: 5), of pure creosote-powder, of flores
sulph., of chinin sulph., in solution, of alumen acid, etc.,  as long as
I supposed the principal  seat of  ozcena to be  in the main part of
the nares, and there only.
    Lately, for the reason given  above, I have  more  and more
abandoned  this treatment, and  have relied chiefly  on  a correct,
conscientious and cautious use of the syringe.
    The results of this treatment are  as follows :
    In the first place the penetrating odor is entirely removed  by
complete cleansing—a result, which  is of great importance  to the
patient.
    After a few weeks the secretion diminishes; it becomes clearer
and more watery, as can be seen in  the water  used  for injection.
If one sees  the patients again after  2—3 months, he is  astonished
to  notice,  how much  they have  changed  in  appearance.   The
morose, vexatious countenance,  the aged, sallow appearance have
passed away.  The complexion  is clear, the face full and round,
the cheeks round, which again gives them a youthful appearance,
corresponding to  their age; they feel clear  and free in the head,
more comfortable, stronger, and  healthier.  As the patients  can
manage the treatment chiefly themselves,  the  greater  number of
them are soon lost sight of.   But in about 25 of the whole number,
treated by me, who were adults  with very extensive ozcena,  I have
made observations for from 1 to 5 years, by having them come to
me every 2  to 6 months.   Some of them could dispense with the
injections for 8 to 10 days without the formation of scales, and bad
odor resulting again.   But  the  majority  had to use  the syringe 
                           OZCENA.                        49

 daily or every other day, whereby sometimes a few yellow scales,
 or thin small crusts were found, but at other times none at all.
    The sense of smell is also often improved.
    The injection  causes  no trouble,  is  accomplished in a few
 minutes, and to those, who have always been accustomed to clean-
 liness, it soon becomes a necessity, as much as the cleaning of the
 teeth.
    Well may I say, that I have merited a feeling of gratitude  from
 many a patient by my method of controling a disease, the ugliness
 of which has even at this time given cause for divorce.  But as yet
 I have not been able to see a real cure  perfected.
    By a real cure  I mean an entire and a lasting cessation of the
 yellow, odorous mucus-secretion, and an exclusive production of
 clear watery normal nasal mucus.
    The cause of its obstinacy evidently lies in  the  fact, that the
 involved side-cavities can not be reached by strong cauterizations;
 that only such persons are affected with the disease—the  lax vas-
 cular tissue of whom tends to a slow degeneration, and who  have
 a scrofulous diathesis.  By  a  removal  of the middle  turbinated
 bone the cavities of the  septum would become  more accessible.
 But a patient may not easily be  found, who is willing to have this
 experiment tried on him.
    What has been said and written  heretofore about a complete
 cure of ozcena, I must very much doubt according to the experience
 I have had.  But I am yet in  hopes, that I  shall approach nearer
 to this end, which may already have been attained by some youth-
 ful patient  without  my knowledge, by the following treatment,
 which I have lately begun to apply.
    After the nares have  been completely cleaned, and  the side-
 cavities are washed out in the  manner described above, water is
 injected successively  10 to 15 times, both morning and  evening,
 with a solution of chlorate of potassium (1, 2 or 3 tablespoons full
 to a liter of water), which is made stronger according to  the  abil-
 ity of the patient to bear it.
   After a few cauterizations or insufflations of pulverized chlorate
 of potassium, which the patient may do in the morning into one
 nares, and in the evening  into  the  other for 1 to 3 weeks, when
the mucous membrane of the nasal cavity  itself is generally found
to be smooth, shining, pale,  and  normaly reddened.
   Chlorate of potassium  has already been  applied  by Siegle, by
means of an inhalation-apparatus, and Eyselein has used it in  con-
        7 
50
SYPHILIS.
centrated solution for cauterization with  the  brush in cases of
ozcena, and has seen good results.
   Permanganate of potassium, which colors lips and cloth, car-
bolic acid, which spreads a very disagreeable odor,  are according
to my experience much inferior to chlorate of potassium, as far as
effect and acceptability are concerned.
   As  large quantities of the salt  (Chlorate  of  potassium) are
generally used, I  advise  the patients  to  buy it at the wholesale
drug stores by the pound.—The sharp spoon (der  scharfe Loeffel
—Schede) can not be used in this  affection;  for there is  nothing
to be removed but the scales and the secretion, and for that the
syringe suffices.
   It might be commendable to apply the term ozcena only to the
disease, which has just been  treated of in the  foregoing remarks,
and which according to my understanding consists  in  a  chronic
purulent inflammation of the side-cavities of the nares, and which
has endured from childhood.
   Other more or less odorous affections  of  the nasal  cavity can
easily be diagnosed by examination, as  also by the fact, that they
have been acquired  in  later  years,  and consist  in  malignant
tumefaction—syphilis, or scrofulous necrosis.   (The latter very
seldom, as I have seen it but once.)
          V. SYPHILIS IN THE NASAL CAVITY.

   In cases of general syphilisation (general lues) the nasal cavity
is often affected with ulceration and  bone-necrosis, a fact, which
is well known.  But hitherto  the diagnosis, made  by  direct ex-
amination, has only been possible  when  striking changes  were
present at the entrance  of the  nasal cavities ;  such occurrences
only being presumed otherwise when purulent secretion appeared.
If pieces  of  bone came  out, this furnished  most  unmistakable
evidence,  and if the nose fell  in, that  was  regarded as the  most
sad reality of its presence.
   The local treatment heretofore was confined to the snuffing up
of water and the nasal douche.   Both of which, however, are in-
sufficient for the treatment of extended  crust-formation.   Clean-
ing of  the cavities, together with a careful touching of the ulcers 
                           SYPHILIS.                        51

in the nares, the mouth, the pharynx, the throat, or in general all
over, wherever it were possible, was  not done.  However  in the
face of such evidence, as has been  given in the  foregoing  pages,
to wit:  that the nasal cavity  can be  inspected and  examined as
completely  as may  be  necessary;  it  can not well be  longer
neglected.   I am convinced, that an early and careful use  of the
speculum and the rhinoscope will  prevent  such disfiguration of
the face  as  is brought  about by  a falling  in  of the nose,  or the
cicatricial distortion of the nasal wings.
    My observations  relate  to  cases, where, after the disease in
general had  been overcome,  a relapse ensued, which was chiefly
confined to  the nasal cavity.
    In one case there was  also an ulcer on the posterior surface
of the uvula.  In a second case a large ulcer was found on the
back.  With others nothing could be seen, which might be traced
to a general affection (Lues).   There was no trace of efflorescense,
or  swelling  of the glands.   3, 5 or to years  even  15 years had
elapsed since an  infection  had  taken place,  and  that had been
cured by means of embrocations with  "gray ointment  (grauer
Salbe), and the use of mercurial pills."
    Whenever this  fact could  not be  learned directly from  the
patients (by  anamnesse—recollection), i. e. in cases  of ladies,  be-
longing to the higher classes, I concluded from the results,  which
were reached in a short time  by the administration of Iodide of
potassium, and a few cauterizations, that  the  ulcers  in the nares
had originated from syphilis.
    After a few days even an improvement would be  noticed, and
soon the healing would be perfected; notwithstanding much effort
with different remedies  had been previously put forth in  vain for
the  relief of the purulent secretion,  crust formation, obstruction
and pain.
    I have not  yet seen an ulcer in the nares,  which could not  be
traced to syphilis, either through the  confession (anamnesse)  of the
patient, or the success reached with the remedies exhibited.
    If a  patient presents  himself,  and complains of having had
for some time obstruction in the nares, due  to formation of  crusts
and  scales, which can only be removed with the greatest difficulty,
and  of pain  in the nares at times, which spreads from the  nares to
the head; then it is evident, that there is ulceration present in the
nares, which has originated in syphilis. 
52
SYPHILIS.
   Ulcers on the middle  turbinated  bone  seem to be  the most
painful.  According to my experience  only malignant tumors of
the nares cause more intense and  extensive  pain.  But an exam-
ination with the speculum shows immediately that these are syphi
litic ulcers insteat of malignant tumors—as  the cavity  shows itself
more or less filled  with light-green scales;  after the  removal of
which by the syringe, an  ulcer is discovered on the  inferior or
middle turbinated bone or the septum
   The latter is often perforated, and very  often a long  or oval
hole is seen in its cartilaginous part, and the bony part bordering
on it.   In one case  only did I see the  free border of the bony
septum  only remain, which  stood  like a thin blade between the
choanae  In twO cases it was wanting for the greatest portion, and
through the left nares I could see the  right Eustachian tube  dur-
ing swallowing, etc.; and in this case I could partially renew my
observations on the action of the muscles of the pharyngeal arch,
as I have described them.
   The parts, where these syphilitic ulcers produce the most  dis-
figuration of the external  appearance  of the nares, are, the carti-
laginous septum, and the anterior  end of the middle  turbinated
bone,  from where an  ulceration can  easily  spread  to the nasal
bridge, and thus necrosis ensue.
   Ulceration on the anterior end  of  the inferior turbinated bone
can easily spread to the cartilaginous nose, and cause disfiguration
of the nasal wings.   An account of a  few cases will follow here in
a condensed description.
   H. B,, of Cologne, 28 years old, had been infected  with syphi-
lis 4 or 5 years ago.  Has been married for two years; is father
of a healthy child.  For the last four  months he suffers with ob-
struction in the left nares.   A thin, watery, yellow  mucus flows
out;  sometimes his breath  has a  disagreeable  odor.   Lately an
unbearable pain became associated with it, which increased, espe-
cially on the left side, just after retiring at night.   His face appears
cachectic, anaemic, and somewhat  emaciated.  Nothing could be
seen on his body, pointing to syphilis.  Finally  his  family physi-
cian had again prescribed "quicksilver pills," but without result.
July 13, 1872.
   The speculum shows, that the left  cavity is obstructed  through
swelling of the middle turbinated  bone, the mucous membrane of
which is intensely reddened, and lies close to the septum, where-
by the view into the pharyngeal cavity is obstructed. 
SYPHILIS.
53
   With the rhinoscope the  middle turbinated bone (as much of
it as can be seen) is found  to be  yellow and ulcerating, and its
immediate  surroundings markedly hyperaemic.
   The right nares  is sound.—I prescribed  Iodide of potassium,
2 : 200.
   On the  19th of June the  patient  returned  and reported, that
after he had taken the medicine for 3 days, the pain passed away,
and that now the nares was open again, and he was able to breathe
through it.
   Examination proves, that the ulcer belongs only to the middle
turbinated  bone.  It has  become  smaller,  and  the  swelling has
diminished.  The view into  the pharyngeal  nasal  cavity is in part
re-established.
   The patient was now directed to use the same remedies for a
few days more.   About a year and  a half after  this, he came to
tell me of his complete recovery.
   Mr.  X., of E., says, that he has for some months had obstruc-
tion  in  the right nares, in connection with profuse production of
yellow—and at times more watery—mucus, with  heavy dull head-
ache.
   On examination, an ulcer is found  in the  right nares  on the
anterior end of  the  inferior turbinated bone,  with  a wall-like
border, which  has  the appearance  of a piece  of bacon,  and  is
about 1 cm. in diameter.   A second ulcer, opposite on  the septum,
is more flat, and a third one is found on the nasal  floor under the
one on the  inferior turbinated bone.  The cavity can only be in-
spected in  its  anterior part.  The  inferior  and middle meatuses
are closed through swelling of the  turbinated bone, etc.
  The patient says, he  was  treated  for  syphilis many years ago,
by a physician in Silesia, but had  since  been pronounced com-
pletely cured by several physicians in Aachen.
   On his breast and back an eruption is  found, consisting of dark
red pimples.—Prescription :  Iodide of potassium 5 : 200, a  table-
spoon full 3—4 times a day.   Aug. 23, 1872.
   On the  first of September the patient reported, that his right
nares was  completely  open, and that the  profuse  secretion of
mucus had nearly ceased.
   All the  ulcers are now  smaller  than  they were—the swelling
having disappeared.  They are cauterized with nitrate of silver in
substance  Iodide of potassium is continued internally.
   September 15th, the ulcers are  completely healed.   The right 
54
SYPHILIS.
cavity is entirely open.  One can see through into the pharyngeal
vault.
   Mrs. B., of D., of healthy, corpulent appearance.  Has for the
last year continually been afflicted with obstruction in the right
nares with yellow secretion,  formation of scales, and  sometimes
pain, which extends to the right  side of the head.  The voice has
somewhat of  a nasal tone.   The sense  of smell is gone.  Snuff-
powders  (Schnupfpulver), cauterization  with bluestone  of  the
supposed polyp, snuffing of water (Schnupfwasser), etc, were used
without avail.
   Examination Nov. 7th, 1873.  The inferior turbinated bone is
wanting up to the posterior third of it, which is also very much
reduced in size, but roughened and reddened.  The middle  tur-
binated bone is much swollen, is in a condition  of  ulceration on
its concave surface and border, and  touches the septum ; poster-
iorly the  septum is nearly in  its entire extent  changed into an
ulcer.
   With  the  rhinoscope the  inferior  turbinated bone can not be
seen.  The middle one is intensely reddened and  swollen.   The
middle meatus is entirely  closed, because the turbinated bone
touches the septum.   Of the superior turbinated bone only a small
part is to be  seen, which is yellow, and in a condition of ulceration.
On the left side the middle  turbinated bone is also swollen, ulcer-
ated and yellow.—Prescription :  Of a solution of Iodide of potas-
sium 4: 180,  one tablespoonful 3 times a day.
    Nov.  16th. Two bottles of medicine have been used. The sense
of smell has returned ; breathing through the nares is easier; nasal
speech has diminished ; the ulcers are smaller, and  the swelling is
much reduced.
    Cauterization with nitrate of silver, and an  application of the
galvano-cautery  were used to  reduce  the  hypertrophy  of the
mucous  membrane.  Within  three  weeks the  ulcers were  com-
pletely healed.
    Mr. H., of C, has suffered for some  months with  obstruction
in the nares  of a high degree.   He complains of profuse yellow,
cream-like secretion; his head feels  dull and heavy, the face is
bloated,  and the eyes are red as in a case of violent acute catarrh.
    On examination the middle  turbinated bones are found  swol-
len, reddened, and touching the septum.  The inferior are moder-
ately hyperaemic, but less swollen, while the middle  and superior
meatuses are completely closed.  Ulcers are nowhere to be found
either anteriorly or by examination with the rhinoscope. 
SYPHILIS.
55
   A solution  of chlorate of potassium is prescribed with which
the superior side-cavities are to be washed 2 to 3 times daily, as
described in the chapter on ozcena.
   After  about ten days his condition appeared  but little  im-
proved.  No change was found on  examination.   Patient says,
that  he was afflicted  with syphilis  about 5 years ago.  He now
began  to take  Iodide  of potassium, which after a few days pro-
duced  a  noticable change, and after 14 days, the yellow mucus,
the obstruction, in short all the symptoms had disappeared.   The
face had a bright healthy appearance.   The inflammation  of the
middle turbinated bone was removed, and the  nasal cavity was in
a normal condition all over.  Whether in this  case  an ulceration,
which  had originated in syphilis, had been present in the cavities
of the  septum,  and had become more violent through the irritation
of a severe acute catarrh—I am not prepared to say.
    Mr. T., a strong man, about 38 years of age, has been afflicted
for the last year with a very irritating formation of  scales in the
right nares, often causing an obstruction with all its inconvenien-
cies.  Lately this has been accompanied  by  violent pain, which
at times came  very suddenly, and  spread  from the nares to the
face and forehead.   Five years ago the patient was afflicted with
 syphilis.
     On examination an ulcer was found on the exterior wall of the
 cartilaginous nares, spreading to the anterior  end of the inferior
 turbinated bone; also one on the anterior end of the middle tur-
 binated  bone.
     Prescribed Iodide of potassium.  After a  few  days the pain
 passed away.  Five cauterizations were made with nitrate of silver
 in   substance,  and  in three weeks the  nares were completely
 healed.—At home the  patient cleaned  his nose twice a day by
 means of injections.
     Mr.  X., of  Westphalia, 40 years of age, of  very healthy consti-
 tution.  Ten years ago he was afflicted with syphilis; i. e. he was
 at that time treated with  sudatory (Schwitzkur), wood-decoctions
 (Holzthee), and pills  for a long time on account of an (ulcuspenis)
 ulcer  on the penis.
     He complains of having had obstruction in the right nares for
 a long time (it is now September 8th, 1875), brought about by the
 formation of scales,  accompanied often by headache to a consider-
 able degree. 
56
SYPHILIS.
    After the  nares had been cleaned, it could be  seen, that the
 anterior end of the middle turbinated bone was in a condition of
 ulceration; the bone being bare in part.
    Iodide of potassium  internally, cauterization  with nitrate of
 silver, and the removal of a piece of bone after it had become
 loose; besides the daily use of a syringe brought  about a healing
 in a few weeks.
    After about six months the patient came again  to me and said :
 " I have fared badly  of late ;  for in the last seven weeks I have
 besides a copious discharge from the nares, suffered with intense
 headache, extending  from the head  to the face.   It began here
 (pointing to the region of the  right nasal wing), at the  side of  my
 nose, and spread to the cheek-bone, and over the forehead, behind
 the ear."
    I thought, it must have been a  trigeminus neuralgia.  The
 family physician had  also  been of the  opinion, that the  pain could
 have no connection with the affection in his nose.  He did not
 deem it prudent however  to prescribe Iodide of potassium, when
 the patient told him, what wonderful effect it  had on  his former
 headache.
   But I  was struck with amazement,  when through the speculum
 I saw the bare bone, gazing at me.  There is not the least doubt,
 that the irritation of the nerve  had been produced from the ulcer-
 ated condition of the inferior turbinated bone.  If  the patient had
 taken Iodide of potassium, as  soon as  the  pain began, the sup-
 posed idiopathic neuralgia would  have passed  away within  two
 days.
   Of  the 25 cases  treated, there were but  a few, who did  not
 complain  of pain, who only complained of a heaviness of the head,
 and a discharge of purulent secretion.
   A bad odor, as  in  ozcena, is not connected with  it,—at least, it
is not nearly as prominent and constant.
   In a few cases a rough piece  of bone  exfoliated, which had
come from the anterior end of the middle  turbinated  bone.   In
some cases thin, smooth laminae from the bony  septum were dis-
charged. 
TUMORS.
57
         VI.  TUMORS IN THE NASAL CAVITY.

    Mucous polyps,  commonly  called  nasal  polyps, rank  first
among all the  tumors found in  the nasal cavity in point of fre-
quency.
    Not less than  135 of the persons, who came to me on  account
of  nasal affections,  were afflicted with  polyps.   The youngest
among them were from 10 to 12, the oldest 70 years of  age.  105
were males, 30 females.   I operated on 125 of them.  They were
generally unable to give any more definite information than that
they had suffered for  a.  long time with  mucus-obstruction in the
nares, and  frequent catarrh.
    Often the same was said of brother, sister or  the  parents, and
the patients always informed me, that they had ever  had  a great
tendency to contract cold, and always felt very delicate in a sud-
den change of temperature, and  that lung  affections  had often
been  present.  In short, there were very  few of them, who had
come from healthy parents, and who had been very healthy them-
selves from their  youth.

                          SYMPTOMS.
    Profuse secretion, mostly of yellowish  mucus,  and  seldom
purely watery, from the nares and pharyngeal vault; obstruction
of the nares often growing worse acutely  from swelling of the
polyps,  uneasy sleep,  snoring,  and loss of  smell—are the most
common phenomena.   Also a sallow  pale appearance, poor taste,
a stale,  sweetish odor of the breath, a frequent want  of appetite,
and choking  every  morning, as the mucus, which had accumu-
lated in the pharyngeal vault, has to be  removed.
    With very  emaciated patients  profuse secretion is almost en-
tirely wanting.  Headache, dizziness, partial loss of memory, and
difficulty in intellectual work are sometimes  observed, especially
where numerous  excresences have been in  existence for years.
The troubles in breathing have as a consequence, an  inability for
physical employment, which requires much excertion.
   Bronchial  catarrh, emphysema with pneumonia, was  often
pointed out, but attacks of asthma, as  Voltolini more recently also
Haenisch has described, as dependent  on nasal polyps, have not
been observed.  Severe spasms of sneezing were observed  once.
   The patient, an old gentleman, was obliged every morning  as
       8 
58
TUMORS.
soon as he left his bed, to sneeze, till  he was quite exhausted, in
consequence of a strange tickling in the left nares. Besides other
polyps there was to be seen in this case a round  soft one  of the
thickness of a finger,  that projected with a thin pedicle from the
anterior end of the middle turbinated bone, as could  be plainly
seen after its removal.
    Through swelling  of the polyp, it evidently rubbed against the
septum, which, as is well known, is richly supplied from the naso-
palatine nerve of Scarpa (II Ast d. trigem.—branch of the trigem);
these producing the sneezing, which ceased from  the moment the
polyp was removed.
    Chronic partial  deafness or frequent acute affections of the
ears were very seldom complained of.   If polyps had grown out
of the choanes, or hypertrophy of the  pharyngeal tonsil was pre-
sent, then the patients complained more frequently of hard hear-
ing, and  of pressure on one or both ears.  But these phenomena
can just as well be brought about in  a mechanical  way—as the
polyps and  the pharyngeal  tonsil hinder the movements of the
Eustachian  tubes,  and  thus prevent  a sufficient opening of the
tubes—as also in consequence  of an  intercurrent catarrh of the
middle ear.
                         DIAGNOSIS.
    If the bony and cartilaginous nose  is swollen—the former con-
dition seldom occurs with polyps of common size—or the  polyps
hang very far toward  the front, the diagnosis can sometimes be
made by simply raising the point of the nose; but generally the
speculum will be needed.  The speculum gives information of the
fact in general, that light gray tumors are in  the  nasal  cavity.
With the rhinoscope it can be learned, whether they extend to the
choanse or not.   Nothing definite can  be  known concerning the
number and seat of the  polyps only  in the course of  treatment,
because they are one behind the other, and mostly too  close to-
gether.
    The seat of the nasal polyps is  according  to my experience in
far  the most cases, not  the superior wall—the  roof  of  the nasal
cavity, but the middle  turbinated bone.   In cases where polyps
have been present  for years,  it is much  larger than the inferior
bone, and its concave  surface is considerably developed.  The
inferior turbinated bone is often found to be much flattened and
diminished in size. 
TUMORS.
59
   First of all, the anterior end of the middle turbinated bone is
to be mentioned as the place, where polyps most often grow,  and
next the free border, the concave  surface, and the posterior  end,
from where those mostly come, which hang down into the choanae.
The elevated position of this turbinated bone enables the swollen,
raised mucous membrane easily to lower itself, and thus gradually
form itself into independent tumors,  and  the  circumstance, that
in blowing the nose, the mucous membrane on these spots is very
much hit by the current of air, whereby the swollen  membrane is
still more raised, may be taken into  consideration,  in explaining
the fact just  mentioned.  Sometimes a chronic inflammation in
the ethmoid cavity, the interior wall of which  is  formed by the
middle turbinated bone, may be the cause of polyp-formation.
   On the inferior turbinated bone soft polyps are  seldom seen ;
only such changes,  as have been  described in the  chapter on
chronic catarrh, are generally to be found there.
   With persons, who for  20 years and longer have suffered  with
polyps, those raspberry-like tumors,  projecting  from the concave
surface, are found much enlarged  and vibrous.
   Only a few times did I see some small polyps project from the
anterior part of the septum.—The roof of the nasal cavity furnishes
but a small strip of mucous membrane, and  I can not say, but that
I have at most  only in 8 or 10 cases  seen  tumors  hanging down
from there.  The nasal floor I have never seen participating.

                     NUMBER OF POLYPS.
   Very seldom is a solitary polyp to  be  seen. Once I operated
on  an  old  lady, who had only  one polyp, which was somewhat
drawn  out lengthwise, of a pale color,  and had  grown on the
anterior end of the inferior turbinated  bone.   Two  patients had
each one  tumor at  the entrance of the  bony cavity, projecting
from the septum.  Twice  I saw two or three tumors, which had
grown on the posterior end of the middle turbinated bone, hang-
ing down into the pharyngeal vault.
   The patients could inspire comparatively easy, but  could  not
expire through the involved nares, because the  polyps acting like
a valve,  closed the  choane.   At first sight  in the rhinoscope I
thought they had their origin on the roof of the pharyngeal head ;
but after the operation I found this to have been a mistake, which
may have occurred before  in the same  manner.
   With  eight  patients one of the nasal  cavities was free;  but 
6o
TUMORS.
generally both nares were filled with tumors, the number of which
varied from 10 to 50.   The small recent polyps  are, as a rule, as
large as a green pea, and round when they arise from the concave
surface of the middle turbinated  bone,  and of  oval form, when
they have grown from its anterior end, or from its free border.
   According to the width of the middle meatus, or the height of
the cavity, the tumors are developed either thicker or longer. The
thickness and width of the thumb will represent even the  largest
polyp which may be found in the nares.
   Those projecting out of the choanes, have  more room  for ex-
pansion, and thus some are found here as large as a  pigeon's egg.
The largest  I have found belonged mostly to those  persons, who
had for many years been afflicted  with the affection,  and who had
wide cavities.  The older polyps are harder, contain more  fibrous
tissue than the younger, which are light  gray, often  nearly trans-
parent, and  for the greatest part contain only liquid matter, and
but little soft fibrous tissue.   In  the  centre  of  some of the soft
tumors a clear white, round spot is often to be  seen, as if  a little
white  grain had been put in there.  On section I found a small
round cyst,  which was  completely filled  with  cream-like,  white,
opaque mucus.   Evidently the yellow whitish mass, which is often
seen coming out  of   polyps,  into  which  incisions  have been
made  with the galvano-cautery, comes from such cysts.  Perhaps
these cysts are formed  through the  bursting of  a bloodvessel in
consequence of too severe noseblowing, when an infarction takes
place, which thus becomes incysted and softened.
   The formation of an abscess  in  a tumor which is wanting in
fibrous tissue to such a degree, seems to me less probable.
   As to the rapidity with which  polyps grow in the nasal  cavity:
no definite time can be given, and the patients can not determine,
when  the tumors were added to the previous obstruction, brought
about by the abnormal secretion of mucus.

                        TREATMENT.
   Spontaneous coming off of polyps has at most been reported to
me but twice.
   Although cures  by means  of astringents (brushing, snuffing-
powder) have now and then  been reported, but I must neverthe-
less—even aside  from  the fact, that examination was wanting—
doubt the correctness of this result;  because I have often  experi-
enced, how carefully even the galvano-cautery  must  be used, to
effect  a complete cure. 
TUMORS.
61
   The instrument, which has mostly been used  heretofore,  and
which  some  seem to use  still exclusively, is found to be  repre-
sented by the cornforceps.
    Voltolini has justly fought this treatment as too violent.  I also
believe, that I am able to offer  the  most substantial reasons in
support of his view.
   The operation with forceps is  not accomplished  under the
guidance  of  the  eye.  One  seeks,  and  feels, and  tries,  whether
something hard or soft is taken hold of, as the forceps are pressed
together.
   But the nasal cavity is not a cavity with  smooth walls, and of
dull feelings.  On  the  contrary it  is supplied with projections
recesses and  has a  mucous  membrane,  which  is richly  supplied
with nerves, and therefore very sensitive.
   No wonder then, that the  unavoidable knocking  and  pressing
against the walls in opening the forceps, and  pulling on the wrong
parts, which  may have been seized,  makes the operation painful
in the highest degree.
    I think, the following sentence can not well  be impugned, viz.,
that it is intolerable to operate  blindly in a  cavity, which lies all
through open  to the eye, and  too with  such a violent instrument as the
forceps.
    But even if the choanes  had been examined with  the  rhino-
scope, and  the  forceps were ever  so thin  (as  recommended by
Schroetter), why should not the speculum be used in the nares,
light thrown  into the cavity and the forceps (if they have to be
used) applied skillfully to the tumors. Knee-formed forceps would
not hinder the view.
    But the  forceps have  great disadvantages,  even  if they are
applied in this  natural, favorable  manner;  for  the  polyps  very
seldom sit on thin stems; the root  is generally ligamentous, from
i to i£ cm.  long, and i  to i| cm. wide,  according as the polyp
has an oval or round shape.
    Hence very often the root is not removed with  the forceps,
but only some of the mass is torn off—some  pieces remain.  And
then, where  at first there was but  one  polyp, two or three new
ones form on the remaining pieces.
    Or in  case the polyps are of a  tougher  nature, the necessary
turning and pulling occasioned  thereby  often makes the patient
feel  as if his brains were  being  pulled out;  the  surrounding
mucous membrane  is  also more or  less torn  off, and a copious 
62                         TUMORS.
hemorrhage, with a terrible shock of the nervous system is  the
frequent accompaniment.
   Dislocations of the cartilaginous septum, fractures of the bony
one, and tearing off of pieces from the  turbinated bones, are oc-
currences, which take place quite frequently—as the distortion of
many a nose, which had previously undergone such an operation,
will show.  No doubt, the pain is much increased thereby, and
the operation becomes very shocking to  the  patient.
   It needs only to be added, that a favorable result, a " healing "
is only accidentally brought about.   Or is it not an accident, when
I seize a polyp, which I do not see, with forceps, so  as to  remove
it, root and all, even if  the  cavity is wide, no bone-projections
reaching into it, and the polyp sits anteriorly on the middle turbi-
nated bone.
   The uncertainty of the result, and the useless suffering of pain
even  in  the  hands of most  highly distinguished surgeons,  has
caused patients, especially those, who had a great many polyps,
to seek no further help.
   Lately the simple  loop  has also  been used by different oper-
ators.   (Ear-surgeons use that of Wilde.)  But without the specu-
lum the result in this manner is also doubtful, as far as the success-
ful removal of the smaller polyps is concerned,  and those  situated
in the posterior part of the cavity.
   Wherever the polyps are somewhat tough, or have a  broader
base,  the wire brakes, for one has to pull  pretty hard, and a very
copious hemorrhage follows.
   The treatment arrived at a  new stage, when Voltolini (in the
year 1868)  came to the  happy thought  of applying the galvano-
cautery and the galvano caustic cutting-loop in all  parts of the
nasal cavity, in connection with the nose speculum, and  thus to
clear  the entire cavity completely of all  its tumors.
   To have discovered a remedy against a disease so far spread,
which, if correctly applied,  completely  cures,  is  a result which
patients cannot prize too much,  and must be looked at as deserv-
ing great merit.
   But in some respects I deviate from the method of Voltolini; in
other respects, I  think that  I  can  recommend  some  important
improvements.
   As to the loop-ecraseur (Schling-Schnuerer)  of Voltolini, I must
freely confess, that I deem it less  convenient  and  durable than
the instrument  which has been  recommended  by v. Bruns for
galvano-caustic operations with the loop. 
TUMORS.
63
   The latter is so easily supplied with a new loop, that it is not
at all necessary to have several handles on hand in order to save
time at the operation (Voltolini).   If previously loops have been
drawn into  different tubes, and  a wire should brake, one needs
only to lose about half a minute to unscrew the tube, and to sup-
ply the instrument with a new one.  A'glance at both the handles
shows, what I have also found on a more close inspection of both,
that that of Voltolini is much more inconvenient.
    The ring in the  slide is also better  adapted than the  lever, to
draw the loop together.  It is not  necessary to make such minute
calculations as  to the size of the loop,  as has to be made with the
lever, by which a loop, that is only a little too  large,  can not  be
drawn together.
    If a polyp projects out of the nares anteriorly, then of  course
the loop can be laid over it, and  after it has been pushed up as
far as possible, a complete removal can be accomplished.
    But only in such a case do I operate without  the speculum ;
for  it is evident to  me, that the loop can  be introduced more
favorably,  and  that one can succeed better, in removing the polyp
completely when he sees, than without the guidance of his eyes.
    Generally and  with sufficient  skill the  common  pharyngeal
light suffices, but in some cases it is very desirable  to have more
intense light; and  for want of it,  one  should not neglect to  ex-
amine with sunlight in order not to be misled.
    I now operate in the following manner:  The patient sits, and
leans his head  on a headrest (v. Burns), as  in laryngoscopic  ex-
amination.   The lamp is placed to the right of the patient.  The
loop is  arranged square-shaped;  the tubes  running at the side of
(not above) each other.
    After the speculum has been put in, the loop is introduced in
sagittal position; then it is held squarely again, and brought under
the free end of the nearest polyp ; then, moving it slowly upward
and downward, it is gradually  pushed  up  higher until  a solid
resistance  is felt.  This  resistance is  either  caused  by the spot,
where the  polyp grows, viz.: the  middle turbinated bone,  or a
projection—a spinous process of  the  septum.  But it  is all  the
same ;  if one now pulls on the ring of the ecraseur for the purpose
of drawing together the loop, he feels  that it has taken  hold of a
soft mass.
    Then the current is caused to work, which is done by a pres-
sure upon a lever-like apparatus on  the inferior surface of  the 
64
TUMORS.
 handle.  At the same time the loop is gradually drawn  together.
 After a few moments of  hissing it yields, and in the next moment
 it is seen coming out of the nares with a  tumor.  If  the current
 is sufficiently strong, the pain  is very moderate, and ceases entire-
 ly, as soon as the instrument  has  been removed from  the nasal
 cavity.
    If one has been  successful in  taking off the polyp clear to the
 root, then the surface of the  burned spot  is seen  to be smaller,
 regarding its length and width, than the  burned  off end of the
 tumor, and  is always surrounded  by a  border of smooth, shining
 undisturbed surface  But if the polyp has only  been  cut through
 in its mass,  then  the white burned spot spreads over the entire
 surrounding surface. But for the present I  pay no attention to
 these remaining portions, as I attempt to re-establish  first of all
 the connection with  the pharyngeal vault—the through-passage of
 air, if possible at the first operation.
    After the field of operation has been cleaned by means of the
 syringe,  or by a bunch of wadding, wound around  the head  of a
 long probe,  I bring the  loop to the next  polyp, and proceed as
 described above; and thus  I continue  until  the choanes  are
 reached.
    According to  the width of  the  nasal cavity, and the  presence
 of obstructing projections from the septum, the number of polyps,
 and of course  the degree of  skill  displayed, this desired  end is
 reached  in the first sitting; or several have to take  place,  before
 one can  see into the cav. phar. nas. (pharyngeal vault.)
    When the great difficulty, the obstruction  has been  removed,
 then a closer inspection must be made, to see, whether  there  are
 small tumors on the concave surface  of the middle turbinated
 bone, or on the roof of the nasal  cavity, or if some remnants of
 removed polyps are  present.   It  is especially necessary to  look
 sharply,  and to examine closely with the probe, in  order to  find
 out, whether the mucous membrane on the  anterior  end  of the
 middle turbinated bone is not  rugged, or in a state of hypertrophy.
    What can not be taken hold of with the loop, is removed  with
 the  galvano-cautery, especially the  hypertrophy of the mucous
 membrane.
    Often in some cases, even after the view through into the cav.
phar. nas. had been established, at the next sitting, polyps of large
 size were found in the middle  meatus, contrary to  ones  expecta-
 tions.  The  cause of it is  this:   after manipulations have been 
TUMORS.
65
carried on in the nares for some time, it is  impossible  in conse-
quence of the swelling of the mucous  membrane,  plainly to  dis-
tinguish between the contents of the cavity.
    If  the polyps hang closely together in the posterior part of the
cavity, or if larger ones are found  there hanging  down  into the
pharyngeal vault, then one will often try in vain, to remove them
with the loop.  At best only little  pieces can be taken  out.   In
the one case the loop can not be pushed up between  the polyps,
in the  other it can not be brought  down, and under the  free end,
reaching out of the choane into the vault of the pharynx.  A very
thick wire (No. o or i) might perhaps  be strong enough  to over-
come more resistance—would not  bend so  easily; but  it would
get hot very slowly, and  thus cause considerable pain, and would
surely  be followed by a strong reaction in the surrounding regions.
I therefore use the galvano-cautery immediately after a few un-
successful attempts with  the loop.
    Tf  the patient gives sounds, the mass of  tumors is seen mov-
ing upward (raised by the velum); and if now the galvano-cautery
is applied as high up as possible, where the  moving is still plainly
to be  seen, then  the  polyp  is generally removed by  the  root.
(Voltolini advises the galvano-cautery  altogether, unless  the loop
is very successful from the beginning.)  In  the following sitting
there will be more room, as the polyps will have shrunk  and died.
The galvano-cautery is  now from 5  to 10  times  applied in the
same manner; or in  case of more favorable circumstances, the
loop can now be laid around  the tumor, which  has grown out of
the choane, and it can  be removed  by the root.
   The polyp often falls down  into the throat, as  the instrument
is drawn out,  because it  (the tumor)  is too large to go into the
nares.   With a choking it is thrown up again. The full air-current
is now  re-established at once.
   The operation becomes very tiresome,  if absolutely no  air
can be forced  through the nares, to blow out the mucus, which
has accumulated in the nasal  cavity, and has to be wiped out, in
order to clean the parts for further  operation    The  mucus is
tough and  sticky, and is produced with great rapidity.  A repeated
introduction  of  the wadding-mop  is  necessary,  whereby  much
time and patience have to be sacrificed, especially with  children,
or sensitive, nervous weak-minded  persons.
   If a nasal cavity  is much obstructed through incurvations of
       9 
66
TUMORS.
the septum, or bone-projections, then only thin, smooth polyps are
found there, whilst thick tumors may hang out of the correspond-
ing choane.
    And if one has cleaned the easiest side first, which for  good
reasons is to be preferred, he will  (if for instance the right cavity
has been made free), often find a portion of a tumor coming from
the left, hanging before  the right choane.
    In one case  I introduced a large sagittal loop (the tubes run-
ning above one  another), through the right nares into the pharyn-
geal vault.   I succeeded at the first in  drawing the loop toward
the left as far as I could, by moving the handle as far  as possible
toward the right; then drawing the  loop together, I caused the
current to work.  In the next moment a broad, very tough polyp,
about one inch  thick, fell  into  the throat of the patient, an old
gentleman, about 70 years of age, and very nervous;  he was just
as much astonished as he was highly  rejoiced  over the painless
operation, and  the considerably  greater current  of air, which
suddenly began to pass through both his nares.—Not even half a
teaspoonful of blood flowed  in consequence of the operation.
    In another case, where an old gentlemen had also been troubled
for a long time  with  polyps,  this treatment was not successful.
Here the cavity was much obstructed  by a curvature  of the sep-
tum, and only small tumors were hanging down from the anterior
part of  the middle  turbinated bone.   The right nares  was  very
wide, and filled with aubout 20 larger and smaller polyps.   Not-
withstanding their previous removal, the patient could not breathe
freely through the right nares; especially was the expiration much
hindered.
    Only a very thin current of air passed through  the left nares.
With the rhinoscope the cause was easily learned.  A large crooked
tumor  lay across the inferior part  of the choanes.  By the septum
it was divided into a larger left and a  smaller right portion.  Al-
though a part of the tumor could be seen from  through the right
nares, and could be pushed back with the probe so far as to defin-
itely establish its origin from the left side ; yet I failed entirely to
seize it in the manner just described.
    I then  had  recourse  to  the pharyngeal  polyp—ecraseur (of
 Voltolini modified by the author).   I  supplied  the same with a
loop about 2\ cm. wide (wire No. 3), bent it somewhat over to-
ward the front,  brought it  behind the velum, and pushed  it up
quickly, until it  hit against  the roof of the pharyngeal head, so 
TUMORS.
07
that the handle nearly came from the  horizontal to the perpendi-
cular position.  Then I  drew the instrument  toward me—the
strong tubes overcoming the strength of the soft palate—until the
bony palate was reached.  Then  1 drew the loop together.  With
gnashing  it settled  down.  A strong  pulling would have been
necessary to draw it out  again, had not the galvanic  current sup-
plied it with cutting force.  It soon yielded, and a  tumor of the
size of a small plum was hanging in it.  A second smaller tumor
was immediately thereafter removed  in the same manner.  The
hemorrhage—the patient being plethoric,  and about 50 years old
—was about half a wineglass full. The pain somewhat increased
by  the fact, that the  tumor rested upon  the soft palate.   From
through  the  nares no more could be seen  of  a tumor, but  the
rhinoscope showed, that the removed pieces had been taken off from
an  old fibrous tumor, which originated on  the posterior end of the
left inferior turbinated bone.   A part of it remained to be removed
at a later sitting.  The patient described the sudden ease in breath-
ing as really refreshing.
    Obstructions, caused  by bone-projections from the septum, are
best overcome, by making the loop as  small as possible,  and  put-
ing it into the nares in sagittal position  below or above the pro-
jection, according to the  relation of the polyp to the same, where
it may be brought into horizontal position.
    Or the little  galvano-cautery is  applied, which one can  put
everywhere.  Fortunately there are, as has been observed already,
only a few small tumors in much obstructed cavities.   A very dis-
agreeable but  infrequent combination occurs, when  small  polyps
are found on the roof of  very narrow nares.
    In narrow cavities the anterior end  of  the middle turbinated
bone always lies  quite near the  septum;  it is  separated  from it
only  by  a small  crevice.  Without the  probe  one  can not  see
through here; but the anterior end of the  turbinated bone, which
in  such cases is always  softened  through  swelling, and loosening
of the mucous membrane, can easily be pushed aside.
    In order to determine, whether thr  gray  shining mass, which
is seen, is a mass of mucus or polyps, the probe, wrapped in wad-
ding, is rubed over the concerned spot, and then it  is again ex-
amined.  Eventually a small loop can  be pushed  up between the
septum and the  turbinated bones  to  the roof, and  everything,
which comes into its way, and can be embraced, must be cut off;
although  the eve can not  follow it everywhere.  But it is  always 
68
TUMORS.
necessary to see, whether there are any low vegetations present,
which must be destroyed by the galvano-cautery.
   In several cases I have used an instrument with success, which
is like a pair of forceps, knee-formed, with strong springs, the distal
ends of which are changed  into thin plates.
   It is to be conducted into the  nares closed, and pushed up-
ward  between  the  turbinated bone and  the  septum;  when the
spring power being left to itself, the superior meatus is thus opened
for inspection, by the  pushing aside of the anterior  end  of the
middle turbinated bone.  The broad  plates make the pressure
bearable, and as they are very thin, they do not obstruct the light
from falling in.   Besides this, their length  and knee-formed shape
also make it possible for the patient to hold them without hinder-
ing the operator in his work.
                INCIDENTS DURING OPERATION.
   Hemorrhage to  a disturbing  degree very seldom  occurs  if
proper care is taken, and a thicker wire is used (No. 4 or 3), when
patients are plethoric, while the current is  checked repeatedly, so
that the tumor is thus burned off somewhat slowly.  If the patients
are old and anaemic, or the tumors are of a tougher kind, then I
use a thiner wire (No. 5), and  let the  current work uninterrupt-
edly, in order to perform the operation as quickly and as pain-
lessly as possible.
   In a  casual occurence  of hemorrhage,  injections  are to be
made, as has been described in the chapter on " Chronic Catarrh."
By turns the stream of water may be turned  to  the  exterior of
the nose.  Only in one solitary case was I  obliged to tampon.
   A healthy old gentleman, whose face and nose were quite red,
had a small red, oval polyp on the anterior end of the left middle
turbinated bone, which I tried to  remove,   At the moment when
I was drawing the loop together—the  most irritating part  of the
operation—the patient struck my  right  hand, which was holding
the instrument, with such force, that the  instrument was carried
off some distance.  Immediately the blood  streamed  out  of the
nares.  The drops followed each  other  in such close succession,
that they almost formed a stream.
   Injection of cold water, and also with  enough persulphate of
iron in it, to make it quite yellow, availed nothing.  I  had  to fill
the cavity with wadding to  control the hemorrhage.
   But in the afternoon the patient came again, because bleeding 
TUMORS.
69
had recurred; much blood being thrown out from the throat.  As
I pulled out the plugs of  wadding one  after the other, I could
see, that the bleeding, which was now more moderate, came from
near the free border of the  convex surface of the middle turbi-
nated bone.
   With the knee-formed forceps I pushed a thick piece of German
tinder up between the middle  turbinated bone  and  the septum,
and  immediately the hemorrhage stopped entirely.   Prudently
the patient, who resided  on  the  dutch borders, remained  over
night.   During the evening he applied  ice water  cloths to his
nose.  On  the fifth day the tampon fell out, but the nose did not
bleed again, as the patient reported, when he came again to have
the galvano-cautery applied on account of chronic catarrh.
   The anterior end  of  the  middle turbinated bone  was quite
normal and smooth; the  mucous membrane was closely attached.
Evidently here was an aneurismatic expansion  of the capillaries,
of which Luschka says, that it often is present on the anterior end
of the middle turbinated bone. This case, on the one  hand, was
very instructive, because I saw a very copious hemorrhage ensue,
after the loop had been torn off, and on the other hand, because I
have learned, that it is better for the future, not to lose too much
time with the injection of water, or the pushing  in of wadding in-
to the nasal cavity,  without  any  direction, to  tampon in the old
manner, but to bring German tinder to the bleeding spot, with the
aid of the  speculum.  One can also without the speculum  get up
between the middle turbinated bone and the septum, if he takes
the septum as his guide, and does not get off its surface.

                      FAINTING  SPELLS.
   In the  chapter, which treats of the examination of the nasal
cavity, it has  been observed, that sometimes, when  the middle
turbinated  bone is touched, or the septum, sudden spells of faint-
ing ensue.   Thus I have  also seen  at the first sitting sometimes—
especially   after a polyp  had  been removed, or only had been
seized on the anterior part of the middle turbinated bone—a  sud-
den paleness of the face appear.  The patient suddenly becoming
indisposed,  perspiration  breaking  out  all  over, &c  The  ope-
ration had  to be discontinued, as  in every subsequent  trial  the
tendency to fainting returned. These phenomena occured  not
only in weak, delicate women,  girls and  boys,  but also in  strong
persons—not at all irritable—in workingmen, soldiers, peasants 
70
TUMORS.
&c.  It seems to be brought about by an irritation of the ethmoi-
dal nerve, and seems to consist in a reflex contraction of the brain
vessels, by  which brain-anaemia  is produced.—There are also
branches of the trigeminus running into the dura mater.

                RESULTS OF  THE OPERATION.
   The patients are generally not at all hindered from going about
their daily business.  They are even in winter allowed to go home
on the  same day without injury.  The  nose secretes profusely a
watery mucus, which often makes the  nares sore, sometimes only
reddens it.  The patients always feel more or less affected in their
head, as with a fresh catarrh. But if the operation was protracted
unusually long, or if  the loop had often been introduced in vain,
in consequence of hinderances, and the nasal cavity had thereby
been irritated more severely, or 10 to 15 polyps had been removed,
and if  thus a large number of wounds had been made—then the
patients often felt hot, with frequent pulse on the second day, no
appetite, felt indisposed, and suffered for several days with  head-
ache, etc.
   A few times a moderate swelling of the face, on  one or both
sides, was also reported. But never has a case of erysipelas of the
face, or any serious  illness, as  a result of the  operation, come  to
my knowledge.
    Nevertheless, I always observe this rule, not to make the first
sitting  too long,  and  to remove only a  few polyps, and then see,
whether the patient has a tendency to fever  or violent reaction
or not.
   Also this fact is not to be overlooked, namely, that on the one
hand the chief seat of the polyps is  very near the nasal roof,
which is formed by the cripri-formed plate of the ethmoid bone;
and on the other hand, that the spheno-palatine foramen, through
which the posterior spheno-palatine, nasal  artery of the septum,
enters  (Art. spheno-palat. s. nasal post?), is found to  be very close
to the end  of the middle turbinated  bone;  that the  ethmoidal
veins as they empty  into the superior ophthalmic vein, communi-
cate more or less with  the sinuses of the dura mater.

                      AFTER-TREATMENT.
    As  to the after-treatment I tell patients to  keep  quiet  in case
of  serious indisposition, to abstain from  coffee,  tea,  spirituous
liquors, and to observe a soup-diet, to  drink  a glass of mineral 
TUMORS.
71
water (Bitterwasser),  to  apply a  wet cloth (kalte Aufschlaege) to
the hot forehead for some hours, and to make cold injections into
the nares as often as is agreeable.
   But patients must  always use nasal injections from two to three
times a day to keep the  nares clean and  free  of  infection until
the next operation.   They use for this at least a liter of water, to
which t or  2  tablespoons full of  chlorate of potassium has been
added.  The solution should not be too strong, should not irritate
or smart.   If this is the  case, the patient must weaken it.   The
chlorate of potassium must be previously dissolved in hot water.

                     NUMBER OF  SITTINGS.
    If there are but a few polyps present, and the  loop can easily
be applied, nothing stands in the way of a complete removal of all
tumors in one sitting. But as a rule from 10—20 polyps are found,
which can, aside  from  everything  else, not be removed in one
sitting, because the smaller ones are soon removed from sight on
account of the swelling of the lining of the cavity.  (Hoehlenbeklei-
dung, i. e. the mucous membrane.)
    The second sitting may take place after 8 to 14 days or three
weeks, in accordance with the desire or leisure of the patients.—
On some patients, who came from a distance, and who could not
return on the same day,  on that  account, I  operated 2 to 3 days
successively.  The general condition did not show  itself much or
not  at all  disturbed  thereby; nevertheless  the pulse was often
somewhat more frequent.
    At the second sitting, very often at the first, I get so far, that
I can see  into the pharyngeal vault.   In exceptional  cases this
does not take  place until after the third sitting.  Then the passage
of air (Luftdurchgang) is  for the greatest part brought about again,
and the patient is relieved of  his worst difficulty.  At this moment
every operator, who has employed any other method, and who has
worked without the speculum and the rhinoscope, would lay aside
his  instrument with  complacency.   But a  minute  examination
would yet discover many remnants and  small  polyps  to  be re-
moved, and would show that there is yet much to be  done before
a final cure could be spoken of.
    To bring about this  result, several sittings are generally neces-
sary, and in all cases of a higher degree a control of the disease must be
maintained for a longer time. If patients desire to be definitely cured,
and do not wait to see whether the obstruction of the nose will recur 
72
PAP1LLOMATA.
again or not, then they must come repeatedly  for  some months.
And with those patients, who have a strong tendency to  contract
cold, several young polyps are often found  again, or roughened
swelling on the anterior  end of  the  middle turbinated bone,
whilst  otherwise  the  mucous  membrane  is closely attached,
and  shows a  normal  condition.  Those  patients  who soon
come with a healthy bright appearance, have no knowledge of their
presence, as the free breathing, and  the feeling of ease (Wohlbe-
hagen—comfort) is not at all disturbed thereby.   The tendency
for bronchial catarrh  is much diminished,  and breathing  is more
free and easy, but the secretion of mucus is very much increased.
   However as long as yellowish mucus is noticed, which some-
times drops out when the patient bends his head  forward, there
must be polyps still left somewhere, and a swollen inflammatory
condition of the mucous membrane must exist, and one must not
yield until he has discovered and destroyed them.
   Those cases require the  most care and demand  the greatest
number of sittings, where former  operations had been made with
the forceps; evidently because the mucous membrane  has become
still more affected in consequence of the irritation.  And from the
pieces, which remained as the polyps were torn out, a large num-
ber of tumors had grown.  Sometimes 2 to 3 or more have sprung
up where one had been.
   In skilful hands  the galvano-caustic operation is  the most
painless, bloodless and  the  easiest.  There is  no instrument so
long  and thin as the galvano-caustic loop, which has at  the same
time  such unyielding  power.   The burner  can not be  replaced.
Nevertheless a careful and skilful examination  is the only surety for
a lasting cure of this disease.
    VII.  PAPILLOMATA OF THE NASAL  CAVITY.

   A Mr. W., from Amsterdam, came to me with an  obstruction
of the left nares, which he said had troubled him for years.
   The entrance of the  concerned nares  was  completely  filled
with a red mass, which had the appearance of  colliflower.
   In  the morning and  afternoon a large number  of  pointed,
kernel-like small tumors were removed with the galvano-caustic 
                    MALIGNANT  TUMORS.                 nn

loop, which were partly  connected  together by a bundle of fine
fascia.
   After they had been removed it could be seen  that only the
anterior end of the inferior turbinated bone, the part of the sep-
tum just opposite it, and the anterior part of the nasal  floor were
affected.   The little papilla and crests, which were too small to be
removed by the loop, were  destroyed  with the galvano-cautery.
The nasal cavity thereby being  made completely  smooth in two
sittings.
     VIII.   MALIGNANT TUMORS IN  THE  NARES.

    In one case it was evident  that common  polyps had  become
changed to malignant growths.  The patient, now about 63 years
old, said that he had been affected with polyps for about 30 years.
About 15 years ago he had called up on a very celebrated operator,
who had refused to remove them for him.
    On both sides I took out with  the loop thick tumors of tough
construction, which had distorted  the cartilaginous nose; but after
6 weeks I found that they had grown again;  the whole cavity was
now very irritable;  the inferior turbinated bones were especially
very much  swollen.  There was everywhere  a  great tendency  to
bleeding.  Altogether  I  had  abundant  cause  for   a  serious
prognosis
    After three months,  an abscess appeared  on  the  right nasal
bone. The probe met with a rough bone, which evidently belonged
to the roof of the  nasal cavity, as I concluded from the direction
it took.   After two months more death ensued under symptoms  of
pyemic  infection and brain-phenomena.
    In two cases the following symptoms were present in common :
Headcache, painful straining in the  nasal cavity and nearest sur-
rounding, copious discharge of mostly  watery  secretion from the
nares, flowing  of  tears,  hawking of blood from  the throat, and
permanent obstruction of the respective nares, which  in  conse-
quence of the great irritability of  that organ  often  became abso-
lute.
   By means of the speculum only the right cavity of the one pa-
tient was found to be diseased, and the left only of the other.  In
the one  case a blue-gray smooth tumor  was found, in the other a
       IO 
74
MALIGNANT TUMORS.
roughened pale-red mass with some objects in it.  They appeared
to come from  the middle turbinated bone.  The inferior turbi-
nated bone was also much swollen, and lay more  or  less close to
the septum, whereby the inspection of the whole  cavity was  pre-
vented.
   In the rhinoscope the meatuses were seen to be obstructed, by
the  swollen  turbinated  bones  touching  one  another  and  the
septum.   The swelling of the nose and face after a trial to  ope-
rate, increasing the suffering, caused thereby, instead of the other-
wise never failing diminution, while the relatively strong hemor-
rhage increased the suspicion of  malignant affection  in the nasal
cavity.  This suspicion  was soon substantiated in as much as the
general condition began to grow worse, also by the  emaciation
feverish pulse, etc.   A progressive new tumefaction (Neubildung
—new formation) on the upper jaw and the  orbit also  took place.
The ages of the patients were 50 and 63 years, respectively.
   A Mrs. T., 49 years old, said that  one year ago  she had  first
observed flowing of tears from the right eye, and  on consultation
had  been told, that  the tears came from ua lachrymal fistula'',
and  that after the flowing of  tears had ceased,  a  red  spot began
to appear on the exterior of the nose, and the right nares became
more and more obstructed
   Of  pain she did not  complain, excepting a feeling of  soreness
on the hard palate.
   The touching of the  swollen cartilaginous nose or the tumor in
the same, would easily and often cause bleeding.
   The appearance of the patient is sallow, emaciated.  A sister
of her's died "with a cancer in the lower bowels ".  In the  right
nares a light red tumor is seen, which is granular on its surface.
   Besides this only the anterior end of the swollen inferior  tur-
binated bone  can be seen,  which  touches  the septum and  the
nasal floor.
   In the rhinoscope no special abnormity is to  be  seen.   The
inferior turbinated bone is moderately swollen and reddened, but
is in part covered by the soft palate.
   The red spot on the nose  corresponds to the  nasal bone.   It
fluctuates—a fact, which shows, that the bone  is softened and
broken through.   Chlorate  of potassium  was prescribed  to be
strewed upon the parts or used for insufflation.  Later information
was to the effect, that perforation had  taken place, that the other
side of the cavity had also been attacked by the disease. 
EPISTAXIS.
75
   If everything can not be destroyed at once clear to the healthy
parts, then the cells only become incited to a more acute inflam-
mation, on which account the knife and saw have to be  employed
instead of the  galvano-cautery.   The latter (knife and saw) will
surely bring about  lasting results,  if persons with  the  described
symptoms are at an early stage examined with the speculum and
the rhinoscope.
                      IX.  EPISTAXIS.

    \t different times persons were examined, who  came with the
 complaint, that from  the slightest cause they would  have nose
 bleeding—remarkably easy and often.  But  only  in  two cases
 could a cause—an explanation—be found.
    A lady, 63 years of age  (widow), of a healthy  plethoric  family,
 yet herself anaemic, and of  a pale-yellow appearance, says, that for
 the last 12 years—i. e. after her always profuse—menstrual  epochs
 had ceased, she has had very frequent hemorrhage from the nares.
 About every  3 to 4  weeks it would bleed from the left nares.
 Sometimes the phenomenon would be wanting for a few months.
 But in October (1874) the hemorrhage ensued almost daily.  The
 least  excitement, i.  e. a glass of wine or  a  lively conversation
 would bring it about.   She was also often  awakened  during the
 night by blood running down her throat and causing cough.
    A tumor was supposed  to be  in  her nose.  But when  by the
 advice of  my  collegue, Dr. Lohmar, she was examined by  me, it
 was found, that the nasal cavity  was quite free ; but in  the left
 nares on the septum. I saw, opposite the anterior  part of  the in-
 ferior turbinated bone, a small black spot of desiccated blood.
    In touching it with the probe, the  blood immediately drizzled
 down from under it, and flowed steadily over the nasal floor into
 the pharyngeal vault.   By pulsations, and keeping  time with the
 pulse, it came  out of a fine  opening about as large as the thickness
 of a needle.
    I applied the galvano-cautery to the spot.  At first the hemor-
 rhage became  stronger, because in taking off the burner, the scab
 made by  it was  also removed.   But after  the hemorrhage had
been checked  somewhat by the  injection of cold water, I applied
 a broad burner;  again laying it on cold, and  then  letting  it  be- 
76
EPISTAXIS.
come red hot.   Then I interrupted  the  current  for a  moment,
and made it red hot again for several times.  After this when the
burner now was carefully removed, the hemorrage did not recur-
The scale  measured about f  cm. in diameter.  It had to  be
large in order to erode not only the bleeding vessel itself, but also
its surrounding communication  for some distance.  The  next day
the lady observed, that she felt a sensation  of increased warmth
in the upper teeth, since bleeding from the nares had ceased.
   The burner was again applied to the gray-black scab, to  con.
nect it more closely with  its underlayer.  The desiccation of the
blood on the inferior surface of it helped to bring this about.
   Second case: A., weaver from Gr., 26 years old, came Jan. 12 ,
1876, with  the  complaint, that he  was  suffering with epistaxis.
For three years previous he had suffered  for a time daily hemor-
rage, and had become " quite feeble in consequence, so  as to  be
almost unable to walk."
   Nearly three years ago Dr. Kueppsr  of Elberfeld had taken
something out of  his nose, thereupon he  had rest for about two
years;  but since  the summer of 1875,  the bleeding had again
ensued several  times a week.   He had bled in  the  morning on
the cars.
   As I put the speculum into the right nares, hemorrhage began
immediately; therefore I thought, the source must be at the en-
trance of  the  cavity.  No blood came  from above.  The nasal
floor only was covered with blood,  but I could  not  discover
whence it came.  I did not see any  spot,  where I might be  able
to apply the burner.   By  a compression  of the  nose the blood
stopped.  All I could now see. was, that the septum  opposite the
anterior end of the inferior turbinated bone appeared more red-
dened, and a few  blood vessels  seemed to  be somewhat largely
developed.  I  touched these parts lightly  with nitrate  of silver,
and advised the patient to come again in a few days.
   January 16.  No  day  had passed without nose-bleeding.   I
barely pushed  the  speculum into the   cartilaginous nose  and
opened it carefully, when I saw—quite anteriorly  at the entrance
of the bony nose, close to the nasal floor, on the septum—a little
spot of desiccated blood, not  larger than the period over the "i",
which I barely  touched, when the blood flowed out copiously.
   With the burner—the battery had  been previously arranged —
I stopped it in  the manner just  described above.
    Jan. 23, the scab  has fallen off, but no hemorrhage has ensued
since the operation. 
FOREIGN  BODIES.
77
    X.   FOREIGN BODIES IN THE NASAL CAVITY.

    The following case  of a girl, from Ems, two years old, I con-
 sider worth mentioning in this connection.   Her mother relates,
 that she has been afflicted with purulent secretion from the nares
 with bad odor, and obstruction of the right nares, since she  was 6
 months old; that during sleep she would snore, and often be dis-
 turbed on  account of dryness of the throat and thirst.
    Notwithstanding  the consultation  of  different authorities,
 her condition did not  improve.   Scrofulous  ulcers were mostly
 mentioned as the cause.  Finally one physician thought he had dis-
 covered a polyp, the operation of which was only incidentally de-
 layed.  The anterior end of the right  inferior turbinated bone
 had by mistake been taken as such, because  it was swollen, and
 could be seen when the point  of the nose was raised.
    The  child quite willingly  permitted a  small speculum to be
 put into her nose.  I then pushed the turbinated bone somewhat
 aside with  the probe, and plainly saw a black object at the anterior
 entrance, and felt a hard body there.   With the knee-formed for-
 ceps I pulled out a piece of black sole-leather, about the size of a
 full grown  thumb-nail.  It was quite black and gave off a penetrat-
 ing foetid odor.
   Anteriorly the septum was somewhat  corroded  near the  nasal
 floor.   Nothing else was to be  found  in  the  nasal cavity, which
 could no,w  be  very well inspected, as the swelling on  the inferior
 turbinated  bone had immediately passed  off.  Evidently the  piece
 of leather had been put  into the nares of  the child—as the mother
 supposed during a long  visit in the country—and having been put
in rolled together, it had expanded through  moisture, and  then
had unrolled itself, und  thus its falling out was prevented,  and  it
remained there. 
78
ULCERS.
   DISEASES OF THE PHARINGEAL
                        VAULT.

   Acute catarrh appears  mostly in connection with  a general
pharyngeal catarrh, or is associated with an acute catarrh  of  the
nares.
   Chronic catarrh of the pharyngeal  vault  is,  according to my
observation, very seldom an idiopathic disease.  The text-books,
in giving a description of it, fail to pay sufficient attention to  the
condition of the nares.   If these  were  always  properly examined,
the complaint of  patients about obstruction of mucus (Verschlei-
mung), of dryness, and sensation as of a foreign body in the throat,
would mostly be explained  by the presence of ozcena in a greater
or lesser degree ; or a chronic nasal catarrh, nasal polyps, or hyper-
trophy of the pharyngeal tonsil, any of which may often be  the
only cause of the affection.   A swelling of the follicles will very
seldom  be found in the  vault of the pharynx.  Only through the
removal of the idiopathic disease can a cure be perfected.
                        I.  ULCERS.
   As to the appearance of ulcers in this cavity (phar. vault), I
have to make the same observation  as in ozcena, i. e. that  yellow
layers of mucus and scales have often through mistake been taken
for ulcerations.
   My experience corroborates  that  of  Mr.  Wendt, who repre-
sents the opinion of Troeltsch, that extensive non-syphilitic ulcera-
tion was often found in  the pharyngeal vault to  be eroneous.
   Wherever I found corrosion (Substanzverlust, loss of substance),
and purulent  secretion  in the cavity after a careful cleaning, I
diagnosed syphilis.  In several cases (6) where the patients, who
complained of insufficient pliability in swallowing (Schlingbeschwer-
den) and pain, and had for a long time struggled against it in vain
with gargles, etc., the cause of the affection was  easily discovered
by means  of the rhinoscope.
   Generally an ulcer might be seen on the posterior wall, oppo- 
ULCERS.
19
site the Eustachian tubes, or  some  round, yellow excavations in
the centre of the posterior wall.   Syphilis had preceded.—The
following cases might be worth mentioning.
    i.  Mr. X., a medical man, has always been healthy.  He knows
nothing of  ever  having been affected  with  syphilis.   But some
years ago, after an operation, he had a swelling of the lymphatics
under the arm.
    A few weeks ago  (in the winter 1874), difficulty in swallowing
(Schlingbeschwerden)  ensued, accompanied by the feeling of a for-
eign body in his throat.  Soon he discovered on the anterior sur-
face of the swollen uvula,  an ulcer, the size of which increased.
The examination undertaken by me with the  rhinoscope, showed
an ulcer of considerable depth and about i-J- cm. long, on the pos-
terior surface of the uvula, about the centre of it.
    Several cauterizations with nitrate of silver in substance, were
unsuccessful.  The ulcers unmistakingly grew in their width ; but
as soon as Iodide of potassium was taken, the troubles diminished,
the local treatment became successful.   The ulcers cleaned them-
selves up, and healed completely within 14 days
    2.  S., a tailor-apprentice, 17 years of age,  says, he has never
had swelling of lymphatics or efflorescence on the skin.  He  also
affirms that  there has been  no  occasion for  infection.  Yet he
complains that he has, for some months, had moderate pain in his
throat, and now (Feb. 8th, 1875), when he drinks, the water, etc.,
flows in part out of his nares again.  He has  no pain now.   The
rhinoscope shows a large round ulcer of i^cm. in diameter on the
posterior pharyngeal wall, toward the  left  side, and opposite the
uvula.  The surroundings of  it (i. e. the  ulcer)  appear much
swollen and reddened.   The uvula is seperated from its root on
the left, and  hangs on the right side like a tumor, about the thick-
ness of a little finger.
    After six strong cauterizations with nitrate of silver in  sub-
stance, and Iodide of potassium taken internally, the  ulcers cica-
trised, occupying about three weeks and a half.  In consequence
of the disappearance of  the swelling on these parts, the phenom-
enon of  the inadequate  shutting  off of  the throat from the
pharyngeal  vault  disappeared.   The  defects  of the  soft palate
remained however.  The lateral aspect of the  posterior surface  of
the uvula has grown to the posterior pharyngeal vault.
    In the beginning of January,  1876,  S. came again in  accord-
ance with  my wish.   The pathological condition, of course, re- 
8o
ULCERS.
 mained the same, but nasal speech had improved in consequence
 of the strengthening  of the uvula.   And only in drinking very
 hastily, would a flow of water, etc., out of the nares take place.
    S. again declares that there had been no occasion for an in-
 fection, as he had up to this day never  touched  a female.   He
 believes, that the beginning of the suffering in  his throat must be
 traced back to a day, when he felt hot,  pulled off his coat, and
 seated himself on the threshold.  The members of his family have
 always  been healthy, parents and  all, but several sisters of  the
 mother have died  of consumption.
    3.   B., a railroad officer, about 40 years of  age,  very  good
 health,  has  served  18 years as a  soldier—a corporal.   Has  been
 through three wars.  About 6—8 weeks  since he  began  to have
 trouble in swallowing to a moderate degree.
    The  anterior surface of the left  posterior palatal  arch is for
 the greatest part in an ulcerated condition, presenting the appear-
 ance of bacon.   Another large crater-like ulcer is  found  on  the
 posterior wall behind the uvula, extending upward  into the phar-
 yngeal vault.  On the right the posterior  palatal arch  has grown
 to the posterior pharyngeal wall.  Some years ago  he was treated
 in a  military hospital  for  an  ulcer,  the  origin  of  which  was
 doubtful.
   Cauterizations, and Iodide  of potassium  internally  soon per-
 fected  a healing of  the ulcer on the posterior wall.  But the  one
 on the uvula would not  clean itself up, even after cauterization
 with potassium and the galvano-cautery had  been  applied.   Em-
 brocations of ciner salve ( Ungt. ciner—ash-ointment), had yet to
be applied to bring about cicatrization.
   4.  H. Bergmann, married, says, he has  never  been infected.
 His wife and children are also healthy.
   The rhinoscope  shows the cause of his trouble  in  swallowing
(in part it can also be seen without it  in the pars nasal.), to be a
large round  ulcer at  the head of the pharyngeal vault, opposite
the superior part of the velum.   The  surroundings of the  exca-
vation  are largely swollen and reddened.
   Within three weeks four strong cauterizations were  made with
nitrate of silver  in substance; with it and Iodide of potassium a
cure was perfected in the described time.
   In all four cases every cicatrice was wanting as  well as efflor-
escence, and generally every other sign that an infection ever had
taken place, was wanting.   The state of health in general was 
HYPERTROPHY.                    8l
not disturbed.  With three of  the four it could  hardly have been
better.  Only  the apprentice  S. appeared somewhat pale and
weakly.
    I could not regard them as scrofulous ulcers.   I  had to con-
clude that either an infection had taken  place through the  use of
a vessel, a pipe, etc., or that hereditary syphilis had long remained
latent, but had finally been brought forth in consequence of the
irritation of a violent angina—and it making itself felt in the way
of ulcers just described.
    Wendt also speaks of having found on  post mortem  examin-
ation tuberculous ulcers, erosions of large dimensions, which were
brought about in consequence of acute inflammation of the mucous
membrane.
    On living persons I have as yet seen nothing of the kind.  This
in part may be owing to the fact that in tuberculous ulcerations
the lung- and throat-phenomena predominate—that they generally
make no complaint of anything else
    A pharyngoscopic examination is not often made, inasmuch as
those,  who  are troubled  with cough, have a  great tendency to
choking, which makes an examination very difficult, if not impos-
sible.
II.   HYPERTROPHY  OF THE  PHARYNGEAL TONSIL.

   Luschka was the first who applied the name " Tonsilapharyngea"
to the glandular  tissue,  which resembles the substance of the
palatal tonsils, and which  covers the greatest part of the pharyn-
geal  roof, and the posterior wall of the pharyngeal arch downward
to a line, which connects  the inferior  ends of the Eustachian
tubes.   Wendt, in his diseases of the  pharyngeal vault and the
throat, has given a comprehensive anatomical description of these
parts, where also a complete list of works, treating of this branch
of medical science, is to be found.  I shall here confine myself to
a description of the clinical  phenomena,  according to my obser-
vations, and give directions for diagnosis and treatment  depend-
ing thereon.
   I have the material of 92 cases to  work upon, which I  have
observed the last four years.  This number is in contradiction to
Voltolini's opinion, who, in comparing his observations with those
       11 
82                     HYPERTROPHY.
of Merer, thinks, that this disease was not of such frequent occur-
rence in  Germany  as in Denemark.

                          symptoms.
    Wil.  Meyer has already described the  symptoms of the cases
of a high degree very comprehensively and  exactly.  On this ac-
count I shall be more brief.
    It is principally the respiration through the nares which suffers.
The mouth being constantly opened.   The face has a shy, indo-
lent expression, because the line of the nasal wing is lengthened
(die Nasenlippenfalte ist verlaengert).  The  nostrils are often re-
markably small, having evidently been checked in their growth.
During the night the patients snore strongly and sleep restlessly.
    The  voice  is  much changed—soundless,  " dead "  Meyer).
Often difficult  hearing  is present,  sometimes  headache, concen-
trated on the vertex.   A pale,  sallow  color of the face  is never
absent. A phenomenon, which  indeed  I have only seen once on a
girl 8 years old, and which I do not find recorded  by Meyer, is a
drawing  down of the inner canthus of the eyes so strongly, that
the little face had  a strange  Chinese appearance.
    Evidently, the  inferior maxillary, in hanging down  constantly,
had strained and stretched the  skin of the face.  For after the
extraordinary hypertrophy of the pharyngeal tonsil had been re-
moved, this distortion  also passed away.
    In cases of a moderate degree of hypertrophy,  especially in adults,
the symptoms are less clearly defined.
    Complaint is made of obstruction  through mucus  ( Verschlei-
mung) collecting in the throat,  of  choking  in  the morning, of a
desire (Beduerfniss) often to breathe (expire)  by  starts through
the nares, and  of being constantly  obliged to  bring down mucus
from above.   The patients find that in singing  they can not long
hold to high notes, that they soon get hoarse, and that  their nares
are very often  obstructed.   Close observation shows that the lips
are seldom closed, but are constantly kept opened  a little (if not
much).   They say, it  is inconvenient for them, to breathe with
closed lips.   During the  night  they sleep with the mouth open.
The voice is sometimes changed a little, but the  weak sound is
only noticed by a  trained and  acute ear.   Again,  if the patients
keep their mouths closed, something unusual  is noticed in their
features.  A lax condition of the lips is observed, while the angles
are drawn down. 
HYPERTROPHY.
83
   The color of  the  face is  bad   also—even  in  cases  of  a
moderate degree;  it is grayish or sallow hue,  though  the patients
—children  as well as adults—may live under the most  favorable
circumstances.   As soon as the swelling  has  been removed, the
face  becomes healthier and more youthful.   It also acquires  a
greater fullness and becomes rounder.  Very  often a chronic ca-
tarrh of the pharynx and hypertrophy of the palatal tonsils are
found in connection with hypertrophy of the pharyngeal tonsil.
Sometimes  also the nares participate through chronic catarrh, or
less often through  polyps.
                          DIAGNOSIS.
   In  most cases—Meyer thinks, a  diagnosis can not  often  be
made—the diagnosis however can be made out through  the nares
—on the one side or the other, by means of the speculum, which
will show that the  pharyngeal arch is not in  a normal  condition.
If the inferior turbinated bone is in the way  through swelling, it
can easily be pushed aside far enough with  a probe for one to
look  through into the  pharyngeal  vault.  Behind the choana, a
pale-red, roughened  tumor may be seen.   It moves upward espe-
cially in swallowing,  less in giving a sound, and as the act is  com-
pleted, it sinks d>»wn again.  In one case (the patient being a boy,
10 years old), I could,  by simply lifting the point of his  nose, see
through the wide nares with the reflex mirror, and the light of the
sun,  to the  tumor  in the pharyngeal vault, without  using a spe-
culum.
   In swallowing the posterior pharyngeal wall below the Eusta-
chian tubes makes a strong movement upward. In giving a sound,
the tumor  is pushed upward  by the uvula  and the Eustachian
tubes.  There generally remains but a  small space between  it
(the tumor) and  the nasal floor.   But if the inferior turbinated
bone is in the way, it can easily be pushed  aside with the probe?
so that one can easily look into the (cavum) cavity.
   With the knee-formed probe, as  already described  by Meyer,
a soft sponge-like mass is felt, which can easily be divided, pushed
apart, and  it will readily be seen, that it has clefts.   It is not sen-
sitive to the touch.
   In a  normal condition the posterior wall of the pharyngeal
vault lies farther backward, and only a  weak  movement of its
smooth shining membrane is perceived.   In the  superior part no
movement  at all is noticed.  The probe meets a hard resistance,
and  causes a sharp painful sensation. 
84
HYPERTROPHY.
   But not  everything which moves  is to be taken as tumefac-
tion.  Sometimes the Eustachian tubes are enormously developed,
which may  give occasion to deception.  Thus one must be care-
ful, and  examine first with the rhinoscope, in order to be sure
what the  condition is before he applies  the  burner.   With the
square loop no  harm  can  be done under  any circumstances.
Meyer thinks, the examination with the rhinoscope is generally
difficult  and unsatisfactory.   Voltolini is of a directly opposite
opinion.   For myself  I have explained in a former essay, how the
presence  of tumefaction makes rhinoscopic  examination  easier,
because it checks the  mobility of the soft palate.
    If one follows, as described above, first the posterior pharyngeal
wall in  the mirror, he will  observe  that below  the Eustachian
tubes it  passes gradually  into  a  pale-red,  cushion-like, rugged
swelling, without well defined border,  and having  several furrows
drawn upward and downward,  covering the  superior part of the
posterior wall and the roof of  the pharyngeal head.
    The superior border (Bogen—arch) of  the  choana can  not be
seen,  nor the  superior third  or half  of the septum ;  frequently
also the posterior end of the middle turbinated bones are excluded.
    Often the tumor appears quite smooth.   One is obliged to ex-
amine very  closely to find some shallow furrows."  In other cases
again, it  has a very rugged appearance, showing deep—broad in-
cisions—according  as the pieces and crests,  of  which it  mostly
consists,  are thicker  and  higher,  and stand closer together  or
farther apart.
    On the descending part of the Eustachian tubes the height of
the crests and edges always running parallel,  can be easily mea-
sured, as the latter  are generally higher than the former.  In  the
fossa of  Rosenmueller long and high crests and bundles ( Wuelste)
are generally found on the posterior wall in cases of hypertrophy
to  a  considerable  degree.  In  the bottom of the fossa smooth,
thin crests are  often seen, standing somewhat sideways.
    On the posterior  part of the Eustachian  tubes  (the  anterior
wall of the fossa of Rosenmueller) some flat, bean-like or roundish
crest-like elevations can always be noticed.   Sometimes they are
found a little farther  downward on the lateral wall of the pharyng-
 eal head  up to the free border of the uvula.   Here the  mucous
 membrane is often  evenly thickened,  which,  in connection with a
 swelling of the follicles—for  as such the  flat, smooth  elevations
 must be looked at—gives a solid block-like  appearance to these
 parts. 
HYPERTROPHY.                    85
    The Eustachian tubes are generally covered  in  part.  At first
sight they appear much larger than in a normal condition, because
at their borders they are connected with  the swollen parts.
    The centre of the  posterior wall,  beginning a  little distance
below the Eustachian tubes, is  sometimes very smooth without
any swelling of the follicles.
    In some cases only a small  part  of the choana—the entrance
of the middle meatus, can be seen, but when the uvula hangs down
very  loosely, the inferior turbinated bone and  the inferior meatus
can be seen partly.
    If the tumefaction is strongly developed, a moderate elevation
of the soft palate suffices to suspend the prospect,  as  both parts
come more or less into contact.
    With children this occurrence takes place  much  easier, as the
passage itself is very narrow, and the distance between the uvula and
pharyngeal wall very small.  Here it also often happens that even
in a case of  moderate hyperthrophy nothing can be seen of the
choanae.  The changes which have just been described, can there-
fore not always be determined or distinguished,  either  with child.
ren or adults, until the swelling has been in part removed, so that
more light can enter, and the posterior wall has at  least in  part
received its normal level again
    On the other hand it is often possible to distinguish the presence
of tumefaction without the mirror, because the pharyngeal arch of
children is very low.  As a sound  is given or a  movement of
choking ensues, or in a condition of quiet, a pale, gray, rugged pro-
jection may be seen winding around the posterior wall, somewhat
above the  free border of the  soft  palate, which is nothing else
than  the  inferior part  of  the  hypertrophied  pharyngeal  tonsil.
Voltolini already speaks of this kind of general diagnosis.
    As the hinderances to rhinoscopic  examination  have already
been  described, and hints have been  given as to  how they can
be overcome,  it may here suffice to say, that with the palatal hook
one can always distinguish, whether  extended  tumefaction exists
in the pharyngeal vault or not.— Voltolini sometimes operates with
the aid of the  palatal  hook.
    In cases of moderate hypertrophy, which on an average is found
more often, the  examination  is  easier and does not  require  so
much time.
    At the  roof and the boundary line of this  from   the posterior
wall the red  cushion-like  tumor  is  thickest.  It  is   more largely 
86
HYPERTROPHY.
developed here than on the posterior wall.  On the sides near the
Eustachian tubes the edges are more abrupt and very low.  The
fossa of Rosentnueller and the Eustachian tubes are  generally en-
tirely free from elevation, and show  a  smooth  normal condition.
With the moveable mirror, which can be brought  into  a  perpen-
dicular  position, every  part  of  the choanes  can  be  inspected.
The swelling has quite a regular, somewhat lengthened quadran-
gular  appearance,  and  diminishes  (especially  at the centre) the
height and depth of the pharyngeal arch.
    Once I saw it hang down  from the  roof free on  all sides, as a
red lump-like pivot, covering  two thirds of  the  septum.
    The normal pharyngeal arch  has  smooth  walls and  has  no
other projections than the Eustachian tubes.  If there is  an ele-
vation between and above them on the posterior pharyngeal wall,
which can be seen  plainly, and which is large enough to be taken
hold of by the  loop and removed, then it is a pathological phen-
omenon.  The  described symptoms will more or less be found,
and will not pass away until the  tumor is removed  and the arch
has been leveled.
   Of course, there are people, to whom obstruction by means of
mucus, difficult breathing through the nose, a  weak   toneless
(matte, klanglose) voice (with often total loss of  voice  in singing),
and even hard  hearing, etc., seem  to be matters of small conse-
quence, and  they therefore will have to keep  their  hypertrophied
pharyngeal tonsil to themselves.
    If an  acute nasal catarrh  is present at  the  same time in con-
sequence of  which the tonsil  is in a state of inflammatory swelling
—a fact which  is noticed by the  intense red color—then this con-
dition  must first pass  away before the degree of permanent hyper-
trophy  can  be discovered.  In general the proportions of  the
swelling are hard to be determined,  because the mirror  is more
or less perpenticularly below the object, and  has  to  render  the
image of it very much diminished in  length.  Sometimes one  is
 astonished at seeing such a thick piece in the loop, as it  appears
 very small in the mirror.
    The failure of  the nasal douche  consists in this  that the in.
 jected water flows out of the same naris again, and that  nothing,
 or only a little of  it, gets into the pharyngeal vault  and the  other
naris,  which fact  is  always  noticed.  During the  time in  which
water is thrown into the nares, the levator  uvulae muscle is in a
strongly contracted condition, because the uvula is drawn up with 
HYPERTROPHY.
87
so much force, and comes into  contact with the tumor, whereby
the pharyngeal vault is divided into two parts, one  on each  side,
as Meyer expresses it.
    If a crest or  a  part of  the swelling is found  on  the roof, only
a centimeter high,  the nasal douche is nevertheless greatly hin-
dered  thereby,  often entirely  prevented, until  the swelling has
been removed, when it can be applied with perfect success.  This
fact is easily explained by the short distance between the roof and
the bony palate, where the soft  palate is inserted, which on an
average is only 2 cm.
    There is  still  another diagnostic  expedient, which  may  be
mentioned—the digittal examination of Meyer.   It has undoubted
merits, especially  for one who is  not skilled  in the use of  the
rhinoscope.   I have applied  the  same but  once.   The case was
that of a girl 14 years of age,  I had removed  a large number of
pieces of  different sizes, which had originated in the  hypertrophy
of the pharyngeal tonsil.   A projection on the posterior wall near
the roof would  not yield.  Several times  I could plainly feel  that
the loop sprang off from a hard  object,  but I was  unable to find
out what  it was,  Through examination with the finger  I  learned
that the elevation  was of bone, and therefore not  an object  for
further operation.
                          TREATMENT.
    Voltolini was the first who operated on the  tumor .under  con-
 sideration, and  who did this with the galvano-cautery under  the
 direction of  the rhinoscope.
    I use  the instruments which he  recommends—excepting the
 catheter.   I  use  the  galvano-cautery also  very seldom now,  and
 the rhinoscope  only for examination.
    In using nothing but the loop I now remove all the larger and
 smaller outgrowths from  the cavity, so that the  walls receive their
 smooth, normal condition again.
    As has been observed above in by far the most cases the tumor,
 can be seen  from the anterior nares, at  least  on  one side,  even
 without the help of the probe.  On this  account I also use the
 speculum in operating.   I introduce the  loop (about i\ cm. long,
 and  1 cm. wide, with the tubes running at  the side of each other)
 in perpendicular  position through  the nares until it reaches the
 choanum.  I then turn it, in  order to get it into a horizontal
 position, press  it  up to the tumor until  resistance is  felt, then 
88
HYPERTROPHY.
 draw'the loop together and open the current.   In  a few seconds
 this is done, and a piece of tumor comes away in  the loop.  In
 this manner, i. e. when I can  see how to bring the loop under and
 onto the tumor, I take out the largest pieces.
    The largest parts  of  the  tumor have a crest-like  appearance
 and measure in length about  2—2% cm., in height 1—2 cm., and in
 thickness  5—10  millimeter   and more.  They  originate  on  the
 posterior wall, or the space lying between there and the roof.  The
 oval pieces or rough roundish pivots, hanging down from the roof,
 are shorter.  The crests, standing laterally (in the  fossa of Rosen-
 mueller), are thin, being flattened by the pressure, which has been
 exerted upon them by the Eustachian tubes in  the act of speaking,
 swallowing, etc.
    The surface has clefts, is  ragged, or  appears smooth, but on a
 more minute inspection it is  always found  to be also granular.
 Sometimes the kernels are close  to each other and well developed ;
 again they  may be quite isolated, and  are then very flat. Once I
 found among them a vesicle resembling a swollen sago-kernel.
    The color is light red, seldom a dark  blue-red.   The smallest
 flat  pieces  are  pale and  rose-colored.   The  texture (Gewebe) is
 fragile, easily torn, loosely put together, sticky and soft; but some-
 times, especially with older persons, it is tougher.
    The only painful moment  is,  when the loop is drawn together,
 and that  only  to a  slight  degree.   The  disagreeable tickling,
 caused by the  loop and tubes in passing through the nares, be-
 comes reduced to a minimum, if it is  done with care, skill and
 gentleness under the guidance of a speculum.  The painful and
disagreeable sensation generally ceases with  the removal of the
instrument.  Blood flows generally but very  little into the throat,
as can be seen by inspecting  behind the posterior  arches of the
palate;  but a few inspirations through  the nares with  the mouth
closed, and with the consequent  hawking, suffices to  bring  it on
again.  If the head is bent forwards, a few drops will run out of the
nares.   A few injections with  the syringe suffice to stop the hemor-
rhage and to clear  the parts  for further operation.   In a few  in-
stances there occured  also attacks  of fainting  and nausea—as in
operations upon  nasal polyps together  with examinations made
with the probe—which  were evidently caused  by  the irritation
of the nasal cavity.  For in using  the pharyngeal-polyp-loop
 (Rachen-Polypen-Schnuerer) I  have  never seen  this occurence.
    Voltolini says in relation to the  employment of the loop: If 
HYPERTROPHY.
89
the vegetations are very long or pivot-like, then the medium sized
galvano-caustic loop can be used.  It is to be conducted through
the nares into the pharyngeal vault; then pressed against  the
superior pharyngeal wall as much as can be done (without its  be-
ing bent too much), and then drawn together, etc. One feels very
plainly when he pushes the loop out of the nares into the cavum
(phar. vault).
   According to this, Voltolini dos not  use  the speculum at  the
same time.  One may succeed in removing parts  of  the tumor
without it, but he can  operate much surer, when he  sees than
when he is  obliged  to feel.  If one  must  rely upon the  feeling
alone, he will  quite often  push  the  instrument  too  deeply down
into the pharynx;  thus  introducing it in vain  much more often
than when  he can see.   Bone-projections and deformities of  the
turbinated bones are insuperable obstructions  to the passage of
the loop.
    Either it can not be  pushed into the pharyngeal vault at  all,
or if this is  accomplished—under loud cries of  pain from  the pa-
tient—it can not be applied to the pharyngeal roof; it can not be
pushed  up, because  the bone-projections  resist it.  Formerly I
brought the galvano-cautery behind the velum, in cases, where the
loop could not be  used  successfully through the nares, and with
the aid of the rhinoscope succeeded  in destroying  the different
elevations ;  or T pushed the galvano-cautery through the nares—
according to circumstances either through the inferior or  middle
meatus—looked for the  point of the galvano-cautery by means of
the rhinoscope, and fallowed it up as  the right hand moved  the
tubes.   Thus I would bring it  upon  the tumor concerned; then
lay aside the mirror; attach the ends  of the tubes to the  handle,
let on the current, etc.  Thus, it will be seen, I operate about the
same as Voltolini does with his galvano-caustic  catheter.
   But for the last six months I have  been able to dispense with
this slow and difficult method, for I learned to use the pharyngeal
polyp-loop, the instrument recommended by Voltolini for  operat-
ing on the hypertrophied pharyngeal tonsil,  but which, as it seems,
is not used by him.   This I had  modified  so as to  have a lock-
apparatus  (a little knob), attached to the side, which can be pressed
down by the ring-finger  after the  loop  is drawn together.   Thus
I need no assistance to close the current, and besides can operate
quicker.   Again the conducting tube can  be  unscrewed, which
can not  be done with the instrument of  Voltolini. The instrument
       12 
9o
HYPERTROPHY.
can be cleaned and the blood blown out, a  thing which  must be
done after each operation.  If one of the wires or tubes becomes
injured it can readily be replaced,  as  the handle is  at  all times
servicable.   In place of the ivory plate and screw there are two
little tacks, made of bone, with holes in them to fasten  the ends
of the wire with.  This is not so easy to manupulate as the screws ;
but as  the screws soon wear out—as the thread  is rubbed off by
use, thereby soon becoming  useless, it is preferable.   Besides the
loop is apt to get loose, become drawn out of the tubes, or  let go
of what it had already taken hold of—an incident, which is very
disagreeable to the operator as well as to the patient.
   Below, on the handle between the two ends of the conducting
wires, there was  a little knob;  this has been removed, and  there-
by the surface has been made smooth, giving a better support to
the  thumb for counter pressure, as the index- and middle-finger
draw the loop together.
   In consideration of the height of the soft palate, which'on an
average amounts to from 2.5 to 2.8 cm., I give to the tubes a bend
of about 2  to  2-£ cms.   The pharyngeal  roof is about 1.8 cm.
distance from the insertion of the uvula, the nasal floor, and  the
hard palate; therefore only a moderate lowering of the handle is
needed, in order to reach the roof.  If an operation is to be per-
performed here,  I bend  the tubes more towards a right  angle.
The loop is about i£ to i£ cm. wide, and bent toward the handle,
so as to form an  obtuse angle with the tube  upon toward the front.
The wire must be strong (No. 3—2), if the irritability is great. Nos.
3 to 4 can be used if from the beginning the walls are quiet, and
tend only moderately to be thrown into spasms, at the moment the
instrument is pushed up.
   Whilst the tongue is held  down with the spatula, the instrument
—the tubes of which are always parallel to  one another—is held
and conducted with the hand in a position about half way between
pronation and supination until the loop has passed the border of
the soft palate;  then the hand holding  the  handle is turned,  so
that the broad surface  of the handle and  the  back part of the
hand  are both turned  upward;  at the  same  time  the hand is
lowered, thereby causing the loop to ascend. The behavior of the
pharyngeal wall  against this invasion  (Eingriff) is as follows:
   As soon as the instrument (loop) gets behind the uvula, more
or less choking ensues in consequence of its coming  into contact
with the parts.   Contraction of the  levator veli, the pharyngo- 
HYPERTROPHY.
91
palat., the stylo-pharyngeal, and  the  superior constrictor muscles
takes place as well as a constriction of the canal itself.   And thus
in a strong spasmodic action, if the loop is  not of strong wire, it
will not remain uninjured, but will be bent and  rendered useless
by the time it gets up there.  Often it can not be carried up along
the posterior wall as  desired, because it strikes either against mus-
cular bunches (Muskelwuelste), or the inferior end of the enlarged
pharyngeal tonsil.
   If the  choking patient is requested to breathe,  which will
cause the general contraction to cease, the walls then will  return
more or less to their  natural position; the favorable moment is  to.
be now quickly improved.  But these  hindrances are  best avoided
when the loop is bent anteriorly, and pushed up on the smooth
posterior surface of the soft palate.
   Once in a case of a boy, 12 years old, after several  unsuccess-
ful attempts,  I finally discovered the hindrances by means  of the
rhinoscope, and  could avoid them  as the pharynx was  exception-
ally  wide.
   It will be readily felt when the loop gets above  the region  of
this muscle-obstruction (lying between the openings of  the  Eusta-
chian tubes)  by  the ease with which it can be  moved.   If it is  to
be pressed to the roof,  the handle is now lowered somewhat, or if
to the posterior  wall, it is raised a little.
   When the roof is reached, which is known  by the  resistance
offered, the loop takes  a position  parallel to  the wall,  and any
elevation on  it is taken hold of.  As the pharyngeal tonsil  has a
lobulated character,  it is better to  use a small loop, as has already
been observed, so that it may get  into  the  furrows of the  tumor,
between the rugae and crests and thus the  easier take  hold.   A
large loop may also strike anteriorly against the ends of the turbi-
nated bones  and cause  severe pain.
   As long as the tumor is still entire, the loop catches  less easy,
especially in a case of moderate hypertrophy, than if  some open-
ing has already been made.  To remove it  all at once can not be
done, because it is  not a pedunculated tumor, but  a swelling,
which spreads over a broad area, which is to be removed.
   If only the centre of the roof  is to be reached, and the pieces
to be removed, are hanging down  before the septum, then the
patient must be  directed to hold his head straight, and the tubes
must remain in  precisely the same direction as the uvula.  The
more the tubes deviate from  this  position,  the more  the  lateral
parts of  the  roof are reached. 
92
HYPERTROPHY.
   If the loop is to be applied on  the  posterior wall, it must be
bent a little less toward the front.  For it will catch on the parts
between the Eustachian tubes or somewhat below, if it is left in
the same direction while the tubes are bent at an obtuse angle.
   The rugae and  crests in the fossa of Rosenmueller (generally
thicker, longer, tougher and harder than  the  other  parts of the
tumor, as Meyer has already described) can only be removed with
difficulty, or not at all from through the  nares.   The  reason of it
is  this:  as soon  as the loop has  come  out  of the choana, the
muscles of the pharynx contract in consequence of the irritation ;
the uvula ascends, as I have shown before, and  a correspondingly
strong elevation of the Eustachian tubes takes place  at the  same
time.   On this account the fossae  are misplaced  and  the  loop  is
prevented from reaching there, as  also  from operating anywhere
at  the sides   This difficulty is still more increased, if the inferior
turbinated bone is largely developed, while the middle meatus is
narrow, in which  case the  loop  can  not be  brought  over the
Eustachian tube into the fossa of Rosenmueller.
   But with the instrument described above the  operation suc-
ceeds completely.  A thick wire, No. 2 is put in, and the  loop  is
made  somewhat wider.   It runs in the  same  direction  as the
tube, bent at an obtuse angle, and  is quickly pushed up  behind
the most lateral part of the uvula, and always remains on the side
and posterior wall of the pharyngeal head. Soon it strikes against
the roof, and  if now the instrument is  drawn  back  a  little, the
loop  will get into the fossa of  Rosenmueller.   Being pressed back-
ward, it catches the elevation, which may then  be removed.—It is
hardly necessary to say, that the loop  can  be used  in this way
without any fear of danger.  Superiorly,  the walls, the roof, and
posterior wall are stiff.   On  the  side  there is  a large layer of
muscles between the large branches of bloodvessels  and nerves
and  the mucous membrane.   Although  below  the  Eustachian
tubes the posterior wall is wrinkled, yet it  is better to have  it
made smooth by an inspiration before the loop is drawn together.
   The Eustachian  tubes, standing as wall-like, smooth  semi-
lunar-shaped projections,  can not  be embraced by  the loop, ar-
ranged  squarely.   The  less  resistance  is offered by the phar-
yngeal walls, the more sensitive  they are, the more surely and
desirably  does the loop work.   I  therefore  always repeat the
request to the patient to breathe, in order to quiet the muscles of
the pharynx. 
HYPERTROPHY.
93
   Sometimes the loop comes out without anything  in it, because
the piece  has been pushed out behind;  but as it (the loop) re-
mained firm and there is bleeding, it may be seen with the mirror,
and to remove all doubt, as to whether the piece has  been taken
off, and to ascertain the bleeding points, the mirror had  better be
employed.
   The pain is generally very moderate and transient.   Behind
the Eustachian tubes it seems to arise somewhat easier and to be
more intense.  It is often described as a head- or neckache, less
often as ear- or toothache.   In very exceptional cases  it is said to
spread like lightning toward the eyes.   In using a thick  wire (No.
3 or 2), it is necessary to supply the batteries with fresh  acids, in
order to furnish a strong current, or else the piece will be burned
off too slowly, when more lasting pain ensues.
   The described mode of  operation is  by most patients said to
be more painless and more agreeable than that  made through the
nares.   The way to the  tumor is much  broader, and  can be
traversed much quicker.   The mucous membrane is not sensitive
to such a degree.  I therefore begin, especially with children (the
youngest  of which was a boy 6 years old),  with the pharyngeal
polyp-loop.   They are thereby made more willing, and the fear is
also taken from them.
   If the conditions are favorable in the nares,  if the patients
bare the tickling, so that they can  keep the head  unmoved after
light has  been thrown in, which  even children of from 8  to 10
years  of age can do, after an earnest persuasive talk—unless they
belong to that effeminate class, who  have been spoiled by false
training—then I' operate  on everything that can  be  seen  and
reached from the nares,  as has already been observed. If the
nasal  cavity is not sufficiently open at the beginning of  the oper-
ation ; after there has been  manipulation carried on in the cavum
several times from through the mouth, then the one or  the other
naris  often  becomes enough widened  or opened.  Evidently a
drawing of  the blood towards  the pharyngeal arch  takes place
in consequence  of the irritation, the submucous  tissue is  less
filled, and  the inferior turbinated bone becomes  smaller.  The
posterior sphenopalato nasal artery supplies both in common.
   The use of the pharyngeal polyp-loop in the manner described,
has this advantage, that  the rhinoscope  needs only to  be  used
when  the seat and size  of  the elevations may be determined.
There is  no need of having the  palatal hook, the spatula, the 
94
HYPERTROPHY.
galvano-cautery and the mirror in the mouth at the same time.
Thus the method which Voltolini describes as the most difficult of
all, can  be dispensed with.
   The patient  is spared many  trials,  and  the physician much
patience and exertion.   The use of the galvano-cautery and the
galvano-caustic catheter through the nares  is also more incon-
venient  and timetaking for  both parties (patient  and physician)
than this method.  Whilst the burner has to be applied repeatedly
to each  elevation, and has therefore to remain in the  nares for a
longer  time, as  its  position has often to  be changed or cor-
rected; but with the loop it is cut off completely and in a moment.
   It is self-evident of  course that one must have a minute con-
ception  of  the cavity, in  order to make the movements skillfully
and easily.  Besides rhinoscopy, the digittal exploration  is of ser-
vice.  The method of  Meyer  consists in  using  the  tonsillotome
by the  guidance  of  the finger; then to apply cauterization  by
means of nitrate of silver.  Sometimes he also uses the galvano-
cautery in  connection  with  the rhinoscope.   (Stoerk has recom-
mended articulating  choanae-forceps.)
   But these instruments are much larger. They produce more pain
and more  hemorrhage than the galvano-caustic instruments, which
are thiner.  That the reaction is also stronger Meyer himself ad-
mits.   Sometimes I have also removed parts of the tumor, for in-
stance soft, small crests with the simple loop.  But the galvano-
caustic  loop is always much less painful.

RESULTS OF THE OPERATION.—AFTER-TREATMENT.--NUMBER  OF
                          SITTINGS.
   It is better not to prolong the sittings too much, but to discon-
tinue them after a few pieces have been removed,  in order to
prevent violent inflammation.  The patients  can  remain without
further  observation.  The after-treatment (consisting of injections
of a solution of  chlorate of potassium, and repeated 2—3 times)
the patients can manage for themselves.
   They feel themselves more or less  affected, either on the same
day only or on the following days.  For a few days they look pale,
but do not  complain of headache.  Sometimes they  complain of
moderate  dysphagia; in their expectoration yellowish  mucus is
noticed.
    In several of myiases a strong vertigo of the head and fever
ensued  the next day after the instruments had  been introduced 
HYPERTROPHY.
95
through the nares (about 10 times), the  patients being obliged to
go to bed.   Although I have never seen any more  serious pheno-
mena,  nevertheless reports  of this kind  induced me thereafter
regularly to make the  sittings short.   Purulent  inflammation of
the middle-ear often followed the operations  of Meyer, and in
cases operated by  Wendt with the  tonsillotome  (Ringmesser—ring
knife) inflammation ensued in both ears.
   In the case of one patient, a strong young man, 26 years old,
violent ear- and headache ensued quite suddenly about two hours
after the operation, as he had been sitting in the coupe of the rail-
road waggon for a while, through the open window of which a strong
draught had blown in the right ear, having entered it (the coupe)
in a state of incalescence.  In a few days perforation and purulent
discharge  followed.   By  a diligent use of  the apparatus  of
Pollitzer and a careful cleansing, a complete  restoration of the
hearing was affected.  But  it is  yet  very doubtful, whether the
operation was the  cause of these phenomena.
    In  another case pain and hard hearing did  not ensue till the
third day, when  perforation and purulent  discharge followed.
But during the same  winter the patient  had  to  go  through the
same process  twice more, without  any operation having preceded.
    Here the extraordinary sensitiveness of the skin and the strong
tendency for contracting cold must be  looked  upon as the main
cause, so much the more  as  after  the frequent operations, which
were performed thereafter, not the least  signs of  inflammation of
the middle-ear were noticed.
    As to the  intervals between the operations, I generally operate
from two to four times  at most within 14 days.  Formerly I had to
operate from  ten to twelve times  in all, but since I have used the
pharyngeal polyp-loop, 4 to 6 sittings are sufficient. 
96
OBSTRUCTION IN THE NARES.
 CONSEQUENCES OP OBSTRUCTION IN
    THE  NARES AND THE  PHARYNG-
                    EAL VAULT.
    The impediment to breathing is the most important, and has
 the greatest influence on the entire organism.   As a rule, inspira-
 tion and expiration are disturbed in about  the same degree,  but
 the  latter more especially  when polyps  are  hanging out of the
 choanas, and by expiration are drawn into the nares by the current
 of air so as to close it (valve-like).
    Whilst naturally breathing is  done through the nares in times
 of rest, and the mouth  is kept closed, such patients are obliged at
 all  times to breathe through the mouth.   By this coercion  the
 unconscious, involuntary  act of respiration is made to be a very
 disagreeable  and  uncomfortable occurance.   It also doubtless
 causes irregularities in the number and depth of the respirations.
 During sleep the mucous membrane of  the throat soon gets dry,
 as  alsp the secretion coming down from the pharyngeal  vault.
 More or less uneasiness  is felt, and sleep becomes  restless—fre-
 quent awakening occuring.
    Snoring is always conspicuous. The narrowness of the passage
between the back of  the  tongue and the soft  palate is made
narrower yet through  the  falling back of  the tongue.  The  in-
creased volume of  air, caused by the deeper inspiration in sleep,
cannot enter quick  enough through this  small space ; consequently
the  air is much diluted in the  mouth and throat; a whizzing
trembling movement of the  velum and epiglottis ensues.
    In such positions, in  which they are  compelled exclusively, or
for  the most part, to breathe through the nares, the patients  ex-
perience much inconvenience.
    In  eating they gasp and pant;  they have  to masticate and
swallow quickly, in order to get the mouth free again.  Smoking,
where the nares are obstructed, is either impossible or is accom-
plished only with so much exertion, that it ceases to be an enjoy-
ment, which to  miss is no small trial to many a one; but after a
few short puffs the  patients have to lay aside the cigar or  pipe  in
order to draw breath, whilst a healthy person can at the same
time with the  same  breath, fill  the mouth with smoke and  the
lungs with pure air through  the nares. 
                OBSTRUCTION  IN THE NARES.             97

    In  singing, speaking, running, lifting  heavy weights,  or,  in
short, during  any physical exertion  whatever,  when  there  is  a
greater abundance of air needed, the necessity arises at the same
time of inhaling as much air as possible in  the shortest time.
    But if one of the air passages be closed or insufficiently open?
then a new hinderance is caused thereby in  satisfying  this want.
To overcome this it  is necessary to breathe  even more quickly,
the exertion must therefore be still greater, and it will also require
more time until the commotion  in  the lungs ceases, and deep
breath can be drawn again.  If  lung or head disease,  or disturb-
ance of respiration from other causes are present, then these difficul-
ties are very much aggravated by an obstructed nasal cavity. Or if
there is a tendency to nervous asthma, the irregularities of exchang-
ing oxygen or nitrogen in the blood, caused by the irregularity of
breathing, may even bring  about attacks of spasms.
    It iemains to be mentioned  that the gieatest number  of pa-
tients affected with  the disease, under consideration  as has been
shown in the different chapters of  this work,  have a weakly con-
stitution, and a tendency more or less to contract cold and catarrh
of the air-passages.  The course of bronchial or lung  catarrh  of
such patients will certainly be  more  lasting and obstinate than
where breathing can be accomplished equally well through both
mouth and nares.
    The fact  that patients, suffering with  chronic catarrh, nasal
polyps or hypertrophied pharyngeal tonsil,  all have a pale,  sallow
appearance, look emaciated and old in proportion to the  degree
of the affection, and that after a complete cure they  soon become
vigorous and healthy—is explained by the irregularities in breath-
ing as  to number and depth of  respirations drawn.   Although the
increased secretion  is  also to  be taken  into  account, but the
purulent character of it being much less prominent than  the mucus,
it can take but very  little part in bringing about this  phenomenon.
    Even after the operation upon a moderately enlarged  pharyngeal
tonsil,  I have often observed a great change in the patients' appear-
ance—which was not only observed by me, but also by their  friends
who knew nothing of the operation.
   This is easily explained, if the size of the pharyngeal vault  is
taken  into consideration;  its width  is  3.5  cm.; its height 1.8
cm.; its  depth 2 cm.   A tumor, for instance, at the roof of the
pharynx or the posterior wall, of only the thickness  or the height
of a single centimeter would reduce the most important diameters
of the cavity one-half. 
98
OBSTRUCTION IN THE NARES.
    I have seen hypertrophied tonsils of the pharynx in children
only three or four years old, as well as chronic catarrh, and nasal
polyps in some of 8 or 10 years of age.   The hinderance to the
action of the lungs resulting therefrom, will, besides the bad influ-
ence in preventing  the exchange of (Blutgaase—bloodgases)  oxy-
gen and nitrogen in the blood, surely  also hinder the  growth of
the lungs, and thus diminish their ability to perform their function
in after-life.
    E.  Wagner, in his diseases of the soft  palate, mentions several
observers who think that hypertrophy of the palatal tonsils in those
of tender age, would bring  about a deformity of the thorax.   In
the lower parts it would be bent inward;  the sternum bent some-
what forward; the spinal column be crooked, similar to the breast
of a chicken.  Or the sternum would be bent inward; on the  con-
trary,  the lateral parts of the thorax projecting  outward;  the
spinal colum not  at all or  but little bent.  The muscles  of the
thorax often strikingly weak.  The cause  of this is said to be the
diminished amount of air admitted into  the lungs, which  would
cause a compression of the thorax by the  exterior atmosphere.
    If this is the case, then these results may also be brought
about, when the air is hindered from passing  through by obstruc-
tions in the nares, or the pharyngeal vault.
    Wagner further remarks! "The entire organism is injured in
a high degree;  the patients mostly appear pale and emaciated, less
often bloated, somewhat bluish.  Soon after the large palatal ton-
sils are cured, the  swelling  is reduced,  these disturbances  dis-
appear."
    With children as well as with adults of about 20 years of  age,
who only suffered with hypertrophied palatal tonsils,  these pheno-
mena are frequently observed to be more or less prominent.   Not
only is the isthmus faucium, the entrance from the  cavity  of  the
mouth into the pharynx narrowed  by hypertrophy  of the palatal
tonsils, but also the posterior palatal arches are pressed  backward
and upward, by which the lateral parts  as well as also the entrance
into the nasal pharyngeal cavity is  much diminished  in  its  space:
Thus breathing through both mouth and nares is hindered.
    The consequences on the physiognomy of the  patients can
plainly be recognized.   The inferior maxillary is always hanging
down; thereby the  upper lip is lengthened  in the angles of  the
mouth; the folds of the nasal wings are flattened (Meyer), and in
one case, of a high degree, I observed, that the inner  angles  of 
                 OBSTRUCTION IN THE NARES.             99

 the eyes were drawn down.  The forehead often lies in wrinkles,
 and has the expression of  a constant feeling of  uneasiness.
    All this in connection with  the pale, sallow color of the face
 disfigures, and often entirely removes inherited beauty.   But if an
 individual is affected with this disease, who was originally endowed
 with less regular features, and if the same is also hard of hearing,
 then  not only a stranger, but even parents, brothers and sisters
 may be induced to  look at such a patient as weak-minded (as  an
 idiot in the highest degree—Meyer).
    The peculiarly changed, perverted speech makes the  idiotic,
 laughable  appearance even more prominent.   In cases of a  high
 degree the nares are strikingly small, also the whole cartilaginous
 nose, in consequence of this incomplete  development.
    Since I have observed the shape of the  roof  of the mouth,  I
 have found in corroboration of a remark in E. Wagner's "diseases
 on the soft palate," that it  is often remarkably pointed  and high-
 arched, that  the front teeth sometimes  project  outward  even to
 some degree in moderate hypertrophy of the pharyngeal tonsil.
    In  breathing through  the  mouth  a  full current of air inces-
 santly  strikes  against the palatal roof, whilst the air  enters but
 sparingly through the nares, and  can not therefore exert its influ-
 ence on the walls of the nasal cavity (in  progress of growth),  to
 expand or widen them.
   Robert after Meyer found the  cause of these deformities to be
 a diminished calibre of the posterior opening of  the nares, which
with the surrounding  parts became arrested in their  growth in
consequence of the  reduced functions of the air.—If not the open-
ing of  the mouth, the pointed shape of  the upper  jaw, so often
observed in those belonging to  the English nation,  may have its
origin in hypertrophy of the pharyngeal tonsil. 
IOO
CHANGES IN SPEECH AND VOICE.
   CHANGES IN SPEECH  AND VOICE,
       CAUSED BY TUMORS IN THE
            PHARYNGEAL VAULT.

    G. Passavant has already shown  that  in the pronunciation of
all the letters except the nasal sounds, a complete shutting off of
the pharyngeal vault from the rest of the  pharynx takes place.
    Aided by favorable circumstances, I was  able to place a mirror
into the pharyngeal arch of a man, who was supplied with normal
parts  of the pharynx, and  thus  I  was able  to  furnish the first
description of the actions of the walls of  the pharyngeal head, in
swallowing, speaking, singing, &c, as viewed from above.*)
    Passavant's statements were  confirmed and  supplemented in
this, that when  the  patient  pronounced an  "em" or  "en", the
shutting  off  ensued  but lasted  only  until  the sound  of the
added "e" or "03" had passed away.  But when only "mm" or
" nn " was pronounced, the shutting off did  not take  place at all
and I could plainly see the vocal cords meet.
   With the speculum one can not look down as far  as the  spot,
where the pharyngeal walls meet; but where the nasal cavities are
very wide (especially in ozcena patients), it is easy to observe the
movements of the soft palate in speaking, singing,  swallowing, &c,
and its  relation  to  the  openings of the Eustachian tubes.   This
was first described by  me.*)  If the word  " land" is pronounced,
the velum ascends as soon as "/" is  pronounced; the Eustachian
tubes also rise;  in this position they remain  until " a" is pro-
nounced; in  "n" both sink, and in  "d" both velum and Eusta-
chian tubes again ascend.
   Besides " m " and " n " all the consonants may be held ever so
long, and the velum does not go down until the  sound is made
and the  noise stops.
   I have  moreover  been  able to  show in my pharyngoscopic
studies of the participation of the  superior pharyngeal contractor
muscle in speaking,  that, if in  the  middle position a moderately
strong counter-tone  is  given, there often remains  so much  space
between the velum and the posterior pharyngeal wall, that one can
look up  to the pharyngeal roof.
*) New observations, &c. Berlin Klin. Wochenschrift, 1875, No. 41. 
CHANGES IN SPEECH AND VOICE.
IOI
   Thus we see, that the irregular vibrations, brought about by
the pronunciation of " m " or " n ", escape exclusively through the
pharyngeal vault and the nares.   They  are  therefore imperfect,
when the pharyngeal  vault, instead of having smooth walls, and
being filled with air, is covered with a rugged, sarcomatous growth,
which can neither reflect nor be brought into vibration.  In cases
of a  high degree, the sound can enter  but  imperfectly.  The  less
precisely or definitely, i.  e. the  shorter these consonants are pro-
nounced, the weaker is the sound, and the  more complete  is the
suppression of it.   But if they  are prolonged  for a  time, that is,
if the lips and the point  of  the tongue remain for  a  time  in the
requisite action, and if  air is forced out more vigorously, then a
plain pronunciation  is  brought about  in consequence of  the
stronger resonance of  the bones  of the head, especially  the
superior maxillary.
   Of the  other consonants it is generally  the "/" and  the " r,"
which,  in  consequence  of inertia or insufficient  action  of the
tongue, or  of a too short and abrupt pronunciation come to the
ear indistinct, blurt.  By a  vigorous, distinct pronunciation of the
consonants, which  consists  in  moving the tongue,  lips  and  soft
palate with energy, and  the continuance of the requisite time in
this  action, by  a soft, clear, free sound, which  is free from  any
mixture of sound, such as is caused by the pressure of the tongue
—conditions, which not  only bring about a complete shutting off
of the pharyngeal vault,  but also give  the sound a free, unhinder-
ed escape through the mouth—it can be accomplished, so that the
distorting  influence of  the hypertrophied pharyngeal tonsil  on
pronunciation is overcome in a degree.
   But the sound is weakened under  all  circumstances; for the
commotions and vibrations  of the soft palate cannot spread.  In-
stead of air, they find an unsuitable medium.  The resonance is
diminished, if not destroyed, as if,  for instance,  a violin case were
partly filled with cloth; the pronunciation  is  accomplished more
or less without the  pharyngeal  arch.  In  cases of a high  degree
with inert,  unfit action of the organs, the perversion of speech is
quite characteristic.   Meyer  calls  it  "dead."   It  seems as if
(as  different relatives  of  the  patients  diagnosed)  something
were behind the nares,  or  behind  the soft  palate, which would
cut  off  the  sound  of  the word, or  the syllable  immediately
after its origin.  Singing is more or less  impossible, or very diffi-
cult, because the soft palate cannot ascend to the  necessary de- 
102
CHANGES IN SPEECH AND VOICE.
gree, and remain in that position.   Hypertrophy to a medium de-
gree always produces a repression of the voice.  In consequence,
the sound is shorter, non-metallic, more limited, less  penetrating.
    To make up for the  deficiency, and to overcome the obstruc-
tion, lungs  and larynx  are  strained to  excess; lassitude of the
epiglottis, and  especially of the real  vocal muscle (the  internal
thyro  arytenoid) ensues,  causing  a  gradual weakening  of the
voice.  As has been observed in speaking of the nasal douche, the
velum  comes in contact with the tumor on  the  roof, if  it (the
tumor)  is but  i cm. high.   Thus in high notes the velum  must
overcome a counter-pressure, and  strain its power to the utmost.
By this over-exertion, its ability to accomplish its functions is
finally  diminished, and thus the voice generally also suffers a loss.
    In my estimation,  chronic pharyngeal catarrh  causes  damage
to the voice in  the same manner. The rugged tumors on the pha-
ryngeal mucous membrane obstruct and injure the reflex of the
voice, producing a snuffled sound, or  almost aphonic; while it
is not as voluminous  and penetrating.    In singing, the  follicles
swell even more in consequence of  the stasis of  the venus blood,
produced by the expiration; the throat is over-heated, dry, and
painfully tired;  from which a new hindrance arises.  The singer or
speaker now forces himself to pronounce or sing distinctly. Thus
the voice loses  its metallic sound—through chronic inflammation,
and atrophy of the different muscular fasciculi—as a rubber cord,
which is often stretched to its utmost, loses its ability to contract;
in other words, its elasticity is lost irrecoverably.
    I have, after a cure of chronic catarrh, by  method of the
galvano-cautery, as recommended by me, often observed that the
voice of the patient was clearer, and more metallic, and that it was
steadier and more pleasant; I have also observed in others, that
they were fast losing the metallic character of their voice through
chronic pharyngeal catarrh, which, had endured for years.
    The pearl-grayish color of the vocal cords, their broad, thick,
symmetrical development, the  sharpness of the free  border, and
their normal movements showed that a voice for singing had been
possessed,* which had been lost, not through  chronic catarrh of
the vocal cords, or the larynx itself, but of the pharynx.
    Gerhard calls attention  to  an  observation of  Philipaux, that,
where pharyngeal inflammation was present, paralysis of the vocal
   ♦Often I found the left vocal cord a little smaller.  A few times also, the rteht onp-
but in connection with this, I always found the patient to be left-handed. 
CHANGES IN SPEECH AND VOICE.
IO3
cords could not be cured by electric treatment.  He says that he
has twice cured paralitic aphonia by the electric current, but not
until after  the  hypertrophied palatal tonsils  had been operated
upon.  He believes that the central apparatus of the voice—con-
ceded to be in the brain—can be irritated from the pharynx, and
thus paralysis can be caused.
   According to this theory, it might also be possible that chronic
pharyngeal catarrh would frequently cause a damaging irritation
of the central apparatus, through which a weakening or paralyz-
ing influence might be brought  upon the vocal muscles, by in-
terfering also with their nutrition.
   A case  lately observed by me may be in place here.  A young
artillery lieutenant came to consult  me about his  being hoarse.
He thought he  had caused it by commanding in too loud a voice.
He complained of suffering frequently with throat inflammations.
An examination showed that his tonsils were in a state  of hyper-
trophy, especially the left.   There  were  coarse granulations on
the posterior and lateral walls of the pharynx.  Behind the poste-
rior palatal arches there were elevations having the form of beans.
In giving a sound, it could be seen, in the mirror, that  the  vocal
cleft was closed incompletely,  especially  posteriorly;  there were
quivering movements in the larynx; while  the vocal cords were
straining themselves to  remain in their position of tension, during
the time in which the  sound was produced ;  their strength, how-
ever, always failed.  By  turns  they grew broader and smaller.
Consequently, the sound became tremulous, quivering, weak, and
mixed with misdirected air.
   On the  second day after  galvano-caustic  treatment, by  which
the hypertrophy was removed, the patient came again when he
could produce  a clear, sure sound.   It could now be seen with the
mirror that the  sound-formation was  normal.  The widening of the
pharyngeal head, through the removal of the hypertrophy of the
tonsils, no  doubt, had brought about this  result.  But the follow-
ing peculiar coincidence in this case seems worthy of note :
    The left and most enlarged tonsil was soldered to the posterior
palatal arch, and thus it was hanging on to the velum like a piece
of lead, when it ought to ascend,—thus hindering its pliability to
a high degree.   The formation of sound was thus  impeded, and
a forced expiration—convulsive straining  of the vocal cords—was
necessary to overcome  the difficulty.  The voice was exposed to
serious danger. 
IO4            CHANGES IN SPEECH AND  VOICE.
    But it was  necessary  to use  the  voice sparingly  for  some
time  until a removal of the pharyngeal  catarrh  was  effected.
Moreover  I  ordered,  that  a  distinct  pronunciation was  to be
practiced (which I always recommend where the organs are weak-
ened^).   For a correct use of the breath, ease  of the tongue and
lips, pliability of the soft palate, in short, a precise pronunciation
of the consonants makes the functions  of the larynx easy to a
high degree.*)
    Meyer reports—to return to our theme—that after the  tumor
has been removed  from the pharyngeal vault, the " dead " pro-
nunciation of "m, n, I" will often  nevertheless remain,  and exer-
cise in pronunciation becomes  necessary  in  order to do  away
with it.
    A few cases of this kind  have also come under my notice.  I
at once showed these  patients, that they  did not hold on to the
consonants long enough, which may have been owing to the im-
perfect sound that had been produced for years; or in part also
to the laxity of the lips; or that  they opened the  mouth too soon
in pronouncing " m ";  or that they touched the hard palate too
lightly with the point  of the  tongue anteriorly in pronouncing "n,
I, d, r."
    Even in a normal condition the  sound of these letters becomes
very indistinct by this manner of pronunciation.  The consonants
should be held onto quite long, pronunciation  should be melodi-
ous, and patients should two or three times a day, for -J—i hour,
read in a moderate power of voice,  and before doing this, practice
the ABC  several times.  Those,  who  carefully followed these
directions, had a clear sonorous voice within a  few weeks.
    I have never found so thick a soft palate, that the breathing
and pronunciation remained  unimproved after the removal of the
tumor, which, I know, is in contradiction to Meyers observations.
  *) A work worthy of recommendation is Gymnastic der Stimme, von Oscar
Quttmann. 
NASAL SPEECH.
r°5
                  NASAL  SPEECH.

    Quite different and  easily discerned by a trained ear is the
change of speech, caused by abnormities in the  nasal cavity.  It
is noticed, that the sound is hindered in its escape from the nares;
it is confined  in a closed avenue.
    The more  anteriorly the obstruction is seated, the more of a
nasal  sound is  produced  (um so mehr brummt die Nase mit).  If
the opening of the nares is obstructed, then the alteration of the
voice is more like the one just  described.  The sound becomes
dull and abrupt.
    The  sound  becomes weakened,  when  tumors, situated  on
the inferior turbinated bone, prevent the vibrations of  the  hard
palate from being communicated to the air contained in the nares ;
also when polyps and a spongy  mucous  membrane diminish the
volume of air in the cavity; or it  is filled with foreign  bodies,
which cannot  be  caused to vibrate.  Bony incurvations, deform-
ities of the septum, also hinder the sound from flowing out freely.
The nasal bones being  shaken  abnormally strong, reverberate to
an  audible  degree.  Indistinct, indolent pronunciation,  and  an
incomplete shutting off of the pharyngeal vault also  increase the
repression, and serve to produce the nasal character of the sound.
    Other kinds of nasal speech, such,  for instance,  as  may  be
caused by paralysis and defects  of the soft palate, do not belong
here, but, if I may be allowed, I  will speak of a very peculiar case
here, which came to my notice.
    A boy, H., from Remscheid,  10 years of age, healthy and of a
lively disposition, has had, as his father says, an error in his speak-
ing ever since he has been able  to speak at all.   To  all syllables,
containing an "s", he  gives  a perfectly nasal  sound, and pro-
nounces them indistinctly as if his  palate were  paralized, or  he
had a cleft palate.  He can not form the sound "j" nor that of lix".
    Hitherto all attempts, to explain the cause, and to remove the
same, had been in vain.   An examination  of  the nares had not
been made; but in inspecting  them I found both the nares and
the pharyngeal vault to be normal;  but it could  be seen, looking
through the nares, that the velum fell down  when lts" was pro-
nounced as if it were " m " or " n ".   Thus we had  here a defec-
tive, unsuitable action of the velum in producing the sound " s ",
existing ever since the boy had tried to speak at  all. 
io6
DEAFNESS.
   I showed the boy, how I could produce a buzzing noise with
my incisor teeth  placed upon each other, which he soon under-
stood ;  and after from \ to f of an hours practice,  he could pro-
nounce  ".$•," and all consonants connected therewith, such as " x,
z," etc.; the defect having been removed.
   He  was advised for  sometime yet,  daily to practice the pro-
nunciation of " s" and hold on to it in a buzzing manner, in order
to bring about  perfect ease in pronouncing it.
   From that time the boy was cured of the  defect  to the great
astonishment and delight of his friends and teachers.  The  latter
were slow to believe however, that the change had been brought
about otherwise than through an operation.
THE RELATION OF DEAFNESS TO THE
       DISEASES JUST DESCRIBED.

   Among the 130 patients examined by me (125  of whom were
operated upon), who suffered from nasal  polyps, there were two,
who were affected with progressive deafness, and three old gentle-
men with chronic catarrh of the ear, without any subjective noise.
   All the rest enjoyed good hearing, only  a  few  complained of
transient dull hearing and pressure on one or both  ears, when the
obstruction in the nares was increased by a fresh acute catarrh.
   125 were affected with chronic nasal, catarrh (Stockschnupfen);
80 of whom  were operated  upon, while the rest  were  only ex-
amined, and cured with insufflations, of simple catarrh, not accom-
panied with hypertrophy. Several suffered with hard hearing, but
in consequence of a former purulent inflammation of the cavity
of  the tympanum, and 8 of them suffered with chronic catarrh of
the ear; three of whom complained of subjective noise.
   Those who suffered at the same time with hypertrophied phar-
yngeal tonsil., or from  polyps having grown out  of the  choanes,
reported most frequently of having acute  catarrh of the ear in a
moderate degree after contracting cold.
   The enlargement of the  pharyngeal  tonsil was found in 92
cases; 72 cases  were operated  upon; and  only 36 were affected
with deafness. 
DEAFNESS.
107
    But it must not be overlooked, that in earlier years  nearly  all
 had suffered from hard hearing, which gradually passed away, as
 the cavity grew  so much faster than the tumor;  and that thus the
 influence of the  latter on the Eustachian tubes became diminished.
    We see,  then, that the condition  of the pharyngeal  arch is  of
 more consequence to the ear than that of the nasal cavity.
    Though  it may  be conceded that a vascular tumor of the
 pharyngeal tonsil is favorable for contracting cold, and for inflam-
 mation ; and that it converts  this  (i. e. the  cavity) into a locus
 minoris resistential, by  which catarrh of the middle ear, and  per-
 haps  swelling of  the  "tonsil of the  tubes" (Tubenmandel),  as
 Gerlach calls the bed of follicles (Balgdruesenlager—sub-mucous
 reticulated tissue) around the Eustachian tubes, is often  produced,
 and even kept up, as the latter and the pharyngeal  roof are both
 supplied by  branches of the ascending pharyngeal artery.  I be-
 lieve, nevertheless, that the  most obstinate deafness (of the high-
 est degree) is often brought about by the hypertrophied pharyngeal
 tonsil in a mechanical way.
    The tumor prevents, in acts of swallowing, the soft palate, and
 with it the Eustachian tubes, from ascending as high as is  necessary.
    Just how detrimental this  influence must be, is seen from the
 fact (as my examinations with the mirror have demonstrated), that
 the Eustachian  orifice  is not  opened until  at the moment when
 these  parts  are raised  to  their  highest point through the act of
 swallowing.  To illustrate further what has just been said, I copy a
 few paragraphs from my article published in No. 41, 1875, of the
 Berliner Klinische Wochenschrift.
    " The movements of the Eustachian tubes are so very promi-
 nent, that there  can  be  no  doubt that Our  Maker has designed
 them  as necessary to the hearing of  sound.   In  my  estimation  it
 is  established  that, without  this  raising of the  Eustachian tubes,
 the tensor,  i. e-, the dilator of the  tubes, can  work but insuffi-
 ciently, and  thus open the  tubes only  inadequately.  The knowl-
 edge  that patients,  afflicted with deafness, while suffering at the
 same  time with an enlarged  pharyngeal tonsil, could hear much
 better or quite normal after  the  swelling had been removed, and
 this, too, without any other treatment of the ears, has strengthened
me in this belief.
   " The tumor, situated behind the Eustachian  tubes, prevents
the movements of these, and prevents its being lifted off the an-
terior  wall of the orifice ; but on  the  contrary in swallowing, the 
io8
DEAFNESS.
  openings of  the tubes are pressed between the soft palate and the
  tumor, and thus become closed rather than opened, by which the
  ventilation  of the  cavity of  the tympanum is prevented  to  a
  greater or lesser degree.
     "A case of deafness came to me of from 5—10 years standing, or
  even longer, against which specialists of eminence could only obtain
  transient results, but  which improved immediately after the first
  or second operation, and then—keeping pace with  the removal of
  the tumor—was cured completely and radically, by the complete
  removal of the tumor.   But if the cause had been swelling or in-
  flammation in the tympanic cavity (im schall-leitenden Apparate—
  in the apparatus for conducting the  sound), this result could not
  have been reached  thus ; and shows  that it must have been caused
  by a mechanical  closure of the opening of  the Eustachian tubes,
  as described before.
     " How much the  mobility—the raising of the soft palate (on
  which the moving of the Eustachian tubes depends), is prevented,
  may  be seen  from  the fact, that after those  parts of the tumor
  which filled the fossa of Rosenmueller have been removed by the
  operation, the rhinoscopy, and rhinoscopic application of the gal-
  vano-cautery—which  previously could  have been accomplished
  quite easily—can now only be done  with  the greatest difficulty,—
  if at all—because  the velum pressing against the posterior  wall,
•  (at least touching it), entirely  prevents an upward view into the
  cavity.
     " Speaking, and especially the holding to high notes in singing,
  which, as is well known, calls for a strong upheaval of the velum,
  is very  difficult, if not  impossible,  (a  fact  to which Meyer has
  already called attention), because of the resistance offered by the
  tumor.  It  does not  always  suffice, therefore, to examine the
  larynx when the voice is affected.
     " Meyer also calls attention to the fact  that hard hearing is
  characteristic with patients  who suffer  from hypertrophy of the
  pharyngeal tonsil;  that it is difficult of cure,  and that the inhala-
  tion of air does not bring the hearing back to a normal condition,
  until after the vegetations  have  been removed; and whilst this
  can not be brought about before the  operation through any treat-
  ment, it is often accomplished through the  operation  alone, with-
  out any other treatment.
     ' I  can but confirm the  experience of  Meyer, and  believe, 
DEAFNESS.
IO9
that I can explain it in  part  by my view of the influence  of the
tumor upon the Eustachian orifice in swallowing, etc, as expressed
above."
    In case of  catarrh of the middle-ear,  great stress has been laid
on the condition of the pharynx;  but after I have  demonstrated,
that the pharyngeal tonsil is very often found  in a state of  hyper-
trophy, certainly not much less often than the palatal tonsils, one
ought not to  neglect the examination of the  pharyngeal head of
every patient, who  is affected  with a  chronic deafness.   If the
requisite skill  for examination and operation  has been acquired
one will often be  astonished at seeing what result may be reached
more or less quickly, often unexpectedly, and he  will, no  doubt,
be influenced  thereby in future to lose  no  time or  labor with the
air-douche and injections, before  bringing  the  pharyngeal  head
into its normal condition again.
finis. 
ERRATA.
Page 9 on the 9th line read grow for grows.
Page 9 on the 19th line read galvano-cautery for galvano-caustery.
Page 10 on the 2d line read     "      "    for   "
Page 15 on the 12th line read site for side.
Page 78 on the 1st line read Pharyngeal for Pharingeal. 
CONTENTS.
                                                             Page.
Introduction to American Edition.
Preface.
Introduction...................................................    7
Examination of the Nasal Cavity................................
  Anteriorly......................................................   11
  Posteriorly.....................................................   I4
Diseases of the Nasal Cavity............................__
  Acute Catarrh.................................................   18
  Chronic Catarrh................................................   22
  Deformities in the Nasal Cavity...................................   33
  Ozoena.........................................................   35
  Syphilis in the Nasal Cavity.....................................   50
  Nasal Polyps.....................................................   57
  Papillomata...................................................   72
  Malignant Tumors...............................................   73
  Epistaxis.......................................................   75
  Foreign Bodies in the Nasal Cavity. ..............................   77
Diseases of the Pharyngeal  vault..................... .......
  Ulcers...........................................................   78
  Hypertrophy of the Pharyngeal Tonsil...............................   81
Consequences of Obstruction in the Nares  and  Pharyngeal
    Vault........................................................   96
Changes in Speech and Voice, caused by  Tumors in the Phar-
    yngeal Vault...............................................   100
Nasal Speech...................................................   105
Relation of Deafness to the Diseases described........ ......   106 
?
t
 
DISEASES
THE NASAL CAVITY
and the
VAULT OF THE  PHARYNX.
y
      TRANSLATES) FROM THE GERMAN OF

Dr. Carl Michel, of Cologne on the Rhine,

    SPECIALIST IN LARYNGO- AND RHINOSCOPIC SURGERY,



        WITH AN introduction BY

  E. L. SHURLY, M. D., and C. C. YEMANS, M. D.,
         OF DETROIT. MICHIGAN.
FIRST AMERICAN EDITION.! J J-Q^f
      DETROIT, MICHIGAN ;
C. Jung, 250 Randolph  Street,
         1877. 
 
 
 
 
 
 
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HI			111
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