284 
THE MEDICAL RECORD. 
[March 14, 1885 
1883. Bazy : Tumours de la Vessie Pousson. Paris, 1884. 
1883. Wells: Two cases. London Lancet, January 27, 1883. 
1884. Tiffany: Papilloma. Maryland Medical Journal, January 
io, 1885. 
1884. Kaltenbach: Papilloma Berl. klin. Woch., June 2, 1884. 
careful and continuous study of a case exhibiting a frequent 
pathological condition, consisting of a thickening of the 
mucous membrane overlying the posterior borders of the 
vomer, shown in this drawing, taken from a life sketch 
(Fig. 1). I was persuaded that the hypertrophied tissues 
THE ETIOLOGY AND TREATMENT OF NASAL 
CATARRH, WITH SPECIAL REFERENCE TO 
THE DEVIATED SEPTUM.1 V 
By WILLIAM CHAPMAN JARVIS, M.D. 
LECTURER ON LARYNGOLOGY AND DISEASES OF THE THROAT IN THE NEW YORK 
UNIVERSITY MEDICAL COLLEGE. 
Few diseases have, until in recent years, at least within 
the last decade, occupied a more obscure position as 
regards their pathology and therapeutics than those 
involving the nasal passages. Such, as is generally 
acknowledged, being the case, it is not surprising that 
chronic nasal catarrh should be classed among the 
“ opprobria medicinae,” giving rise to the somewhat gen- 
eral impression that it is an incurable disease. It seems 
to me to be our duty as medical men to determine whether 
this belief is based upon the reliable testimony of care- 
fully conducted scientific investigation, and if not to 
promptly condemn the circulation of such an erroneous 
opinion. 
In pursuance of a line of inquiry, recommended by 
me in 1880,2 I will seek the solution of this unsettled 
question by discovering and removing the cause and 
effects. In 18823 I extended this line of thought and 
considered more in detail the part played by the deviated 
septum in nasal catarrh, accentuating as in the first 
paper, pressure irritation produced by contact of the 
septum with the turbinated tissues. I also gave my 
grounds for attributing chronic rhinitis to this and de- 
fective nasal drainage and finally offered novel remedial 
methods for dealing with the deflected septum. 
In order to simplify and at the same time systematize 
the description of this deformity, I have for several 
years employed a classification which, at least, possesses 
the merit of simplicity, in addition to other advantages 
already enumerated by me. 
Deviation of the septum narium may obviously be 
either, in character, osseous, cartilaginous, osseo-carti- 
laginous, or hypertrophic. In form these varieties may 
be either localized, that is, limited to small portions of 
the septum, or general, involving the whole extent or a 
large surface of the septal structure. I cannot discuss 
here my reasons and right for employing so simple a 
classification, suffice to say for the present it accords 
with the various conditions, and has afforded me an ex- 
cellent guide for the surgical management of these con- 
ditions. 
Osseous deflection of the septum rarely occurs alone, 
being almost invariably associated with the cartilaginous 
form, namely, osseo-cartilaginous. Long-standing devi- 
ated septa always exhibit hypertrophic changes over 
their most prominent points. These changes are due to 
pressure against structures lying opposite, /.<?., the turbi- 
nated bones. By far the most frequent form of deviated 
septum is the cartilaginous variety. As regards the ques- 
tion of the manner in which the deviated septum plays 
the part of a cause, I would ask attention to two most 
prominent and common factors, accounting for the pro- 
duction and persistence of the catarrhal processes in the 
majority of cases, namely, pressure irritation and defec- 
tive nasal drainage. Farther on I shall have occasion to 
show that these conditions are also traceable to other 
important underlying causes of a more or less direct 
nature. The part played by pressure irritation in the 
causation of rhinitis hypertrophica I described in a paper 
read before the American Laryngological Association, 
session of 1880.4 My deductions were based upon the 
Fig. i. 
were caused by pressure of the turbinated structure lying 
opposite. This impression was received by my observ- 
ing that the shape of the tumefaction was cup-shaped, 
and that the depression corresponded in shape and size 
with the convexity of the nearest turbinated bone. At 
times the depression was entirely concealed by the tem- 
porary impaction against its surface of a congestive tur- 
binated hypertrophy. Retraction of the erectile structure 
soon revealed the mischief it had wrought by persistent 
contact, or in other words, by prolonged pressure irri- 
tation. 
Do not understand me as attributing any particular 
pathological importance to this condition. I only con- 
sider it of value as proving the existence of a special de- 
termining factor in nasal catarrh, namely, pressure irri- 
tation. 
Fig. 2. 
Fig. 3. 
Fig. 4. 
The drawing (Fig. 2.), taken from a life sketch, exhibits 
the action and effects of pressure irritation. The right 
anterior naris shows the deviated tissue pressing against 
the opposite turbinated structure. In the right posterior 
naris (Fig. 3) is seen the result—a post-inferior tur- 
binated hypertrophy, almost entirely occluding the choana. 
The next drawing (Fig. 4) was taken from a life sketch, 
showing an antero-inferior turbinated hypertrophy in the 
left nostril, caused by the combined catarrhal extension, 
and respiratory irritation from a deviated septum closing 
the right nostril. 
I will now consider the second etiological factor, men- 
tioned by me—defective nasal drainage. All intelligent 
observers must have been impressed with the fact that the 
peculiar inclination and semi-ovoid form of the nasal floor 
subserved a useful purpose, namely, that of a gutter for 
the efflux of nasal secretions and accretions. This view, 
described by me several years ago, has steadily gained 
ground in my mind until I find myself this evening pre- 
pared to present it in a more elaborate and favorable 
form. 
This diagram (Fig. 5), built up from drawings of the 
normal structures will enable you to trace with me the 
nasal discharges from their origin, through the pharynx 
and gullet, until, with the salivary and buccal secretions, 
they find their way into the stomach. The heavy, dotted 
lines represent the course of the nasal fluids. Beginning 
at the anterior portion of the nasal gutter, the nasal mu- 
cus streams slowly downward over the easy convexities of 
1 Read before the New Yoik Academy of Medicine, March 5, 1885. 
2 Archives of Laryngology, vol. ii., p. 147. 
3 Archives of Laryngology, vol. iii., p. 300. 4 Loc. cit. March 14, 1885] 
THE MEDICAL RECORD. 
285 
the turbinated bodies, and striking the nasal floor, gravi- 
tates backward along its gradual incline toward the pos- 
terior nares and pharynx. Posteriorly it is prevented 
from oozing down along the uvula anrf Hrinninor infn thp 
larynx or pharynx by a slight 
elevation of the mucous mem- 
brane over the palate, which 
I have denominated the pala- 
tine prominence {prominentia 
palatina). This peculiar 
ridge-like elevation (Fig. 5, 
//), beginning at the lower 
edge of the vomer and extend- 
ing backward to a point just 
over the uvula, has, as far as 
I have been able to ascertain, 
been assigned no special func- 
tion ; the absence of this con- 
stant condition, in numerous 
drawings of the posterior 
nares, is a familiar example 
of its oversight. An attack 
of acute uvulitis, with oblitera- 
tion of this palatine promi- 
nence, and consequent dis- 
charge of mucus into the larynx 
and pharynx, will convince one 
of its value in the economy of the throat. After leaving 
this point, the nasal fluids stream down, in a fan-shaped 
manner, along the pharynx, to the gullet. The discharges 
are prevented from falling into the larynx by the semi- 
circular ridge formed by the arytenoid and Wrisberg 
prominences and their various folds. 
The importance of this system of nasal drainage is very 
clear, when one considers that it not only disposes of the 
natural excess in moisture, employed for olfaction, moist- 
ening the respired air, etc., but also is a means for the re- 
moval of the accumulations from the eye and accessory 
nasal cavities. This system once understood, it is easy to 
appreciate the consequences due to disturbance of its bal- 
ance. Prominent among disturbing causes is the deviated 
septum. This interference, on the part of a deviated sep- 
tum, is invariably associated with more or less turbinated 
hypertrophy. To these combined conditions are to be 
attributed most of the troubles due to defective drainage. 
Nasal mucus, of the proper specific gravity, readily finds 
its way into the stomach as just described. The ob- 
struction presented by a deviated septum stops the nasal 
fluids on their way into the throat, the retardation leading 
to evaporation and consequent inspissation of the nasal 
discharges, producing the well-known train of symptoms, 
such as clogging of the nostrils, dropping of phlegm into 
the pharynx and larynx, etc. 
The importance of pressure irritation and defective 
nasal drainage merits a more extended notice than I 
have accorded it, but the consideration of other causes 
which help to account for their existence urges me to 
leave it for the present. 
Deviation of the septum can be traced as originating 
from certain well-defined causes, conspicuous among 
which I might mention heredity, traumatism, and ac- 
quired deviation of the septum. 
Heredity.—In 1880 I reported1 a case of congenital 
stenosis relieved by operation, in which was noted a pecu- 
liar malformation of the superior maxilla, and I sought to 
establish a relationship between it and the co-existing 
coryza and turbinated hypertrophies. Since then, by dint 
of close investigation and comparison, I have been able to 
supply the necessary links in a chain of evidence which 
demonstrates, at least to my mind, that one of the most 
common indirect causes of catarrh is to be found in the 
conformation of the hard palate. This peculiar malforma- 
tion is transmitted from parent to offspring, and by its 
proper recognition we can at once account for the origin 
of a vast majority of certain cases of chronic nasal ca- 
tarrh. Attention has been called, from time to time, to 
the various congenital conditions of the hard and soft pal- 
ate, known as cleft palate, bifid uvula, etc. I shall, however, 
have nothing to say concerning these malformations. Sev- 
eral years ago a medical student, whom I was examining, 
called my attention to the great height of the roof of his 
mouth. I had been treating him for an extreme deflec- 
tion of the nasal septum ; the deviated structure was 
pressing directly against the left lateral nasal wall and 
had been in this position as far back as he could remem- 
ber. I at once associated the high-pitched and narrow 
palatine arch with the bend in the septum, reasoning that 
inasmuch as the septum lay directly over the point of 
highest elevation, there must be a corresponding bulging 
of this structure, its amount depending upon the extent 
of encroachment of the elevated and contracted arch 
upon the nasal chambers. 
Subsequent observations not only proved this infer- 
ence to be correct, but also enabled me to trace the con- 
dition in many instances to its origin, the parent. These 
plaster impressions, kindly presented to me by Dr. Eddy, 
nicely illustrate this peculiar palatine formation. They 
were selected from among thirty other plaster casts, as 
the only two in which I could positively pronounce the 
existence of a chronic nasal catarrh. The doctor then 
referred to the name of the subject, who, happily for 
me, proved to be one of my old patients, afflicted with a 
severe catarrh, and almost forgotten by me. This was 
the only case of well-marked catarrh sent me by the 
Doctor, and both casts had been taken from the same 
patient. 
On comparing this plaster impression (Fig. 6) with 
the normal palatine arch, you will readily discern certain 
[ VI.f ORD. 
' C.H-COi, 
Fig. 5. 
Fig. 6. 
well-defined differences. The distance between the 
alveolar ridges is much greater in the normal specimen. 
The transverse diameter in the abnormal specimen is not 
only smaller, but its surface is markedly irregular. 
The palatine arch may be considerably higher than this 
normal specimen, and yet not constitute a pathological 
condition. No two palatine arches are exactly alike, 
and some show an elevation readily mistaken for a de- 
formity. The important distinction to bear in mind is 
the abrupt elevation along the line of the median raphe. 
When such a condition is observed, we may at once look 
for, and, in my experience, invariably find, a correspond- 
ing deviation of the septum. 
Such, in numerous cases observed by me, has always 
proved the case, and the condition has been invariably 
associated with a chronic rhinitis. Indeed, I believe it 
is possible to diagnosticate the existence of a chronic 
nasal catarrh by the simple inspection of the roof of the 
mouth, or, what amounts to the same thing, an impres- 
sion in wax or plaster sent from any part of the world. 
Having interested myself from time to time in the study 
of the external nose, and particularly in the persistence 
of certain types in the same family, I was induced to 
consider it a special hereditary manifestation. 
By employing a similar method of reasoning to the 
internal configuration of the nares, I have been able to 
* Archives of Laryngology, vol. ii., p. 105. 286 
THE MEDICAL RECORD. 
[March 14, 1885 
trace the same condition back to a common parental 
origin. This, in my experience, occurs as an hereditary 
manifestation with great constancy. Once the peculiar 
nasal type of the parents recognized, its modifications in 
the children is easily determined. Sometimes this con- 
dition, with the co-existing intra-nasal catarrhal processes, 
can be inferred or diagnosticated at a distance by the 
conformation of the nose and the alveolar borders of the 
upper jaw. Last year I was afforded an excellent example 
of this in the family of a physician, the facial expression 
of whose children I had the opportunity of observing at 
a respectful distance. I afterward became acquainted 
with the gentleman, and was consulted by him concern- 
ing a throat affection afflicting his wife. I surprised the 
doctor by not only diagnosticating the catarrhal troubles 
of his children, but also satisfied him that the peculiar 
shape of his hard palate accounted for the existence of 
the disease in his offspring. 
A few days since I examined several members of the 
same family, all adults, the condition of whose nostrils I 
correctly diagnosticated through a single member of the 
same family, who happened to be my patient. 
In this family the nasal asymmetry was very well 
marked, the septum in one instance being deviated to 
such an extent as to disturb the external symmetry of 
the nostril. All the young men, three in number, pos- 
sessed the paternal nasal type and palatine arch in an 
exaggerated form. All have suffered with nasal catarrh, 
dating far back in the memory of the family, and, I am 
informed that an absent son, not yet examined by me, is 
severely afflicted with the same complaint. The pa- 
tient, an engineer by profession, and a very intelligent 
individual, referred to me by Dr. J. L. Corning, stated, with- 
out giving me his name, that a physician had informed him 
that his condition was due to a scrofulous taint probably 
inherited from his father. This piece of news did not 
surprise me, since it was only a few years ago that a 
statement was made in this Academy involving a similar 
proposition ; and just here I would like to emphatically 
express my disagreement with this too prevalent idea of 
a diathesis or specific constitutional taint being the de- 
termining factor in the majority of those suffering with 
nasal catarrh from childhood. Furthermore, the view 
that these manifestations, though not retraceable one or 
more generations, are nevertheless to be attributed to 
diluted syphilis of several preceding generations, seems 
to me even more unreasonable, and yet we find it men- 
tioned in recent works on the subject and soberly dis- 
cussed by physicians. Although scrofula and inherited 
syphilis are responsible for certain cases of catarrh, 
it is high time that these stigma, too often placed upon 
innocent and intellectual families, should be removed. I 
say intellectual advisedly, for it is my conviction that re- 
markable mental development is likely to be associated 
with a nasal catarrh. 
It is well known that a.marked increase in the dimen- 
sions of the cranial dome is apt to be accompanied by a 
contraction of the osseous framework of the face. A re- 
markable example of this kind lately came under my 
notice, in the person of a girl, aged sixteen, the daughter 
of a physically and intellectually enormous man. The 
father’s head measured seven and three-eighths inches, and 
yet his large hat closely covered the head of his delicate 
little daughter. She, in other words, possessed the face 
and body of a child, with the head of a Webster. I was 
not surprised to find the contracted nares of this child 
the seat of extensive disease. If you compare these 
two sections taken from a wax cast, you will observe the 
high palatine arch of the father is markedly exaggerated 
in his daughter. I could cite numerous other instances 
in proof of the correctness of this view did time and 
space permit. From what has been said, I think I can 
safely say that early acquired nasal catarrh, instead of 
being of scrofulous or diluted syphilitic origin may in 
many cases prove to be an intellectual disease. 
I will now briefly consider the second mentioned direct 
cause of a deviated septum, and indirect cause of nasal 
catarrh, namely, traumatism. 
Traumatism.—The effects of injury as an etiological 
factor, are identical with those resulting from heredity. 
So much so is this the case that I am not surprised 
to find the bulk of easily discernible deviated septa 
attributed to blows of various kinds, for want of a 
better explanation. There is now but little excuse for 
such a mistake, for although the deviated septum of a 
malformed maxilla may be increased by injury, the dis- 
covery of such a condition, associated with the usual 
signs, furnishes reasonable grounds for the assumptio 1 
that it is hereditary and not of traumatic origin. This 
inference is, of course, strengthened by the history of 
the patient. Traumatic deviation of the septum, though 
occasionally found in the higher strata of society is 
more frequently met with in low life, the exposure and 
recklessness of the latter class of individuals rendering 
them more liable to injury. As an example I might state 
that I have yet to discover the nostril of a prize-fighter 
or reckless sparrer unaffected with a chronic nasal catarrh. 
It matters little what may be their so-called powers of 
resistance, the strongest must as surely succumb to nasal 
catarrh as a child similarly afflicted from a button in the 
nose. 
By acquired or induced deviation, the third variety 
mentioned by me, I include such internal agencies as 
prolonged intra-nasal pressure upon the septum, as pro- 
duced for instance by turbinated hypertrophies, polypi, 
and various tumors, the action of foreign bodies, inflam- 
matory infiltration, the frequent employment of the finger 
for freeing the nostrils, etc. 
The indirect influence of the high-pitched palatine 
arch and deviated septum observed in the production 
of aural, pulmonary, and eye troubles, also gelatinous 
polypi, and other intra-nasal growths, and its interesting 
etiological relation to phthisis must be passed by for the 
present, with little more than a mere mention. 
Treatment.—I shall conclude my remarks with a neces- 
sarily brief consideration of the treatment of deviated 
septa. Employing a modified scriptural paraphrase of 
Dr. Didama’s, “and now abideth Physiology, Pathology, 
and Therapeutics, these three, but the greatest of these is 
Therapeutics.” 
In other wrords, just in proportion as the first two ele- 
ments add meaning to the third, are they to be valued as 
aiding in the one grand effort to ameliorate the misery of 
mankind. To accentuate this point I may be permitted 
to recall a remark made by a distinguished anatomist, 
the late Dr. Darling, who several years ago, after en- 
couraging me to enthusiastically converse upon certain 
pathological conditions observed by me in the nose, sud- 
denly interrupted the conversation with the remark, “ But 
do you cure your patients ? ” That, gentlemen, is the 
important question with all of us. 
An experience derived from several hundred opera- 
tions has convinced me that no single method can be 
fairly recommended or successfully employed to remedy 
all deviated septa. Assuming the correctness of the 
propositions embodied in my previous remarks, I shall 
discuss the treatment of the deviated septum, as a most 
common cause of catarrh. As with a button in the nos- 
tril, so that thorn in the flesh, a deviated septum, must 
be removed to cure the catarrh. 
Since several instruments will be presented to your no- 
tice, I trust you will not interpret them as indicating dis- 
satisfaction with any one method and recourse at random 
to another, but as providing against certain possible 
contingencies. The very structure and shape of the sep- 
tum warrants this assertion. We may meet bone, carti- 
lage, or mucous membrane. The bone w’ill dull or break 
our knives, the rongeur-forceps may strip off and mutilate 
unnecessarily the mucous membrane, and either may 
unfortunately perforate the deviated cartilage. For 
opening the field of operation I employ my ring-drop 
nasal speculum, since in my hands it has proved the March 14, 1885] 
THE MEDICAL RECORD. 
287 
best for painlessly and persistently dilating the nostrils. 
In the treatment of cartilaginous and soft structural devi- 
ations of the septum, I have for several years employed 
nothing more than my ecraseur with transfixion needles. 
Instead of using the No. 5 piano wire originally recom- 
mended and introduced by me for the removal of turbin- 
ated hypertrophies, I employ No. o and 00 piano wires. The 
exclusion of the question of hemorrhage in operations by 
ecrasement, is an additional recommendation for the em- 
ployment of fine wires, cutting like knives. The employ- 
ment of the ecraseur for this purpose must be invariably 
combined with the use of my transfixion needles. 
These needles (Fig. 7) require no special description. 
They are pointed like the ordinary glover’s needle. 
A great advantage possessed by this bone forceps is 
the control exercised over it by the operator. Each 
osseous projection can be distinctly distinguished over 
the edge of the upper blade and deliberately crushed 
away by the keen-edged cutting surfaces, and by a kind 
of gnawing process large sections of the bone are 
Fig. 9. 
Fig. 7. 
removed with rapidity and precision. All the methods 
thus far mentioned accomplish their purpose by remov- 
ing the superfluous or deviated tissues or the turbinated 
structures opposite the deviated point. 
Although this, in the majority of instances, can be ac- 
complished without perforating the septum narium, or 
weakening the nasal supports, it is obvious that a certain 
class of cases, usually those presenting an extreme de- 
gree of deflection, may be followed by the above-men- 
tioned undesirable consequences. I have, therefore, 
made it a rule to resort to a different method in this class 
of cases. This consists in the employment of Steele’s 
stellate punch in conjunction with a peculiar nasal clamp 
or splint. Probably the least important feature of the 
operation is the cutting part, at least such a view is now 
current. The great difficulty rests in the proper ap- 
proximation of the divided fragments, and just at this 
stage the bad results show themselves. While observing 
the behavior of a case operated upon and afterward 
treated by the usual method, the nasal plug, I was con- 
vinced that just here the trouble arose. From what I 
have already said, you will thoroughly appreciate the ef- 
fects of such a foreign body lodged within the nostril. 
The intense irritation and secondary hemorrhage, profuse 
rhinorrhcea, high fever and inflammation, and general mis- 
ery, is no exaggerated picture in my experience. W’hy, 
then, should we expect other than unfavorable results from 
the practice of this method ? This little clamp has, in my 
practice, relegated these inconveniences to the history of 
the past. The septum, made sufficiently plastic by means 
of the punch, is simply held in place by a slight pressure 
Four sizes are made, running from one to four inches in 
length. Each number has a straight needle and three 
others of varying curves. They are all furnished with a 
light, convenient handle. 
The removal of cartilaginous and soft deviated tissues 
by ecrasement has been followed by most excellent 
results in my hands, and where there is plenty of time at 
the operator’s disposal, it is to be preferred for this pur- 
pose. 
It is often desirable to economize time, and in order to 
do so I have devised instruments with which I have most 
satisfactorily accomplished this purpose. They are essen- 
tially cutting instruments, and consist of a fenestrated 
cartilage forceps and trimming scissors. Their blades 
are made almost at a right angle to enable the operator 
to obtain a clear view of the field. 
The cutting edges of the fenestrated forceps (Fig. 8) 
Fig. 8. 
resemble somewhat, in shape and action, the ordinary 
ticket-punch. A ring on the fixed blade is intended to 
slip over the middle finger, and a knob on the free one 
is manipulated with the thumb. This arrangement en- 
ables one to seize and divide the cartilage with great 
facility. The trimming scissors (Fig. 9) are conve- 
nient for removing asperities remaining after the other 
instruments have been employed. The instrument is 
grasped like a pistol, firm pressure being exercised against 
its lateral margin by the index finger. 
Thus far the instruments shown have applied only to 
cartilage and hypertrophied mucous membrane. Bone 
blunts or breaks their keen edges, and we may have to 
treat an osseo-cartilaginous deviation of the septum. 
I his little instrument (hig. 10), essentially a rongeur 
forceps, has, in my hands, most satisfactorily accomplished 
this result. Its two blades are hollowed to cut like the 
teeth of a rodent. The instrument has the proper nasal 
curve. 
Fig. io. 
exercised over the cutaneous surfaces of the alse nasi. 
No foreign substances disturb the equilibrium of the in- 
ner nares, and, therefore, the above undesirable conse- 
quences are avoided. The pressure of the splint can be 
nicely regulated by the patient by means of a delicate 
screw. Any tendency to loosen may be easily overcome 
by affixing adhesive plaster to the pressure-pads, and 
then sticking it to the skin. 288 
THE MEDICAL RECORD. 
[March 14, 1885 
rhinometer (Fig. n) is used for measuring the size 
and shape of normal and diseased nares. 
Pain.—I will not weary you with more than a passing 
reference to cocaine. My experiences have been al- 
ready recorded, with a series of reported cases.1 I con- 
ON THE CHOLERA. OF EGYPT IN 1883, AND 
FRANCE, ITALY, AND SPAIN IN 1884. 
By JOHN C. PETERS, M.D., 
NEW YORK. 
I have read many brilliant essays of late on these topics, 
but not with unalloyed pleasure, for I believe that many 
writers have fallen into errors which it is important to 
correct. No really well-informed person has believed 
for a long time that carbolic alcohol will destroy the 
cholera poison ; but many fully and correctly believe 
that real germicides will. It has been known since 1872 
that microbes, bacilli, and bacteria could live in very 
strong solutions of carbolic alcohol, and that the dilute 
mineral acids, tannin, chloride,'corrosive sublimate, and 
others would kill them. 
In 1883 cholera did not arise alone in Egypt from 
filth, but from importation. It did not commence at 
Alexandria, but at Damietta, which is the nearest Nile 
port to Port Said, which is the outlet of the Suez Canal. 
These were 37,500 deaths from cholera in the Bombay 
Presidency in 1883. Bombay merchants came both to 
Port Said and Damietta to attend a great fair there, to 
which at least 15,000 people congregated, in addition 
to the 35,000 inhabitants. The barbers who shave and 
prepare the dead are the first registrars of vital statistics 
in many Egyptian towns, and the principal barber of 
Damietta was among the first to die of cholera ; hence 
all the earliest records of deaths were lost, and the more 
fatal and infective diarrhceal cases were never recorded. 
Next the principal European physician of Damietta had 
his attention called to the rumors of numerous deaths, 
and investigated the matter to find that cases of cholera 
had occurred in May, whereas none had been reported 
publicly until June 21st. A zadig, or canal, runs through 
Damietta from one branch of the Nile to another, and 
this is the principal source of the water-supply. 
Mosques and many houses are on the banks of this 
canal, and their drainage goes into it. Every mosque 
has a public • privy, and also a tank for the ablution, 
which all good Mohammedans must use before entering 
a holy place. There was, of course, great choleraic 
water contamination, and a sudden outburst of cholera 
took place. The 15,000 people who came to the fair 
were stampeded out of Damietta, together with about 
10,000 of the inhabitants, who carried the disease with 
them back into Egypt. Then only was a rigid quaran- 
tine established, and a cordon put round Damietta to 
keep everybody in, and let no one go out, neither food or 
medicines, or doctors, or supplies of any kind. Such is 
nearly the history of every town attacked in Egypt in 
1883. 
When the pestilence had been let out en masse, severe 
measures were taken to keep it in Cairo, for up the Nile 
was attacked long before Alexandria suffered. This 
cholera broke out, as it almost always does in Egypt, 
when the river Nile is low and the water unusually bad. 
It disappeared like magic, as it always does in Egypt, 
when the Nile rises and washes all impurities away. 
There had been little or no cholera in Egypt since 1865, 
and there had often been as much filth as in 1883. It 
has never become endemic there, as it is a rainless 
country, and generally too dry for the cholera germ to 
thrive. 
Marseilles had a small outbreak of cholera, in the fall 
of 1883, probably derived from Egypt, which she care- 
fully concealed. In addition, cholera was also brought 
to Toulon from Tonquin by the Sarthe and other ves- 
sels. Toulon concealed her cholera for at least seven- 
teen days, and did not confess it until it had got such 
headway that it could no longer be concealed. At least 
twenty thousand Italians fled from Toulon and Mar- 
seilles, and others were brought away in transports by 
the Italian government. Rome refused to receive any 
fugitives ; Genoa and Naples welcomed them. There 
were at least three large importations into Naples. The 
tinue to find it useful in operations on the septum, and 
consider it more effective when the displacement is situ- 
ated well anteriorly, or less when deeper within the nares. 
Believing with Jebinek in the increased efficiency of con- 
centrated solutions. I employ a ten per cent, prepara- 
tion of Foucar’s cocaine hydrochlorate. In spite of every 
precaution, extreme pain will be at times inflicted in a 
certain class of cases. In these instances I employ 
rhigolene in the form of a fine spray, with the same suc- 
cess as already reported by me. I have now been using 
it for more than a year. Pain is an actual impossibility 
when rhigolene is properly employed for this purpose. 
The great and only objection to its use in the nose is 
the danger of an explosion. This I have effectually 
removed by employing an electric light isolated in a glass 
bulb. The carbon filament is rendered incandescent by 
means of Mr. W. Foster’s electric cell. This cell is 
the same exhibited by me at the last meeting of the 
New York State Medical Society, and continues to prove 
highly satisfactory in my hands. It amounts really to a 
combined battery and secondary accumulator in a single 
cell, and runs without refilling for many months. Fos- 
ter’s portable mercury bisulphate battery may also be em- 
ployed for the same purpose. 
Fig. 11. 
ILLUSTRATIVE CASES. 
I shall very briefly report three cases selected as ex- 
amples from a number of the same kind : 
Mr. , from St. Catherine’s, Canada ; aged twenty. 
Referred to me, March, 1882, by Dr. W. H. Snow. Very 
much annoyed by constant accumulation of phlegm in 
throat and larynx, and by nasal stenosis. Examination : 
Post-inferior turbinated hypertrophy (bilat.), localized 
deviation of septum to left. Turbinated obstructions 
and deflected septum removed in twelve operations by 
means of transfixion needles and ecraseur. The patient 
reported in person two years subsequent to the opera- 
tions, pronouncing himself perfectly well. 
Miss , aged nineteen, New York City. Re- 
ferred to me in February, 1884, by Dr. J. Williston 
Wright, for a long-standing chronic coryza. Breathes at 
night through the mouth and suffers from other catarrhal 
complications. Examination: Complete occlusion of 
left nostril from an osseo-cartilaginous deviation of the 
septum with associated turbinated hypertrophies. Ex- 
traordinary elevation of the hard palate, traced back to 
the father, a life-long sufferer from catarrh. Successfully 
removed the hypertrophied and deviated tissues by means 
of cartilage and bone forceps. Reported six months 
afterward as free from catarrh and respiratory disturb- 
ances. The structures operated upon presented all the 
appearances of a normal nostril. 
Dr. , New York State ; aged forty. December, 
1884. Complete occlusion of left nostril, with partial 
and increasing deafness. Extreme general deviation of 
cartilaginous septum to the left. Operated twice with 
Steele’s forceps, using elliptical glass tubes and nasal 
clamp, with rhigolene and cocaine. Stenosis and pressure 
relieved. Decided preference given to nasal clamp and 
rhigolene. The good results reported as permanent. 
25 East Thirty-first Street. 
1 The Medical Record, December 13, 1884.