A 
TREATISE ON DISEASES 
OF THE 
NOSE AND THROAT 
IN TWO VOLUMES 
BY 
FRANCKE HUNTINGTON BOSWORTH, A.M., M.D. 
PROFESSOR OF DISEASES OF THE THROAT IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK * 
CONSULTING PHYSICIAN TO THE O. D. P. DEPT. OF THE BELLEVUE HOSPITAL; FELLOW OF THE AMER- 
ICAN LARYNGOLOGICAL ASSOCIATION, OF THE AMERICAN CLIMATOLOGICAL ASSOCIATION, OF 
THE NEW YORK ACADEMY OF MEDICINE ; MEMBER OF THE NEW YORK LARYNGOLOGICAL 
SOCIETY, OF THE MEDICAL SOCIETY OF THE COUNTY OF NEW YORK, ETC., ETC. 
Volume One 
DISEASES OF THE NOSE AND NASO-PHARYNX 
WITH 4 COLORED PLATES AND 182 WOOD-CUTS 
NEW YORK 
WILLIAM WOOD & COMPANY 
'56 & 58 Lafayette Place Copyright, 1889. 
By WILLIAM WOOD & COMPANY. 
PRESS OF 
THE PUBLISHERS’ PRINTING COMPANY, 
157-159 WILLIAM STREET, 
NEW YORK. PREFACE. 
The following work was originally undertaken with the inten- 
tion of preparing a Second Edition of the volume on “ Diseases 
of the Nose and Throat ” published by myself in 1881, but it soon 
became evident that the great advances made in the study of dis- 
eases of the upper air passages during the period which had elapsed 
since that work was issued, had rendered it necessary to rewrite 
practically the whole volume. I therefore determined to abandon 
the attempt to base the present work on my former one, and to 
write an entirely new treatise. Two chapters, however, of the 
earlier publication, with some changes and additions, I have re- 
tained, viz.: that on “Mucous Membranes” and that on “Taking 
Cold,” for while these subjects may possibly seem somewhat ele- 
mentary to the older practitioner, to the younger physician and to 
the medical student, I am confident they will prove of value. 
Aside from these two chapters, the work is entirely new and has 
been written without reference to the earlier volume. It has been 
my endeavor to present a full and complete treatise on the sub- 
jects covered by the title, and in carrying out this endeavor the 
work has grown on my hands in proportions beyond, perhaps, my 
original conception, and in place of a single volume which I origi- 
nally contemplated, I have been compelled to divide the work into 
two volumes. In the first volume, I have embraced, in the first 
section, a consideration of diseases of the nasal cavities proper, in 
the second section that of diseases of the naso-pharynx, while I 
have added a third section in which there is presented brief de- 
scriptions of all the various operations which have been resorted to 
for the removal of growths from the nasal passages or naso- IV 
PREFACE. 
pharynx, and which involve incision either of bone or the soft 
parts. 
The very large space devoted to a study of diseases of the nose, 
cannot, I think, subject me to criticism, when we remember the very 
intricate and highly important functions, which, as we havte so 
clearly learned in the past decade, have their seat in the mucous 
membrane lining this cavity; and the very wide area of both phys- 
ical and reflex disturbances which are prone to follow the morbid 
conditions which are met with there. 
A chapter on asthma, in a treatise on nasal diseases, may possi- 
bly be considered somewhat out of place ; its propriety, however, 
I am sure will be more generally recognized when the views which 
I have so long advocated receive fuller acceptance, as I am con- 
fident they will, that, in the very large majority of instances, an 
asthma is dependent primarily upon a diseased condition of the 
nasal mucous membrane. The separation of the nasal cavity 
from the naso-pharynx, from an anatomical, physiological, and 
pathological point of view, has been made in the present volume, 
more distinctly and more definitely, I think, than has been usually 
done in our text-books on diseases of the nose and throat. This 
is as it should be, and clears up much that has heretofore been 
vague and unsatisfactory in our classification of diseases of these 
regions. 
In the section on “ External Surgery ” the description of the 
various surgical procedures which have been resorted to for gaining 
a wider access to the nasal cavity and the naso-pharynx, will, I 
hope, prove of value. While I have not deemed it necessary to 
enter into a fully detailed description of each operation, I have 
given a brief resume of each procedure, thus enabling the reader 
to obtain a somewhat rapid, yet complete, survey of the resources 
at his command in dealing with the graver forms of neoplasms 
which are met with in these regions. As far as I am familiar 
with surgical literature, these various operations have not been 
heretofore grouped together in so full and complete a manner as 
in the present volume. PREFACE. 
V 
At the end of the volume there will be found a number of col- 
ored plates, illustrative of some of the operations described. These 
have in each instance been made from colored sketches of opera- 
tions on the cadaver. 
It has been my earnest effort to present the study of each dis- 
ease as fully and as comprehensively as possible; in most instances 
I have depended entirely on the descriptive text, in others I have 
introduced illustrative cases, as they seemed to add interest and 
clearness to the context; while in still further instances it has 
seemed to me that a better comprehension of the subject would be 
reached, by presenting a brief resume of all the cases which have 
been recorded in medical literature. This latter plan has been 
followed in the consideration of most of those diseases which are 
comparatively rare, such as carcinoma and sarcoma of the nose 
and also of the naso-pharynx, nasal hydrorrhcea, etc. 
The work is fully illustrated, but this I have had done design- 
edly. In many instances I have illustrated and described instru- 
ments which I do not consider of value. This has been done on 
the ground that there is oftentimes something of suggestion and 
even instruction in not only becoming familiar with the methods 
by which others attempt to carry out clinical indications, but even 
more in recognizing their faults. The atomization of medicated 
fluids for application to the upper air tract will always occupy a 
prominent place in our armamentarium. In the historical account 
of the development of the atomizer, therefore, I have introduced 
illustrations of the various devices out of which grew the perfect 
instrument of the present day. This may not be of any practi- 
cal value, but I am sure it will prove of interest, and to many, 
instructive. 
In presenting personal views and opinions, I have desired to do 
so with all modesty, and yet with the positiveness of conviction. 
In differing with, or in criticising the views of others, I have en- 
deavored to do so with becoming diffidence. In making a com- 
plete treatise of the character of the present, it is impossible not to 
make use of the literary research and compilation of previous VI 
PREFACE. 
writers; this I have done in several instances, but in all cases it has 
been my desire and effort to give full credit therefor. The work 
has been done for the older practitioner as well as for the beginner 
and medical student, and from all I ask a kindly acceptance, to- 
gether with a full indulgence for such faults and errors as may be 
found in it, for while prepared by a specialist, and undoubtedly 
largely written from the specialist’s point of view, it has been my 
conscious and strenuous effort, throughout, to present such a thor- 
oughly candid and unbiassed study of the diseased conditions of 
the upper air tract, as may prove acceptable to the general practi- 
tioner. 
In closing, I desire to express my great obligations to my asso- 
ciate, Dr. E. B. Dench, for his most valuable assistance to me, not 
only in the literary research which the volume has required, but 
also in the preparation of the index, reading of proofs, and other 
labors incident upon carrying the work through press. 
F. H. B. 
26 West 46th St. TABLE OF CONTENTS. 
SECTION I. 
Diseases of the Nasal Passages. 
CHAPTER I. 
PAGE 
Methods of Examining the Upper Air Passages, .... 3-27 
The Laryngoscope, 5-10 
The Fixed Apparatus, 10-13 
The Examination, . . 13-15 
Rhinoscopy, 15-25 
The Rhinoscopic Image, 25-27 
CHAPTER II. 
Methods of Treating the Upper Air Passages by Means of Instru- 
ments, 28-46 
Insufflations, . . 28-31 
Douches, 31-34 
Atomizers 34-43 
Inhalations 43-46 
CHAPTER III. 
Mucous Membranes, 47-56 
Anatomy, 48-50 
Physiology, 50-51 
Inflammation of Mucous Membranes, 51—56 
CHAPTER IV. 
Taking Cold, 57-68 
CHAPTER V. 
The Anatomy of the Nose, 69-85 
The External Nose, 69-70 
The Nasal Fossae, 70-74 
The Accessory Sinuses 74-78 
The Mucous Membrane, 78-81 
The Turbinated Bodies, 81-84 VIII 
TABLE OF CONTENTS. 
CHAPTER VI. 
PAGE 
The Physiology of the Nose 85-98 
The Sense of Smell, 85-87 
The Function of the Nose in Phonation, 87-89 
The Function of the Nose in Respiration, .... 89-98 
CHAPTER VII. 
General Considerations Concerning Catarrhal Diseases, . . 99-104 
CHAPTER VIII. 
Acute Rhinitis, 105-118 
CHAPTER IX. 
Hypertrophic Rhinitis, 119-153 
CHAPTER X. 
Purulent Rhinitis of Children 154-161 
CHAPTER XI. 
Atrophic Rhinitis 162-179 
CHAPTER XII. 
Croupous Rhinitis, 180-185 
CHAPTER XIII. 
Nasal Reflexes, 186-198 
CHAPTER XIV. 
Hay Fever, or Vaso-Motor Rhinitis, 199-231 
CHAPTER XV. 
Asthma, or Vaso-Motor Bronchitis, 232-257 
CHAPTER XVI. 
Nasal Hydrorrhoea 258-271 
CHAPTER XVII. 
Anosmia, 272-280 
CHAPTER XVIII. 
Deformities of the Nasal Septum 281-309 
Dislocation of the Columnar Cartilage, 306-307 
Perforation of the Septum 307-309 
CHAPTER XIX. 
Epistaxis 310-320 
CHAPTER XX. 
Foreign Bodies in the Nasal Passages 321-325 TABLE OF CONTENTS. 
IX 
CHAPTER XXL 
• PAGE 
Rhinoliths, 326-330 
CHAPTER XXII. 
Parasites in the Nasal Cavities, 331-335 
CHAPTER XXIII. 
Syphilis of the Nasal Passages, ■ . . 336-359 
The Primary Lesion, 336-337 
The Syphilitic Coryza or Erythema 337-338 
The Mucous Patch, 338-339 
The Superficial Ulcer, 339-341 
The Gummy Tumor, ' 341-344 
The Deep Ulcer of Syphilis and Bony Necrosis, . . . 344-351 
Treatment, 352—359 
CHAPTER XXIV. 
Congenital Syphilis of the Nasal Passages, 360-368 
CHAPTER XXV. 
Tuberculosis of the Nasal Passages 369-375 
CHAPTER XXVI. 
Lupus of the Nasal Passages 376-380 
CHAPTER XXVII. 
Rhinoscleroma, 381-386 
CHAPTER XXVIII. 
Nasal Polypus, or Myxoma 387-408 
CHAPTER XXIX. 
Fibroma of the Nasal Passages, 409-416 
CHAPTER XXX. 
Osteoma of the Nasal Passages, 417-421 
♦ CHAPTER XXXI. 
Papilloma of the Nasal Passages 422-426 
CHAPTER XXXII. 
Adenoma of the Nasal Passages, 427-428 
CHAPTER XXXIII. 
Cystoma of the Nasal Passages, 429-430 
CHAPTER XXXIV. 
Angioma of the Nasal Passages, 431-434 X 
TABLE OF CONTENTS. 
CHAPTER XXXV. 
PAGE 
Chondroma of the Nasal Passages, 435-436 
CHAPTER XXXVI. 
Sarcoma of the Nasal Passages, 437-452 
CHAPTER XXXVII. 
Carcinoma of the Nasal Passages, 453-464 
CHAPTER XXXVIII. 
Diseases of the Accessory Sinuses of the Nose 465-498 
Disease of the Antrum, 465-479 
Disease of the Ethmoidal Sinuses 479-485 
Disease of the Sphenoidal Sinuses, 486-492 
Disease of the Frontal Sinuses, 492-496 
Differential Diagnosis between Diseases of the Accessory 
Cavities, 496-498 
SECTION II. 
Diseases of the Naso-Pharynx. 
CHAPTER XXXIX. 
The Anatomy and Physiology of the Naso-Pharynx, . . . 501-507 
The Anatomy of the Naso-Pharynx 501-506 
The Physiology of the Naso-Pharynx, 506-507 
CHAPTER XL. 
Acute Naso-Pharyngitis, 508-514 
CHAPTER XLI. 
Naso-Pharyngeal Catarrh 515—539 
CHAPTER XLII. 
Hypertrophy of the Pharyngeal Tonsil, or Adenoid Growths of the 
Vault of the Pharynx, 539-569 
CHAPTER XLIII. 
Fibroma of the Naso-Pharynx, 570-587 
CHAPTER XLIV. 
Myxo-Fibroma of the Naso-Pharynx, 588-594 
CHAPTER XLV. 
Chondroma of the Naso-Pharynx, 595 TABLE OF CONTENTS. 
XI 
CHAPTER XLVI. 
PAGE 
Sarcoma of the Naso-Pharynx 596-611 
CHAPTER XLVII. 
Carcinoma of the Naso-Pharynx 612-616 
SECTION III. 
External Surgery of the Nose. 
External Surgery of the Nose, 619-651 
Manne’s Operation, 621 
Maisonneuve’s Operation . . 621 
Nelaton’s Operation, 622 
Botrel’s Operation, 622-623 
Richard’s Operation, 623 
Sedillot’s Operation 623-624 
Dezeanneau’s Operation 624 
Dieffenbach’s Operation, 624-625 
Lariche’s Operation, 625 
Rouge’s Operation 626 
Palasciano’s Operation, 626-627 
Boeckel’s Operation 627-628 
Ollier’s Operation, 629-630 
Lawrence’s Operation, 630-631 
Langenbeck’s Operation for Resection of the Nasal Bone, . 631-632 
Linhart’s Operation, 632-633 
Bruns’s Operation, 633-634 
Fournaux-Jordan’s Operation, 634-635 
Huguier’s Operation 635-636 
Cheever’s Operation 637-638 
Cheever’s Double Operation 638-639 
Waterman’s Operation, 639 
Roux’s Operation, 639-641 
Annandale’s Operation, 641 
Langenbeck’s Operation for the Temporary Resection of the 
Superior Maxilla 641-643 
Billroth’s Operation for the Temporary Resection of the Su- 
perior Maxilla, 643-644 
Boeckel’s Operation 644 
Demarquay’s Operation, 644-645 
Maisonneuve’s Operation, 645-647 
Pean’s Operation, 647-649 
Berard’s Operation 649-650 
Huguier’s Operation, 650 
Vallet’s Operation, 650-651 
CHAPTER XLVIII. LIST OF ILLUSTRATIONS. 
FIGURE PAGE 
1. Throat Mirrors, Actual Size 6 
2. The Lennox-Browne Calcium Light, 7 
3. Beseler’s Lime Light Laryngoscope, 7 
4. Reflecting Mirror, Mounted on Schroetter’s Head-band, . . 9 
5. Reflecting Mirror, Mounted on Pomeroy’s Head-band, ... 9 
6. The Author’s Head-band and Mirror, 10 
7. Head Mirror Mounted on a Spectacle Frame, .... 10 
8. Tobold’s Laryngoscope Mounted on the German Student Lamp, . 11 
9. The “Sass” Laryngeal Stand, with Globe Inhalers, Atomizing 
Tubes, and Laryngoscope 12 
10. Mackenzie’s Light Condenser, Mounted upon a Ratchet Move- 
ment Gas Fixture . . 13 
11. Frankel’s Nasal Speculum, 15 
12. Goodwillie’s Nasal Speculum 15 
13. Elsberg’s Nasal Speculum, 16 
14. The Author’s Self-retaining Nasal Speculum, Actual Size, . . 16 
15. Jarvis’ Nasal Speculum, 16 
16. Method of Making an Examination of the Anterior Nares by 
Means of Sunlight, the Head of the Patient being in Position 
for the Inspection of the Inferior Meatus, 17 
17. Anterior Rhinoscopy, the Head of the Patient being in Position 
for the Inspection of the Middle Turbinated Body, . . 18 
18. Anterior Rhinoscopy, Position of the Head for Inspecting the 
Wall of the Pharynx through the Nasal Passages, ... 18 
19. Turck’s Tongue Depressor, 19 
20. Sass’s Tongue Depressor, ........ 20 
21. Goodwillie’s Folding Spatula, 20 
22. The Author’s Tongue Depressor, 21 
23. Church’s Self-retaining Tongue Depressor, . . . . . 21 
24. Method of Depressing the Tongue for Examining the Pharynx 
and for Posterior Rhinoscopy, 22 
25. Method of Making a Posterior Rhinoscopic Examination, . . 23 
26. White’s Self-retaining Palate Retractor, ...... 25 XIV 
LIST OF ILLUSTRATIONS. 
FIGURE PAGE 
27. The Posterior Nares, 25 
28. Rauchfuss’s Insufflator, 29 
29. Lefferts’ Insufflator, 29 
30. Ely’s Powder Blower, 29 
31. Stoerck’s Insufflator 30 
32. Post Nasal Syringe, 31 
.33. Post-Nasal Pipe, fitted to the Ordinary Davidson Syringe, . . 31 
34. Warner’s Post-Nasal Douche 32 
35. The Ordinary Form of the Nasal Douche, ..... 32 
36. Method of Using the Nasal Douche, 33 
37. Dessar’s Nasal Cup 33 
38. Sales-Giron’s Portable Atomizer, 35 
39. Mathieu’s Nephogene 35 
40. Bergson’s Apparatus with Foot Bellows, 36 
41. Sass’s Spray Tube, 36 
42. Newmann’s Spray Tubes, Worked by Means of the Double Bulbs, 37 
43. The Richardson Double-bulb Hand Atomizer, .... 38 
44. The Ordinary Hand-pump and Air Receiver, 39 
45. Air Pump Worked by Fly-wheel 40 
46. The Hydro-pneumatic Pump, ........ 41 
47. The Ordinary Single-Bulb Hand-Ball Atomizer fitted for Nasal 
Applications, . • '42 
48. Delano’s Atomizer 42 
49. Mackenzie’s Inhalator, . . 43 
50. Lewin’s Apparatus for Inhaling Nascent Muriate of Ammonia, . 44 
51. Large Globe Inhaler ... 45 
52. Diagrammatic Section of Mucous Membrane 48 
53. Cartilages of the Nose seen in Profile 69 
54. Superficial Layer of the Muscles of the Nose, 70 
55. Outer Wall of the Right Nasal Cavity seen from Within, the Soft 
Parts being Removed, 72 
56. Outer Wall of Left Nasal Cavity, the Inferior and Middle Turbi- 
nated Bones having been Removed 56 
57. Transverse Section through the Nasal Cavities and Maxillary 
Sinuses, Showfing Irregularities of Development of the Latter, 75 
58. Transverse Section through the Nasal Cavities and the Maxillary 
Sinuses, Showing Irregularities in the Development of the 
Antrum, ........... 76 
59. Abnormal Opening between the Frontal Sinus and the Orbit, . 77 
60. Abnormal Opening between the Ethmoidal Cells and the Orbit, . 77 
61. The Olfactory Cells in Man, 79 FIGURE PAGE 
62. The Sphenopalatine Ganglion, seen on its Internal Surface, . 80 
63. The Formation of the Spheno-palatine Ganglion, .... 80 
64. Section of the Cavernous or Erectile Tissue of the Middle and 
Lower Turbinated Bones, Inflated and Dried, .... 83 
65. Microscopical Characters of Hypertrophic Rhinitis, . . . 133 
66. Myxomatous Hyperplasia of the Nasal Mucosa, from the Anterior 
Termination of the Middle Turbinated Bone, .... 135 
67. The Outer Wall of the Nasal Cavity, showing the Mucous Mem- 
brane in a State of Hypertrophy over the Lower Turbinated 
Bone, 136 
68. The Outer Wall of the Nasal Cavity Lined with Normal Mucous 
Membrane, 137 
69. Transverse Section through the Nasal Cavities, showing the Mu- 
cous Membrane over the Lower and Middle Turbinated Bones 
in a State of Hypertrophy, 137 
70. Large Masses of Hypertrophied Membrane on the Posterior Ter- 
mination of Lower Turbinated Bones, More or Less Com- 
pletely Filling the Posterior Nares, 138 
71. The Author’s Chromic Acid Applicator, 145 
72. Meyrowitz’s Portable Galvano-Cautery Battery, . . . . 146 
73. Meyrowitz’s Storage Battery, . 147 
74. Galvano-Cautery Handle with Flat Electrode for Use upon the 
Turbinated Tissues, 148 
75. Nasal Electrodes 148 
76. Jarvis’s Wire Snare Ecraseur, 150 
77. Sajous’s Snare 151 
78. Lateral View of Posterior Hypertrophy of the Mucous Membrane 
of the Lowei Turbinated Bone, with Jarvis’s Snare in Position 
for Section 152 
79. Jarvis’s Transfixion Needles, ........ 152 
80. Microscopical Appearances in Atrophic Rhinitis, .... 165 
81. The Outer Wall of the Nasal Cavity in the Late Stage of Atrophic 
Rhinitis, the Mucous Membrane, and also the Lower and Mid- 
dle Turbinated Bones, having Undergone the Atrophic Process, 173 
82. Horizontal Deviation of the Septum, probably the Result of a 
Fracture, 284 
83. Horizontal Deviation of the Septum, 284 
84. Dislocation between the Lower Border of the Septum and the 
Superior Maxilla 285 
85. Sigmoid Deflection of the Septum, probably the Result of a 
Fracture, 285 
LIST OF ILLUSTRATIONS. 
XV XVI 
LIST OF ILLUSTRATIONS. 
FIGURE PAGE 
86. Bulging of both Cartilaginous and Bony Portions of the Septum 
into the Right Nasal Cavity, 286 
87. Transverse Section of Deformity of the Septum, .... 290 
88. Transverse Section of Deformity of the Septum 290 
89. Blandin’s Septal Punch, 299 
90. Steele’s Septal Punch, . 299 
91. Adams’s Forceps for Refracturing a Deflected Septum, . . 300 
92. Adams’s Nasal Clamp, 300 
93. Adams’s Nasal Plugs, 300 
94. Jarvis’s Cutting Forceps, 301 
95. Burrs for the Removal of Septal Deformities, .... 302 
96. Curtis’s Nasal Trephines, . 302 
97. Seiler’s Nasal Chisel and Gouges, 302 
98. The Author’s Nasal Saw 303 
99. Dislocation of the Columnar Cartilage of the Nose into the Right 
Nostril, 307 
100. Perforation of the Cartilaginous Septum, 309 
101. Microscopical Appearance of a Syphilitic Ulcer at the Muco-Cuta- 
neous Junction, 340 
102. Microscopical Appearance of Lupus, 378 
103. Microscopical Appearance of Rhinoscleroma, .... 384 
104. Microscopical Appearance of Nasal Polypus, 389 
105. Microscopical Appearance of a Nasal Polypus which has Under- 
gone Cystic Degeneration 390 
106. Nasal Polypi, 393 
107. Microscopical Appearance of Myxoma Changing to Mvxo-Sar- 
coma, 401 
108. The Author’s Snare 404 
109. The Galvano-Cautery Snare, 404 
no. Mackenzie’s Snare 405 
in. Wright’s Snare, 406 
112. McKay’s Forceps 407 
113. Papilloma of the Nasal Mucous Membrane 425 
114. Microscopical Appearance of Cavernous Angioma, . . . 433 
115. Microscopical Appearance of Adeno-Sarcomaof the Nasal Mucosa, 448 
116. Microscopical Appearance of Round-celled Sarcoma of Nasal Mu- 
cosa, . 449 
117. Microscopical Appearance of Scirrhus of the Nasal Mucosa, . 459 
118. Transverse Section of the Maxillary Sinuses, showing the Roots 
of the Molar Teeth Projecting into the Cavities through the 
Floor 467 LIST OF ILLUSTRATIONS. 
XVII 
FIGURE PAGE 
119. Silver Drainage Tube for Antrum 476 
120. Anel’s Lachrymal Syringe for Use in Disease of the Antrum, . 477 
121. The Glandular Structures at the Vault of the Pharynx, . . . 505 
122. Glandular Structures of the Pharyngeal Vault seen in Antero- 
posterior Section. 506 
123. Lymphatic Hyperplasia of the Pharyngeal Mucosa, illustrating the 
Morbid Changes in Ordinary Naso-pharyngeal Catarrh, . . 523 
124. The Author’s Porte Caustique for the Pharyngeal Vault, . . 535 
125. Electrode for the Naso-Pharynx, to be Manipulated through the 
Nasal Passages, . . . . . . . . . . 537 
126. Microscopical Appearance in Adenoid Disease of the Vault of the 
Pharynx, 542 
127. Face, illustrating the Facial Expression Characteristic of the Ex- 
istence of an Hypertrophied Pharyngeal Tonsil, . . . . 551 
128. The Author’s Electrode fitted with a Shield for Use in the 
Pharyngeal Vault, 559 
129. Straight Electrodes for the Application of the Galvano-Cautery to 
the Pharyngeal Tonsil through the Nasal Cavity, . . . 559 
130. Meyer’s Instruments for the Removal of Hypertrophic Pharyngeal 
Tonsils, 560 
131. Lowenberg’s Forceps, 561 
132. Curtis’s Forceps, 561 
133. Major’s Adenotome, . v 562 
134. The Author’s Sharp Curette for the Pharyngeal Vault, . . . 563 
135. Hooper’s Instruments for the Removal of Hypertrophied Pharyn- 
geal Tonsils, . . 565 
136. The Author’s Modification of Jarvis’s Snare ficraseur for the Re- 
moval of an Hypertrophied Pharyngeal Tonsil, . . . 566 
137. Microscopical Appearance of Fibroma of the Naso-Pharynx, . 573 
138. Microscopical Appearance of Myxo-Fibroma of the Naso-Pharynx, 590 
139. Microscopical Appearance in Round-Celled Sarcoma of the Naso- 
Pharynx, ........... 607 
140. Microscopical Appearance in Carcinoma of the Naso-Pharynx, . 614 
141. Lines of Bony Section in Nelaton’s Operation 622 
142. Sedillot’s Operation ; Lines of Bony Section, 623 
143. Dezeanneau’s Operation ; Lines of Section of Hard Palate, . . 624 
144. Dieffenbach’s Operation ; Line of Cutaneous Incision, . . . 624 
145. Lariche’s Operation ; Lines of Cutaneous Incision, . . . 625 
146. Line of External Incision in Palasciano’s Operation, . . . 627 
147. Line of Cutaneous Incision in Boeckel’s Operation, . . . 627 
148. Line of Bony Section in Boeckel’s Operation, .... 628 XVIII 
LIST OF ILLUSTRATIONS. 
FIGURE PAGE 
149. Line of Cutaneous Incision in Ollier’s Operation, .... 629 
150. Line of Bony Section in Olliei’s Operation, 629 
151. Line of Cutaneous Incision in Lawrence’s Operation, . . . 630 
152. Line of Bony Section in Lawrence’s Operation, .... 630 
153. Line of Cutaneous Incision in Langenbeck’s Operation, . . 631 
154. Lines of Bony Incision in Langenbeck’s Operation, . . . 631 
155. Lines of Cutaneous Incision in Langenbeck’s Later Operation, . 632 
156. Lines of Cutaneous Incision in Bruns’s Operation, .... 633 
157. Lines of Bony Section in Bruns’s Operation, ..... 633 
158. Line of Cutaneous Incision in Fournaux-Jordan's Operation, . 634 
159. Lines of Cutaneous Incision in Huguier’s Operation, . . . 635 
160. Lines of Bony Section in Huguier’s Operation, .... 636 
161. Line of Cutaneous Incision in Cheever’s Operation, . . . 637 
162. Lines of Bony Section in Cheever’s Operation, .... 637 
163. Lines of Cutaneous Incision in Cheever’s Double Operation, . 638 
164. Lines of Bony Section in Cheever’s Double Operation, . . . 638 
165. Lines of Cutaneous Incision in Roux’s Operation 639 
166. Lines of Bony Section in Roux’s Operation 640 
167. Line of Bony Section of Palate in Roux’s Operation, . . . 640 
• 168. Lines of Cutaneous Incision in Langenbeck’s Operation, . . 642 
169. Lines of Bony Section in Langenbeck’s Operation . . . 642 
170. Lines of Cutaneous Incision in Billroth’s Operation, . . . 643 
171. Lines of Bony Section in Billroth’s Operation, .... 644 
172. Lines of Cutaneous Incision in Demarquay’s Operation, . . 645 
173. Lines of Bony Section in Demarquay’s Operation 645 
174. Line of Bony Section in Maisonneuve’s Operation, . . . 646 
175. Lines of Bony Section in Maisonneuve’s Operation, . . . 646 
176. Line of Cutaneous Incision in Pean’s Operation 648 
177. Line of Bony Section in Pean’s Operation, 648 
178. Line of Bony Section in Pean’s Operation 648 
179. Line of Cutaneous Incision in Berard’s Operation, . . . 649 
180. Lines of Bony Section in Berard’s Operation, .... 649 
181. Lines of Bony Section in Huguier’s Operation, .... 650 
182. Lines of Bony Section in Vallet’s Operation 651 Section I. 
Diseases of the Nasal Passages. DISEASES OF THE NASAL PASSAGES. 
CHAPTER I. 
METHODS OF EXAMINING THE UPPER AIR PASSAGES. 
The essential physiological process by which the human voice 
is produced in the larynx, its pitch regulated, and its volume and 
other qualities governed, was a source of speculation even in the 
earliest days of medicine, and hence the devising of some method 
by which the mechanism and movements of the larynx might be 
inspected during life, exercised the ingenuity of many and able in- 
vestigators, such as Bozzini, Babington, Bennati, Avery and others, 
who devised special appliances of various forms for the accomplish- 
ing of this purpose. None of these devices proved successful, how- 
ever, until, among others, Manuel Garcia, a distinguished teacher 
of vocal music in London, interested himself in the subject. He 
fully succeeded in obtaining an ocular view of his own larynx and 
thereby in studying the special function of the vocal cords in pho- 
nation, the results of which he presented before the Royal Society 
of London in a paper entitled “ Physiological Observations on the 
Human Voice.” 1 
Garcia’s method was exceedingly simple, and consisted in hold- 
ing an ordinary dental mirror, inclined at a proper angle, well back 
in the fauces in such a manner that it should receive the direct 
rays of sunlight, while, at the same time, the visual image was re- 
flected back in the same direction and perceived by Garcia in a 
hand-mirror held before his eyes. Garcia’s observations were pub- 
lished merely as a contribution to vocal physiology. Tiirck, of 
Vienna, however, soon after, becoming acquainted with Garcia’s 
experiment, conceived the idea that this method might possess a 
certain value in the recognition of diseased conditions of the larynx. 
Failing, however, to improve on Garcia’s simple manipulation, Tiirck 
1 Proc. Royal Soc. London, Vol. VII., No. 13, 1855. 4 
DISEASES OF THE NASAL PASSAGES. 
accomplished no encouraging results. Czermak, of Pesth, however, 
took up the matter where Tiirck left off, and improving on his 
methods, suceeded in demonstrating conclusively that this device 
might be made to render the greatest possible service to medical 
science, both as a means of diagnosis and as suggesting improved 
methods of treatment of diseases of the upper air passages. 
Czermak’s success was due entirely to the fact that, discarding sun- 
light, he resorted to the use of artificial light, which was managed 
after the manner already suggested by Helmholtz and perfected by 
Reute. 
It is interesting in this connection to notice what a fortunate 
train of events led up to the perfected laryngoscope, and how sim- 
ple the development of it became. At this time, the subject of ex- 
amining the interior of the eye had, for a number of years, been a 
subject of study by enthusiastic workers, and became really prac- 
ticable only when Helmholtz first devised his simple apparatus for 
illuminating the fundus of the eye, consisting of polished plates of 
glass, by means of which rays of light were projected upon the 
retina, the arrangement of which need not be entered upon here, 
but in which the principle was observed that the illuminating and 
the visual rays must be absolutely in the same line. Soon after 
this, Reute substituted for Helmholtz’s plates the concave reflecting 
mirror with the perforation in the centre, which forms the principal 
feature of the ophthalmoscope. Czermak, substituting artificial 
light for sunlight, and making use of Reute’s concave mirror, suc- 
ceeded in rendering practicable this method of examining the upper 
air passages, and is undoubtedly, therefore, entitled to all credit in 
having introduced an instrument which has proved of such incal- 
culable value in the management of diseases of this region, thus 
giving birth really to a new branch of medicine, whose great service 
in the diagnosis and successful treatment of hitherto unrecogniza- 
ble and incurable diseases, no one at the present day will question. 
Garcia’s and subsequently Czermak’s experiments were largely di- 
rected to the investigation of the larynx. Hence, the instrument 
by which the air passages were examined was called the laryngo- 
scope, and the investigation of those diseases which became a sub- 
ject of study by means of the laryngoscope, was termed laryngology. 
This has always seemed to me a somewhat unfortunate designation, 
in that it rather narrowed the field of study, and gave a somewhat 
undue importance to the larynx; for, very soon after laryngoscopy 
became practicable, the facility with which the nose and naso-phar- 
ynx might be inspected by the same means was recognized, and 
while these regions were studied with a certain amount of lukewarm 
interest, the larynx was studied with a degree of enthusiasm which METHODS OF EXAMINATION. 
5 
resulted in a too great refinement of classification, together with an 
exaggeration of the clinical significance of what were oftentimes 
trivial departures from the normal standard. This tendency, I think, 
has undoubtedly hampered us very much in our study of diseases 
of the upper air passages, and the proper recognition of the devel- 
opment of morbid conditions, especially of a catarrhal nature. 
Much of this limitation, however, has disappeared at the present 
day, although undoubtedly much still remains. In the following 
pages the view will be taken that many forms of inflammatory 
action in the larynx are really secondary to a diseased condition in 
the nose or naso-pharynx, and therefore a through investigation of 
these passages is of quite as much, if not greater importance than 
an examination of the larynx, and hence that a familiarity by prac- 
tice with the nice manipulations, by means of which the nose and 
naso-pharynx are examined, is to be sought as of greater impor- 
tance even than an examination of the larynx, especially in that 
rhinoscopy requires a much nicer training, both of the eye and hand, 
than laryngoscopy. In other words, the practice of rhinoscopy is 
specially urged upon beginners as not only of more importance 
than laryngoscopy, but as requiring greater manipulative skill, and 
a better trained eye. 
The Laryngoscope. 
This term is generally used to designate the special illuminating 
apparatus by which the upper air passages are examined, and of 
course applies equally to rhinoscopy and laryngoscopy. The es- 
sential features in the art of examining the upper air passages con- 
sist in projecting a powerful light through the anterior nares for 
the practice of so-called anterior rhinoscopy, or into the open 
mouth for the inspection of the pharynx, or so-called pharyngos- 
copy. In addition to this, as in laryngoscopy and posterior rhinos- 
copy, small mirrors are introduced into the fauces, by means of 
which the illuminating rays are deflected to those parts which are 
without the line of direct vision, while at the same time visual rays 
are re-conducted from the illuminated parts back to the retina in 
the same line as the illuminating rays. 
The essential parts of the laryngoscopic apparatus then are: 
i. The laryngoscopic or rhinoscopic mirror. 2. The source of illu- 
mination, or the light. 3. The concave reflecting mirror. 
The Throat Mirror.—The laryngeal mirror is a small round mir- 
ror encased in a German-silver frame, and attached by its rim to a 
slender wire stem at varying angles, the whole measuring from six 
to seven inches in length. They are made in sizes from three- 6 
DISEASES OE THE NASAL TASS AGES. 
eighths of an inch to one inch in diameter, and are numbered from 
o to 5, as shown in Fig. i, actual size, each number increasing one- 
eighth of an inch in diameter from No. o upwards. They were for- 
merly made of various shapes, such as oval, square, oblong, etc., 
but the round mirror has been found best adapted for all purposes. 
The best mirrors are made of very thin glass and with a narrow rim 
such as will afford the largest reflecting surface to the smallest bulk, 
the stem being sufficiently stout to admit of the application of 
considerable force without bending. The mirror is attached to its 
stem at varying angles, although usually at about 1350 for laryn- 
goscopy and at about 105° for rhinoscopy. Many attempts have 
been made to attach the mirror to the stem by an adjustable hinge- 
joint, without success, however. 
The Light.—The illumination may be derived from the sun, the 
oxygen-hydrogen light, a gas-jet, or an ordinary coal-oil lamp. If 
gas is used, the Argand burner gives undoubtedly the better and 
Fig. 1. Throat Mirrors, Actual Size, from No. o, % inch in diam., to No. 5, 1 inch in diam. 
steadier light, although ordinarily a coal-oil lamp is quite satis- 
factory in giving a whiter and more intense light than the usual 
city gas supply, and of these undoubtedly the best is one mounted 
either with the Duplex or Rochester burner. Sajous1 states that 
the whiteness of this light may be increased by dropping a small 
piece of camphor into the oil, a suggestion which I have verified. 
The direct rays of the sun afford by far the best source of illumina- 
tion, and should be used where available in all cases, especially in 
the first examination of a case, in that it gives a light unequalled 
in intensity and whiteness by any artificial illuminator that we 
have. Unfortunately this is not available at all times. Hence, 
any one devoting his attention largely to this branch of medicine 
should make use of the oxy-hydrogen light, in that it is only by 
those powerful illuminators that the parts are brought fully under 
that nicer inspection which enables us to make the clearest and 
most thorough diagnosis. Lennox Browne 2 was, I believe, the first 
1 “ Diseases of the Nose and Throat,” Phila., 1886, p. 7. 
2 “ The Throat and its Diseases,” Second ed., London, 1887, p. 40. METHODS OF EXAMINATION. 
7 
to devise an apparatus of this kind suitable for office work. This 
is shown in Fig. 2. It is, however, I think, somewhat unnecessarily 
Fig. 2.—The Lennox Browne Calcium Light. L, The lime candle; S, two concentric tubes through which 
the gases are directed upon the candle, the inner one connected with the tube at T carrying oxygen, the 
outer one connected with the tube at T carrying either hydrogen or common street gas; PC, a perpendicu- 
lar cylinder of metal inclosing the light; RL, a horizontal cylinder containing the lenses; AC, a. glass cell 
containing water, placed in front of the lenses to arrest the heat rays. The whole apparatus is mounted on 
a split socket, £>S, which admits of free vertical motion; and this is carried by the metal arm, GS. 
complicated. I have, therefore,- had constructed for my own use 
an instrument in which the water-chamber is abandoned as un- 
necessary and other portions of the apparatus much simplified. 
Fig. 3.—Beseler’s Lime Light Laryngoscope. A, hood for cutting off the rays from the observer’s eye; 
B, oxygen supply tube; C, lime candle. 
The main features of this device are embodied in the instrument 
shown in Fig. 3. It is light, movable, easily manipulated, and 8 
DISEASES OF THE NASAL PASSAGES. 
serves a most excellent purpose, and moreover, is much cheaper 
than Browne’s device. It is manufactured by Charles Beseler, of 
this city. The expense of the oxy-hydrogen light is about thirty- 
five to forty cents an hour, burning continuously. It will be 
understood that in this device ordinary street gas is substituted 
for hydrogen and seems to serve fully as good a purpose. A very 
ingenious and exceedingly powerful light has recently been intro- 
duced, known as the Wellsbach light, which consists of a hood, as it 
were, composed of a patented material which, when suspended over 
a gas-jet which has been converted into a Bunsen burner, is 
rendered incandescent. This light where available answers a most 
excellent purpose in examining the upper air passages, although, of 
course, it is not as powerful as the lime light or the rays of the sun. 
Sajous1 speaks very highly of the so-called albo-carbon light which 
consists of a metal globe containing a material called albo-carbon, 
located in such a way that it is subjected to the heat of the flame, 
while at the same time the gas passes through it before combus- 
tion. This, undoubtedly gives a very brilliant white light, but this 
is due probably entirely to the fact that the gas becomes so far 
heated before it reaches the burner as to insure the complete com- 
bustion of its carbon, although the claim is made that it receives 
certain gases in passing through this material in the metal chamber 
which add to the intensity of the flame. The incandescent electric 
light offers no advantages over the ordinary gas jet or coal-oil 
lamp. Those various devices by which a small incandescent light 
is attached to a throat mirror, modelled after Trouve's polyscope, 
I think are to be regarded as mere playthings and of no practical 
value, in that a much more powerful light can be thrown into the 
throat or nose than can be introduced bodily. The same should 
be said also of the incandescent light attached to the head-band. 
The Reflecting Mirror.—The really important feature of every 
laryngoscopic apparatus is the concave reflecting mirror of Reute, 
in that by means of this device the rays of light are so far con- 
verged as to thoroughly illuminate a part, even if the source of the 
light is not particularly intense, and furthermore this device enables 
us to manipulate and direct the illuminating rays at our conveni- 
ence. Whether we examine directly, as through the anterior nares, 
or whether we deflect the rays by the mirror into the fauces, it is 
absolutely necessary that this concave mirror be perforated in the 
centre, in order that the illuminating rays and visual rays shall be 
exactly in the same line, as it is easy to understand, and does not 
require any elaborate demonstration to show, that we thus obtain 
1 Loc. cit., p. 5. METHODS OF EXAMINATION. 
9 
the best inspection of the parts. This mirror may be attached to 
a simple head-band carried on the forehead, or it may be attached 
to a fixed apparatus. Fig. 4 represents Schroetter’s head band. 
A stout band passes around the head and is fastened with a buckle. 
In front there is attached a thick pad which lies against the fore- 
head, and two smaller pads below, which rest upon the bridge of 
the nose. From the metal plate to which the pads are attached, 
there projects in front a split socket, regulated by a screw, which 
receives a ball attached to the reflecting mirror, In this manner it 
is intended that the mirror shall be held in any position, or turned 
in any direction in front of the eye. A simpler affair than this is 
what is known as the Pomeroy head-band, shown in Fig. 5, con- 
structed on much the same principle, but simpler and lighter, doing 
away with the nose-rest. In both these head-mirrors, the knob 
which is received into the split socket of the head-band, projects 
from the back of the mirror-frame; the result is that the lateral 
Fig. /.—Reflecting Mirror Mounted on Schroetter’s Head-band. 
Fig. 5.—Reflecting Mirror Mounted on Pomeroy’s Head Band. 
motion of the mirror is notably restricted. Furthermore, it has been 
the custom to make use of mirrors of large diameter, even as great 
as five inches. The weight of a mirror of this size is objectionable, 
in that a prolonged examination thus becomes wearisome and even 
painful. There is no great advantage of illumination gained by a 10 
DISEASES OF THE NASAL PASSAGES. 
large-sized reflector. I, therefore, much prefer a smaller-sized mir- 
ror, as possessing all the advantages and none of the disadvantages 
of the larger ones. Fig. 6 shows 
the writer’s head-mirror which is 
two and a half inches in diame- 
ter, with the knob attached to 
the periphery of the frame, thus 
giving an absolutely unrestricted 
movement to the mirror, en- 
abling the wearer to turn it free- 
ly in any direction. In addition 
to this, the split socket is only 
of sufficient size to receive the 
knob, while the plate to which 
the socket is attached is but one 
and a half inches long. 
These head-mirrors are usu- 
ally attached to the head by 
an elastic band, which is always objectionable. In the writer’s 
head-mirror, the band is made of half-iijch alpaca braid, which 
is worn with much more com- 
fort and possesses sufficient 
elasticity to maintain the in- 
strument firmly in place. In 
addition to this, the whole 
affair is perfectly flat and is 
carried easily in the vest 
pocket. A method of arrang- 
ing the head mirror much in 
vogue among our English 
friends is by means of a spec- 
tacle-frame, shown in Fig. 7. 
This is a somewhat cumber- 
some affair, and, moreover, 
the field of vision is in no small degree restricted in that the mir- 
ror is held at so great a distance from the eye. 
Fig. 6.—The Author’s Head Band and Mirror. 
Fig. 7.—Head Mirror Mounted on a Spectacle Frame. 
The Fixed Apparatus. 
In the early days of laryngoscopy the idea seems to have pre- 
vailed that this art could only be practised by means of a somewhat 
elaborate apparatus. This idea, I think, had its impetus largely in 
the introduction of Tobold’s1 instrument, which seems to be the 
* “ Laryngoskopie und Kehlkopf-Krankheiten,” Dritte Auflage. Berlin, 1874, p. 19. METHODS OF EXAMINATION. 
11 
pattern on which most of the laryngoscopes which came later were 
constructed. This instrument (Fig. 8) consisted of a metal bonnet 
fitting over a lamp or gas jet, from which projected a cylinder about 
seven inches in length, containing three double convex lenses, two 
of which were placed at the proximal end of the cylinder, their 
faces being in contact, while a larger lens was inserted in the distal 
end of the cylinder. This apparatus was attached to an upright 
support from which sprang a jointed arm carrying at its distal ex- 
tremity the concave reflecting mirror. I have never been able to 
discover what optical principle was involved in this arrangement of 
the lenses. Tobold’s idea seemed to be that the emerging rays be- 
Fig. 8.—Tobold's Laryngoscope Mounted on the German Student Lamp. 
came parallel and were subsequently converged by the reflecting 
mirror. Practically, I do not think this occurs. The only effect of 
the lenses in the laryngoscope is, that the light thrown into the 
parts which it is desired to illuminate, assumes the form of a rounded 
disc, and does not reflect the shape of the flame. The illumination, 
however, is not increased, and the practical advantage of any laryn- 
goscope cannot be shown, other than as affording a somewhat con- 
venient method of office work. In other words, a simple head-band 
on the forehead, and a good strong source of light, afford us in 
every respect as good a method of practising laryngoscopy, as the 
most elaborate apparatus. Dr. Sass, of New York, modified the 
Tobold’s laryngoscope in presenting an instrument, shown in Fig. 
9, of far more elaborate construction, in which the metal hood was 12 
D IS EASES OF THE NASAL PASSAGES. 
largely increased in size, the light completely shut in, while the 
cylinder containing the lenses was also much larger. He further- 
more inserted two plano-convex, in place of Tobold’s three double 
convex lenses, one at the distal, and one at the proximal ex- 
tremity of the cylinder. The illustration further shows the heavy 
standard which Sass devised for carrying not only the laryngoscope, 
but also the glass inhalers known under his name. In general, 
however, his laryngoscope does not differ in any of its essential fea- 
Fig. 9.—The “ Sass ” Laryngeal Stand, with Globe Inhalers, Atomizing Tubes, and Laryngoscope. 
tures from Tobold’s. It marked, however, a period in the develop- 
ment of a tendency toward most luxurious and expensive fittings 
for a throat specialist’s office, in that the mere cost of an elaborate 
Sass laryngoscope, in connection with the pumps and receivers for 
compressed air, involved an outlay which but few were enabled to 
meet. 
A much simpler apparatus is Mackenzie’s light condenser, shown 
in Fig. io, which consists of an upright metal cylinder of about three 
inches in diameter, in the side of which is a fenestra, into which is METHODS OF EXAMINATION. 
13 
fitted a plano-convex lens, two and a half inches in diameter and 
comprising about one-third of a sphere. This is so constructed as 
to be easily fitted over a coal-oil lamp or an ordinary gas jet. 
It will be observed that in all these laryn- 
goscopes there is an evident design to shut 
in, as far as possible, all the rays of light ex- 
cept those which emerge from the lenses, the 
idea being that these examinations should be 
conducted in a darkened 
room, This is by no means 
essential, although, where ar- 
tificial light is used, it is de- 
sirable that daylight should 
be excluded to a certain ex- 
tent, but that a rhinoscopic 
examination demands that 
the operating room should 
be thoroughly darkened is 
quite a mistake. As before 
suggested, I regard the use 
of an elaborate larynoscopic apparatus as by no means necessary, 
in that the examinations can be thoroughly well made simply by 
means of a head-mirror and a good light. 
Fig. io.—Mackenzie’s Light Condenser Mounted upon a 
Ratchet Movement Gas-Fixture. 
The Examination. 
By far the best source of illumination is sunlight. These rays 
are utilized by using the small device shown in Fig. 16 which con- 
sists of a plane mirror, about four inches in diameter, which is 
mounted on an upright support, to which it is attached by a uni- 
versal joint. This may be placed in a window, exposed to the sun, 
and turned in such a direction that the rays of the sun shall be de- 
flected upon the concave reflecting mirror of a fixed apparatus, or 14 
DISEASES OF THE NASAL PASSAGES. 
in such a direction as that they will fall upon the forehead-mirror 
of the operator, as shown in the same illustration. In making use 
of sunlight, the unpleasant effect of the rays striking directly upon 
the eye, is easily avoided by placing the heliostat a few feet above 
the right shoulder of the patient being examined, and in such a 
manner that the rays shall fall at about an angle of 450 upon the 
mirror. 
In the absence of sunlight, a very satisfactory examination can 
be made by the aid of an ordinary coal-oil lamp or gas jet. In 
making the examination, the lamp is placed at the right hand of 
the patient, and at about the elevation of his shoulder, while the 
operator, sitting in front of him, arranges his head-mirror in such a 
way that the face of the patient is plainly seen through the per- 
foration, when the mirror is to be turned in such a direction as that 
the part illuminated is brought under direct vision, without any 
effort of the eye. 
In making, an examination with Sass’s or Tobold’s laryngoscope, 
the patient is placed in such a manner that the laryngoscope is on 
his right, and at about the elevation of the face, when the reflect- 
ing mirror, supported by its flexible bar, is brought into such a 
position as to fully intercept the illuminating rays as they emerge 
from the laryngoscope, and to deflect them upon the face of the 
patient. 
In using Mackenzie’s light condenser, the patient is placed in 
much the same way, while the condenser is so arranged that the 
rays of light fall upon the head mirror of the operator. A very 
convenient method of mounting this, is by the ratchet-movement 
gas-fixture, shown in Fig. 10, whereby the lenses can be easily ad- 
justed to the level of the mirror on the forehead of the operator. 
In using this instrument, one’s movements are somewhat hampered, 
in that the head with the mirror attached must be held in one posi- 
tion, which is necessarily somewhat wearisome, whereas with the 
unhooded lamp or gas jet, the rays can be easily intercepted in what- 
ever position, or at whatever level the head of the operator may be. 
After all, any method of examination is largely a matter of prefer- 
ence on the part of the operator. There is no great advantage in 
any, and certainly no great advantage in an elaborate apparatus. 
If one knows just what one wishes to accomplish, the procedure 
becomes the simpler as the apparatus is the less complicated. I 
think, however, while there is a certain amount of convenience in 
making use of the fixed light, as in the Tobold and Sass laryn- 
goscopes, one should always become thoroughly accustomed to 
work with the simple head-mirror and ordinary light, in that thus 
he is not dependent upon elaborate office-fixtures, but can make METHODS OF EXAMINATION. 
15 
his examination in the sick-room, or under whatever circumstances 
he may be called upon to do so. 
A special operating chair is recommended by many authorities 
as not only adding to the convenience of a laryngoscopic examina- 
tion, but more particularly as aiding in the performance of the 
minor operations upon the throat and nose. I have always accus- 
tomed myself to the use of an ordinary straight-back chair in my 
own office work, and believe this method is much to be preferred, 
in that it better enables the surgeon, in operating outside his office, 
to adapt himself to improvised conveniences. 
Rhinoscopy. 
The nasal cavity is examined and diseased conditions recognized 
by illumination and direct inspection through the nostrils, called 
anterior rhinoscopy, and also by placing mirrors in the fauces in 
such a manner that the rays of light are reflected through the pos- 
terior nares, while at the same time the illuminated parts are seen 
reflected in the same mirror, and conditions of health or disease 
recognized. This latter is designated as posterior rhinoscopy. 
Anterior Rhinoscopy.—This examination is made by dilating 
the flexible portions of the nostrils by means of a suitable spec- 
Fig. 11.—Frankel’s Nasal Speculum. 
Fig. 12.—Goodwillie’s Nasal Speculum. 
ulum, and illuminating the cavity by means of light reflected from 
the concave mirror, so placed that the focus of illumination may fall 
as nearly as possible upon the part to be examined. 
A number of instruments have been devised for dilating the 
nostril for this inspection. In Fig. 11 is shown Frankel’s instrument, 
composed of two blades regulated by a set screw. It may be in- 
serted in both nostrils, or in one, at pleasure, and serves to open the 
parts with considerable force. It is only partially self-retaining, 
however. Goodwillie’s speculum, shown in Fig. 12, is a much sim- 
pler device, whose action is evident from the cut. Its third blade, 
however, it seems to me, accomplishes no good purpose. Elsberg 
has modified Delaborde’s tracheal dilator, by inserting a set screw 16 
DISEASES OF THE NASAL PASSAGES. 
to hold it open, as shown in Fig. 13, thus adapting it for use as a 
nasal speculum. This is an instrument of undoubted value in cases 
where the parts are rigid, and require to be opened with consider- 
able force. The objection to this speculum is that it occupies one 
Fig. 13.—Elsberg’s Nasal Speculum. 
hand in its manipulation. The little device shown in Fig. 14, is an 
instrument devised by the writer, in which the blades are placed 
at a right angle to the spring, and is so constructed that the instru- 
ment is thoroughly self-retaining, and holds the nostril open excel- 
lently well, while at the same time both hands are left free for other 
Fig. 14.—The Author’s Self-retaining Nasal Speculum, actual size. 
manipulations. When properly constructed, this instrument has 
served a better purpose in my own hands than any of those men- 
tioned. On much the same principle is the convenient little in- 
strument devised by Jarvis, shown in Fig. 15. 
In making an examination of the parts, the patiejat is placed 
Fig. 15.—Jarvis’ Nasal Speculum. 
with his face directly on a level with that of the operator, when, the 
speculum being inserted, the bridge of the nose is grasped firmly 
between the index and second finger, while, at the same time, the 
tip of the patient’s nose is tilted up by the thumb, with a consider- METHODS OF EXAMINATION. 
17 
able degree of force, as shown in Fig. 16, in order that the light 
from the head-mirror may be thrown into, and along the inferior 
meatus. The patient’s head, now, is to be turned very slightly, 
first to one side and then to the other, enabling the operator to 
successively inspect the lower portion of the septum, and the face 
of the lower turbinated body. After these have been thoroughly 
inspected, the head should be thrown backward, as seen in Fig. 
17, until the lower border of the middle turbinated body is brought 
into view, when, by the same lateral motion of the patient’s head, 
the face of this body, and that portion of the septum opposite 
Fig. 16.—Method of Making an Examination of the Anterior Nares by Means of Sunlight, the Head of 
the Patient being in Position for the Inspection of the Inferior Meatus. 
is brought successively into view. This backward motion being 
continued, there is brought under inspection the main portion of 
the middle turbinated body, and finally its anterior termination, and 
the vestibule of the nose. This inspection having been made as 
thoroughly as possible, a ten or twenty per cent solution of cocaine 
should be thrown in, and sufficient time allowed to elapse for the 
tissues to undergo thorough contraction, and the blood-vessels to 
become completely emptied, after which the same process should 
be gone through a second time. In this manner anterior rhinoscopy 
becomes of far greater importance even than posterior rhinoscopy, 
in that by this means the whole of the nasal passages may be 
brought under examination, from the nostrils to the posterior nares, 18 
DISEASES OF THE NASAL TASS AGES. 
and after the membrane has been contracted by cocaine, a part of 
the glandular structure of the upper pharynx even can be inspected 
Fig. 17.—Anterior Rhinoscopy, the Head of the Patient being in Position for the Inspection of the 
Middle Turbinated Body. 
on one or on both sides. By this means, information is obtained 
as regards the existence, or degree of inflammatory action in the 
nasal mucous membrane covering the turbinated bones, the extent 
of hyperaemia, the existence of deformities or deflections of the 
Fig. 18.—Anterior Rhinoscopy, Position of the Head for Inspecting the Wall of the Pharynx, through 
the Nasal Passages. 
septum, the presence of polypi or other tumors, the character of 
the secretions of the part, whether mucus or pus, and the existence METHODS OF EXAMINATION. 
19 
of ulceration, necrosis, etc. In looking directly down the nasal 
passages, the view of the lower turbinated body is very much fore- 
shortened, but where the cavity has been dilated with cocaine, as 
before stated, in many cases it is quite easy to recognize the pos- 
terior wall of the pharynx, as an elongated, triangular patch, pre- 
senting a lighter color than that of the turbinated bodies, and 
moreover the light, falling directly upon it from the mirror, causes 
it to stand forth, as it were, a bright, glistening patch in the back- 
ground. It is always easy to ascertain whether the pharynx is seen 
by this examination, by directing the patient to swallow, or better 
still, simply to enunciate the letter K, by which the levator palati 
muscle is brought into vigorous contraction, and thereby swings 
across the lower and outer portion of the 
posterior nares, the movement being easily 
and immediately recognized. The position 
of the head necessary for this inspection is 
shown in Fig. 18. 
Another method of examining the nasal 
cavities consists in dilating each nostril by 
means of a speculum, after which the illu- 
minating rays are projected into one cavity 
and against the septum, when the other cav- 
ity is to be inspected. It will be found that 
the septum is so thoroughly translucent that 
one of the nasal cavities will be fully illu- 
minated by rays of light projected through 
it. The parts seen in this manner present 
quite a different picture from that shown by 
the direct illuminating rays, and information 
will often be afforded by this method, not 
easily obtained by the ordinary procedure, in that the light is pro- 
jected more directly into the recesses beneath the turbinated bones, 
and hence its prominences and variations from the normal are 
more easily recognized. In addition to this, transmitted light 
brings out in a striking manner the irregularities of contour in the 
septum itself. 
Posterior Rhinoscopy .—This examination is somewhat more diffi- 
cult of accomplishment chan that through the anterior nares, and re- 
quires therefore a nicer manipulative skill and dexterity. In order 
that these parts may be brought into view, it is necessary to so place 
a mirror in the pharynx as that light may be thrown up into the pos- 
terior nares, while, at the same time, the palate remains completely 
relaxed, and the tongue is prevented from protruding itself into the 
line of vision. Occasionally a patient is met with who will depress 
Fig. 19.—Tiirck’s Tongue 
Depressor 20 
DISEASES OF THE NASAL PASSAGES. 
his own tongue in so satisfactory a manner, as to tolerate the exam- 
ination without the aid of instruments. Ordinarily, however, it is 
necessary to press the tongue down by means of the spatula. In Fig. 
19 is shown Tiirck’s tongue-depressor, a somewhat elaborate and 
Fig. 20.—Sass’ Tongue Depressor. 
expensive instrument, which is of value, undoubtedly, where the pa- 
tient can manipulate the instrument himself. It is usually, however, 
better for the operator to manage the spatula, in which case this 
instrument is, I think, somewhat awkward. The Sass spatula (Fig. 
20) is also, I think, open to the same objection. Some form of 
the folding spatula, such as is shown in Fig. 21, is a very convenient 
instrument, and can also be carried in the pocket. 
Depressing the tongue by means of the spatula would seem to 
be one of the simplest of manipulations, and yet, where awkwardly 
done, the fauces may be so far irritated as to render the examina- 
Fig. 2i.—Goodwillie’s Folding Spatula. 
tion entirely impossible; whereas, if properly done, the examina- 
tion may be made even in cases of exceedingly irritable throat. It 
should be borne in mind that if the tongue is pressed directly down 
into the floor of the mouth, its root is pressed backward into the METHODS OF EXAMINATION. 
21 
fauces, which in the majority of cases will cause retching or gag- 
ging on the part of the patient. On the other hand, if the tongue 
is grasped by a spatula in such a way as to press it forward, it can 
be entirely controlled without excit- 
ing any involuntary movements. As 
best accomplishing this purpose I 
have had constructed the spatula 
shown in Fig. 22. The blade is 
composed of a thin plate of metal 
three and a half inches long and 
one inch wide, which tapers toward 
the handle, which is three inches in 
length and to which it is attached 
at a right angle. The blade is fenes- 
trated at its distal extremity to per- 
mit of an arching of the tongue into 
it by which the organ is more firmly 
grasped, and is slightly curved. A self-retaining tongue depressor 
is usually not well tolerated by the patient; where feasible, how- 
ever, the advantage of this device is quite obvious. Church’s 
instrument, shown in Fig. 23, is perhaps the best of these. 
In introducing the tongue depressor, its beak should always be 
carried beyond the arch of the tongue, that is beyond the high- 
est point tQ_.which the tongue is visible; otherwise, in pressing 
it downward, its an- 
terior end will be de- 
pressed, while its cen- 
tre will arch up and 
interfere with the in- 
spection. Further- 
more, the beak of the 
ispatula should be 
carried just far 
enough to cover the 
arch of the tongue, 
and no farther; 
otherwise, its pres- 
sure on the sensitive 
parts near the base 
of the tongue will be 
liable to excite 
retching. The spatula should be held between the thumb and 
the forefinger, the thumb pressing against its angle, while the 
second finger passes under the chin of the patient. In this man- 
Fig. 22.—The Author’s Tongue Depressor. 
Fig. 23.—Church’s Self-retaining Tongue Depressor. 22 
DISEASES OF THE NASAL PASSAGES, 
ner a grasp is maintained of the lower jaw, and control of the 
movements of the head secured. Then the tongue should be 
pressed, not downward, but downward and forward, by a rotary 
movement of the spatula, the beak of the instrument being made to 
revolve in the arc of a circle which has its centre in the teeth of 
the lower jaw. If this movement is made with a slow but firm 
pressure, the whole of the lower pharynx will be brought into open 
view, while at the same time the palate remains pendulous and re- 
laxed. If retching occurs during this manipulation, the attempt 
Fig. 24.—Method of Depressing the Tongue for Examing the Pharynx and for Posterior Rhinoscopy. 
should always be abandoned for the time, and a few moments of 
rest given. The position of the hand and the spatula is well shown 
in Fig. 24. 
The tongue being depressed, and the palate seen to be relaxed, 
a rhinoscopic mirror should now be selected, the size of which 
should be determined upon by the space seen to exist between the 
base of the tongue and the border of the palate. The largest mir- 
ror should be selected which can be introduced without touching 
the parts, in that the parts to be brought under inspection, depend 
entirely for their illumination on the amount of light reflected from 
the rhinoscopic mirror, and, of course, the larger the mirror the 
better the illumination. The rhinoscopic mirror, as before noted, METHODS OF EXAMINATION. 
23 
is attached to its stem at an angle of about 105°. This should be 
held lightly in the right hand (see Fig. 25), and passed backward 
somewhat edgewise, in order that it may pass through the niche be- 
tween the uvula and right pillar of the fauces, in such a manner 
that it may not touch the parts, there not being, as a rule, sufifi- 
Fig. 25.—Method of Making a Posterior Rhinoscopic Examination. 
cient room for it to pass under the uvula. After it has reached the 
pharyngeal space behind the palate, by slightly rotating the handle 
from right to loft between the fingers, the reflecting surface should 
be brought around so as to face the operator, and the mirror carried 
upward until its upper border is slightly hidden by the soft palate. 24 
DISEASES OF THE NASAL PASSAGES. 
The position of the mirror should now be at a right angle with the 
line of vision, and inclined slightly backward, the handle being held 
at one side, with its shaft lying against the corner of the mouth, as 
seen in Fig. 25. The tongue being well under control, the main 
difficulty of examination now lies in the inability of the patient to 
control the movements of the palate. If the palate is touched in 
the slightest degree during the manipulation, it is immediately 
drawn up against the posterior wall of the pharynx, and of course, 
the examination entirely prevented. This will only be overcome 
by the exercise of great care and patience in the manipulation. If 
a patient is directed to breathe through the nose, while the tongue 
is being held by a spatula, he will find it an exceedingly difficult 
thing to do. He can, however, oftentimes succeed in relaxing the 
palate by uttering a nasal sound. Much aid, therefore, will be ob- 
tained if the patient be directed to say “ Eh,” giving it as full a 
nasal twang as possible. If there is still difficulty in controlling 
the movements of the fauces, they should be anaesthetized by 
means of a ten or twenty per cent solution of cocaine. This is an 
exceedingly unpleasant application to the fauces, giving rise to a 
curious sensation of choking or feeling of suffocation, and yet it is 
never attended with anything more than a temporary inconvenience. 
As a last resort, other means failing to control the move- 
ments of the fauces, we may proceed to tie up the palate after 
the manner first suggested by Desgranges.1 This procedure con- 
sists in passing a cord through each nostril to the pharynx, and 
drawing it out through the mouth, when it is passed over the 
ear on each side and tied behind the head. By this means a 
gentle traction can be exercised on the palate, under which it 
gradually yields, and is finally folded on itself, as it were, and 
a broad space afforded for inspection of the parts above. This 
device of Desgranges is very simple, easily accomplished, and fairly 
well tolerated by the patient, and should always be resorted to in 
any case where it would add to the completeness of a diagnosis. 
An ordinary cord is somewhat irritating and not easily passed. 
Better still we may use a soft rubber cord, as first suggested by 
Wales,2 about one-eighth of an inch in diameter and a yard long. 
The ends are passed successively, first through one nostril and then 
through the other, until they emerge in the fauces, when they are 
drawn out through the mouth, and tied behind the neck, or held by 
an assistant. Their passage is facilitated by smearing the rubber 
with oil. If any difficulty is experienced in passing the cord, a 
small velvet-eyed English catheter may be used, the stylet being 
‘Cited by Brevet. These de Paris, No. 117, 1855. 
2 Med. Record, 1875, vol. x., p. 785. METHODS OF EXAMINATION. 
25 
inserted for passing it through the nares. This procedure is 
quite easy of accomplishment, and secures all that can be desired 
in the way of drawing forward the palate for inspection or treat- 
ment of the upper pharynx. Unfortunately, many patients will 
Fig. 26.—White’s Self-retaining Palate Retractor. 
easily tolerate the manipulation but for a brief period, perhaps no 
longer than is sufficient to make the examination. 
Palate-hooks, palate-retractors, combination rhinoscopic mirrors 
with retractors, such as Duplay’s instrument and other devices of 
this sort, I have never found of any practical value. The best of 
these probably is the instrument shown in Fig. 26 which has been 
devised by Dr. Jos. A. White.1 
The Rhinoscopic Image. 
The mirror being placed in the position described, there will be 
brought into view the oval-shaped openings of the posterior nares. 
Fig. 27.—The Posterior Nares. 
This posterior rhinoscopic image is shown in Fig. 27, although it 
should be borne in mind that these parts are only seen in detail and 
not as a whole. Separating the choanae, in the median line will be 
'Virginia Med. Monthly, March, 1888. 26 
DISEASES OE THE NASAL TASS AGES. 
seen the septum, broad above and tapering to a sharp and narrow 
edge below. On each side of the septum will be seen, as dark cav- 
ities, the nasal passages, with the turbinated bodies projecting into 
them, from the outer wall of each. The superior turbinated body 
will be just visible, a light reddish band, in the upper part of the 
image, emerging as it were from the shadow, and seeming to slant 
upward and forward. Immediately below it, and separated from it 
in the posterior portion by a dark line, the superior meatus, will be 
seen the middle turbinated body, appearing as an elongated and 
somewhat fusiform projection, of a yellowish-red color. Below this 
again may be seen a considerable portion of the middle meatus, 
and below this the upper half of the inferior turbinated body, of 
much the same color as the middle, and giving the impression of a 
somewhat elongated mass resting on the floor of the nares. The 
inferior meatus and floor of the nares cannot be brought into view. 
If, now, the mirror be turned somewhat to one side, there will be 
seen the eminence surrounding the orifice of the Eustachian tube, 
separated from the posterior wall of the vault of the pharynx by 
the sinus of Rosenmiiller. The Eustachian tube being seen in pro- 
file, the orifice simply shows a dark line on a bright yellow back- 
ground, which is the anterior wall of the depression leading into it. 
By changing the inclination of the mirror now to a more obtuse 
angle, there will be brought into view the dome-like cavity of the 
vault of the pharynx, presenting a somewhat irregular outline, the 
surface being marked by furrows and depressions which indicate 
the site of the pharyngeal tonsil; the parts becoming smoother as 
the view passes down, until there is seen the deep red, smooth, 
shining surface of the mucous membrane of the lower pharynx. 
In adult life, however, as we know, the glandular structures of the 
pharyngeal vault undergo a certain amount of atrophy, and hence 
are not prominently visible. In these cases we simply bring into 
view the smooth surface of the mucous membrane lining this cavity. 
This change in the inclination of the mirror is best accomplished by 
simply turning the handle in the fingers, as the attempt to accom- 
plish it by elevating or depressing the hand, is liable to end in caus- 
ing retching. To obtain a complete inspection of the vault of the 
pharynx, it will generally be found best to change the mirror and 
use one mounted at an angle of 130°, the same used in making a 
laryngeal examination. 
This examination reveals the condition of the mucous mem- 
brane of the nasal cavity, the variety and extent of such hyper- 
trophic thickening as may exist in nasal catarrh, the condition of 
the pharyngeal tonsil, the extent of hypertrophy that may exist 
there, the character and amount of the secretions from the parts, METHODS OF EXAMINATION. 
27 
the existence of tumors in the nose or vault, ulceration, necrosis, 
etc. 
As regards the nasal cavity, not much information is obtained 
by this inspection, that cannot better be obtained by anterior rhinos- 
copy. Thus, morbid conditions of the septum I have never seen 
shown in this way, except the hypertrophy of the mucous mem- 
brane on either side posteriorly, in connection with hypertrophic 
rhinitis. Occasionally, however, small polypi well up beneath the 
middle turbinated body posteriorly, are seen, where the anterior ex- 
amination fails to reveal them. The pus discharged from the acces- 
sory sinuses can be recognized also in this manner, although usually 
this is best detected by the anterior examination. CHAPTER II. 
METHODS OF TREATING THE UPPER AIR PASSAGES 
BY MEANS OF INSTRUMENTS. 
In the local treatment of the mucous membrane of the upper 
air passages, resort has been had to various mechanical devices, by 
which the parts were thought to be more thoroughly and efficiently 
medicated. Thus, various forms of brushes have been devised, to- 
gether with sponge-holders, douches, atomizers, etc. In the earlier 
days of laryngoscopy, a considerable amount of importance was 
attached to these various methods. I think no one will question, 
at the present time, that their value was greatly over-estimated, 
and that in the discussion as to the comparative merits of the dif- 
ferent methods by which local applications were made, we often- 
times lost sight of the question as to how far these applications 
were efficacious in curing or relieving diseased conditions. With 
our larger knowledge of the physiology and pathology of the mu- 
cous membranes of the upper air passages, our dependence upon 
these various instrumental aids has greatly diminished, and a large 
majority of them are thrown aside for the simpler methods by 
which the desired end is accomplished, now that the indications 
for treatment have become so clear, positive, and direct. Local ap- 
plications by means of brushes, largely resorted to in former years, 
have fallen almost completely into disuse in this country. Those 
desiring still to make use of this instrument will require no direc- 
tions for carrying out the procedure. The same, I think, can be 
said of sponge-holders or probes for holding pledgets of cotton. 
As regards the use of solids, such as nitrate of silver, chromic acid, 
etc., the methods for their use will be described in the chapters de- 
voted to the consideration of those diseases in which the use of 
these remedies is indicated. 
Insufflations. 
The use of snuffs, and their application by means of specially 
devised instruments, possesses a certain amount of value in the treat 
ment of the upper air-passages, as was recognized by Galen,1 anc 
1 “ De Compositione Medicamentorum Localium,” etc., lib. vii., cap. 3. METHODS OF TREATMENT. 
29 
is resorted to by most physicians up to the present day. These may 
be used by auto-insufflation or by special applicators. Among the 
earliest mechanical devices for insufflation was that of Pserhofer,1 
which consisted of a perforated reservoir containing the powder, 
Fig. 28.—Rauchfuss’ Insufflator. 
to which was attached a tube extending into the mouth, the powder 
being drawn up into the air passages. A somewhat similar device 
was used by Prof. Darwin, while Burow2 accomplished the same 
result by means of a simple tube. The first to suggest an instru- 
ment by which the powders are thrown into the upper air passages 
was Rauchfuss, whose instrument, shown in Fig. 28, consisted of a 
long curved tube, with a fenestra, covered with a slide, through 
which the powder is inserted. The proximal end of the tube is 
fitted with a soft-rubber bulb, pressure on which expels the powder 
from the tube, the distal extremity of which is curved to direct the 
Fig. 29.—Lefferts’ Insufflator. 
Fig. 30.—Ely’s Powder Blower. 
powder upon the diseased part. Rauchfuss’s instrument is rather 
awkward of manipulation—an objection which is avoided by attach- 
ing a rubber tube with a mouth-piece to the proximal end of the 
tube, as in Lefferts’ insufflator shown in Fig. 29, thus enabling the 
1 Schmidt’s Jahrb., 1856, vol. 92, p. 170. 
2 Deut. Klin., 1853, No. 21. DISEASES OE THE NASAL PASSAGES. 
30 
manipulator to expel the powder from the tube by blowing, and 
thus depositing it upon the part which it is desired to medicate. 
An objection to the tubes is that they deposit the powders in mass. 
A very ingenious instrument is shown in Fig. 30 
which is usually attributed to Ely, of Rochester. 
It consists simply of a glass bottle, through the 
cork of which there pass two tubes bent at a right 
angle immediately above their point of entrance. 
To one of the tubes is attached an air-bulb, while 
the other is bent at its distal extremity, upward 
or downward, or in whatever direction it is desired 
to carry the powder. The tube to which the air- 
bulb is attached passes down into the lower por- 
tion of the bottle, while the other merely passes 
through the cork. The powder having been placed 
in the bottle, a quick pressure on the air-bulb 
drives a current of air down into the bottle, which 
striking the powder, stirs it into a cloud, and at 
the same time drives it out through the other 
tube, and deposits it upon the part it is desired to 
medicate, in a state of fine and even diffusion. 
This instrument, made of hard rubber, can be ob- 
tained of the instrument makers, or anyone having 
a stock of glass tubing may make his own supply. 
This is unquestionably the best insufflator in use. 
Its advantages are that it thoroughly diffuses the 
powder, that it deposits it in a smooth thin film, 
that it does not pile it on any of the parts, and 
that it carries it throughout the sinuous cavities. 
Its only disadvantage is that it does not enable the 
operator to estimate nicely the amount of powder 
used, though, as a rule, this is of no consequence. 
Fig. 31 represents Stoerck’s insufflator which com- 
bines the advantages of all the above-mentioned 
instruments. It consists of a small central cham- 
ber for the reception of the powder, fitted with a 
movable cover. Projecting from this is the long 
curved tube for directing the medicament to the 
part it is desired to reach. At its proximal end it 
is provided with a tapering socket, communicating 
with the powder chamber by a tube containing a 
spring cut-off. This instrument is intended for use in connection 
with the compressed air apparatus. Its working is obvious; the 
distal point being placed in position to throw the powder in the 
Fig. 31.—Stoerck’s Insuf- 
flator. METHODS OF TREATMENT. 
desired direction, and the instrument connected with the air cham- 
ber, pressure on the valve lets on a sudden blast which drives the 
powder to the spot intended to be reached. 
The advantage to be gained by the use of powders, is a certain 
amount of permanency of action, as they remain for some time in 
contact with the part, and becoming slowly dissolved in the mucus, 
are absorbed by the membrane. The remedies usually employed 
in this form are tannin, bismuth, alum, borax, ferric alum, zinc, ni- 
trate of silver, iodoform, opium, morphia, belladonna, benzoin, san- 
guinaria, galanga, etc. When it is necessary to reduce the strength 
of an agent, it may be combined with pulv. cretae, pulv. acaciae,’ 
magnesiae carbonas, sacch. alb., etc. If the powder is heavy, it 
may be rendered lighter by combining with powdered starch or 
lycopodium. 
31 
Douches. 
Fluids may be thrown against the diseased membrane of the 
larynx, pharynx, or nasal cavity by means of syringes arid douches 
of forms variously devised for special ends. Fig. 32 shows the 
ordinary post-nasal syringe, a common barrel syringe, fitted with a 
Fig. 32.—Post-nasal Syringe. 
curved tube which terminates in a rose douche, delivering jets in 
every direction. This may be passed up behind the soft palate for 
injecting through the nasal cavities, or it may be turned downward 
for injecting the pharyngeal cavity. Fig. 33 represents the pipe of 
the same instrument fitted for use with the Davidson syringe. It 
Fig. 33.—Post-nasal Pipe fitted to the Ordinary Davidson Syringe. 
is equally adapted to the fountain syringe. For injecting through 
the anterior nares, an ordinary ear syringe answers the purpose very 
well, but better still is the post-nasal syringe shown above, with the 
tube straightened. This can be introduced well into the cavity if 32 
DISEASES OF THE NASAL PASSAGES. 
desired. Fig. 34 shows the instrument sold in the drug stores as 
Warner’s Nasal Douche, a very convenient device for cleansing the 
naso-pharynx, in cases where the patient can acquirp the necessary 
skill for manipulating it himself. The use of the syringe is to a cer- 
tain extent limited, in that it is probably not specially indicated in 
Fig. 34.—Warner’s Post-nasal Douche. 
other than the atrophic form of chronic rhinitis, in naso-pharyngeal 
catarrh, and possibly in syphilitic ozaena. 
The nasal douche is an expression which we ordinarily use to 
define the application of a continuous stream of water through the 
nasal cavities. The principle on which it acts was first suggested by 
Weber,1 who, in conducting a series of experiments on the sensi- 
bility of the nasal mucous membrane, ob- 
served that when a-fluid was introduced into 
the nasal cavities, the soft palate was lifted 
so firmly against the posterior wall of the 
pharynx, as to completely prevent the es- 
cape of the fluid into the parts below. 
Acting on this idea, Thudicum 2 introduced 
what is now known as the nasal douche, 
which is shown in Fig. 35. It consists of 
a reservoir, from the bottom of which 
leads a rubber tube terminating in a 
rounded tip so shaped as to fit into the 
nostril. This tip being placed in the nos- 
tril, the reservoir containing the fluid is to 
be raised above the head, which is bent over 
a bowl as shown in Fig. 36. As the reser- 
voir is raised, the fluid enters one nostril, 
and passing around the posterior border of the septum, escapes 
through the other in a continuous stream, probably reaching 
pretty thoroughly the whole of the mucous membrane of the two 
Fig. 35.—The Ordinary Form of the 
Nasal Douche. 
1 “ Ueber den Einfluss der Erwarmung und Erkaltun der Nerven auf ihr Leitungs- 
vermogen.” Muller’s Archives, 1847, p. 351. 
2 London Lancet, Nov. 24th, 1864. METHODS OF TREATMENT. 
33 
chambers. In Thudicum’s original instrument, the reservoir was 
fitted to a standing rod in such a way as that its height could be 
regulated according to indications. The little device shown in Fig. 
37, which was first suggested by Dr. Dessar,1 is somewhat unique 
in its simplicity and would seem 
to afford a convenient method of 
applying fluids to the nasal cavi- 
ties, especially of young children, 
where a more complicated appara- 
tus cannot well be used. Woakes’2 
nasal irrigator is also constructed 
on much the same plan. 
The value of the douche, as a 
means of applying cleansing fluids 
to the nasal cavity in certain cases, 
cannot be denied, especially in 
atrophic rhinitis, and perhaps sy- 
philitic necrosis. In these affec- 
tions, of course, it is not a curative 
measure, while in the ordinary 
chronic inflammatory action with 
hypertrophy, it probably not only 
fails to be of permanent value, 
but may be mischievous, as first 
suggested by Roosa,3 who reported a number of cases of acute otitis 
media resulting from its use, attributing this accident to the en- 
trance of fluids into the middle ear. I think it is to be borne in 
Fig. 36.—Method of Using the Nasal Douche. 
Fig. 37.—Dessar’s Nasal Cup. 
mind here, that the very large proportion of cases of hyper- 
trophic rhinitis of long standing, suffer from a mild form of mid- 
1 N. Y. Med. Record, 1889, vol. xxxv., p. 280. 
2 “ Post-nasal Catarrh,” Phila., 1884, p. 154. 
3 Archives of Ophthalmology and Otology, vols. i. and ii. 34 
DISEASES OF THE JVASAL PASSAGES, 
dle-ear disease, which acts as a predisposing cause of the acute 
form, which probably may be precipitated by the use of the douche. 
Considering, however, this possible danger, and the fact that the 
use of the douche probably accomplishes no good result in hyper- 
trophic rhinitis, its use in this affection is therefore to be condemned 
unreservedly. In atrophic rhinitis, the danger of middle-ear disease 
from its use is absent, and I consider the douche of great value in 
this disease, and see no reason for hesitating to recommend it. 
Atomizers. 
Following out the idea that the successful treatment of catar- 
rhal affections depended on our ability to thoroughly reach the 
parts with our medicating fluids, the plan of reducing our solutions 
to a state of fine atomization would naturally suggest itself as af- 
fording the best method by which they could be carried into the sin- 
uous passages of the nasal cavities, or thrown into, the air passages 
below. In view of the very large extent to which the use of atom- 
izers has grown in late years in the treatment of diseases of the 
upper air passages, it becomes a matter not only of historical, but 
also to a certain extent of practical interest, to trace their develop- 
ment from the cruder devices of former days, to the perfect instru- 
ments now provided for our use. This system was first put in 
practice at certain of the mineral springs of Europe. As these 
waters were considered as possessing notable virtues, both when 
taken internally, and as used for bathing, it occurred to the pro- 
prietors of these springs, that their local action upon the mucous 
membrane in the air tract might be equally efficacious. For this 
purpose, a large number of minute jets of water were projected 
against the walls of the chambers into which patients, well covered 
with water-proof clothes, were introduced for the purpose of inhal- 
ing the sprays thus produced The first to carry this plan of treat- 
ment into operation was Auphan1 at Euzet-les-Bains, the same device 
being subsequently adopted at Lamotte-les-Bains, and by Sales- 
Girons,2 who, in conjunction with Flube, elaborated the system 
more fully than had ever been done before, and published his re- 
sults. Sales-Girons also constructed a portable atomizer shown in 
Fig. 38 by means of which inhalations could be given of any medi- 
cinal agent other than the natural waters, the principle being much 
the same as that already suggested. This instrument was the pre- 
cursor of a large number of devices for accomplishing the same 
1 Cohen: “ Inhalation, its Therapeutics and Practice,” Phila., 1876, p. 184. 
2 “ Therapeutique Respiratoire,” Paris, 1858. METHODS OF TREATMENT. 
35 
purpose, such as the Nephogene of Mathieu,1 shown in Fig. 39, and 
the atomizers of Lewin, Waldenburg, Schnitzler, Fournier and 
others, based on different principles of action, all of them, how- 
ever, somewhat crude and imperfect. In 1863, Dr. Nathanson sug- 
gested to his friend Dr. Bergson,2 that if a current of air be driven 
through one tube, placed at right angles to a similar tube which 
led to a reservoir of water, a vacuum would be created, by which 
the water would be drawn up into the 
vertical tube, until meeting the cur- 
rent of air, it would be broken into a 
fine spray. On this principle were con- 
structed what are usually known as 
Bergson’s tubes. Bergson, in con- 
structing his apparatus, supplied the air 
current by means of a pair of rubber 
bulbs connected by tubing, pressure 
Fig. 38.—Sales-Girons’ Portable Atomizer 
(Cohen), a, Compression pump; b, reservoir; 
<r, stream of fluid about to strike the button, 
which is concealed within the drum; d, tube 
with stop-cock;/, drum in which the excess of 
spray is condensed; g, the waste tube to carry 
off the condensed fluid; /z, the manometer. 
Fig. 39.—Mathieu’s Nephogene (Cohen), a, the 
compression pump; b, glass globe containing fluid to 
be nebulized; c. the exit tube; d, flexible tube con- 
veying condensed air from the reservoir to the exit 
tube; /, air reservoir. , 
being applied to the distal bulb as shown in Fig. 40, while the cen- 
tral bulb acted as a sort of reservoir. This device was subjected 
to various modications until finally Dr. Sass, of New York, con- 
structed the atomizing tubes generally known as Bass's tubes. 
These are made on the Bergson principle, and of heavy barometer 
glass tubing, but instead of placing the two tubes at right angles, 
they are joined together, the upper end of the water tube being 
1 Gaz. Hebdomadaire, May 4th, i860, p. 300. 
2 Deut. Klin., 1863, No. vii. 36 
DISEASES OF THE JVASAL PASSAGES. 
bent at its upper extremity around to meet the air current at a 
right angle, as shown in Fig. 41. Subsequently these tubes were 
Fig. 40.—Bergson’s Apparatus with Foot Bellows (Lewin). a, Reservoir for fluid; b, a tray; c, verti- 
cal tube; d, horizontal tube; /, flexible tubing; g, air reservoir; h, rubber compressor to be compressed 
by the foot; i, joint connecting the tubes; k, the spray; i, the cap of the reservoir to which the tubes are 
attached (Cohen). 
constructed of hard-rubber and metal. An objection to metal is 
made, that it is liable to the action of the chemical agents used—an 
Fig. 41.—Sass’ Spray Tube. METHODS OF TREATMENT. 
37 
objection which is easily obviated by attention to cleanliness, while 
at the same time a large element of loss by breakage is also avoided 
by their use. Dr. Newmann, of New York, modified the Bergson 
tubes by placing one tube within the other, as shown in Fig. 42, the 
principle on which they act being the same as in Bergson’s. 
Previous to this, Manz 1 had made a somewhat ingenious change, 
consisting of the introduction of a third tube, passing through the 
cork of the reservoir bottle in such a way that air from the bulbs 
was forced both into the tubes and into the reservoir, thus driving 
the fluid up into the tube to meet the air current. 
Dr. Richardson, of London, combined the Newmann and Manz 
Fig. 42.—Newman’s Spray Tubes, Worked by Means of the Double Bulbs. 
devices into what is ordinarily known as the Richardson spray, in 
which the projecting portion consists of two hard-rubber tubes, one 
within the other. To the outer tube is fitted, at its distal extrem- 
ity, a movable cap, perforated in its centre by a small opening. 
The inner tube passes from immediately behind the opening in the 
cap, through the centre of the outer tube, through the neck of the 
reservoir, and down into the fluid. The small projecting nipple on 
the neck of the bottle or reservoir is for the attachment of the air- 
bulbs which furnish the air pressure. It opens into the larger tube, 
and also communicates with the reservoir. As will be seen, when 
a current of air is pumped in by the bulbs, it is divided into two 
streams. One stream passes into the reservoir above the fluid, 
where, being compressed, the fluid is forced up through the central 
1 Deut. Klin., 1866, p. 224. 38 
DISEASES OF THE NASAL PASSAGES. 
tube and driven in a small jet against the opening in the movable 
cap. The other current from the air-bulb passes into the larger 
tube, and escapes through the opening in its movable cap. The 
small jet of the fluid striking against the edge of the small opening 
in the cap, and at the same time meeting with the current of air 
Fig. 43.—The Richardson Double-bulb Hand Atomizer (Seiler). 
escaping therefrom, is broken up into a fine spray, and in this state 
is carried with the current some distance beyond the tube. A sep- 
arate movable cap is ordinarily supplied, fitted with a tip, curved in 
such a manner as to deflect the atomized fluid either upward or 
downward. This apparatus is shown in Fig. 43. We thus have METHODS OF TREATMENT. 
39 
illustrated two principles upon which all atomizers are constructed 
in our day—that of Bergson and of Richardson. 
The air-current may be supplied by means of the rubber bulbs 
or by more elaborate devices. The Richardson atomizer is usu- 
ally provided with a double bulb. This, I think, is an entire mis- 
take, as the principle upon which the atomizer is constructed 
gives a continuous atomization by the one bulb, while at the same 
time it forces the spray much better when the pressure of the 
hand on the single bulb is the motive power, rather than the 
contractile force of the central rubber bulb which is usually in- 
Fig. 44.—The Ordinary Hand-pump and Air Receiver. 
troduced in the continuity of the tube. In the use of the Sass’ 
tubes, a simple hand-ball, ordinarily, is insufficient, hence the com- 
pressed air apparatus so much in vogue of late years has been 
introduced. This consists simply of a pump and air receiver, as 
shown in Fig. 44, the cylinder being charged with air by means of 
the pump, which is then drawn off as wanted for the production of 
the sprays; the advantage of the air receiver being that the force 
of the spray can be regulated with a certain degree of nicety, while 
the jet is delivered instantly upon turning on the pressure, and 
arrested instantly upon its being shut off. The charging of the 
air receiver by the small pump shown above involves no small 
amount of laborious exertion. This is to an extent avoided by 40 
DISEASES OF THE NASAL PASSAGES. 
the instrument shown in Fig. 45, in which the pump piston is 
worked by means of a heavy fly wheel. Of course, all this labor 
is saved by the substitution of hydraulic pressure, as was first 
suggested by Dr. Arnold of Roxbury.1 He makes use of two jars, 
connected by a piece of long rubber tubing, one jar being filled 
with water, while the other is empty. By raising the full jar 
to a certain height, the water flowing into the empty one pro- 
duces compression of the air 
there contained, which is avail- 
able for use until the air is ex- 
hausted and the jar is full of 
water, when the process is re- 
versed. A continuous supply 
of air is thus obtained by the 
alternate use of one jar and 
then the other, the atomizing 
tube being connected with the 
lower jar. No apparatus yet 
devised, perhaps, is more con- 
venient for use than the hy- 
dro-pneumatic pump, shown 
in Fig. 46, which is worked by 
the ordinary city vvater supply. 
It consists of a metallic box 
into which water runs from 
the public main. As soon as 
the box is filled, by means of 
a simple mechanism in its up- 
per portion, the supply is shut 
off and a waste valve opened, 
which, in turn, is closed as 
soon as the box is empty, and 
the water supply turned on 
again. We thus have the 
water-head acting as a piston- 
head and pumping air through 
the tube, shown in the figure, 
into the air receiver, and storing it for use. This pump continues 
working until the air-pressure in the receiver equals the water-pres- 
sure in the supply pipes of the house. It is an excellent device, and 
will work for weeks and even months without requiring attention. 
A great deal of ingenuity has been exercised in the construction 
of these various devices for atomizing fluids, and it has been a 
Fig, 45.—Air Pump Worked by Fly-wheel. 
1 Boston Med. and Surg. Journal, Dec. 27th, 1866. METHODS OF TREATMENT. 
41 
broadly prevalent impression that our success in the treatment of 
diseases of the upper air-passages was largely dependent upon the 
elaborateness and perfection of our mechanical devices, especially 
those used for the production of sprays. Furthermore, a good 
deal of importance has attached, in the minds of many, to the pres- 
sure of the air by which the fluids are atomized, the ground being 
taken that at a pressure of fifty or sixty pounds atomized fluids 
come more thoroughly in contact with the membrane lining the 
sinuous passages of the nose, and are so driven farther down into 
the bronchial tubes, the idea still being held that local applications 
constitute the essential element necessary for the cure of catarrhal 
diseases. This I believe to be an entire mistake. A catarrhal 
inflammation, as a rule, is not cured by the local application of 
Fig. 46.—The Hydro-Pneumatic Pump. 
astringent, alterative, stimulant or other remedies, as will be more 
fully elaborated when we come to discuss the particular forms of 
inflammatory disease met with in the upper air tract. Local ap- 
plications undoubtedly have done good; they are convenient for 
cleansing purposes possibly, and astringent applications in the nose 
or larynx aid us somewhat in the treatment of catarrhal inflammation 
of these regions, and we cannot well dispense with them, but I am 
confident that those who place their main reliance on the use of 
sprays will find themselves disappointed in the results of treatment. 
Elaborate apparatus is unnecessary. I have always entertained 
the opinion that all the apparatus necessary for the successful 
treatment of the ordinary class of cases which come under our 
observation might easily be carried in a small hand-bag. Regard- 
ing, then, an atomizing apparatus as a very great convenience, al- 
though not an absolute essential, it remains to suggest that perhaps 42 
DISEASES OF THE NASAL PASSAGES. 
the most convenient device is the ordinary Sass’s tube, constructed 
of metal, with the air receiver and pump, preferably the water 
pump if one’s office is supplied with the public water service; but 
FrG. 47.—The Ordinary Single Bulb, Hand Ball Atomizer, fitted for Nasal Applications. 
this apparatus possesses no notable advantages over the simpler 
devices. In my own office work, after an experience of many years 
with various methods of atomization, I have finally arrived at the 
conclusion that one’s work can be quite as well performed, and 
much inconvenience even avoided, by using an ordinary single bulb 
hand-ball atomizer. Of these, perhaps the best is that shown in 
Fig. 47, which is constructed on the principle of Richardson’s 
atomizer. The device shown is fitted with a rounded bulb to 
adapt it for nasal application, 
although the same instrument 
is supplied with both the la- 
ryngeal and post-nasal tip. 
This instrument is used, in 
the main, to apply cleansing 
and disinfecting lotions to the 
upper air passages, and deliv- 
ers an abundant, yet finely 
divided spray. For making 
applications of astringent, sed- 
ative, or other medicating 
solutions, preference should 
be given to some of the ato- 
mizers constructed on the 
Bergson principle. In Fig. 48, there is shown an atomizer, con- 
structed on this principle, and sold in the drug stores under the 
Fig. 48.—Delano’s Atomizer. METHODS OF TREATMENT. 
43 
name of Delano’s Atomizer, which delivers a very fine spray, the 
flow of which ceases immediately upon relaxing the pressure upon 
the bulbs; it is therefore useful in making applications of cocaine, 
and for this purpose I regard it as of especial value. 
Inhalations. 
In 1864 Siegle 1 put in practice the plan of using steam as the 
power by means of which fluids were atomized in the Bergson 
tubes. This, however, was not available for a direct application, 
but could only be used as an inhalation, and it is this principle 
which Is made use of in the ordinary steam atomizers sold by the 
instrument makers at the present day. The principle on which 
they act is too well known to need remark. The drugs that can 
be made use of by means of the Siegle apparatus include nearly 
the whole list of astringents, alteratives, etc. In addition to these, 
there are certain drugs which contain principles which are volatil- 
ized when brought in contact with hot water at a temperature 
of not less than 150°. This list in- 
cludes carbolic acid, creosote, cam- 
phor, oil of tar, tincture of benzoin, 
tincture of myrrh, oil of eucalyptus, 
terebene, pine-needle oil, ethereal tinct- 
ure of iodine, etc. A teaspoonful of 
any of the above, placed in an open- 
mouthed bottle or cup containing half 
a pint of water slightly below the 
boiling point, is placed beneath the 
mouth, and the fumes inhaled. The 
same purpose is accomplished in the 
somewhat elaborate instrument known 
as Mudge’s inhaler, in which an inhal- 
ing tube is inserted into the cup, in 
such a way that the inhaled air is 
drawn through the fluid. In MacKen- 
zie:s inhalator, shown in Fig. 49, and 
instruments of that type, the volatile 
oils of the medicament used are driven 
off more actively by means of a burning lamp placed beneath the 
reservoir or cup. 
There are quite a number of drugs which are volatile at the 
ordinary temperature, the properties of which, as inhalants, possess 
a certain amount of value. The method by which these are used 
Fig. 49.—MacKenzie's Inhalator. 
1 “ Die Behandlung und Heilung der Hals-und Lungenleiden durch Einathmungen 
mittelst eines neuen Inhalations-Apparates,” Stuttgart, 1864, p. 16. 44 
DISEASES OF THE JVASAL PASSAGES. 
varies, but ordinarily is quite simple. A glass or vulcanite tube, 
into which has been inserted either cotton-wool or sponge, is 
the ordinary form. The absorbent material is charged with the 
drug which it is desired to use, and the little tube held either 
to the nostril or to the mouth, for the purpose of inhaling the 
fumes. In this way we make use of iodine, creosote, ammonia, 
oil of tar, oil of peppermint or any of the mint series, and, in 
fact, most of the aromatic oils. Lewin has suggested a rather 
ingenious device, by which nascent muriate ammonia is used for 
inhalation. His apparatus, shown in Fig. 50, consists of three 
flasks, one containing a solution of caustic ammonia, the second 
a solution of muriatic acid, the two being connected by means 
of glass tubes with a third flask, partially filled with water, to 
Fig. 50.—Lewin's Apparatus for Inhaling Nascent Muriate of Ammonia, a, Glass vessel, containing 
strong aqua ammonise; 6, glass vessel containing muriatic acid; c, glass vessel containing distilled water, 
slightly acidulated; d, rubber tubing, to which is attached the mouth-piece; e,f, connecting glass tubes; 
g, A, glass tubes for admittance of atmospheric air. 
which is attached the inhalation tube. When the air is drawn 
through the third flask, it draws fumes from the first and second 
flasks containing muriatic acid and ammonia, which, meeting in the 
third flask, give rise to the fumes of nascent muriate of ammonia. 
This apparatus is oftentimes of no little use in the later stages 
of a winter cold or a bronchial attack, in stimulating the mem- 
brane to freer transpiration, and thereby promoting a resolution of 
the inflammatory process. 
Too much value should not attach to the use of inhalations, in 
the various forms of acute inflammation which involve the upper 
air passages. They undoubtedly serve to relieve pain, and per- 
haps to mitigate the severity of the attack. Certainly, they add 
much to the comfort in relieving the irritability of the parts, and 
lessening the severity and frequency of the cough. METHODS OF TREATMENT. 
45 
On the whole, however, inhalations are to be regarded largely 
as palliative measures. The elaborate apparatus for inhaling pur- 
poses may serve to produce a certain moral effect upon the patient, 
but I doubt if the action of the drug is not quite as efficacious in 
the simpler devices suggested above, as in the more elaborate in- 
haler. The steam atomizer, while a somewhat entertaining toy, 
Fig. 51.—Large Globe Inhaler for Inhaling Fluids Atomized by meansof Compressed Air. 
I have long ago discarded, on the ground that it not only accom- 
plishes little good, but is capable oftentimes of doing mischief. 
Especially is this true in all forms of chronic disease of the air pas- 
sages, in that the hot steam, I think, serves to so far relax the parts 
as to largely counteract all good that may be accomplished by 
the medicament used. Indeed, none of the above methods of in- 
halation are to be used in chronic affections, unless, perhaps, the 46 
DISEASES OF THE NASAL PASSAGES. 
muriate of ammonia, which oftentimes serves to loosen the thick 
inspissated mucus of a chronic bronchitis. 
Cold inhalations, by means of compressed air in the atomizer, 
have been, in the past few years, largely resorted to in the treatment 
of chronic affections of the upper air passages. The method by 
which they are administered is to direct the spray into one end of 
a large globe, while the patient, sitting in front of the opposite end, 
draws the atomized fluids into the air passages. The principle of 
its action is that the large particles of atomized fluids are arrested 
in the globe and fall to the sides, while the finer particles of the 
spray are carried to the air passages by the inspiratory act. The 
drugs used in this way embrace nearly the whole list of astringents, 
alteratives, etc., which are supposed to possess a certain amount of 
controlling influence on catarrhal processes. This is undoubtedly 
a valuable method of applying astringent remedies directly to the 
upper air tract, and in those cases where the inflammatory process 
has invaded the larger bronchial tubes its use is attended with better 
results than any other device which we possess. Certainly, it is far 
preferable to hot inhalations, either by means of the steam atomi- 
zer or the ordinary inhalator. In Fig. 51 is shown one of the more 
elaborate forms of the globe inhaler. CHAPTER III. 
MUCOUS MEMBRANES. 
A MUCOUS membrane practially resembles very closely the 
external integument, but so modified as to adapt it for the special 
purpose which it is designed to serve in the economy, viz., to 
afford a proper lining for the various passages and cavities of the 
body which communicate with the external world ; for, as we know, 
all these cavities, such as the genito-urinary passages, the alimen- 
tary canal, and the respiratory tract, are lined with a membrane of 
this kind. In order to adapt it for the special purpose which it is 
designed to subserve as a lining membrane for these cavities, it be- 
comes essential that it should be soft, moist and pliable, and more- 
over that it should be endowed with an apparatus for maintaining 
this soft, moist, and pliable condition; for, as we know, in many of 
the cavities of the body, especially the air tract, the conditions are 
such that this soft, moist, and pliable condition would be destroyed, 
were it not that the membrane contains within itself some appara- 
tus for supplying the conditions necessary to counteract this ten- 
dency. Hence, for this purpose, we find the mucous membrane 
covered with epithelial cells of various characters and arranged in 
various ways, according to the location and special function which 
it subserves; the object of the epithelial cells being merely the se- 
cretion of mucus. In these tissues, we may regard each individual 
cell as a typical gland, displayed over the surface of the mucous 
membrane, whose object is to keep the membrane softened and 
moistened. In fact, nature endows the membrane, in this manner, 
with its own lubricating apparatus. It is found, however, that 
epithelial cells simply displayed in layers on an unbroken surface are 
unequal to the demand. In other words, distributed in this manner, 
they are not equal to supplying a sufficient quantity of mucus 
for lubricating the passages. To remedy this deficiency, nature 
resorts to a very simple device for extending the secreting surface. 
This consists in folding the membrane upon itself, as it were, or in 
other words, bending it down into the tissues and back again, to 
form a small flask-like cavity which is called a follicular gland. In 
other cases, instead of forming a straight fold, the pouch-like cavity 
of the simple follicle is folded on itself a number of times, forming 48 
DISEASES OF THE NASAL PASSAGES. 
a group of small flask-like pouches, as it were, which uniting, open 
upon the surface by a single orifice, thus constituting what is known 
as a racemose gland. The arrangement of glands and follicles in 
the mucous membrane, therefore, I take it, are for the purpose of 
enlarging the surface over which the epithelial cells may be distrib- 
uted, and, therefore, increasing the secreting power of the mem- 
brane, in order that its surface shall be constantly supplied with an 
abundant quantity of mucus, the normal lubricant of the mem- 
brane. This, then, briefly and simply stated, is the design and 
function of a mucous membrane, a proper understanding of which 
is of the greatest importance to the proper appreciation of diseased 
conditions of the upper air tract. A mucous membrane, wherever 
Fig. 52.—Section of Mucous Membrane, drawn Diagramatically. Submucous layer of connective tissue; 
d and <?, mucous membrane proper, containing blood vessels, nerves, closed follicles, connective and elastic 
tissues fibres, and marked by villi; c, epithelial layer; b, simple follicle; a, racemose gland. 
met with, is much the same thing, its function varying simply with 
the conditions and environment in which it is placed. Its function 
in the economy is largely complete when it has provided the cavi- 
ties of the body with a proper lining. Any other functions which 
it performs are mainly adventitious. 
Anatomy. 
From an anatomical point of view, we describe a mucous mem- 
brane as composed of three layers. 
First, a superficial layer, composed of epithelial cells. 
Second, the mucosa proper, a layer composed of white fibrous 
and yellow connective elastic tissue, embracing within their meshes 
blood-vessels, smooth muscular fibres, different varieties of small 
glands, and presenting minute processes or villi. 
Third, an external layer of loose connective tissue; the sub- 
mucous cellular tissue (see Fig. 52). MUCOUS MEMBRANES. 
49 
First. The epitJielial layer.—An epithelial cell, the typical or 
elemental gland, is simply a soft rounded cell, containing a nucleus 
and cell contents, pellucid or granular, and all contained in a cell 
wall, whose varying shape gives to it its name; such as: i. Pave- 
ment or tesselated epithelium, so called from their being pressed 
down and flattened from above, and crowded together in such a 
manner as to give an angular outline to each cell. 2. Columnar 
epithelium: elongated cells with rounded or square ends. 3. 
Columnar ciliated epithelium: the same shaped cell as the col- 
umnar, but endowed with fine hair-like processes on the free end, 
which possess the power of vibratory motion. 4. Squamous 
epithelium: worn out or dried cells, which are thrown off from 
the surface. 
These cells may be arranged in a single layer, or in several 
layers, one above the other; this latter arrangement is generally 
found in mucous membranes, in two varieties. 
a. The laminated pavement. Commencing with the elongated 
or columnar cells beneath, and becoming rounded above, until they 
reach the surface, where they become of the pavement variety. 
This arrangement is found in the lower portion of the pharynx, 
and in the oesophagus. 
b. The laminated ciliary. Commencing with rounded cells be- 
low, which, becoming elongated as they approach the surface, show 
on the upper layer the columnar ciliated cells. This variety is 
found in the lungs and air passages, except the smaller bronchi. 
Second. The mucous membrane proper.—Beneath the epithelial 
cells is found the mucous membrane proper; composed, as stated, 
of connective tissue, elastic tissue, muscular fibres, glands, blood- 
vessels, and nerves, and marked by minute processes or villi. 
The connective tissue which is found in this layer is composed 
of fine fibrils united into bundles by a small quantity of a clear 
connecting substance, and forms a close network or an almost 
homogeneous membrane. In this connective tissue we find certain 
cells, resembling the white corpuscles of the blood, the so-called 
leucocytes. This is the connective-tissue corpuscle, or, as it is 
sometimes called, the migrating corpuscle, and again, the amoeboid 
cell, from its observed power of motion. This cell performs an im- 
portant part in inflammations, not only of mucous membranes, but 
of other tissues, as will be noticed further on. The elastic tissue, 
one of the elementary structures of the body, is displayed more or 
less freely throughout this layer, and is composed of simple thread- 
like fibrils, crossing and interlacing in every direction. It is of a 
yellow, color, and possesses a high degree of elasticity. 50 
DISEASES OF THE NASAL PASSAGES. 
The muscular fibres are of the unstriated variety, and are very 
sparsely distributed through the layer. 
The glands are of two varieties, the simple follicular gland, and 
the compound follicular or racemose gland. The simple follicle is 
merely an infolding of the membrane into a straight tube, or flask- 
like cavity. The racemose gland is composed of a cluster of flask- 
like follicles, opening into a single duct, whose orifice is upon the 
surface of the membrane. 
The vessels are very numerous, and form close meshes in the 
membrane proper, sending a loop into the smaller villi, and into the 
larger, a close network. 
Third. The subimicous cellular tissue.—This is composed of a 
more or less loosely connected network of connective tissue, by 
which the mucous membrane is attached to the parts beneath, and, 
of course, allows of a very free play between the membrane and 
these parts. This fact becomes of extreme importance in connec- 
tion with acute inflammatory affections of the membrane, as it 
admits of the effusion of serum into this layer, where its attachment 
is very loose, as in the ary-epiglottic folds of the larynx, the posterior 
surface of the epiglottis, and the ventricular bands. 
Physiology. 
The function of a mucous membrane is to afford a soft, moist, 
and pliable lining to those cavities and passages of the body which 
communicate with the external world. It is lubricated by a clear 
fluid mucus, which is poured out upon it by the follicular and race- 
mose glands, whose ducts open upon its surface, and also by the 
epithelial cells which compose its superficial layer, each epithelial 
cell being in its small way an independent and secreting gland. 
Owing to the constant mechanical disturbance to which the 
membrane is subjected in mastication, speaking, etc., the cells of its 
superficial layer are being constantly detached and thrown off. In 
order to compensate for this loss, new cells are being continuously 
generated from below. The method by which this is accomplished 
is exceedingly simple, and may be explained by a very brief refer- 
ence to cell pathology. Virchow first advocated the doctrine, some 
twenty years ago, which now meets with general acceptance, that 
every cell grows from a parent cell; and in no department of histo- 
logical study is the observation more clearly confirmed than in that 
of mucous membranes. The method of cell-development is prob- 
ably by one of three processess: 
i. Division.—A constriction develops across the centre of a cell 
which, becoming narrower and of an hour-glass shape, finally sepa- 
rates, and in place of one cell two cells exist. MUCOUS MEMBRANES. 
51 
2. Gemmation.—In this process, there appears at some point in 
the cell-wall a small projection, which protrudes more and more, 
while its attachment to the parent cell becomes narrower, and 
finally it drops off, a newly developed cell. 
3. Endogenous growth.—A new cell is developed inside the 
parent cell, as the foetus in the mother’s womb; and finally, when 
it has attained maturity, it bursts its wall and escapes. 
It is by one of these processes that new cells are being con- 
stantly generated in the deeper layer of the epithelial coat of the 
membrane, to make good the waste which is constantly going on at 
its surface. 
Another physiological characteristic of mucous membranes is 
their permeability, by which fluids may penetrate them from with- 
out, and become absorbed by the blood-vessels, or perceived by the 
nerves. The activity of this function depends mainly on the thick- 
ness of the epithelial coat, thus where this is very thin, as over the 
papillae of the lips and the tip of the tongue, we find the sensitive- 
ness very acute. An exception to this rule is found in the fact that 
the virus of the snake does not permeate mucous membranes, and 
is in no way absorbed by them, it being necessary that it should 
meet with an abraded or cut surface, in order to reach the blood- 
vessels, and be taken up by them. The same is true of the syphilitic 
virus, which is only inoculable through an abrasion of the mem- 
brane. 
Inflammation of Mucous Membranes. 
Inflammation is that series of changes which takes place in any 
tissue as the result of an injury, provided the injury is not of such 
a character as to completely destroy its vitality. This injury may 
be a direct irritation of the tissue by a mechanical or chemical 
agent, or by substances carried to it by the blood, or it may be an 
indirect irritation, as is the case in inflammation of internal organs, 
as the result of exposure to cold. 
Through the researches and experiments of Cohnheim, Strieker, 
Burdon-Sanderson, and others, the nature of these changes is well 
known. The process comprises: 
1. Changes in the blood-vessels and circulation. 
2. Exudation of liquor sanguinis, and migration of white blood- 
corpuscles. 
3. Alteration in the nutrition of the inflamed tissues. 
1. The first effect of an irritation of the tissues is to cause dila- 
tation of the arteries, followed soon by dilatation of the veins. The 
dilatation is also attended by an increase in the length of the ves- 
sels, and they become more or less tortuous. 52 
DISEASES OF THE NASAL PASSAGES. 
The enlargement of the vessels is attended, at the outset of the 
process with an acceleration in the flow of blood, but this is soon 
followed by a retardation of the flow, the vessels remaining dilated. 
As the circulation becomes slower, the white corpuscles, or leuco- 
cytes, accumulate in the veins, and their natural tendency to adhere 
to the sides of the vessels is increased to such an extent that they 
nearly fill the calibre of the tube, and accumulate against its walls, 
remaining almost stationary, while the blood-current passes by 
them, though with a greatly diminished velocity. Those immedi- 
ately in contact with the wall of the vessel are now seen to press 
against it, and finally to pass through into the tissue beyond, sim- 
ply transuding the wall, the opening closing up behind them. 
2. Associated with the passage of the blood-corpuscles is the 
exudation of liquor sanguinis. This exudation, which constitutes 
the well-known inflammatory effusion, differs from the effusion 
which escapes from the blood-vessels in simple mechanical obstruc- 
tion, as in dropsy from heart disease or cirrhosis, in containing an 
amount of fibrin and albumen, varying with the extent and severity 
of the inflammatory process. 
3. The remaining constituent of inflammation is the alteration in 
the nutrition of the inflamed tissue. The cells which constitute a 
normal part of the tissue take on an increased activity; the normal 
processes of physiological growth become greatly exaggerated, and 
new cells are developed by one of the methods before alluded to. 
This, in brief, completes the picture of inflammation in general. 
Confining ourselves now to mucous membranes, we find certain 
peculiarities manifesting themselves in the processes. 
Inflammation of mucous membranes occurs in three different 
varieties: catarrhal, croupous, and diphtheritic. 
Catarrhal inflammation.—This is by‘far the form most fre- 
quently met with. In its milder degrees it is characterized merely 
by an increased secretion of mucus. An increased flow of blood 
to the parts, occurring at the outset of the process, seems to stimu- 
late the cell-elements to an abnormal activity, in which new cells 
are generated; the glands pour out their normal secretion in excess- 
ive quantities; an abundant liquor sanguinis transudes the vessels; 
and the result is an increased secretion of mucus, which is highly 
charged with young cells, many of them having their source within 
the epithelial cells, while others are emigrant blood-corpuscles. 
The membrane at the same time becomes swollen and reddened, as 
the result of the increased vascularity. 
If the irritation be more severe, the vascular phenomena are 
more marked; the cell-generation is more rapid; and as the result 
of this rapid generation they seem to fail of attaining maturity, and MUCOUS MEMBRANES. 
53 
are poured out in an unripe state; hence they are smaller, and not 
so well developed. Many of these imperfectly developed cells can- 
not be distinguished from pus-corpuscles; while others are larger, 
and resemble the mucus-corpuscles or leucocytes. Between the 
mucus-corpuscle and the pus-corpuscle we have no method of dis- 
tinguishing, except that the former is larger, and of a somewhat 
more regular outline. The epithelium also loosens, and falls off more 
rapidly from the surface of the membrane, under the stimulus of 
the inflammatory process; and as it progresses we have the mucous 
discharge gradually becoming a purulent one, from being so highly 
charged with these unripe cell-elements, many of which are vir- 
tually pus-cells. 
The process continuing, its activity, which so far has been largely 
confined to the superficial layer of the membrane, extends to the 
sub-epithelial layer, or the mucous membrane proper, which now 
becomes more involved, and the cell-elements here take on renewed 
activity, and becoming rapidly generated, they distend and infiltrate 
the parts. The membrane becomes thickened and more swollen; 
and there now may occur several secondary manifestations of the 
inflammatory process. As the result of the loss of surface epithe- 
lium, the membrane may become denuded of its epithelial coat, and 
there may occur an abrasion, or so-called catarrhal ulcer. As the 
result of the distention and infiltration of the membrane proper, 
the glands may become so choked that their contents are impris- 
oned, and as the result, there is formed a minute abscess, which 
breaking and discharging, there is left a small ulcer. The acute 
process may subside, or it may lapse into the chronic state. In this, 
the increased vascularity subsides to an extent, though the vessels 
remain permanently somewhat dilated. The cell-production, how- 
ever, goes on both in the epithelial layer and in the mucous mem- 
brane proper; and the increased secretion persists; but all in a 
somewhat diminished degree. 
Chronic catarrh differs from acute catarrh in that in the former 
the sub-epithelial layer of the membrane is much more involved. 
It is thickened and indurated by its infiltration with the young cells 
before spoken of, the mucus-corpuscles, and migrating blood-cor- 
puscles; and also by a renewed activity in another elemental tissue 
of the membrane, viz,, the connective tissue, which plays an import- 
ant part in chronic inflammation. This tissue is developed now by 
a slow process of proliferation, and by its peculiar characteristics 
gives rise to those features of chronic catarrh which render it ex- 
tremely obstinate to manage. 
Having been once developed, it is probable that connective tis- 
sue is never absorbed or excreted as the other cell-elements in 54 
DISEASES OF THE NASAL PASSAGES. 
catarrh; but becoming organized, it remains a permanent element 
in the membrane to deform, disorganize, and interfere with its 
proper function. As the result, then, of the new deposit in the 
membrane, we may have its normal thickness so much increased as 
not only to interfere with its proper function, but also to impair by 
mechanical means other functions; as in the hypertrophied mem- 
brane of the nose, causing nasal stenosis, and thereby interfering 
with normal nasal, breathing. Again, this tissue may be so depos- 
ited as to press upon the glands and follicles of the membrane in 
such a manner as to cause their atrophy, thus robbing the mem- 
brane of its proper supply of lubricating fluid, its mucus, and giving 
rise to the so-called dry catarrh. It may be deposited about the 
individual follicles or glands in such a manner as to press upon the 
outlet alone, thus closing them up, giving rise to small cysts; or 
their contents becoming imprisoned, undergoing fatty degeneration, 
and acting as a renewed source of irritation, there may occur a 
glandular hypertrophy of an individual follicle or gland, giving rise 
to the so-called follicular inflammation. 
-In addition to this, we notice a tendency in chronic processes 
to differentiation, by which in the one case the morbid process 
expends itself upon the epithelial and lymphoid structures, while 
in the other case it acts upon the connective-tissue elements of 
the membrane. Thus, in the former we may have a chronic catar- 
rhal inflammation in which a rapid degeneration of epithelial cells 
occurs in such a manner as to increase to a very large degree not 
only their growth, but their loss from the surface, giving rise to a 
form of secretion from the membrane in which a large amount of 
mucus is thrown off, heavily surcharged with unripe epithelial cells, 
causing muco-purulent discharge. Thus, in the purulent rhinitis 
of children, to be described later, the essential lesion consists in 
an intense activity in the epithelial structures. Again, we may 
have the same activity in the lymphoid cells giving rise to a forma- 
tive inflammation, as it were, in which the lymphoid cells are rapidly 
generated and remain a portion of the membrane, instead of being 
thrown off in the form of a purulent discharge. A lymphoid hyper- 
trophy is the result of this form of catarrhal inflammation, such 
as is met with in adenoid disease of the vault of the pharynx, or 
hypertrophy of the faucial tonsil, or enlargement of the follicles of 
the lower pharynx. Activity of morbid processes confined largely 
to epithelial and lymphoid structures, belongs essentially to the 
younger period of life, the diseases above referred to, it will be 
noticed, being all of them diseases of youth and childhood. The 
morbid activity in the connective-tissue structures, on the other 
hand, belongs essentially to later life, hence a chronic inflamma- M UCO US MEMBRANES. 
55 
tion of the mucous membrane, resulting in a connective-tissue hy- 
pertrophy, such as in hypertrophic rhinitis, is essentially a disease 
of adult life. This is due probably to the fact that the develop- 
ment and ripening, as it were, of a connective-tissue cell is a process 
of years, and that a true connective-tissue hypertrophy can only 
exist after a catarrhal inflammation has been in operation for a 
long period of time. 
Croupous Inflammation.—This form of inflammation is of a 
higher grade, and of a more intense form than the catarrhal; for 
while it commences in the same manner, with distention of the 
blood-vessels, escape of liquor sanguinis and blood-corpuscles, and 
proliferation of cells, it differs from it in the fact that the exuded 
liquor sanguinis contains a large amount of fibrin and albumen, 
which coagulates upon the surface of the membrane, and forms a 
false membrane. This false membrane is of a more or less dense, 
firm character, and is composed of fibrin, inclosing a large num- 
ber of epithelial cells in its meshes. At times it may be soft and 
almost granular in character, so much so that it may be easily re- 
moved with a soft brush, coming away in small broken particles. 
At other times it may be of so dense a character that after re- 
moval it can be torn only with considerable force. As a rule it 
can be easily removed, leaving the membrane beneath it in the 
main intact, merely deprived of some of its superficial epithelial cells. 
After removal, the same process may be renewed, and a new mem- 
brane form, or the parts may be restored to their normal condition. 
The favorite site for this form of inflammation is in the upper 
air-passages, the pharynx, tonsils, larynx, and trachea, though it 
may occur in the bronchi, intestinal canal, and other parts. 
Why this form of inflammation occurs, it is impossible to state; 
but it is not improbable that it is due to some previously existing 
blood condition, which dominates the inflammatory process, and so 
far enriches the exuded liquor sanguinis with the fibrinous material, 
that it coagulates on its exposure to the air, and so a false mem- 
brane is formed, in place of the fluid catarrhal discharge. Further 
evidence that this form of inflammation is due to some previous 
condition in the blood, is afforded by the fact that its onset and 
course are usually marked by a febrile movement, far more aggra- 
vated in character than we would expect to find as merely symp- 
tomatic of so limited an extent of local inflammation. The tem- 
perature in simple membranous sore throat, characterized by a 
croupous deposit on the tonsil, often ranges as high as I03°-I04°. 
Croupous inflammation may manifest itself in a fibrinous exu- 
dation on the surface of a mucous membrane, as in croupous laryn- 
gitis, or true croup, membranous sore throat, croupous rhinitis, 56 
DISEASES OE THE JVASAL TASS AGES. 
etc.; or the exudation may take place in the follicles of the mem- 
brane, giving rise to an acute follicular inflammation, such as occurs 
in the affection generally known as acute follicular tonsillitis, which 
is a croupous inflammation of the tonsil, in which the exudation 
takes place in the crypts of the organ, rather than upon its surface. 
Diphtheritic Inflammation.—This variety of inflammation, again, 
is characterized by the formation of a false membrane, and also 
commences as a catarrhal inflammation, with its increased blood 
flow, cell proliferation, and exudation of liquor sanguinis, the exu- 
dation, as in the croupous form, containing largely of fibrin and 
albumen; but there is this difference, that while in the croupous 
form the exudation is poured out upon the surface of the mucous 
membrane, in the diphtheritic form it permeates and infiltrates its 
whole thickness, down to the submucous tissues. 
This exudation permeates the membrane so densely that in 
coagulating it completely destroys its vitality, and there results 
a dead membrane, involving the whole thickness of the mucous 
membrane. It is removed with considerable difficulty; and in its 
removal, carrying with it the whole thickness of the membrane, 
leaves the parts beneath entirely denuded. The false membrane 
declares itself to the eye as a dead membrane, a genuinely necrosed 
or sloughing tissue, of a dark grayish color, resembling boiled mac- 
caroni; in contradistinction from a croupous membrane, which is of 
a bluish, pearl-gray color, presenting no appearance of necrosis, 
but rather of an unmistakably living tissue. 
It should be understood, in regard to these terms, croupous and 
diphtheritic inflammation, that they only refer to forms of inflam- 
mation to which mucous membranes are subject, and not to the 
specific diseases which are spoken of under the names croup and 
diphtheria; as, for instance, membranous croup is generally under- 
stood to be a croupous inflammation of the mucous lining of the 
larynx, although a better classification would suggest the more 
expressive and correct name of croupous laryngitis; and also of 
diphtheria, it is a blood disease, characterized by a local manifesta- 
tion in the throat, consisting of an acute inflammation of its mucous 
membrane, which assumes the diphtheritic form; so that when we 
speak of croupous and diphtheritic inflammation, we simply define 
the form which the inflammatory process assumes. 
In regard to catarrhal inflammation, or as it is generally called, 
catarrh, the same may be said; properly speaking, it means that 
form of inflammation of a mucous membrane which is characterized 
by an excessive discharge of mucus or muco-pus; but a better 
usage in the direction of an exact classification, would suggest that 
the local designation should be prefixed, as nasal, laryngeal, bron- 
chial catarrh, etc. CHAPTER IV. 
TAKING COLD. 
Although this is one of the commonest and most familiar of 
phenomena, both as a matter of clinical observation and of per- 
sonal experience, if we ask ourselves what especial influences pro- 
duce the morbid changes which we call taking cold, or what is the 
true relation between the recognized causes and observed effect, 
we find it somewhat difficult to give a correct answer to the ques- 
tion. 
Among the numerous theories advanced, may be mentioned that 
of Rosenthal, who asserts that the immediate effect of cold, acting 
on the surface of the body, is to excite contraction in the peripheral 
vessels, by which the blood is driven from the surface, in upon the 
internal organs, and acts there as an irritant, exciting inflammation. 
This view of the matter is somewhat mechanical, and scarcely ex- 
plains the action of cold in many instances. Not infrequently, as 
the result of an exposure, it is not really internal organs that be- 
come the seat of the consequent inflammation, as an attack of acute 
eczema, or acute conjunctivitis, may follow; or, as in the case of the 
commonest of all inflammatory affections resulting from exposure, 
an attack of acute coryza, a membrane so near the surface is involved 
that, under the action of Rosenthal’s theory, the blood should, to an 
extent at least, be driven from the membrane, rather than that it 
should be flushed upon it from without. Furthermore, as we know, 
mere mechanical congestion does not lead to true inflammatory 
action, as shown by the old familiar and often repeated experiment 
of ligating the efferent veins of the frog’s foot, and observing the 
result in the web under the microscope. It must be borne in mind 
that a cold does not result from a low temperature; in other words, 
absolute cold and taking cold are two entirely distinct expressions. 
A far more plausible view of the matter is that of Seitz. His 
theory is that disorders resulting from catching cold are due to the 
removal of heat to an unusual extent from the external or internal 
surface of the body; that this causes some functional disturbance, 
which in its turn gives rise to certain morbid processes in some 
portion of the body, far removed from the part immediately affected 58 
DISEASES OF THE JVASAL PASSAGES. 
by the cold. That the morbid changes are not due to the imme- 
diate or direct effect of this exposure, is evident from the fact, that 
as a rule, a certain length of time elapses before these changes set in. 
The theory of Seitz, it seems to me, is not complete, but leaves 
the matter still somewhat in the dark. The true action of cold 
upon the body, in producing morbid conditions, is probably on those 
nutritive changes which are constantly going on, and by which the 
animal heat is developed. This heat-production is going on in all 
the tissues of the body. In order that this function shall not be 
impaired, it is necessary that the normal temperature shall be 
maintained. This we know is 98!°. Any marked deviation from 
this normal standard, as the result of extraneous influences, results 
in morbid changes. If heat-production is arrested in a portion of 
the body, under the action of intense cold, molecular death of the 
part ensues, as is the case when gangrene of a limb results from 
freezing. If the action of the cold is insufficient to arrest the 
nutritive processes of the part, it may cause only inflammatory 
action. In these cases, we have only the direct action of a low 
temperature on the organism. In the ordinary phenomena of 
“ taking cold,” we have still the results of a low temperature acting 
on the heat-producing processes, but in an indirect manner. The 
direct action of the cold is, as a rule, upon the surface of the body, 
but the resultant morbid condition is upon some organ remote 
from the exposed part. In both cases, however, the cause and the ef- 
fect are the same, and the connection between the exposure, and the 
resultant inflammatory condition, is the disturbance of those nutri- 
tive changes in the tissues which result in the production of animal 
heat. I think this action may be fairly well illustrated by the famil- 
iar example of a chandelier of, say, six burners. If these are all 
lighted, each jet gives forth a steady and equable flame. If now 
four or five jets are turned off, the remaining jet burns up with a 
flaring and increased intensity. In the same manner, I think we may 
explain the phenomenon of an ordinary cold. The nutritive pro- 
cesses going on in the whole economy are governed by the central 
nervous system, and furthermore, a certain amount of nervous force 
is expended in the regulation of these nutritive processes. If, as the 
result of exposure to cold, these nutritive changes are arrested in 
a certain portion of the body, the same nervous force being sent 
out from the central system, it will be understood how this local 
arrest of the nutritive process in one portion would be attended 
with a certain amount of increased nutritive activity in another 
portion; the activity of the nerve centres going on as before. 
Now, increased nutritive activity constitutes inflammation, and this 
inflammation locates itself at the point of least resistance, viz., as 71AKING COLD. 
59 
a rule, at some point in the economy where a mild chronic in- 
flammatory process is going on, which is lighted up into an acute 
process as the result of a cold. It is not then from an expo- 
sure of the whole body, that a cold is contracted, but from an ex 
posure of a part of the body, as the result of which the phy- 
siological processes of heat production in that part alone are 
disturbed, giving rise to increased nutritive activity or inflamma- 
tion in some organ, far removed perhaps from the site of the pri- 
mary exposure. As a matter of clinical observation, we know that 
colds occur during the spring and fall months, seasons which are 
characterized by moderately low temperature, but with notable 
dampness of the atmosphere, together with considerable atmo- 
spheric motion, or high winds. Hence we recognize that there are 
three factors generally necessary for the production of “a cold,” 
low temperature, air in motion, and moisture. It is also necessary, 
as a rule, that one or more of these factors should act for a some- 
what prolonged duration of time. As we know, the momentary 
action of an intense cold, or draft, or moist atmosphere, does not 
usually result in any morbid changes, but it is only after a some- 
what prolonged exposure of the body that the familiar phenomena 
of a cold ensue. * In our ordinary life, there are few of us but that 
subject to slight temporary exposures with impunity; as for 
instance, upon rising in the morning in a cold room, changing one’s 
clothes, etc. On the other hand, the sitting in a draft for a pro- 
longed period, with even only a small portion of the body exposed, 
may lead to serious or grave morbid changes. Among the most 
familiar causes of taking cold may be enumerated, sitting in a 
draft, wearing insufficient clothing, wearing thin-soled shoes, insuf- 
ficiently protected feet, going from a warm room to a cold room, 
slight exposure while perspiring, etc. Wearing thin-soled shoes, 
or insufficiently protected feet, is a very prolific source of trouble; 
as the loss of heat in this manner is far greater than is usually rec- 
ognized. Especially is this the case if the soles of the shoes are 
damp, as in this case, of course, the radiation takes place much more 
rapidly. 
Again, when the body is perspiring, the loss of heat is going on 
with considerable activity; hence we find that in this condition, 
even a slight exposure is liable to result in far more serious dis- 
turbance than would occur from the same exposure were the body 
not in an overheated condition. There should, however, be borne 
in mind this difference, if the perspiration is the result of violent 
exercise, all the nutritive processes are stimulated to an abnormal 
activity, animal heat is being generated rapidly, and the perspira- 
tion necessarily sets in as a conservative measure, to prevent too 60 
DISEASES OF THE NASAL PASSAGES. 
great accumulation of heat in the system, but still as the direct 
consequence of the violent exercise. If now, in this condition, the 
body is exposed to the influence of cold, and the perspiration sud- 
denly checked, very serious consequences may ensue. If, however, 
on the other hand, a copious perspiration is brought on by artifi- 
cial means, while the body is in a state of quiescence, as in the hot 
room of the Turkish bath, the heat source is from without, the 
heat-producing forces of the system are not disturbed, and the cold 
plunge, while of course it suddenly checks the perspiration, does 
not, as a rule, give rise to any untoward consequence. Moreover, 
the exposure by the cold plunge is only temporary and of short 
duration, and by the subsequent manipulation, any serious loss of 
heat which mry have resulted is speedily and completely restored. 
A swimmer will remain in water at a temperature twenty or 
thirty degrees below that of the body, and that, too, for a some- 
what prolonged period of time; but while in the water, he is in a 
state of constant and laborious activity, thereby setting in play 
those processes by which animal heat is generated. But even with 
this constant activity, if the bath becomes too prolonged, there 
comes a time when the body is unequal to the task of supplying 
sufficient animal heat to make up for the loss, and the bather suc- 
cumbs to the direct influence of this tremendous drain upon the 
system. But here the result is not an inflammatory attack, as usu- 
ally accompanies an exposure to cold, but on the contrary it pro- 
duces great prostration, violent cramps, weakened circulation, 
intense venous congestion, and in fact, evidence that the whole 
system is robbed of its normal heat, which tends to retard all healthy 
functional activity in the body; whereas the results of an exposure 
to cold are due to a localized arrest of heat production, and a dis- 
turbance of the balance, as it were, by which nutritive activity goes 
on in the system. As was said before, the loss of animal heat does 
not directly produce these morbid changes, but creates or gives 
rise to certain functional disturbances, with the nature of which we 
are not entirely acquainted, and these give rise, after a certain in- 
terval of time, to the morbid changes which we call taking cold. 
This interval may be short, lasting perhaps but a few hours, as is 
usually the case in slighter disorders, or it may be prolonged one 
or two days, or even more. In this case, as a rule, the resultant 
disorders are of a more serious character. There is generally at- 
tendant upon taking cold, fever of a more or less marked character. 
That this fever is not symptomatic, but an essential fever, is shown 
by the fact that it stands in no constant relation to the morbid 
changes which result, as in even slight disorders we may have the 
febrile motion more marked than the fever which accompanies the TAKING COLD. 
61 
more aggravated forms of inflammatory troubles which may arise 
from a cold. Moreover, the fever generally sets in immediately 
after exposure, and when the later morbid changes appear, no in- 
crease of fever, as a rule, is detected. As regards the local dis- 
orders, which result from an exposure to cold, we find them mani- 
festing themselves in any part of the body. We may have acute 
coryza, pharyngitis, gastric catarrh, muscular rheumatism, cystitis, 
or, in fact, an attack of inflammation involving any of the organs 
of the body, as the result of a cold. Owing to their exposed situa- 
tion, being the first to receive the current of inspired air, with its 
impurities, or whatever of irritating qualities it may possess, the 
upper air-passages are perhaps more subject to inflammation than 
any other portions of the body, and once having become the seat of 
morbid changes, there is always a liability to a recurrence of the 
attack, from a slighter exciting cause than that which gave rise to 
the first attack. 
Hence, it is probable that catching cold, in a very large major- 
ity of cases, develops in an attack of acute inflammation of some 
portion of the upper air-passages, as being the point of least resist- 
ance, and further, as these attacks recur with increased frequency 
and gravity, we find that the morbid process localizes itself farther 
down, and nearer to the vital centres, and finally this liability, so 
called, to take cold, which at first manifested itself in attacks of 
simple coryza, or sore throat, gives rise to a bronchitis, or some still 
graver affection which, fixing itself upon the lungs, may prove far 
less amenable to treatment than the simple attacks which preceded 
it, or even lead to the development of those still graver forms of 
pulmonary disease, in the management of which our present thera- 
peutic resources are so feeble. 
The question is often put to the physician, whether a catarrh 
will lead to the eventual development of lung disorders; and it 
seems to me that the answer should be that it may, and that it 
often does, in the manner above noticed. 
This may not occur by absolute extension of the inflammatory 
process, but there can be no question that an individual suffering 
from a chronic laryngeal catarrh is far more liable to an attack of 
tracheitis, and that one suffering from a tracheitis is far more sus- 
ceptible to a bronchitis than one in whom there exists no catarrhal 
inflammation, and so on, down to the deeper lung tissues. Other 
causes, of course, may operate in inducing such a sequence of 
events, such as an impairment of the general health from any cause, 
but a prominent factor still remains in the existing catarrhal in- 
flammation above. 
As regards this so-called liability to take cold, it should be un- 62 
DISEASES OF THE NASAL PASSAGES. 
derstood that this, in a large majority of cases, and probably in 
every case, is due to an existing chronic catarrhal inflammation, of 
perhaps so mild a type as to give rise to but very trivial symptoms, 
or even pass unnoticed; but still, an existing catarrh, the result 
probably of a neglected cold, and the renewed attacks to which 
the individual becomes so liable, consists in a lighting up of the old 
trouble. As each fresh attack subsides, the resolution which the 
inflammatory process undergoes is less complete, the chronic trou- 
ble makes itself known by more decided symptoms, fresh colds 
occur with greater frequency, and there is finally established a 
chronic catarrh, be it laryngeal, nasal, or of any other part, with its 
many annoyances, its intractability, and unquestionably the possi- 
bility of its leading to graver trouble lower down in the air-passages. 
Our concern, of course, is mainly with affections of mucous mem- 
branes; but in those cases in which we find that a cold gives rise 
to an attack of rheumatism, gastric catarrh, cystitis, or any dis- 
order other than a catarrh of the lining membrane of the respira- 
tory tract, probably the same rule holds true as before; from some 
inherited tendency, or acquired weakness, the parts involved in 
these affections have become the points of least resistance, and 
hence invite those morbid changes which result from exposure 
to cold. 
PREVENTION OF a Cold.—The natural deduction, of course, from 
what has been said before is, that those conditions which give rise to 
a cold should be avoided; especially should this be enjoined upon 
those possessing hereditary tendencies or weaknesses, and those of 
whom we speak as liable to take cold. These directions, of course, 
are more important in the months of the year when we have, to the 
greatest extent, the prevalence of those conditions which, as we have 
seen, are concerned in the production of a cold : as low temperature, 
moisture, and air in motion; these we find in the spring and fall. 
Perhaps the most important direction that can be given in regard to 
preventing colds, is as to the proper regulation of the clothing. The 
body should be sufficiently clothed for warmth and comfort, no 
less and no more. If too little clothing is worn, there will neces- 
sarily result a loss of animal heat. If too much is worn, the body 
becomes overheated, and perspiration necessarily ensues to reduce 
the temperature and restore the proper equilibrium, and conse- 
quently, as we have before seen, a condition arises in which the 
body is extremely sensitive, and in which it is especially liable to 
succumb to the influence of cold or moisture. This rule in regard 
to clothing the body applies to all parts of it. The mistake should 
always be avoided of coddling any portion, or of leaving any por- 
tion insufficiently protected. A very frequent and common error TAKING COLD. 
63 
is fallen into by many, of crowding on too much clothing upon 
those portions of the body which they suppose to be subject to 
some special weakness; as for instance, many people, supposing 
themselves to have weak lungs or throats, fall into the error of 
piling wrap upon wrap, muffler upon muffler, around their necks 
and about their chests, thereby encouraging the very condition 
which they fear, and incurring the risk they desire to avoid; for the 
excessive muffling of the parts necessarily leads to perspiration, 
and consequently the danger of its being suddenly checked upon 
the removal of the wraps. I know of no more prevalent mistake, 
nor one which is a more prolific source of mischief, than the habit 
which prevails to so great an extent among us, of muffling up the 
neck. Especially is this the case when a cold is contracted which 
develops in a sore throat. As a rule, when a sore throat comes 
on, the very first remedy which is adopted is to tie a piece of red 
flannel about the neck. The only advantage of this procedure lies 
in a certain amount of counter-irritation, due to the harsh fibre of 
the flannel rubbing against the skin. Aside from this, there is no 
possible good to be accomplished. It is put on for a protection; 
it simply renders the neck and throat more sensitive, and entails a 
greater liability to take another cold. Of course, what is said about 
the neck may be said about any other portion of the body. There 
could be no greater error than to suppose that mufflers about the 
neck protect the throat or that the chest is protected in any way 
by extra thickness of covering about it. Indeed, the contrary is 
quite true. Perhaps the very worst place in which to wear the 
so-called chest protectors, sold in the drug stores, is on the chest. 
The chest is infinitely better protected, in one liable to bronchial 
attacks, by an extra sole worn on the boot, than by a felt pad worn 
across the chest. The whole theory of clothing should be based 
on the idea that exposure to cold results in an interference with 
nutrition in some part of the body. Therefore, to prevent taking 
cold, the heat-producing force of the body should be thoroughly 
and equably protected in all parts; in other words, the clothing 
should be uniformly distributed over the body, with simply enough 
of it for comfort, and absolutely no more. 
The selection of the proper fabric to be worn next the skin is 
too often dictated by a consideration of luxury, rather than of 
health. The most important function that goes on in the skin, is 
that by which the body is kept at an equable temperature, by 
means of perspiration. Theoretically, this is accomplished by 
means of an insensible perspiration, and practically too, except 
under extraordinary circumstances, when the perspiration becomes 
profuse. Now this function of perspiration, or heat radiation, takes 64 
DISEASES OF THE JVASAL PASSAGES. 
place best when the fabric next the skin is a thoroughly porous 
one. We have no fabric comparable to pure wool in this respect; 
the virtues of this fabric being, I take it, due to the fact that vvool- 
fibre is highly elastic, and also curls upon itself in such a way, as that 
when converted into thread, and woven into a garment, it still 
affords a highly elastic and porous textile fabric, which best ad- 
mits of the escape of heat. Silk probably would never be worn 
as underwear, were it not for the fact that it is the most expen- 
sive of fabrics. From a sanitary point of view, its use is very 
objectionable, in that cutaneous transpiration is interfered with. 
The same is true of cotton and linen, in that their fibre is per- 
fectly straight, and is also inelastic. A textile fabric, manufactured 
from material of this character, is denser and less porous than one 
made from the kinky wool fibre. Hence the latter furnishes us 
with a material for underwear which in the least degree interferes 
with the important function of the skin, above alluded to. As re- 
gards the heat-conducting properties of these different materials, 
this I regard as a matter of little moment, as compared with the 
far greater importance of wearing next to the skin a thoroughly 
porous and elastic fabric. 
It is the habit to change the thickness of the underwear twice 
and sometimes even three times during the year, through the vary- 
ing degrees of cold and heat. This plan is not wise in all cases, 
and is even a source of mischief. We practically live, during a 
large portion of our time, in much the same temperature, summer 
and winter, or rather, we endeavor to keep our houses during winter, 
at a temperature of about 70°. I doubt very much then the wis- 
dom of wearing very heavy underwear in rooms heated to this 
degree of heat, as the necessary consequence is a more or less pro- 
fuse perspiration. A better plan is, therefore, to wear the same 
thickness of underwear throughout the year, while the protection 
from the extreme cold of winter is supplied by a change in the 
outer garments. 
As before stated, excessive covering should be avoided under 
all circumstances. This perhaps is a greater error than insufficient 
protection, although the latter is undoubtedly a frequent source of 
trouble. This may be said, perhaps, in regard to the feet, quite as 
much as of any other part of the body, for coming in contact, as 
they do, with cold floors and pavements, especially when there is 
water or moisture on the ground, the loss of heat from the general 
system from that source is necessarily rapid, unless the foot is 
thoroughly well protected by a thick, dry sole to the boot. There 
are few but have experienced the direct effect of standing in slip- 
pers or thin-soled shoes upon a damp or cold pavement, and noted TAKING COLD. 
65 
the rapidity with which such exposure makes itself felt. In our 
climate, with its sudden and marked changes of temperature, the 
proper regulation of the clothing becomes a matter of considerable 
importance, and perhaps of no little difficulty. The hands and 
face are rarely covered, as a rule, or protected, and yet we never 
take cold from their exposure. The deduction is obvious; if cer- 
tain parts of the body may be exposed with impunity, the converse 
conclusion is suggested, that by keeping our bodies too warmly 
clad we have thereby engendered a necessity, which possibly might 
have been avoided, with benefit to the health and vigor of the sys- 
tem. The rule may be safely laid down, that, in clothing the body, 
the trunk and limbs should be made simply comfortable, but never 
wrapped to the extent of inducing perspiration by the amount of 
clothing. The foot should be covered with a boot or shoe, with a 
sole sufficiently thick to prevent the cold or dampness of the pave- 
ment being felt through it. The neck should never be muffled, or 
covered with thick wraps or furs, unless rendered necessary by 
the piercing winds or cold of midwinter, as a mere matter of pro- 
tection. The head is endowed by nature with its own protection; 
hats and caps are luxuries, born of modern civilization; had they 
never been worn, mankind would be better off, and the demand for 
hair restorers would never probably have existed. Hats and caps, 
however, being a necessity of modern life, should be light, well 
ventilated, and designed to retain as little heat as possible; they 
should not be too heavy, or press with too much weight upon the 
head, the crown should be perforated, to allow of as free circula- 
tion of air as possible between the top of the head and crown of 
the hat, and should be constructed of such material as will allow 
of the escape of heat. 
The hair, the natural covering of the head, should be so regu- 
lated as to avoid the exposure resulting from the removal of a 
considerable amount at one time by cutting; if it possesses a lux- 
urious growth, it should not be cut when the removal of so much 
protection of the head is liable to result in catching cold. 
In short, the body in all its parts should be made comfortable. 
It should not be so clothed as to cause perspiration, nor that chill- 
ing can occur. It is said that sealskin sacques have caused more 
deaths than small-pox in New York, in the last five years. I have 
no doubt that this is quite true, and the fact is due simply to the 
vanity or indolence by which a woman will go from the cold air 
into a warm room, with her sacque on, and remain there for hours, 
it may be, without removing it. In addition, it might be said that 
very much harm is done by the habit of wearing heavy clothing, 
and sitting in overheated rooms. Those who allow themselves to 66 
DISEASES OE THE NASAL PASSAGES. 
grow into the habit, by which they are only comfortable in a room 
at 8o°, are simply making hot-house plants of themselves, and are 
engendering a condition of the system which renders its resisting 
power very feeble. It is purely a habit, and one easily overcome, 
not only without risk, but with undoubted benefit to the individual, 
in the increased vigor of body which will result. 
In our variable climate, where the daily changes are oftentimes 
so great, it is a mistake to suppose that we can so regulate our 
clothing as to protect ourselves from the results of these great 
changes. We protect ourselves from absolute cold by wearing 
clothing, but not from taking cold. We protect ourselves from 
taking cold, by so regulating our habits of life as regards clothing, 
etc., that we expose ourselves to these changes with impunity. In 
other words, we inure ourselves to.the climate. Perhaps no better 
aid to this is afforded than in the use of the bath. I think the 
direct connection between the daily use of the bath, and the avoid- 
ance of taking cold, will be clearly understood if what has been 
stated is true, viz., that taking cold is a disturbance of the heat- 
producing forces, and furthermore, that the nice adjustment of the 
animal heat in the body, is regulated by the function of cutaneous 
transpiration, and hence depends on the healthy functional activity 
of the skin. Perhaps we have no better way of maintaining this 
function at the highest point of healthy activity, than in the daily 
use of the cold bath. For those whose physique is equal to it, the 
daily use of the cold plunge or shower bath is to be recommended, 
as the best protection possible against taking cold. If this is not 
well borne, it is indicated clearly by the feeling of lassitude, and 
chilly sensations, which will follow the use of the bath; the contrary 
being indicated by the sense of warmth and general invigoration 
which attends its use. If the plunge or shower is not tolerated, the 
cold sponge, either of the whole body or to the waist, is to be com- 
mended. The time at which the bath should be used is preferably 
in the morning, in that not only the night sleep is a better prepa- 
ration for it, but also the exhilaration and vigor which follow it, is 
an excellent preparation for the labor of the day. The Turkish 
bath, which has become so deservedly popular in our day, while 
undoubtedly a luxury, is to be commended with a certain amount 
of reserve as a preventive, or in the treatment of a cold. It is a 
popular saying, that after a violent perspiration the pores of the 
skin are so thoroughly opened that the cold gets in, as it were. Of 
course this is an error. Perspiration due to violent exercise ren- 
ders one liable to a cold if exposed to a draught. The excessive 
perspiration of the hot-room of a Turkish bath does not expose 
one to the same extent, but I think there is an exposure even in TAKING COLD. 
67 
the Turkish bath, especially in the shampooing room, which follows 
immediately the hot-room, where one is apt to receive a slight 
chill. As a luxury, then, the use of a Turkish bath is certainly 
wrarmly to be recommended. By those suffering from weakness of 
the upper air-passages, or who are especially liable to take cold, 
its use is to be resorted to with a certain amount of watchfulness. 
These suggestions are, of course, such as every physician is 
familiar with; they are given here, however, more in the way of 
suggestions than for instruction, for we are far too prone to over- 
look and forget them, in our dealings with our patients, and allow 
them often to violate, through ignorance, simple laws of well liv- 
ing, whose observance might save them much suffering. 
Treatment of a Cold.—It is very much to be deprecated, that, 
as a rule, an ordinary cold is allowed to take its own course with- 
out treatment. If a part has once become inflamed, and is permitted 
to undergo resolution without interference, it is left in a weakened 
condition, which invites renewed attacks from a very slight cause; 
for when the acute inflammatory process subsides, complete reso- 
lution does not take place, but there is left a morbid condition, very 
mild in character perhaps, but nevertheless one of chronic inflam- 
mation. This may be so slight as to be scarcely noticeable by the 
patient, and yet it is this condition, which takes on a renewed in- 
flammation from a very slight provoking cause, which oftentimes 
the patient would escape did it not exist. The ordinary plan of 
treatment of a cold is so simple, and involves so little trouble, that 
it is the duty of the physician to urge that all cases, however sim- 
ple, should be subjected to it. 
Remembering the causes, as laid down above, which operate in 
the production of a cold, the first indication for treatment will be 
to supply as promptly as possible the deficiency caused by this loss 
of body heat. If this can be done in the early stages, when the 
secondary inflammatory process has not progressed, or better still, 
before it has set in, vizs, during the preliminary febrile stage, the 
further progress of the disorder may be promptly arrested; this 
constitutes what we generally call the abortive plan of treatment. 
This plan consists, in short, of producing copious perspiration; this 
perspiration, be it remembered, however, is not primarily the ob- 
ject it is desired to attain, but it is simply the evidence that that 
object has been attained. The condition to be corrected is loss of 
body heat; the measures resorted to for this are measures which 
have a tendency to increase body heat. The evidence that this 
has been accomplished, viz., the restoration of this heat, or even 
more, that an excessive heat has been produced, is manifested by the 
perspiration. If this so-called sweating can be brought on in the 68 
DISEASES OF THE NASAL PASSAGES. 
early stage, it serves the purpose of arresting the future progress of 
the trouble, and putting an end to the inflammatory process. If it 
can be brought about early in the progress of the inflammatory 
stage, its gravity can be very materially lessened ; hence, the earlier 
this abortive treatment is resorted to, the better the result. The 
means of accomplishing this is by simple remedies, familiar to all. 
A decoction of hot tea, taken at bed-time, with the addition of a 
foot-bath, and a moderate dose of Dover’s powder, is all that is 
necessary; after which the body should be warmly covered in bed, 
and extreme care exercised to prevent any exposure while the 
perspiration is going on. If the constitutional symptoms assume a 
graver form, that is, if the fever seems excessive, and the effect on 
the general system marked, much benefit will be gained by the 
administration of ten grains of quinine, in connection with the 
diaphoresis. It is generally asserted that following a copious per- 
spiration there is danger of contracting additional cold, on leav- 
ing the bed in the morning. This probably is a mistake, although 
the simple precaution should always be taken of allowing the body 
to cool off gradually before rising, by removing a portion, at a 
time, of the bed covering, and also remaining indoors for a few 
hours after dressing. If, as the result of this treatment, all symp- 
toms disappear, little else is needed, except the exercise of ordinary 
precaution. 
If, however, the inflammatory stage has set in, and the result of 
the sweat has been simply to modify, and not to remove it, other 
measures, directed to the special locality of the inflammation, should 
be resorted to. The remedies indicated will be referred to when 
we come to treat of special diseases. Confinement to the house 
should be urged in all cases, as of equal if not of greater import- 
ance than therapeutic measures, especially if the inflammatory con- 
dition shows any possible grave tendencies. CHAPTER V. 
THE ANATOMY OF THE NOSE. 
The External Nose, 
The external nose, the most prominent feature of the face, is 
composed of a bony and cartilaginous framework, covered with 
muscular tissue and in- 
tegument. The bony 
portion of the frame- 
work is composed of the 
nasal bones, and the na- 
sal processes of the supe- 
rior maxillae. 
The Nasal Cartilages. 
—The cartilages are five 
in number, the two upper 
and two lower lateral car- 
tilages, often called to- 
gether the alar carti- 
lages, and a single carti- 
lage in the median line 
supporting these, the tri- 
angular cartilage of the 
septum. At the junc- 
tion of the lateral cartila- 
ges with the bony frame- 
work, two or three sesa- 
moid or accessory car- 
tilages are ordinarily 
found (see Fig. 53). 
These cartilages are 
joined to each other and 
to the bony framework, 
by articulations which 
allow of a certain amount of motion, which is accomplished through 
the action of muscles distributed upon their outer surfaces (see 
Fig- 54)- 
Fig. 53.—Cartilages of the Nose, seen in Profile. (Sappey.) 1, 
Right lateral cartilage; 2, its anterior border; 3, an accessory car- 
tilaginous nucleus attached to the inferior border of the same 
cartilage; 4, anterior accessory cartilages remarkable for their 
ovoidal form and the constancy of their existence; 5, external 
branch of the alar cartilage; 6, union of this branch with the in- 
ternal branch; 7, 8, 9, secondary cartilaginous branches added to 
the external branch of the alar cartilage; 10, accessory cartilage 
not constantly found. 70 
DISEASES OF THE NASAL PASSAGES. 
The External Muscles of the Nose.—These may be divided, for 
the sake of brevity of description, into those which dilate the nos- 
trils, and those which contract them. To the first group belong the 
levator labii superioris alaequi nasi, which, arising from the nasal 
process of the superior maxillary bone, passes obliquely downward 
and outward, and is inserted into the alar cartilage; the dilator 
naris posterior, arising from the nasal notch of the superior max- 
illa and from the sesamoid cartilages, is inserted into the skin near 
the margin of the nos- 
tril ; the dilator naris 
anterior, whose origin 
is entirely cartilaginous, 
and lies immediately in 
front of the preceding; 
the compressor nasi, 
which arises near the 
incisive fossa, and is in- 
serted by means of a 
broad aponeurosis into 
the fibro-cartilage of 
the tip of the nose, in 
conjunction with its fel- 
low of the opposite side. 
The only muscle 
which diminishes the 
lumen of the nostrils is 
the depressor alae nasi, 
which arises from the 
incisive fossa, and, lying 
between the mucous 
membrane and the 
muscles of the lip, ap- 
pears to be inserted in- 
to the septum and pos- 
terior portion of the ala of the nose. In the lower animals these 
muscles are highly developed, and perform an important function 
in the economy, both with reference to respiration and olfaction. 
In man, however, their importance is not great, although they per- 
form minor duties in connection with respiration, and possibly in 
the modification of facial expression. 
Fig. 54.—Superficial Layer of the Muscles of the Nose. (Sap- 
pey.) 1, Levator labii superioris alaeque nasi; 2, nasal fibres of this 
muscle; 3, labial fibres of this muscle; 4, deep portion of this mus- 
cle; 5, anterior border of this muscle; 6. anterior fibres of the same 
muscle inserted at the superior and posterior part of the ala of the 
nose; 7, Pyramidalis; 8. 9, transvere muscular fibres which con- 
verging posteriorly pass beneath the anterior border of the levator. 
The Nasal Foss.®. 
The nasal passages are composed of two wedge-shaped cavities, 
extending from the nostrils in front, to the posterior nares, two THE ANATOMY OF THE NOSE. 
71 
oval-shaped openings, by which they communicate with the upper 
pharynx. The roof of these cavities is narrow, and somewhat 
arched from before backward, and is composed of the nasal bones 
in front, the body of the sphenoid behind, and the cribriform plate 
of the ethmoid between them. The floor is formed by the palatine 
processes of the superior maxillae and the palate bones. The two 
cavities are separated from each other in the median line by the 
septum, which is composed of the perpendicular plate of the eth- 
moid above, and the vomer below. The articulation of these two 
bones with each other, leaves anteriorly a triangular space which 
is filled by a cartilaginous plate, the triangular cartilage of the 
septum. Up to the seventh year of life the septum lies in the 
median line, but after this time, as Zuckerkandl1 has pointed out, 
there is usually some slight deviation to one or the other side, not, 
however, enough to encroach in any degree upon the breathing 
space. The outer wall of each cavity is formed by the superior 
maxillary, lachrymal, palate and sphenoid bones, and is traversed 
antero-posteriorly by three scroll-shaped bones, commonly called 
the turbinated. 
The lower turbinated bone is a very thin lamella of osseous 
tissue, curled upon itself, and forming a scroll, as it were, which is 
attached to a slight horizontal ridge presenting on the outer wall of 
the cavity. The extent to which this bone is curled upon itself 
varies in different cases. The lower border of the bone may be 
smooth, or incisures of various depths may be seen along its sur- 
face. 
The middle turbinated bone belongs really to the ethmoid, and 
hence it is sometimes called the lower ethmoidal turbinated. It 
consists of a broad, thin plate of bone, which, springing from the 
lateral mass of the ethmoid, passes downward, and is curled upon 
itself in the same scroll-shaped manner as the lower turbinated. 
The superior turbinated springs also from the lateral mass of 
the ethmoid. It is smaller and less scroll-shaped, and really pre- 
sents but a small ridge on the outer wall of the cavity, which, while 
in its posterior portion it is entirely distinct from the middle tur- 
binated bone, anteriorly, is merged with and lost in it. 
A fourth turbinated bone, designated as the concha santoriniana, 
has been described by anatomists. Zuckerkandl2 has found it in 
fifty-five cases out of 150. Voltolini3 says that this fourth turbi- 
nated bone is found normally in the negro race. 
These turbinated bones are nearly parallel with one another, 
1 “ Anatomie der Nasenholen,” Wien, 1882, p. 45. 
2 Op. cit., p. 31. 
3 “ Rhinoscopie und Pharyngoscopie,” Breslau, 1879, p. 70. 72 
DISEASES OE THE NASAL PASSAGES. 
and divide each cavity into three passages; the lower meatus, be- 
tween the floor of the nose and the lower turbinated; the middle 
meatus between the lower and middle turbinated bones, and the 
superior meatus between the middle and superior bones. 
In the normal state that portion of the fossa, bounded by the 
cartilaginous framework, consists of a smooth-walled ovoidal cavity, 
which is suspended in front of the lower and middle passages, and 
is usually termed the vestibule. In the anterior third of the lower 
Fig. 55.—Lateral Wall of the Right Superior Maxilla, seen from Within, the Soft Parts being Removed. 
(Zuckerkandl.) a, The unciform process of the ethmoid bone; b, spaces between the unciform process, the 
lower turbinated and the palate bones leading into the antrum, normally closed by the soft parts; c, a pro- 
cessus maxillaris; d, point of union between the unciform process and the lower turbinated bone; e, a portion 
of the furrow between the unciform process and the bulla ethmoidalis; g, bulla ethmoidalis; 7’, the lach- 
rymal bone. 
meatus, below the lower turbinated bone, is found the opening of 
the lachrymal duct. Aside from this, the lower meatus presents 
no points of special interest. Zuckerkandl1 attaches a certain 
amount of importance to the fact that the outer wall of the cavity 
may be more or less hollowed out, thus encroaching upon the cavity 
of the antrum. 
The middle tubinated bone is more or less scroll shaped, Jike 
the lower turbinated, and may be described as projecting into the 
1 Op. cit., p. 34. THE ANATOMY OF THE NOSE. 
73 
nasal cavity from the lateral mass of the ethmoid. As a rule, the 
outlines of this bone are convex, although in many instances we 
have it presenting a concavity toward the median line. Zucker- 
kandl1 finds, in a certain number of cases, that the ethmoidal cells 
may be continued into the body of the middle turbinated bone, 
thus giving rise to certain abnormalities of contour, as for instance, 
when its anterior termination presents a rounded expansion, con- 
sisting of a hollow bony shell covered with mucous membrane. 
This tumor may attain sufficient dimensions to close the normal 
orifices of the frontal and maxillary sinuses. 
Beneath the middle turbinated bone, lies the long unciform pro- 
cess of the ethmoid (see Fig. 55). This may be described as a 
narrow bony plate, running downward and backward from the tip 
of the middle turbinated, and almost parallel with its lower border. 
Its purpose is twofold: to articulate with the superior maxillary 
bone, by means of thin bony plates, projecting from it, to the wall 
of the antrum, and with the inferior turbinated by delicate pro- 
cesses from its lower border. These last-named processes close to 
a greater or less extent, the opening between the nasal cavity and 
the antrum of Highmore. 
Just above the anterior termination of the middle turbinated 
bone, we find a rounded bulging of the ethmoidal cells, where the 
ethmoid articulates with the nasal process of the superior maxilla, 
the agger nasi, as first described by H. Meyer.2 
Beneath the middle turbinated bone, and extending from near 
the anterior extremity downward and backward, is seen a deep 
hiatus, the hiatus semilunaris (see Fig. 56). This is, as its name 
implies, crescentic in shape, and has a direction downward and 
backward, the convexity looking forward. This furrow is bounded 
above by a prominence, which is in reality an expanded ethmoidal 
cell, and is known as the bulla ethmoidalis, below, by the unciform 
process already described. The superior extremity of the hiatus 
semilunaris presents a somewhat circular opening, the orifice of the 
frontal sinuses. Following this furrow backward, we find it merging 
into an opening of a more or less circular shape, and of varying 
dimensions, the ostium maxillare, leading, as the name implies, into 
the maxillary sinus. This opening is sometimes absent.3 
Behind this opening, we occasionally find a second leading into 
the same cavity, known as the ostium maxillare accessorius. In 
this same furrow we also find the openings of the anterior ethmoidal 
cells, somewhat irregular in their location, but as a rule near the 
orifice of the frontal sinuses. 
1 Op. cit., p. 29. 2 “ Lehrb. d. phys. Anat.” Leipzig, 1856. 
3 Zuckerkandl, op. cit., p- 41. 74 
DISEASES OF THE NASAL TASS AGES. 
Above the middle turbinated bone we find the superior meatus, 
of chief interest from the fact, that into it open the posterior eth- 
moidal cells and the sphenoidal sinus, by means of the recessus 
Fig. 56.—Outer Wall of Left Nasal Cavity, the Inferior and Middle Turbinated Bones having been 
Removed. (Zuckerkandl.) A, Roof of nose; B, floor of nose; b, Hiatus Semilunaris and ostium maxillare; 
r, portion of outer wall of nose encroaching upon cavity of antrum; </, opening of lachrymal canal; e, bulla 
ethmoidalis; g, small canal between anterior insertion of middle turbinated and the ethmoidal cells; i, Os- 
tium frontale; k, furrow forming boundary between the nasal and nasopharyngeal cavities. 
ethmoidalis. This small opening lies in the very posterior part of 
the superior meatus, and when a fourth turbinated bone is present, 
is situated immediately behind this. 
The Accessory Sinuses. 
Communicating with each nasal fossa, there are four cavities, 
usually designated as the accessory sinuses. These are the maxil- 
lary, frontal, sphenoidal, and ethmoidal sinuses. 
The Antrum.—The maxillary sinus, or antrum of Highmore, 
the largest of these accessory cavities, is a pyramidal-shaped cavity, 
hollowed out of the body of the superior maxilla. Its roof is 
formed by the floor of the orbit; its inner wall is composed of the 
outer wall of the nasal cavity, while its anterior wall is the malar 
process of the superior maxilla, the posterior aspect of the cavity THE ANATOMY OF THE NOSE. 
75 
forming the zygomatic face of the superior maxilla. This cavity 
varies considerably in individuals, and even among races. Thus, 
the depth of the canine fossa may encroach notably upon its ante- 
rior wall. As the result of this peculiarity, in the Mongolian races, 
this cavity is usually small, as noted by Zuckerkandl.1 Or, again, 
deficient absorption of the alveolar processes in foetal life, may 
produce marked encroachment upon the lower portion of the 
cavity. On the other hand, the cavity may be abnormally enlarged 
from excessive absorption of osseous tissue in foetal life, downward 
into the alveolar process (see Fig. 57) or forward, as the result of 
Fig. 57.—Transverse Section through the Nasal Cavities, and Maxillary Sinuses, Showing Irregularities 
of Development in the Latter. (Zuckerkandl.) a, Antrum enlarged by absorption of the alveolus. 
which the antrum may extend between the floor of the nose and 
the hard palate, as seen in Fig. 58, or it may extend up into the 
malar bone or into the frontal, as the result of a similar process of 
absorption in this direction. 
The Frontal Sinuses.—The frontal sinuses are two triangular- 
shaped cavities, which lie between the two tables of the frontal 
bone, the floor being formed by the roof of the orbit. They are 
absent in childhood, but become developed in adult life. They 
communicate with the nares through the infundibulum, a rounded 
opening in the anterior extremity of the hiatus semilunaris. Occa- 
sionally these sinuses are entirely absent. As a rule, they are sep- 
arated from one another, but more frequently than in any other of 
1 Op. cit., p. 102. 76 
DISEASES OF THE JVASAL PASSAGES. 
the accessory sinuses, a normal opening exists from one side to the 
other, and in still rarer instances, an opening is found between the 
frontal sinus and the orbit, as seen in Fig. 59, or between this 
cavity and ethmoidal sinuses. 
The Sphenoidal Sinuses.—The sphenoidal sinuses are two compar- 
atively large rounded cavities hollowed out of the body of the sphe- 
noid bone, and are separated from each other by a thin lamella of 
bone or septum. They communicate with the nares by a small 
opening into the superior meatus. These sinuses are also occa- 
Fig. 58.—Transverse Section through the Nasal Cavities and the Maxillary Sinuses, Showing Irregular- 
ities in the Development of the Antrum. (Zuckerkandl.) a, Palatine portion of the antrum projecting be- 
neath the floor of the nose; 6, small bony ridge; c, groove of the infra-orbital canal; d, infra-orbital portion 
of the antrum; <?, prolongation of the antral cavity into the malar bone. 
sionally absent, their places being filled by solid bone. Zucker- 
kandl1 has also found, in rare instances, instead of two lateral si- 
nuses, a horizontal plate dividing the cavity, in which case the 
upper cavity opened directly into the ethmoidal cells, the lower 
opening into the nasal fossa. A still rarer anomaly is that in which 
the anterior wall is entirely wanting, the cells opening directly into 
the ethmoidal sinuses. 
The Ethmoidal Sinuses.—The ethmoidal sinuses differ from all 
the other accessory cavities, in that, instead of being large hollow 
cavities, they are composed of a large number of small cells, sepa- 
1 Op. cit., p. 171. THE ANATOMY OF THE NOSE. 
77 
Fig. 59.—Abnormal Opening between the Frontal Sinus and the Orbit. (Zuckerkandl.) 3, Point of 
abnormal communication. 
Fig. 6o.—Abnormal Opening between the Ethmoidal Cells and the Orbit. (Zuckerkandl.) a, Point of 
abnormal opening. 78 
DISEASES OF THE NASAL PASSAGES. 
rated from each other by thin lamellae of bone. They divide them- 
selves naturally into two groups, the anterior and the posterior 
ethmoidal cells; the anterior opening into the nasal cavity in the 
hiatus semilunaris by means of small openings called the ostia eth- 
moidalia, while the posterior group opens into the superior meatus. 
The ethmoidal cells are less definite in their boundaries than any of 
the others, as they may extend either into the sphenoidal cells pos- 
teriorly, or into the frontal sinuses. Again, we may have an abnor- 
mal opening into the orbital cavity, as seen in Fig. 60, in conse- 
quence of which emphysema of the orbit may occur. 
The mucous membrane lining these sinuses is continuous with, 
and differs in no marked degree from that lining the nasal cavities, 
unless we note that in the maxillary sinuses the membrane is 
thrown into folds by a sort of redundancy of tissue, as it were. 
The Mucous Membrane. 
The mucous membrane lining the nasal cavities is continuous 
with that of the pharynx, and extends into the Eustachian tubes 
and the accessory cavities. Its superficial layer is composed of 
columnar epithelium in the upper portion of the cavities, as low as 
the middle turbinated bones, and the upper third of the septum. 
The remaining portion of the lining membrane is endowed with 
columnar ciliated epithelium, although, according to some writers, 
the epithelium is also ciliated in some portions of the olfactory 
tract. This fact becomes of some importance, in connection with 
those diseases of the cavity which act to destroy, or impair the 
vibratory motion of the ciliae, as this function undoubtedly has an 
influence in promoting the movement of the mucus, and facilitating 
its discharge; hence, therefore, its abolition increases the tendency 
to an accumulation of the discharges in diseased conditions. 
The muciparous glands are generally of the tubular variety, and 
possess no peculiar characteristic,.except, as observed by Zucker- 
kandl,1 that they are very long, and extend to the deep layers of 
the mucous membrane, even to the periosteum. 
In addition to the muciparous glands, we also find in the olfac- 
tory region, namely, that par.t above the middle turbinated bones, 
tubular glands which, from the name of their discoverer, are called 
Bowman’s glands.2 These glands are lined with rounded epithe- 
lium, which in the blind extremities is large, granular, and contains 
a certain amount of pigment. 
In that portion of the nose immediately within the nostril, 
1 Wien. Med. Wochenschr., 1884, vol. 34, No. 38, p. 1124. 
2 Todd Bowman’s ‘ Physiology and Anatomy ” vol. ii. THE ANATOMY OF THE NOSE. 
79 
called the vestibule, we find the mucous membrane largely endowed 
with vascular papillae, and covered with squamous epithelium, in 
fact, so closely resembling the integument that, as Moldenhauer 
observes,1 it is really to be regarded as a process of the skin. 
We find, also, in this locality a number .of stiff hairs, termed 
vibrissae, whose object is merely to purify the inspired air. 
The Nerves.—The innervation of the nasal mucous membrane 
has its source in the olfactory nerve, together with the nasal branch 
of the ophthalmic, the superior maxillary branches of the tri- 
geminus, and filaments from Meckel’s ganglion. The olfactory 
nerve supplies the nasal cavity with the special sense of smell. 
This nerve arises by three roots, an external root commencing in 
the deep substance of the middle lobe of the cere- 
brum, a middle root from the carunculum annulare, 
and an internal, from the inner and back part of the 
anterior lobe. These three roots unite in a flat band 
which passes forward along the base of the brain 
until it reaches the upper surface of the ethmoid plate. 
Here it is expanded into the olfactory bulb, which 
gives off from fifteen to eighteen branches on either 
side, which, piercing the cribriform plate, are distrib- 
uted to the mucous membrane covering the superior 
and middle turbinated bones, and the upper third of 
the septum. They terminate in minute thread-like 
filaments, which pass to the surface of the membrane, 
between the epithelial cells. In the continuity of this 
filament, before it reaches the surface, there is found 
a minute bulb-like expansion, the olfactory cell, as 
shown in Fig. 61. 
The nasal nerve, arising from the ophthalmic di- 
vision of the trigeminus, enters the orbit between the 
two heads of the external rectus, crosses the optic nerve and passes 
into the cranial cavity through the anterior ethmoidal foramen, 
only to pass out again into the nose through a slit beside the crista 
galli, and there immediately divides into two branches: an internal, 
which supplies the mucous membrane near the anterior part of the 
septum, and an external, which, descending in a groove on the inner 
surface of the nasal bone, and sending a few filaments to the mu- 
cous membrane as far down as the lower turbinated, becomes cuta- 
neous at the junction of the upper lateral cartilage with the nasal 
bone, and furnishes cutaneous sensibility to the tip of the nose. 
The branches of the anterior dental nerve supplying the mucous 
Fig. 6i.—'l'hfc Ol- 
factory Cells in man. 
(Max Schultze.) 
1 “ Die Krankheiten der Nasenhohlen,” Leipzig, 1886, n, 9. 80 
DISEASES OF THE JVASAL PASSAGES. 
membrane, are distributed to the inferior meatus and inferior tur- 
binated bone. 
The branches from Meckel’s ganglion (see Figs. 62 and 63) 
enter the nasal cavity through the spheno-palatine foramen, and 
Fig. 62.—Spheno-palatine Ganglion. Seen on its Internal Surface. (Sappey.) 1, Terminal branches of the 
olfactory nerve; 2, external division of the ethmoidal branch of the nasal nerve; 3, spheno-palatine gan- 
glion; 4, termination of the great palatine nerve; 5, posterior palatine nerve; 6, middle palatine nerve; 7, 
branch of the great palatine nerve supplying the lower turbinated bone; 8, branch from the spheno-pala- 
tine ganglion to the middle turbinated bone; 9, origin of the branch from this ganglion to the septum; 10, 
vidian nerve; ii, great superficial petrosal nerve; 12, carotid branch of the vidian nerve communicating 
with the corresponding branch of the superior cervical ganglion; 13, carotid branch of the superior cervical 
ganglion. 
here divide into two sets: the superior nasal, and the naso-pala- 
tine branches. The former supply the mucous membrane covering 
the superior and middle turbinated bones, the lining of the poste- 
rior ethmoidal cells, and the upper and posterior part of the sep- 
Fig. 63.— The Formation of the Spheno-Palatine Ganglion. (Heitzmann.) 
turn. One of these branches forms a communication with the 
anterior dental nerve within the antrum, giving ris*e to the so-called 
ganglion of Bochdelek. The naso-palatine branch passes forward 
across the roof of the nose, and runs obliquely downward and for- THE ANATOMY OF THE NOSE. 
81 
ward, along the lower part of the septum, and pierces the hard 
palate through the anterior palatine foramen, joining the anterior 
palatine nerve. 
The Vidian nerve is formed by the union of the greater super- 
ficial petrosal and the carotid branches. The former arises from 
the facial nerve; the latter from the sympathetic plexus which 
surrounds the carotid artery. These branches unite into one nerve 
trunk,which passes through the Vidian canal, terminating inMeckel’s 
ganglion. 
We thus find the mucous membrane endowed with general sen- 
sation through the same nerve trunk as that by which vaso-motor 
control is exercised, namely through the fifth nerve. This peculiar 
anatomical characteristic in the nasal mucous membrane, has been 
very largely made use of to substantiate the various theories as 
regards the causation of hay-fever, asthma and other so-called re- 
flex neuroses. I question if these theories rest on any well-sub- 
stantiated grounds as yet. 
Blood-Vessels.—The vascular supply of the nasal fossae is derived 
from the anterior and posterior ethmoidal arteries, branches of the 
ophthalmic, which supply the ethmoidal cells, frontal sinuses, and 
roof of the nose; the spheno-palatine, from the internal maxillary 
artery, distributed to the mucous membrane covering the spongy 
bones, and the septum; and the alveolar branch, from the internal 
maxillary artery, supplying the lining membrane of the antrum. 
The Turbinated Bodies. 
In addition, however, to the parts already described, there are 
found beneath the surface of the mucous membrane, on the faces of 
the lower and middle turbinated bones, large plexuses of blood- 
vessels, the turbinated bodies, which have figured so extensively 
in our literature of the last fifteen years, and have been the sub- 
ject of so much speculation and discussion. This mass of blood- 
vessels was recognized by anatomists in the last century, but in a 
vague and somewhat indefinite way. 
According to John Mackenzie,1 the spongy character of this tis- 
sue attracted attention as early as 1656, being mentioned by Rol- 
finc.2 
Schneider3 recognized it as containing vascular tufts, but did 
1 “ Historical Notes on the Discovery of the Nasal Erectile Tissue.” Boston Med. and 
Surg. Journal, Jan. 1st, 1885. 
2 “ Dissertationes Anatomicse,” Noribergae, lib. ii., cap. 20. 
8 “ De Catarrhis,” Wittburgae, 1661-62, lib. v., passim. 82 
DISEASES OF THE NASAL PASSAGES. 
not recognize its cellular structure. This was first mentioned by 
Ruppert.1 
Duverney2 gives a more detailed description, and states that 
the membrane can be inflated by a blow-pipe inserted into the 
veins. 
The first to announce distinctly its true erectile nature was 
probably Cruveilhier,3 who described it as a very vascular and truly 
erectile tissue, and demonstrated its structure by the injection of 
mercury through the lymphatics. 
The first careful anatomical investigation of the tissue was made 
by Kohlrausch,4 who described what he supposed to be large 
venous sinuses, existing in the deep layer of the membrane. Such 
a plexus had been previously referred to by Hyrtl, as acknowledged 
by Kohlrausch. It was subsequently claimed as an independent 
discovery by Kolliker.5 In 1873, Bigelow6 made some very care- 
ful observations of these structures, in which he demonstrated the 
existence of erectile tissue. It should be .stated, however, that 
Kohlrausch7 in his investigations had shown the existence of loops 
or helicine arteries, which at that time were recognized as an ana- 
tomical condition characteristic of erectile tissue. Kohlrausch’s 
investigations were made in the moist tissue. Bigelow inflated the 
moist tissue with a blow-pipe inserted into the veins themselves, 
as had been already done by Duverney8 and made his sections 
after the preparations had been allowed to dry. Bigelow’s demon- 
strations showed a very beautiful spongy tissue, as shown in Fig. 
64. These observations were subsequently very nicely confirmed 
by Ischwald.9 All these investigators asserted that this tissue was 
erectile tissue, their conclusions being based apparently on anatom- 
ical study alone. 
Zuckerkandl,10 however, whose classical work on the anatomy of 
the nose is the standard authority to-day on this subject, has made 
an exhaustive anatomical study of this membrane, in which he de- 
scribes the mucous membrane covering the turbinated bones as 
consisting of connective tissue, the upper surface covered with flat 
1 “ Diss. inaug. med. de tunica pituitaria, ejus anatomiam, physiologiam et pathologiam 
exponens,” Vetero Pragae, 1754, pars i., p. 23. 
2 “ CEuvres Anatomiques,” Paris, 1761, tome i., p. 222. 
3 “ Traite d’Anatomique descriptive,” Paris, 1845, tome iv., p. 55. 
4 Muller’s Archives, 1853, p. 149. 
5 “ Handbuch d. Gewebelehre des Menschen,” Leipzig, 1867, p. 741. 
6 Boston Med. and Surg. Journal, April 29th, 1875. 
7 Loc. cit. 8 Loc. cit. 
9 Progres Medicale, Sep. 10th, 1887. 
10 Wiener medizinische Wochenschrift, 1884, vol. 34, No. 38, pp. 1121-1125. “ Schwell- 
gewebe der Nasenschleimhaut. und dessen Beziehungen zum Respirationspalt.” THE ANATOMY OF THE NOSE. 
83 
epithelium, the deep layer forming the periosteum of the turbinated 
bones. Between these two layers we have abundant lymph tissue, 
and possibly lymph glands, although these have not been definitely 
made out. The tissue covering the turbinated bones is studded 
here and there with tubular mucous glands, many of which extend 
completely through to the periosteum. Within this lymphoid 
structure we have abundant venous plexuses to which he gives the 
name “ Schwellkorper ” (swell bodies). About the venous plexuses, 
the unstriped muscular fibre is abundantly distributed. The defi- 
nite localization of the venous plexuses serves to distinguish this 
tissue from true erectile tissue, such as is found in the corpora 
cavernosa of the penis. The arterial supply is derived from the 
spheno-palatine artery. The capillaries are divided into three sets, 
Fig. 64.—Section of the Cavernous or Erectile Tissue of the Middle and Lower Turbinated Bones, 
Inflated and Dried, X 2 diameters. (Bigelow.) 
one set being distributed to the periosteum, the second to the glands, 
the third to the surface. The capillaries distributed to the surface 
form loops which empty into the veins, together with the super 
ficial gland capillaries. The deeper gland capillaries, and those dis- 
tributed to the periosteum, pass into the veins, forming the so- 
called Schwellkorper, and the blood is then conveyed by venous 
channels in the periosteal surface of the membrane, to five distinct 
plexuses, one going to the veins of the face, the second to the veins 
of the cranium, the third to the orbit, the fourth to the soft palate, 
and the fifth to the hard palate. These Schwellkorper are dis- 
tributed according to Bresgen,1 as follows: one over the lower 
turbinated body, one along the border of the middle turbinated 
1 “ Der Circulationsapparat in der Nasenschleimhaut, vom klinischen Standpunkt be- 
trachtet,” Deut. med. Wochenschrift, Berlin, 1885, Nos. 34, 35. 84 
DISEASES OF THE NASAL PASSAGES. 
body, and one at the posterior extremity of each of the turbinated 
bodies. 
We find, therefore, the nasal cavity containing this most intri- 
cate and delicate apparatus, which is designed to subserve the 
function of serous exudation. The special method by which this 
serous transudation takes place we are scarcely ready to describe, 
though a very important suggestion comes to us from the notable 
observation of Chatellier,1 who describes certain minute canals, 
running at right angles to the mucous membrane, penetrating to 
the lymph channels. Chatellier makes the suggestion that these 
canals serve the purpose of serous channels. The question arises, 
whether Chatellier’s canals may not be the tubular mucous glands 
of Zuckerkandl. 
1 Annales des Mai. de l’Or., etc., No. 6, June, 1887. CHAPTER VI. 
THE PHYSIOLOGY OF THE NOSE. 
The nose performs a threefold function in the economy. It is 
the organ which presides over the sense of smell; it gives a certain 
character and resonance to the voice; and it has a special duty to 
perform in connection with respiration. 
The Sense of Smell. 
Minute particles of odorous bodies, floating in the atmosphere, 
are drawn into the nasal cavity with the act of inspiration, where, 
being arrested, and lodging against the moist membrane of the 
olfactory tract, they are dissolved in its mucus, and in this state of 
solution, coming in contact with the terminal filaments of the olfac- 
tory nerve, their peculiar qualities are recognized and appreciated. 
The proper enjoyment of this function requires that the membrane 
shall be in a moist condition, that it shall not be clogged by any 
accumulation of unhealthy mucus or other matters, and that the 
nasal cavity shall be freely open, and not occluded by tumors or 
other morbid conditions, but that the inspired air shall have free 
access to the olfactory tract; and, furthermore, that the olfactory 
nerve shall be in a healthy condition. 
That the membrane must be in a moist condition, is shown by 
the loss of the sense of smell in those suffering from atrophic rhini- 
tis or dry catarrh. Again, if the membrane is clogged by the 
secretions of a syphilitic ulcer, or occluded in any way which pre- 
vents the transmission of the odorous particles to its surface, this 
sense is abolished. Of course, the occlusion of the nares from the 
presence of tumors, or from an ordinary acute rhinitis, more or less 
completely abolishes the enjoyment of this function. 
It is still a subject of speculation as to just how the olfactory 
nerve receives impressions from odorous particles. Liegeois1 con- 
tends that the minute particles from odorous substances, impinging 
upon the surface of the mucous membrane, come in contact with, 
and mechanically irritate the terminal filaments of the olfactory 
1 Arch, de Physiologie, 1868. 86 
DISEASES OE THE JVASAL PASSAGES. 
nerve. Graham 1 has a curious theory that an odor is appreciated 
by means of its oxidation in the nasal mucous membrane, basing 
this view on the ground that all odorous particles are easily oxidiz- 
able, while the converse is true of inodorous matter. Ramsay2 finds 
a relation between the molecular weight of bodies and their odor- 
ous qualities, and hence advances the theory that olfaction is the 
result of molecular vibration. Those bodies possessing high odor- 
ous qualities, are made up of molecules in a state of high molecular 
activity, in which the rate of vibration is very rapid. Going down 
in the scale, we come to bodies made up of molecules in which the 
rate of molecular movement is too slow to be appreciated by the 
olfactory nerve. Tyndal3 has found matters to be odorous in 
proportion as they possess the property of heat absorption, which 
would suggest a theory of olfaction based on the action of heat. 
Ogle,4 in a somewhat elaborate study of this subject of olfaction, 
has found the sense of smell intimately connected with the distribu- 
tion of pigment, supporting his view with a number of very ingenious 
clinical observations, as for instance, he notes that white herbivor- 
ous animals are far more frequently poisoned than others, owing to 
the feebleness of their olfactory powers. He also cites the case of 
a negro boy, who, as the result of a cutaneous affection, became 
white, with the result of complete loss of the sense of smell; and 
still further observes the fact, that the dark-skinned races in general, 
possess far more acute olfactory powers than the Caucasian races. 
Hence, he evolves the theory that the pigment in the nasal fossae, 
secreted by Bowman’s glands, serves an important part in the olfac- 
tory function, but confesses a difficulty in explaining just how it 
acts. He instances, however, the well-known fact that dark cloth- 
ing is a far more active vehicle of contagion than light, and, further, 
that odors are retained for a greater length of time by dark cloth- 
ing. He goes on to draw an analogy between sight, hearing, and 
smell, in that the pigmentation of the choroid layer, and the aural 
ampullae, serves as a vehicle for the reception of light and sound, 
and he goes on to suggest that, if color is dependent upon heat, why 
may not an odor, and therefore that the pigment in the nose serves 
simply as a vehicle for receiving the waves of odor. 
These theories, at best, are largely speculative, and we content 
ourselves merely with the assertion already made, that the apprecia- 
tion by the olfactory nerve, of odorous particles, requires simply a 
healthy condition of the nerve, a healthy membrane, and a patulous 
cavity. That olfaction is accomplished entirely by the olfactory 
i Gain’s “ Science and Intellect,” 3d ed., p. 152. 2 Nature, vol. 26, p. 187. 
3 “ Contribution to Molecular Physics in the Domain of Radiant Heat,” p. 99. 
4 Med. Chirurgical Trans., vol. 53, p. 263. THE PHYSIOLOGY OF THE NOSE. 
87 
nerve, has been amply demonstrated by physiological experiment, 
and is further shown in the fact that the nerve, and the olfactory 
bulb, are very largely developed in those animals in whom the sense 
of smell is unusually acute. 
The general sensibility of the membrane is derived from the 
branches of the trifacial already described. The sense of smell is 
intimately associated with the sense of taste, in that the loss of 
olfaction is always attended by more or less complete loss of the 
sense of taste. This is explained by the fact, that the special sense 
of taste is supplied to the tongue from the glosso-pharyngeal nerve 
and perhaps the gustatory, and really consists in the appreciation 
of either the acid, bitter, sweet, or saline character of substances 
applied to it, and nothing more. The nicer appreciation of flavors 
is entirely the result of impressions made on the terminal filaments 
of the olfactory nerve. 
The Function of the Nose in Phonation.' 
The function of the nasal cavity in modifying the voice, is one of 
no little importance, and consists mainly in acting as a resonant 
chamber, as it were, by which the vocal tones are re-enforced. The 
voice is formed by vibrations of a column of air, set in play by the 
movements of the vocal cords; its pitch being regulated by their ten- 
sion ; and its volume being dependent upon the force with which the 
current of air is driven through the rima glottidis, and hence, by the 
lateral reach of each cord in a single vibration. The character of 
the voice, on the other hand, or the tone by which each voice is 
given its individuality, is dependent largely on the pharynx, mouth, 
and the formation of the nasal cavity. The larynx simply forms the 
voice, articulate language being constructed out of the vocal waves, 
by the movements of the soft palate, tongue, lips, and cheeks. 
In uttering certain sounds, the soft palate is raised against the 
wall of the pharynx, and the nasal cavity is more or less shut off. 
This occurs in the utterance of all the vowels, which are purely 
oral tones. In the utterance of other sounds, the palate is relaxed, 
and the air in the nasal cavity, as well as that in the mouth, is 
thrown into vibration, giving a nasal twang to the voice; this occurs 
in uttering m, n, ng, etc. A good voice is dependent on the proper 
use of both the nasal and oral vibrations, and therefore requires 
that the nasal cavity shall be free from obstruction (by tumors, 
hypertrophy of its lining membrane, etc.), and that the movements 
of the soft palate shall not be interfered with. 
When we make the statement that the vowels are purely oral 
tones, we overlook a very important fact observed by Meyer,1 that 
1 “ The Organ of Speech,” Amer.' ed., New York, 1884, p. 236. 88 
DISEASES OE THE NASAL PASSAGES. 
the vibrations of air in the oral cavity, give rise to vibrations in the 
nasal cavity, the force being transmitted directly through the hard 
palate. In this connection Czermak,1 who has investigated the 
movements of the soft palate in the utterance of the vowel sounds, 
by means of a probe passed through the nose, showed the soft 
palate elevated to the highest degree in the utterance of i (Eng- 
lish ee), and the lowest in the utterance of a (American ah), which 
would indicate a notable change in the nasal chambers, in the utter- 
ance of these various sounds. Furthermore, a nasal element, I 
think, is recognizable in the utterance of all sounds, whether oral or 
nasal. This is even more notable by their absence, as in cases in 
which the anterior nares are completely occluded, the voice is nota- 
bly affected, although still possessing the nasal element, by the 
transmission of vibrations through the hard palate. The same is 
true, also, where the posterior nares are occluded, as by the result 
of an adenoid growth in the pharynx. The complete ablation of 
the nasal chambers, as when they are filled with neoplasms, gives 
rise to a totally different character of the voice, in which the nasal 
twang is absolutely destroyed. The prominent function, then, of 
the nose in phonation, is as a resonant chamber to the voice, used 
in the production of all articulate sounds. 
We find an additional and somewhat important function of the 
nose, in that its upper partial tones, or the overtones described by 
Helmholz,2 serve to re-enforce the harmonics of the voice. In 
other words, the fundamental note of the voice gives rise to a 
secondary series of vibrations of the current of air in the nasal 
chambers, viz.: Helmholz’s overtones, the resultant tone being one 
which is pleasing to the ear. 
It would seem also, that the nasal cavities possess a certain 
amount of importance as an aid to articulate speech, as is evidenced 
by the fact, that where these cavities are closed, articulation is 
fatiguing and the voice soon breaks down with any effort requir- 
ing prolonged use, the whole difficulty disappearing, as a rule, upon 
the removal of the obstructing conditions in the nose. 
In the same way, we find that the integrity of the nasal cavity 
is of special importance in the production of the so-called head- 
notes, as is shown by Gordon Holmes.3 Hence, while the singing 
voice demands an absolutely healthy condition of this cavity for 
the management of all its registers, it is absolutely essential for 
1 “ Ueber das Verhalten des weichen Gaumens beim Hervorbringen der reinen Vocale.” 
(Sitzungsberichte der Wiener Akademie—mathematisch-naturwissenschaftliche Klasse, Bd. 
xxiv., S. 4, Marz 1857.) 
2 “ Die Lehre von den Tonempfindungen,” Heidelberg, 1863. 
3 “Vocal Physiology and Hygiene,” London, 1879, p. 129. THE PHYSIOLOGY OF THE NOSE. 
89 
vocalization, and especially for articulation in the upper or head 
register. 
The Function of the Nose in Respiration. 
The nose is usually regarded as merely the organ of olfaction, 
while its respiratory and phonatory functions are looked upon as 
somewhat secondary in character. This view I regard as an en- 
tirely mistaken one, in that the nasal passages contain an exceed- 
ingly important, perhaps the most important, arid certainly the 
most intricate apparatus, connected with the function of respiration, 
of the whole respiratory tract, and one on whose normal functional 
activity depends the integrity of the whole of the mucous mem- 
brane of the respiratory tract below. 
The ancients believed that respiration was for the purpose of 
cooling the blood. Helvetius, in 1729, supporting this view, adduced, 
as an argument in its favor, the fact that the area of the pulmonary 
vein was larger than that of the pulmonary artery. In 1823, Fried- 
erich Hempel1 asserted that the air was heated in the lungs, making 
no reference to the nose or mouth as bearing part in this function, 
regarding the nose as an organ to test the quality of the inspired 
air, before its passage into the lungs. In 1829, Magendie2 wrote: 
“ By successively traversing the mouth, nasal cavities, pharynx, 
larynx, trachea, and bronchi, the inspired air becomes of a similar 
temperature with the body. . . . The inspired air is charged 
with vapor which it carries away from the mucous membrane of 
the air-passages, and in this state, always hot and humid, it arrives 
at the pulmonary lobules." In the same year, Adelon,3 making no 
mention of the functions of the nose in respiration, speaks of the 
moisture of the expired air having its sole source in the lungs. In 
1844, we find Dunglison4 making the following statement: “In 
passing through the mouth, nasal fossae, pharynx, larynx, trachea 
and bronchi, the inspired air acquires pretty nearly the temperature 
of the body." As early as 1845, however, we find appearing in 
medical literature, evidence of the recognition of other and im- 
portant functions as belonging to the nasal chambers, independent 
of the other portions of the upper air-tract. The first evidence of 
this I find given by Vierordt,3 who, I think, was the earliest to 
emphasize the fact that the air is raised in temperature in passing 
through the nasal chambers, thus recognizing the fact that the 
1 “ Einleitung in die Phys. und Path, des Mensch.” 
2 “Physiology,” Edinburgh, 1829, Milligan’s translation, 3d ed., p. 387. 
3 “ Physiologie de l’homme,” Paris, 1829. 
4 “ Human Physiology,” 5th ed., vol. ii., p. 31. 
5 “ Physiologie des Athmens,” Carlsruhe, 1845. 90 
DISEASES OF THE NASAL TASS ACES. 
other portions of the upper air-tract contribute no part in this im- 
portant function. 
In 1864, we find Nestor Grehant1 investigating this subject 
experimentally. His apparatus consisted of a glass tube contain- 
ing a thermometer, through which the expired air was made to 
pass by inserting the tube in the mouth. To protect the ther- 
mometer from the temperature of the surrounding air, which might 
thus vitiate the experiment, the tube containing it was enclosed 
within a second tube, and the space between was filled with cotton. 
Grehant found, with the temperature of the room at 120 C. 
(53.6° F.), and the patient breathing seventeen times per minute, 
inspiring through the nose, that the temperature of the air expired 
through the mouth and apparatus was 35.30 C. (95-5° F.). If, in- 
stead of inspiring through the nose, the end of the tube within the 
mouth was closed with the tongue, and inspiration was performed 
through the mouth and expiration through the tube, then the tem- 
perature of the expired air was only 33.90 C. (930 F.). Although, 
as will be shown further on, these results are erroneous, the investi- 
gations go to show that, even at this time, the importance of the 
nose as an organ of respiration was beginning to be recognized. 
In a second series of experiments, Grehant showed that the ex- 
pired air was saturated with moisture at a temperature of 350 C. 
(950 F.) and not at 38° C. (100.4° F.) as Valentine had before stated. 
The error had been made on account of the momentary cooling of 
the surface of the hygrometer by the expired air; by correcting 
this error of experimentation, by enclosing the polished face of the 
hygrometer so that the expired air should not momentarily cool its 
face, the true result was obtained. 
Subsequent to this, we find such standard works on physiology 
as Dalton and Foster making no mention of the fact that the air is 
warmed and moistened within the nose and mouth, before entering 
the lungs. Flint,2 however, writes as follows: “ The vapor in the 
expired air is derived from the entire surface which is traversed in 
respiration, and not exclusively from the air-cells. The air which 
passes into the lungs derives a certain amount of moisture from the 
mouth, nares, and trachea. The great vascularity of the mucous 
membranes in these situations, as well as of the air-cells, and the 
great number of mucous glands which they contain, serve to keep 
the respiratory surfaces constantly moist. This is important, for 
only moist membranes allow the free passage of gases, which is, 
of course, essential to the process of respiration.” 
1 These de Paris, 1864, No. 161, “ Recherches physiques sur la respiration de l’homme.” 
2 “ Text-book of Human Physiology,” N. Y., 1876, p. 154. THE PHYSIOLOGY OF THE NOSE. 
91 
Rosenthal1 claims that air is already warmed and saturated 
when it reaches the alveoli. 
These functions, however, are attributed to the nose in a some- 
what adventitious manner, and the general view seems still held 
that olfaction is the main function of the nasal mucous membrane. 
Even as late as 1878, we find Remy2 alluding to the nose as the 
organ of olfaction, and directly stating that its other functions are 
purely secondary and adventitious. Remy first states that the 
watery secretion of the nose is for the purpose of moistening odor- 
ous particles by which they are rendered sensible to the olfactory 
nerve. His exact language is as follows: “ Cette membrane forme 
l’extremite superieure des canaux respiratoires, mais ce n’est pas 
la son principal but. Cette muqueuse fait partie constituante d’un 
organe des sens, et ce n’est qu’accessoirement qu’elle sert a un 
autre usage qu’a la function sensorielle.” 
In a paper on this subject in 1885 3 I gave somewhat in detail 
certain views entertained in regard to the respiratory function of 
the nasal chambers, which were based largely on clinical observa- 
tion, which I quote somewhat in detail here, as follows: 
“ The normal function of the mucous membrane is to secrete 
mucus, and only in such quantities as are sufficient to keep the 
membrane in a soft, moist, and pliable condition. Any excess of 
this amount becomes a morbid secretion. Normally, nasal mucus 
is composed of 93 per cent of water and 7 per cent of solid matter. 
Robbed of a small portion of this water it becomes thick, inspis- 
sated, and unhealthy. Now, as we know, every breath of air that 
passes through the nasal chambers, and reaches the passages below, 
must become surcharged with moisture; otherwise it would rapidly 
exert a deleterious influence on the mucous membrane of the air 
passages beyond, by robbing them of their moisture, and so render- 
ing their mucus thick and inspissated. It is estimated by physiolo- 
gists that in the course of twenty-four hours about five thousand 
grains of water are taken up by the inspiratory current of air, in 
its passage through the respiratory apparatus. If, in other words, 
the humidity of the inspired air be compared with that of the ex- 
pired air, it will be found that, in addition to the other changes as 
regards carbonic acid and oxygen, the inspired air will have gained 
five thousand grains of water. Now, I think, I am safe in saying 
that if five thousand grains of water were extracted from the mu- 
cous membrane of the bronchial tubes and air-cells in the course 
1 “ Handbuch der Physiologie ” von Hermann, 1880, iv., 2 S. p. 389. 
2 These de Paris, 1878, “ La Membrane muqueuse des fosses nasales.” 
3 Hay Fever, Asthma and Allied Affections,” N. Y, Med. Jour., April 24th and May 
'st, 1886. 92 
DISEASES OF THE NASAL PASSAGES. 
of twenty-four hours, the result would be complete destruction of 
their function, to such an abnormally dry condition would they be 
reduced; for, as we know, in each act of respiration, the inspired 
air reaches only the larger bronchial tubes, and the source of 
moisture, therefore, of the inspiratory current cannot be from the 
smaller bronchial tubes or air cells. We are, therefore, forced to 
the conclusion that this surplus of five thousand grains is taken up 
by the inspiratory current during its passage through the nasal 
chambers, and is still retained by it as it makes its way out through 
the air-passages, for the only source from which this amount of 
water could be taken up is the nasal mucous membrane. Certainly 
from no other mucous membrane of equal area in the body, is it 
possible that such an mount of water could be secreted in twenty- 
four hours in health. Now, the mucous membrane of the lower air- 
passages is endowed with no especial apparatus for the secretion 
of water; the only secretory apparatus with which it is endowed is 
in the mucous glands, which secrete mucus alone. 
“ In the nasal mucous membrane, however, we find an apparatus 
capable of furnishing this water, and this is the so-called erectile 
tissue of the turbinated bodies. The necessity for some such ap- 
paratus I need not refer to, further than to say that it is absolutely 
necessary and essential, for the integrity of the lower air-passages, 
that the air which reaches them should be so far charged with 
moisture that they should not be robbed of any of their secretion. 
Especially is this true in a variable climate like ours, in which so 
great changes occur, characterized by excessive humidity or abso- 
lute dryness of the atmosphere. 
“ This, then, is the great and prominent function of the nasal 
chambers, to so prepare the ingoing current of air that it shall 
exercise no injurious influence on the mucous membrane of the 
passages below. It has always seemed to me that this great re- 
spiratory function of the nasal chambers, has been to an extent 
overlooked, in regarding the nose as an olfactory organ, for whereas 
impairment or loss of the sense of smell is but an inconvenience, 
and not dangerous to the health, the impairment of the respiratory 
function of the nasal cavities involves very serious danger. Thus 
the nose as a respiraotry organ, becomes infinitely more important 
to us than as an olfactory organ. 
“As before stated, the nasal chambers contain no glands which 
secrete other than mucus. There are no serous glands. The 
mechanism, however, by which the water is poured out into the 
nasal chambers, and the ingoing current thus surcharged with 
moisture, is in this so-called erectile tissue. The watery constitu- 
ents of the blood transude the mucous membrane, and appear on THE PHYSIOLOGY OF THE NOSE. 
93 
the tortuous surfaces and passages of the cavity. Now, unless, the 
blood-vessels underlying a membrane called upon for this duty 
were very large and very numerous, they would be inadequate to 
supply this large demand. Nature, therefore, has furnished the 
membrane in this region with such an abundant supply of large 
tortuous vessels, that they assume the appearance of erectile tissue, 
and thus have given rise to this erroneous idea as to their function, 
suggested by the name erectile tissue. Were the blood-vessels in 
this region of the same calibre and capacity as those of other por- 
tions of the air-tract, it is easy to understand how the extraction of 
so great a quantity of water would soon render the current sluggish, 
by its greater consistence, and so completely arrest the function 
which they were designed to subserve. In addition to this large 
blood-supply, there must be, of course, some delicate mechanism 
by which this function is regulated. This control is exercised by 
the vaso-motor system of nerves. So delicately must this be ar- 
ranged, that the transudation of serum must accurately adapt itself 
to every existing atmospheric condition. To-day, for instance, 
with air saturated with moisture, the turbinated vessels must be 
so far kept in control by the vaso-motor nerves, that no serum es- 
capes. To-morrow, again, with an almost absolutely dry atmo- 
sphere, under the action of the vaso-motor nerves, the blood control 
is unlocked, as it were; the turbinated vessels are so charged with 
blood that the current becomes active, and the amount of serum 
poured out on the mucous surface of the nasal cavity is such as to 
thoroughly saturate the ingoing current of air with moisture, and 
still not impair the consistence of the blood flowing through the 
vessels. This control must be so delicately exercised as to meet 
not only daily, but even momentary changes in the humidity of the 
inspired air. It is easy to see, therefore, how great the demand 
must be upon the vaso-motor nerves which regulate the calibre of 
these blood-vessels, how constant the watchfulness which controls 
this exosmotic action, and therefore how easily any impairment of 
this function might occur.” 
These views were based on the result of many years of clinical 
observation of this membrane, both in health and disease. 
From an anatomical point of view, it is difficult to understand 
why nature should have placed in these passages the somewhat in- 
tricate and complex mechanism which we there find, unless it was 
designed to subserve some important purpose. That this purpose 
is not connected with the function of phonation or olfaction, I think 
cannot be questioned. We must then conclude that its design is 
connected with the function of respiration—a view which I think 
can alone be entertained after the investigation of the anatomy of 94 
DISEASES OF THE NASAL PASSAGES. 
the membrane already made. We can only conclude, therefore, 
that this most intricate and delicate apparatus is designed to serve 
the function already described, of serous exudation. 
The special method by which this serous transudation takes 
place we are scarcely ready to describe, though a very important 
suggestion comes to us from the notable observation of Chatellier.1 
He describes certain minute canals, running at right angles to the 
mucous membrane, penetrating to the lymph channels. Chatellier 
makes the suggestion that these canals serve the purpose of serous 
channels. The question arises, whether Chatellier's canals may 
not be the tubular mucous glands of Zuckerkandl. 
As before stated, these observations were based entirely on 
clinical study of the respiratory tract both in health and disease, 
continuing through a number of years. They have, however, since 
my views were first published, been confirmed in a very striking 
manner by Aschenbrandt’s2 exhaustive experiments, in which data 
of a sufficiently definite character are given to establish all of my 
conclusions. 
Aschenbrandt’s experiments were conducted in the Phyisologi- 
cal Institute of Professor Fick, of Wurzburg, and in the following 
manner: An air aspirator, with a capacity of five litres (five and a 
quarter quarts), is attached to one of the nostrils by means of a 
glass tube, in which a thermometer is fixed in such a manner as to 
register the temperature of the air immediately upon its exit from 
the nose. One litre (quart) of air is passed every six seconds, each 
experiment being finished in thirty seconds. In a large number of 
experiments Aschenbrandt found, that with the temperature of the 
air in the room varying from 8° C. (46.4° F.) to 12° C. (53.6° F.), 
the temperature of the air as it passed from the nose did not vary 
from 30° C. (86° F.). Now the temperature of the expiratory cur- 
rent in ordinary respiration is 30° C. (86° F.), which shows conclu- 
sively that the warming of the air in respiration is done exclusively 
by the nose. 
Experiments were also made as to the amount of moisture in 
the expired air, and were conducted with the same apparatus. He 
found that each five litres (five and a quarter quarts) of expired air 
contained 0.18 gramme (2.77 gr.) of water, which constitutes com- 
plete saturation,' and furthermore, that the whole amount with- 
drawal from the body in twenty-four hours was 500 grammes (7715 
grs.), and that the source of this, therefore, was in the nose. A 
still further conclusion was drawn from these experiments, that all 
1 Annales des Mai. de l’Or., etc., No. 6, June, 1887. 
2 “ Ueber die Bedeutung der Nase im Respiration,” Wurzburg, 1886. THE PHYSIOLOGY OF THE NOSE. 
95 
mechanical dust is completely arrested during inspiration, and is 
deposited on the moist surfaces of the nasal membrane. 
Subsequent to Aschenbrandt’s observations, Kayser1 made a 
series of investigations in the same line. He made use of the same 
aspirating bottle as Aschenbrandt, and the thermometer-tube fitted 
into the nostril was essentially the same. In Aschenbrandt’s investi- 
gations, however, the upper pharynx was not shut off, and hence 
warm air could be drawn from the mouth out through the nose, by 
the aspirator, and thus vitiate the experiment. To obviate this 
source of error, in Kayser’s experiments the palate is held up by a 
spatula, after the application of cocaine, and the upper pharynx 
and nose shut off completely from the lower pharynx and mouth. 
The temperature of the air after passing through both nostrils, five 
litres (five and a quarter quarts) in thirty seconds, was found to be 
the same as in Aschenbrandt’s experiments, 30° C. (86° F.), when 
the temperature of the inspired air was I2°C. (53-6° F.); with an ex- 
ternal temperature of o° C. (320 F.)to—4°C. (24.8° F.), the tempera- 
ture of the expired air was 27.50 C (81.5 F.). If the temperature 
of inspired air was 190 (66.2° F.) to 20° (68.7° F.), the expired air 
was 32.30 (90.i°F.) to 33.50 (92.30 F.). 
For testing the heating power of one nostril, instead of passing 
a tube through the mouth behind the palate, closing one nostril, 
and aspirating through the other as Aschenbrandt did, Kayser 
passed a caoutchouc tube through the inferior meatus of one side, 
the posterior end of this tube passing beyond the choana; the an- 
terior end was fitted closely into the nostril by means of a rubber 
cork. The apparatus for aspiration and determining the tempera- 
ture was then fitted to the other nostril. It is easy to see that by 
this means the heating effect of only one nasal cavity was obtained. 
The palate was held up as in the preceding experiment. 
In this experiment Kayser differs somewhat from Aschenbrandt, 
for while Aschenbrandt found that the air was heated just as much 
in passing through one nasal cavity as through both, Kayser found 
that it was heated about 0.50 C (0.90 F.) less. Variations in ex- 
ternal temperature made the same difference in the expired air as 
in the first experiment. 
Kayser also performed a series of experiments for the purpose 
of finding how much the air was warmed in oral breathing. A 
caoutchouc tube was passed through the inferior meatus of one 
side to the choana, and the opposite nostril closed with the finger. 
The tube containing the thermometer was fitted into a cork, and 
held between the lips. The aspiration was then performed in the 
1 Pfleuger’s Archives, vol. xli., 1887, pp. 127-47, 96 
DISEASES OF THE NASAL PASSAGES. 
usual way. It was found that the air was heated almost half a 
degree less than in passing through both nostrils. 
For determining the amount of moisture in the air after its 
passage through the nasal chambers or mouth, the thermometer- 
tube was replaced by a U-tube containing pumice-stone and sul- 
phuric acid. The increase in weight of the tube at the end of each 
experiment enabled him to calculate the amount of water contained 
in the expired air. As a result of these experiments he found that 
in its passage through the nose or mouth, the air was completely 
saturated with moisture. 
The above experiments, as originally suggested by Aschen- 
brandt, were intended to approximate, as nearly as possible, the 
conditions of normal respiration, the tidal air being taken as five 
hundred cubic centimetres, and the respiration rate as twenty. In 
thirty seconds, then, five litres (five and a quarter quarts) of air 
would pass through the respiratory passages. Kayser points out 
that at least half the time is consumed by expiration and repose, 
and consequently in the experiment the air has been allowed to 
remain in the nose and mouth at least twice as long as it does in 
normal respiration. He, therefore, repeated all of the above ex- 
periments, regulating the aspirator so that five litres (five and a 
quarter quarts) would pass in fifteen seconds instead of thirty 
seconds. He found, however, that this increased rapidity did not 
notably influence the result, either with reference to temperature 
or saturation. 
To simulate as nearly as possible the conditions found in the 
trachea and bronchi, Kayser made use of a glass tube, of such a 
length and diameter that its area was about equal to that of the 
trachea and larger bronchi. This tube was lined with filter paper 
saturated with water. A thermometer was fixed in this tube so 
that its temperature.could always be determined, and the tempera- 
ture was kept constant by enclosing it in a hot-air bath. One end 
of the tube was left open, the other was connected with the tube 
containing a delicate thermometer, the same apparatus, in fact, used 
in the preceding experiments for determining the temperature of 
the expired air. Here he found that lowering the temperature of 
the air before aspiration, made considerable difference in the tem- 
perature of the air after aspiration, and that doubling the rate of 
aspiration also exerted an influence upon the temperature and 
moisture of the air after aspiration. 
For the filtering out of mechanical dust, Kayser claims that 
Aschenbrandt’s investigations are not conclusive, since with the 
apparatus with which the experiment was made, very little dust 
could get into the nose at all. He consequently improved the ap- THE PHYSIOLOGY OF THE NOSE. 
97 
paratus, using a glass globe with three openings. One of these 
communicated with a bellows used to agitate finely powdered mag- 
nesia, the second was open to the air, the third was connected with a 
glass tube fitting tightly into one nostril. A similar tube connected 
with the aspirator was fitted to the other nostril. If now aspiration 
is conducted in the usual manner, and at the same time the dust 
is agitated by the bellows, Kayser finds that dust can still make its 
way around into the nostril connected with the aspirator, thus 
proving that the nose is not a perfect filter for mechanical dust. 
Kayser makes the further observation, that when cold air is in- 
spired through the nose, there is a notably increased blood supply 
in the turbinated bodies, thereby increasing their heating capacity. 
In this connection he suggests that in tracheotomy the inspired air 
in summer must be of a temperature of 30° (86° F.) to 350 C. (950 F.), 
and in winter of 250 (770 F.) to 28° C. (82.4° F.), and in each case 
must be saturated with moisture in order not to produce bronchial 
irritation; the reason being that the bronchial membrane is not 
endowed with a special apparatus for moistening and heating the 
air. 
It will be noticed that Kayser makes no definite statement as 
to the amount of moisture poured out by the venous sinuses of the 
nose in the twenty-four hours. Aschenbrandt, however, makes 
the statement that the whole quantity of water, which the air in 
respiration draws from the human body, amounts to about 500 
grammes (7715 grs.) in the twenty-four hours, and this is taken from 
the mucous membrane of the nose. This observation, however, 
was scarcely necessary, since the amount given in my original 
paper, as from twelve to sixteen ounces, is the amount given by all 
physiologists as the amount taken from the lungs. Both Aschen- 
brandt and Kayser, however, make the definite statement that all 
the air which passes to the lungs through the nose is in a state of 
saturation. Of course, saturated air passing in and out of the 
lungs, takes absolutely no moisture from the bronchial mucous 
membrane. The general accuracy of these results has received 
still further confirmation, in a series of experiments by Bloch,1 vvho 
reaches, practically, the same conclusions as Aschenbrandt and 
Kayser, with the exception, that he finds that the expired air 
reaches only to two-thirds of the saturation point, and that the 
heating capacity of the oral cavity is inconsiderable. Clinical 
observation, I think, should add sufficient weight to the accuracy 
of the earlier experiments, to practically establish the truth of their 
teaching. 
The proposition is proven beyond question, as previously stated 
1 “Archives of Otology,” vol., xvii. No. iv.; vol. xviii., No i. 98 
DISEASES OF THE NASAL PASSAGES. 
by myself, that the sole source of moisture is in the nose. I think 
we may declare it as an established truth, that the function of the 
so-called erectile bodies is serous transudation, and that they are 
designed to subserve no other function in the economy. 
The observers already quoted have made allusion to the fact 
already generally accepted by physiologists, that the air in passing 
through the nose is cleansed, in that floating particles of foreign 
matter lodge against the moist and tortuous surfaces. Probably, 
however, this is an adventitious function; certainly it is a very un- 
important one. I have never regarded the bronchial mucous mem- 
brane as subject to any serious danger from floating particles of 
foreign matter making their entrance with the inspired air. In 
seeking for a proper function to assign to these falsely called erectile 
bodies of the nose, the assertion has been made, notably by John 
Mackenzie, that they are designed to swell up and thereby close the 
nasal passages to prevent the entrance of foreign bodies. This 
observation, it has always seemed to me, was based on the original 
mistaken idea that the turbinated bodies were erectile tissue; and, 
therefore, their function was to become erect. I think it has been 
demonstrated that these bodies are not erectile tissue. Further- 
more, they never become erect in health or disease. Certainly, if 
nature intended that they should swell out, and thereby occlude 
the nasal passages to prevent the entrance of foreign bodies, thus 
compelling the opening of a far more vulnerable tract through the 
mouth, nature has been guilty of an awkwardness of design which 
presents no analogy in the whole human economy. CHAPTER VII. 
GENERAL CONSIDERATIONS CONCERNING CATAR- 
RHAL DISEASES. 
There are so many misconceptions in regard to what is ordin- 
arily called “ nasal catarrh,” not only among the laity, but also to 
no small extent among professional men, that it seems wise here 
to discuss, in a somewhat general way, certain questions connected 
with this subject. Perhaps the most prevalent misconception in 
regard to nasal catarrh is that it is a special disease of the nasal 
cavity, which leads ultimately to ulceration of the soft parts with 
necrosis of bone. This view is the one largely encouraged in the 
advertisements of proprietary remedies for the cure of this affec- 
tion. It scarcely needs to be stated here, that a simple catarrhal 
inflammation is always a catarrhal inflammation from its onset, and 
never results in anything more than a simple hypertrophy of the 
tissues. Ulceration and necrosis belong to syphilis or some other 
of the constitutional dyscrasiae alone, and bear no relation whatever 
to the inflammatory process. Another somewhat prevalent idea, 
entertained both by the medical men and the laity, is that there is 
a catarrhal diathesis, a peculiar systemic condition, under the in- 
fluence of which a patient becomes especially liable to catarrhal 
inflammation, which may attack indifferently any of the mucous 
membranes of the body. We not infrequently hear a patient 
making the statement that all his mucous membranes are weak, 
and that an inflammation .of the mucous membrane, say of the air 
tract, is liable to be followed by a similar weakness of the intestinal 
tract, or possibly of the genito-urinary tract. I know of no good 
ground for this assertion. Certainly, my own clinical experience, 
which has been somewhat large, fails to justify this view in any 
manner. The mucous membranes of different portions of the air 
tract are in exceedingly close sympathy, and a morbid process in 
one portion is very liable to be followed by a morbid process in 
another part of the tract, but that there is any sympathy or con- 
nection between the mucous membrane of the air tract, and the 
mucous membrane of the food tract, I do not believe to exist. 
There are many who honestly entertain, and many who dis- 100 
DISEASES OE THE NASAL PASSAGES. 
honestly encourage the idea, for commercial purposes, that a 
simple catarrhal inflammation of the upper air tract has a tendency 
to lead to the development of pulmonary diseases. Thus, I find 
so excellent an authority as Beverley Robinson1 making the state- 
ment that “ undoubtedly the patient affected with long-standing 
follicular disease of the naso-pharyngeal space, sooner or later de- 
velops this same follicular disease of the remaining portions of the 
respiratory tract; of the pharynx at its middle and lower portions 
first, then of the larynx and finally of the bronchial tubes. Hence 
comes, I am now thoroughly convinced, the initial stage in certain 
instances of what afterward develops into different forms of 
pulmonary diseases.” A somewhat similar view is advocated by 
Jarvis.2 Notwithstanding such authority, I fail to find in Robin- 
son’s argument or Jarvis’s report of cases, any clinical evidence in 
substantiation of this view. Possibly, a patient with a family his- 
tory of phthisis, is more liable to fall a victim to this disease with a 
bad chronic catarrhal affection of the upper air passages, than if his 
upper air passages were in a state of perfect health, and yet even 
this assertion it would be difficult to establish on any grounds of 
clear, clinical observation. I think, therefore, that we must con- 
tent ourselves for the present certainly, with the view that a chronic 
catarrhal disease of the nose or naso-pharynx tends to the develop- 
ment of a process of a similar character in the larynx, trachea and 
bronchial tubes, but nothing further. In other words, the tendency 
of a catarrhal inflammation is to extend downward, but it remains 
a catarrhal inflammation always. The worst outlook, therefore, is 
in the development of a chronic bronchitis with asthma, excluding 
cases of purely nervous asthma, which while undoubtedly dependent 
on a rhinitis or naso-pharyngeal catarrh, are not directly the result 
of it, but only occur in connection with the peculiar neurotic habit. 
This question, however, is more fully discussed in the chapter de- 
voted to the subject of asthma. 
The word catarrh is derived from two Greek words xard psiv, 
which translated mean “ to flow downward,” the name being given 
primarily to a disease of the upper air passages in which the prom- 
inent symptoms seemed to be a flowing down of the mucus or 
muco-pus. In this manner, this term “ Catarrh ” came to be used as 
designating all diseases of the nasal passages which were character- 
ized by an abnormal discharge, including tumors, syphilis, scrofula, 
ozaena, as well as the simple chronic forms of rhinitis. If we trans- 
late the word and use it as meaning simply a discharge, I think we 
obtain a true estimate of its proper scope. A patient who suffers, 
1 “Nasal Catarrh and Allied Diseases,” second ed., New York, 1885, p. 131. 
2Trans. Amer. Climatological Assn., New York, 1886, p. 30. GENERAL CONSIDERA TIONS. 
101 
therefore, with a chronic nasal catarrh suffers from a chronic nasal 
discharge, the one word being quite as definite as the other This 
we understand may be the result of a large number of different dis- 
eases of the nasal cavity. We reach the conclusion, therefore, that 
a patient suffering from nasal catarrh really has some diseased con- 
dition of the upper air tract. What this condition is, simply re- 
mains for us to determine by the improved diagnostic methods of 
the present day. A somewhat later use of the term was that first 
described, I think, by Virchow, who restricted it to the designa- 
tion of a particular form of inflammatory action taking place in 
mucous membranes, which he termed a catarrhal inflammation, 
namely an inflammation which was characterized by the pouring 
out upon its surface of a secretion which was fluid in character, in 
contradistinction from a croupous and diphtheritic inflammation, 
in which the material poured out on the surface contains largely 
of fibrin and therefore coagulates, thus forming a false membrane. 
This use of the term catarrh is the one which alone should find 
place in medical literature. In this manner we obtain a definite 
classification of the diseases affecting mucous membranes, in that 
when we speak of a chronic laryngitis or a chronic rhinitis, we mean 
a chronic catarrhal inflammation, and when allusion is made to a 
croupous or diphtheritic inflammation of these parts, we specify 
this form in including the term croupous or diphtheritic. We re- 
ject, therefore, entirely, the use of the word catarrh, and in place of 
it adopt that nomenclature which designates the character of the 
inflammation and the region involved, and simply regard catarrh as 
a symptom of any of the many diseases which may affect the upper 
air tract. 
A very prevalent idea in regard to catarrhal inflammation is 
that its prominent symptom is excessive secretion, either of normal 
mucus or of muco-pus. This is rather a nice question to determine 
in hypertrophic rhinitis. It is altogether probable that this appar- 
ent excessive secretion is really a diminished secretion. In health 
the nose secretes probably a pint of serum, which becoming min- 
gled with the normal mucous secretion, disappears, without the 
patient being conscious of it, by evaporation, the water being taken 
up largely by the inspired current of air. In diseased conditions 
the amount of serous exudation is not infrequently diminished as 
the result of hypertrophy, and therefore the mucous secretion not 
being diluted with this large amount of serum, become thick and 
inspissated. A pint of healthy sero-mucus, secreted by a healthy 
membrane, does not make itself felt. Diminish the serous exuda- 
tion one-half, and we have seven or eight ounces of secretion from 
which the limited amount of water is taken up rapidly; hence we 102 
DISEASES OF THE NASAL PASSAGES. 
will find an inspissated mucus which makes itself felt, and gives 
rise to unpleasant symptoms. In atrophic rhinitis the exosmosis of 
serum is more or less completely abolished. The whole secretion 
of the mucous membrane is confined to a mucus, largely surcharged 
with epithelial cells, giving rise to a muco-purulent discharge, 
which is dried up by the ingoing current of air, thus resulting in 
the formation of masses of dried mucus or crusts. We have here 
a very marked diminution of secretion, and yet apparently an ex- 
cess, m that every portion of the limited secretion manifests itself 
in the form of green crusts, which give rise to unpleasant symp- 
toms. In a naso-pharyngeal catarrh we have an apparent excess 
of secretion. The vault of the pharynx contains glands in health, 
whose function is to pour out mucus for lubricating the bolus 
of food, and thus facilitate its passage to the stomach. The nor- 
mal secretion from this region in health is large, but it is a thin 
fluid, and passes into the pharynx in even large quantities without 
the individual being conscious of it. In a diseased condition of 
the naso-pharynx, the secretion becomes impaired, and undoubtedly 
notably diminished, certainly in its watery constituents. It is this 
change into a muco-pus, which while apparently secreted in large 
quantities, remains a thick tenacious mass of mucus adhering to 
the mucous membrane lining the pharyngeal vault, in such a man- 
ner that the patient expels it with the greatest difficulty; and 
hence its presence becomes a source of exceeding great annoyance. 
The same I think we may say of the larynx and trachea in simple 
chronic laryngitis and tracheitis, which I regard as almost invariably 
secondary affections to diseases of the nasal passages. The tract 
above failing to do its proper duty of warming and moistening the 
inspired air, the parts below are subjected to the influence of an ab- 
normally dry current of air in respiration, under the action of which 
the normal mucus is robbed of a certain proportion of its watery 
constituents, and becoming thick and inspissated, proves a source 
of irritation, and is expelled with a certain amount of difficulty. 
These diseases are not characterized by an excess of secretion but 
by a diminution of secretion. We are thus led to the view that it 
is an entire mistake to regard excessive secretion as the prominent 
feature of a chronic catarrhal inflammation. A proper appreciation 
of these diseases will be better obtained, I think, when we clearly 
understand in just what manner a chronic catarrhal inflammation 
interferes with the very important functions which these parts are 
designed to subserve. This question is more fully discussed in a 
later chapter. I have tried to make clear that a nasal catarrh, so- 
called, means nothing more than that there is some diseased condi- 
tion of the nasal passages. In treating such a case our first duty is GENERAL CONS ID ERA T/ONS. 
103 
to make a careful examination of those passages to determine what 
special morbid condition exists there to give rise to such symptoms 
as present. A discharge from the nose anteriorly is somewhat un- 
common. We should understand that in what is called an ordinary 
catarrh, viz., a liability to cold with more or less obstruction to 
nasal respiration, together with a tendency to accumulation of thick 
mucus in the fauces, we have to do, usually, with either hypertrophic 
rhinitis or a naso-pharyngeal catarrh, and these are not infrequently 
complicated with a deformity of the nasal septum. We have here 
the three prominent conditions which give rise to an ordinary mu- 
cous catarrh so-called. These three conditions are somewhat in- 
timately associated in most cases, and it is by no means easy to 
determine just where the morbid lesion lies. Certainly the nasal 
cavity and naso-pharynx react upon each other in a very intimate 
manner. I am disposed to think that in most cases a naso-pharyn- 
geal catarrh is dependent primarily on hypertrophic rhinitis, and 
that an attempt to deal with it is unsuccessful until the hypertrophic 
rhinitis is brought under control. Furthermore, the hypertrophic 
rhinitis in the large majority of instances is dependent upon a de- 
formity of the septum. We have here, therefore, two lesions to re- 
move before we can successfully attack the naso-pharynx. Further- 
more, it is by no means easy to recognize by the closest rhinoscopic 
inspection, what constitutes the morbid lesion in a naso-pharyngeal 
catarrh. Hence we are compelled to remove the disease of the 
nasal passages first, in order to determine that the naso-pharyngeal 
disorder is not entirely dependent upon the nasal. These ques- 
tions are mainly suggested here as illustrating some difficulties in 
diagnosis, and of course will be discussed at length in the chapters 
devoted to their consideration. Furthermore, it may be noted that 
the idea that a hypertrophic rhinitis gives rise to discharge from the 
nostril is altogether mistaken. It is altogether probable that the per- 
verted mucus which accompanies the disease, makes its way largely 
into the pharynx, and we thus find that a faucial catarrh, often 
spoken of as a pharyngitis, follicular disease of the pharynx, sore 
throat, etc., is really a disease of the nasal cavities, and in most in- 
stances of the mucous membrane covering the turbinated bones. 
The character of the discharge, whether anteriorly through the 
nostrils, or through the posterior nares and the fauces, is always 
something of an indication of the form of disease with which we 
have to deal. A purely watery discharge usually indicates a vaso- 
motor disturbance, such as hay-fever or nasal rhinorrhoea. A pro- 
fuse sero-mucous discharge in which the serum is more or less 
charged with flakes of grayish mucus, is characteristic of nasal 
polypi. It also occurs in the second stage of acute rhinitis. A 104 
DISEASES OF THE NASAL PASSAGES. 
thick mucous discharge containing flocculi of whitish mucus, and 
rendered opaque by a moderate mixture of young cells, may occur 
in connection with hypertrophic rhinitis, but is usually indicative 
of a disease of the naso-pharynx. This occurs more especially in 
young children suffering from adenoid vegetations of the pharyn- 
geal vault. A thick whitish mucus discharged into the fauces, 
which is drawn down by a nasal screatus, and expelled by hawking, 
is characteristic of either hypertrophic rhinitis or naso-pharyngeal 
catarrh. A purulent discharge composed of masses of somewhat 
thick yellow pus, attended with something of an odor, should always 
call attention to the probability of the existence of suppurative 
disease of one of the accessory sinuses, usually the antrum in an 
adult. A similar form of discharge occurs in the purulent rhinitis 
of childhood, and in the last stages of acute rhinitis. A purulent 
discharge through the nostrils, mixed with shreds of necrotic tissue 
and blood, and also with offensive crusts, indicates the existence of 
ulceration and probable necrosis, and should always suggest syphilis, 
although small crusts detached from just within the margin of the 
nostril may be discharged from slight erosions of the septum. The 
discharge of greenish crusts, in connection with somewhat healthy 
looking pus, or muco-pus, in connection with a mild offensive odor, 
the crusts being bright yellow or greenish in color, and containing 
neither blood nor necrotic tissue, should suggest the existence of 
atrophic rhinitis. CHAPTER VIII. 
ACUTE RHINITIS. 
Acute rhinitis is an acute inflammation of the mucous mem- 
brane lining the nasal cavities proper, which may confine itself 
entirely to these passages or, as not infrequently happens, it may 
extend to neighboring passages, as the pharynx, larynx, and the 
air passages below, as well as in a mild degree to the accessory 
cavities, such as the frontal sinus, the antrum of Highmore, and 
also the Eustachian tube. This tendency to extension, however, 
it should be stated, is not a characteristic of the earlier attacks of 
acute rhinitis, but only occurs, as a rule, in those who are ac- 
customed to take cold easily on slight exposure and are frequently 
subject to these attacks; each successive attack being to an extent 
of a more aggravated character and also showing increased dis- 
position to extend to the passages below, so that, whereas the 
earlier attacks were confined to the cavity of the nose alone, the 
subsequent attacks, years later even it may be, show a disposition 
to extend downward, as it is said, thus giving rise to a laryngitis, or 
an ordinary winter-cold. As this habit increases, and only as it 
becomes a habit, do we find these processes reversed, and as a 
result of exposure the patient now commences to have attacks of 
laryngitis and bronchitis which show a disposition to travel upward, 
resulting later in an attack of acute rhinitis. The original seat of 
trouble in all these cases is to be found in the nasal cavities. 
ETIOLOGY.—It is ordinarily stated that an acute rhinitis is the 
result of exposure to cold and this is undoubtedly true, but behind 
this is a very prominent predisposing cause in an already existing 
chronic inflammation of the nasal mucous membrane, the chronic 
morbid process preceding the acute process, and rendering the pa- 
tient especially liable to the occurrence of an exacerbation on slight 
exposure. It is often stated that cold in the head may arise from 
the inhalation of acrid vapors, and also that it occurs as the result 
of a peculiar idiosyncrasy which renders the nasal mucous mem- 
brane particularly susceptible to certain odors, such as ipecac and 
iodine. I am disposed to question whether what occurs in these 
cases is a genuine attack of acute rhinitis, and am rather disposed 106 
DISEASES OF THE NASAL PASSAGES. 
to think it is a temporary disturbance of the great respiratory 
function of the nose, giving rise to what has been called an in- 
fluenza, or what in its aggravated form constitutes hay-fever or 
rose-cold, these affections giving rise to a morbid condition of the 
nasal mucous membrane which differs essentially from an acute 
rhinitis, as will be discussed more fully in the consideration of 
those diseases. Under the same category I should be disposed to 
place those rare epidemics which are recorded in history as having 
affected large portions of the population where they prevailed, such 
as that described by Anglade1 as quoted by Mackenzie, in which 
an entire army was suddenly prostrated with the disease; or the 
great epidemic of 1762 s in which the type of the disease was so 
severe as to cause a mortality of two per cent. It should also be 
borne in mind that the internal administration of iodides is liable 
to produce nasal symptoms closely resembling those of acute rhini- 
tis. It, however, is not attended with any observable constitutional 
symptoms. Moreover, its action is limited to the production of 
turgescence of the blood-vessels with watery discharges. In these 
cases, the morbid process manifests much the same symptoms and 
runs much the same course as an ordinary attack of acute idiopathic 
rhinitis. 
In general then, we may say of this affection that it is caused by 
exposure to cold, in the manner already so fully discussed in the 
chapter on taking cold as to render any discussion of the subject 
here unnecessary. Acute rhinitis also occurs at the onset of cer- 
tain of the exanthemata, such as measles, typhus, typhoid, erysip- 
elas, etc. 
SYMPTOMATOLOGY.—The attack is not usually ushered in by chill, 
but rather by chilly sensations, a feeling of lassitude and general ma- 
laise, followed by a mild febrile condition with pains in the muscles 
and loss of appetite. These symptoms, as a rule, however, are not 
well marked, and the patient’s attention is first called to a sense of 
stuffiness about the frontal region, with burning or prickling sensa- 
tion in the nose, with dryness and heat. This may last a few hours 
or more, when there sets in a watery discharge of a somewhat acrid 
character, which gradually changes to a mucous discharge, more or 
less copious in amount. This, in time, leads to a free discharge of 
a muco-purulent character. The dryness of the membrane, which 
characterizes the onset of the attack, is coincident with the stage of 
congestion and arrest of secretion which mark the commencement 
of any acute inflammation of a mucous membrane. Following this, 
there occurs a free transudation of liquor sanguinis from the en- 
1 “ Sur le Coryza simple,” These de Paris, 1837. 
2 “ Encyclop. Brit.,” vol. xiii., gth ed., p. 73. ACUTE RHINITIS. 
107 
gorged blood-vessels, which goes to make up the more or less pro- 
fuse serous or watery discharge which constitutes the main portion 
of the secretion which characterizes the second stage of the attack. 
The normal glandular structures of the membrane are soon stimu- 
lated into an excessive and morbid activity and a profuse discharge 
sets in, consisting of clear, transparent mucus, together with an ad- 
mixture of epithelial cells and leucocytes and perhaps a few red 
blood-corpuscles. As the inflammatory process develops, the nor- 
mal nutritive processes of the membrane are stimulated to an ex- 
cessive degree, epithelial cells are generated with increased rapidity, 
and the discharge assumes a muco-purulent character, being thick, 
yellow and turbid, the color and consistency being entirely due to 
the very large number of young, unripe cells which become incor- 
porated with the discharge. The nasal cavity proper is so far the 
seat of most of the symptoms, these being mainly confined to a 
sense of discomfort referable to the nose, increased secretion, a 
sense of fulness or complete closure of the passages due to the 
swelling of the membrane, together with frequent and often dis- 
tressing attacks of sneezing. If the frontal sinuses are involved, the 
attack is attended with frontal headache, oftentimes of a distressing 
character. This is not due, necessarily, in every case to an exten- 
sion of the inflammatory process, but rather to the congestion of 
the mucous membrane lining the cavity, with pressure upon the 
nerves. In many cases, there is marked irritation of the conjunctiva, 
together with overflow of tears. This is undoubtedly due to ob- 
struction of the tear-duct, the swollen mucous membrane of the 
lower turbinated bone pressing against and occluding the orifice. 
That this can occur I do not question, although Dr. Allen,1 in 
discussing this matter, maintains that the closure of this duct can- 
not occur except as the result of atrophy, osteitis, or necrosis. 
The orifice of the antrum of Highmore is often closed, giving rise 
to a sense of fulness and stuffiness, and oftentimes severe neuralgic 
pains referable to that region, although fortunately the diseased 
process rarely extends in its activity to this cavity. When this does 
occur, however, we have a condition of things of somewhat grave 
import. This, however, will be discussed in a subsequent chapter. 
Obstruction of the Eustachian tube, giving rise to deafness, and 
not infrequently, ringing in the ears, is not an unusual symptom, 
this berng due merely to obstruction, and not to any extension of 
diseased action, although a direct extension of the inflammatory 
process to the middle ear, giving rise to acute middle ear disease, is 
one of the accidents which may occur. 
1 “ Relation between Nasal Catarrh and the Closing of the Lachrymal Duct,” Philadel- 
phia Medical News, February 6th, 1886. 108 
DISEASES OE THE NASAL PASSAGES. 
As has been already stated, the tendency to extension of the 
inflammatory process to the accessory cavities is very limited, but 
this is not true of the pharyngeal vault, for the membrane here, I 
think, is in all cases in a state of mild acute inflammation, the mu- 
cous membrane proper being swollen, while the glands, which con- 
stitute the pharyngeal tonsil, are stimulated to an excessive activity. 
This is further aggravated by the fact that their normal function is 
interfered with, which, as has been already stated, is largely de- 
pendent on a healthy functional activity of the nasal mucous mem- 
brane; for, during an attack of acute rhinitis, the normal mucous 
secretion is not swept over and diluted by the moisture-laden vapor 
of the inspired current of air, it therefore becomes thick, viscid, and 
inspissated, and so accumulates in the pharyngeal vault, hindering 
the normal function of the palate, preventing the renewal of air in 
the middle ear, and increasing the obstruction of the orifice of the 
Eustachian tube, and giving rise to marked faucial irritation. 
The sense of smell is generally lost for a time, and as a conse- 
quence also the sense of taste, this being due mainly to the fact 
that the odoriferous particles are entirely excluded from the olfac- 
tory region. The integument about the orifices of the nostrils is 
liable to become inflamed, as a result of the irritating qualities of the 
discharge, which contains largely of saline matter, a condition which 
is undoubtedly aggravated by the frequent use of the handker- 
chief to which the sufferer is obliged to resort. 
DIAGNOSIS.—The recognition of an acute rhinitis should be based 
on the same general rules which govern us in the recognition of an 
inflamed mucous membrane in any portion of the body. An inspec- 
tion in the first stage reveals to us the mucous membrane covering 
the turbinated bones in a red and swollen condition, the color being 
of a distinctly bluish-red or venous tinge, while the surface of the 
membrane presents a dry and somewhat glazed appearance. The 
nasal cavity is, of course, largely encroached upon by the swollen 
membrane, and#a deep inspection, therefore, is not easily obtained. 
During the second stage, we have the color of the membrane 
notably changing its aspect. It now presents a brighter, more rose- 
colored tint, somewhat more nearly approaching the arterial color, 
while its surface is bathed in a profuse discharge of clear, white, 
watery serum. The deeply-red, highly-turgid appearance which 
characterizes the first stage has changed notably, the membrane 
seems less swollen and less highly distended. 
In the third stage, a still further change is noted. As the secre- 
tion becomes surcharged with the rapid desquamation of epithelial 
cells, it assumes a bright yellow color, is notably less in amount, 
and is of a somewhat thick and viscid character. The membrane ACUTE RHINITIS. 
109 
beneath it still presents the appearances of active acute inflamma- 
tion, being swollen in contour and of a bright red color, the normal 
lumen of the cavity being greatly encroached upon, the tissues over 
the middle turbinated bone being in contact with the septum almost 
invariably, and in most cases the same condition existing in the 
lower meatus. 
An examination by posterior rhinoscopy shows each posterior 
naris more or less completely blocked by the swollen membrane 
of the lower and middle turbinated bones, their gross appearance 
on inspection corresponding to that of the membrane seen in front, 
in the different stages of the disease. The vault of the pharynx 
will be found to contain a large mass of thick, yellow, inspissated 
mucus, adhering to the crypts of the pharyngeal tonsil, while the 
membrane surrounding the Eustachian orifice is reddened, but 
rarely swollen. The lower pharynx oftentimes presents a dry and 
glazed appearance, due to the habitual mouth-breathing which 
results from the obstruction of the nasal passages. It may be 
somewhat reddened as the result of this irritation, but is not, as a 
rule, in a state of active inflammation, not being a part of the air- 
passages. It is true of the acute form, as well as of the chronic 
form of inflammation of these regions, that it confines itself to the 
physiologically associated tracts, and in extending down, it passes 
immediately from the nasal passages to the larynx and trachea. 
When the larynx and trachea are involved, they present the 
same appearances as are found in ordinary sub-acute catarrhal in- 
flammation of these regions. 
PROGNOSIS.—The prognosis in this disease is favorable. It in- 
volves no danger to life and will run its course, as a rule, in about 
seven days without interference, leaving behind it probably, how- 
ever, an aggravation of the chronic condition which undoubtedly 
underlies and is the most prominent predisposing cause of the acute 
inflammation. 
It is understood, of course, that this statement applies to those 
cases where the accessory sinuses are not involved, and in which 
there are no aural complications. 
Prophylaxis.—Those who are especially liable to take cold 
should exercise additional carefulness in the avoidance of those 
causes which experience teaches them may give rise to an attack of 
acute rhinitis. Yet, an excessive zeal in this direction is always to be 
avoided, since that over-carefulness for one’s health which results in 
muffling the head and neck with too much covering, leads to an over- 
sensitiveness of the parts, by which the liability to take cold is much 
increased. It is not well, as a rule, to wear thick wraps about the 
neck and head, unless it becomes absolutely necessary as a matter of 110 
DISEASES OF THE NASAL TASS AGES. 
comfort. It must be borne in mind that exposure to low tempera- 
ture alone is not sufficient to produce a cold. It is a draft of damp 
air, usually of a mild temperature, which causes the mischief. The 
proper regulation of clothing is of the utmost importance, but it is 
always a mistake to wear more clothing than is absolutely neces- 
sary, as has already been stated. Furthermore, an equable distri- 
bution of clothing over the body should be the inflexible rule. 
We do not protect the throat by wrapping the neck; we weaken 
it. Exposure from wearing thin shoes never gives rise to cold in 
the feet. A chest-protector does not protect the chest. In fact, we 
do not protect ourselves from taking cold in our climate by exceed- 
ing carefulness in dress. We can only endure with impunity the 
changes and rigors of our changeable seasons by inuring ourselves 
to them. There are few measures of greater value as a preventive 
of colds than the daily use of a cold plunge bath. This not only 
acts to keep the emunctory functions of the skin in a healthy state 
of activity, but also serves to harden the parts, as it were, and thus 
render them less susceptible to the action of cold. This, however, 
is a measure that we cannot recommend in all cases, for the shock 
to the heat-producing force is too great in some cases. To those, 
however, who can take a daily cold bath it is not only a luxury, but 
a valuable sanitary measure. If, however, the cold plunge is not 
feasible, sponging the body with cold water to the waist every 
morning is a measure of undoubted benefit. Of more importance 
still as a preventive measure is the removal of that condition which, 
it has been already suggested, is the predominant, predisposing 
cause of acute rhinitis, namely a chronic rhinitis. Perhaps no fact 
has been more strikingly noticeable in my practice than the rarity 
with which patients take cold after commencing treatment for a 
chronic rhinitis, even the limited improvement secured by one or 
two applications being sufficient to control this tendency. Too 
much stress, cannot be laid on the fact, that in all cases the habit 
of taking cold means a chronic rhinitis, although this may be of so 
mild a character as to give rise to no marked symptoms, other 
than this special susceptibility to cold. 
Treatment.—An attack of acute rhinitis may often be aborted 
if measures are resorted to for the accomplishment of this purpose 
sufficiently early. This must needs be done very soon after the first 
local symptoms show themselves, and, as a rule, before the copious 
discharge of watery serum has set in which marks the second stage 
of the attack. This plan consists in the administration of from five 
to ten grains of quinine, followed by some warm drink, such as cham- 
omile-tea, or a hot lemonade, with the addition perhaps of a hot foot- 
bath. The object of this, of course, is to produce copious perspira- ACUTE RHINITIS. 
111 
tion and thus restore the normal heat which has been lost, and to re- 
establish a proper equilibrium between heat-production and heat- 
waste. If there is much pain over the forehead and neuralgic pain 
in the face, due to the involvement of some one of the accessory 
cavities, ten grains of Dover’s powder may be given with advantage, 
both to relieve the pain and aid in producing diaphoresis. A 
popular measure to break up a cold and one much resorted to is 
the Turkish bath. Now, a Turkish bath is a pleasure and a luxury 
in health, but I seriously question if its advantages are not very 
greatly overestimated as a remedial agent. Certainly in inflamma- 
tory affections of the air-passages, and especially those of an acute 
character, I believe this resort to be one capable of doing great 
mischief. The hot room of the bath is unobjectionable while it 
, lasts, but the necessary exposure of the sponging room and the 
* rubbing room so much over-weighs its advantages, that a cold is 
more liable to be aggravated than benefited by this method. A 
still further danger is the exposure which one undergoes neces- 
sarily, on leaving the bathing establishment after the profuse per- 
spiration. This danger is obviated, and the good effect of a hot 
bath secured by the excellent suggestion of Cohen,1 who recom- 
mends that the patient be given a hot air-bath immediately before 
retiring, by wrapping himself in a warm flannel sheet and sitting in 
a chair under which an alcohol-lamp is placed. The bath should 
last from fifteen to twenty minutes. A profuse perspiration is 
usually the result, and the patient is to wrap himself in the same 
blanket and retire to his couch. It is also recommended that he 
take some warm drink, such as hot lemonade, immediately after 
the bath, and a pitcher of water be placed by his side and that he 
drink as freely of this as he may desire, although this is contrary 
to the somewhat curious suggestion of Lower and Williams, that a 
cold may be aborted by complete abstention from the use of water 
until the symptoms abate. I have never known this procedure to 
be put in practice successfully. Cohen also advises as an abortive 
measure the administration of chloroform, although he fails to sat- 
isfactorily explain the rationale of its employment. Possessing, as 
we do, simpler and more efficient remedies, I should hesitate to em- 
brace this suggestion. 
The early administration of opium presents a remedy of un- 
doubted efficacy in mitigating the severity of the attack, and often- 
times in completely aborting it. This measure, which belonged to 
the practice of the olden times, receives the indorsement of Mac- 
kenzie2 who gives preference to the use of the tincture of opium, 
1 “ Diseases of the Throat and Nose.” First ed. 
2 Loc. cit., vol. ii., p. 2gi. 112 
DISEASES OF THE JVASAL PASSAGES 
advising that it be administered in doses of from five to seven drops 
on an empty stomach; this to be repeated, if necessary, at the end 
of six to eight hours. Lees,1 while indorsing the administration 
of opium, expresses preference for the use of bromide of potassium 
combined with belladonna, which he administers to the extent of 
producing dryness of the fauces. Belladonna, in a somewhat dif- 
ferent combination, is recommended by Beverley Robinson 2 who 
advises the use of the following powder: 
R Pulv. fol. belladonnas, ..... gr. xx 
Pulv. morphiae sulph. ..... gr. ij. 
Pulv. gum. acaciae, . . . . ad § ss. 
A small quantity of this is to be thrown into the nose at intervals 
of three or four hours by means of an insufflator. Both Sajous3 
and Robinson advise the administration of small quantities of the 
tincture of aconite, in combination with some form of opium, when 
the fever is unusually high. 
It is a very common procedure among physicians to confine 
their patients with a cold in the head absolutely to their rooms and 
oftentimes to the bed. I am by no means sure that this is wise in 
all cases. Confinement in the house certainly should be enjoined 
during inclement weather, but even in the height of an acute rhinitis 
I have frequently seen benefit result from a brisk walk in the open 
air in the middle of the day, when the sky is clear and the air not 
too cold. Confinement in bed I should deem unnecessary, unless 
the constitutional symptoms were aggravated, or some of the 
serious complications of acute rhinitis threaten, such as the in- 
volvement of the accessory sinuses, or an attack of middle ear 
disease. 
The foregoing suggestions are made as specially indicatea in 
the first stage of the disease, and before the discharges have set in, 
with the idea of arresting the further progress of the attack. Any 
of these measures may be resorted to in the second or third stages 
of the disease, but not probably with the result of more than 
curtailing the duration or the severity of the symptoms. In the 
later stages of the disease we have to deal with the vexatious ele- 
ment of excessive secretion, together with the nasal stenosis. 
The prominent indication then would seem to be the use of 
astringents, and, as following this indication, we find recommended 
a long list of drugs, both in the liquid and solid form, which are 
supposed to possess astringent properties, such as tannin, zinc, 
1 Brit. Med. Journal, Feb. 13th, 1886. 
2 Loc. cit., p. 56. 
3 '* Diseases of the Nose and Throat,” Philadelphia, 1886, p. 68. ACUTE RHINITIS. 
113 
copper, alum, bismuth, etc. My own experience teaches me that 
these drugs possess but an exceedingly limited astringent power, 
if by an astringent we mean an agent which will limit and control 
excessive secretion. That these drugs do possess this power in a 
certain degree it would not be wise to question, when we consider 
that they have been maintained in practice from the earliest days 
of medicine. Without, then, especially recommending these reme- 
dies, they are simply offered as to a certain extent curtailing and 
diminishing the excessive discharge which characterizes the later 
stages of the disease. For this purpose there may be used, by 
means of some simple spray apparatus, a solution of tannin grs. xv. 
to the ounce; alum grs. v. to the ounce; sulphate of zinc grs. iij. 
to the ounce; nitrate of silver grs. ij. to the ounce. Or the same 
astringents may be used in the form of a powder incorporated in 
similar proportions with powdered starch, magnesia, or lycopodium. 
If nitrate of silver be used, its better administration would be in the 
same proportions incorporated with talc. Michel, of Hamburg, 
advises the use of this drug in the strength of one part in twenty. 
Another form in which the local use of drugs may be secured is by 
inhalation. Here we make use of the fact that certain drugs are 
volatilized by heat. Vapors, it should be stated, however, as a 
rule, can have but limited action on the mucous membrane of the 
nose in a state of acute inflammation, on account of the difficulty of 
thoroughly medicating the whole tract. The drugs which may be 
used in this manner are benzoin, lupulin, oil of tar, creosote, oil of 
pine, turpentine, camphor, etc. The method by which these may 
be used is either by one of the elaborate inhalators sold in the drug 
stores, or by the following device, which is much simpler and perhaps 
quite as efficacious. Place from one to four teaspoonfuls of any of 
the above drugs in an open-mouthed bottle, or even in an ordinary 
coffee-cup, and pour over it half a pint of water of about the tem- 
perature of i6o°. This being held near the face the vapor of it is 
drawn in through the nose, or, if that is impossible, drawn through 
the mouth and expelled through the nose. Cohen recommends the 
vapor of iodine inhaled in the following manner. A few crystals 
of the drug being placed in a slender glass tube or quill, this is held 
in the hand, whose warmth is sufficient to cause a certain amount 
of volatilization and the vapor is then inhaled through the nostrils. 
The fumes of chloride of ammonium have, for a long time, enjoyed 
a well-deserved popularity, not only in the cases under considera- 
tion, but in all catarrhal affections of the respiratory tract. Their 
action, as I conceive it, is not to diminish secretion or limit the 
catarrhal process, but to stimulate the membrane to a certain ex- 
tent, to dilute, as it were, the mucous discharge, and render its ex- 114 
DISEASES OF THE NASAL PASSAGES. 
pulsion more easy of accomplishment by the patient. Perhaps also 
the stimulating action serves to relieve the distended blood-vessels 
in producing a freer serous exudation. In early times the volatiza- 
tion of the salt was accomplished by means of heat. The result of 
this was a vapor composed of hydrochloric acid and ammonia. 
Lewin, of Berlin, however, devised an especial apparatus for the 
accomplishment of this purpose (see Fig. 50) the principle of which, 
has been imitated in the various devices which are sold in the drug- 
stores. The additional action of any of the volatile oils or resins 
mentioned above may be secured by adding them to the water of 
the third bottle in Lewin’s apparatus. A remedy popular in Ger- 
many known under the name of Hager’s remedy, is as follows: 
B Carbolic acid, ....... 1 pt. 
Strong alcohol, ...... 3 pts. 
Caustic ammonia, ...... 1 pt. 
Distilled water, ...... 2 pts. 
This to be used as an inhalation from an open-mouthed bottle. 
This has been indorsed by Brand 1 and is of undoubted value in 
giving relief to some of the distressing features of a coryza. 
An old-fashioned household remedy for a cold consists in put- 
ting equal parts of vinegar and water on the stove, and thus charging 
the room in which the patient sits with the vapor of acetic acid. 
Following this idea, Fritsche2 recommends the following: 
Acidi acetici glacialis, 
Acidi carbolici, . . . . . aa grs. ij. 
Mist, oleo-balsamic., ..... grs. viij 
Tine, moschi . . . . . . gr. i. 
This is to be used by inhalation from an open-mouthed bottle, 
or as a vinaigrette. 
While these remedies possess unquestioned value in the treat- 
ment of the disease under consideration, we possess in cocaine a 
remedy, whose action is definite and absolutely certain in controll- 
ing what is probably the most distressing feature of the attack, 
namely, the venous turgescence. The peculiar action of cocaine 
on the blood-vessels has already been referred to and need not 
be entered upon here. I repeat, however, that in no case since I 
first observed this peculiar action have I ever failed to recognize its 
promptness and certainty in expelling the blood from the mucous 
membrane, whether in a normal state or in a state of inflammation. 
This action, however, of cocaine, lasts but three or four hours, when 
1 Berlin. Klin. Wochenschrift, 1872, No. 12. 
2 Ibid, 1887, No. 27. ACUTE RHINITIS. 
115 
it is followed by relaxation of the blood-vessels, not by a reaction, 
as has been claimed by many writers. The question arises, then, as 
to how far may we depend upon this drug to permanently control 
the acute inflammation of the nasal membrane under discussion, if 
repeated every four hours. My own experience teaches me that 
when the action of cocaine has exhausted itself, the blood-ves- 
sels do not return to their original highly distended condition, but 
that the relaxation is less marked, so that, if in an acute rhini- 
tis we repeat the application of cocaine as soon as the patient ex- 
periences any sensation of recurring stenosis, we may eventually 
depend on very markedly curtailing the duration of the attack, if 
we do not completely arrest it and keep it under control. In co- 
caine, then, I believe that we possess a remedy whose value cannot, 
or should not be questioned, and the efficacy of which is far greater 
than that of any other single drug, and probably than those above- 
mentioned combined. 
A favorite method of administration is as follows: 
R Cocainae hydrochlor., ..... grs. xx. 
Morphiae, ....... grs. ij. 
Aquae, . . . . . . . . 3 i. 
Ft. solutio et adde, 
Cosmolini liquid., . . . . . . § i. 
This is to be used in the Burgess atomizer (see Fig. 47). The 
above prescription makes an excellent and fairly permanent emul- 
sion, though, before using, it is well that the atomizer should be 
thoroughly shaken. An objection lies against the fluid cosmoline 
ordinarily sold by druggists in that it contains a considerable 
amount of the volatile oils of petroleum, notably the kerosene, 
which gives rather an unpleasant odor and taste to the mixture. A 
preferable oil, but not generally in the market, is the Voschano oil, 
which I believe is the Russian petroleum product. 
The immediate effect of this application is an exceedingly agree- 
able and pleasant one, and if its use is continued, an ordinary cold 
in the head may be rapidly brought under control. 
If the above mixture and apparatus are not available, an ordi- 
nary watery solution of cocaine acts as an excellent substitute. It 
is well, however, in applying the watery solution of cocaine, to bear 
in mind that, when the nose is in a highly sensitive state, its reaction 
is mildly acid. This may produce an unpleasant effect, hence a 
sufficient amount of bicarbonate of soda should always be added to 
render the solution alkaline. 
As a matter of convenience, cocaine may be given in the form 
of a powder, although it is doubtful if any snuff reaches the parts 116 
DISEASES OF THE NASAL TASS AGES. 
with the same degree of thoroughness as a fluid. An excellent 
formula for this is: 
R Cocainae hydrochlorat., ..... grs. x. 
Pulv, magnesiae, . . . . . 5 ss. 
The use of camphor in the past few years has gained a consider- 
able degree of popularity and is unquestionably a valuable adjuvant 
in the relief of an acute coryza, if used properly. It should be used 
well diluted, and in a small quantity. Several serious accidents 
have been reported from its indiscriminate use. The above formula 
may be used with the addition of grs. iij. of powdered camphor. 
The various preparations of mint form both an agreeable and 
efficacious remedy in catarrhal affections of the nose. The follow- 
ing excellent formula has been suggested by Rabow:’ 
R Menthol pulv., ...... grs. iij. 
Coffae toastae, 
Sacchari albae, ..... aa grs. I. 
M. Use as a snuff. 
After the vascular plethora has been brought somewhat under 
control, and the profuse serous exudation has diminished, I find it 
an excellent practice to make an application of chromic acid directly 
to che swollen membrane. This is done, not with the idea of de- 
stroying tissue, but in the method described fully in the chapter on 
hypertrophic rhinitis, as affording us one of our most effective 
remedies for directly controlling an inflammatory process. The 
membrane having been thoroughly contracted with cocaine, and 
cleansed by repeated wiping with pledgets of cotton, one or two 
small crystals of chromic acid are applied to the face of the mucous 
membrane covering the lower turbinated bone, making a small 
eschar whose office is to pin down the swollen membrane and pre- 
vent a return of blood to the part. This may seem a somewhat 
irrational mode of procedure, and yet it is one which, if deftly 
accomplished, will often secure results of a most gratifying charac- 
ter. If this measure fails and we find that, after the cauterization, 
the membrane swells to its original contour, we will have done 
more harm than good by our efforts, hence exceeding great care 
should be exercised that the tissues be thoroughly contracted before 
the acid is applied, and, furthermore, that the caustic should be so 
laid on as to burn deeply into the membrane over a limited area, 
rather than spread broadly over its surface. 
Before closing, mention should be made of the great value of 
dry heat applied externally over the forehead. A nice way of ac- 
1 Deut. Med. Wochenschrift, No. 5, 1886. ACUTE RHINITIS. 
117 
complishing this is by means of the small hot-water bags sold in 
the drug-stores, which can be bound upon the forehead and allowed 
to remain in situ for several hours at a time. The relief to the 
frontal headache and the sense of distention or fulness across the 
root of the nose, is often very striking, while at the same time the 
inflammatory action is probably modified to an appreciable degree. 
The remedy suggested by Woakes1 for the controlling of neur 
algic pain accompanying the disease, may well be resorted to 
where the usual narcotics either fail of their action, or are not well 
tolerated. He recommends that gelsemium be given in the form 
of the tincture, in doses of 10 minims each, to be repeated every 
three hours until relief is obtained. A more potent remedy and 
an exceedingly agreeable one is aconitine, which may be given in 
doses of of a grain every three hours, care being taken to note 
the occurrence of the peculiar prickling of the fauces, with numb- 
ness of the tongue or extremities, which indicates the limit of tol- 
eration of the drug. 
If, during the course of the attack, symptoms should appear of 
threatened involvement of one of the accessory sinuses, resort must 
be had to measures of a most active character to prevent so serious 
an accident. These consist mainly in the moderate use of anodynes, 
and active counter-irritation, with local blood-letting. If the frontal 
sinus or the antrum of Highmore is in danger, dry cupping imme- 
diately over the part should be resorted to, and if this fails of relief, 
no hesitation should be felt in immediately applying a blister. At 
the same time it will be found that the application of water to the 
nasal chambers, as hot as can conveniently be borne, will aid much 
in arresting this serious complication. This is usually accomplished 
by the ordinary fountain syringe, additional hot water being added 
to the reservoir as the flow is established through the nares. 
Schech2 advises the use of leeches to the root of the nose in 
these cases. This local blood-letting is accomplished without in- 
volving the temporary disfigurement which attends the blister or 
cupping, but I question if it is as efficacious. 
If inflammation of the middle ear is threatened, vesicating col- 
lodion may be applied in front of the tragus, but a more effectual 
remedy probably in this case would be in the use of leeches, in ad- 
dition to this. Politzeration, as recommended by Woakes,3 may be 
resorted to, although this measure should be used with the greatest 
caution. Schech 4 further recommends incision of the membrana 
tympani, although Buck5 questions the advisability of this, when 
1 “ Post-nasal Catarrh,” Amer. ed., Philadelphia, 1884. 
2 “ Diseases of the Mouth, Throat and Nose,” English ed., Edinburgh, 1S86, p. 224. 
•3 Loc. cit. 4 Lee. cit. 5 “ International Cyclop, of Surgery,” vol. iv., p. 7x0. 118 
DISEASES OF THE NASAL PASSAGES. 
the morbid process is of a simple catarrhal nature, on the ground 
that the incision speedily closes and, furthermore, while open it 
may admit of the entrance of disease-germs. The warm douche, of 
course, should be freely used in the extenal ear. CHAPTER IX. 
HYPERTROPHIC RHINITIS. 
This is a chronic inflammation of the mucous membrane lining 
the nasal cavities, characterized by a permanent dilatation of the 
blood-vessels, together with increased thickening of the intra-vas- 
cular tissues, as a result of which the normal lumen of the nasal 
passages is so far encroached upon as to interfere with free nasal 
respiration. In addition to this, and what is of still more serious 
import, the great respiratory function of the pituitary membrane 
of serous exosmosis becomes obstructed to a notable degree, where- 
by the mucous membrane lining the air passages below is subjected 
to such abnormal conditions as lead ultimately to the development 
of secondary inflammatory processes in this region. 
Probably in no single disorder of the upper air passages is a 
thorough understanding of its causes, development, and symptoms 
more important than in the one under consideration, for, as I firmly 
believe, a morbid process setting in primarily in the nasal mucous 
membrane is the cause of a large number of secondary affections 
involving not only the air passages below, but also organs having 
no especial physiological or regional connection with the nose. 
ETIOLOGY.—Perhaps no tissue of the body is more prone to be- 
come the seat of a chronic inflammatory process, than the nasal mu- 
cous membrane. Why this should be so, it is easy to understand if 
we thoroughly appreciate the physiological function which it is de- 
signed to subserve, as has already been shown in a previous chapter, 
for through no other mucous membrane of the body, probably, does 
there pass during the twenty-four hours proportionately as large a 
supply of blood. Furthermore, this is not in a constant, unvarying 
stream. On the contrary, the amount of blood, and therefore the 
calibre of the blood-vessels, changes with every variation in the 
temperature and humidity of the atmosphere. In this fact, then, I 
think lies the primary reason why morbid changes are so commonly 
met with in this region. This, however, will only account for those 
mild cases of rhinitis which scarcely approach the dignity of a true 
diseased condition, but constitute merely a source of occasional 120 
DISEASES OF THE NASAL PASSAGES. 
temporary annoyance. For the origin of the graver forms of so- 
called nasal catarrh we must look further. 
Taking cold figures in medical literature as a probable cause of 
most of the acute inflammatory diseases which we meet with in the 
upper air passages, and chronic inflammation is said to be the result 
of repeated attacks of acute inflammation. Cohen, Mackenzie, and, 
in fact, most writers make this assertion. My own belief, how- 
ever, as already stated, is that the chronic inflammation sets in first, 
and that repeated attacks of acute inflammation become simply one 
of the prominent features of the chronic morbid process. 
Climatic conditions also are said to exercise an unfavorable in- 
fluence on the development of catarrhal diseases. This assertion 
cannot be questioned, but that this is an important factor in the 
production or causation of nasal catarrh I think is open to question. 
A given case of catarrhal disease which is a source of exceeding 
great annoyance in the winter, becomes a trivial affection in the 
warm, dry atmosphere of the summer months, but a change from 
the damp climate of our seaboard to the pine forests of southern 
Georgia effects the same thing. It is not fair, however, to say that 
the winter weather or the seaboard in the one case, has been the 
cause of the disease, any more than it is to say that the return of 
the summer or a visit to the pine woods on the other hand has 
cured it, for a change to a favoring climate or region gives simply 
a temporary relief. The disease returns as soon as the climatic 
conditions reappear. The essential cause of the disease exists still, 
and has existed all the time. 
I think we are safe in saying, then, that the climatic influences 
on a catarrhal process are temporary only, whether in affording re- 
lief to the symptoms or in causing an aggravation of the trouble. 
I have no disposition to underestimate the value of a change of 
climate or the benefit often obtained by the temporary relief which 
it gives. In the graver forms of disease, we are often compelled to 
order a change of climate for our patients as affording the only hope 
of relief. But I think we are never justified in giving hope that a 
change of climate is going to afford anything but temporary relief 
in ordinary catarrhal disease of the upper air passages. In those 
cases, however, in which the disease has given rise to a severe 
laryngitis or a bronchitis, a change of residence to a more favorable 
climate often becomes imperative. 
Catarrh is often designated as an American disease, and without 
stopping to question the truth of this assertion, search has been 
made for some peculiar quality of our climate which has given rise 
to the universal affliction. I think it is very doubtful if the Ameri- 
can people suffer more generally from catarrhal disorders than HYPERTROPHIC RHINITIS. 
121 
those living in the same latitudes on the other side of the ocean. 
Certainly the general assertion is a somewhat loose one, based on 
no careful observation. I believe the origin of this mistaken view 
to be largely due to the fact that diseases of the nasal cavities 
engaged the earlier and more industrious attention of specialists 
in this country than in Europe, so that a survey of our literature 
would naturally lead to the conclusion that nasal disease was ex- 
ceedingly common here. We find Mackenzie1 making the asser- 
tion that, until the year 1880, it had not been his custom to examine 
the interior of the nose except in patients who referred their symp- 
toms directly to the nasal passages, whereas we recognize the fact 
that in the majority of our cases of nasal disease the patient refers 
the symptoms to the fauces or other parts, and oftentimes denies 
the existence of nasal trouble. 
The assertion is also made, in searching for a cause of American 
catarrh, that it is due to our dry and dust-laden atmosphere. I do 
not think American people, as a rule, are greatly subjected to the 
deleterious influence of a dry and dust-laden atmosphere, nor, 
furthermore, that those who are thus exposed, suffer as a result 
necessarily from catarrhal disease. Lenox Browne2 ventures the 
assertion that “mechanical irritation, as from particles of snuff, the 
pollen of grass and of flowers, fine dust, etc., is almost as important 
a factor in the production of nasal erection as changes in the tem- 
perature of the atmosphere, and if long continued will certainly 
lead to a permanently enlarged, swollen, and hypertrophied condi- 
tion of the erectile tissue and mucous membrane generally.” Mac- 
kenzie3 also states that chronic catarrh may be caused by the in- 
halation of irritating vapors or solid particles suspended in the 
atmosphere. Turning now to one of the most accomplished of our 
American writers on this disease, we find Beverley Robinson stat- 
ing: that “trades in which irritating vapors or dust are breathed 
more or less constantly are an efficient cause of chronic coryza. Such 
are, in my experience, those of carpenters, tobacconists, workers in 
carpet factories, woollen factories, machine shops, chemical works, 
etc.” 
One naturally hesitates to take issue with such careful observers 
as those referred to, and yet my own experience teaches me that, 
whereas a dust-laden atmosphere may be the source of discomfort 
and irritation to the nasal passages, yet as an efficient factor in the 
1 “ Hay Fever,” London, 1885, p. 28. 
2 “ The Throat and its Diseases,” London, 1888, p. 501. 
3 “Diseases of the Throat and Nose,” American Edition, Philadelphia, 1884, vol. 2, 
P- 313. 
4 “ Nasal Catarrh and Allied Diseases,” New York, 1885, p. 65. 122 
DISEASES OF THE NASAL PASSAGES, 
production of organic changes in the deep tissues of the membrane, 
I believe it to be greatly overestimated. I do not think that 
workers in tobacco or carpet factories, or mines, suffer as a rule 
from nasal disease. The old discussion in regard to “ miner’s lung,” 
it seems to me, sustains this point, for it is a well-known fact that 
workers in coal mines inhale the dust of coal to such an extent that 
the lung tissue itself even is oftentimes stained with the carbon, 
yet this occurs without involving these delicate structures in serious 
danger. When we consider the far greater vulnerability of these 
tissues than the tissues affected when the dust enters the nasal 
cavities, the fact referred to would seem to go far toward estab- 
lishing the view that a dust-laden atmosphere is comparatively 
harmless to the mucous lining of the upper air tract. 
As regards the influence of tobacco, on catarrhal diseases, I can 
only repeat here what I stated in a former work,1 when, in discuss- 
ing the use of tobacco as a habit, I wrote as follows: “ The progress 
of the chronic pharyngitis is marked, of course, by repeated acute 
attacks of ordinary sore throat. As the disease develops under the 
stimulus of these repeated attacks of acute pharyngitis, or devel- 
oping from the commencement as a chronic affection, as it occa- 
sionally does, it comes under the influence of certain secondary 
predisposing and aggravating influences whose effect is to greatly 
increase the morbid condition. The use of tobacco is a habit which 
it is the fashion to charge with having a large influence in the pro- 
duction and aggravation of chronic pharyngitis. Smoking and 
chewing are, undoubtedly, pernicious and uncleanly practices, but 
that they are responsible to the extent usually laid to their charge 
in influencing a throat catarrh is probably not true. Tobacco 
smoke is without question an irritant to the mucous membrane of 
the air-passages, especially if inhaled in a concentrated form. On 
the other hand, it is also true that the mucous linings easily become 
inured to the action of the smoke, so that breathing or inhaling an 
atmosphere charged moderately with it, is tolerated with immunity. 
Cubans are, perhaps, among our most inveterate smokers, and that 
in its worst form in the use of cigarettes, and yet they suffer some- 
what rarely from throat catarrhs. 
“ I do not wish to say that the use of tobacco may not, or does 
not exercise an injurious influence on the throat, for it undoubtedly 
does in many cases, but that this is the result of the direct contact 
of the smoke with the membrane I regard as very improbable. The 
effect of smoking in producing gastric disturbance, as shown in the 
various forms of dyspepsia with which excessive smokers suffer, and 
this, in turn, leading to the aggravation of an existing pharyngeal 
1 “ Diseases of the Throat and Nose,” N. Y., 1881, p. 82. H YPER TROPHIC RHINITIS. 
123 
catarrh, would seem to me to present the true explanation of the 
injurious action of the habit on the throat. And, again, the absorp- 
tion of nicotine which necessarily takes place, as evinced by the 
headache, palpitation of the heart, and muscular tremor which re- 
sults from the excessive use of tobacco, produces a systemic con- 
dition, which cannot but react unfavorably on the morbid process 
in the fauces. From what has been said it will be easily under- 
stood that, while condemning the use of tobacco as a vicious and 
uncleanly habit, and asserting that its excessive use may exercise 
a very injurious influence on the throat, the idea is only intended 
to be conveyed that the pernicious influence is an indirect one, and 
not due to the contact of the smoke with the mucous lining of the 
upper air-passages. Hence, in estimating the influence of the habit 
on an existing throat-catarrh, the judgment must be based mainly 
on the evidence of the injurious action of the nicotine absorption, 
as shown by gastric disturbance or cardiac symptoms. 
“ In addition, it may be said that the fumes of tobacco come in 
contact, to a very moderate extent, with the mucous membrane 
beyond the palate, and the only smoke which reaches the parts 
farther down is that which impregnates the atmosphere which the 
smoker breathes in common with others near him, or in the same 
room. Hence, of two persons, one smoking, and the other not ac- 
customed to the habit, it is probable that the smoker escapes with 
the greater impunity from the direct effect of the vitiated atmo- 
sphere. I am disposed to regard the habit of chewing as even more 
vicious than smoking in its effect on the throat, and yet, as a rule, 
the tobacco chewer does not allow the saliva to reach beyond the 
mouth, hence it cannot be that its bad effects are the result of 
direct contact, but are rather due to the indirect effect of the 
nicotine absorption which must necessarily result from the habit.” 
The question of diathetic conditions, as influencing catarrhal 
disorders, figures largely in our older literature, many writers even 
asserting that there exists a true catarrhal diathesis. This condi- 
tion, I think, lingers mainly in the minds of the laity, and we fre- 
quently hear statements made on the part of patients that all their 
mucous membranes are weak. That there is any special connec- 
tion between the different mucous membranes of the body not 
physiologically connected, or anatomically continuous, I think is 
incorrect. My own observation leads me to the conclusion that 
catarrhal diseases of any mucous membrane are largely local in 
character, and that any constitutional disturbance which accom- 
panies them is secondary in character. Certainly I have never met 
with any case which seemed to me to present evidence of a catar- 
rhal diathesis. 124 
DISEASES OF THE IVASAL PASSAGES. 
How far the rheumatic or gouty habit may influence catarrhal 
processes is an exceedingly nice question to decide. Rheumatic or 
gouty pharyngitis is undoubtedly met with not infrequently, but 
the pharynx, as I believe, has no physiological connection with the 
breathing apparatus. Catarrhal inflammation of the nose due to 
the gouty or rheumatic diathesis I have not met with. 
The graver dyscrasias, such as have been called the tubercular 
and scrofulous diatheses, undoubtedly exert a certain amount of 
predisposing influence in the production of catarrhal diseases, if 
we use this term in the sense of an unhealthy or excessive discharge 
from the nasal passages. It is doubtful, however, if they ever lead 
to the production of connective-tissue hyperplasia, the prominent 
condition which obtains in the disease under consideration. Their 
influence is, then, to aggravate the symptoms of an existing catar- 
rhal inflammation, and perhaps hasten the hypertrophic process, 
rather than to exercise any clearly recognizable causative influence 
in the development of the inflammatory action. 
By far the most frequent cause of hypertrophic rhinitis, I believe, 
lies in a deformity of the nasal septum, giving rise to nasal stenosis, 
which generally occurs in the anterior portion of the passage. Its 
method of development is, to a certain extent, mechanical, and may 
be explained as follows: During infancy or childhood, as we know, 
the cartilages and bones of the nose are soft, somewhat pliable, and, 
furthermore, especially subject to injury. The child learning to 
creep perhaps, or learning to walk, has a fall and strikes naturally 
the most prominent feature of the face; or again, in childhood or 
youth, in the rude and boisterous amusements which children in- 
dulge in, a blow on the nose is, one of the most frequent of acci- 
dents. The effect of this is that, while in many cases it gives rise to 
noticeable symptoms, as when a true fracture occurs, in a far larger 
number of cases, the injury gives rise to mere temporary discom- 
fort, the symptoms pass away, and the accident probably is for- 
gotten. Now, in the case of fracture with resulting deflection of 
the septum, the symptoms may set in and develop with a consider- 
able degree of rapidity, whereas in other cases, where the blow has 
been less severe, a mild deformity takes place, a low grade of in- 
flammation, possibly at one of the sutures of the septum, an arthritis 
perhaps, resulting from a separating of the two plates which form 
the septum, producing a bony or cartilaginous projection into the 
one or other nostril which may reach its full extent at the time of 
the injury, or may gradually develop as the result of a low grade of 
inflammatory action, and become more extensive in character as 
time lapses. In every case, however, the effect is a stenosis of the 
nasal cavity. If now we study the effect of the simple mechanical H YPER TROPHIC RHINITIS. 
125 
obstruction to the entrance of air to the nasal passages during the 
act of inspiration, we shall find, I think, that it throws much light 
upon this question of the causation and development of catarrhal 
diseases in these cavities. Now with each act of inspiration, that 
portion of the mucous membrane which lies immediately behind 
the point of obstruction becomes subjected to diminished atmo- 
spheric pressure. This diminished pressure acting on the soft, 
spongy, vascular tissues covering the turbinated bones, results in a 
tendency to abnormal turgescence. This action is probably very 
slight in the first few years after the injury has been received. But 
as time goes on, there is gradually developed a permanent hyper- 
aemia or distention of the blood-vessels. Furthermore, it may be 
noticed that if the obstruction be but partial, this turgescence is de- 
veloped in the narrower passage. If, on the other hand, the injury 
is such as to completely occlude one passage, all of the inspired air 
is compelled to pass through the opposite side, and we have the 
hyperaemia and hypertrophy developing in the open side. In fact, 
' it is necessary for the development of this chronic congestion that 
a current of air should pass through the side affected, as we often 
see the membrane in that passage which is completely stenosed, as 
the result of a deflected septum, absolutely bloodless. Not only 
does it not become the seat of hypertrophic changes, but there is a 
certain amount of shrinking as it were, in the tissues, not the atrophy 
which we meet with in atrophic rhinitis, but a bloodless condition 
of the vessels due to abolition of function. The result of hyperaemia, 
of course, is to increase nutrition and we have finally set up certain 
structural changes in the membrane proper. The superficial blood- 
vessels and the large venous sinuses of the membrane, more espe- 
cially the latter, become excessively dilated, the vascular walls lose 
tonicity, vascular control is impaired, while at the same time, as a 
result of this hyper-nutrition, the intra-venous tissues become 
notably thickened, and we have, as a consequence, true hypertrophy 
taking place, a permanent structural thickening of the membrane. 
The point which I endeavor to make here of traumatism as the 
original cause of so large a proportion of these cases of hyper- 
trophic rhinitis is, I think, an exceedingly important one, and I re- 
peat again that an essential point of this theory is the fact that the 
injury itself antedates the morbid symptoms, oftentimes many 
years, and that the development is essentially an exceedingly slow 
process. This must necessarily be true, for I think when we ex- 
amine the mucous membrane histologically we cannot but be con- 
vinced that the condition is one which has only resulted after long 
years of development. The natural history of the connective- 
tissue cell from its first development until it eventually becomes 126 
DISEASES OF THE NASAL PASSAGES. 
an elemental part of the tissue, as a well-developed connective tis- 
sue cell, is a process of years. 
Deformities and deflections of the septum are by no means the 
only cause of nasal stenosis. Any deformity which causes narrow- 
ing of the nostril, will produce the same train of symptoms. A dis- 
placement of the triangular cartilage of the septum I have seen act 
in the same maner. Weakness of the dilator muscles of the nostril 
also, although rarely, is a very efficient factor in the production of 
hypertrophic rhinitis. Deformity of the alar cartilages, by which 
the normal aperture of the nostril is narrowed, we occasionally meet 
with acting in the same manner. Not infrequently we meet with 
cases in which hypertrophy has taken place without any mechanical 
stenosis. These cases may be attributed to taking cold, for this 
we must recognize as one of the causes of catarrhal disease; for, 
while undoubtedly the habit of taking cold, as before stated, is due 
primarily in these cases to the chronic inflammation, and that, 
as before stated, in the majority of instances is due to deflected 
septum, we must acknowledge that repeated attacks of acute in- 
flammation may precede the chronic process. 
If we search further for the causes of these cases, I think we 
find them largely in errors of clothing, vicious habits of life, undue 
exposure, neglect of the skin, and that long train of bad habits which 
we include under the general designation of improper hygienic 
surroundings. Any one who dresses improperly, who wears ex- 
cessively heavy clothing, or, on the other hand, is too thinly clad, 
who neglects the proper use of the bath, who is badly nourished 
from improper or insufficient food, who is badly housed, who sleeps 
in close, illy ventilated rooms, of course is liable to catarrhal 
troubles unless he possesses some more vulnerable hereditary or 
acquired habit. In other words, when a man is subject to serious 
exposure in perfect health, he suffers from a cold in the head far 
more frequently than anything else unless he has inherited or ac- 
quired a rheumatic or gouty habit, or possesses some other special 
weakness, under the influence of which affections of this nature de- 
velop, as the results of exposure, rather than the catarrhal disorder. 
Symptomatology.—The prominent symptoms resulting from 
this condition are due primarily to changes in the normal secre- 
tion of mucus. As we have aleady learned in the chapter on the 
physiology of the nose, the secretion in health consists of a limited 
amount of mucus together with a very large amount, a pint or more, 
of serum, whose source is in the venous sinuses, in the deep layer 
of the membrane, from which it makes its way probably by ex- 
osmosis. Now, the deposit of connective tissue in the inter-vascu- 
lar tissues, giving rise to notable thickening, necessarily results in HYPERTROPHIC RHINITIS. 
127 
an obstruction to this exosmotic process. The amount of serum 
which transudes is diminished, while at the same time the blood-ves- 
sels, not being unloaded by normal transudation, become distended. 
The discharge from the nose itself, instead of being a sero-fluid 
mucus, becomes thick and inspissated. The membrane becomes 
swollen and thereby encroaches notably on the normal lumen of 
the nares, thereby obstructing nasal respiration. This sero-mucus, 
which in health makes its way imperceptibly into the fauces and 
disappears, now shows a tendency to lodge in the nasal chambers, 
or, flowing back into the posterior part of the lower meatus, is 
hawked back by a sort of nasal screatus into the pharynx. Further- 
more, as the result of increased nutrition, there is a certain amount 
of activity in the epithelial elements on the surface of the mucous 
membrane by which normal proliferation is notably increased, so 
that we have the character of the secretion from the nose still 
further changed by the admixture of young epithelial cells, which 
renders it somewhat thicker in consistency and opaque in character. 
There is no tendency whatever to the formation of crusts or in- 
spissated masses, nor do foetid and offensive secretions accompany 
this form of catarrhal disease. If such symptoms are present, they 
should always be regarded as evidence that some other form of 
disease is to be dealt with. It is a popular delusion, fostered by 
even very intelligent writers and observers, that the secretions in 
hypertrophic rhinitis are foetid and irritating. Now, the only 
change that takes place, as I before said, is in the relative amount 
of normal mucus and serum which affects the consistency of the 
mucus alone. There are a few epithelial cells added, but these do 
not affect the character of the discharge to any notable degree. 
Now, this discharge differs, in its irritating qualities, in no essential 
degree from the healthy secretion. Probably no secretion of the 
body is blander and less irritating than that of the nose in health. 
If there is any element in it which is irritating it is the serum, con- 
taining as it does a certain amount of saline matter. In hyper- 
trophic rhinitis this element is diminished, so that we might say, if 
there is any difference in the secretion in the two conditions, it 
would be in favor of the secretion from the diseased membrane. 
The popular fear in regard to nasal catarrh is that sooner or 
later it will result in offensive discharges. This is based partly on 
the teaching of irregular practitioners that catarrh, so-called, leads 
to ulceration and necrosis. It is scarcely necessary to say that 
ulceration and necrosis belong in no possible manner to hyper- 
trophic rhinitis,but are only met in connection with syphilis, scrofula, 
and other grave diseases. This theory of offensive discharges oc- 
curring in this disease is based also on the teaching that atrophic 128 
DISEASES OE THE NASAL TASS AGES. 
rhinitis is a later stage of hypertrophic. This assertion, I think, 
was originally made by Frankel in his admirable article on the 
nose in the fourth volume of Ziemssen’s Encyclopaedia, and subse- 
quently adopted by most other writers. The assertion is, I believe, 
based on absolutely incorrect clinical observation, as the two dis- 
eases are totally separate and distinct in character from the com- 
mencement, as will be shown when we come to the discussion of 
atrophic rhinitis. The foetid odor, therefore, is never met with in 
connection with hypertrophic rhinitis, though we find so careful an 
observer as Frankel1 stating that hypertrophic rhinitis may give 
rise to an odor, although not the characteristic odor of ozaena. 
Frankel’s error here is one easily explained, as I have had occasion 
of observing in a number of instances which have been under my 
own care, where it was strenuously insisted upon, on the part of 
patients under treatment for hypertrophic catarrh, that there was 
an offensive odor. In every case I was enabled to trace the odor 
to the mouth. The patients sleeping with the mouth open, the 
tongue became dry and furred, and the thick velvety epithelium 
on its dorsum was the source of a slightly offensive odor, which 
persisted for some hours, perhaps, after arising in the morning. 
In other cases I have traced the odor to the existence of decayed 
teeth, amalgam fillings in the teeth, etc. In all cases the mouth is 
to be inspected in the search for the cause of a fetid breath in hy- 
pertrophic rhinitis, as it cannot be found in the nasal passage. 
Nasal stenosis with mouth-breathing is always a prominent 
symptom of the disease, as a necessary result of the mechanical ob- 
struction to the passage of air through the nose. Mouth-breathing 
is often considered to be a habit, and we even find various devices 
resorted to to break up this so-called habit. Now, mouth-breathing 
probably is never a habit. It is a necessity due to the fact that the 
individual cannot get air enough through the nose, and hence is 
compelled to open the mouth. 
In consequence of the impairment of the normal function of the 
nose, under which the exudation of serum is interfered with, we 
soon have certain changes setting in in the air passages beyond. 
The first to become affected is the vault of the pharynx. Now, as 
has already been stated, we have in the vault of the pharynx a large 
mass of glands which in health pour out a certain amount of 
mucus which, passing down behind the palate, serves as a lubricant 
to the bolus of food and facilitates its passage into the oesophagus. 
This mucus is poured out in large quantities, of which the indi- 
vidual is unconscious. Now, in order that this function shall go on 
uninterruptedly, it is necessary that the nasal passages in front of 
1 Transactions of the International Medical Congress, 1881, vol. 3, p. 302. HYPERTROPHIC RHINITfS. 
129 
it shall perform their functions in a normal manner. In other 
words, it is necessary that the air which sweeps over the glandular 
structures at the vault of the pharynx should be saturated with 
moisture. As soon as this nasal function is hampered, and nasal 
respiration is interfered with, air is largely taken through the mouth, 
while that which passes though the nose fails to take up sufficient 
moisture in its passage to bring it to the point of saturation; when, 
therefore, it reaches the pharyngeal vault it takes up moisture from 
the mucous secretion of this region. The result is, that the normal 
secretion of mucus in the pharyngeal vault becomes thick and in- 
spissated, and adheres to the parts in a thick tenacious plug, which 
hangs down behind the velum of the palate, causing excessive an- 
noyance and oftentimes distress to the patient. During waking 
hours this is not so noticeable on account of the voluntary efforts 
of the patient in clearing the nose and fauces. During sleep, how- 
ever, this pharyngeal mucus accumulates in a large mass, the 
removal of which in the morning becomes a considerable effort to 
the sufferer. 
Furthermore, the pharynx becomes excessively irritable, and the 
hawking and coughing in the morning is often attended with retch- 
ing and vomiting. This involvement of the fauces is scarcely notice- 
able in the earlier stages of hypertrophic rhinitis, but as time goes 
on, the faucial symptoms become more prominent, and soon the 
patient is likely to refer most of his symptoms to the pharynx and 
say he has a bad throat, very frequently entirely overlooking the 
nasal disorder. His story will often be that in former days he 
suffered a good deal of annoyance from his nose, but that it has 
“gone down” to his throat. The explanation of this I take to be 
that there has been no amelioration of the nasal symptoms, but a 
marked development of faucial symptoms, and while the nasal dis- 
ease still persists in as aggravated a form as ever, he gets to a cer- 
tain extent accustomed to the discomforts of nasal stenosis and 
overlooks it in the more aggravated discomfort of his throat dis- 
ease. Throat difficulties are always looked upon with more appre- 
hension by patients than nasal disorders, and, furthermore, they are 
the source of more discomfort as involving a far more sensitive 
region. 
This faucial accumulation is usually spoken of as naso-pharyn- 
geal, or post-nasal catarrh. In very many cases, however, we can 
undoubtedly trace its development to a previously existing disease 
of the nasal passages proper, in the manner above outlined. That 
it is met with, however, as an independent disease cannot be ques- 
tioned, but even in such a case there is still an intimate patholog- 
ical connection between the two regions, under which they natu- 130 
DISEASES OF THE JVASAL TASS ACES. 
rally react the one upon the other. These questions, however, will 
be discussed at length in the chapter devoted to the consideration 
of catarrhal disease of the naso-pharynx. 
Catarrhal inflammation of the lower pharynx does not occur in 
connection with rhinitis, but we not infrequently find the scattered 
follicles along the surface of the pharynx enlarged, and inflamed, 
together with the chain of glands immediately behind each pillar 
of the fauces. This follicular enlargement is probably entirely the 
result of the nasal disorder. It gives rise, however,, to no marked 
symptoms, as a rule, except in nervous, hysterical female patients. 
As the disease progresses, we find the larynx, trachea, and air pas- 
sages beyond involved in a mild catarrhal process. This is not due 
to any extension of disease from the nasal passages, but is due to 
the same cause which gave rise to the pharyngeal symptoms, and 
follows very soon upon their appearance. The air reaching the 
larynx and trachea in an abnormally dry condition, robs the mucous 
secretion in these organs of its moisture, and renders it thick and 
inspissated. Its fluidity being destroyed, it adheres closely to the 
membrane and gives rise to irritation and a subsequently mild in- 
flammation. As this secondary largyngitis and tracheitis sets in, 
we find a rather curious development of the disease occurring. 
Heretofore the patient, as the result of exposure, suffered from cold 
in the head. Now his colds result in a laryngitis or bronchitis which, 
running a somewhat slow and persistent course, seems to travel up- 
ward. A cold in the head sets in oftentimes days after a bronchitis 
or a winter cold. This is not the rule, but is of very frequent occur- 
ence. Why it should be so, I do not pretend to explain. Certainly 
it is not due to the fact of any improvement in the nasal condition, 
for that is progressive as long as it is allowed to go on without 
treatment. 
Elongated uvula not infrequently occurs in connection with 
chronic rhinitis, and probably is a direct result of the faucial irrita- 
tion set up in the later stages of the disease. This elongation, 
however, is confined entirely to the mucous membrane at the tip of 
the organ, and does not necessarily involve the muscular tissues; 
the membrane becomes swollen and infiltrated, and hangs down on 
the base of the tongue, this condition being aggravated undoubtedly 
by the hawking and clearing of the throat, which is rendered neces- 
sary by the faucial accumulation. 
Cough also is not infrequently present, and oftentimes consti- 
tutes an exceedingly troublesome symptom. This may be present 
during acute exacerbations only, or it may complicate the chronic 
affection. This is often referred to as a reflex cough due to intra- 
nasal disease. I do not think it necessary to bring in this obscure HYPERTROPHIC RHINITIS. 
131 
explanation of the symptom, where it is so evidently a direct result 
of the catarrhal process. In most cases, probably, it is due to the 
nasal stenosis, causing habitual mouth-breathing with a resultant 
dryness of the larynx and trachea. In other cases it is due to the 
catarrhal inflammation which sooner or later involves the whole 
upper air tract, in the one case giving rise to a dry, hacking, irri- 
tating cough, unaccompanied by secretion, while in the other case 
there is a moist cough with more or less profuse expectoration. 
Symptoms referable to the ears, I believe to be present in a 
far larger proportion of cases than is usaully recognized by our 
standard authorities either on throat or on ear diseases. Deaf- 
ness is perhaps the earliest and most easily recognized symptom 
with which we meet in this connection, and yet this is a some- 
what vague expression. A moderate diminution in the hearing 
distance as tested by the watch will probably be recognized in a 
very large proportion of cases of intra-nasal disease, and yet where 
this diminution is but moderate it is not always safe to say that it 
constitutes a morbid condition directly due to the nasal disease, 
especially when we remember that, while the watch-test is perhaps 
the best we possess for testing the hearing, yet it is an exceedingly 
unreliable and uncertain one. We should avoid, therefore, attach- 
ing too great importance to it. 
Disease of the middle ear as recognized by notable impairment 
of hearing, retraction, atrophy, or calcification of the membrana 
tympani, together with obstruction of the Eustachian tube as de- 
termined by politzerization or the use of the catheter, is by far the 
most frequent morbid condition of the auditory apparatus met with 
in connection with intra-nasal disease. This affection is undoubt- 
edly a direct result of the hypertrophic process in the nasal cham- 
bers. As regards the method of its development, there would seem 
to be some difference of opinion. Older writers almost invariably 
attributed it to the extension of the catarrhal process to the Eusta- 
chian tube, causing obstruction. In this manner the renewal of air 
in the middle-ear chamber was said to be mechanically interfered 
with. An examination with the rhinoscopic mirror of the Eustachian 
orifices in a very large number of cases shows, I think, that one of 
the rarest conditions with which we meet is catarrhal inflammation 
involving the membrane lining the Eustachian orifice, as evinced by 
redness, swelling, and hypersecretion. Even in cases in which the 
middle-ear symptoms are well marked, and in which the morbid 
process has resulted in an extreme degree of impaired hearing, this 
examination fails to show any evidence of this extension of inflam- 
mation by continuity of tissue. We must, therefore, seek for some 
other explanation of this complication. As we know, the integrity of 132 
DISEASES OF THE NASAL PASSAGES. 
the function of audition is dependent upon equable air pressure on 
both sides of the membrana tympani. In other words, the air within 
the middle-ear chamber must be constantly renewed in order that the 
pressure within the tympanic cavity shall not be diminished. Now, 
this renewal of air is accomplished during the respiratory process 
through the nose. If nasal stenosis exists, with each act of inspira- 
tion there is diminution of the air pressure behind the point of ob- 
struction. We find, then, a more or less permanent condition of air 
rarefaction in the vault of the pharynx. This condition necessarily 
makes itself felt through the Eustachian tube and in the middle- 
ear chamber. This slight force, acting through a long period of 
time, results eventually in producing an hyperaemic condition of the 
mucous membrane lining the Eustachian tube and the middle ear 
chamber, together with retraction of the drum-membrane. This 
action we see, then, is purely a mechanical one, but it seems to me, 
it is one which harmonizes more clearly with clinical observation, 
and lends also intelligence and clearness to our therapeutic efforts. 
It may be stated here, in support of this view, that this form of 
middle-ear disease, while frequently met with in hypertrophic rhini- 
tis, nasal polypus, deflections of the septum, and in fact any disease 
which gives rise to stenosis, is far less frequently met with in con- 
nection with atrophic rhinitis and ozaena. The above reference is 
mainly to cases of catarrhal inflammation of the middle ear, but it 
may be added that, in cases of suppurative otitis, I have seen results 
so gratifying in character as to warrant the statement that in all 
cases of this affection treatment of intra-nasal disease, if present, 
becomes an imperative duty. 
In a certain proportion of cases of hypertrophic rhinitis, tinnitus 
aurium is met with, usually in connection with middle-ear disease, 
though in a smaller number of cases there is apparently no organic 
lesion. That this distressing symptom may be dependent on the 
nasal disease is shown by the fact that, in a flattering proportion of 
cases, it disappears under treatment, and even in those instances in 
which complete cure is not accomplished, marked relief is afforded. 
Hypertrophic rhinitis is also a prominent factor in the causation 
of attacks of hay fever and asthma. This, however, will be dis- 
cussed in the chapters devoted to those affections. 
Headaches, eye troubles of various kinds, together with a large 
number of nervous diseases, such as chorea, epilepsy, etc., occur 
also in connection with intra-nasal disease. The discussion of this 
relation is more properly relegated to the chapter on nasal re- 
flexes. 
PATHOLOGY.—The accompanying cut (Fig. 65) represents a sec- 
tion of a mass removed from the posterior portion of the lower tur- H YPER TROPHIC RHINITIS. 
133 
binated bone. The changes may be described as follows : The whole 
mucous membrane is markedly thickened and deeply corrugated. 
The epithelial layer is augmented or increased in width. The outer- 
most layer of epithelium in specimens from the middle turbinated 
bones exhibit fine ciliae, while in sections from the lower turbinated 
bones the ciliae are occasionally wanting in places. There are deep 
valleys running downward into the adenoid layer which are filled 
with stratified epithelia. The latter consist of elongated epithelia, 
ten to twelve layers in diameter. The layer nearest the adenoid 
tissue is occupied by distinctly developed large columnar epithelia, 
which, especially where they go to fill the valleys, are very large, 
Fig. 65.—Hypertrophic Rhinitis. X500. a, Epithelial layer; limiting structureless membrane; c, ad- 
enoid layer; d, blood-vessels filled with blood; e, acinous gland; /, venous sinus composing the so-called 
erectile tissue. ' 
and composed of several strata. The boundary line between the 
epithelia and the adenoid tissue is everywhere well marked, and 
in some places there is even present a layer without distinct struc- 
ture, the so-called structureless membrane. 
The adenoid layer is very wide, and is composed largely of a 
myxomatous reticulum, with numerous lymph-corpuscles, while in 
some portions the lymph-corpuscles are very scanty, and the whole 
mucosa is composed of very dense decussating bundles of fibrous 
connective tissue. The mucosa is in all instances richly supplied 
with relatively wide capillary blood-vessels, mostly filled with blood. 
The acinous mucous glands are very numerous, and evidently in- 
creased in size and number. They are composed of cuboidal epithe- 
lia, which, in many instances, exhibit the features of inflammatory 
corpuscles. The ducts of the glands are traceable into the valleys 134 
DISEASES OF THE NASAL PASSAGES. 
on the surface of the membrane, where their columnar epithelia 
blend with that of the outer epithelial coat. 
The submucous coat, beneath the adenoid tissue, consists of a 
broad layer of either myxomatous, or fibrous reticular structure, in 
which there are present enormously enlarged blood-vessels of a 
venous character. These veins are so abundant that they resemble 
a true erectile tissue. The connective tissue, however, between 
these large veins is broader than is usually found in true cavernous 
tissue, and is supplied with bundles of smooth muscular fibres. 
The muscle-coat of the veins is also increased in breadth 
The arteries, though scanty, are all of a wavy course, constitut- 
ing the so-called helicine arteries. The submucous layer also con- 
tains a number of racemose mucous glands, increased in size. The 
presence of these glands in this layer of the membrane is, I believe, 
anomalous. Around these glands there are found, as a rule, heaps 
of lymph-corpuscles. 
The characteristic features of hypertrophy of the nasal mucous 
membrane, then, may be briefly summarized as follows: 
First.—Increase of the covering epithelium, without desquama- 
tion. 
Second.—Increase of the adenoid layer and its capillaries, with 
stagnation of blood, together with a new formation of fibrous con- 
nective tissue replacing the adenoid layer. 
Third.—Increase of the racemose glands, both in the adenoid 
and submucous layer. 
Fourth.—Hypertrophy of the connective tissue between the en- 
larged veins in the submucous layer 
Fifth.—In advanced stages of the hypertrophic process, an ab- 
sence of lymph-corpuscles, they having evidently been transformed 
into connective tissue. 
At the anterior termination of the middle turbinated bone, the 
hypertrophic process develops in a somewhat different manner, in 
that, while there is still evidence of inflammatory action, the 
thickening of the membrane is largely due to a myxomatous trans- 
formation, which gives to the tissue a somewhat soft, gelatinous 
consistency, with a gross appearance closely resembling that of 
an ordinary nasal polypus. The histological structure of this tissue 
is well shown in Fig. 66. 
DIAGNOSIS.—The question has been raised as to what constitutes 
a diseased condition of the nasal mucous membrane, and whether we 
can recognize it in its milder forms by sufficiently characteristic ap- 
pearances. I think not only that we can do this, but that we should 
do so in all cases, with the same delicacy of appreciation as is used 
in the recognition of diseased conditions of other organs, and this HYPERTROPHIC RHINITIS. 
135 
by ocular inspection; for since the introduction of the use of 
cocaine we are enabled to bring into view the whole of the nasal 
cavities, in a manner so thorough that no morbid process existing 
there should escape notice. 
An examination anteriorly will show the mucous membrane 
swollen and of a bright reddish-gray color, with perhaps a pink 
tinge. This is not the bright scarlet color of acute inflammation, 
nor again the purplish hue of purely venous congestion, but some- 
thing between the two, the swollen condition being, as we know, 
due entirely to the plethoric state of the venous sinuses, although 
the superficial color is given by the hypersemia of the capillaries of 
the mucosa proper. The surface of the membrane is rounded, 
Fig. 66.—Myxomatous Hyperplasia of the Nasal Mucosa from the Anterior Termination of the Middle 
Turbinated Bone. E, Columnar ciliated epithelium; /, infiltration of outermost portion with lymph-cor- 
puscles; M, myxomatous tissue; A, lymph follicle; C, crypt of mucosa cut obliquely; A, acinous mucous 
glands. 
somewhat irregular in shape, and coated with a limited amount of 
grayish semi-transparent mucus. If the swelling is but moderate, 
we may inspect a considerable portion of the membrane covering 
the lower and middle turbinated bones. 
On the lower turbinated, behind its anterior extremity, we find 
the surface presenting a slightly rugous appearance, while on the 
middle turbinated we notice a brighter red color, together with a 
smooth, shining surface, but slightly coated with mucus, and accord- 
ing to the extent of the turgescence, approaching more or less closely 
toward contact with the septum. If there is considerable swelling 
of the membrane, we find also the lower turbinated bone approx- 
imating itself to the septum, thus rendering an inspection of the 
cavities beyond impossible. 136 
DISEASES OF THE NASAL PASSAGES. 
Examination posteriorly simply brings into view the membrane 
covering the posterior termination of the middle turbinated bone, 
together with the posterior half or two-thirds of that of the lower 
turbinated bone. . We find here an appearance differing essentially 
from that seen in front. The membrane here presents a condition 
which has been called grubworm hypertrophy, from the fact of its 
striking resemblance to a large white grubworm, lying one on either 
side of the septum. On the lower turbinates will be seen a rounded, 
whitish mass, with a raspberry-like outline of surface, presenting 
minute furrows and fissures crossing it in irregular lines. This 
Fig. 67.—The Outer Wall of the Nasal Cavity Showing the Mucous Membrane in a State of Hypei- 
trophy over the Lower Turbinated Lone. 
same appearance is seen on the middle turbinates, although the 
masses are much smaller, and present an elongated, spindle-like 
contour. 
The superior turbinated tissues may occasionally be seen by 
this examination, but are rarely the seat of any morbid process. 
These appearances, as seen through the nostrils, cannot be intelli- 
gently illustrated, but in Fig. 67 is shown a lateral view of the 
outer wall of the nasal cavities, in which the mucous membrane is 
in a state of hypertrophy, and, as a contrast to this, there is shown, 
in Fig. 68, the same view in which the membrane is in a fairly nor- 
mal condition. 
In Fig. 69, there is shown a transverse section through the nasal 
cavities still further illustrating a general hypertrophic process as H YPER TROPHIC RHINI TIS. 
137 
Fjc. 68.—The Outer Wall of the Nasal Cavity Lined with Normal Mucous Membrane. 
Fig. 6o.—Transverse Section through the Nasal Cavities Showing the Mucous Membrane Covering 
the Lower and Middle Turbinated Bones, in a State of Hypertrophy (Zuckerkandl). 138 
DISEASES OF THE NASAL PASSAGES. 
involving the mucous membrane covering both the lower and mid- 
dle turbinated bones. 
A still further development of the hypertrophic process is oc- 
casionally recognized by the examination, in which the posterior 
termination of the lower turbinated bones presents the appearance 
of large rounded masses with the same rugous surfaces, which more 
or less completely fill the oval openings of the posterior nares 
(see Fig. 70)— a condition first described, I believe, by Lefferts 
and to which the name of posterior hypertrophy has usually been 
given by writers. Bigelow,1 in demonstrating the turbinated bodies, 
called attention to the fact that, if this tissue is artificially distended 
Fig. 70.—Large Masses of Hypertrophied Membrane on the Posterior Termination of the Lower Tur- 
binated Bones, More or Less Completely Filling the Posterior Nares. 
by a blowpipe, “a pouch-like process projects from the rear of the 
bone, increasing its length.” 
Bigelow’s observation easily explains why these so-called “ pos- 
terior hypertrophies ” occur. 
So far our examination has shown us the existence of hyperae- 
mia of the membrane, the amount of which has been recognized by 
the eye. The amount of true hypertrophy, which exists in the 
membrane, has not yet been ascertained. There is now to be 
thrown into the anterior nares, a four-per-cent solution of cocaine 
by means of the spray apparatus, the effect of which will be to 
thoroughly expel the blood from the membrane. The action of 
the cocaine should be carefully watched, and the thoroughness of 
the application and the completeness of its action be awaited. 
When the membrane has become thoroughly exsanguinated, we 
will find the whole of the nasal passages brought completely 
under observation, unless some condition other than the one under 
1 Boston Med. and Surg. Jour., April 29th, 1875. H YPER TROPHIC RHINITIS. 
139 
consideration exists to interfere with the inspection. We find now 
the lower turbinated bone covered with a soft, thick, somewhat 
velvety membrane, which adheres closely to it, and reveals the 
bony outline more or less completely, according to the extent of 
the structural thickness of the membrane. Now, if there were no 
hypertrophy existing in the mucous membrane, the lower tur- 
binated bone would appear almost like a cord lying against the ex- 
ternal wall of the nose, covered by a closely adherent, thin, parch- 
ment-like membrane, possessing a thickness not sufficient to mask 
the general contour of the bony structure beneath. If, however, 
the membrane is the seat of connective-tissue hypertrophy, this 
will be recognized by the extent to which it does mask the normal 
bony contour. In front there will be a soft, rounded, cushion- 
like knob, as it were, grayish-white in color, and which can be 
moderately indented by the probe, which in all cases should be 
used freely over its surface, in order to gain accurate knowledge of 
the extent of the hypertrophic process. Looking along this sur- 
face beyond the anterior extremity, we will find the membrane pre- 
senting, as a rule, less evidence of thickening, both on inspection 
and to the impact of the probe, but still sufficient to give a rounded 
outline to the bone beneath. 
If now the head is thrown backward and the middle turbinated 
tissues are brought into view, they will be seen covering the bone 
somewhat closely, of the same general tint as the membrane below, 
but as a rule presenting also a thickened mass anteriorly, which 
here, instead of hypertrophy, assumes more of a polypoid nature 
(see Fig. 66). The hypertrophy is of a somewhat myxomatous 
character, and hence the swelling is not so markedly reduced by 
the use of cocaine. The probe should be used here also to deter- 
mine the character and location of the hypertrophic process. 
If now we examine posteriorly, the same appearances will pre- 
sent as were seen before the cocaine was applied, with this change, 
however, that the swollen masses on the posterior terminations of 
both middle and lower turbinated bones present less prominently, 
and are smaller in size. Superficially, however, they show the same 
grubworm-like membrane as before described. 
TREATMENT.—The first question which arises in the discussion 
of the treatment of this affection is as to the value of local appli- 
cations, such as astringents, alteratives, and stimulants. That these 
have an effect in temporarily relieving the troublesome symptoms 
of the disease, I think, no one will question, but when we consider 
what the morbid lesion is, namely, a deposit of connective tissue in 
the intervascular tissues, whereby the important functions of the 
membrane are hampered, I think that all must concede that a simple 140 
DISEASES OF THE NASAL PASSAGES. 
local application by means of spray or douche, can have but a very 
ephemeral effect. Furthermore, their efficiency is quite as great 
when applied at the hands of the patient himself, as when applied 
in the office of the physician. There are certain remedies, then, 
whose action we all recognize, and whose aid we seek by directing 
that the patients shall make use of them in the intervals of their 
attendance upon office-treatment. If there is much nasal stenosis 
with mucus-accumulation in the upper pharynx, a cleansing wash is 
always grateful to the patient, and he should have it near him for 
frequent use, simply as a part of his toilet-apparatus. With this 
we may combine both the cleansing properties of the alkalies with 
one of the simple astringents, such as: 
B Acidi carbolici, ...... grs. iij. 
Sodii bicarb., ....... grs. xij. 
Sodii biborat., ....... grs. xxx. 
Glycerini, . . . . . . . § ss. 
Aquae, . . . . . . . ad § vi. 
M. ft. lotio. 
Or, 
3 Sodii benzoat., 
Sodii biborat., ..... aa grs. xxx. 
Thymol., ...... grs. ij. 
Aquae, . . . . . . . § iv. 
Or, 
IJ Acidi borici, . . . . . . . 3 ss. 
Sodii chloridi, ....... grs. xl. 
Sodii tartrat., ....... grs. xv. 
Aquae camphorae, . . . . . 5 ij. 
Aquae, . . . . . . ad 1 vi. 
To any of the above there may be added a vegetable or mineral 
astringent, such as: 
Acidi tannici, .... grs. x. to the ounce. 
Zinci sulphatis, . . . grs. ij. to the ounce. 
Aluminis, . . . grs. v. to the ounce. 
Zinci sulpho-carbolat., . . grs. iij. to the ounce. 
Zinci chloridi, .... grs. i. to the ounce. 
These are best used by the convenient little atomizer shown in 
Fig. 47, thus avoiding the inconvenience and possible dangers of 
the Thudichum nasal douche, which, moreover, is no more advanta- 
geous, either as a cleansing device or as a medicating medium, than 
the atomizer. In the absence of an atomizer, I think the simple 
device of insufflation of warm salt water from the hand may be 
safely recommended to the patients, where any comfort results from 
the cleansing of the passages thereby secured. Snuffs, whether in- sufflated from the fingers or blown by an insufflating apparatus 
possess no advantages over aqueous solutions. They simply call 
upon the mucous membrane for a sufficient amount of water to 
dissolve their efficient ingredient, before they can exert any influ- 
ence, unless we except those which are used for stimulating pur- 
poses, and here we have a method of local relief to those cases 
which is oftentimes of undoubted temporary benefit. There are 
certain remedies which, when applied to the nasal membrane, give 
rise to pain and irritation, for the time, followed by a more or less 
profuse watery discharge from the nose. Their first effect is rather 
distressing; the ultimate effect, exceedingly grateful to the patient. 
The watery discharge which they excite, seems, as it were, to un- 
load the plethoric veins by this profuse exosmosis, which in its dis- 
charge seems to wash out the glands, and carry away a lot of surface 
debris, by which the membrane is for a time very markedly relieved, 
and the discomfort of the patient much alleviated. The ultimate 
effect, however, is of somewhat questionable advantage. Certain 
of the largely advertized catarrh snuffs sold in the drug-stores act 
on this principle. The most notable of these remedies are perhaps 
bicarbonate of soda, bromide of potassium, sanguinaria, galanga, 
etc. None of these remedies should be applied undiluted to the 
nasal mucous membrane in a state of hypertrophy, although all of 
them possess beneficial qualities in the atrophic form of the disease. 
The only advantage of powders is, that they may be carried in 
the vest-pocket and used at frequent intervals. The principle of 
their action is the same as the lotions above given, hence we may 
prescribe them of the same proportions, substituting a bland, neu- 
tral powder for the water, as follows: 
B Argent, nitrat., ...... grs. ij. 
Zinci chloridi, ...... grs. iv. 
Bismuthi subnit., . . . . . 3 ij. 
Sacchari lactis, . . . . . . 3 vi. 
M. 
B Acidi tannici, . • . . . . . grs. x. 
Pulv. acaciae, . . . . . . j i. 
M. 
5 Hydrarg. chloridi mitis, ..... grs. xx. 
Bismuthi subnitratis, . . . . 3 i. 
Magnesiae calc., . . . . . . § ss. 
M. 
B Iodol, grs. xx. 
Pulv. camph., . . . . . . . 3 ss. 
Pulv. acaciae, . . . . . . . 3 iv. 
M. 
H YPER TROPHIC RHINI775. 
141 142 
DISEASES OF THE NASAL TASS AGES. 
If the stenosis in these cases is troublesome, I see no objection to 
placing in the hands of the patient a two-per-cent solution of co- 
caine, with a small atomizer, by the occasional use of which he may 
give himself the temporary relief that this drug affords. 
All of these remedies, it should be understood, are merely pallia- 
tive; the permanent cure of these cases depends upon measures 
which will diminish hyperaemia, remove structural hypertrophy, and 
restore the normal calibre of the passages, while at the same time 
the healthy respiratory function of the membrane is re-established. 
Wagner1 advocates the use of flexible metallic bougies which are 
introduced daily into one or both passages, and allowed to remain 
in situ for several minutes at a time. Wagner claims that absorp- 
tion of redundant tissue is thereby promoted. On general princi- 
ples, in order to produce absorption, equable pressure must be 
continuously maintained for a long period of time. Certainly in 
this case, the pressure is neither equably distributed over the hyper- 
trophied membrane, nor maintained sufficiently long to produce any 
permanent results. The injection of ergot into the hypertrophied 
tissue by means of a hypodermic syringe, as suggested by DeBlois,2 
we can easily understand, might have an effect on engorged blood- 
vessels; but we should scarcely expect it to produce absorption of 
connective tissue. The removal of redundant membrane can un- 
doubtedly be produced by the method suggested by Henderson,3 
who advises that a few drops of pure carbolic acid should be in- 
jected into the tissues in several localities along the face of the tur- 
binated bone, thereby securing more or less extensive destruction 
of tissue by the slough which must naturally ensue. But, the object 
of treatment, it must be remembered, is not destruction of tissue, 
but its restoration to a healthy condition. Extensive sloughing, 
followed by cicatrization, might result in a condition quite as dele- 
terious, or even more so, than the disease which it was originally 
designed to remove. The last stage of atrophy is really a stage 
of cicatrization. If this plan of treatment were carried too far, we 
might easily produce a condition closely resembling an atrophic 
rhinitis in its advanced stages. The same objection lies with equal 
force against the various devices which were greatly in vogue some 
years since, for wrenching away this hypertrophied membrane by 
means of forceps, such as those of Robinson,4 which consist of long, 
tapering blades with teeth in their whole length, which, seizing the 
membrane laterally, enable the operator to tear it away. In the 
1 “ Diseases of the Nose,” pp. 70, 71. 
2 Arch, of Laryngology, vol. iv., p. 20. 
3 St. Louis Med. and Surg. Jour., Jan., 1886, p. 28. 
4 Op. cit., p. 115, HYPERTROPHIC RHINITIS. 
143 
same category should be mentioned the canula scissors of A. H. 
Smith as described by Robinson,1 and Woakes’s2 nasal plough. It 
should be stated, however, that these devices have deservedly fallen 
into general disuse. Local astringents having failed to accomplish 
any notably good results in these cases, these harsh measures, above 
alluded to, were taken up, and advocated for a while with consider- 
able earnestness, but the results of treatment proving even disas- 
trous in many cases, search was made for still other medicaments 
for controlling the disease and, naturally, the use of caustics was 
then taken up, and with the idea, I think still, that the destruction 
of tissue was the end to be accomplished, for we early find recom- 
mended the most powerful chemical agents, such as Leyden paste, 
Vienna paste, and nitric acid, together with the galvano-cautery. 
Some years since, in discussing this question,3 I entered my protest 
against these measures, claiming that better results would be se- 
cured by milder treatment, where the object was merely to reduce 
hypertrophic conditions, and then advocated the use of glacial 
acetic acid. Since that time, I have abandoned the use of this 
agent for one possessing more valuable properties as a caustic, 
namely, chromic acid, on the ground that these powerful agents 
were apt to do harm rather than good, on account of the difficulties 
in limiting their application. The question suggests itself in this 
connection, On what theory or conception of the disease has the 
use of these powerful caustics been based ? 
In order to understand the application of caustics to the hyper- 
trophied nasal mucous membrane, we must first form a clear idea 
of the pathological conditions which we wish to overcome. An 
hypertrophic rhinitis is the result of certain changes in the mucous 
lining of the nose. These changes do not affect the epithelial layer 
at all; the submucosa suffers, if at all, only a slight dilatation of its 
blood-vessels. It is in the third, or deeper, or cavernous layer, that 
the important changes take place. Here we have a dilatation of 
the venous sinuses, increased blood supply, hypernutrition, and a 
consequent increase of all the elements of the intervenous connec- 
tive tissue. 
Again, this hypertrophy does not lead to increased secretion, 
as is so often supposed. It is the function of the venous sinuses to 
pour into the nasal cavities about sixteen ounces of clear serum 
daily, for the purpose of moistening the air before it enters the 
lungs. This clear serum, mixed with the normal mucus secreted 
by the lining membrane of the nose, forms a bland and non-irritating 
1 Op. cit., p. 114. 2 Op. cit., p. 201. 
3 “ Some of the Unsettled Questions concerning Nasal Catarrh.” New York Med. 
Record, November 6th, 1880. 144 
DISEASES OF THE NASAL PASSAGES. 
fluid, whose presence we are not cognizant of in a state of health. 
Diminish the diluting serum, by thickening the walls of the vessels, 
and the secretion becomes thick and gives annoyance. 
From what has already been said, it is evident that the object 
of treatment should not be to destroy tissue, but to constrict the 
blood-vessels, diminish the nutrition,'and thus counteract hyper- 
trophy. We have found that the deep cavernous layer, by furnish- 
ing an increased blood supply, is the primary seat of the trouble. 
No destructive agent, applied as we are in the habit of using them 
in treating the nasal mucous membrane, can cause necrosis of more 
than the superficial epithelium, and possibly, to a very slight degree, 
of the submucosa; it does not affect the deep or cavernous layer, 
which is the one chiefly concerned. To what, then, is the beneficial 
action of a caustic application due, for it certainly is of great 
benefit. 
Until quite recently our caustic applications were effective sim- 
ply by the contraction of the superficial slough formed. By this 
contraction the calibre of the venous sinuses was diminished, and 
the walls of the vessels enabled to regain their proper tone. Since 
the discovery of the wonderful power which cocaine has of contract- 
ing blood-vessels, our caustic applications have been much more effi- 
cient. The ordinary procedure is, by an application of cocaine, to 
deplete the vessels by diminishing their calibre; then by applying 
our caustic to the most prominent points, to pin down this already 
contracted tissue by the formation of a superficial slough, maintain 
the vessels in a state of contraction until they can regain their nor- 
mal tonicity, and thus control nutrition. 
What agent shall we use to accomplish this purpose ? Shall we 
resort to the various chemical agents, or to the potential cautery ? 
The effect is the same in either case. For a considerable time I 
have used chromic acid to the exclusion of all other agents. Its 
advantages are well expressed by Dr. Squibb,1 as follows: 
“ It is, perhaps, the most important and most valuable of all the 
erosive caustics, for one simple and characteristic reason, namely, 
that it is self-limiting in its action, to a degree that no other de- 
structive caustic is. It is an active oxidizing agent, and destroys 
the tissues to which it is applied by oxidation. Thus far, its action 
is similar to other caustics, such as nitric acid, for example. But 
every molecule of chromic acid which destroys a molecule of or- 
ganic tissue, is itself destroyed, and rendered inert by being reduced 
to an insoluble and inert oxide of chromium, and this principle and 
degree of self-limitation is not obtained from any other caustic. 
Sulphuric acid is also a destructive caustic, but not in the same way 
1 The Ephemeris, July, 1883. HYPERTROPHIC RHINITIS. 
145 
or by the same reaction as chromic acid, and it is not self-limiting. 
Both sulphuric acid itself, and the products of decomposition by it, 
are more continuously and injuriously irritant. It is, therefore, a 
more painful caustic than chromic acid, produces deeper, more pro- 
longed, and more irritable sloughing.” 
We have, then, in chromic acid an agent which fulfils all the 
indications. The extreme nicety with which it can be applied, 
without cumbersome or expensive apparatus, its efficiency, and 
the absence of unpleasant effects following its intelligent use, have 
been sufficient to commend it to me, to the almost total exclusion 
of other agents. It has been claimed that cicatrices result from its 
use, but I have never observed them. It seems almost paradoxical 
to control a morbid process by a destructive agent, but at the pres- 
ent stage of our therapeutic resources we possess no better method. 
The special manner in which it should be used is as follows: 
A small, slender probe, such as is shown in Fig. 71, is first dipped 
in a little mucilage, and then four or five of the slender acicular 
Fig. 71.—The Author’s Chromic Acid Applicator. 
crystals of the acid are taken up upon it, and held over a flame 
until they are fused into a small tear, as it were, on the end of the 
probe, which on cooling will present a small, solid red bead of amor- 
phous chromic acid, which can be easily manipulated and carried 
to the part, already anaesthetized and exsanguinated by the ap- 
plication of cocaine, which it is desired to medicate, without danger 
of injuring healthy tissue. 
The galvano-cautery, since its use was first advocated by Mid- 
dledorpf,1 has come into very extensive use, and is warmly advo- 
cated by Mackenzie, Moldenhauer, Sajous, Lennox Browne, Seiler, 
Schech, Robinson, Moure and others. All of these writers give it 
preference over other methods, and many of them have presented 
us with ingenious forms of batteries which are claimed to possess 
certain advantages. 
A smaller number of authorities, while recommending it, fail to 
give it the first place as a caustic agent, such as Woakes, Cohen, 
Wagner and others. I think I do not overstate the case, when I 
say that the potential cautery possesses no advantages over the 
chemical cautery if properly and deftly applied, and with a nice 
appreciation of what is to be accomplished. The galvano-cautery 
1 “Die Galvano-kaustik,” Breslau, 1854. 146 
DISEASES OF THE NASAL PASSAGES. 
battery is a large, unwieldly, cumbrous apparatus, exceedingly lia- 
ble to get out of order, and a constant source of annoyance by its 
liability to fail us just when it is most needed, from short circuiting, 
polarization, or more likely still some hidden and undiscoverable 
fault which hampers its working. In treating hypertrophic rhinitis, 
this somewhat complicated apparatus is used to develop a certain 
amount of heat in a small platinum electrode, for the purpose of 
Fig 72.—Meyrowitz’s Portable Galvano-Cautery Battery. 
endowing the electrode with a moderate amount of destructive 
potency. Now, as we have already shown, the amount of absolute 
destruction which we wish to accomplish is very limited. It would 
seem, therefore, that we resort to a somewhat irrational process 
for accomplishing all this, when a few crystals of chromic acid, fused 
on the end of a probe, will accomplish the same purpose equally 
well. In condemning the use of the galvano-cautery methods, I do 
not attempt to criticise the results thereby obtained. There can H YPER TROPHIC RHINITIS. 
147 
be no question as to the success of the so-called galvano-caustic 
treatment. I merely say that we put ourselves to a vast deal of 
unnecessary trouble and inconvenience when we use this instru- 
ment. I think, however, another point worthy of consideration is 
that, in introducing the cautery electrode into the nose, and devel- 
oping in it a high degree of heat, we do incur a certain amount of 
risk. The chemical cautery, I think, involves no danger. A plati- 
num electrode introduced well into the nasal cavity, and heated to 
a white heat, or even a dull red heat, in contact with the lower and 
middle turbinated bones, 
does certainly add to the 
danger of the application. 
Most writers recognize this, 
and make special allusion 
to the violent reaction that 
may set in following its use, 
giving rise to an acute rhi- 
nitis, a distressing neural- 
gia, an acute dermatitis, or 
even an attack of facial 
erysipelas, as I have seen 
in three cases—complica- 
tions which rarely, if ever, 
attend the proper manipu- 
lation of a chemical agent. 
Notwithstanding what has 
been said, the galvano- 
cautery is an exceedingly 
attractive method of treat- 
ing affections of the nasal 
cavities, and undoubtedly 
will always remain a pop- 
ular instrument, for, when 
in working order, the manipulation of the instrument is a pleasure to 
the operator, and undoubtedly produces no slight moral effect on the 
patient. I have had personal experience with a number of different 
forms of cautery-batteries, and find it difficult to designate any par- 
ticular apparatus as offering special advantages. Of the two forms of 
galvano-cautery batteries, viz., the chemical and’the storage, I think 
the preference usually will be given to the former, in that the charging 
of the storage battery either requires a somewhat elaborate apparatus 
in one’s office, or the inconvenience of sending it to the electrician for 
restorage. Of the dip-plate batteries, perhaps none is better than 
the inexpensive instrument manufactured by Meyrowitz, Fig. 72, 
Fig. 73.—Meyrowitz’s Storage Battery. 148 
DISEASES OF THE NASAL PASSAGES. 
for although somewhat bulky in size, it is simple, and not especially 
liable to get out of order. In Fig. 73 is shown a simple storage bat- 
tery which has served the writer well in the somewhat limited use 
of this method to which he resorts. The cautery handle should 
be light and easy of manipulation. In Fig. 74 is shown perhaps 
Eig. 74.—Galvano Cautery Handle with Flat Electrode for Use upon the Turbinated Tissues. 
as efficient an instrument as any other. It is mounted with a 
flat electrode, suitable for use upon the turbinated tissues. Other 
forms of electrodes, designed to fulfil special indications, will be 
selected according to each operator’s preference. Various forms 
of these are shown in Fig. 75. The electrode should be bent at an 
angle of forty-five degrees with the handle, thus enabling the opera- 
tor to follow the platinum tip closely with his eye, in order that the 
cauterization shall always be accomplished directly at the summit 
of any projecting mass of hypertrophied tissue. The 
platinum tip used should, as a rule, be quite small, 
and in making the application a limited surface only 
should be burned over at each sitting. Furthermore, 
it is well to keep up a slight motion, if possible, in 
the instrument after the current is turned on, which 
should always be done after it is carried to the desired 
locality, and shut off before it is withdrawn, in order 
that the electrode may cool, and thus healthy tissue 
in other parts of the nostril escape injury by the in- 
strument on its removal. The object of the slight 
motion recommended, is to prevent the electrode 
from adhering to the burned tissues, for when this 
occurs its withdrawal is usually attended with a tear- 
ing away, by which the blood-vessels are ruptured, 
and hemorrhage ensues. The degree of heat in the 
instrument, where feasible, should be regulated. This 
is not possible, however, in all cases. A red heat is 
preferable, as there is danger of the extreme white 
heat burning more extensively than may be desired. 
It is often recommended to use a cautery-knife, by 
which the surface of the membrane may be incised as it were, thus 
burning a furrow well into the turbinated tissues. I think, how- 
ever, as a rule, a superficial burning, producing a slough such as 
has been described in connection with chromic acid, will be all 
that is sufficient, using for this purpose a small flat electrode. A 
Fig. 75. — Nasal 
Electrodes. 
pointed; B, knife; 
C, curette; Dy point. HYPERTROPHIC RHINITIS. 
149 
twenty-per-cent solution of cocaine, of course, should be used in 
the manner already described in connection with chromic acid. 
After the burning, the cavity should be repeatedly washed out with 
a cleansing spray, thus cooling the membrane and allaying such 
irritation as may be caused by the application. 
As a rule, caustic applications are not specially painful and yet, 
in many cases, notwithstanding the use of cocaine, a certain amount 
of pain referable to the burned surface will be produced, while in 
others severe neuralgia will be caused as the result of the caustic 
acting on the terminal filaments of the nerves. Where this occurs, 
it is well to allay it immediately, otherwise it may persist many 
hours. For this purpose nothing is better than the application of 
dry heat, which is usually accomplished by holding a towel against 
the hood of the rhinoscope or the chimney of a coal-oil-lamp for a 
few seconds, and applying it to the face, changing the towel fre- 
quently. This is simple and perhaps more convenient than the hot 
water bag or the Japanese pocket-stove, either of which may be 
used. The caustic applications should be repeated at intervals of a 
week or ten days. 
These measures will be fully equal to the reduction of chronic 
hyperaemia with hypertrophy of the nasal mucous membrane, where 
no complications exist. As has already been stated, probably the 
most frequent cause of hypertrophic rhinitis is a deflected septum, 
and it is scarcely necessary to state that any measure for the reduc- 
tion of the hypertrophic process will give but temporary relief, 
while the exciting cause remains. Hence, from the full apprecia- 
tion of the mechanism of the development of the disease, we easily 
understand that our first efforts should be directed toward the re- 
moval of the obstructing septal deformity. This question, however, 
is fully discussed in the chapter on that subject. 
A condition is not infrequently found in these cases which has 
already beep alluded to, and which consists of an hypertrophy of 
the posterior extremity of the lower turbinated bone. Cauteriza- 
tion does not reduce these masses, and surgical interference is 
always necessary. 
For the removal of this redundant tissue, we possess no device 
which is so efficient as the cold wire snare ecraseur which has 
come so largely into use of late for the removal of growths, hyper- 
trophic masses, etc., in the nasal passages. It is interesting to 
note in this connection that, as Mackenzie has observed, one of the 
earliest forms of the snare was devised by Robertson1 for the 
removal of nasal polypi, and that this instrument was subsequently 
modified by Wilde to adapt it for operating upon aural polypi, 
1 Edinburgh Med. and Surg. Jour., 1805, vol. i., p. 410. 150 
DISEASES OE THE NASAL PASSAGES. 
while a still later modification was made by Hilton, who in turn 
adapted it again for use in the nose, for the extraction of nasal 
polypi. These instruments were designed to be mounted with 
annealed wire,1 for the purpose of encircling the pedicle of the 
growth, after which it was torn from its attachments. Hence we 
see that they were all technically snares rather than ecraseurs. 
To Dr. Jarvis is undoubtedly due the credit of having 
introduced the principle of ecrasement, as applied to 
nasal growths, or certainly to have demonstrated its 
great value, when he devised the very ingenious and 
yet simple device which is known as Jarvis’ Snare2 
(shown in Fig. 76). It consists of a slender but stout 
tube, about the size of a No. 3 sound, English scale, 
on the proximal end of which is turned a thread for 
about two and a .half inches of its length. On this 
thread there plays a milled nut which carries before it 
an outer tube, two and a half inches long which slides 
over the threaded portion. The end of the outer tube 
is fitted with two small pins for fastening the wire with 
which the snare is mounted. The wire to be used in 
this instrument is the highly tempered steel piano-wire, 
the No. 5 being perhaps best adapted for all purposes. 
The working of the instrument is obvious. The two 
ends of the wire are passed up through the inner tube, 
and firmly fastened to the projecting pins on the outer 
tube, leaving a loop projecting from the distal extrem- 
ity, which is drawn within the canula by turning the nut, 
and thus carrying the outer tube before it. 
One great advantage of this instrument consists in 
the substitution of the principle of dcrasement for that 
of snaring, whereby the growth is separated without in- 
juring healthy tissues, and at the same time the danger 
of hemorrhage notably diminished. Another, and very 
important feature of it, consists in the use of the steel 
piano wire, which furnishes a loop of such strength and 
resistance, that it can be readily carried into the nasal 
cavity and fitted about a growth without yielding or 
bending, thus affording a facility in manipulation, which is in no 
manner equalled by the soft annealed wire loop. 
A somewhat ingenious modification of the Jarvis’ snare has been 
constructed by Sajous, as shown in Fig. 77, which consists of a solid 
Fig. 76.—Jarvis’ 
Wire Snare- 
Ecraseur. 
1 Robertson makes mention of the use of harpsichord wire, though evidently with the 
design of snaring the growth, rather than of severing its attachments by ecrasement. 
2 Trans. Am. Laryngol. Ass’n, 1880, p. 130. H YPER TROPHIC RHINITIS. 
151 
stem playing in an outer tube. The proximal end of the stem is 
fitted with a thread on which plays a nut, while its distal end is 
slotted on either side for a short 
distance, and perforated by a small 
opening. Into this opening are in- 
serted the two ends of the steel 
wire, when the stem is drawn with- 
in the outer tube, thus bending the 
wire in such a way as to hold the 
loop firmly in position. The ad- 
vantage of this device seems to be 
in the simplicity of its mounting, 
and the economy of wire. 
In dealing with the above con- 
dition of posterior hypertrophy 
already alluded to, the Jarvis in- 
strument is to be preferred. This 
is mounted with a loop, which 
an examination of the mass has 
shown to be sufficiently large to 
embrace it, and is then passed 
through the nares until the end of 
the loop passes the end of the tur- 
binated bone, and is free in the 
upper pharynx. The loop having 
been bent slightly to one side be- 
fore entering the nares, will, by its 
own elasticity, slip over the mass, 
when it can easily be drawn into 
place and the tumefaction cut 
through. Of course, there is liable 
to be a considerable hemorrhage as 
the result of this procedure, but if 
the operation be done slowly, a half 
hour or even an hour being con- 
sumed, it may often be done with- 
out loss of blood. If, however, 
hemorrhage does occur, a plug of 
absorbent cotton can easily be 
passed back and wedged between 
the cut surface and the septum, and 
allowed to remain until the follow- 
ing day, if necessary. The relief 
attending this operation is immediate and striking. The accom- 
Fig. 77.—Sajous’ Snafe. a, Sectional view; 6, 
snare showing the method of inserting the wire 
loop; c, distal end of the inner stem, enlarged. 152 
DISEASES OF THE NASAL PASSAGES. 
panying illustration, Fig. 78, gives a side view of this posterior 
hypertrophy. It is a drawing by Dr. Jarvis of a morbid specimen 
in his possession. There is also shown in the plate the snare in 
position for severing the mass. 
A condition not unlike this at the posterior termination of the 
lower turbinated bone is frequently met with, though in a far less 
Fig. 78.—Lateral View of Posterior Hypertrophy of the Mucous Membrane of the Lower Turbinated 
Bone, with Jarvis’ Snare in Position for Section. 
degree, at the anterior termination of the same body. This consists 
of a rounded, puffy-looking mass, which encroaches on the lumen 
of the anterior nares, more or less completely filling it, and serving 
to obstruct materially the entrance of air. 
A very simple device for removing this by means of the same 
snare 6craseur has been suggested by Dr. Jarvis.1 This consists of 
transfixing the mass from below upward and backward by a long, 
slender transfixion needle, either straight or slightly curved as 
shown in Fig. 79, and mounted in a suitable handle. The loop of 
the snare is then passed over the handle of the needle, and subse- 
Fig. 79.—Jarvis’ Transfixion Needles. 
quently over its point, when that portion of the mucous membrane 
which has been transfixed is cut through and removed. There is 
thus taken out a small mass about the size of a split pea. The cut 
surface heals kindly, and the result, in my experience, has been in- 
variably to relieve the conditon of stenosis. This, of course, ac- 
complishes what the forceps does, but it does it in an almost painless 
1 N. Y. Med. Record, vol. xxi., p. 563. HYPERTROPHIC RHINITIS. 
153 
manner, and with absolutely no bruising. The hemorrhage result- 
ing is not great, and is easily controlled by a plug of cotton inserted 
for a few minutes. Occasionally there will be found on the an- 
terior extremity of the lower turbinated bone, a mass which will 
demand removal by the snare. 
Hypertrophy of the membrane covering the middle turbinated 
bone occurs in a large majority of cases on its anterior termination, 
and occurs here as a condition rarely met with on the lower tur- 
binated, in that it possesses a looser structure, and assumes more 
of a myxomatous character (see p. 135), presenting to the eye a 
bluish-gray appearance, between that of the nasal mucous mem- 
brane and a nasal polyp. This may develop on an otherwise healthy 
turbinated bone, or the bone itself may become enlarged and un- 
rolled, as it were, on itself, in such a way as to present a large, 
shuttle-like prominence, projecting downward and inward, thus 
encroaching upon the normal lumen of the cavity. No hesitation 
should be felt in removing this mass, and we possess no method 
better than the use of the steel wire snare. The steel wire loop 
possesses sufficient firmness to enable the manipulator to carry it 
well over the mass which can be then easily severed. In many 
cases a portion of the bone is removed with the thickened mem- 
brane, which I think is always permissible, as probably the de- 
formity of the bone has much to do with the development of the 
hypertrophy. The snare, I think, should always be used in these 
cases, as caustics are inadequate to their destruction. The galvano- 
cautery loop may be used, but the cold wire is more easily manipu- 
lated and the operation is completed more rapidly. 
Hemorrhage as the result of operations on the middle turbinated 
bone is comparatively rare, although three cases of operation in 
this region at my hands have been followed by this accident; the 
hemorrhage being exceedingly intractable, plugs not only being 
rendered necessary, but their removal not being feasible until the 
third day. 
In the treatment of all cases of catarrhal disease, special stress 
should be laid on the enforcement of those general hygienic mea- 
sures which already have been fully discussed in the chapter on tak- 
ing cold. A catarrhal process is kept up oftentimes and aggravated 
by the same conditons which give rise to the phenomenon of tak- 
ing cold. The same general hygienic laws which we have already 
discussed under the heading of prevention of cold should be spe- 
cially enforced, therefore, on our patients under treatment for a 
chronic catarrhal process. CHAPTER X. 
PURULENT RHINITIS OP' CHILDREN. 
THIS expression is used to describe an affection, which is met 
with exclusively in children, and in which the inflammatory process 
is attended with a purulent discharge from the nasal mucous mem- 
brane. In literature we find it used in a somewhat vague and in- 
definite manner by writers, who describe a number of different 
diseases under this name. Thus Mackenzie recognizes two forms 
of purulent rhinitis, acute and chronic. Under the acute form 
this writer1 describes that form of purulent nasal discharge, met 
with in infancy, which is usually ascribed to a gonorrhoea or leucor- 
rhoea in the mother, although he questions the accuracy of this 
assigned cause. The chronic form of the disease, on the other hand, 
he2 seems to think is only met with in that curious affection, which 
was first described by Stoerck, as found among the inhabitants of 
Poland, and which consists in a purulent discharge from the nostrils, 
with no injection of the mucous membrane, thus distinguishing it 
from a coryza. The disease runs a very chronic course, and is said 
to extend to the lower air-passages, giving rise to severe dyspnoea. 
In one case tracheotomy is recorded as having been rendered neces- 
sary. Stoerck regarded the affection as due to personal uncleanli- 
ness. 
Frankel3 describes but one form, referring apparently to the 
same as Mackenzie’s acute variety of the disease. 
Cohen,4 in the chapter on chronic nasal catarrh, describes a 
purulent form of catarrh, as commencing in infancy, and which, 
running a chronic course, may develop eventually in ulceration and 
necrosis. Cohen attributes all these cases to a remote specific in- 
fection. 
Beverley Robinson, Sajous, Lennox Browne, and Seiler make 
no definite allusion to the purulent form of nasal disease. A care- 
ful examination of the above authorities leads me to think, that 
they have entirely overlooked that form of the disease, which is 
the subject of this chapter. 
1 “ Diseases of the Throat and Nose,” vol. ii., p. 294. 
2 Loc. cit., p. 335. 3 “Ziemssen’s Encyclopedia,” vol. iv., p. 139. 
4 “ Diseases of the Throat and Nose,” 2d ed., N. Y., 1875. PURULENT RHINITIS OF CHILDREN. 
155 
While recognizing the existence of the acute purulent rhinitis 
in new-born children, as dependent, probably in many cases, on in- 
fection from the vaginal passages of the mother, we meet with a 
large number of cases, which commence in the earlier years of 
childhood, in which the disease pursues an essentially chronic course, 
and in which a purulent discharge is the prominent feature. It is 
purely local in character, dependent on no constitutional dyscrasia, 
and consists essentially in an increased secretion of mucus in the 
earlier stages, together with a rapid desquamation of epithelial 
cells, which, running its course as a purulent disease, in from five to 
ten years, develops finally into what is known as atrophic rhinitis. 
The disease, in fact, is the first stage of so-called dry catarrh or 
ozsena. From a clinical point of view, it is a very noticeable fact, 
in pathological processes involving mucous membranes certainly, 
and probably all tissues of the body, that in youth the epithelial 
structures are especially liable to become the seat of diseased action, 
whereas in adult life this tendency seems to disappear, and in place 
of it, there obtains a tendency to the involvement of the connective- 
tissue structures. Thus, in the earlier years of life we notice this ten- 
dency in the development of enlarged tonsils, and follicular disease 
in other portions of the air tract, as well as in the vulnerability of the 
lymphatic glands, whereas in adult life inflammatory changes in 
the mucous membranes result mainly in a true connective-tissue 
hypertrophy. This general law has been adduced in my own mind 
entirely from clinical observation, not from any special pathological 
study. Furthermore, in searching for some support in works on 
general pathology, I fail to find any direct statement to this effect. 
Wagner,1 however, would seem rather ’to suggest it, for he makes 
the statement, that “ during childhood the skin and mucous mem- 
branes are more excitable, more prone to disorders of the circula- 
tion. The function of the lymphatics is prominent in childhood, 
the quantity of lymph is increased, the lymphatic glands at this 
time have their greatest development; and in the latter we more 
often observe alterations of nutrition than in adults (the so-called 
scrofulous diseases).” 
Now, this peculiar tendency in childhood shows itself in a 
notable activity in the development of the epithelial cells, under 
the stimulation of any of those causes, whose agency we recognize 
in the production of inflammatory processes. Furthermore, this 
activity in epithelial development may result in two distinct pro- 
cesses. In the one, we find the new epithelial cells building them- 
selves upon the parent structures, and remaining a permanent 
element in the tissue. In other words, a true epithelial hypertrophy 
1 “ Manual of General Pathology,” N. Y., 1876. 156 
DISEASES OF THE NASAL PASSAGES. 
takes place, with the result of, in the case of the tonsillar gland for 
instance, an hypertrophied tonsil. In another case, the same 
activity going on in the mucous membrane, and characterized by 
rapid evolution of epithelial cells, we find that the epithelium is 
thrown off. In other words a rapid process of desquamation sets 
in. Now, why these new cells in the one case build themselves 
upon the membrane, and in the other case are thrown off, I do not 
suggest a reason. Certainly it is not dependent on any constitu- 
tional dyscrasia, which destroys the power of the individual cell to 
maintain its identity as an integral part of the membrane, for if 
there is any notable dyscrasia in these cases, it would seem to be 
more marked in those instances in which hypertrophy takes place, 
rather than the desquamative process. Furthermore, it is a notice- 
able fact in young children that acute rhinitis, referring to the 
form of cold in the head, which is met with in adult life, is an 
exceedingly rare disease. An ordinary acute inflammation of the 
mucous membrane of the nasal passages in a child, does not result 
in congestion of the mucous membrane involving the turbinated 
tissues. If a child has an attack of what is ordinarily called cold 
in the head, in a majority of instances, it is an acute inflammation, 
with swelling of the glands, of the vault of the pharynx, producing 
more or less complete nasal stenosis, from occlusion of the posterior 
nares. In the less frequent cases, it is the mucous membrane lin- 
ing the nasal chambers. When this occurs, we notice this suscep- 
tibility already spoken of, immediately showing itself, and the 
superficial layer of the mucous membrane, the epithelial layer, be- 
comes the seat of marked morbid activity, differing essentially from 
the process which occurs in adult life. Now, with the first attack 
of a cold, the symptoms may not differ in a very marked manner 
from a cold in adult life, but as these attacks recur, there sets in 
a notable tendency to a rapid proliferation of epithelial cells, which 
being thrown off in connection with an excessive mucous discharge, 
gives rise to a muco-purulent secretion. These repeated attacks of 
the acute disease finally develop into a chronic rhinitis, character- 
ized by no very noticeable nasal stenosis, but by a more or less 
profuse purulent discharge, and the disease which is the subject of 
this chapter is established. Commencing, as a rule, at from three 
to five years of age, it runs a somewhat slow course of from ten to 
twelve years, when it develops into an atropic rhinitis, the rapid 
desquamation of epithelial cells gradually extending to the mucous 
glands, robbing them of their epithelial lining, and therefore of 
their secreting power, and so resulting in crust-formation, and other 
symptoms of atrophic rhinitis, as will be more fully described when 
we consider the development of that disease. PURULENT RHINITIS OF CHILDREN. 
157 
It should be stated, that the morbid process, from the beginning 
to the end of the disease, is identical in all its features, except as to 
the degree of activity. It is a catarrhal process in the first year, 
and it is a catarrhal process always. The deeper tissue-structures 
are but slightly involved, and the surface layer becomes the site of 
but one form of diseased activity, and that consists of an epithelial 
desquamation together with a muco-purulent discharge. Ulcera- 
tion of the soft parts, or necrosis of the bone beneath, are never, 
under any circumstances, a part of the progress of the disease. 
In some cases, the disease commences in the first year of life, 
although, in these cases, there is no tendency to a more rapid de- 
velopment of the later symptoms. As a rule, the purulent character 
of the discharge is maintained until about the fourteenth or fifteenth 
year, although, in one case which has come under my observation, 
the atrophic stage with crust-formation developed as early as the 
eighth year of age. 
Etiology.—It is a very common assertion, that atrophic rhinitis 
and ozsena are dependent on the scrofulous diathesis. Of course, 
this assertion would necessarily include this dyscrasia as the cause 
of the disease in question. In my own experience, children affected 
with this affection present a picture of rugged health, which would 
scarcely warrant the suspicion of any constitutional dyscrasia, nor 
can syphilis be said to have any influence, either in producing, or 
indirectly causing the disease. The clinical history of syphilis 
presents a series of symptoms, of a totally different character. 
Many forms of catarrhal disease in children have their origin in 
an attack of scarlet fever, measles or some other of the exan- 
themata. My experience is, that a purulent rhinitis rarely com- 
mences in this way. On the contrary, the catarrhal affections which 
have their origin in a febrile attack, are characterized by hyper- 
trophic changes. In fact, I find but very few instances of the disease 
we are considering, recorded among my notes, as having commenced 
in this way. I know of no assignable cause for the disease, other 
than taking cold, and this we explain by the neglect of the ordi- 
nary hygienic rules of proper living, as already discussed in a pre- 
vious chapter. 
SYMPTOMS. — The prominent symptom of the disease, is a 
muco-purulent secretion, generally of a bright yellow character, 
and having its source from both nostrils. This is expelled in con- 
siderable quantities into the handkerchief, and also makes its ap- 
pearance about the nostrils, constituting what is often called a 
“ dirty nosed ” child. There is no especial obstruction to the nasal 
passages, except as the result of the accumulation and drying of 
the secretion about the anterior nares. The discharge is generally 158 
DISEASES OE THE NASAL PASSAGES. 
through the nostrils, although more or less of it is drawn down or 
makes its way into the fauces. During sleep the secretions are apt 
to accumulate to such an extent as to cause mouth-breathing. The 
child, of course, is liable to take cold, during which there are ex- 
acerbations, and the attack is attended with a more profuse dis- 
charge containing a large amount of serum. During the exacerba- 
tion sneezing is a rather prominent symptom, though at other times 
it is not present, the sensibility of the nose being diminished rather 
than increased. Fetor, so prominent a symptom in the atrophic 
stage of the disease, is never present while the discharge remains 
fluid and moist. 
DIAGNOSIS.—A rhinoscopic examination anteriorly, reveals the 
mucous membrane covering the turbinated bones somewhat swol- 
len, and of a reddish tint, with perhaps the appearance of a mild 
subacute inflammation, but rarely presenting the active turgescence, 
and bright red appearance of an acute inflammatory process. 
Coating the faces of both the lower and middle turbinated bodies 
will be seen flakes and strings, and even large masses of bright 
greenish-yellow muco-pus, in a semi-fluid state. An examination 
of the fauces will show muco-pus coating the posterior wall of 
the pharynx, and trailing down its wall in stringy masses. This 
condition, however, it should be remembered, is also seen in con- 
nection with disease of the adenoid glands of the vault of the 
pharynx. An examination of the vault of the pharynx, however, 
will usually reveal whether any morbid condition exists there to 
account for this post-nasal discharge. 
The diagnosis, however, is not based on the rhinoscopic exam- 
ination alone, but can easily be made both from the objective 
symptoms, and by elimination. A purulent discharge is met with 
in children as the result of strumous ulceration and necrosis, the 
presence of foreign bodies, blennorrhoea, diphtheria, and the late 
stages of acute rhinitis met with in connection with the exanthemata. 
If there are any other causes, they are of exceeding rare occur- 
rence. Syphilitic or scrofulous disease gives rise to an exceedingly 
offensive discharge of pus, mingled with blood, from one or both 
nostrils, but it is accompanied by so many marked symptoms of 
the blood-poisoning, that a mistake in diagnosis need not be made. 
A foreign body in the nose gives rise to a purulent discharge, as 
a rule, from but one nostril. A purulent rhinitis invariably in- 
volves both sides. Furthermore, inspection and examination with 
a probe should alway eliminate this source of error. Blennorrhoea 
occurs as a rule in the new-born child, and is characterized by an 
activity of the morbid process both as regards the amount of dis- 
charge, and the swollen condition of the membrane, as to render PURULENT RHINITIS OF CHILDREN. 
159 
its recognition comparatively simple. Furthermore, the conjunc- 
tival membrane rarely escapes the blennorrhceal poison. Purulent 
discharge from the nose in connection with diphtheria and the ex- 
anthemata need, of course, not be confounded with the disease 
under consideration. 
PROGNOSIS.—These cases, as before stated, run a course of from 
eight to ten years’ duration, the symptoms developing slowly, and 
the discharge increasing in amount, showing a tendency to accumu- 
late in the passages and becoming thicker and more inspissated in 
character, as the years go on. During this time the mucosa proper 
becomes the seat of no marked changes other than a moderate 
congestion of its blood-vessels. The epithelial layer, on the con- 
trary, is slowly but surely wasted, from the loss of its superficial 
layers, and becomes abnormally thin, while at the same time the 
mucous glands and follicles become, to an extent, involved, so that 
they also becoming subjected to the desquamative process, lose a 
certain amount of their lining epithelium. Hence, it will be easily 
understood, how that, in the later years of the disease, the progno- 
sis becomes somewhat unfavorable as regards an ultimate cure. In 
earlier years, however, I believe if proper treatment is adminis- 
tered, and carried out with sufficient persistence and attention to 
detail, that we may hope not only to arrest its further progress, 
but to ultimately entirely cure the affection. 
TREATMENT.—The first step in treatment will consist in the use 
of some simple lotion, by which the pus-discharge may be thoroughly 
removed from the cavity, and the surface of the membrane thor- 
oughly cleansed. For this purpose any simple alkaline wash will 
be found efficient, to which may be added a small amount of car- 
bolic acid or listerine. 
Dobell’s solution answers an excellent purpose, or perhaps better 
still we may use one of the following formulae: 
I£ Listerine, . . . . . . . . 3 ss. 
Sodii biborat., . . . . . . . 3 ss. 
Glycerini, . . . . . . . 3 vi. 
Aquae, . . . . . . ad 3 vi. 
Or, 
$ Thymol., . . . . . . . . gr. x. 
Sodii chloridi, . . . . . . 3 ss. 
Sodii benzoat., ....... gr. xx. 
Aquae, . . . . . . ad § vi. 
Or, 
IJ Icthyol., . . . . . . . . gr. i. 
Potass, chlorid., . . . . . .3 ss. 
Liquor calcis, . . . . . . ad 5 vi. 160 
DISEASES OF THE NASAL PASSAGES. 
These cleansing lotions are best used by means of a small single- 
bulb atomizer, such as is sold in the drug-stores, the best of which 
perhaps is that shown in Fig. 47. This should be used at the com- 
mencement of treatment at least three or four times daily, the 
wash being thrown into both nostrils, and the child being taught to 
cleanse the passages as thoroughly as possible by blowing the nose 
immediately after. In lieu of the atomizer an ordinary ear-syringe 
may be used, but as a rule I think the atomizer preferable. 
After the membrane is thoroughly cleansed, an astringent should 
be used in the same manner, by means of the syringe or atomizer, 
preference being given to those agents which possess the property 
of controlling cell-proliferation. 
For this purpose we may use one of the following: 
IJ Zinci sulpho-carbolat., . . . - . gr. xx. 
Hydrarg. chloridi corros., . . . . gr. 
Aquae, ad 3 iv. 
M. 
Or, 
5 Acidi borici, . . . . . . . 3 ij. 
Aquae, . . . . . . ad 3 iv. 
Or, 
$ Acidi salicylic., ...... gr. iv. 
Aquae, . . . . . . ad § iv. 
To any of the above there may be added, with benefit, one of the 
simple astringents, or they may be used alone, in order of prefer- 
ence as follows: 
Glycerole of tannin, . . . . 3 i. to § i. 
Argenti nitrat., . . . . . gr. iij. to \ i. 
Zinci sulphat., . . . . . gr. v. to 3 i. 
Cupri sulphat., . . . . . gr. ij. to 3 i. 
Aluminis, . . . . . . gr. x. to § i. 
The effect of these agents should be noted, and a change in the 
special drug employed occasionally made, as it would seem that 
even the best of local remedies lose to a certain extent their effect 
from long usage. Occasionally good results will be obtained by the 
use of ordinary skimmed milk, or even better still, buttermilk. 
These may be used pure or in combination. To equal parts of 
lime-water and buttermilk may be added sulpho-carbolate of zinc 
of a strength of two grains to the ounce. Permanganate of potash 
is a remedy of a certain amount of value in controlling cell-prolifer- 
ation, and may be often used with benefit, in the strength of three 
to five grains to the ounce. 
Watery solutions are to be preferred, in the treatment of these PURULENT RHINITIS OF CHILDREN. 
161 
cases, to other forms of medication. Inhalations and vapors are 
probably without effect. Powders, however, for convenience of use, 
may be used with benefit, the patient being directed to carry a box 
in his pocket for frequent application. For use in this way boracic 
acid may be used in full strength, or one of the following: 
B Iodoh, 
Mag. carb., aa § ss. 
M. 
Or, 
B Hydrarg. chlor. mitis, . . . . . . 3 ss. 
Bismuthi subnitrat., . . . . ad 3 i. 
Or, 
B Zinci oxidi, . . . . . . . . 3 i. 
Bismuthi subnitrat., . . . . ad 3 i. 
Or one of the following astringents may be used, incorporated 
with any unirritating powder, such as starch, lycopodium, sugar of 
milk, etc.: 
Acidi tannici, ..... gr. x. to 3 i. 
Plumbi acetatis, . . . . . gr. ij. to § i. 
• Argenti nitratis, ..... gr. i. to 3 i. 
Cerii oxalatis, . . . . . gr. xx. to 3 i. 
In addition to local treatment, general hygienic measures are 
especially indicated in these cases, not perhaps from any features 
belonging to the disease itself, but rather on account of the tender 
age of the patients with whom we have to deal, and their peculiar 
vulnerability to changes of temperature. These measures are em- 
braced briefly under the injunction that a daily cold sponge-bath 
should be used to the waist; absolutely pure, all-wool flannels, worn 
next to the skin in summer and winter; together with the other 
general directions as to sleeping apartments, clothing, exercise, etc., 
which have been given in the chapter on taking cold. 
Internal medication is not indicated, and yet it has been my 
habit for some years past, perhaps as a matter of routine, to ad- 
minister cod-liver oil. As stated before, the general health is not 
impaired in these cases, and yet cod-liver oil seems to exercise a 
certain amount of controlling influence on the disease, and I think 
it should be given, provided it is well tolerated, and does not inter- 
fere with the digestion. CHAPTER XI. 
ATROPHIC RHINITIS. 
It will be noticed that we embrace all forms of catarrhal inflam- 
mation of the nasal mucous membrane under really the two heads, 
atrophic and hypertrophic. This distinction was first, I think, 
suggested by Frankel,1 although he did not attempt to elaborate the 
distinction between the two forms of disease, rather indorsing the 
view that the atrophic form was but the later stage of the hyper- 
trophic. That this view is incorrect has already been suggested in 
the previous chapter. The distinctive character of atrophic rhinitis 
was, I believe, first pointed out by myself, in a paper read before 
the Seventh Session of the International Congress of London in 
1881.2 The view there laid down I still regard as the true explana- 
tion of the development of the disease. Commencing in a desqua- 
mative inflammation of the nasal mucous membrane, there is set 
up the disease described in the previous chapter, under the name 
of purulent rhinitis, which, as was there suggested, constitutes the 
early stage of the disease under consideration. We may describe 
atrophic rhinitis, then, as that form of catarrhal inflammation of 
the nasal mucous membrane which, developing in the direction of 
a glandular atrophy, leads eventually to a more or less complete 
destruction of the muciparous glands and follicles, together with 
a true cirrhotic condition of the mucosa proper, resulting in a con- 
dition of the nasal mucous lining, in which the prominent and 
characteristic symptom consists in the formation of crusts and scabs, 
which lodging in the sinuous passages of the nose, undergo de- 
composition, and become the source of a fetid and offensive odor. 
The progress of the disease as a purulent rhinitis has already 
been fully described. In that chapter it was stated that the pre- 
dominating morbid condition consisted in the desquamation of 
epithelium from the surface of the mucous membrane. Now, as 
long as this desquamation is confined to the superficial epithelial 
cells, we can easily understand that the disease is attended with a 
thin and fluid muco-purulent discharge. Naturally, however, the 
morbid process will not confine itself to the superficial layer of the 
1 “Ziemssen’s Encyclopedia,” vol. iv., p. 138. 
2 Transactions, vol. iii., p. 329. ATROPHIC RHINITIS. 
163 
membrane, but there soon occurs an involvement of the glands, by 
which this desquamative process extends to these elements of the 
membrane, resulting in a certain amount of loss of secreting power. 
As soon as the glands have become seriously impaired, as to their 
function, by this epithelial loss, we find the secretion becoming, to 
a certain extent, limited; the muco-purulent discharge assumes a 
more inspissated character, and lodging upon the convex surfaces 
of the turbinated bodies, dries and forms a closely adhering film, 
clinging to the membrane in such a way as to interfere with the 
vascular circulation. The mechanical action of this dried film is not 
unlike that of collodion, for in drying, it contracts, and embraces 
the turbinated bones in a grasp which necessarily must interfere 
with the circulation of blood in the venous sinuses. The action of 
this, as we see, is far-reaching. The circulation of the blood in the 
large venous sinuses of the turbinated bodies being hampered, the 
great and important respiratory function of the nasal mucous mem- 
brane is more or less completely arrested; the exosmosis of serum 
ceases, or is markedly diminished. The result is obvious. The 
muco-purulent secretion is no longer diluted by the amount of serum 
which is normally exuded, and the tendency to muco-purulent in- 
spissation, and crust-formation, is markedly increased. Further- 
more, the nutrient arterial supply of the membrane is also shut 
off in such a manner as to promote a degeneration of the tissue, 
by which the atrophic process is still further accelerated. As the 
disease progresses, we have still another element added, in the 
atrophy of the turbinated bones themselves. As we know, the 
periosteum of the turbinated bones is the deep layer of the mucous 
membrane. As the result of impeded circulation, due to the adher- 
ing crusts already described, the circulation of the blood in the 
deep layer of the membrane is so far arrested as to rob the bone 
itself of its normal nutrient blood-supply, thus causing an atrophy, 
by which eventually the bones disappear more or less completely 
from the nasal cavity, leaving only small and scarcely recognizable 
ridges on the outer wall. We have here, I think, a rational theory 
of the development of purulent rhinitis, and ultimately of atrophic 
rhinitis, which harmonizes fully with the clinical history of the dis- 
ease, and affords a rational explanation of the symptoms which 
characterize its various stages of development. 
We have thus established, under the name of atrophic rhinitis, 
a disease which probably comprises a large number of the cases 
which have heretofore been embraced under the general term of 
ozaena. It may be repeated, in this connection, that this term is 
one used to describe a symptom, and not a disease, and by earlier 
writers has been used to describe all diseases of the nasal cavity 164 
DISEASES OF THE NASAL PASSAGES. 
characterized by an offensive discharge, and a fetid odor. With 
our increased knowledge of intranasal disease, and the advance- 
ment in our methods of diagnosis, the term ozaena, as describing 
any definite form of nasal disorder, of course, disappears from our 
literature. 
Michel upholds still, I think, the view advanced in his excellent 
work on diseases of the nose,1 that a purulent discharge from the 
accessory sinuses may give rise to the disease under discussion. I 
question if disease of the accessory sinuses ever gives rise to other 
than a discharge of fluid pus, which remains fluid until it is expelled 
from the cavity, nor, in its passage through the nose, does it cause 
any morbid condition in the nasal membrane. Lowenburg2 considers 
the disease due to a micro-organism of large dimensions, which bur- 
rows deeply into the membrane, and is thus not removable by appli- 
cations, although Habermann 3 in a series of microscopical examina- 
tions did not discover these organisms. The theory, however, is 
supported by Noquet,4 of Lisle. Thost5 also claims to have found 
diplococci in the secretions from ozaena. These observers undoubt- 
edly laid too much stress on the micrococcus as a cause of the dis- 
ease. It is undoubtedly present in the secretions in atrophic rhinitis, 
but as the result of decomposition, for it must be remembered that 
these crusts, which are the source of the fetor, have remained in the 
nasal cavity in many cases for several days, and necessarily have 
undergone putrefactive changes, of which the presence of micro- 
organisms are an essential feature. My own view, as originally ad- 
vanced, was based both on clinical observation, and on the result of 
microscopic study of portions of the membrane, removed from the 
nasal cavity during life. 
PATHOLOGY.—The changes as involving the three layers of the 
membrane (see Fig. 80) may be described as follows: 
The Epithelial Layer.—The epithelial layer is considerably de- 
creased in width. The outer, nearly smooth surface is occupied 
by a relatively broad layer of flat epithelia, partly in a state of 
desquamation, and entirely devoid of ciliae. Below this, there is 
found stratified cuboidal epithelium, displayed in five or six layers, 
while the portion nearest to the adenoid tissue, in some portions 
at least, is occupied by a row of columnar epithelium. Where the 
latter is plainly visible, the boundary line between the epithelial 
coat and the adenoid tissue is distinctly marked. In many places, 
1 “ Krankheiten der Nasenhohlen,” Berlin, 1876. 
2 L’Union Medicale (3d Series), 1884. 
3 Zeitschrift ftir Heilkunde, Bd. 7, 1886. 
4 Revue mensuelle de laryngologie, May, 1887. 
3 Hamburg Society of Physicians, May 17th, 1887. A TROPHIC RHINITIS. 
165 
however, the boundary line cannot be traced, and the adenoid 
seems to blend with the covering epithelium, while the latter ex- 
hibits features similar to those of the adenoid tissue. 
The Adenoid Layer.—The adenoid layer is thinner in diameter 
than normal, and is occupied by crowded lymph-corpuscles, in a very 
* delicate fibrous reticulum. The capillary blood-vessels are small, 
scantily distributed and, as a rule, quite empty. The acinous glands 
are small, and evidently diminished in number. They are lined by 
a short columnar or cuboidal epithelium, while their ducts exhibit, 
Fig. 8o.—Atrophic Rhinitis. A, Adenoid layer; B, epithelial layer; C, empty blood-vessel; E, acinous 
layer; E, submucous connective-tissue layer, the remains of the previously existing cavernous tissues. 
around a large calibre, well-defined columnar epithelium. Around 
the scanty acinous glands there are heaps of lymph-corpuscles. 
The Stibmucous Layer.—The adenoid layer merges into a layer of 
a more fibrous construction, with relatively less numerous lymph- 
corpuscles. There is a larger number of blood-vessels found in this 
layer, which on an average exhibit a wider calibre than those of 
the adenoid tissue. 
The prominent features of the atrophic process then are briefly 
as follows: 
First—Decrease of covering epithelium, with profuse desqua- 
mation. 
Second—Decrease of the adenoid layer, with lack of blood- 
vessels, together with destruction of the acinous glands. 
Third—A total disappearance of the venous sinuses of the sub- 
mucous layer of the membrane. 
In brief, we find here an atrophy of the mucous membrane, in 166 
DISEASES OF THE NASAL PASSAGES. 
which the morbid process is not due to a connective-tissue hyper- 
trophy encroaching on the glandular structures of the membrane, 
but rather to the transformation of epithelial structures into inflam- 
matory corpuscles, together with an active epithelial desquamation 
from the surface of the membrane, and from the lining of the acini. 
As has been seen, the follicles are surrounded by heaps of 
lymph-corpuscles, but there is no evidence of transformation of 
these corpuscles into connective tissue, showing thus that the in- 
flammatory process is most marked in the neighborhood of the 
acini, but that it does not develop into a hyperplastic process. The 
morbid changes are, therefore, atrophic from their outset, and bear 
no relation whatever to the hypertrophic form of the disease. 
I am cognizant of no other investigations of like character, 
made on the living subject, although Frankel, Gottstein, Krause, 
Hartmann, and Habermann have all made microscopical study of 
the pituitary membrane in this disease, from the dead subject. 
The results of their investigations do not differ materially from my 
own. 
Frankel1 finds the lesion to consist essentially in the disappear- 
ance of Bowman’s glands, the mucous glands of the lower turbinated 
bone remaining unchanged. Gottstein2 finds thickening of the 
connective tissue about the glands, with cloudiness of the epithelial 
lining. Krause3 finds a fatty degeneration, both of the mucous 
membrane, and of the gland-epithelium. Habermann4 believes the 
lesion to consist of a fatty degeneration of the gland-epithelium, 
not alone of Bowman’s glands, but of the acinous glands, thus par- 
tially coinciding with Krause. 
These views, it seems to me, are important, as affording us a 
probable explanation of the epithelial desquamation, which char- 
acterizes the earlier stage of atrophic rhinitis, for although my own 
studies fail to reveal evidences of this fatty degeneration, some ex 
planation was needed to account for the desquamative process. If 
this fatty degeneration is found in a large number of cases, we 
need seek no further for a cause for the desquamation. 
Etiology.—We have already discussed the question of causa- 
tion of purulent rhinitis, and this disease I believe to be, in every 
case, a cause of, or the primary stage of the atrophic form. Allu- 
sion has already been made to the statement, that atrophic rhinitis 
develops as a later stage of the hypertrophic form. Frankel,5 as 
before stated, was, I think, the originator of this idea, which has 
1 Virchow’s Archiv, vol. lv. 
2 Breslau Aerztl. Zeitschrift, Sept., 1879, Nos. 17-18, p. 6. 
3 Transactions International Medical Congress, London, 1881, vol. iii., p. 311. 
4 Loc. cit. 5 Loc. cit. A TROPHIC RHINITIS. 
167 
been followed very generally by subsequent writers. Thus, Mac- 
kenzie 1 says, “ Atrophy appears to be always a secondary affection, 
or in other words the changes are of a quasi-cirrhotic character, 
resulting from previous inflammatory thickening.” He also quotes 
Schaffer’s assertion that he has “ followed cases through from 
the hypertrophic to the atrophic stage;” while Sajous2 is more 
guarded in his statements, and says that “ atrophy of the mucous 
membrane of the nose occurs as an occasional result of hyper- 
trophy.” Seiler3 also guards his statement, by saying that “ dry 
catarrh may either be a sequence to the hypertrophic stage, or it 
maybe of the atrophic variety from the start.” Wagner4 also 
states that “ Ozaena is merely a later stage of chronic rhinitis,” and 
also reports a remarkable case,5 in which the atrophic variety of the 
disease had supervened upon the hypertrophic, between the 
“ spring of 1881 ” and the “ following autumn.” Schaffer, as already 
quoted above by Mackenzie, asserts that “the hypertrophic stage 
lasts from eight to ten years before the atrophic stage sets in.” 
Schech6 in discussing this point, while not making the sweeping 
assertion of Mackenzie, states that “ numerous observations go to 
prove that, in the majority of cases, atrophic rhinitis is preceded 
by the hypertrophic stage.” Lennox Browne7 gives us, a trifle more 
in detail, the rationale of this process, in the statement that “ con- 
gestion and hypertrophy may, after a longer or shorter time of per- 
verted growth and secretion, lead to an increase of the connective- 
tissue elements of the membrane; these ultimately contract and 
culminate in fibroid shrinking, and in atrophy of both membrane 
and bones.” 
If we look carefully into the views above expressed, I think it 
will be noticeable that these writers content themselves with ac- 
cepting Frankel’s original view, without stopping to question 
seriously the grounds on which it was based. Furthermore, a full 
examination of their writings shows a striking absence of careful 
clinical observation to establish the teaching. The only clinical 
support that I have been able to discover, are the observations of 
Wagner and Schaffer, the one having discovered this change to 
have taken place in a child of fourteen at the expiration of about 
six months, while the latter asserts that it only takes place after 
the expiration of ten years or more. 
1 “ Diseases of the Throat and Nose,” Philadelphia, 1884, vol. ii., p. 331. 
2 “ Diseases of the Nose and Throat,” Philadelphia, 1886, p. 114. 
3 “ Diseases of the Throat,” Philadelphia, 1883, p. 256. 
4 “ Diseases of the Nose,” N. Y., 1884, p. 84. 
5 Op. cit., p. 93. 
6 “ Diseases of the Mouth, Throat and Nose,” English Ed., Edinburgh, 1886, p. 238. 
? “ The Throat and its Diseases 2d ed., London, 1887, p. 502. 168 
DISEASES OE THE NASAL PASSAGES. 
Now, I have studied my own cases very critically, and without 
further discussing the question, I find it a universal, general rule, 
that in one case purulent rhinitis is a disease of childhood, and 
atrophic rhinitis of adult life; that purulent rhinitis develops into 
atrophic rhinitis very rarely later than the twentieth year, and in the 
majority of cases earlier than the sixteenth; and, furthermore, on 
carefully investigating the clinical history of the cases of atrophic 
rhinitis which have been under my own observation, I have failed 
to discover any evidence that the hypertrophic form of the disease 
had ever existed before the patient came under my care. Now, 
there can be no question, but that a large number of our cases of 
hypertrophic rhinitis come under treatment between the ages of 
twenty-five and thirty-five. If it is possible that this disease can 
result in the atrophic form in six months according to Wagner, or 
in ten years according to Schaffer, our clinical records certainly 
would show some evidence of it. I have never seen a case of 
atrophic rhinitis which developed its atrophic symptoms later than 
the twenty-fifth year. 
Zaufal1 I think is alone in the view, that atrophic rhinitis or 
ozaena is due to congenital deficiency in the turbinated bones. This 
curious theory is certainly based on careless observation, for the 
atrophy of the turbinated bones only occurs in the late stages of 
the disease, and is rarely met with before puberty. Zuckerkandl2 
finds in an examination of two hundred and fifty-two skulls of chil- 
dren no single case of congenital atrophy. Chatellier3 believes the 
atrophy of the turbinated bones to be due to a rarefying osteitis. 
Gelle,4 on the other hand, does not believe there is an osteitis, but 
refers the atrophy to interference with nutrition. 
Chatellier’s idea naturally suggests a general dyscrasia, whereas, 
as already stated, I think these cases are rarely, if ever, attended 
by any evidence of impaired general nutrition. Gelle, however, 
would seem to have arrived at something of the same conclusion 
which has been advocated by myself. 
What has been said as to the causation of purulent rhinitis, 
applies of course to the atrophic form of the disease. In the 
chapter on the former, the statement was made with marked em- 
phasis, that atrophic rhinitis bore no possible relation to syphilis in 
any of its stages or manifestations. The same broad statement 
may be made in regard to tuberculosis and scrofula, and yet we 
find Schaffer5 making the statement, that in one hundred and 
1 Aerztl. Correspondenzblatt, 1874, No. 33; ibid.., 1877, No. 24. 
2 “ Normale und Pathologische Anatomie der Nasenhohlen,” Vienna, 1882. 
3 French Society of Otology and Laryngology, April, 1887. 
4 Ibid. 5 Op. cit. ATROPHIC RHINITIS. 
169 
nineteen cases, he found ninety-nine of strumous, and twenty of 
syphilitic origin. In two cases the complaint was distinctly due to 
hereditary syphilis; while Wyss 1 makes the statement, that more 
than half of his cases of ozaena had a tuberculous history, but he 
found very few cases complicating phthisis. By the term ozaena 
he excludes all cases of syphilitic or carious disease of the nose. 
Symptomatology.—The symptoms which characterize the 
disease, are the direct result of the apparent increase of secretion, 
and of the impairment of function of the mucous membrane. This 
increase of secretion, however, is only apparent. As a fact, the 
gross amount of normal sero-mucous discharge from the nose, being 
principally a serous exosmosis, is decreased, while at the same time 
there is an increase of the flow of mucus, which being mixed with 
epithelial cells, constitutes a muco-pus discharge. On account of 
the limited amount of serous exosmosis, this discharge becomes so 
far thickened that it lodges within the cavity, or is expelled with 
considerable effort through the anterior nares. When the atrophic 
process has become fully developed, we find, as before stated, 
crust-formation the prominent symptom of the disease. The pres- 
ence of these crusts in the nasal cavity gives rise to more or less 
irritation, as of the presence of a foreign body, although this is not 
specially notable, since the sensibility of the membrane is to an 
extent diminished, and their presence is, therefore, often tolerated 
and not a source of discomfort. Occlusion of the nares is the re- 
sult of the accumulation of dried crusts, and is often present, es- 
pecially noticeable in the morning when the patient has passed 
some hours without voluntary effort at clearing the passages. 
As soon as this tendency to dryness has so far developed that 
these crusts are retained in the cavity for from twenty-four to 
forty-eight hours, we have, as a necessary consequence, the develop- 
ment of fetor, which always constitutes the most prominent, and 
probably the most distressing feature of the disease. This fetor is 
of a somewhat peculiar character, which cannot well be described, 
but to one familiar with the disease, is easily recognized as differing 
essentially from the nauseous intolerable odor of necrosis. It is a 
musty, graveyard-odor, containing just sufficient of the fetid hydro- 
gens to give it a decidedly fetid character. This odor, it seems 
to me, undoubtedly arises from the decomposition which takes 
place in the animal matter contained in the viscous, inspissated, 
muco-purulent discharge from the nasal mucous membrane. This, 
lodging in the cavity for a sufficient length of time, and exposed to 
the air, undergoes the same process which characterizes all animal 
1 “ Clinical Investigations of Aural Complications of Gzaena/’ Centralblatt fiir Laryn- 
gologie, vol. iii., No. 12, p. 519. 170 
DISEASES OF THE NASAL PASSAGES. 
matter, under the same conditions. A number of theories have 
been propounded in explanation of this peculiar fetor of atrophic 
rhinitis, and yet none of them seem to me so simple and altogether 
rational as the above. Frankel1 suggests the possibility of a special 
ferment as the cause of the odor. As we generally understand it, 
fermentation is a vital process, and not attended with the ordinary 
phenomena of decomposition, especially the evolution of fetid gases. 
Fournier2 believes the odor is due to a specific secretion of the 
glands of the pituitary membrane, likening the fetid odor of ozaena 
to that which is occasionally observed -in'connection with the feet. 
This is ingenious, but I believe it is a universal rule that a fetid 
secretion does not occur in nature. An excretion may be fetid, but 
never a secretion. 
Epistaxis occasionally occurs as the result of the erosions pro- 
duced by the presence of the dry incrustations, especially on the 
septum. This, however, is rather rare. These erosions, it should 
be stated, are of a trivial character and never, under any circum- 
stances, develop into anything resembling an ulcerative process, 
although they may occasionally-develop into small perforations of 
the cartilaginous septum, leaving permanent communication be- 
tween the two sides. Mackenzie3 explains these perforations by 
the habit of picking the nose, which patients resort to, in order to 
remove the accumulated crusts. 
Dryness of the pharynx becomes a prominent symptom of the 
disease very early in its history, due to the fact that the inspired 
air passes through a nasal cavity, whose walls are largely covered 
by dry mucous crusts, thus failing to receive its proper amount of 
moisture. The result of this impact of the inspiratory current on 
the vault of the pharynx, is to rob the mucus there secreted of 
its water, and thus produce a mass of dry inspissated mucus, 
which forms a thick plug in the upper pharynx, which hanging 
down behind the palate, causes a sense of irritation and discomfort, 
its presence giving rise to vigorous efforts of expulsion. The lower 
pharynx also becomes parched as the result of the same process, 
and presents a dry, glazed appearance, swallowing being thereby 
rendered somewhat difficult, in the absence of a properly lubricated 
pharyngeal wall. This abolition of the respiratory function of the 
nose, causing an abnormal dryness of the inspired air, causes also 
more or less irritation' of the larynx and bronchial tubes, not 
sufficient as a rule to give rise to a bronchitis, but rather to a 
constant sense of irritation due to the fact that the normal mucous 
secretion becomes dry, and lodging in the passages, gives rise to a 
1 Trans. International Med. Congress, London, iS8r, vol. iii., p. 302. 
2 Ibid., p. 306. 3 “ Diseases of the Throat and Nose,” vol. ii., p. 329. A TROPHIC RHINITIS. 
171 
constant hawking or hemming by which the patient attempts to 
clear the throat. Hoarseness is often present, and impaired vocal 
function always. 
A form of laryngitis has been described by writers, notably 
Lennox Browne,1 characterized by the formation of dry crusts in 
the larynx and trachea. The implication seems to be, that a dis- 
eased condition really exists in these parts. As a rule, it is difficult 
to determine any notable morbid lesion here, and I should rather 
lean to the view that it was purely a symptomatic affection. Spasm 
of the glottis, of a very distressing character, I have met with in 
connection with atrophic rhinitis. Several of these cases were in 
young women of highly nervous organization, while in others, I 
have seen it in men of full habit, and vigorous health, with no sus- 
picion of neurotic tendencies. In these cases it has disappeared by 
vigorous measures directed to the nose. Its occurrence can only 
be explained by the presence of inspissated mucus or pus in the 
larynx acting as a foreign body. 
Moderate impairment of hearing occurs in the later stages of 
this disease in probably a large proportion of cases, while a graver 
form of deafness is not an infrequent complication. Wyss, of 
Geneva, in an examination of sixty cases of the disease, found ear 
trouble in forty-seven, including, probably, all cases of moderate 
diminution of hearing distance. Burnett,2 of Philadelphia, found 
an atrophic condition of the nasal mucous membrane in fourteen 
and one-half per cent of cases of chronic catarrhal otitis media. 
Beverley Robinson,3 without giving definite statistics, makes the 
statement that aural complications are met with in atrophic rhinitis, 
far more frequently than in hypertrophic. Buck, Roosa, and 
Mittendorf apparently make no distinction between the two forms 
of rhinitis, as causing ear-complications. 
I have always regarded hypertrophic rhinitis as a very active 
cause of middle-ear troubles, in the manner already d-escribed in 
the chapter on that disease, and am disposed to think it the more 
frequent cause of the more serious cases. Certainly in a given 
number of cases of grave impairment of hearing, the number due 
to the hypertrophic disease outnumbers those due to the atrophic 
disease in far greater proportion than the comparative frequency 
of the two affections. Furthermore, when we consider the success 
of our treatment of hypertrophic rhinitis, and our failure to more 
than relieve the atrophic form, it would seem that my own obser- 
vation as regards the relative frequency of these causes of ear 
1 “ The Throat and its Diseases,” London, 1887, p. 278. 
2 Medical Record, vol. xxviii., p. 134. 
3 Trans. Amer. Laryngological Association, 1883, p. 140. 172 
DISEASES OE THE NASAL PASSAGES. 
disease, is the correct one. The manner in which hypertrophic 
rhinitis acts to produce middle-ear disease, has already been de- 
scribed, and would seem clear and direct. On the other hand, the 
action of the atrophic form of the disease in producing ear com- 
plications does not seem so clear. Woakes1 attributes the aural 
changes quite as much to an atrophy of the tubal muscles from 
impaired nutrition, as to an atrophic process in the mucous lining 
of the tubes, this atrophy of the muscles resulting in a condition 
in which ingress and egress of air is impeded by the flaccid and 
collapsed tubal walls. Woakes’ theory is ingenious, but involves 
the necessity of conceiving a condition of things which is hardly 
rational. Purulent rhinitis, and its resultant atrophic form, be- 
longs simply to the nasal passages and never extends beyond. All 
its symptoms and complications result from the abolition of function 
in the nose, beyond which it never extends as an atrophic process. 
We may say of the ear, as we do of the bronchial tubes, that its 
integrity is dependent on the condition of healthy functional activity 
in the nasal passages, and that a morbid condition in this region 
makes itself felt very quickly in the auditory apparatus. In fact, 
I am disposed to think that the ear is quite as dependent upon 
healthy nasal passages as the bronchial tubes. In other words, 
the air which reaches the orifice of the Eustachian tubes, should 
reach that region through the nose, and be at normal atmospheric 
pressure, of the temperature of the body, and in a state of satura- 
tion. Any departure from these conditions involves danger both 
to the ear and to the bronchial tubes. 
DIAGNOSIS.-—An examination anteriorly will reveal on first in- 
spection each cavity more or less filled with greenish-yellow crusts, 
lying upon the faces of the lower and middle turbinated bones, and 
bridging across the intervening space to the septum. These crusts 
present an appearance which is absolutely characteristic of atrophic 
rhinitis, in their peculiar greenish-gray tint, thus differing essen- 
tially from the crusts found in ulceration and necrosis, which are 
mingled with blood, unhealthy pus, and necrotic tissue. These 
crusts are generally found in the front portion of the nasal cavity, 
while an examination by posterior rhinoscopy will show the tur- 
binated bones comparatively clean. If now the crusts be removed 
by the forceps or probe from the surfaces of the turbinated bones, 
there will be found underlying them, and apparently oozing from 
the fissure between the lower and middle turbinated bones, and also 
from beneath the upper, healthy-looking whitish yellow muco-pus. 
After thoroughly cleansing the cavity by means of the syringe or 
coarse spray, if the disease is in its earlier stages, we find the mucous 
1 “ Post-Nasal Catarrh,” Amer. Ed., Philadelphia, 1884, p. 147. A TROPHIC RHINITIS. 
173 
membrane over the lower and middle turbinated bones presenting 
a fairly healthy aspect, normal in color and contour. Thus far, 
the only evidence of the disease which we have met with, is in the 
characteristic crusts. In the later stages of the disease, however, 
we find on thoroughly cleansing the cavity, the membrane cover- 
ing the lower and middle turbinated bones presenting a somewhat 
bloodless appearance, and adhering closely to the turbinated bones 
beneath, and having the appearance of a thin, and somewhat atten- 
uated membrane, while the bones themselves, according to the 
stage of the disease, present a shrunken and atrophied appearance, 
Fig. 8i.—The outer wall of the nasal cavity in the late stage of atrophic rhinitis, the mucous membrane, 
and also the lower and middle turbinated bones, having undergone the atrophic process. 
leaving a noticeably large roomy cavity, through which the wall of 
the pharynx may easily be recognized. In advanced cases the 
turbinated bones may even be difficult to find, presenting simply 
small, cord-like protuberances along the outer wall of the cavity, as 
seen in Fig. 81. 
An inspection of the pharynx, both in the early and late stages 
of the disease, will show a dry, glazed, parchment-like condition in 
its lower portion, while in the vault will be noticed a plug of thick 
mucus, adherent to the pharyngeal roof and more or less discolored 
by the dust of the inspired air, which has not been arrested in its 
passage through the nose. The larynx and trachea present a fairly 
normal appearance, unless there are visible flakes of inspissated 174 
DISEASES OF THE NASAL PASSAGES. 
mucus, or in rarer cases dry incrustations. The membrane lining 
these cavities may be somewhat congested, presenting evidences of 
a condition of chronic hypersemia, but rarely of a catarrhal inflam- 
mation. 
PROGNOSIS.—When we consider the essential character of the 
disease, we can easily appreciate that we have to deal with an ex- 
ceedingly obstinate'affection, and one which in most cases will 
resist all treatment. The question presents, Can we cure it ? 
Frankel, of Berlin, very frankly says: “A cured ozaena is un- 
known to me,” referring to atrophic catarrh. In the early stage of 
the disease, before the fetid symptoms have set in, I have seen cases 
recover. In the advanced stages, characterized by fetor, and in 
which the turbinated bones have almost entirely disappeared, I 
have not seen a case cured, if, by a cure, is meant a condition 
secured in which there remains no necessity for any measure of 
local treatment. All cases can, I believe, by thorough and pains- 
taking treatment, be brought to that point when, by the use of 
very simple means, the ground that has been gained can be secured, 
and the patient be kept entirely free from any annoying symptoms, 
as long as he continues to make use of some simple cleansing lotion, 
applied three or four times daily, but we are never justified in hold- 
ing out to our patient any hope of a genuinely radical cure. 
Treatment.—The first indication in the treatment of the 
disease is, of course, the thorough cleansing of the cavities, by the 
removal of all the incrustations. In the accomplishment of this 
end, there is no special virtue in any remedy, or local agent. The 
literature of the subject embraces a formidable array of drugs, 
among which are prominent, carbolic acid, salicylic acid, boracic 
acid, permanganate of potash, phosphate of soda, bicarbonate of 
soda, thymol, borax, etc. The essential requisites of a good cleans- 
ing lotion, are secured by the use of any solution which is alka- 
line and is disinfectant. The fluid should be alkaline for its solvent 
action upon mucus. It should be disinfectant, in order to neutralize 
the results of the process of decomposition, which is going on in 
the retained secretions. Any fluid, then, possessing these quali- 
ties, is an efficient cleansing solution. The formula I generally 
prefer is the Dobell’s solution, as follows: 
Acidi carbolici, ...... gr. xij. 
Sodii bicarb., . . . . . . 3 ss. 
Glycerini, . . . . . . f ij. 
Sodii biborat., . . . . . . 3 i. 
Aquae, ....... ad Oi. 
M. 
Of quite as much importance is the .method by which the ATROPHIC RHINITIS. 
175 
cleansing is accomplished. The most efficient douche we possess 
is the ordinary post-nasal syringe. By means of this instrument, a 
stream can be driven with great force through the cavities. In or- 
dinary cases, this is sufficient to thoroughly detach all the crusts, 
and cleanse the parts. In advanced cases, however, it will be neces- 
sary to use a probe wrapped with a pledget of cotton. This can be 
passed through the nostril, and along the turbinated bones, thereby 
separating the crusts, after which they can be easily washed out 
with the syringe. Occasionally it will be necessary to throw a 
stream through the nostril, by means of an ordinary ear-syringe. 
The essential point is to remove all secretions from the nose, and 
the success of the manipulation can only be determined by repeated 
inspections by means of a good illumination, and with the anterior 
nasal speculum in place. After the parts are thoroughly cleansed, 
the next step consists in the application of a stimulant agent. If 
the disease is essentially an atrophic process, and the fetor is due to 
a process entirely outside of the membrane, then the rational treat- 
ment, and the one directly curative of the disease in the membrane 
proper, is to stimulate the parts to a better performance of their 
normal function, viz., the secretion of mucus. 
Gottstein 1 advocates the use of the cotton tampon, for the pro- 
motion of secretion and the correction of fetor, in atrophic rhinitis. 
His plan consists in packing pellets of cotton between the turbin- 
ated bones and the septum, and allowing them to remain twenty- 
four hours. His paper has been the subject of much comment, and 
has excited no little interest since its publication. The plan is a 
novel one, certainly, but it seems a somewhat cumbersome and 
roundabout way of accomplishing a very simple purpose. It is, 
moreover, attended with no little discomfort, as it involves a 
plugged-up nose for the twenty-four hours. What is accomplished 
by Gottstein's plugs, is simply the stimulation of the membrane 
by the irritating presence of a foreign body. A flow of mucus is 
necessarily excited, and of course the fetor corrected, for the cause 
of the fetor in retained secretion no longer exists, as long as the 
profuse discharge of mucus continues. Gottstein’s plan, therefore, 
is rational in its action, but we can accomplish the same end by 
means much more simple, more thorough, and with much less dis- 
comfort to the patient. It is alluded to here mainly on account of 
its originality, and from the fact that it recognizes the main indica- 
tion for treatment, in stimulating the membrane. Beverley Robin- 
son 2 indorses their utility, while Woakes makes use only of Gott- 
stein’s tampons for the purpose of applying powders to the diseased 
membrane, thus securing the local action of his medicament to- 
1 Berliner Klinische Wochenschrift, No. 4, 1881. 
2 Op. cit. 176 
DISEASES OF THE NASAL PASSAGES. 
gether with such benefit as may result from the plugging process. 
Both Sajous and Mackenzie1 advise the use of the galvano-cautery 
at white heat, as first recommended by Frankel. Lennox Browne2 
considers this decidedly the best treatment, and follows the applica- 
tion of the cautery with insufflations of iodoform or iodol, claim- 
ing thereby to relieve both the ozaena and the aural symptoms. 
Woakes1 recommends the application of iodoform in ether, in the 
form of spray. Cohen1 recommends the vapor of ammonium 
chloride, administered by means of Lewin’s apparatus. 
As regards the use of the galvano-cautery, it seems to me this 
measure should be resorted to with the greatest caution, as it is an 
agent capable of doing much mischief. The essential feature of 
the disease is loss of tissue, a condition which might be enhanced 
by so powerful a destructive agent. As a stimulating measure, 
however, I can see how, with care, it might be attended with good 
results, especially in the earlier stage of the disease. Thus, Abeille3 
reports a case in which a boy aged fifteen was radically cured by 
this agent, by a course of treatment lasting fifteen months. Iodol 
and iodoform I have never regarded as agents of much power, 
other than as disinfectants, although Seifert4 recommends the in- 
sufflation of iodol, after the cavity has been tamponed for one or 
two hours according to Gottstein’s method. One curious method 
of treatment may be noted, that of Baratoux and Debousquet- 
Laborderie5 who transplanted minute portions of frog-skin to 
eroded surfaces on the mucous membrane, resulting from atrophic 
rhinitis, claiming successful results from the procedure. In the 
same category we might note the suggestion of Harrison Allen6 
who recommends denudation of the middle turbinated bone by 
means of the finger passed into the nasal cavity, the patient being 
under an anaesthetic. 
Noquet,7 of Lille, claims excellent results from the following 
course of treatment. The patient is to use daily a douche of one 
litre of tepid water, in which a tablespoonful of chlorate of potash 
has been dissolved. After this has been used for eight days, a solu- 
tion of carbolic acid, gr. ij. to the litre, is substituted. After each 
douche, the patient is to use the following as a tepid spray: 
IJ Chloral hydrat., ...... .50 
Acidi borici, ....... 6. 
Glycerini puri, ...... 10. 
Aq. lauro-cerasi dest., ..... 20. 
Aq. dest., ....... 200. 
M. 
1 Op. cit. 2 Op. cit., p. 528. 
4 Miinch. Med. Woch., No. 4, 1887. 
6 Internat. J. of Med. Sci., April, 1886. 
3 Courier Medical, No. 51, p. 488. 
s Progres Medicale, April 9th, 1887 
7 Rev. Mens, de Laryngol., May, 1887. ATROPHIC RHINITIS. 
177 
In the middle of the day, the patient is to use a spray of 
“ Vinaigre Antiseptique ” in the proportion of a coffee-spoonful to 
seven ounces of water. Three times a week the surgeon is to use, 
as a spray to the anterior and posterior nares, and also as an ap- 
plication by means of a cotton pledget, a twenty-per-cent solution 
of chloride of zinc, to which enough hydrochloric acid has been 
added to form a clear solution. If any points remain red and a 
little hypertrophied, they are to be touched by the galvano-cautery. 
The author claims excellent results from the above method, and 
says that there seems to be an actual regeneration of the mucous 
membrane in a certain number of cases. He adds, however, that 
in the most advanced cases no such regeneration can be expected. 
Following a previous suggestion of Shurley,1 as to the treatment 
of pharyngitis sicca by means of the galvanic current, Bryson Dela- 
van,2 of New York, recommends this treatment for a similar nasal 
condition. His method is as follows: The positive electrode is to 
be placed on the nape of the neck, while the negative is wrapped 
in absorbent cotton, and applied directly to the nasal mucous 
membrane. The strength of the current is from four to seven 
milliamperes, the duration of the application being from seven to 
fifteen minutes, or until a moderate watery secretion is induced. 
Delavan secures excellent results from this plan of treatment, which 
seems exceedingly rational, and well worth a trial. 
As regards any destructive measure, such as the cautery, or 
Allen’s suggestion of denuding the middle turbinate, I can see no 
rational justification for such procedures. The use of iodoform, 
chloride of ammonium, or indeed of any local application, is attended 
with good results. But we possess no drugs which can claim any 
specific virtues in this affection, and our best results will be at- 
tained only by a careful attention to the thorough cleansing of the 
parts, and the subsequent endeavor to keep them, as far as possible, 
constantly moistened, in order to prevent the drying of the mem- 
brane, for as long as the membrane is kept moist, even if with 
nothing more than clear water, crust formation, and its resultant 
fetor, cannot occur. 
The primary cleansing of the parts must be done at first by the 
physician, in the manner already suggested. At the commence- 
ment of treatment, it will be necessary to see the patient daily, or 
perhaps three times each week. After the disease has been brought 
somewhat under control, the intervals of attendance at the office 
may be lengthened as may seem best. At the same time the patient 
should be directed to provide himself with an atomizer, preferably 
1 Trans, of the American Laryngological Association, 1880, p. 20. 
2 Trans. Amer. Laryngological Assn., 1887, p. 145. 178 
DISEASES OE THE NASAL PASSAGES. 
the Burgess, shown in Fig. 47, in which there may be used any 
simple alkaline or disinfectant lotion, such as the Dobell’s solution 
aleady given. This is to be thoroughly applied to each passage 
five or six times daily if necessary. The patient being instructed 
as to the character of his disease, and the indications for treatment, 
will easily appreciate the object of the spray, viz., to prevent crust 
formation, and will make the applications as they may be needed. 
An exceedingly convenient cleansing lotion, and one which I 
frequently use, has been suggested by Seiler,1 composed of several 
of the salts of soda in combination with thymol, eucalyptol, men- 
thol, etc. It is made into the form of a tablet, and sold in the drug 
stores as Seiler’s Antiseptic Tablets. One tablet being dissolved in 
two ounces of water forms a solution of the proper strength. 
In addition to the frequent use of the spray, the patient should 
be directed to use once each day, by means of the nasal douche 
(Fig. 36), from one to two quarts of hot water, in each quart of which 
a tablespoonful of salt has been dissolved. This should be used as 
hot as can be tolerated. The beneficial effect of this is especially 
noticeable at the commencement of the treatment, in altering the 
character of the discharge, rendering it less purulent, and thus con- 
trolling crust formation. It acts probably both in controlling cell 
proliferation and giving tone to the walls of the venous sinuses, as 
well as a cleansing wash. 
In addition to the above plan I have occasionally found some 
benefit from the use of local applications, in the form of snuff, of 
certain drugs whose action is to stimulate the membrane to a freer 
secretion. Among them we mention, in the order of preference. 
Pulv. galangae, 
. gr. xx. 
in 
3 i. 
Pulv. sanguinarise, 
. gr. xv. 
u 
3 i. 
Pulv. belladonna?, 
. gr. vi. 
u 
3 i. 
Acidi salicylic., . 
. gr. v. 
u 
3 i. 
Sodii salicylatis, . 
• gr. viij. 
u 
3 i. 
Sodii bicarb., 
. gr. xv. 
u 
3 i. 
Potass, bromidi, 
. gr. xx. 
u 
3 i. 
These drugs may be incorporated in any convenient vehicle, in 
the strength given above, such as starch, calcined magnesia, lycopo- 
dium, sugar of milk, etc. A box of the snuff being carried in 
the pocket, a small amount of it can be insufflated three or four 
times daily. 
As before stated, the general health of patients suffering from 
atrophic rhinitis is not usually affected, and hence there are no in- 
dications for internal medication. These patients, however, as well 
1 N. Y. Med. Record, Feb. 18th, 1888. ATROPHIC RHINITIS. 
179 
as all who suffer from catarrhal disorders, are peculiarly susceptible 
to changes in the weather, etc., and hence their habits of life, gen- 
eral hygienic surroundings, clothing, bathing, etc., should receive 
full attention at the hands of the physician. The general rules 
which govern our advice on these matters have already been given 
in sufficient detail in a previous chapter and hence need not be re- 
peated here. CHAPTER XII. 
CPOUPOUS RHINITIS. 
CROUPOUS rhinitis is an acute inflammation of the mucous mem- 
brane lining the nasal passages. Tt occurs both in children and 
adults, although in children it runs a somewhat more protracted 
course, and its symptoms show a more aggravated character. It 
is characterized by a deposit of fibrinous exudation, constituting a 
false membrane, which presents the characteristic anatomical fea- 
tures of a croupous membrane, viz., one which is superimposed 
upon the epithelial layer, and does not involve the deeper tissues. 
It has already been stated, in the chapter on mucous membranes, 
that a fibrinous exudation is mainly to be regarded as a local 
manifestation of a general blood-condition, a local exudation involv- 
ing no serious danger to life, except from the somewhat adventi- 
tious choice which it exercises of certain localities, as for instance, 
when deposited in the larynx, it involves great danger of death 
from suffocation. 
This disease is of somewhat frequent occurrence, and yet is 
mentioned but rarely in current literature. Frankel1 refers some- 
what casually to it, as a complication of diphtheritic disease of the 
nose, while Schuller2 gives a somewhat more accurate description 
of it, in reporting a case of what was probably a case of croupous dis- 
ease of the nose, but still appends the name diphtheritic. Cohen3 
refers to a fibrinous exudation, as a somewhat rare occurrence in 
acute coryza. Cohen undoubtedly recognized the disease as dis- 
tinct from diphtheria, but, with this exception, we find most writers, 
up to within the past two years, entertaining exceedingly vague 
ideas as to the distinctive character of the two affections. Among 
the earliest to recognize it was Moldenhauer4 who has given us a 
very accurate description of its course and'symptoms; while Hart- 
mann,5 of Berlin, has reported six cases, and Seifert,6 G. R. Ryer- 
1 “ Ziemssen’s Encyclop.,” Amer. ed., vol. iv., p. 136. 
2 Jahrbuch fur Kinderheilkunde, N. F., iv. Jahrg. 1871, p. 331. 
3 “ Diseases of the Throat and Nose,” 2d. ed., p. 332. 
4 Monatsschrift fur Ohrenheilkunde, No. 9, 1887. 
5 Deutsch. Med. Wochenschrift, 1887, No. 29, s. 641. 
6 Miinchener Med. Wochenschr., 1887, No. 38. CROUPOUS RHINITIS. 
181 
son,1 Gluck,2 Bresgen,3 and Potter,4 have also reported cases of the 
disease which had been under observation 
Etiology.—The cause of the disease is to be sought for in the 
same source in which we find the causation of an acute fibrinous 
exudation in any other portion of the upper air-passages, viz., in 
a germ floating in the atmosphere, which lodges upon the surface 
of the mucous membrane, where it excites a specific form of in- 
flammation. This germ, lodging upon the mucous membrane, be- 
comes embodied, as it were, in the meshes of its epithelial layer, in 
a manner which we are unable to describe; it may be determined 
by the existence of an erosion at the point of lodgment, or it may 
lodge upon an intact surface. As a matter of clinical observation, 
the most frequent site upon which a croupous exudation is met 
with, is on the surface of the faucial tonsil, taking the form either 
of a croupous exudation, or an ordinary follicular tonsillitis. Why 
this should be the case it is easy to understand, for the ragged 
spongy surface of the tonsil forms almost a trap, as it were, for the 
entanglement of disease-germs. In the nasal mucous membrane, 
on the other hand, we find a field where the large quantity of out- 
poured serum cleanses the tissue; a state of activity constantly 
kept up by the ceaseless waving of the nasal ciliae; and finally a 
constant to-and-fro current of air, all going to make up a condition 
strikingly unfavorable to the lodgment of a disease-germ. Hence, 
we find croupous exudation of the nose an exceedingly rare affec- 
tion. The source of the germ, we may say, is in the sewer-pipes, 
or other recognized sources of infection. Aside from this, we 
hazard no further suggestion. What the germ is, the pathological 
laboratory has not yet told us. That it is a germ, however, I am 
convinced, basing this view largely on clinical observation. 
In a discussion on croupous rhinitis, at the sixtieth meeting of 
the German Naturalists and Physicians, September 21st, 1887, Bres- 
gen asserted, as the result of observation, that many cases followed 
the application of the galvano-cautery to the nose, the wound be- 
coming covered with a false membrane; while Hering suggested 
the insufflation of impure water as a cause of the disease, and con- 
sequently forbids this, after operations. Schmithinsen, coinciding 
with Hering’s views, reported twelve cases, in some of which there 
was a history of hereditary syphilis. This suggestion of syphilis, I 
think, may be dismissed, in connection with the disease, as an acute 
fibrinous exudation is probably never a manifestation of hereditary 
1 New York Med. Record, July 30th, 1887. 
2 Med. Record, April 27th, 1889, vol. xxxv., p. 461. 
3 Deutsch. Med. Wochenschr., 1888, No. 4. 
4 Journal of Laryngology, March, 1889. 182 
DISEASES OF THE NASAL PASSAGES. 
syphilis. A very frequent source of the disease, undoubtedly, is to 
be found in operations in the nose, not only after the galvano- 
cautery, as suggested by Bresgen and Hering, but also and more 
notably, after any operation which involves a section of the mem- 
brane. A croupous membrane forms on the cut surface in these 
cases, without manifesting any tendency to extend, and while 
the local symptoms are not so marked, the febrile symptoms 
are often quite as acute as those in an idiopathic case of the 
disease. 
Pathology.—The essential pathological lesions observed in the 
mucous membrane proper, are those of an ordinary acute rhinitis, 
and consist briefly of a hyperaemia of the blood-vessels, both of the 
turbinated tissue and of the mucosa proper, together with the gen- 
eral increase of the nutritive processes met with in that disease, 
viz., increased exudation of serum, and cell-proliferation. On the 
surface of the membrane, and somewhat closely adherent to it, is 
found a false membrane, presenting the following characteristics: 
there is a basement substance of fibrillae of fibrin, and considerable 
granular fibrin; entangled in this basement substance, we find nu- 
merous white blood-cells and epithelial cells, undergoing granular 
degeneration and coagulation necrosis. Some red blood-cells are 
often to be observed. The exudation presents then under the 
microscope the ordinary characteristic appearances of a croupous 
membrane. Exudation occurs on the faces of the lower and mid- 
dle turbinated bones, and in aggravated cases, on the septum in the 
anterior portion of the nares. I have never noticed any tendency 
to extension to the accessory sinuses, although their orifices are 
closed by the swollen nasal membrane, and distressing symptoms 
referable to those cavities may occur thereby. 
Symptomatology.—The disease is generally ushered in by 
chilly sensations, and more rarely by a well-marked chill. This is 
followed by general febrile motion, characterized by headache, 
pains in the bones, and loss of appetite. Coincident with these, 
symptoms of acute rhinitis set in, characterized by swelling of the 
nasal membrane, stenosis, watery discharge, and sneezing. The 
dry stage here is omitted, and there immediately sets in a sero- 
mucous discharge from the nose, which soon becomes somewhat 
purulent in character. The amount of the discharge is rather ex- 
cessive throughout the whole course of the disease, but never as- 
sumes a fetid character or gives rise to any offensive odor. 
At the onset of the disease, the thermometer will often show a 
temperature of ioi° to 103°, which lasting one or two days, subsides 
somewhat, and the further progress of the attack is accompanied 
by a temperature of ioo° to ioi°; although in adults, the tempera- CROUPOUS RHINITIS. 
183 
ture may become normal after the second or third day. The whole 
course of the attack is characterized by a feeling of illness and de- 
pression, with loss of appetite, indisposition to exertion, and the 
whole train of symptoms which we embrace under the general term 
malaise, although the patient is rarely confined to the bed, and not 
necessarily to the house. The local symptoms referable to the 
nose are oftentimes of a very distressing character. There is usu- 
ally complete stenosis, with loss of the sense of smell, together with 
frontal headache, and oftentimes severe neuralgic pain along the 
course of the nasal nerve. The disease usually extends to the 
glands in the vault of the pharynx, and occasionally to the faucial 
tonsil. In these regions, however, we usually find a simple follicular 
tonsillitis, the croupous exudation confining itself to the crypts of 
the follicles, although Moldenhauer1 has seen a true fibrinous mem- 
brane on the faucial tonsil. 
Diagnosis.—An examination of the case will not always reveal 
the presence of the membrane at first, but if care be exercised, and 
the secretions removed from the passages, the characteristic pearly- 
white membrane will be seen covering the nasal lining, and extend- 
ing down very closely to the muco-cutaneous junction. If now a 
careful examination is made of the false membrane, it will be found 
that it is easily detached from the mucous membrane beneath it 
without causing hemorrhage. This, I think, constitutes the pathog- 
nomonic symptom of a croupous exudation in this region, as dis- 
tinguished from a diphtheritic. In some cases, the membrane does 
not extend near to the margin of the nostril, and the nasal cavity 
is obscured by the swelling of the turbinated tissues, and the ex- 
cessive amount of secretion; and, furthermore, cocaine is of little 
avail in shrinking up the membrane, and opening the cavity to in- 
spection. In such cases, the diagnosis can only be made, by gently 
wiping out the cavity with a pledget of cotton on the probe, and 
endeavoring to detach a portion of the false membrane, whose 
presence should be suspected in every case of apparent acute rhini- 
tis, in which the constitutional symptoms seem excessive, and the 
local symptoms of so aggravated a character. 
In adults, the false membrane is small, thin and easily recog- 
nized as a croupous exudation, and furthermore is not attended 
with excessive muco-purulent secretion. In children, however, we 
see the notable tendency, already alluded to, to active cell-prolifera- 
tion, which distinguishes morbid processes in the mucous mem- 
branes in early years, hence we find in them the exudate often 
forming a soft, thick, almost granular mass, very friable, which in 
1 Loc. cit. 184 
DISEASES OF THE NASAL PASSAGES. 
some cases can almost be wiped from the mucous membrane in 
small fragments. 
PROGNOSIS.—The prognosis is favorable, in that the disease 
confines itself mainly to the nasal cavity, and never, as far as I 
know, shows a tendency to the development of a similar process in 
the larynx. The membrane forms more or less rapidly, and being 
exfoliated in small shreds, or in patches, renews itself; a fresh crop 
developing in from five to eight days, this exfoliation occasionally 
being attended with moderate epistaxis. 
The disease runs its course in adults in from eight to fourteen 
days, while in children it usually lasts from three to five weeks. 
Hartmann 1 gives the course of the disease as from eight to four- 
teen days, his experience evidently having been confined to cases 
in adult life, while Bresgen2 assigns a course of several weeks. 
General Treatment.—The disease is essentially a constitu- 
tional affection, attended with prominent local symptoms. What 
the blood-condition is, we have no means of determining, but it is 
probably, in the main, that condition of hyperinosis which is present 
in croupous laryngitis, tonsillitis, and all diseases characterized by 
fibrinous exudation. I believe there is no agent possessing the 
property of controlling this blood-condition in a higher degree 
than tincture of iron, which should be administered in full doses, 
as soon as the disease is recognized. This remedy may be given 
combined wich glycerin as follows: 
B Tinct. ferri chloridi, . . . . . 3 ij. 
Glycerini, . . . . . . . ad § ij. 
M. S. Half a teaspoonful to be given every four hours. 
In connection with the iron, there should be given some prepara- 
tion of quinine or cinchona, for its general tonic effect. In young 
children, in whom the pseudo-membranous formation assumes a 
rapid and efflorescent type, I believe the efficacy of mercurial treat- 
ment should be thoroughly tested in the early stage of the attack. 
Preference should be given to the use of the mild chloride, which 
may be administered in full doses, frequently repeated. To a child 
of six years of age, there may be given the following: 
B Hydrarg. chloridi mitis, .... grs. xx. 
Sacch. lactis, . . . . . . 3 ij. 
M. div. in cht. No. xx. S. One powder to be given every four 
hours. 
If, at the end of the second day, decided amelioration of the 
local symptoms is not noticed, the iron treatment had best be 
substituted. If fever is present, it should be managed on the same 
1 Loc. cit. 
2 Loc. cit. CROUPOUS RHINITIS. 
185 
general principles which govern our administration of remedies in 
other febrile conditions in childhood. The same, of course, may 
be said in regard to the necessity of laxatives, etc. 
Local Treatment.—Our first effort should be directed toward 
the removal of the membrane. This is to be accomplished with 
such care and delicacy as will accomplish the purpose without in- 
jury to the soft parts beneath, or better still, if free access can be 
obtained to the pseudo-membrane, it should be destroyed in situ, 
its capacity for mischief being ablated, and the inert film left in 
place, to prevent a new growth. This also, I think, should be ac- 
complished by means of one of the iron preparations. The muco- 
purulent discharge being carefully removed, and the surface of the 
false membrane cleansed as thoroughly as possible by means of a 
cotton-pledget, it should be thoroughly but delicately coated with 
either the tincture of iron, or the persulphate in officinal strength. 
This process should be repeated at least once, and if practicable, 
twice daily. The use of cleansing washes by means of an atomizer 
is grateful to the patient, if feasible, but in young children the 
stenosis is so complete as to render their availability somewhat 
limited. 
Moldenhauer1 recommends the use of warm inhalations, while 
Hartmann1 and Bresgen1 both recommend the use of iodoform 
after the removal of the membrane, either as an insufflation, or in 
suspension in glycerine. Cocaine, as before stated, has but a limited 
action in controlling the stenosis. If the part can be sufficiently 
cleansed, however, to admit of the application of cocaine, a four- 
per-cent solution should always be resorted to, and frequently re- 
peated, both as controlling the blood-supply, and relieving nasal 
stenosis. 
The indications for treatment being so clear, we need not con- 
fine ourselves to the use of any one remedy, or any one line of pro- 
cedure, but resorting to those which our experience has taught us 
are efficient in modifying the systemic condition, or in limiting the 
activity of the membrane-formation, their efficacy will always be 
early recognized, and, pursuing such measures as we observe to 
control the two prominent features of the disease, I think, as a rule, 
we may feel confident of oftentimes aborting, and certainly, in most 
cases, mitigating the severity, and curtailing the duration of the 
attack. 
1 Loc. cit. CHAPTER XIII. 
NASAL REFLEXES. 
The question of nasal reflexes, is one which possesses many 
points of exceeding great interest, not only on account of its curi- 
ous development of symptoms, but also from the exceedingly broad 
field which it embraces, as the result of our increased knowledge of 
intra-nasal disease, and the great activity which has characterized 
their study from a clinical point of view. To Marshall Hall is 
probably due the credit of first making clear to us the phenomena 
of reflex actions, although at the safne time Johann Mueller1 was 
pursuing a similar line of investigation, which was published the 
same year. It should be stated, however, that many of the earlier 
physiologists had already recorded these phenomena with a consid- 
erable degree of accuracy of observation. Notably Whytt,2 Pro- 
cheska,3 and Cullen,4 who recognized the reflex character of certain 
of the ordinary phenomena of daily life, as the act of sneezing, 
coughing, vomiting, etc. 
As recognized by all physiologists at the present day, in order 
that we may have a true reflex phenomenon, we must have, (1) a 
sensitive nerve fibre, connected with (2) a central nervous cell or 
mechanism, which in its turn is connected with (3) a motor fibre, 
supplying some motor organ. I think the first physiologists to 
bring out clearly these three parts of the reflex arc were Johann 
Mueller in the first edition of his work, and Marshall Hall;5 al- 
though Le Galois6 cites the difference between the muscular irrita- 
bility in the amputated thigh of a frog, and the movements which 
can be excited by stimulating the integument of a decapitated frog, 
thus clearly recognizing the necessity of a ganglionic centre. Sub- 
‘ “ Elements of Physiology,” by Johann Mueller, translated from the second German 
edition by William Baly, Philadelphia, 1843. 
2 “Vital and other Involuntary Motions of Animals,” Edinburgh, 1751. (Works, pp. 
153, 162, 506, and 511.) 
3 “Annotat. Academiciae,” 1784. “ Opera Minora,” 1800. “ Lehrsatze aus der Physi- 
ologic,” Vienna, 1797. 
4 Works, Edinburgh, 1827, vol. i., pp. 105 and 109. 
3 Philosophical Transactions, 1833. 
6 “ Experiments on the Principles of Life ; ” translation by N. C. & J. G. Nancrede, 
Philadelphia, 1813, p 36. NASAL REFLEXES. 
187 
sequently, Marshall Hall1 makes a very clear statement of the re- 
flex apparatus as follows: “ these actions are excited and ultimately 
accomplished through the medium of appropriate incident and re- 
flex nerves and their communicating medium, the spinal marrow. 
If any part be interrupted, the phenomenon ceases instantly.” The 
term reflex, as defined by Flint,2 can be applied to any generation 
of nerve force, which occurs as a consequence of an impression 
received by a nerve-centre ; and reflex phenomena are by no means 
confined to the action of the spinal cord. The movements of the 
iris are reflex, and yet they take place in many instances without 
the intervention of the cord. The movements of respiration are 
reflex, and these are presided over by the medulla oblongata. 
Movements of the intestines and the involuntary muscles generally 
are reflex, and they involve the action of the sympathetic system 
of nerves. 
Applying this to the generation of reflex diseases, we find that 
a local morbid condition of one portion of the body creates an 
impression, which is conveyed to a nerve-centre, from which there 
is transmitted to an entirely different locality in the economy a 
certain force, by which there is generated in that locality, either a 
pathological lesion, or a train of morbid symptoms. Probably in 
no one of the great systems of the body do we find this reflex ten- 
dency, as we may call it, so active as in the respiratory apparatus. 
Mueller3 goes still further, and makes the general assertion that the 
irritation of any mucous membrane of the body is the most fre- 
quent cause of reflex manifestations in the respiratory system, 
while irritation of the cutaneous system is most likely to give rise 
to general convulsions. As we have already claimed in our study 
of the physiology of the nose, its mucous lining contains the most 
intricate, and the most delicately sensitive nervous organization of 
any portion of the respiratory tract. We should naturally then 
expect it to be a very frequent source of reflex phenomena. Thus 
Plrown-Sequard as cited by Ruault4 observed that by plunging the 
nose into cold water, respiration and cardiac action would be 
stopped, while Kratschemer and Francois-Franck, as cited by the 
same author, show that thermic, mechanical or chemical irritation 
of the nasal fossa, can reflexly produce a drawing up of the nares, 
arrest of respiration in expiration, momentary arrest of the heart, 
and slackening of the pulse. All these actions are produced through 
the medium of the trigeminus. Gourewitscha and Luchsinger have 
1 “ Memoirs of the 'Nervous System,” London, 1837. 
2 “ Text-book of Human Physiology,” New York, 1876, p. 683. 
3 Op. cit., p. 552. 
4 Gaz. des Hopitaux, December 10th, 1887. 188 
DISEASES OF THE NASAL PASSAGES. 
observed the same phenomena by acting on the olfactory nerves. 
Probably the first writer to call attention to the nasal reflex was 
Voltolini1 who reported a case of spasmodic asthma, dependent on 
the existence of nasal polypi, which was cured by the removal of 
the growths. This observation has been verified by so large a 
number of writers, that it seems to me the connection between the 
two diseases cannot well be questioned, although Lennox Browne 
and Boecker of Berlin state that, in many instances, the asthmatic 
symptom persists, even after the removal of the polypi. This ques- 
tion, however, is more fully discussed in the chapter on asthma. 
The possibility of there being other reflexes due to intra-nasal 
disease seems not to have been opened up, until Seiler2 published 
two cases of reflex cough, due to a hypertrophic rhinitis; followed 
by Hack3 who observed a case of spasmodic cough due to a fibrous 
polypus. A similar observation was made by John Mackenzie.4 
Some years previously, however, Richet5 had reported a case of 
convulsive tic douloureux, which was cured by the removal of an 
enchondroma of the nasal septum. 
The general interest of medical men in this subject of nasal re- 
flexes, was probably first excited, when Hack6 published the series 
of papers, which was subsequently enlarged into his well-known 
monograph. He reports a large number of nasal reflexes covering 
a very wide field, as follows: gastralgia and dyspepsias; cardiac 
palpitation; tumefaction and redness, either temporary or per- 
manent, of the skin of the nose; transitory and circumscribed 
oedemas; salivation; neuralgia of the first two branches of the 
trigeminus; cephalalgia; migraine; scotoma; ciliary neuralgia; pho- 
tophobia ; vertigo; agoraphobia; and exophthalmic goitre. 
These affections Hack found were due to various forms of intra- 
nasal diseases, although the large majority were dependent upon 
hypertrophy, or chronic hyperaemia of the nasal membrane. Hack 
makes the further statement, that simple hyperaemia without hy- 
pertrophy is more frequently a source of nasal reflex than a true 
hypertrophy with tissue change. Going still further, he makes the 
assertion that sneezing, watery discharge with stenosis alternating 
from one side to the other constitute conditions which indicate, 
almost pathognomonically, that the turbinated bodies are the 
source of reflex phenomena, if such exist. This latter statement is 
undoubtedly true, for these symptoms indicate not an ordinary 
1 “Die Anwendung der Galvano-kaustik," Vienna, 1872. 
2 Arch, of Laryngology, vol iii., No. 3, p. 240. 
3 Berlin. Klinische Wochenschrift, 1882, No. 25. 
4 Amer. Journal of Medical Sciences, July, 1883. 
5 Cited by Casabianca, These de Paris, 1877. 
6 Wien. Med. Wochenschrift, 1882-3. NASAL REFLEXES. 
189 
catarrhal inflammation, but a vaso-motor paresis of the blood- 
vessels of the nasal mucous membrane, the essential condition 
which exists in hay-fever. This disease is only met with in highly 
neurotic individuals, and the neurotic habit, I take it, is the most 
active predisposing cause of a nasal reflex. 
A rather interesting symptom has been observed by Max 
Schaffer,1 of Bremen, who reports a case of complete loss of voice, 
with no observable lesion of the larynx, in a case of hypertrophic 
rhinitis. Local faradization proving useless, the cure was effected by 
treatment directed to the nasal hypertrophy. Elsberg2 reports a 
case of chorea, which he had seen in 1863, as occurring as a reflex 
phenomenon due to hypertrophic rhinitis. Similar observations 
have been made by J. L. Sallinger3 and also by the author.4 Cases 
of epilepsy, due to intra-nasal disease, have been reported by Sal- 
linger,5 Fincke,6 and also by the author,7 while a case of psychical 
epilepsy has been reported by T. A. McBride.8 Ziem9 reports, 
among other reflex symptoms, a case of nocturnal enuresis. Dr. 
North,10 in adding neurasthenia to the list of nasal reflexes, goes so 
far as to state that he has yet to see a case of neurasthenia, in 
which there is not some catarrhal trouble. Guye,11 of Amsterdam, 
describes, under the term aprosexia, a mental condition, under the 
influence of which the individual is unable to concentrate the mind 
on any one subject, and reports a case of a boy, three years of age, 
suffering from adenoid disease of the vault of the pharynx, who 
could not learn the first three letters of the alphabet, after an entire 
year at school. After the removal of the growths, the whole alpha- 
bet was mastered in one week. 
Salivation would seem a rather curious reflex disturbance, as a 
result of intra-nasal disease, and yet two such cases have come under 
my own observation, in elderly people, in whom this symptom, al- 
though not present in an aggravated form, became a source of very 
great distress both physically and mentally, for in each of these 
cases, a very prominent subjective symptom was the notable de- 
pression of spirits. The flow of saliva, though small, gave rise to 
the necessity of an almost uninterrupted expectoration, which was 
1 Monatsschrift fur Ohrenheilkunde, No. n, 1886. 
2 Trans. Amer. Laryngological Association, 1883. 
3 Polyclinic, Philadelphia, June, 1887. 
4 “ Deformities of the Nasal Septum,” N. Y. Med. Record, Jan., 1887. 
3 Loc. cit. 6 Moniteur de la Polyclinique, June 7th, 1885. 1 Loc. cit. 
8 N. Y. Med. Record, vol. xxix., p. 137. 
9 Monatsschrift fiir Ohrenheilkunde, Nos. 8 and 9, 1886. 
10 Medical Register, Philadelphia, May 14th, 1887. 
11 Sixtieth meeting of German Naturalists and Physicians, Subsection of Otology, Sep- 
tember 20th, 1887. 190 
DISEASES OF THE JVASAL PASSAGES. 
a source of annoyance, not only to themselves, but to those about 
them. In both these cases, the result of treatment was quite suc- 
cessful. A similar case has been reported by E. Frankel, as cited 
by Ruault.1 
The question of ocular disturbances dependent on intra-nasal 
disease seems to have excited the attention of American observers 
more notably than foreign, although Hack mentions weak, watery 
eyes in his list of affections. In an able paper by Dr. Gruening,2 
of New York, read before the Academy of Medicine a number of 
cases of photophobia with mild conjunctivitis, were reported as 
cured by treatment for intranasal disease. Similar observations 
have been made by Beverley Robinson.3 Cheatham,4 also holds that 
many cases of asthenopia are due to intranasal disease. B. Bett- 
man,5 of Chicago, reports six cases of epiphora, conjunctivitis, pho- 
tophobia and pain above the eyes, due to nasal disease, and which 
were cured by galvano-caustic applications to the inferior turbin- 
ated bones. Lennox Browne,6 reports a case of glaucoma, not 
benefited by iridectomy, but cured by the eradication of a nasal 
polyp. Hack and Schaffer mention muscae \olitantes also, occur- 
ring as reflex nasal symptom. Moldenhauer7 makes the rather 
curious statement, that rheumatic muscular pains not infrequently 
occur in connection with nasal disorders, but fails to substantiate 
the observation by the report of cases. 
If we attempt to explain these various reflexes we find ourselves 
compelled to adopt rather vague and indefinite theories, which are 
quite as obscure as the reflexes themselves. Thus, Hack’s theory 
is, that from a number of causes, some within the nasal cavities, 
some from without, there is developed reflexly, a tumefaction of 
the mucous membrane covering the anterior portion of the lower 
turbinated bone on one or both sides, so that from slight nervous 
irritation, a so-called secondary reflex will be developed in remote 
parts of the body. Moldenhauer* controverts this theory of Hack’s, 
on the ground that both nasal polypus and polypoid thickening, as 
well as atrophic rhinitis, are a source of reflex phenomena, in neither 
of which does hyperaemia exist. This statement of Moldenhauer 
is scarcely tenable, for in polypi and polypoid thickening, we have 
morbid conditions exceedingly favorable for the development of 
1 Loc. cit. 
2 N. Y. Medical Record, January 30th, 1886, p. 122. 
3 Medical Record, April 3d, 1886, p. 397. 
4 American Practitioner and News, Louisville, April 2d, 1887. 
5 Journal of the American Med. Association, May 7th, 1887. 
6 “ The Throat and its Diseases,” London, 1887, p. 507. 
7 “ Die Krankheiten der Nasenhohlen,” etc., Leipzig, 1S86, p. 176. 
8 Op. cit., p. 176. NASAL REFLEXES. 
191 
reflexes, Atrophic rhinitis, however, is a condition which in my 
experience is rarely the source of a reflex disturbance, although 
Ruault1 makes the statement that the crust-accumulation in this 
disease may become the exciting cause of reflex phenomena. John 
Mackenzie2 claims to have discovered certain sensitive areas in the 
nose, which are peculiarly connected with the evolution of the re- 
flex act. These areas are “ limited to the mucous membrane cov- 
ering the middle and inferior turbinated bodies, and posterior half 
of the septum.” This conclusion was based on a series of experi- 
ments, which demonstrated that reflex action was produced by 
stimulation of these particular localities only. It will be noticed 
that Mackenzie’s areas embrace simply that portion of the nasal 
mucous membrane wherein we have the turbinated bodies, which, 
owing to their intense and constant activity, as an important part 
of the respiratory apparatus, must necessarily be exquisitely sensi- 
tive, far more so than other portions of the nasal chambers. Mac- 
kenzie’s theory of sensitive areas in the nose is virtually, then, an 
assertion that the area of reflex action is the respiratory tract, if 
by respiratory tract we understand that portion in which we find 
the large venous plexuses, which constitute the turbinated bodies. 
E. J. Moure3 adopts the theory that nervous reflexes arise sim- 
ply from mechanical irritation in the nasal chambers, basing this 
view on the experiments of Schiff and Bert, who have shown that 
any mechanical, chemical or thermal irritation in the mucous mem- 
brane of the nose, can reflexly affect respiration. I think it will be 
noticed that all these theories fail to explain why a reflex occurs, 
but rather seem to exhibit the morbid conditions in the nose, which 
are liable to be the source of a reflex manifestation. That the 
condition in the nose which more frequently causes reflex action, 
is hyperaemia rather than hypertrophy, as stated by Hack, I think 
is fully borne out by clinical observation. Moreover this is easily 
explained by the fact, that hyperaemia generally occurs in patients 
of a decidedly neurotic temperament, for extreme congestion of 
the blood-vessels only occurs, as a rule, as the result of vaso-motor 
paralysis or paresis, whereas simple hypertrophic changes occur 
purely as a local disease. That the neurotic temperament is a 
prominent predisposing cause of a nasal reflex, I think none will 
question. The assertion of Moldenhauer and Ruault, that reflexes 
occur in an atrophic rhinitis, is hardly borne out by clinical observa- 
tion. John Mackenzie,4 also recognized this in his statement that 
“ where complete atrophy of the turbinated structures existed, as 
for example in ozsena, reflex action was not present, nor could it be 
1 Loc. cit. 2 Amer. Journal of Med. Sciences, July, 1883. 
3 “ Manuel pratique des maladies des fosses nasales,” etc., p. 250. 4 Loc. cit. 192 
DISEASES OF THE NASAL PASSAGES. 
induced by artificial stimulation.” That reflexes, however, never 
occur in connection with atrophic rhinitis, cannot be asserted when 
we consider that such a careful observer as B. Frankel has reported 
cases of facial neuralgia and vertigo occurring as nasal reflexes in 
atrophic rhinitis, while Schmaltz also reports similar cases. Finne 1 
also cites a case of neuralgia of the fifth nerve, of three months’ 
duration, in an anaemic woman of fifty, which was dependent on 
atrophic rhinitis. The reflex in these cases is probably due to im- 
paired general nutrition, from the fact that these patients constantly 
live in a polluted atmosphere, every breath of air which is taken 
into the nostrils passing over putrid masses of decaying animal 
matter in the nose. Furthermore, some of these neuralgias can be 
explained in the same manner in which we explain the frontal 
headache which occurs in acute coryza, either from occlusion of the 
orifice, or congestion of the lining membrane of some of the acces- 
sory sinuses, producing nerve-pressure. To these cases, the term 
reflex does not properly apply, and yet we generally class them 
under this head. If we glance now at the various diseases which 
occur, we find that they divide themselves into neuralgias, spas- 
modic or paralytic nervous affections, and ocular symptoms; the 
neuralgias, embracing migraine and cephalalgia, I think may be 
explained as far as we can explain them, by the general principle, 
that they only occur in patients suffering from impaired general 
nutrition. Any patient, I take it, suffering from an obstructive lesion 
in the upper air passages, by which the respiratory function is in 
any degree hampered, thereby feels, to a certain extent, the sys- 
temic effect of the resultant impairment of the process of oxidiza- 
tion. 
In the large majority of cases, spasm of the glottis is a direct 
symptom, rather than a reflex from intra-nasal disease. In the 
former case, its development can be explained on the basis of a 
catarrhal laryngitis, developing as it so frequently does, as the 
sequela of a chronic rhinitis. Where it occurs as a reflex, the 
method of development probably is much the same as an asthmatic 
attack. Owing to the intimate connection between the two regions, 
as parts of the respiratory apparatus, any vaso-motor disturbance 
in the nasal mucous membrane is liable to give rise to disturbances 
in other portions of the passages. In the same manner, we may 
explain the occurrence of spasmodic contraction of the faucial or 
palatal muscles, which has been recorded by Seifert,2 who reports 
a case of chronic contraction of the muscles of the face, soft palate 
and Eustachian tube, with objective and subjective gurgling sounds 
1 Norsk Magazin for Laegevidenskaben, June, 1887. 
2 International Klin. Rundschau, 1887, No. 29. NASAL REFLEXES. 
193 
in the ear, due to a chronic rhinitis, although local treatment failed 
to afford any relief; while Michel1 has observed “chronic spasm of 
the Eustachian tube, with objective and subjective gurgling sounds 
in the ear ” in a lady of forty years of age, relieved by removal of 
polypi with the cold snare. 
Functional aphonia is always, I think, a pseudo-paresis of the 
adductor muscles of the larynx, and occurs, as a rule, in hysterical 
females. I have seen cases such as Schaffer2 reports, in which the 
loss of voice was apparently a nasal reflex, and furthermore where 
apparently the success of nasal treatment justified this view, and 
yet the aphonia sooner or later recurred, as is the usual rule in 
hysterical affections of the larynx. 
Chorea is one of the diseases which when dependent upon in- 
tranasal disease, gives most satisfactory results from treatment. I 
have seen a number of such cases, in which the choreic movements 
disappeared completely and permanently with the cure of the nasal 
disorder. I take it that these patients all suffer to an extent from 
impaired general nutrition, as the result of interference with the 
normal respiratory act, as is so frequently observed among young 
people with any obstructive lesion in the upper air passages. Dr. 
Jacobi3 also has found chorea associated with chronic rhinitis, as 
well as with enlarged tonsils and other obstructive lesions of the air 
passages. 
Sallinger4 and Fincke4 both report cases of epilepsy, cured by 
treating concurrent intranasal disease, while R. W. Richardson5 
reports a case of a lady thirty-four years old, cured of an epilepsy 
by the removal of a post-nasal fibroma. My experience has been 
less fortunate, for although, in three cases which have been under 
my treatment, great apparent improvement, and in one case an 
apparent cure followed the removal of obstructive nasal lesions, in 
all cases the disease returned. The marked improvement which oc- 
curred in these cases—in one of them the attacks remaining absent 
for four months—would seem to indicate that they were probably 
of reflex origin. In these cases, the epileptic habit probably had 
become so far fixed, that the seizures were not controlled by re- 
moving the contributing cause. In the same category, probably, 
might be included vertigo, which is perhaps a rather frequent re- 
flex nasal symptom. Joal6 attributes this to the irritation of the 
terminal fibres of the trigeminus, although it would seem more easily 
1 Journal of Laryngology, vol. i., p. 335. 2 Loc. cit. 
3 New York Med. Record, January 30th, 1886. 4 Loc. cit. 
s Asclepiad, January, 1887. 
6 Memoir at French Congress of Laryngology, 1887; Journal of Laryngology, vol. i., 
p. 252. 194 
DISEASES OF THE JVASAL PASSAGES. 
accounted for in a disturbance of the circulation at the base of the 
brain, the two regions being so intimately connected through the 
anterior and posterior ethmoidal arteries and veins, and separated 
only by the thin cribriform plate. Moldenhauer1 adopts this view 
in the consideration of reflex headaches of a congestive type, and 
headache and vertigo, probably, are somewhat intimately related. 
Ocular reflexes present many points of clinical interest, and yet 
when we attempt to state the direct connection that exists, we find 
ourselves again treading on purely theoretical grounds. Gruening2 
was probably the first to call prominent attention to these reflexes, 
in reporting cases of conjunctivitis, photophobia, asthenopia, etc., 
all of which were relieved by treating a pathological condition of 
the nasal membrane. Cheatham2 goes so far as to state that most 
cases of asthenopia are dependent upon nasal disease; while Bev- 
erley Robinson3 cites one case, of what was apparently a simple 
conjunctivitis, which had resisted treatment, but on the application 
of the galvano-cautery to several sensitive areas in the nose, the 
ocular symptoms were relieved. 
Bettman, contributing a similar series of cases, adds to the list 
by reporting one of epiphora, which was cured by nasal treatment. 
Browne’s case of glaucoma has already been alluded to. The eye 
symptoms of acute rhinitis are generally explained, in the main, by 
continuity of tissue, although a sympathetic element is generally 
recognized. The occurrence of the non-inflammatory reflexes is 
to be accounted for probably in the same manner. Those, how- 
ever, which are inflammatory in character, such as conjunctivitis, 
etc., are not really genuine reflexes, in the sense in which the term 
has been used heretofore. Here, I think, we need seek no further 
for the cause than in the simple continuity of tissue. As regards 
photophobia, asthenopia, etc., in which no inflammatory lesion is 
recognized, we may simply say that the connection between the 
two regions is purely sympathetic in character. The more practical 
question, however, is as regards the success of treatment, and of 
this it is safe to say, that in none of the reflexes are results more 
thoroughly satisfactory, and although we know of no tests by which 
we can make a positive assertion in any given case, that a morbid 
lesion of the eye is dependent upon a diseased condition of the 
nasal mucous membrane, certainly in all obstinate ocular troubles, a 
careful inspection of this region becomes an urgent duty. 
While there are no diagnostic signs which enable us to recognize 
reflex disturbances as due to intranasal disease, it should be borne in 
mind that those cases in which such phenomena occur, as a rule 
1 Op. cit., p. 176. 
3 New York Med. Record, April 3d, 1886, p. 397, 
2 Loc. cit. NASAL REFLEXES. 
195 
show evidence of a decided neurotic temperament. Perhaps the 
one recognized lesion which characterizes a neurosis is vaso-motor 
paresis in some locality of the body, recognized by physical signs 
or subjective symptoms. A vaso-motor paresis, occurring in the 
nasal mucous membrane, then, should, I think, as a rule be regarded 
as evidence of the neurotic habit, and this we recognize with com- 
parative ease. If on examination of the nasal cavity, we find the 
mucous membrane swollen to such an extent as markedly to oc- 
clude the passage, while at the same time it presents the watery 
appearance given by the exudation of serum on its surface, while 
it is not itself notably reddened, it should immediately suggest to 
us a paretic condition of the vaso-motor control. If, now, a four- 
per-cent solution of cocaine be applied by means of an atomizer, 
and the membrane, after contraction, is seen to cling closely to the 
turbinated bones beneath, showing no evidence of true hypertrophy, 
we have further indication of a neurotic condition. The point I 
would emphasize here is, that while in acute or chronic rhinitis the 
membrane is swollen and reddened as the result of hyperaemia, this 
hyperaemic condition involves not only the venous sinuses, but the 
superficial capillaries, while in vaso-motor paresis the venous sinuses 
alone are distended. In one case we have superficial evidence of 
an inflammatory process; in the other case, the surface of the mem- 
brane shows no marked departure from the normal tint. Again, 
in inflammatory processes, the surface of the membrane will show 
mucous secretion. Vaso-motor paresis gives rise to a leakage, by 
which the normal respiratory function of serous exudation is let 
loose as it were and serum is freely poured out—a process which is 
not ordinarily recognized by the naked eye in health. Again, in 
either an acute or chronic rhinitis, the membrane, after contraction 
by cocaine, shows evidences of thickening by the deposit of con- 
nective tissue. Vaso-motor paresis and inflammation are terms 
which are used oftentimes rather loosely, as defining the same con- 
dition. Now, it should be borne in mind that these two conditions 
are essentially different. Vaso-motor paresis, as we know, is the 
first stage of inflammation, but the inflammation really is not es- 
tablished until this paresis is followed by the later inflammatory 
stages, the escape of leucocytes from the blood-vessels, with the 
intense nutritive activity taking place in the extra-vascular tissues. 
Now, the vaso-motor paresis which we recognize as constituting the 
essential lesion of hay-fever, is the same morbid process which I 
have attempted to explain as constituting the lesion of the nose 
which is most frequently connected with the reflex disturbances 
under consideration. But this process differs from the first stage 
of inflammation, in that in the nasal mucous membrane we have 196 
DISEASES OE THE NASAL PASSAGES. 
a letting-up of- vaso-motor control over the large venous sinuses, 
which are the source of serous exudation in the nasal cavities, con- 
stituting the respiratory function of the nose. In the first stage of 
inflammation, the vaso-motor paresis consists practically of a dis- 
tention of blood-vessels and nothing more, in the vaso-motor paresis 
of hay-fever, or of a neurasthenia in which a nasal reflex occurs, 
there is added serous exudation as a morbid phenomenon, an in- 
crease of the normal respiratory function of the nose, whereas an 
inflammation is an increase of the normal nutritive processes in 
the nasal lining membrane. 
Hack has made much of his cocaine test for the existence of a 
reflex, making use of it to produce anaesthesia, which, he says, 
when thoroughly established, oftentimes will abolish the reflex 
phenomena, which could be demonstrated by the probe before the 
membrane was anaesthetized This would apply to reflex cough, 
laryngeal or faucial spasm, and possibly certain cases of neuralgia. 
Headache, if it is dependent upon nasal reflex, readily yields to 
the local application of cocaine in a very few minutes, and here, of 
course, the diagnosis is immediately established. This, however, I 
think applies only to the congestive headaches, the result being 
due to the contractile properties of cocaine, rather than to the 
anaesthesia. In ocular and other obscure reflexes, we have no 
method of making a diagnosis other than by observing the success 
of local treatment. 
Nasal polypi and deformities of the nasal septum are not in- 
frequent conditions which give rise to reflex phenomena. I do not 
think, however, in either of these cases that it is the original lesion 
which causes the reflex, but rather a paretic condition of the mem- 
brane to which they give rise. The mechanism by which a de- 
flected septum causes congestion of the membrane, resulting either 
in a vaso-motor paresis, as in hay-fever, or in a hyperplasia as in 
hypertrophic rhinitis, has already been fully discussed elsewhere, and 
need not be entered upon here, further than to state, that in the 
ordinary act of inspiration the air immediately behind the point of 
obstruction in the nasal cavities, is maintained in a state of almost 
constant rarefaction, resulting in a swelling of the membrane, dilata- 
tion of the venous sinuses and ultimately in a paretic condition of 
the vascular walls. In nasal polypus it is generally stated that the 
watery secretion which flows from the nose is due to the hygroscopic 
character of the growth, by which it absorbs and discharges moist- 
ure according to the state of the weather. I am disposed to think 
that the source of the serous exudation here is in the venous 
sinuses, which under the stimulus of the presence of these irritating 
growths, assume a condition of paresis, by which serous exudation NASAL REFLEXES. 
197 
constantly takes place. In other words, here also we have a vaso- 
motor paresis of the mucous membrane, a condition most frequently 
associated with the reflex phenomena, due to the presence of the 
growths. The frequency with which polypus is attended with 
reflex neuroses, I think, is due to the fact that in the majority of 
cases it impinges upon and irritates the mucous membrane covering 
the middle turbinated bone, and this region is probably more 
frequently the source of reflex disturbances than the lower passage, 
on account of its more delicate sensibility, for in this region we 
have not only general sensibility, together with the rich nerve- 
distribution necessary for the management and control of the res- 
piratory function, but also the olfactory nerve distribution, which 
naturally renders it more susceptible to irritation. 
When, therefore, we find a nasal polypus giving rise to an 
asthma, this is not due directly to the presence of the polypus, but 
to the morbid condition in the mucous membrane, caused by the 
presence of the polypus. On the other hand, when a supraorbital 
neuralgia, or a simple headache, occurs as a reflex symptom, I think 
we find a more rational explanation of the symptom in saying that 
it is due to pressure exercised on the peripheral nerves, although 
Moldenhauer1 states, that he has never met with a reflex of this 
character. When an examination fails to reveal any evidence of 
vaso-motor disturbance in the nasal mucous membrane, we must 
attribute reflex disturbances to a simple hypertrophic rhinitis. In 
rare cases, adenoid growths in the vault of the pharynx become a 
source of reflex symptoms. 
The local treatment of those conditions involves no points of 
interest for discussion, other than those which are sufficiently dis- 
cussed in the chapters devoted to these special affections. Dr. 
McBride,2 of Edinburgh, raises the question whether the control 
of these reflexes is due to local applications to the nasal mem- 
brane, controlling a morbid lesion there, or whether they may not 
act as counter-irritants; while Ruault, following the same line 
of suggestion, quotes Bouchard as having cured a case of sciatica 
by cauterizing the lobe of the ear. Another question may be sug- 
gested here, in this same line, as to how much the moral effect of 
local applications to the nose might divert the patient’s mind, and 
so facilitate a cure. That these influences may have a certain 
amount of force, is very probable, but this is purely secondary and 
adventitious. I am convinced that successful results are due pri- 
marily and mainly to the removal of the local intra-nasal disease. 
As will be gathered from what has been stated above, the neu- 
rotic habit is a prominent factor in the production of these disturb- 
British Med. Journal, Jan. 29th, 1887. 
1 Loc. cit., p. 180. 198 
DISEASES OF THE NASAL PASSAGES. 
ances in many cases, and hence will oftentimes require attention. 
It is not probable that any large proportion of these patients 
require general medication, and yet a certain number will not in- 
frequently resist local treatment until internal medication is insti- 
tuted. In these cases, no measure is of greater importance than 
the use of cold water. If well tolerated, a cold sponge down the 
spine once daily, or better still a shower or douche, will aid us very 
materially. In addition to this, there are two drugs which I re- 
gard as of special value, viz.: zinc and belladonna. These may be 
given either singly, or, as I prefer it, in the following pill: 
Ext. belladonnae, ...... grs. v. 
Zinci oxidi, ....... grs. x. 
M. ft. mass, in pil. numero xx. div. S. One pill to be taken 
three times daily before eating. 
Arsenic is a remedy which possesses a certain efficacy in these 
cases, and may be given in the form of either Fowler’s or Pierson’s 
solution, preferably the latter, in doses of three minims, taken three 
times daily after eating, and gradually increased to five or six, if 
toleration is established. A form of this drug which has come into 
considerable favor of late years is “ Clemens’ solution of the brom- 
ide of arsenic.” My experience with this remedy, although some- 
what limited, leads me to suggest that it deserves further trial 
Iron, strychnine, and general tonics, which we are so often led 
to prescribe, I think possess but limited value in controlling the 
neurotic habit, and hence should not be administered unless spe- 
cially indicated by other general conditions CHAPTER XIV. 
HAY FEVER, OR VASO-MOTOR RHINITIS. 
The term hay fever, although a somewhat unfortunate one, has 
come into such general use, that it scarcely seems wise to discard 
it. When the disease was first recognized, it was thought by many 
to be due to the emanations of dry hay, and hence the term hay- 
fever became its ordinary designation, as applying to the form of 
the disease usually met with in the later months of the summer. 
Subsequent investigation revealed that a form of the disease oc- 
curred in the early summer months, to which the name rose-cold 
was given. Still later we find appearing in the literature of the 
subject such names as summer catarrh, pruritic catarrh, pollen 
catarrh, peach cold, etc. The disease is essentially the same in 
whatever season it may appear, and hence we use the term hay 
fever as a generic expression, and as embracing all forms of the 
affection. 
Definition.—We may define hay fever, then, as a disease char- 
acterized by the annual recurrence, at a certain season of the year, 
usually the same period in each individual case, of an attack of a 
more or less aggravated form of influenza, the prominent symptom 
of which is an intensely swollen condition of the mucous mem- 
brane lining the nasal cavities, attended with sneezing and profuse 
watery discharge, these symptoms being due to the direct impact 
upon the mucous membrane of the nasal passages of the pollen of 
certain flowering plants present in the atmosphere. Each individ- 
ual, as a rule, is susceptible to the action of the pollen of some one 
or more individual plants, and thus becomes affected annually dur- 
ing the time that this special plant is in flower. In many cases the 
course of the attack is marked by the development of a paroxysm 
of spasmodic asthma, or as it is usually termed, hay asthma, which 
is precipitated by, and is to a large degree dependent upon, the 
nasal affection. 
HISTORY.—Prominent attention was first attracted to this affec- 
tion by John Bostock,1 who gives a somewhat detailed account of 
1 Med. Chirurgical Trans., 1819, vol. v., p. 161. 200 
DISEASES OF THE NASAL PASSAGES. 
a mild attack as affecting his own person, although Beschorner1 in 
his admirable monograph, has shown that it was recognized by 
writers as early as the sixteenth century. Thus, Botallus2 states 
that he knew persons in whom the odor of roses caused headache, 
sneezing and itching of the nose, while van Helmont3 (1577 to 1644) 
had observed cases in which the odor of sweet-smelling plants 
seemed to produce symptoms of influenza, with difficult breathing, 
and in one case, an attack of spasmodic asthma, persisting through 
the summer months, and disappearing on cold weather. Still later 
(1673) Binningerus4 observed a case of what would be now termed 
merely rose-cold. A similar case was observed by Ledelius.5 In 
1691 J. Constant de Rebecque,6 in describing a similar case, sug- 
gests the name “ coryza a rosarum odore.” Most modern writers 
assert that the disease is a somewhat aristocratic one, in that it 
affects only the upper classes. As sustaining this view we find a 
report by Herlinus,7 of the case of the Roman cardinal, Oliver 
Caraffa, who was so susceptible to the odor of roses that his palace 
gates were kept constantly guarded to prevent the entrance of 
individuals carrying them. Similar observations were made by 
Riedlin,8 Hiinerswolf,9 and Heberden.10 Bostock’s paper in 1819 
excited no little attention, and seems to have awakened physicians 
of the day to the fact that the disease was by no means uncommon, 
for in a second paper11 wherein he analyzes twenty-eight cases of 
the disease which he had collated, he objects to the use of the term 
hay fever, which apparently had already become current, because, 
as he says, in his own case he found the emanations of dry hay 
absolutely innocuous. His conclusions were that the attack was 
produced by moist heat, sunshine and dust. MacCulloch,12 ob- 
serving a certain daily intermittency in the symptoms, suggested 
the relation between this disease and intermittent fevers, while 
1 “ Ueber Heufieber und dessen Behandlung;” Jahresberichte der Gesellschaft fur 
Natur- und Heilkunde zu Dresden, Sitzungsperiode 1885-1886. 
2 “ Commentarioli duo, alter de medici, alter de eegroti Munere,” p. 23. Lugduni, 
1565. 
3 “Asthma et tussis.” Cap. x., opera omnia, p. 344, Hafnce, 1707 ; ibid., cap. xxiw, 
opera omnia, p. 346. 
4 “ Obs. et curat. Medicinse Centuriae quinqure. ” Cent, secundo, obs. Ixxxvi. 
s “ Miscell. Nat. curios.,” dec. ii., ann. 2, obs. 140, p. 309 (probably 1682). Lipsiae. 
6 “Atrium medicinae Helvetior,” obs. 92, p. 15 et seq. Geneva, 1691, 
7 “ De remediis sudoriferis et analepticis,” p. 32. Lipsiae, 1693. 
8,“ Lineae medicae,” p. 177. Augustae Vindelicot, 1695. 
9 “ Ephem. nat. curios.,” dec. ii., ann. v., obs. xxii., p. 34. 
10 “ Commentarii de morborum historia et curatione,” pag. 118 et seq., cap. 24, 
I.ondoni, 1802, und Derselbe, “Commentary on the History and Cure of Diseases,” 9th 
edition, chapter Destillatio, p. 113. London, 1816. 
11 Med. Chirurgical Trans., 1828, vol. xiv., p. 437. 
12 “ Remittent and Intermittent Diseases,” London, 1828, vol. i., p. 394. HAY FEVER, OR VASO-MOTOR RHINITIS. 
201 
Gordon/ from a careful study of the disease, concluded that it was 
due to the emanations from flowering grasses, notably from an- 
thoxanthum odoratum. A somewhat similar view was adopted by 
Elliottson,2 who indorsed the use of the term hay fever. Subse- 
quent contributions were made by Cazenave,3 Laforgue,4 and De- 
chambre,5 which consisted mainly in the reports of cases. In 1854, 
Phoebus began a series of very elaborate investigations, pursued 
by means of printed circulars, issued to different medical societies, 
which was completed and published in 1862 in the form of a mono- 
graph,6 which was based on the study of one hundred and fifty-four 
cases. Phoebus estimated at this time, that altogether three hun- 
dred cases had been brought under observation. Phoebus’s contri- 
bution added largely to our knowledge of the disease, and yet the 
vagueness of his conclusions only serves to illustrate the difficulties 
which necessarily attend the study of an affection, so varied in its 
manifestations, and inconstant in its clinical history, and whose ex- 
citing causes are so illusive. 
The next notable observation on the subject was that of Helm- 
holtz, who in a letter to Binz,7 detailed the history of his own suffer- 
ings from the disease, and propounded the theory, that the symp- 
toms were due to the activity of certain vegetable spores, which he 
had found in the mucus discharged from his nose. It is a notable 
fact that most observers, up to this time, based their deductions 
largely on their own personal experience of the disease. Thus 
Roberts8 finds a variety of causes active in producing the exacer- 
bation, while he attaches special importance to personal idiosyn- 
crasy as predisposing to the attacks. In 1873 appeared Blackley’s9 
classical monograph, in which he details the results of by far the 
most thorough and exhaustive series of experiments yet undertaken 
for determining the causes of the disease. Blackley’s scientific 
methods of study leave no room to question the fact, that the im- 
pact of the pollen of flowering plants on the mucous membrane of 
the upper air passages, is the true source of the symptoms which 
characterize an exacerbation of hay fever. In 1876 there appeared 
the admirable monographs of Wyman10 and Beard.” The former 
1 London Med. Gazette, 1829, vol. iv., p. 266. 
2 London Med. Gaz., 1831, vol. viii., p. 411. 3 Gaz. Medicale, 1837, p. 631. 
4 Union Medicale, December 17th, 1859. 3 Gaz. Hebdomadaire, i860, p. 67. 
6 “ Der typische Friihsommer-Katarrh oder das sog. Heufieber, Heu-Astbma,” 
Giessen, 1862. 
7 “ Pharmakologische Studien iiber Chinin,” Virchow’s Arch., Feb., 1869, p. 100. 
8 New York Med. Gaz., Oct. 8th, 1870, p. 226. 
9 “Hay Fever,” London, 1873 ; and 2ded., 1880. 
19 “Autumnal Catarrh,” New York, 1876. 
11 “ Hay-fever, or Summer Catarrh,” New York, 1876. 202 
DISEASES OF THE NASAL PASSAGES. 
made an exhaustive study of the geographical features of the dis- 
ease as it is known in America, establishing the fact that in certain 
regions patients were exempt from their annual visitation; while 
Beard, following the method of Phoebus, pursued his investigation 
by means of circulars sent to physicians and others throughout the 
country, thus collecting a series of over two hundred cases, an 
analysis of which led him to the conclusion that the disease was 
essentially a neurosis. In 1877, Marsh 1 published his well-known 
essay, in which special emphasis was laid on the activity of the pol- 
len of rag-weed, or ambrosia artemisiaefolia, as previously noted 
by Wyman. An exceedingly important observation was made by 
Daly 2 in 1882, who questions “ whether we are warranted in believ- 
ing any case of hay asthma purely a neurosis, without first elimin- 
ating the possible causation due to local structural or functional 
disease in the naso-pharynx.” The importance of Daly’s paper 
cannot be overestimated, I think, in thus suggesting a diseased con- 
dition of the nasal cavities as being an important factor in all cases 
of hay fever, a fact which, while at first received with considerable 
hesitancy, is, I think, generally accepted now by all observers. In 
1883 appeared important papers by Hack,3 Roe.4 Hertzog5 and 
Sajous,6 in which a morbid condition of the nasal mucous mem- 
brane was recognized as a predisposing factor of the disease. We 
now meet with the first recognition of the inappropriateness of the 
term hay fever in the suggestion of Hertzog, that the disease might 
more properly be termed rhinitis vasomotoria. In the following 
year was published a paper by Harrison Allen,7 in which the im- 
portance of an obstructive lesion in the nose was emphasized, as a 
predisposing cause of the disease, and in the same year appeared a 
very suggestive paper by John Mackenzie,8 in which he designates 
the disease coryza vasomotoria periodica. In 1884 there also ap- 
peared Morell Mackenzie’s second volume9 in which he discusses 
hay fever in a very lucid manner, adopting the pollen theory of 
Wyman and Blackley, while he seems rather to attach little im- 
portance to a diseased condition of the nasal mucous membrane as 
a predisposing factor. It is noticeable, however, that, in subsequent 
monographs on the subject,10 he recognizes the fact, that in the 
1 Trans. Med. Society, State of New Jersey, 1877. 
2 Arch, of Laryngology, vol. iii., No. 2, p. 157. 
3 Wien. Med. Wochenschr.. No. 14, 1883. 4 N. Y. Med. Journal, May 12th, 1883. 
5 Allgemein. Med. Central-Zeitung, Oct. 24th, 1883, p. 1,125. ♦ 
6 Med. and Surg. Reporter, Dec. 22d, 1883. 
7 American Journal of Med. Sciences, Jan., 1884, p. 157. 
8 New York Med. Record, July 19th, 1884. 
9 “ Diseases of the Throat and Nose,” London, 1884. 
10 “ Hay Fever,” London, 1884 ; 3d. ed. 1885 ; 4th ed. 1887. HA V FEVER, OR VASO-MOTOR RHINITIS. 
203 
majority, if not in all cases of hay fever, the nasal mucous mem- 
brane presents evidence of disease. In 1886, the author1 published 
a paper in which it was argued that the prominent predisposing 
cause of all cases of hay fever was an obstructive lesion in the nose, 
giving rise to a vascular dilatation, caused by the rarefaction of air 
in the nasal chambers behind the point of obstruction, and further 
that three conditions were essential for the production of the dis- 
ease: (1) an obstructive lesion in the nose, (2) a neurotic habit, and 
(3) the impact of pollen upon the nasal mucous membrane. At the 
same time it was argued that hay fever and asthma were identical, 
in that one disease was a vasomotor rhinitis while the other was a 
vasomotor bronchitis. In the same year, Beverley Robinson 2 took 
the ground that an obstructive lesion of the nasal mucous mem- 
brane was not necessarily a part of the disease. In 1887 Sir 
Andrew Clark3 published a paper on the subject, pursuing much 
the same line of argument as that already advocated by the writer, 
in assigning three causes for the disease, viz.: a neurotic habit, an 
intra-nasal pathological condition, and an external exciting cause. 
The later literature of the subject recognizes and indorses these 
views, and we find few writers who do not accept what I think is 
to be regarded as the most important of these conclusions, viz.: 
that which regards a morbid lesion of the nasal membrane as a 
prominent factor in causing the attacks. 
Etiology.—Bostock4 in his first paper, which was based en- 
tirely on his own personal experience, seems to have arrived at no 
conclusion as to the cause of the disease. At the time of the pub- 
lication of his second paper,4 the idea seems to have been preva- 
lent that the emanations of dry hay had much to do in causing the 
attack, although Bostock himself regarded this as less active than 
heat and physical exertion. The elaborate investigations of Phoe- 
bus5 also led him to the conclusion that sunlight played an impor- 
tant part in the production of the disease, although he conceded a 
certain amount of activity to the emanations from flowers and 
grasses. Subsequent investigations merely served to specify the 
peculiar characteristics of dust and vegetable emanations which 
caused the attacks, in determining that the pollen of certain flower- 
ing grasses and plants was the morbific agent. I think a great 
mistake was made by these investigators, in that while searching 
successfully for the cause of an exacerbation of hay fever, they 
1 “ Hay Fever, Asthma and Allied Affections,” N. Y. Med. Journal, April 24th and 
May 1st, 1886. 
2 Med. News, July 17th, 1886. 
3 “ Speedy and Sometimes Successful Method of Treating Hay Fever,” Brit. Med. 
Journal, June nth, 1887, p. 1,255. 
4 Loc. cit. 5 Op. cit. 204 
DISEASES OE THE NASAL PASSAGES. 
seemed to regard this as a cause of the disease itself. When we 
have discovered the specific agent which produces the attack, we 
have not explained why any given individual should be subject to 
this specific cause, while numberless others are exempt. Beard’s 
admirable brochure, then, was a notable departure from the line 
of investigation hitherto pursued, in that the analysis of the large 
number of cases which he collated, proved beyond question, as it 
seems to me, that the neurotic habit was present in all individuals 
subject to hay fever, and still later, Daly’s1 original suggestion of a 
local morbid condition of the nasal mucous membrane added a 
third factor to the causation of the disease. We thus find that there 
are three essential conditions necessary for the production of an 
exacerbation: 
1. The presence of pollen in the atmosphere, 
2. A neurotic habit, and 
3. A local morbid condition of the nasal mucous membrane. 
I think, these three conditions are, unquestionably, present in 
all cases, and that no individual is liable to an attack in whom one 
or more of these conditions is absent, as a fuller consideration will 
easily demonstrate. 
1. The Presence of Pollen hi the Atmosphere.—The pollen theory 
of hay fever has probably received larger discussion than any other. 
Its advocates, and those who deny its activity, maintaining their 
individual positions with considerable skill, and oftentimes with no 
little acerbity. Certainly, when the pollen theory is advocated as 
fully explaining an attack of hay fever, the position undoubtedly 
cannot be maintained; but that the presence of pollen in the atmo- 
sphere, and its impact upon the mucous membrane of the upper air 
passages is the immediate cause of the exacerbation, I think cannot 
be questioned, in view of the exhaustive experiments, and unassail- 
able conclusions of Blackley,2 which are of so interesting a charac- 
ter as to warrant their being detailed somewhat fully. Blackley 
himself was a victim of hay fever, coming on about the 10th of 
June. He made a series of experiments to determine the amount 
of pollen in the atmosphere, extending through several seasons, 
from 1866 to 1878, using for this purpose different devices. The 
apparatus which gave the most accurate results, consisted of a disc 
of glass, seven-eighths of an inch square, mounted on a central 
staff, which was surmounted by a weather-vane, the disc itself being 
protected by a hood. This apparatus was exposed under varying 
atmospheric conditions, and in different situations, usually in an 
open field. The device for collecting the pollen consisted in plac- 
ing vertically in a slot, on the surface of this glass plate, a micro- 
1 Loc. cit. 
2 Op. cit. HAY FEVER, OR VASO-MOTOR RHINITIS. 
205 
scope slide, one centimetre in diameter, which was coated with a 
preparation of glycerin, by which the pollen floating in the atmo- 
sphere settling upon the slide remained adherent to it. This plate 
was generally exposed day after day for a certain fixed period, 
usually about twenty-four hours, the object of the vane being to 
keep the vertical slide directed constantly to windward. From 
the 28th of May to the 7th of June, pollen was found in the air in 
small quantities. On the 30th of May the number found on the 
slide was twenty-five, and with this number he began to suffer with 
perceptible, but not troublesome symptoms. On the 8th of June 
the number rose to seventy-six. On the nth of June, however, 
the number of pollen grains found on the small discs rose to a little 
over two hundred and eighty, and it was at this date that the ex- 
perimenter began to have unmistakable signs of the commence- 
ment of his summer attack in a troublesome form. From the nth 
of June onward, the amount of pollen varied in a notable degree, 
until on the 28th of June he counted eight hundred and eighty 
grains on his disc. He noticed that on rainy days the amount 
decreased in a very marked degree, while at the same time his 
symptoms very notably abated, although on warm days following 
rain, the number of grains increased very markedly. Moreover, he 
noticed that a few hours’ rain made no perceptible difference in his 
symptoms, whereas a rain of twenty-four hours or longer gave 
very striking relief, in connection with a notable decrease in the 
number of grains of pollen found. From the 28th of June onward, 
there was a gradual diminution, until the 1st of August, when the 
pollen disappeared, with complete abatement of all his symptoms. 
These experiments, it seems to me, are not only conclusive as far 
as the individual case is concerned, but also their accuracy and 
nicety of detail, and their complete demonstration of the close re- 
lation between the symptoms and the amount of pollen discovered, 
go far toward absolute proof of the pollen theory, so-called, in all 
cases of hay fever. Furthermore, Blackley’s experiments were not 
conducted in connection with his own individual case alone, but 
with others. 
The question arises here, How does pollen act on the mucous 
membrane ? This we cannot answer, other than to state that it 
produces vascular dilatation, when present in the atmosphere in 
certain quantities. Thus, Blackley has shown that the condition of 
the atmosphere, which will deposit twenty-seven grains of pollen 
on a disc one centimetre in diameter, in twenty-four hours, is un- 
irritating, but increase the strength of the atmospheric suspension of 
pollen, until it will deposit two hundred and eighty, and we find it 
producing marked symptoms of irritation. In the same way, a 206 
DISEASES OF THE NASAL PASSAGES. 
solution of cocaine one grain to the ounce, will have little or no 
effect locally applied to the mucous membrane, increase the 
strength of the solution to twenty grains to the ounce of water, 
and apply it to the mucous membrane, and the result is marked 
contraction of the blood-vessels. In other words, pollen in the air 
produces vascular dilatation in certain individuals, in exactty the 
same manner as a solution of cocaine produces vascular contrac- 
tion. The most active pollens in the production of hay fever*are 
those of the flowering grasses, such as the different varieties of 
meadow grass, sweet-scented vernal grass, meadow fox-tail, golden- 
rod, etc. Thus, Blackley found in his investigations that the pol- 
lens of these plants constituted ninety-five per cent of the pollens 
present on his discs. In America, rag-weed enjoys the reputation 
of being the most active of all plants in producing the autumnal 
form of the disease. The activity of the pollen of roses is well 
known, as well as that of the cereals, wheat, rye, Indian corn, oats, 
etc. In general it may be stated, that probably all pollens which 
are found floating in the atmosphere, or the so-called anemophilous 
pollens, possess a certain amount of activity, while the coherent or 
entomophilous pollens are innocuous. Peaches are also said to 
excite attacks. This, however, is explained by the fact, that the 
coat of the peach presents a favorable site for the lodgment 'of 
pollen grains, and in that undoubtedly lies the source of irritation. 
The same may be stated of other fruits, such as pears, plums, the 
flowers and stalks of potatoes, etc. 
2. The Neurotic Habit.—The neurotic habit, as demonstrated 
by Beard, is an essential element of causation in hay fever, and 
serves to explain why certain individuals are sensitive to the action 
of a pollen-laden atmosphere, while others are exempt. What the 
essential pathological lesion is, in what we call the neurotic ele- 
ment in hay fever, it is not easy to explain. If we term it an idio- 
syncrasy, it adds nothing to our information, and yet its existence 
cannot be questioned. These peculiar idiosyncrasies have been 
recognized by observers from the earliest times. Under this cate- 
gory can be placed those cases in which violent sneezing is excited 
by the presence of ipecac, nausea by the odor of camphor, urticaria 
by eating shell-fish, and the poisoning of Rhus toxicodendron, etc. 
These are simple clinical facts which admit of no classification or 
systematic consideration. In the same manner, clinical investiga- 
tion shows in a sufficiently large proportion of cases of hay fever, 
the existence of a family history showing evidence of neurotic ten- 
dencies, such as fully to justify the conclusion, that behind all cases 
of hay fever lies a neurotic habit, as a powerful predisposing cause 
of the disease. HAY FEVER, OR VASO-MOTOR RHINITIS. 
207 
3. A Local Morbid Condition of the Nasal Macons Membrane.—A 
local morbid condition of the nasal mucous membrane, as a predis- 
posing cause, is present in probably all cases of true hay fever. 
This lesion must necessarily be one of an obstructive character, 
and one attended with vascular dilatation. The primary lesion, 
probably in most cases, is the obstruction, as shown by Harrison 
Allen.1 The method by which an obstructive lesion in the nose 
may give rise to local conditions favoring the development of hay 
fever has already been described in the chapter on hypertrophic 
rhinitis, the essential condition being that an obstruction in the an- 
terior part of the nasal chambers gives rise to a diminution of air 
pressure immediately behind the point of obstruction, in every act 
of inspiration. This process going on for any lengthened period of 
time, will necessarily result in a permanent dilatation of the blood- 
vessels of the soft spongy tissues covering the lower and middle 
turbinated bones, thus rendering the parts susceptible to the action 
of the pollen, in that its impact upon a mucous membrane, whose 
blood-vessels are already weakened, and their contractility impaired, 
exercises its peculiar action with less resistance. 
In addition to the three elements of causation already described, 
I think we must recognize a psychical influence in many of these 
cases, as acting to produce the attacks, a peculiar mental anticipa- 
tion, as it were, which can only explain the fact of the annual re- 
currence of the disease at fixed dates, some patients going so far 
as to notice that their disease recurs even at a certain hour of the 
day each year. Now with the varying character of our seasons, it 
is impossible that the plant which is the active cause of an attack 
of hay fever in any individual case, should flower at exactly the 
same time each year, or that the pollen of these grasses should 
permeate the atmosphere in a sufficient quantity, as that for in- 
stance, Blackley’s discs would contain two hundred and eighty 
grains on the nth of June each year. We can, therefore, only ex- 
plain the recurrence of attacks in certain cases on fixed dates each 
year, by the fact that the individual’s mind is so far concentrated 
on the anticipation of his attack, that when the day comes the hay 
fever symptoms set in. This psychical influence is well illustrated 
by the case of John Mackenzie2 in which an attack of rose-cold was 
precipitated by means of an artificial rose. Mackenzie3 also re- 
ports a case in which an attack of hay-fever was brought on by a 
patient’s gazing upon a picture of a field of hay. The explanation 
of these cases, I take it, is much the same as that of those cases of 
intermittent fever in which the paroxysm is postponed by altering 
1 Loc. cit. 2 American Journal of Med, Sciences, Jan., 1886. 
3 “Hay Fever,” London, 1887, p. 56. 208 
DISEASES OE THE NASAL PASSAGES. 
the hands of the clock. Many of the earlier writers regarded heat 
and sunlight as active among the causes of hay fever. This is not 
to be wondered at, for we not infrequently find patients recognizing 
this apparent influence. This mistake is accounted for by Blackley, 
who has shown that the true explanation lies in the fact that a hot 
dry day is exceedingly favorable for the dissemination of pollen, 
whereas rainy weather, while interfering with its diffusion, favors 
its development, hence, pollen becomes unusually active where 
rainy weather is immediately followed by a heated period. 
The minute organisms which Helmholtz discovered in the mu- 
cous discharge from the nose, to whose activity he attributed the 
symptoms of his disease, have never been verified by other observers. 
It is altogether probable that what Helmholtz really saw, were frag- 
ments of mycelium-like threads thrown out by the pollen-cells, 
under the influence of heat and moisture, and containing the minute 
fovillae of the pollen-cell. The relief which Helmholtz obtained by 
the injection of his quinine solution, therefore, must be attributed 
largely to psychical influence, for while immediately following the 
publication of Helmholtz’s experience, the use of quinine solutions 
became exceedingly popular, it has fallen into complete disuse at 
the present day. Thus, De Budberg1 cites a case treated after 
Helmholtz’s method with complete success. It was found, however, 
that a douche of chlorate of potash solution was equally efficacious. 
In this case a large number of spores were found in the mucus, 
which De Budberg regarded as pollen granules. 
Age seems to exert a certain predisposing influence in the causa- 
tion of the disease, in that the larger number of cases develop early 
in life. Thus, in a series of eighty cases observed by the writer, 
there occurred: 
Between the ages of 1 and 10, . .9 cases. 
“ “ “ 10 “ 20, . . 27 “ 
“ “ “ “ 20 “ 30, . . . 16 “ 
“ “ “ “ 30 “ 40, . . .21 “ 
“ “ “ “ 40 “ 50, . • .3 “ 
Over 50, ....... 4 “ 
Total, ...... 80 cases. 
We thus find the large proportion of cases occurring between 
the ages of ten and twenty, while the predisposition seems to dis- 
appear very largely at the age of forty, although rather curiously, 
among my own cases, I have had under’treatment a patient in whom 
the disease developed at the age of seventy-three. Wyman,2 in an 
1 Brit. Med. Jour., vol. ii., p. 18, 1881. 
2 Loc. cit., p. 97. HAY FEVER, OR VASO-MOTOR RHINITIS. 
209 
analysis of the seventy-two cases which he collated, found the dis- 
ease occurring as follows: 
Under io years of age, . . . . n cases. 
Between io and 20, . . . 15 “ 
“ 20 “ 30, 25 “ 
“ 30 “ 40, . . . . . 8 “ 
“ 40 “ 50, 11“ 
Above 50, . . . . . 2 “ 
These results differ, as will be seen, somewhat from my own, 
although it should be stated that my own tables give the date of 
occurrence of the first attack, while Wyman simply reports the age 
of the patient at the time of observation. All writers coincide in 
the statement that the disease belongs essentially to the better edu- 
cated classes, and that it occurs very rarely among the laboring 
people. This we can easily understand, when we consider that the 
disease is essentially a neurosis, and that its development is favored 
by the surroundings and habits of life of the upper classes, while 
the contrary is true among the laboring people. 
That the large preponderance of cases occur among males, is 
also a fact noted by all observers. Of my own cases, fifty-eight 
were males, while twenty-two occured in females. Of Wyman’s 
seventy-two cases, twenty-five were females and forty-seven males. 
Of two hundred cases reported by Beard 1 one hundred and thirty- 
three were males and sixty-seven females, while Phoebus, out of 
one hundred and fifty-four cases, found one hundred and four males 
and fifty females. We thus find in five hundred and six cases, three 
hundred and forty-two males and one hundred and sixty-four fe- 
males. This observation would seem rather to conflict with the 
idea that hay-fever is essentially a neurosis, in that we ordinarily 
associate the delicate female physique with a neurotic tempera- 
ment. I do not think it is a well-established fact, that frail physi- 
cal development is a necessary feature of the nervous temperament, 
so that I do not think that these statistics argue against the fact 
of hay fever being a neurotic disease. The true explanation of the 
preponderance of male cases of hay fever, is in the fact that males 
are much more exposed to those conditions which favor the devel- 
opment of catarrhal disease, such being not only traumatic causes 
as previously discussed, but also the varying conditions of climate 
and weather. This fact, then, would seem to lend weight to the 
view already indorsed, that a catarrhal affection of the upper air 
passages is a powerful predisposing cause to the development of 
hay fever. 
1 Loc. cit., p. 43. 210 
DISEASES OF THE NASAL TASS AGES. 
The powerful influence of heredity is well illustrated by Wy- 
man’s statistics, who found that in one-fifth of all his cases, more 
than one member of the same family was affected. The same is 
true of eighteen of my own eighty cases, while in thirty-nine cases 
there was either hay-fever or asthma in the family. Wyman1 
further quotes in illustration of this feature of the disease, the very 
curious case of the family of Chief Justice Shaw, who was the only 
child, in a family of several, who arrived at maturity; his mother 
had autumnal catarrh; out of four children one son is a sufferer; 
a son and a daughter have summer cold; a son who has autumnal 
catarrh, has a daughter who is now twenty-two, who has had au- 
tumnal catarrh six or eight years. Another striking case is that of 
the Rev. Henry Ward Beecher, whose sister and nephew suffered 
from the disease. 
The impairment of the general health which is occasionally ob- 
served after a protracted convalescence from a continued fever, 
would occasionally seem to act as a predisposing cause of hay fever. 
Thus, Sajous2 has observed cases coming on after an attack of ty- 
phoid fever, whooping cough, malaria and chicken pox, an observa- 
tion which fully coincides with my own clinical experience. 
Diathetic conditions probably exert little if any influence upon 
the development of the disease, and yet Leflaive3 believes that it is 
a manifestation of the gouty diathesis, an opinion also shared by 
Lermoyez.4 
PATHOLOGY.—The essential pathological changes which take 
place in the nasal mucous membrane, are not those which charac- 
terize an inflammatory process, and yet from the various names 
which have been proposed for the disease, such as Rhinitis vaso- 
motoria (Hertzog), Coryza vasomotoria periodica (John Mackenzie), 
Rhinitis sympathetica, etc., the inference would naturally be drawn 
that the exacerbation is regarded as an inflammatory process. 
Now, it should be stated that the first stage of an inflammation is 
vasomotor paresis, hence every case of rhinitis, whether periodical 
as the result of pollen, or idiopathic, is a vasomotor process, hence 
the use of this expression would seem to be redundant. Further- 
more an inflammatory process runs through certain definite stages, 
and usually terminates by spontaneous resolution. This is not the 
case in an exacerbation of hay fever, for although its onset in some 
cases is gradual, in others it comes on quite suddenly, but in its 
termination it is apt to be quite abrupt, all the symptoms disap- 
1 Loc. cit., p. 103. 
2 “ Diseases of the Nose and Throat,” Philadelphia, 1887, p. 178. 
3 “ Rhinobronchite Annuelle,” Paris, 1887. 
4 Annales des mal. de 1’oreille, March, 1888. HAY FEVER, OR VASO-MOTOR RHINITIS. 
211 
pearing immediately on the escape of the individual from the pollen- 
laden atmosphere. Moreover, the appearances of the membrane 
in the nose, as will be shown later, do not present the characteristic 
features of an inflammatory action. In order to understand what 
the essential lesion is in an exacerbation of hay fever, it is necessary 
that we should fully appreciate the physiological function of the 
nasal mucous membrane in respiration. This, as has already been 
shown before, consists in a process of serous exosmosis, by which 
there is poured out on the surface of the mucous membrane lining 
the nasal cavities, from twelve to sixteen ounces of water in twenty- 
four hours, this process being directly under the control of the/ 
sympathetic system of nerves, by which the amount of serum dis- 
charged is regulated with an extreme degree of nicety, according 
to the varying conditions of the atmosphere. Now, the pollen of 
flowering plants, as has already been noted, possesses the peculiar 
property of producing more or less complete paralysis of the nerves 
which control this exosmotic function, in other words the impact 
of pollen upon this membrane produces a complete relaxation of 
the large veins which compose the turbinated bodies, under which 
they become dilated, and their walls admit of free transudation of 
serum, the veins remaining in this state of dilatation as long as the 
pollen is present upon the surface of the membrane in sufficient 
amount, regaining, however, their normal calibre immediately upon 
the removal of the exciting cause. The capillary blood-vessels of 
the mucous membrane proper, as a rule, are not involved in the 
morbid changes which take place in the deep tissues. The pollen, 
moreover, acts only to dilate those blood-vessels which are involved 
in this respiratory process, namely the venous sinuses of the turbin- 
ated bodies, for we find that the blood-vessels of the mucous mem- 
brane proper are unaffected by its action, retaining their normal 
calibre. We thus find that the exacerbation is due entirely to 
peripheral causes. It might be charged that this view militates 
against the neurotic theory. The part which the general predis- 
posing neurosis plays in the production of the disease, is that it 
gives rise to a weakness of the vaso-motor control, which the sym- 
pathetic and trigeminus nerves exercise over the calibre of the 
venous sinuses, whereby they are rendered susceptible to the action 
of pollen. The question arises now, whether this vaso-motor sus- 
ceptibility can be accounted for in any other way than by conced- 
ing some pathological change in the ganglionic centres. This is a 
question which cannot easily be decided, and any discussion of it 
can be carried on only upon purely theoretical grounds. I see no 
reason, however, why the condition may not exist, without neces- 
sarily involving the nerve centres in pathological changes, although 212 
DISEASES OE THE NASAL PASSAGES. 
the theory of a central lesion is ably advocated by John Mackenzie 1 
who designates it as a “ disordered functional activity of the nerve 
centres,” while Kinnear2 is more definite in his conclusions, finding 
two forms of the disease, which are due in one case to a hyperaemia, 
and in the other to a condition of anaemia of the sympathetic gan- 
glia. Hack,3 on the other hand, believes that the morbid lesion 
consists essentially in a hyperaesthetic condition of the olfactory 
and the fifth pair of nerves. The same view is also entertained by 
Robinson.4 
Symptomatology.—The onset of the attack is marked by a 
sense of irritation referable to the upper regions of the nasal cham- 
bers, with a sense of fulness or tightness across the bridge of the 
nose, accompanied with sneezing of more or less violent character. 
At the same time patients complain of a curious burning or itching 
sensation about the roof of the mouth, apparently referable to the 
upper surface of the soft palate. As the attack develops, the nasal 
membrane becomes swollen, and the passages thereby more or less 
completely occluded. At the same time the serous exudation sets 
in, pouring out on the surface of the membrane, and escaping from 
the nostrils in, oftentimes, large quantities. So profuse is this dis- 
charge, that patients oftentimes feel apparently the passage of the 
serum in its escape from the blood-vessels, in a sense of intense 
irritation or formication about the root of the nose. The escape 
of serum seems to increase the intense irritation in the passages, as 
shown by the increased violence of the sneezing, which often occurs 
in paroxysms of considerable duration. With the occurrence of 
the nasal symptoms, in many cases there is felt at the same time 
irritation of the mucous membrane of the eyes, and in rarer cases 
even of the mouth and ears. These symptoms are undoubtedly 
due to the pollen acting on these membranes in exactly the same 
manner that it acts upon the nasal passages. This, I think, was 
conclusively demonstrated by the experiments of Blackley5 who 
prepared a decoction of the pollen of gladiolus, the injection of 
one drop of which into the eye, being followed almost instantly by 
an intense congestion, and finally oedema of the conjunctiva, with 
pain and photophobia. This would indicate that susceptibility to 
the action of pollen is not necessarily confined to the air passages. 
Blackley6 found the mucous membrane of the mouth also sensitive 
to the irritation of pollen. 
1 “ Coryza Vasomotoria Periodica,” N. Y. Med. Record, July 19th, 1884. 
2 “ Hay Fever: A Disease of Central Nervous Origin.” N. Y. Med. Record, July 
14th, 1888, p. 32. 
3 Wien. Med. Wochenschr., 1883, No. 14. 
4 Philadelphia Med. News, July 17th, 1886. 
5 Op. cit., p. 103. 6 Op. cit., p. 104. HAY FEVER, OR VASO-MOTOR RHINITIS. 
213 
These symptoms commencing somewhat mildly on the first day 
of the attack, gradually increase until the exacerbation has reached 
its full height at the end of the third or fourth day, by which time 
the mucous membrane of the whole upper air tract is swollen and 
intensely irritated, the nasal passages being as a rule completely 
occluded, while at the same time there is a constant dripping of 
serum from the nostrils, in quantities sufficient oftentimes to satu- 
rate six or eight handkerchiefs in the course of the day. 
The blood in the membrane shows a certain hydrostatic charac- 
teristic, in that it tends to collect in the most dependent portion. 
Thus, if the sufferer lies on the back, the fluids collect in the pos- 
terior extremities of the turbinated bodies in such a way as to com- 
pletely occlude the nares, while lying on the side will often have 
the effect of securing patency of the uppermost nasal passage, 
while the fluid collects in the lower. The escape of fluid from the 
nostril often causes an eczema of the skin about the margin of the 
nostrils and upper lip, which is aggravated by the constant use of 
the handkerchief. These symptoms show a mild tendency to 
abatement during the night, which is probably due to the fact, that 
the air of the sleeping apartment is less laden with pollen than the 
atmosphere breathed during the day. The waking hours, however, 
constitute a period of almost unbroken discomfort, and oftentimes 
suffering. The onset of the attack in most cases is sudden and 
without warning, although occasionally it is preceded by a feeling 
of general malaise, with loss of appetite and mental depression, 
these premonitory symptoms persisting during the course of the 
exacerbation to a more or less well-marked degree. Aside from 
these symptoms, evidences of the effect of the disease on the gen- 
eral system are not present. Thus Blackley1 in a series of careful 
observations of pulse and temperature, found no deviations from 
the normal. 
After the disease has persisted for a varying period of time, 
usually about two to three weeks, in a certain number of cases an 
attack of asthma sets in, marked by the ordinary symptoms which 
characterize any attack of so-called nervous or spasmodic asthma. 
The patient having fallen asleep, is awakened at the end of two or 
three hours with oppression of breathing, which persisting for some 
hours, ceases in the early morning, only to return again the follow- 
ing night. These asthmatic attacks rarely occur with the first 
attack of hay fever, but the repeated annual visitation seems to 
develop a tendency, which results eventually in the development of 
the bronchial disorder. 
The question arises whether the asthma is due to the hay fever, 
1 Op. cit., p. 205. 214 
DISEASES OF THE NASAL LASS AGES. 
or whether they both may not be due to the same cause. I have 
already discussed elsewhere the connection between hay fever 
and asthma, taking the ground that they are essentially one and 
the same disease, regarding hay fever as a vaso-motor paresis of the 
walls of the blood-vessels lining the nasal cavity, while asthma is a 
vaso-motor paresis of the blood-vessels of the mucous membrane 
lining the bronchial tubes; an attack of asthma consisting in a 
sudden dilatation of the blood-vessels of the bronchial mucous 
membrane producing a structural stenosis of these tubes, giving 
rise to the characteristic inspiratory and expiratory dyspnoea, while 
hay fever is due to a paresis of the walls of the blood-vessels forming 
the turbinated bodies, giving rise to their excessive dilatation, thus 
causing nasal stenosis with profuse serous exosmosis. This being 
true, the walls of the blood-vessels of the bronchial mucous mem- 
brane in a hay-fever patient are in a condition peculiarly favoring 
their becoming relaxed, when the special exciting causes become 
active, for the general neurotic condition which renders the nasal 
membrane of a patient susceptible to the action of pollen, un- 
doubtedly acts to render the bronchial mucous membrane predis- 
posed to its action. This condition, then, of the bronchial mucous 
membrane being present, we can easily understand why the nasal 
disorder persisting for ten days to two weeks or longer, should 
result finally in bringing on an attack of bronchial asthma, in much 
the same manner as an obstructive lesion in the nose predisposes to 
hay fever, as already described, for here we have two factors acting. 
Nasal stenosis tends to produce rarefaction of air in the bronchial 
passages with every act of inspiration, thus producing a tendency 
to dilatation of the bronchial blood-vessels; and again, there is an 
intensely active and quick sympathy between the nasal mucous 
membrane and the bronchial mucous membrane, under which a 
diseased condition in the nasal cavity tends to develop a similar 
morbid condition in the bronchial mucous membrane. It is proba- 
ble aTso that the pollen acts with a certain amount of potency on 
the bronchial membrarie, in much the same manner as upon the 
nasal membrane. The reason why it does not act to produce an 
attack of asthma with the first onset of the hay-fever, probably lies 
in the fact that this susceptibility in the bronchial tubes only oc- 
curs after they have been subjected to the weakening influence of 
the nasal disorder for a certain period of time. As the patient goes 
through his attack year after year, it is noticeable that the asthma 
occurs in many cases earlier each year, until finally the asthma sets 
in immediately on the advent of the hay-fever season. Still an- 
other curious fact noticed in these cases, is that not infrequently 
the bronchial asthma seems to take the place of the hay fever, and HAY FEVER, OR VASO-MOTOR RHINITIS. 
215 
that a patient may suffer for a number of years with hay fever 
alone, subsequently having developed asthma in connection with 
the hay fever, the hay fever gradually subsides, and his attack be- 
comes what is called hay asthma, or spasmodic asthma, occurring 
and persisting through the hay-fever season without hay-fever 
symptoms. A still further change I have seen in these cases, by 
which the disorder becomes a perennial asthma, or in other words, 
asthmatic attacks occur at all seasons of the year without reference 
to pollen in the atmosphere. 
It is a notable fact in connection with cases such as these, that 
the purely nervous element, as manifested by the general systemic 
condition, seems to have increased in a very marked degree. Why, 
then, in these cases the hay fever should disappear and the asthma 
take its place, it is not easy to explain, unless possibly that the 
peripheral irritation has resulted in an intensely irritable condition 
of the ganglionic centres, or possibly some organic change occurs 
there, the result of which is that they gradually become overtaxed 
as it were, or less sensitive to the periodical stimulation, character, 
istic of the hay-fever season. The essentially neurotic character of 
the disease is still further shown by the fact that in a certain num- 
ber of cases the attack is preceded by a cutaneous eruption, usually 
of a lymphatic character, although Laflaive 1 has met with cases of 
urticaria and even eczema. 
COURSE and Duration.—In a very large majority of cases of 
hay fever, the annual attack commences in the latter part of August, 
and lasts until frost sets in. The usual date assigned is the 29th of 
August. Many patients assert that their attack recurs each year 
on exactly the same date, and even at the same time of day, al- 
though in most cases the date varies, it may be, several days. As 
before stated, I believe that in those cases in which the date and 
hour of the attack are absolutely unvarying, it is due to a peculiar 
state of mental anticipation which precipitates the attack. I know 
of no reason why so large a proportion of individuals are attacked 
in August, other than the fact that the pollen of rag-weed, as demon- 
strated by Wyman, Marsh and others, is probably the most virulent 
of all the pollens, and that this weed fructifies most actively at this 
time. Moreover, rag-weed flourishes throughout a large portion of 
the country, in a state of luxuriance that is equalled by few other 
of the anemophilous plants. These cases are usually designated as 
autumnal catarrh. The next in frequency to this variety, is that 
which occurs in June, and which is commonly spoken of as rose- 
cold, from the fact that these patients are susceptible to the action 
of the pollen of the different varieties of roses which flourish at this 
1 “ Rhino-Bronchite Annuelle,” Paris, 1887, p. 47. 216 
DISEASES OF THE NASAL PASSAGES. 
season of the year. Most writers have regarded all cases as com- 
ing under these two varieties. Beard 1 lays special emphasis on the 
fact, that he had demonstrated a third variety as occurring in 
September. As before stated, however, this classification I think 
only serves to add confusion to the subject, as the disease is essen- 
tially the same at whatever season it occurs, and, moreover, in not 
a few instances we find that patients subject to the so-called rose- 
cold, are subsequently attacked in August with what is called au- 
tumnal catarrh. Still further, an analysis of cases will show that 
the attack may come on at any time from the first of May to the 
last of September. Thus, Beard2 found that the attack set in, as 
follows: 
From May 1st to 10th, ..... 2 
“ 10th “ 20th, 
“ “ 20th “ 31st, 
“ June 1st “ 10th, 11 
6 
“ “ 10th “ 20th, 
“ “ 20th “ 30th, 
8 
“ July 1st “ 10th, 6 
“ “ 10th “ 20th, 6 
“ 20th “31st, 7 
“ August 1st to 10th, 7 
10th “ 20th, 81 
“ “ 20th “ 31st, 54 
“ September 1st to 10th, .... 7 
“ 10th “ 20th, .... 1 
“ “ 20th “ 30th, .... 2 
Total 198 
These figures only apply to the onset of the attack, its duration 
not being given. An analysis of the duration of the disease in my 
own eighty cases is as follows: 
From May 1st to frost, ..... 1 
“ I5th-25th to July 1st, .... 3 
“ 10th to August 1st, .... 1 
“ June 1st “ July 1st, .... 2 
“ “ 1st “ “ 14th, .... 1 
1st “ frost, 5 
loth “ July 4th, .... 4 
“ “ 10th “ “ 26th, 5 
“ July 1st “ Sept. 1st, . . . . 1 
1 Op. cit., p. 49. 
2 Op. cit., p. 50. HAY FEVER, OR VASO-MOTOR RHINITIS. 
217 
From July ioth to Aug. ist, i 
“ ioth “ Sept. ist. .... i 
“ 25th “ frost, ..... 4 
“ Aug. ioth-27th to frost, . . . 51 
Total ........ 80 
A mere glance at these figures, I think, shows conclusively the 
futility of any attempt at a close classification. Furthermore, it is 
impossible to assign any special pollen as the active irritant in any 
of the above classes, inasmuch as definite facts of this character 
could only be ascertained by very close personal experimentation 
and observation, and of this few patients are capable. It should 
be added, moreover, in regard to these cases, that it is exceedingly 
difficult to elicit an accurate clinical history from the patient, with- 
out close questioning, and even then, the principal points of the 
histories which an inquirer desires to ascertain, are but vague im- 
pressions, hence their answers will be of a very general and inde- 
terminate character, based on an imperfect recollection of their last 
annual attack. 
The above figures refer to the disease as manifested in America. 
In England it usually appears in May and June and rarely lasts 
into September. The same is true of France, Germany and other 
European countries. The autumnal variety of the disease would 
seem then to be exclusively American. An interesting question in 
this connection arises as to whether the disease is not greatly on 
the increase. Certainly it fills a much larger space in our literature 
than ever before, and this is increasing from day to day. Thus, in 
1862 Phoebus, as the result of three years’ labor was only able to 
collate one hundred and fifty-four cases, while Beard in 1876 was 
able to collate two hundred, whereas, at the present time, collated 
cases could easily be made to reach into the thousands. This can 
be explained either by the fact that, with increased knowledge of 
the disease, cases come under observation more frequently, or that 
the number of cases which occurs has greatly increased. My own 
impression is that the latter is true. This belief is based not only 
on the fact that a larger number of cases come under my own per- 
sonal observation each year, but on the increased severity of the 
symptoms observed to develop year by year; as, in many instances, 
a patient hitherto suffering from a mild rose-cold in the early sum- 
mer, will now have, in addition, an autumnal attack; and, further- 
more, patients hitherto suffering merely from the influenza, com- 
mence now to suffer, in addition, from hay asthma as well. 
It might be stated here, in regard to my own cases, that they 
are entirely made up of patients in my own private practice, and, 218 
DISEASES OF THE JVASAL PASSAGES. 
furthermore, that whereas I have reported but eighty, quite a large 
number are not included, owing to the fact that the recorded his- 
tories are incomplete. 
Geographical Distribution of the Disease.—Wyman, in 
his elaborate treatise on Autumnal Catarrh, has made a special study 
of the regions of this country where the disease prevails, and of 
those which are exempt. He found the disease confined mainly to 
that region of the country east of the Mississippi, between the 
thirty-fifth and forty-fifth parallels. In this territory the exempt 
regions consisted of Canada, the Adirondack Mountains, the ele- 
vated plateau through the centre of New York, and the Apallachian 
range. The exempt region consisted of the territory west of the 
Mississippi, and of those Southern States south of the thirty-fifth 
parallel, with the exception of a limited area about Milledgeville, 
Ga., Montgomery, Ala., and Beaufort, N. C. A larger familiarity 
with the disease, I think demonstrates that Wyman’s conclusions 
were based on insufficient research, and that we will find hay fever 
prevalent throughout the whole United States, with the exception 
of certain elevated districts, such as the White Mountains, the 
Adirondacks and a portion of the Southern States. That patients 
are exempt from the disease in the mountains, I think is to be ex- 
plained by the fact that the flora of mountainous districts differs 
materially from that of the valleys, and that the flowering plants 
whose pollen is the immediate cause of an exacerbation of hay 
fever, are not found in those elevated regions. That the disease is 
comparatively rare in the Southern States, is to be explained by the 
fact that the morbid conditions of the nasal mucous membrane 
which constitute so powerful a predisposing cause of the disease, 
do not prevail in these semi-tropical regions. That it exists in this 
region, however, cannot be questioned. However, a few cases are 
found even in the extreme Southern States, their frequency in- 
creasing as we go northward. That the territory west of the Mis- 
sissippi is to a certain extent exempt, is explained by Beard on the 
ground of the lack of vegetation, and the sparsity of population in 
these immense districts. This immunity, however, is disappearing 
rapidly each year, as there is nothing in the flora or the climate of 
the West which affords exemption from the disease, for as popula- 
tion extends, and urban life increases, the diseases of civilization 
become more common. 
It is also a noticeable fact, that some parts of the White Moun- 
tains, which have hitherto been classed among the exempt regions, 
have failed in late years to give that complete relief which patients 
have formerly enjoyed there. This is probably due to the exten- 
sion of the railroads which have increased the amount of travel, HAY FEVER, OR VASO-MOTOR RHINITIS. 
219 
and as a consequence probably, extended to a degree the flora of 
the valleys. 
Diagnosis.—The disease, it is well known, is not infrequently 
looked upon as summer cold, and its periodicity overlooked. A 
mistake in diagnosis, however, need never be made, for there are 
certain characteristics which distinguish it in a marked way from 
an ordinary attack of acute rhinitis. These are the comparative 
suddenness of its onset, as well as its disappearance, together with 
the peculiar symptoms which characterize its progress, which are 
the violent sneezing and profuse watery discharge. Now, in an 
ordinary acute rhinitis, the stage of the disease which is accom- 
panied by a serous discharge from the nose is of comparatively 
short duration, whereas in hay fever this feature of the disease con- 
tinues during the whole course of the attack. Moreover, in a cold 
in the head, intense sneezing lasts but a few days, and does not 
occur in the violent paroxysms characteristic of hay fever. The 
appearances of the membrane on examination, moreover, are totally 
distinct in the two affections. In acute rhinitis the membrane is 
red, highly congested, and pours forth a more or less profuse mu- 
cous or muco-pus discharge, in connection with the serous exuda- 
tion, which is seen coating its surface in yellowish semi-opaque 
flakes or masses. In hay fever, on the other hand, the membrane, 
although swollen, never presents the bright red appearance of an 
acute inflammation, but is of a bluish-gray tinge, verging on opales- 
cence. This is due to the fact that the hyperaemia is confined en- 
tirely to the large venous sinuses which comprise the turbinated 
bodies, the capillaries of the mucous membrane proper not being 
congested. In addition to this, the surface of the membrane is 
covered with slightly viscid watery serum, which gives it a glassy 
semi-translucent aspect. The swollen condition of the membrane 
gives rise to more or less complete occlusion of the nasal cavity, 
the turbinated bodies lying in contact with the septum. At these 
points of contact, little bridges of viscous serum will be noticed 
stretching across from one side to the other, giving the appearance 
•of air-bubbles, as it were. Posterior rhinoscopy adds little to our 
information, other than showing the posterior nares occluded by 
the swollen grayish membrane covering the turbinated bodies pos- 
teriorly. Suffusion of the eyes, with photophobia and epiphora, 
afford a certain amount of diagnostic information, although those 
may occur in connection with an ordinary cold in the head. 
PROGNOSIS.—Hay fever rarely involves any marked impairment 
of the general health, and hence the prognosis is never grave. The 
main question of interest, however, is whether the disease can be 
cured It is a noticeable fact in the voluminous literature on this 220 
DISEASES OF THE NASAL PASSAGES. 
subject, that this feature of the disease has received but slight 
consideration. In a certain proportion of cases the disease seems 
to disappear spontaneously, from no apparent cause. This ten- 
dency is, however, manifested in but a small proportion of cases. 
As before noted, eighty cases have come under my personal obser- 
vation and treatment, while four additional cases have come under 
treatment for a diseased condition of the upper air-passages, who 
had in previous years suffered from annual attacks of hay fever. 
This perhaps will fairly represent the proportion of cases in which 
we may expect this spontaneous disappearance of the affection. 
In discussing the question of causation, eighty cases were analyzed 
in which the disease was periodical, and the histories fully as- 
certained. I have, however, comparatively full records of one 
hundred and twenty-one cases. Of this number there were: 
Cured, . . . . . . . . . 51 
Relieved, ........ 43 
Unrelieved, ........ 13 
Results unknown, ....... 14 
The above tables embrace all the cases of vaso-motor rhinitis 
that have come under my observation, including not only the 
periodical cases, such as autumnal fever and rose-cold, but a large 
number of patients in whom the symptoms were perennial. Roe 1 
presents statistics even more favorable than these, in that of forty- 
four cases under treatment thirty-six were cured, although in 
sixteen of the thirty-six there was some return of the symptoms. 
The question arises, How far can we feel assured in any indivi- 
dual case of accomplishing a successful cure of hay fever ? This I 
think is impossible, as the disease is essentially a treacherous and 
fickle one, and in those cases which apparently promise the best 
results, we are often disappointed. 
The duration of the disease apparently has no influence on the 
prognosis, for the case of a year’s standing will often prove quite as 
obstinate to treatment as one of twenty or even thirty years’ stand- 
ing. 'We would naturally suppose that where hay fever has led to 
the development of hay asthma, the neurotic habit was so firmly 
fixed in the individual as to render the prognosis more grave; and 
yet this is not true, as is shown by an analysis made by the writer 
of eighty case of asthma.2 Thirty-four of these cases were hay 
asthma, and of these eighteen were cured, fourteen relieved, one 
was lost sight of, and in one, treatment was apparently without 
effect. The prognosis in hay asthma would therefore seem to be 
1 Trans. Amer. Laryng. Ass’n, 1887, p. 126. 
2 Amer. Journ. of Med. Sciences, Sept., 1888. HAY FEVER, OR VASO-MOTOR RHINITIS. 
221 
more favorable even than in hay fever. Age, I think, has an un- 
doubted influence on prognosis, in that for younger patients a more 
favorable prognosis can be given. 
As before stated, rose-cold seems to affect young people rather 
than those more advanced in life, hence in a case of rose-cold, the 
prognosis is more favorable than in a case of autumnal catarrh. 
We are not warranted, then, in giving an absolutely favorable prog- 
nosis in any individual case, and yet I think statistics justify us in 
the expectation that a large proportion of cases can be cured. 
TREATMENT.—The treatment of hay-fever consists in: 
First.—General treatment, for the correction of the neurotic 
habit. 
Second.— Local treatment, for the relief of the diseased condi- 
tion of the upper-air passages. 
Third.—The treatment of the exacerbation. 
First. Constitutional Treatment.—The efficacy of internal medi- 
cation was recognized very early in the history of this disease, and 
the list of drugs which we find recommended for the correction of 
the neurotic habit, embraces a large proportion of the so-called 
nervines as well as many of the anodynes. Among these we include 
belladonna, zinc, arsenic, phosphorus, strychnine, hydrocyanic acid, 
valerian, assafcetida, musk, lobelia, amber, the bromides and iodides, 
chloral, opium, hyoscyamus, quinine, and the various preparations 
of iron. 
The usual method of administration of these drugs is to com- 
mence with small doses from two to four weeks before the annual 
attack sets in, and gradually increasing the dose, to get the patient 
thoroughly under the influence of the drug by the time the parox- 
ysm comes on, and to continue its administration while the attack 
lasts. Blackley was a homoeopathic physician, but his experiments 
in the therapeutics of this disease seem to have been quite as thor- 
ough as his investigations of its etiology. He obtained excellent 
results from the use of arsenite of potash and arsenite of quinine, 
but his best results were obtained from the use of the iodide of 
arsenic, administered in the form of a trituration containing about 
of a grain in a dose. As early as 1828 MacCulloch 1 urged that 
the disease be treated by anti-periodic measures, and since his time 
quinine has been quite a favorite remedy, Beard 2 giving this drug 
the very highest place among therapeutic agents, as having “ helped 
more cases than any other single remedy.” Bromides have been 
extensively used, both for the constitutional habit, and to mitigate 
the severity of the paroxysms. Few observers, however, have found 
them to possess any great efificacy, although combined with chloral, 
1 “ Remittent and Intermittent Diseases,” London, 1828. 
2 Op. cit., p. 158. 222 
DISEASES OF THE JVASAL PASSAGES. 
their use is not infrequently indicated during the exacerbation, to 
allay nervous irritability and to produce sleep. Long before the 
essential pathological lesion which characterizes an attack of hay 
asthma was recognized, the use of belladonna was resorted to as 
an anti-spasmodic. Thus we find Laforgue1 claiming specially 
good results from its administration in connection with opium, 
while Dechambre 2 obtained equally good effect from its adminis- 
tration in connection with quinine. Since the disease has been 
shown to consist in a vaso-motor paresis, I think we must recognize 
the fact that the efficacy of this drug is due mainly to its peculiar 
action on the vaso-motor system of nerves. That belladonna exer- 
cises a notable influence in controlling the manifestations of this 
disease has been confirmed by most observers. Dechambre ad- 
vised that it should be given in gradually increasing doses, until its 
full physiological effect was obtained, after which the doses should 
be slowly decreased. This, however, was during the attack. Better 
results I think are obtained by commencing the administration of 
the remedy three or four weeks before the attack, and continuing 
it until its termination. Mackenzie3 has found “ valerianate of zinc 
in combination with assafcetida more valuable than any other drug.” 
He commences with the administration of one grain of the zinc, in 
combination with two grains of compound asafcetida pill, before 
the attack comes on, and at the end of two weeks doubles the dose. 
I fully believe in the therapeutic value of the salts of zinc in this 
affection, but regard belladonna as far more efficacious and certain 
in its action. No combination in my own experience has been at- 
tended with better results than the administration of both these 
remedies as in the following: 
k Zinci phosphidi, ...... grs. viij. 
Extract, belladonnas, . . . . . gr. x. 
M. ft. mass, in pill no. xl. div. S. One pill three times a day 
after eating. 
Most cases of hay fever show no evidence of impaired nutrition, 
but on the contrary I think the rule is that they present every evi- 
dence of vigorous general health. Where, however, there is evidence 
of impaired nutrition, I think the administration of arsenic is often 
attended with the best of results, and in these cases the above 
formula can be amended as follows: 
k Zinci phosphidi, ...... grs. viij. 
Acidi arseniosi, . . . . . . gr. i. 
M. ft. mass, in pill no. xl. div. S. One pill after each meal. 
1 Union Medicate, December 17th, 1859. 2 Gaz. Hebdomadaire, i860, page 67. 
3 “ Hay-fever and Paroxysmal Sneezing,” 4th ed., London, 1887, p. 66. HA Y FEVER, OR VASO-MOTOR RHINITIS. 
223 
Or, again, in certain cases I have combined the three drugs in the 
same prescription in the above proportions. 
As noted above, most writers tell us to commence the adminis- 
tration of constitutional remedies three or four weeks before the 
hay-fever season. This is not the time, as a rule, when the patient 
comes under observation; in fact, I think in most instances they 
come during the attack, or just after it; and this it seems to me is 
by far the better time to commence treatment, for, as already in- 
timated, I regard local measures of treatment as of more impor- 
tance than constitutional. I think, therefore, the time to administer 
internal remedies for the correction of the general habit, is at the 
same time in which our local treatment is instituted. The general 
neurosis which requires correction exists during the whole year, and 
certainly if the case is one of autumnal fever, the winter or early 
spring months are quite as favorable to commence treatment as 
midsummer. If one were to choose the season, however, for treat- 
ing these patients, I think perhaps the preference might be given 
to the early summer months, when the warm dry atmospheric con- 
ditions are least unfavorable to catarrhal disease involving the upper 
air-passages. As regards the other drugs of the long list above 
enumerated, I have but limited experience, and little faith in their 
value. 
There are certain general hygienic measures, which are of 
undoubted importance, such as the regulation of the clothing, 
and the habits of life. These have already been sufficiently elab- 
orated in previous chapters. There is, however, one measure 
which I regard as of the greatest importance. This consists in 
the use of the cold douche on the spine. A sponge bath is not 
sufficient. The end to be accomplished is the general tonic 
effect on the central nervous system, which is produced by the 
sudden and decided shock of cold water down the spine. The cold 
shower bath accomplishes the purpose in an admirable manner, 
and yet this is not always tolerated by the patient. I have rarely, 
however, seen a patient who could not endure easily the cold douche 
confined to the spine alone. This plan of treatment is by no means 
new, for we find Gordon1 as early as 1829 laying special emphasis 
on the value of cold baths in these cases. I believe, howTever, that 
the spinal douche is of the greater value. The principle on which 
this acts has been recognized and rather ingeniously explained by 
Kinnear,2 who reports six cases of hay fever, in which flattering 
results were obtained, by the daily application to the spine of 
Chapman’s ice-bags, the ice being kept in position from an hour to 
1 London Med. Gaz., 1829, vol. iv., p. 266. 
2 New York Med. Record, July 14th, 1888, p. 32. 224 
DISEASES OF THE NASAL PASSAGES. 
an hour and a half. Kinnear’s method secures a longer continued 
action of the cold, but I am disposed to think equally good results 
can be obtained by the simple procedure of sitting in a bath-tub, 
and pressing a sponge full of cold water over the back. Further- 
more, I take it, a greater shock is secured by an interrupted appli- 
cation, rather than by a continuous contact. 
In this connection there might be noted a rather curious and 
perhaps somewhat homoeopathic experiment of Blackley,1 who seems 
to have allowed no possible feature of the disease to escape his ex- 
perimental investigations. With the view of determining whether 
invulnerability might not be secured by inoculation, Blackley 
rubbed some pollen into an abraded surface on the arm. It is 
needless to state that the" results were negative. The above mea- 
sures of treatment may of course be continued during the exacerba- 
ation, with promise of either modifying or controlling the symp- 
toms. Such other treatment as may be required during an attack, 
is simply that which would be suggested by the general laws which 
govern the administration of drugs for the control of such symp- 
toms as may be presented. Of these opium is undoubtedly the 
most valuable, both to allay the nervous irritability, and for pro- 
curing sleep. Mackenzie2 gives preference to the tincture over any 
other preparation, giving small doses, of from five to seven drops 
twice daily. This, however, as a rule, should be governed by the 
tolerance and preference of the patient. In many cases, the best 
action of the drug would be secured by the hypodermatic adminis- 
tration of morphine, as recommended by Moorhead,3 who first used 
in this manner, of a grain of morphine, with of a grain of 
atropia twice daily, but subsequently found his best results from 
the administration of of a grain of the tartrate of morphia twice 
daily, increasing the dose, as the attack developed, to T1y of a grain 
three times daily. 
Opium undoubtedly does more than control the general condi- 
tion, in that it goes far to modify the severity of the local symp- 
toms. No physician, however, should take the responsibility of 
administering to a patient of a grain of morphia three times 
daily, through the three months of a hay-fever exacerbation, with- 
out recognizing the exceeding great danger the patient incurs of 
contracting the opium habit. While, therefore, opium is undoubt- 
edly among the most efficacious of our constitutional remedies 
during an exacerbation, I think it well to depend mainly on less 
dangerous anodynes, such as hyoscyamus, or the bromides alone or 
in combination with chloral. 
1 Op. cit., p. 254. ' 2 Op. cit., p. 66. 
3 Brit. Med. Journ., 1886, vol. 2, p. 18. HAY FEVER, OR VASO-MOTOR RHINITIS. 
225 
Second.— Treatment of the Diseased Condition of the Upper Air 
Passages.— If the view maintained in discussing the causation of 
hay fever be correct, that in all cases a powerful predisposing cause 
lies in a diseased condition of the upper air passages, it necessarily 
follows that by far the most important feature of treatment consists 
in the removal of the morbid local lesion. Local treatment of the 
nose and upper air passages is recommended by most writers on 
the subject, and yet I think a glance over the literature of the sub- 
ject impresses one with the idea, that in a large majority of in- 
stances the rules laid down for this are exceedingly vague and in- 
definite. As early as 1837 we find Cazenave 1 recommending in a 
general way that the nasal mucous membrane be cauterized with 
nitrate of silver, a plan of treatment which found many advocates 
up to the time that the use of the galvano-cautery was introduced 
by Middledorpf,2 which soon became the favorite method of cau- 
terization, and we commenced to hear much of the treatment of 
hay fever by the electro-cautery. Now, we certainly do not treat 
hay fever by this method, but we treat simply the local morbid 
lesion which predisposes to it. 
The special affections which act as predisposing causes of hay 
fever are hypertrophic rhinitis, naso-pharyngeal catarrh, deflections 
of the septum, nasal polypi, and indeed any obstructive lesion in 
the nose which tends to produce a chronic turgescence of the 
blood-vessels. When we include naso-pharyngeal catarrh among 
the local exciting causes of the disease, and as one constituting an 
obstructive lesion, it is to be understood that we refer to the very 
intimate and close sympathy which we find existing between the 
nose and the naso-pharynx, under the action of which, a morbid 
process in the latter region seems to act as the immediately exciting 
cause of an hyperaemic condition of the turbinated tissues, this 
latter being the directly predisposing cause of the hay-fever ex- 
acerbation. The special indications for treatment are to be sought 
by careful investigation and diagnosis of each individual case, and 
such lesion as may be found is to be treated .according to the rules 
laid down in a previous chapter. If nasal polypi or other tumors 
are discovered, they should be extirpated: if a deflection of the 
septum exists, the obstructing portion should be removed. If hy- 
pertrophy or chronic hyperaemia are discovered, these conditions 
should be reduced in the manner already described. In brief, the 
essential requirements of treatment demand that the whole of the 
upper air-tract be restored to a condition of normal patency. 
Sajous,3 in his interesting monograph, takes the ground that the 
1 Gaz. Medicale, 1837, p. 631. 2 “ Die Galvanokaustic,” Breslau, 1854. 
3 Med. and Surg. Reporter, Dec. 22d, 1883. 226 
B/SEASES OF THE NASAL PASSAGES. 
cauterization of the nasal mucous membrane results in an alteration 
of superficial nutrition, which renders the membrane invulnerable 
to the action of pollen. This theory is an ingenious one, but I fail 
to understand what is meant by an alteration of nutrition. Nutri- 
tion is a definite process, and any alteration of it results in a mor- 
bid condition. I am disposed to think that the excellent results 
which Sajous obtained from treatment, were really in subduing tur- 
gescence and reducing the hypertrophied membrane. Sajous,1 
writing at a later date, lays special emphasis on the necessity of 
confining his caustic applications to the sensitive areas, having pre- 
viously determined these by means of the cold probe, following the 
method previously described by John Mackenzie.2 The sensitive 
areas in the nose described by John Mackenzie,3 I have never been 
able to definitely locate as such, and still adhere to the belief that 
the indications for treatment are the reduction of inflammation and 
the removal of obstructive lesions, and not the control of a hyper- 
aesthetic condition in the nose. I think it is a more rational view 
that the success in treatment undoubtedly obtained by the advocates 
of the sensitive area theory by means of cauterization, is directly due 
to a reduction of inflammation and diminution of blood-supply. Cer- 
tainly the use of the galvano-cautery would scarcely commend itself 
to us as a proper application for the overcoming of a purely hyper- 
aesthetic condition of the tissues. Stoker4 reports a rather unique 
method of treatment, successful in two cases, in which the caustic 
was applied “ at the junction of the nasal bone with the cartilage 
of the nose, where the external branch of the nasal nerve passes be- 
tween these structures to become superficial.” I have had no expe- 
rience with this method, but am disposed to think that the morbid 
lesion to be controlled is beyond the domain of the nasal nerve. 
Third.— Treatment of the Exacerbation.—It is a somewhat curi- 
ous commentary on the correctness of our clinical observations, 
that although many writers fail to find any benefit whatever from 
local applications during the attack of hay fever, others advocate, 
even with a certain degree of warmth, the efficacy of local medica- 
tion. Thus, Elliottson 5 finds a special efficacy in the local applica- 
tion of the chlorides in solution, directly to the membrane, and also 
by vaporous inhalations, while Cazenave6 recommended the irriga- 
tion of the parts with weak solutions of corrosive sublimate, as pre- 
viously suggested by Trousseau. The weight of Helmholtz’s6 great 
1 “ Diseases of the Nose and Throat,” Phila., 1887. 
2 N. Y. Med. Record, July 19th, 1884. 
3 Amer. Jour, of Med. Sciences, July, 1883. 
4 Annual of the Universal Medical Sciences, vol. iii., p. 269. 
5 London Medical Gaz., 1831, vol. 8, p. 411. 6 Loc, cit. HAY FEVER, OR VASO-MOTOR RHINITIS. 
227 
name gave considerable popularity to the quinine solutions which 
he recommended, until De Budberg1 demonstrated the fact that a 
solution of chlorate of potassium was equally efficacious. And yet 
at a quite recent date we find Sir Andrew Clarke 2 claiming most 
flattering results from the local application of solutions of quinine, 
carbolic acid, and perchloride of mercury. It is a striking feature 
of these cases, that the curious psychical condition of mental an- 
ticipation is such, that every new remedy is attended at first with 
a certain amount of relief, which in most instances, however, is but 
temporary. At one time the use of salicylic acid, as recommended 
by Binz,3 obtained a certain amount of popularity, and still later 
that of boracic acid. None of these remedies probably exercise 
any special controlling influence on the paroxysm. 
The early recognition of the fact that floating pollen in the at- 
mosphere was the exciting cause of the attack, led to attempts to 
protect the mucous membranes from its impact. Thus we find 
Blackley4 testifying to the very great relief afforded by the wear- 
ing of a wire gauze respirator, the efficacy of which was increased 
by moistening the gauze with a weak solution of carbolic acid. As 
accomplishing the same purpose Mackenzie5 advises that the nos- 
trils be plugged with cotton wool, although at a later writing6 he 
simply suggests that much relief may be afforded, and in certain 
cases the attack even warded off, by wearing a thick veil over the 
face. I have never had much faith in the efficacy of these measures, 
and furthermore the discomfort of wearing a respirator or a thick 
veil during the whole of the hay-fever season would be so great, 
that many patients would prefer to risk the exposure to the pollen. 
No local remedy that has ever been used for the relief of an ex- 
acerbation of hay fever is comparable to cocaine, both as regards 
the certainty and promptness of its action, and the completeness of 
the relief afforded. The properties of this drug as an anaesthetic 
were first published in America by Dr. H. D. Noyes, in a letter to 
the Medical Record7 in which he gave a detailed account of 
Roller's great discovery. A few days later, while making use of 
this agent as an anaesthetic in the nose, I first observed its peculiar 
action in producing contraction of the blood-vessels. As oppor- 
tunity afforded, I made use of it in cases of hay fever as well as 
other nasal disorders characterized by vascular turgescence, and 
1 British Med. Journal, 1881, vol. ii., p. 18. 
2 British Med. Journal, June nth, 1887, p. 1,255. 
3 Deut. Med. Wochenschr., Sept. 22d, 1877. 
4 Op. cit., p. 260. 
5 “ Diseases of the Throat and Nose,” Amer. ed., Phila., 1884, p. 310. 
6 “ Hay-fever and Paroxysmal Sneezing,” London, 1887, p. 61. 
7 New York Med. Record, Oct. nth, 1884. 228 
DISEASES OF THE NASAL PASSAGES. 
found it to give complete relief from all the symptoms for the 
time, publishing soon after the. results of my experience.1 This 
action of cocaine in hay fever I attributed purely to its property of 
contracting the blood-vessels. In subsequent contributions on this 
subject the view was advocated, notably by Bartholow and Da 
Costa, that the anaesthetic properties of the drug had much to do 
with the relief afforded. This view, I think, is hardly tenable, when 
we consider that a local application of a two-per-cent solution gives 
such complete relief in from two to four minutes. Now, as we 
know, anaesthesia only follows an application of a two-per-cent 
solution of cocaine in about fourteen minutes, whereas contraction 
of the blood-vessels ensues in from two to four minutes. In other 
words, the hay fever symptoms abate as soon as the vascular tur- 
gescence is allayed. It has been charged, notably by Beverley 
Robinson,2 that after the vascular distention has been subdued by 
cocaine, the relief is but temporary, and is followed by a reaction 
in which the distressing nasal stenosis is even greater than before. 
I have used the drug very extensively since its introduction, and 
recall but three instances in which any such reaction was observed. 
As before stated, the relief is prompt and efficient, although not 
permanent, lasting but from two to three hours, when relaxation of 
the blood-vessels occurs, demanding a second application. The 
formula which I usually give is as follows: 
R Cocain. hydrochlorat., . . . . . grs. xx. 
Sodii bicarb., 
Acidi borici, ..... aa grs. x. 
Aquae, % i. 
M. ft. sol. 
\ 
This is to be used by means of the small hand atomizer shown 
in Fig. 48 or any small cologne atomizer, such as is sold in the drug- 
stores. The patient is directed to apply this freely to the nasal 
cavities as often as may be necessary to control the symptoms. 
The above solution, as will be seen, is about a four-per-cent solu- 
tion. It is well to mention this to the patient, directing him to 
reduce the strength until he finds, what in his own experience, is 
the weakest solution which may be used and still give relief. In 
many instances I have found that even a one-half-per-cent solution 
was quite as efficacious as the preparation given above, and of 
course it is always desirable that the end should be accomplished 
with as weak a preparation as possible, as it is well known that the 
absorption of a drug through the nasal mucous membrane is proba- 
1 “A New Therapeutic Use of Cocaine,” N. Y. Med. Record, Nov. 15th, 1884. 
2 Med. Record, October 17th, 1885, p. 425. HAY FEVER, OR VASO-MOTOR RHINITIS. 
229 
bly more prompt than through that of the stomach, hence the con- 
stitutional effect of the agent is liable to be experienced; and while 
I regard cocaine as one of the most harmless of drugs as far as any 
danger of the cocaine habit is concerned, its excessive use is objec- 
tionable in the same manner as the excessive use of tea and coffee, 
which are apt to render one somewhat nervous perhaps and wake- 
ful. A very nice method of administering cocaine is as follows: 
Ijt Cocain. hydrochlor., ..... grs. x. 
Aquae, . . . . . . . . q. s. 
M. ft. sol. 
Adde 
Fluid cosmoline vel 
Ol. voschano (see page 115), . . . . § i. 
Shake well before using. 
This is to be used in the atomizer shown in Fig. 47. This is per- 
haps a less convenient form than the watery solution, but the cos- 
moline affords an exceedingly grateful and soothing application to 
the mucous membrane, while the cocaine exercises the same action 
as in the watery solution. Robinson,1 in reporting cases of hay 
fever in which cocaine failed to relieve, obtained success from pen- 
cilling the nasal mucous membrane with a preparation of one part 
of carbolic acid to three parts of glycerin, one case being com- 
pletely cured, while two were notably relieved. I should be dis- 
posed to attribute the results in these cases in part, perhaps, to the 
peculiar anaesthetic properties of the strong preparations of carbolic 
acid, but mainly to its caustic action. I am confident, however, 
that the cocaine promises relief in the larger proportion of cases. 
The main objection to the use of cocaine is not that its use is at- 
tended with any unpleasant results, but, it must be confessed, that 
in a certain proportion of cases it fails to give entire relief. This 
proportion is very small. In many cases, I think its failure must be 
attributed to inefficient methods of application, such as by droppers, 
bougies, etc. Certainly we have no means by which the whole 
membrane can be medicated with the thoroughness of the spray, 
and hence the atomizer should be preferred in all cases. Macken- 
zie2 recommends the use of gelatin bougies containing yV of a 
grain of cocaine combined with of a grain of atropine. These 
are to be inserted into the nasal passages by the patient, and al- 
lowed to remain there until they melt. This method of application 
is uncleanly, and furthermore is not thorough, as I think the ap- 
plication to the middle turbinated bodies is even more important 
than to the lower, and certainly patients suffering from hay fever 
1 Loc. cit. 
3 Op. cit., p. 62. 230 
DISEASES OF THE NASAL PASSAGES. 
would not tolerate the insertion of a bougie into the middle meatus. 
The same objection, I think, lies against all suppositories of cocaine, 
as well as the gelatin discs and other preparations of the sort. In- 
sufflations of powders are not open to this objection and are to be 
recommended as follows: 
hi Cocain. hydrochlorat., ..... gr£. x. 
Bismuthi subcarb., . . . . . 3 i. 
Magnesia carb. lev., . . . . . 3 ij. 
M. 
Or, 
IJ Hydrarg. chloridi mitis, ..... grs. v. . 
Cocain. hydrochlorat., ..... grs. x. 
Sacch. lac., ....... 3 iij. 
M. 
The addition of morphine to one of these powders is always grate- 
ful to the patient, but a combination of morphine with cocaine 
should always be used judiciously. Keeping this in view, the fol- 
lowing may be used. 
IJ Morphinae tartratis, . . . . . . gr. i. 
Cocain. hydrochlorat., grs. x. 
Sulphuri flor., . . . . . . . 3 ss. 
Sacch. lac., 3 iiss. 
The only objection to the use of a snuff is that we do not, as a rule, 
get the same thorough penetration of the nasal cavities, as by means 
of the atomizer. 
Hinkle1 claims excellent results from the local application of 
antipyrine alone and also in combination with cocaine. A careful 
reading of his cases, however, would suggest that his results may 
have been due to the local effect of the cocaine together with the 
constitutional effect of the antipyrine, for this drug has been shown 
by Cheatham2 as well as by Tyrrell Brooks3 to possess the prop- 
erty, when administered internally, of notably mitigating the sever- 
ity of the paroxysm in hay-fever. Jedkins4 reports a case of hay 
asthma relieved by the syrup of hydriodic acid administered in tea- 
spoonful doses until relieved. 
The ocular symptoms, being due quite as much to the direct 
impact of the pollen upon the cornea and conjunctiva, as to sym- 
pathetic action, are to be relieved by the same local applications 
1 N. Y. Med. Journal, October 20th, 1888, p. 429. 
2 Annual of Universal Med. Sciences vol. iii., 1888, p. 267. 
3 British Medical Journal, May 19th, -1888. 
4 N. Y. Med. Record, vol. xxvi., p. 260. HAY FEVER, OR VASO-MOTOR RHINITIS. 
231 
which are applied to the nasal cavity, although with this proviso, 
in applying cocaine to the eye, the solution should not be stronger 
than one per cent. If, however, the eye is well protected by col- 
ored glasses, as first suggested by Cazenave,1 in most instances the 
relief will be such as to render local applications unnecessary. 
Cheatham 2 makes the very excellent suggestion that eserine, in the 
strength of of a grain to the ounce, should be added to the co- 
caine solution in order to prevent the dilatation of the pupil. 
1 Loc. cit. 
2 Medical Record, Nov. 21st, 1885, p. 567. CHAPTER XV. 
ASTHMA, OR VASO-MOTOR BRONCHITIS. 
ASTHMA is a disease characterized by the diurnal and seasonal 
recurrence of attacks of dyspnoea, due to an obstruction occurring 
in the bronchial tubes, in such a manner as to interfere with both 
the entrance of air to the air-cells, and its exit therefrom, in other 
words, a dyspnoea both of an inspiratory and expiratory character. 
The diurnal character of the disease is shown by the recurrence of 
the attacks at certain times during each twenty-four hours, usually 
at night, and lasting for some hours, when relief occurs, which may 
be more or less complete, until the next daily attack comes on. 
The seasonal character of the attack manifests itself in the disposi- 
tion of the symptoms to undergo complete relief at certain periods 
of the year, usually the warm dry months of summer, and in a less 
degree, the dry, cold months of winter, during which the patient 
enjoys complete immunity from his diurnal attacks. 
ETIOLOGY.—In reviewing the literature of asthma, at the pres- 
ent day, when our knowledge of this disease has become systema- 
tized and definite, one is particularly struck with the exceedingly 
vague and indefinite views which have prevailed in regard to it, up 
to comparatively recent times, and particularly with the curious 
theories which have been advanced to account for the symptoms 
which characterize it; for, while ancient observers could not fail to 
have their attention prominently attracted to it, by the peculiar 
character of its manifestations, yet I find that it is rather as a 
symptom than as a disease, that most writers deal with it. Even 
as late as 1874, we find Bennett1 devoting only a few lines to its 
consideration as a symptom of emphysema and bronchitis, rather 
than as a distinct disease, while Watson, in his classical work on 
the “ Practice of Physic,’’ although devoting a chapter to the subject, 
makes the somewhat naive confession that he has never listened to 
a case by auscultation. As early, however, as 1852, we find careful 
observers searching for some rational explanation of the peculiar 
symptoms which characterize this curious affection. As far as we 
1 “ Principles and Practice of Medicine.” American edition, Philadelphia, 1874. ASTHMA, OR VASO-MOTOR BRONCHITIS. 
233 
know. Bergson 1 was the first to make it a distinct disease, although 
its individuality was denied by Rostan2 and by Beau.3 
The ancients believed the disease to be due to spasmodic con- 
traction of the bronchial tubes. This view was, however, contro- 
verted by Laennec, who cites, as an argument, those cases of asthma 
in which we have puerile breathing over the entire chest, thus show- 
ing that the capacity of the lungs may be increased during a par- 
oxysm rather than diminished. Copeland calls the same cases 
nervous asthma, while Walshe suggests the term haemic asthma. 
Dr. Bree takes a different view, believing the disease due to some 
specific irritant in the air tubes and that the asthmatic paroxysm is 
an effort to expel these so-called irritating humors. Beau,4 whose 
treatise has already been referred to, believes that all cases develop 
from a primary bronchitis. Todd5 regards the disease as humoral, 
■comparing it to gout or rheumatism, and believes that the materies 
morbi affects the respiratory centre; while Budd6 divides it into two 
forms; one depending upon cardiac disease, emphysema, etc., the 
second form due to a spasm of the respiratory muscles. The mere 
fact that an attack of asthma is always preceded by a feeling of a 
want of air and increased respiratory effort, is enough to controvert 
this view. That this view has been held, though, for some time, is 
shown by the fact that so recent an author as Wintrich7 advances 
essentially the same idea. 
The first to write a really exhaustive work on asthma was Henry 
Hyde Salter.8 His work has become a standard one, and his views 
have been adopted by most subsequent writers on general medi- 
cine. He makes the following propositions: 
First. Asthma is essentially, perhaps with the exception of a 
single class of cases, a nervous disease, the nerve centres being 
the seat of the essential pathological condition. Second. The phe- 
nomena of asthma, distressing sensation and demand for extraor- 
dinary respiratory efforts, immediately depend upon spasmodic 
contraction of the cells of unstriped muscular fibre in the bronchial 
tubes. Third. The phenomena are excito-motor or reflex actions. 
Fourth. The extent to which the nervous system is involved differs 
much in different cases, being, in some, restricted to the nervous 
apparatus of the air-passages themselves. Fifth. In a large num- 
1 “ Recherches sur l’asthme,” 1852. 
2 “De 1’asthme Gaz. des hopitaux, No. 31, 1856 
3 “ Traite clinique et pratique de l’auscultation,” Paris, 1856. 
4 Arch. Generale, vol. 78, p. 155. 
5 Medical Gazette, 1850. 
6 Med. Chir. Transactions, vol. xxiii., London, 1840. 
7 Virchow’s “ Handbuch der Path, und Ther.,” Bd. v., Ab. 1. 
8 “ On Asthma ; Its Pathology and Treatment,” London, i860. 234 
DISEASES OF THE NASAL PASSAGES. 
ber of cases, the pneumogastric, both gastric and pulmonary por- 
tions, is the seat of the disease. Sixth. In a large class of cases 
the nervous circuit involves other nerves beside the pneumogastric, 
Seventh. There is still another class of cases in which the irritation 
is central. Eighth. In a certain proportion of cases the irritation 
is humoral. 
We find here that the bronchial spasm theory of the ancients 
was fully adopted, as the result of large clinical observation and 
study, and maintained by Salter in the several editions of his popu- 
lar work. This theory is the one adopted by Biermer1 also. 
We see, then, that, according to Salter, asthma is essentially a 
neurotic disease, and this theory, with some modifications, is the 
one adopted at the present day. Dr. Burney Yeo2 attempts to 
draw an analogy between the extreme distention of the lungs in 
asthma and abdominal distention in hysteria. This observation is 
curious perhaps, but scarcely harmonizes with clinical observation. 
Morton3 draws a similar analogy between asthma and spasmodic 
croup. The sudden nightly attacks, with daily remissions; a cer- 
tain periodicity observed in the attacks of both diseases; a dry first 
stage and moist second stage; all seem to him to point to a certain 
similarity between the two diseases. Another curious observation 
which he makes, is that the tendency to asthma begins at about 
the time when the tendency to spasmodic croup ceases. He be- 
lieves that both croup and asthma are due to disorders of innerva- 
tion of the larynx, on the one hand, and of the bronchial tubes, on 
the other; the immediate cause of the paroxysm being excess of 
venous blood in the medulla. This observation is also incorrect, 
by the decided error in both premises. 
In the diligent research after the hidden causes of disease, so 
characteristic of the present day, Leyden 4 claims to have discovered 
certain elements in the sputa of asthmatics, known as “ Leyden’s 
crystals,” and misnamed, for some reason, Charcot’s crystals. 
Ungar, of Bonn, in an investigation of thirty-nine cases of spas- 
modic asthma, as recently as 1882, found these crystals in the 
sputa, but also found that they increased in number the longer the 
sputa stood, thus, to a certain extent, vitiating Leyden’s theory. 
Quite recently, Dr. Pfuhl5 relates the case of a soldier whose sputa 
contained large numbers of the crystals of Leyden, without any 
evidence of asthma. Furthermore, he has examined the sputa in 
eight hundred and fifty-five cases of pulmonary disease, and has 
only found the crystals in the one case mentioned above. An 
1 “ Ueber bronchial Asthma,” Sammlung klinischer Vortrage, 1875. 
2 London Practitioner, 1881. 3 British Medical Journal, January 22d, 1877. 
4 Virchow’s Arch., Bd. 54, 1871. 5 Deutsche med. Zeitung, 1887, No. 76. ASTHMA, OR VASO-MOTOR BRONCHITIS. 
235 
attack of asthma, as we know, consists in the occurrence of more 
or less well-marked symptoms of oppression of breathing, with a 
certain amount of periodicity, coming on suddenly, generally at 
night, and lasting for several hours, the dyspnoea obtaining both 
during inspiration and expiration, while the cessation of the attack 
is accompanied by a more or less profuse serous and sero-mucous 
expectoration. This series of phenomena has been explained by 
the writers quoted above, on the theory that this dyspnoea is due 
to the contraction of certain muscular fibres, which anatomists 
have demonstrated as existing in the bronchial tubes, down to their 
smallest ramifications. It seems rather curious that this theory 
should not long ago have been questioned. All observers very 
properly recognize asthma as a neurotic disease, and muscular 
spasm is undoubtedly a manifestation of the neurotic temperament, 
and apparently on this trivial ground, the theory has been accepted. 
If the paroxysm is due to muscular spasm, why should the attack 
occur, in most instances, only at night ? Why should it be affected 
by changes in temperature ? Why should relief be obtained by 
high altitudes ? Why should an attack be aggravated by a damp 
atmosphere ? There is everything in the repose of a quiet sleep, 
which should protect one from an attack of asthma, and yet a par- 
oxysm almost invariably comes on during the night. Changes in 
temperature are not usually recognized as having any marked 
effect on the nervous system, and yet a change in climate not in- 
frequently precipitates a seizure of asthma. The sea-shore, rather 
than mountainous districts, is favorable to the toning up, as it is 
called, of the nervous system, and therefore asthmatics should suffer 
least at the sea-shore on this theory; yet'the converse is true. 
Again, a paroxysm of asthma is ushered in suddenly, and during 
its persistence is characterized, it is true, by symptoms which are 
easily explained upon the theory of spasmodic muscular contraction 
of the circular fibres of the bronchial tubes, but the culmination of 
the attack is invariably marked by a more or less profuse sero- 
mucous exudation, with cough and expectoration. This in no 
way can be harmonized with the spasmodic theory. I think, then, 
this view must be abandoned, as failing to explain the clinical his- 
tory of asthma, or the clinical history of a paroxysm. 
In 1872, however, we find the spasm-theory called in question, 
and what, to my mind, is a far more plausible one advanced by 
Weber,1 who was the first to teach us that the cause of the parox- 
ysm lay in a paresis of the vaso-motor nerves, presiding over the 
vessels of the bronchial mucous membrane. Under the influence 
of this vaso-motor paralysis, there occurs, from some cause, a sud- 
1 Tageblatt der 45ten Naturforscherversammlung zu Leipzig, page 159, 1872. 236 
DISEASES OF THE NASAL PASSAGES. 
den letting up of the control which is exercised over the calibre of 
the blood-vessels, whereupon they become distended to such an 
extent as markedly to interfere with the passage of air through the 
bronchial tubes. This paralytic condition having lasted several 
hours, the membrane maintaining a dry condition, as is always the 
case in the first stage of the inflammatory processes, there follows 
an escape of serum and sero-mucus, thus relieving the engorged 
blood-vessels, which soon regain their normal calibre, coincident 
with the cessation of the paroxysm. We thus have a thoroughly 
rational and plausible theory, in explanation of the symptoms of 
spasmodic asthma. As to the causes, however, of the disease, little 
has been said, further than the causes already stated, as laid down 
by Salter. Weber’s paper, however, was followed by a series of 
clinical observations, which largely lent weight to his theory, and 
also threw much light on the causes of the disease. The first ob- 
servation of note in this connection was that of Voltolini,1 who re- 
ported a case of asthma due to the existence of nasal polypi, as 
shown by the fact that the asthma promptly disappeared on the re- 
moval of the nasal growths. This observation was followed by a 
large number of similar reports by Hanisch, Porter, Daly, Toda, 
Spencer and others, as noted by Mackenzie,2 and gave rise to 
voluminous discussions by Schaffer, Frankel, Bresgen, Hack and 
others, not only on asthma as a reflex disease due to nasal polypi, 
but also as due to other nasal disorders. 
As before stated, the literature of this subject has assumed large 
and voluminous proportions, but it still inclines itself to the sub- 
ject of asthma as a reflex disease. Now, I do not propose to enter 
into this subject of reflexes, which has always seemed to me as a 
term oftentimes used as a cloak to conceal our ignorance of the 
direct relation between cause and effect, but I am convinced that, 
in very many instances of morbid symptoms occurring as a result 
of reflex disturbance, we can offer a more rational explanation than 
“ reflex,” in the sense in which the term reflex is so often used at 
the present day. Following Voltolini’s observations, that nasal 
polypus was the cause of asthma, and intimately connected with 
the same line of investigation, came the study of hay fever. The 
first impetus, as I think, to this line of investigation, was a paper 
by Daly.3 Up to this date, hay fever had been regarded as simply a 
periodical coryza or influenza, in which the paroxysms were charac- 
terized by the same symptoms as are met with in an ordinary cold 
1 “ Die Anwendung d. Galvanokaustik, ” Wien, 1872, p. 246, 4th ed. 
2 “ Diseases of the Throat and Nose.” American edition, vol. ii., Philadelphia, 1884, 
P- 357- 
3 Archives of Laryngology, vol. iii., p. 157. ASTHMA, OR VASO-MOTOR BRONCHITIS. 
237 
in the head. As a matter of fact, however, acute rhinitis, and an 
attack of hay fever, differ in a marked way in many respects. This 
fact was soon recognized, and a new name was given to hay fever, 
vaso-motor rhinitis. We have, thus, suggested a connection between 
the two diseases, and as a clinical fact, the two diseases are inti- 
mately connected; for, as we know, a large number of hay-fever 
patients suffer from asthma, following soon after the onset of their 
nasal symptoms. A natural division of cases of asthma into hay 
asthma and perennial asthma is thus made, the one term being ap- 
plied to those cases that are attended with hay fever, the other to 
those cases in which asthma occurs without reference to seasons, 
and without the preceding influenza. The question now arises, 
What, if any, connection exists between the two, or how far are 
these two diseases one and the same; and, again, what is the con- 
nection between hay fever and asthma, and are they not, in many 
respects, the same disease ? In a paper read before the American 
Climatological Association, May 28th,1 1885, I first advanced the 
view that hay fever and perennial asthma were virtually one and the 
same disease, the one being a vaso-motor rhinitis, the other being a 
vaso-motor bronchitis, the paroxysms being excited, in each case, 
by some peculiar atmospheric condition. The atmospheric condi- 
tion, as we know, in hay fever is the presence of the pollen of flow- 
ering plants, or some other vegetable emanation; whereas the at- 
mospheric condition in perennial asthma, as we may designate those 
cases of asthma which occur during the whole year, and do not 
depend upon hay fever, is dependent upon some obscure element 
which we are, as yet, unable to trace with the same degree of defi- 
niteness as we are enabled to trace it in hay fever. Hay fever is 
dependent upon three conditions: 
First. A neurotic habit, as was conclusively shown by Beard.2 
Second. The presence of pollen in the atmosphere, as shown by 
the unrivalled experiments of Blackley.3 
Third. A disordered condition of the nasal passages, as shown 
by Daly.4 
Now, the view that I advocate is that asthma also is dependent 
on three conditions: 
First. A general neurotic condition, as demonstrated by Salter.5 
Second. A diseased condition of the nasal mucous membrane 
(not the bronchial). 
Third. Some obscure condition of the atmosphere exciting the 
paroxysms. 
1 New York Medical Journal, April 24th, May 1st, 1886. 
2 “ Ilay-fever or Summer-catarrh,” New York, 1876. 
3 “ Hay-fever,” London, 1873. 4 Loc. cit. 5 Op. cit. 238 
DISEASES OF THE NASAL TASS AGES. 
The view as regards the neurotic condition is generally ac- 
cepted; that as regards the atmospheric condition, I think, is one 
which must be generally accepted by all observers, when we con- 
sider the diurnal and seasonal periodicity of the paroxysms. As 
regards the nasal condition, as a predisposing cause of the attacks, 
the view is a novel one, and, naturally, would be looked upon as 
the hobby of a specialist. In my original paper, I made this as- 
sertion, that “a large majority, if not all, cases of asthma were de- 
pendent upon some obstructive lesion in the nasal cavity. This is 
evidenced by the immediate relief from the exacerbation, by the 
use of cocaine in the nose, in every case in which I have tried it, 
and, futhermore, by the cure of so many cases by the removal of 
the obstructive lesion in the upper air-passages.” 
This paper was read two years ago. The views there stated I 
would repeat with even more emphasis, for subsequent clinical ob- 
servation has only served to confirm me in my belief of their cor- 
rectness. That the lesion in a paroxysm of asthma is a vaso-motor 
paresis of the blood-vessels supplying the bronchial mucous mem- 
brane, and not a bronchial spasm, I do not discuss, but accepting 
this theory as the only one which can explain the symptoms, the 
question arises, What is the connection between the nasal mucous 
membrane and that of the bronchial tubes ? The subject of the 
great respiratory functions of the nasal mucous membrane has 
already been fully treated of in a former chapter, and need not be 
repeated here. In brief, the most intricate, the most delicate, and 
most important part of the whole respiratory tract lies in the nose, 
in that mass of blood-vessels which we call the turbinated tissues, 
and which serve to supply the inspired air with moisture, by pour- 
ing out upon the surface of the mucous membrane a large amount 
of water—sixteen ounces in the course of the day—by which the 
inspired air becomes saturated with moisture, this function being 
necessarily regulated with an extreme degree of nicety of adjust- 
ment. This establishes, in what way or through what nerves or 
ganglia I do not discuss, but to my mind does unquestionably 
establish, a most intimate connection between the two portions of 
the respiratory tract. The blood supply in the nose being reg- 
ulated by the same vaso-motor tract as that which regulates the 
blood supply of the bronchial tubes, a disturbance in one region is 
liable to be followed by a disturbance of the other; a morbid con- 
dition in one region renders the other especially susceptible to 
diseased processes. This, briefly, is the history of the connection 
between the two parts. Hence, we see, therefore, how a diseased 
condition in the nasal cavity may predispose a neurotic patient, 
under favorable atmospheric conditions, to an attack of asthma; ASTHMA, OR VASO-MOTOR BRONCHITIS. 
239 
the same line of reasoning, as will be noted, being followed here as 
in the case of hay fever. This connection between the two regions 
I have not found alluded to by any writers, and yet I cannot but 
think that Hyde Salter 1 must have entertained a somewhat similar 
idea, when he says, in speaking of the causation of asthma, that we 
may divide the cases into two classes: First, cases in which the 
essential cause of disease, “ that which constitutes the individual an 
asthmatic,” is some organic lesion, possibly not appreciable, either 
in the bronchial tubes or some part physiologically connected with 
the bronchial tubes. Second, cases in which the organic lesion 
does not exist, in which the tendency to asthma is due to some- 
thing from within, not from without, in which the cause of disease 
is a congenital and possibly inherited idiosyncrasy. The large 
clinical observation and study which were the basis of Salter’s 
classical work, could not fail to have impressed upon him, that a 
diseased condition of the upper air-passages was prominently active 
among the predisposing causes of asthma. It would seem a rather 
broad statement to make, that all cases of asthma find their predis- 
posing cause in intra-nasal disease, and yet I am very confident that 
it is very largely, if not entirely, true. Certainly, in my own ob- 
servation, I have seen no case in which this could not be stated. 
The question suggested by Mackenzie2 here arises, What consti- 
tutes a typically healthy nose ? Mackenzie seems to think that 
there is a very large difference in individuals, even in health, and 
rather suggests that a typically healthy nasal cavity is difficult to 
find. On the contrary, I think that every nasal cavity, which 
shows a departure from the normal type, should be regarded as in 
a diseased condition. The true test, however, in these cases is this: 
if we find diseased conditions, the removal of which cures an asthma, 
my proposition, in that individual case, is certainly established. I 
make the general statement, that all cases of asthma have intra- 
nasal disease, without giving definite proportions. This may seem 
rather broad, when we find eminent physicians of the present day, 
such as Fothergill, Flint, Loomis and others, adhering to the old 
theory of bronchial spasm, and not mentioning pathological condi- 
tions in the nasal chamber as a possible cause of the disease. That 
my view is by no means entertained by laryngologists, is shown by 
the fact that Bocker3 makes the statement that asthma is seldom 
associated with polypi, and seldom cured by their removal, and 
that hay asthma is caused by direct irritation of the bronchi, and, 
further, that, normally, asthma cannot be produced in the nose. 
1 Op. cit., page 81. 
2 “ Hay-Fever,” London, 1885, p. 25. 
3 Deutsche medicinische Wochenschrift, 1886, Nos. 26 and 27. 240 
DISEASES OF THE NASAL PASSAGES. 
This first assertion of Bocker seems to me to be a very grave 
reflection on his skill as an operator. In the Union for Internal 
Medicine, May and July, 1886, Lublinski, Heyman, Bocker and 
Krause assert that, in many cases, asthma is independent of a path- 
ological condition of the nasal passages. Schech,1 however, states 
that, in sixty-four per cent of cases of asthma, he found intra-nasal 
disease, and further adds that there must be associated with it 
excessive nervous irritability—in other words, the neurotic habit. 
In looking over my notes, I find I have recorded histories of 
eighty cases of asthmatics treated during the last five years. Not 
satisfied with the study of these records, and in order to make my 
investigation as thorough as possible, and, at the same time, bring 
the reports up to date, I mailed to each one of these patients, some 
of whom I had not seen for a considerable time, a printed circular, 
in which I propounded a series of questions. These questions I 
will not recapitulate, as they are suggested by the headings in the 
following analysis of my tables. The last question was, “ Please 
state candidly and without favor, what benefit, if any, you have 
received from the treatment, and to what you attribute your im- 
provement or cure.” The following analysis sets forth the result: 
Total number of cases of asthma, 80 
Males, 47 
Females, ........ 33 
Hay asthma, 34 
Males .26 
Females, . 8 
Perennial asthma, . 46 
Males, 21 
Females, 25 
Perennial Asthma—Family History. 
Clear in, 9 
Neurotic, 3 
Bronchitis and asthma 2 
Asthma, ........... 4 
Asthma and hay fever, ........ 4 
Bronchitis 2 
Asthma, bronchitis and neurosis, 1 
Phthisis 1 
Hay fever 1 
Asthma and neurosis, I 
Unknown, . . .18 
Total, ........ 46 
1 Munchener medicinische Wochenschrift, 1887, Nos. 40 and 41. ASTHMA, OR VASO-MOTOR BRONCHITIS. 
241 
Hay Asthma—Family History. 
Asthma in, 14 
Clear in 5 
Phthisis and neurosis, 1 
Neurotic, 2 
Hay fever, ........... 2 
Asthma and neurosis, ........ 2 
“ “ hay fever, ........ 2 
“ “ neurosis and hay fever 1 
Neurosis and hay fever, * 1 
Unknown, ........... 4 
Total, 34 
The prominent feature shown here is the large preponderance of 
cases which show a decided neurotic family history; twenty-five of 
the thirty cases of hay asthma being of inherited neurotic habit, 
where the history is known, while in the perennial form sixteen of 
the twenty-eight cases, in which the history is ascertained, show 
the neurotic tendency. 
Age of First Attack. 
Perennial Asthma. 
Hay Asthma. 
ist ten years of life, ..... 
5 
5 
2d “ 
9 
7 
3d “ “ 
12 
11 
4th “ “ “ 
6 
6 
5* “ “ 
5 
4 
Over fifty years of age, .... 
8 
1 
From birth, ...... 
. 1 
Total, ... 
. 46 
34 
Average age of first attack, 
Oldest case, 72 years ; youngest, congenital. 
. 29 years. 
24 years. 
We notice that the tables show that the largest number of cases 
of asthma, in both forms, develop during the third decade of life, 
while no period is notably exempt. This differs from Salter, who 
states that most cases develop during the first decade. 
Climatic Influence on Hay Asthma. 
Greatest relief at high altitude, 11 
“ “ “ low “ i 
“ “ “ sea “ 6 
“ “ in New York City, 3 
Suffer equally everywhere, 3 
Unknown. . . .10 
Total, 34 242 
DISEASES OF THE NASAL TASS AGES. 
Climatic Influence on Perennial Asthma. 
Greatest relief at high altitude 11 
Suffering more “ “ i 
Greatest relief at sea 2 
Suffering more “ 7 
“ equally everywhere, 12 
Greatest relief at low altitude, 1 
“ “ in New York City 1 
Unknown, . 11 
Total 46 
Combining these two tables in one we find as follows: 
Climatic Influences on the Two Forms of Asthma. 
Better at high altitudes, ........ 22 
“ at sea shore, 8 
“ in city, . 9 
Unaffected by locality, 13 
Irregular, ........... 9 
Effect of locality unknown, 19 
Total, 80 
We notice here, that whereas, in hay fever, the seashore affords 
the greatest relief, after asthmatic symptoms set in, the same rule 
applies to both forms, and that high altitudes are most beneficial; 
and yet, I think, no rule can be formulated for the cases as a class. 
They are essentially fickle, and each one must be advised from per- 
sonal and individual considerations. 
Hay Asthma. 
Nasal symptoms immediately preceding attack, such as sneezing 
with watery discharge from the nose 29 
No symptoms preceding attack 5 
Total, 34 
Perennial Asthma. 
Nasal symptoms preceding attack, 33 
No nasal symptoms preceding attack, 12 
Cutaneous eruption preceding attack, 1 
Total, 46 
This showing, it seems to me, is of the greatest importance, as 
sustaining the original assertion made in the early portion of the 
chapter. 
It should be mentioned that many patients entirely ignore the ASTHMA, OR VASO-MOTOR BRONCHITIS. 
243 
nasal symptoms, in the larger discomfort arising from the dyspnoeic 
attack, and only recall them, when their attention is turned in that 
direction. We see, then, that, of the eighty cases, the asthmatic 
attack set in with sneezing, etc., in sixty-two. 
The one case in which a cutaneous eruption occurred is interest- 
ing only with reference to the neurotic explosion. 
Hay Asthma. 
History of previous catarrhal trouble, 23 
No history of previous catarrhal trouble, 11 
Total 34 
History of previous catarrhal trouble, 31 
No history of previous catarrhal trouble 15 
Total, 46 
Perennial Asthma. 
We see here that, of the eighty cases, fifty-four give a history of 
previous catarrhal trouble. Yet the testimony of patients in this 
matter is not to be relied upon, as many patients have undoubtedly 
notable impairment of the nasal respiratory function, without being 
conscious of suffering from what they call catarrh. Moreover, in a 
large proportion of nasal disorders, the symptoms are referred, by 
the individual, to the throat, while “ catarrh ” is popularly referred 
to the nose. 
Hypertrophic rhinitis, 9 
“ “ and deflected septum, . . . .12 
Polypi and deflected septum, ....... 5 
Polypi, 4 
Deflected septum, 3 
Elongated uvula, 1 
Total, 34 
Intra-nasal Condition—Perennial Asthma. 
Hypertrophic rhinitis, 13 
Nasal polypi, 11 
Hypertrophic rhinitis and deflected septum, . . . .11 
Polypi and deflected septum 6 
Deflected septum, 3 
Adenoid and hypertrophic rhinitis 2 
Total, . 46 
I have never known a case of hay fever or asthma to occur in 
other than an obstructive lesion of the nose or upper air-passages, 
Intra-nasal Condition—Hay Asthma. 244 
DISEASES OF THE NASAL TASS AGES. 
as will be seen by this table; this was the case in every one of the 
eighty cases, including the elongated uvula, which became a source 
of respiratory obstruction. 
Treatment—Hay Asthma. 
Hypertrophic rhinitis, treatment by caustics : 
Cured, 7; improved, 6; unimproved, 1. 
Deflected septum, operated on by author’s nasal saw: 
Cured, 8 ; improved, 6. 
Nasal polypi treated by snare, without caustics : 
Cured, 2; improved, 1. 
Treatment by snare and septal saw in cases of polypi and deflected septum: 
Cured, 1 ; improved, 1. 
Cases treated by uvulotomy : 
Cured, 1. 
Treatment—Perennial Asthma. 
Hypertrophic rhinitis, treated by caustics : 
Cured, 8 ; improved, 5. 
Polypi treated by snare, without caustics: 
Cured, 15 ; improved, 3. 
Deflection of septum operated on by author’s nasal saw: 
Cured, 3; improved, 4; unimproved, 1. 
Adenoid growths removed by snare: 
Cured, 2. 
The treatment, as will be seen, has been such as our English 
friends regard as harsh, and in many cases unwarranted. I think 
it but justice to say that, in some cases, patients have been unwill- 
ing to continue on account of this, and yet, with the use of local 
anaesthesia, these operations are not painful; it is the nervous strain, 
on this class of patients, which has taxed them most severely. 
That the surgical treatment of nasal diseases is fully justified I think 
the following table amply demonstrates: 
Cured, 19 
Improved 14 
Unimproved, , . 1 
Unknown o 
Total 34 
Results of Tfeatment—Perennial Asthma. 
Cured, 28 
Improved, 12 
Unimproved 1 
Unknown 5 
Total, 46 
Results of Treatment—Hay Asthma. ASTHMA, OR VASO-MOTOR BRONCHITIS. 
245 
I have thus given all the results obtained from the analysis of 
my cases, as bearing not only on etiology, but also on other branches 
of our subject. The point upon which I wish to lay special em- 
phasis here, is the very close and intimate physiological and patho- 
logical connection between the nasal mucous membrane and that 
lining the bronchial tubes, and the further fact, that in asthma we 
must look for the active predisposing cause of the attack, in a dis- 
eased condition of the nasal mucous membrane. In the above sta- 
tistics, we have included hay asthma and perennial asthma, consider- 
ing these two affections as virtually one and the same disease, from 
a clinical point of view. This is shown by the fact, that, in many 
instances, they are interchangeable, in that a patient may suffer a 
number of times from hay fever, without developing asthmatic 
attacks; finally, however, his hay-fever paroxysm winds up with an 
attack of true nervous asthma, a still further change consisting in 
the cessation of the hay-fever attacks, and the patient becoming sub- 
ject merely to attacks of perennial asthma. This fact I have noticed 
in quite a number of instances. Why, then, do we regard an intra- 
nasal disorder as a prominent factor in the causation of a paroxysm 
in the large majority of cases ? It is not intended to convey the 
idea, that this condition may alone be responsible for an attack of 
this disease. Thus, it cannot be questioned that, in many instances, 
cardiac disease is to be regarded as a prominent factor of causa- 
tion, as well as renal disease, or gastric disturbance; and of the 
more remote causes, we must recognize the presence of worms in 
the intestinal canal, uterine disorders, an overloaded stomach, etc. 
Chronic bronchitis is ordinarily recognized as one of the causes of 
asthma. This I think is not to be placed in the same category. 
In this affection, the chronic morbid process of the bronchial mucous 
membrane develops a relaxation of blood-vessels, which ultimately 
leads to attacks somewhat resembling an ordinary attack of nervous 
asthma, and yet I think the two things should not be confounded; 
the form of disease which we are now discussing being a totally 
different disease, I take it, from that which occurs in connection 
with bronchitis, and this should therefore be excluded from con- 
sideration here. 
As regards those remote causes, then, I think we must recognize 
the fact, that even here there must be, in many cases, some local 
disorder of the nasal cavities, which leads to the development of 
the reflex disturbance; otherwise, the presence of worms in the in- 
testinal canal, or other disturbing influences, would scarcely result 
in the development of an attack of asthma. We have already 
shown the intimate physiological connection between the nasal mu- 
cous membrane, and that of the bronchial tubes, and that a weakened 246 
DISEASES OF THE NASAL PASSAGES. 
condition of the passages above, tends to develop a similar condi- 
tion in the parts below. I think, therefore, we must recognize, in 
all these unusual reflexes, this tendency to vaso-motor weakness of 
the bronchial tubes, under the action of which, worms in the intes- 
tinal canal, undigested food in the stomach, and other causes, may 
produce an asthmatic attack. We find it often stated, that a par- 
oxysm is precipitated by flatulent distention of the bowels; indeed 
a number of such cases have come under my own observation, but 
in no single instance has such a case been observed, in which there 
was not abundant evidence of the reflex disturbance having been 
directed to the bronchial mucous membrane, by a local lesion in 
the nasal cavity. In other words, wherever we have had, what 
appeared to be an attack of asthma brought on by flatulent disten- 
tion, I have been convinced that the paroxysm was really excited 
by nasal polypi, hypertrophic rhinitis, or some other lesion of the 
nasal passages, and the flatulence was either an adventitious symp- 
tom, or possibly a complicating circumstance, which precipitated the 
asthmatic attack. Perhaps it would be not wise to say that a patho- 
logical intra-nasal condition is present in every one of these cases 
of obscure reflexes, and yet I think it is still less wise to accept 
evidence of cardiac lesion, or gastric disturbance, as presenting a 
sufficient cause of the attack, without also examining the nasal cav- 
ities, to ascertain whether some lesion may not also exist there. 
The disease being essentially a neurosis, we would naturally ex- 
pect to find heredity exercising a notable influence, a fact which all 
statistics fully bear out, in that this disease, as well as hay fever, 
seems to run in families, as it were. The influence of age and sex 
has already been clearly shown, in the statistics before given. The 
possible existence of a rheumatic or gouty diathesis should of course 
not be overlooked, as factors in the development of these attacks. 
How they should act, it is impossible to say, and yet here, as be- 
fore, I think still the possible existence of a predisposing nasal dis- 
order should not be overlooked. We regard, then, an intra-nasal 
disorder as not only a powerful predisposing, but exciting cause of 
an attack of asthma. It should be stated, however, that when we 
speak of pathological intra-nasal conditions, we include not only a 
diseased condition of the nasal cavity, but also of the naso-pharynx. 
Among these, we may enumerate as the most prominent, hyper- 
trophic rhinitis, deformities of the septum, nasal polypi or other 
tumors, adenoid tumors of the vault of the pharynx, and naso-pha- 
ryngeal catarrh. How this latter affection acts, it is not easy to 
state definitely. As we all know, it is dependent, in no small degree, 
upon a diseased condition of the nasal cavities proper, and on the 
other hand, as Tornwaldt has so clearly shown us, it may give rise ASTHMA, OR VASO-MOTOR BRONCHITIS. 
247 
to a turgescence of the turbinated tissues. We have, therefore, 
really here two morbid conditions which react the one upon the 
other, in such a way as to leave us somewhat in the dark as to 
which is the more active. However this may be, the clinical fact 
remains, that they both exercise a notable influence in producing 
that peculiar weakness of vaso-motor control over the blood-vessels 
of the bronchial mucous membrane, which leads to the development 
of an attack of asthma. 
It will be noticed that, in the tables previously given, naso- 
pharyngeal catarrh was not included among the causes of the dis- 
ease. This was present in a number of cases, but is to be regarded 
as a somewhat secondary cause, in that the vaso-motor paresis which 
constitutes an asthmatic attack is more intimately associated with 
disturbances of circulation in the turbinated bodies, and when naso- 
pharyngeal catarrh was present, it was regarded as either due to the 
intra-nasal disease, or as a cause of it. 
Symptomatology.—A paroxysm of asthma usually occurs at 
night, and perhaps, in the majority of instances, during sleeping 
hours. A patient retires without any premonition of danger, and 
after sleeping a few hours, is awakened by a most distressing dysp- 
noea, or feeling of suffocation. He springs up from his bed terri- 
fied, alarmed, and gasping for breath. His face is turgid, eyes pro- 
truded, mouth open, with the perspiration starting upon his face. 
The dyspnoea is both inspiratory and expiratory; inspiration being 
shorter and somewhat quicker, in that it is aided by all the volun- 
tary and involuntary muscles of respiration,.while the expiration is 
somewhat prolonged, in that the patient apparently seeks a 
momentary period of rest, in allowing such air as he has drawn into 
the lungs, to escape voluntarily. Whereas the dyspnoea character- 
izes both acts of inspiration and expiration, the muscular struggle 
is largely expended on the inspiratory act. The patient is apt to 
be somewhat restless in his movements, in search of some position 
which will afford relief, a search which is usually disappointed, 
although the greatest ease is ordinarily obtained in the semi-re- 
cumbent position. Not infrequently, when the attack is severe, the 
distress is so great that the patient springs from the bed, and rushes 
to the window in search of air. The pulse is ordinarily somewhat 
rapid and weak, especially if the paroxysm is prolonged. The 
temperature usually falls somewhat below the normal, due probably 
to the fact of insufficient oxygenation. This represents a typical 
and well-developed attack of asthma, which may last for one to 
two, three or four hours, and in rare cases may persist from one to 
three days. In other cases, the attack presents a somewhat milder 
type, in that the dyspnoea is by no means so great, and the par- 248 
DISEASES OF THE NASAL PASSAGES. 
oxysm is simply characterized by oppression of breathing, and per- 
sists for a few hours or a day, in which the patient experiences 
mere discomfort, rather than actual suffering. When the paroxysm 
comes on during waking hours, in the large majority of instances, 
it commences with sneezing and watery discharge from the nose, 
which may be of such a character as to give considerable annoy- 
ance to the patient, or be so slight as to scarcely excite attention. 
In that form of asthma which occurs in connection with hay 
fever, of course, the attacks are confined only to the hay-fever 
season, but in the ordinary form of asthma, which we have already 
designated as perennial, the attacks are usually aggravated by the 
damp atmosphere of the spring and fall, the patient enjoying a 
certain degree of immunity during the clear cold weather of winter, 
and the warm weather of summer. During the damp season, how- 
ever, the attacks usually occur about the same time each day. 
During the intervals, the patient enjoys almost complete immunity, 
although even now, a careful examination of the chest will reveal 
evidences of contraction of some of the bronchial tubes, as shown 
by the sibilant and sonorous rales on deep inspiration. 
The character of the paroxysm is also notably influenced by the 
changes in weather, in that the attacks are much less severe during 
the pleasanter days of the spring and fall months. Moreover, in 
the midst of the bad season, the attacks may be arrested by a 
change to a dryer climate, especially to high altitudes, where an 
atmosphere is encountered which seems exceedingly favorable in 
its influence upon these cases. In most of these patients, also, a 
peculiar hyperaesthetic condition of the whole upper air-tract is 
present, evidenced by the fact, that the presence of irritating 
vapors, dust, gases, etc., will produce a temporary sense of dysp- 
noea, or even a well-marked paroxysm of asthma,- which, however, 
usually disappears promptly on the removal of the exciting cause. 
The cessation of the paroxysm is usually attended with a more or 
less profuse sero-mucous discharge, the clinical significance of 
which has already been fully discussed, in the statement that this 
was due to the unloading of the engorged blood-vessels by a serous 
exosmosis, by means of which their calibre is diminished, and thereby 
the patency of the bronchial tubes restored. 
PHYSICAL Signs.—On inspection of the chest during a par- 
oxysm, the first noticeable feature will be, the very marked impair- 
ment of motion, in that the whole chest-wall seems somewhat rigid, 
and to move together. This, however, is, to an extent, deceptive, 
the limited movement of the chest being really due to the limited 
amount of air which is drawn in, with each act of inspiration. 
Percussion simply reveals perhaps a slight exaggeration of normal ASTHMA, OR VASO-MOTOR BRONCHITIS. 
249 
resonance. The diagnosis, of course, is based entirely on ausculta- 
tion, by means of which there will be recognized the characteristic 
sibilant and sonorous rales throughout the whole of the chest cav- 
ity, and heard equally at any point. These are blowing, purring, 
whistling, cooing sounds, that are caused by the passage of air 
through the narrowed tubes of various calibres, the walls of which 
are perfectly dry. In other words, there is total absence of any 
moisture, but the mingling of dry rales constitutes a confusion of 
musical sounds, as it were, which can be likened to nothing so much 
as the cooing of a bevy of pigeons. So loud are these sounds, that 
they can be heard frequently even across the room. The normal 
respiratory murmur is of course completely masked by these loud 
rales, which are heard both in inspiration and expiration, although, 
as before stated, the expiratory sounds are somewhat prolonged. 
At the termination of the paroxysm, the dry rales diminish in in- 
tensity, and to an extent disappear. The moist rales may now be 
heard, as the serum transudes the blood-vessels, and makes its ap- 
pearance in the bronchial tubes. 
Differential Diagnosis.—It scarcely seems necessary to sug- 
gest any points of differential diagnosis, and yet there might be a 
possibility of mistaking an attack of asthma, for spasm of the 
glottis, hydrothorax, oedema of the lungs, and cardiac disease. In 
laryngeal spasm, the voice would necessarily be affected, and the 
dyspnoea would be entirely of an inspiratory character, and its 
locality recognized by the peculiar sub-clavicular and sub-sternal 
depression, which would characterize each inspiratory act. More- 
over the impairment of voice would give further evidence of the 
laryngeal disorder. In angina pectoris, and hydrothorax, there 
would be of course no sibilant or sonorous rales. The same is true 
also of pulmonary oedema, which also is characterized by moist 
rales, and more or less profuse serous expectoration. In the dysp- 
noeic attacks of cardiac disease, there is an entire absence of the 
characteristic sibilant and sonorous rales. 
PROGNOSIS.—Asthmatic patients are said to be long-lived, which 
is probably true, in that there is nothing in the disease itself which 
would tend to shorten life. During attacks, the sufferings of the 
patient are extreme, but during the intervals, he enjoys ordinarily 
the best of health, excluding, of course, those cases which are 
dependent upon a chronic bronchitis, which, as before stated, is not 
to be classified with nervous asthma. As regards the disease itself, 
however, the prognosis, of course, depends largely on our ability to 
control it. From the analysis of cases given above, it would seem 
that the plan of treatment there carried out, affords us a method of 
controlling the severity of attacks, in the large majority of instances, 250 
DISEASES OF THE NASAL PASSAGES. 
and in a very flattering proportion of cases, of radically curing the 
disease. As regards any tendency to recover unaided by therapeutic 
efforts, this would seem to exist in but a small degree, although in 
many cases, especially in youth, the disease seems to disappear 
without treatment. The longer, however, the attacks have lasted, 
the less tendency there is for the spontaneous cure. Moreover, it 
is probably also true, that the longer the attacks 'have existed, the 
less amenable they are to treatment. 
TREATMENT.-—The consideration of the treatment of this dis- 
ease naturally divides itself into three heads, namely: 
1. The treatment of the local predisposing cause, which, as we 
have endeavored to show, consists of a morbid condition of some 
portion of the upper air-tract. 
2. The treatment of the paroxysm. 
3. The constitutional treatment, or the treatment of the general 
neurotic habit. 
The Treatment of the Local Morbid Condition in the Upper Air-pas- 
sages.—We place this first in importance, in that, as has already been 
intimated, we regard these measures, not only as the first to be in- 
stituted, but as those which promise the best and surest results, 
and even in those cases where local treatment fails to thoroughly 
relieve the disease, we certainly have prepared the way for the 
better action of general remedies. In resorting to these local 
remedies, we search not only the nasal cavities, but the cavity of 
the naso-pharynx, for the local predisposing cause, but of these 
two, the measures of treatment are to be first directed to the nasal 
passages proper, in that, as has already been intimated, we find in 
the large proportion of cases, that the morbid condition of the 
naso-pharynx disappears upon the restoration of the nasal passages 
to a healthy condition of patency, and its lining membrane to a 
normal condition of functional activity. These measures failing to 
give relief, treatment must be directed to the naso-pharynx, accord- 
ing to such indications as present, in the manner to be discussed 
at length in a subsequent chapter. The conditions which we may 
encounter in these regions which demand treatment, may be briefly 
enumerated as follows: hypertrophic rhinitis, deformities of the 
septum, nasal polypi or other neoplasms, chronic naso-pharyngeal 
catarrh, adenoid growths or other tumors in the vault of the 
pharynx, or in fact any condition of the nose or naso-pharynx 
which constitutes an obstructive lesion. 
The Treatment of the Paroxysm.—I have endeavored, in a former 
chapter, to make clear the intimate sympathy which exists between 
the nasal and bronchial mucous membrane, and to show how a 
plethoric condition in one region, is exceedingly prone to be ac- ASTHMA, OR VASO-MOTOR BRONCHITIS. 
251 
companied by a similar condition in the other. Now, if, as I think 
has been clearly demonstrated, a paroxysm of asthma consists 
essentially in a turgescent condition of the blood-vessels of the 
mucous membrane lining the bronchial tubes, which turgescence 
is prone to be accompanied by turgescence of the nasal mucous 
membrane, it is easy to understand how the local application of 
any remedy to the nasal passages, which will control vascular 
dilatation in this region, should result in either marked arrest or 
the complete relief, for the time being, of the asthmatic paroxysm. 
A large clinical experience, has shown this observation to be cor- 
rect, and hence probably we possess few remedies more active 
or more certain in their action than cocaine. This, therefore, 
should be our first resort. It may be applied by means of the small 
atomizer, shown in Fig. 48, or failing this, an ordinary dropper an- 
swers an excellent purpose, a small amount being applied to each 
nostril, and repeated every five minutes, until relief is afforded. In 
my own hands, I have seen but few cases in which this remedy was 
not notably successful. 
Next in importance to this, we should place datura stramonium, 
the efficacy of which we find recorded in the early part of the cen- 
tury. Thus Christie 1 reports it as having been used with good re- 
sults, as early as 1805, while similar observations were made by 
English2 and other writers.3 This drug is used by burning the 
leaves and inhaling the smoke, this procedure being accomplished 
by smoking the leaves in a pipe, or in the form of a cigarette, or 
simply by burning them on a plate. What the action of the drug 
is, it is difficult to state, other than on purely speculative grounds. 
Clinical experience, however, teaches us that the fumes of the 
leaves have a very powerful effect in controlling the distressing 
features of an asthmatic paroxysm, and, although probably, in the 
majority of instances, they fail to afford perfect and entire relief, 
they rob the attack of much of its distressing character. 
Another remedy of great efficacy is the fumes of burning salt- 
petre. This was first reported, I believe, by Harrison,4 who obtained, 
the remedy from a friend, who found notable relief in saturating 
paper in a strong solution of nitrate of potash, and then setting it 
on fire, and inhaling the fumes, having previously allowed the paper 
to dry, whereby the solids were deposited upon it, the object of 
the paper being simply to produce ignition of the potash salt. 
While, perhaps, not as efficacious as the stramonium, the saltpetre 
1 Edinburgh Med. and Surg. Jour., 1811, vol. vii., p. 158. 
2 Edin. Med. and Surg. Jour., 1811, vol. vii., p. 277. 
3 Med. Repository, 1812, vol. iii., p. 311. 
4 LoncJ. Lancet, 1845, vol. i., p. 383. 252 
DISEASES OF THE NASAL PASSAGES. 
is a remedy which rarely fails to afford a certain amount of relief. 
The combination of these two remedies is one which enters largely 
into the manufacture of a large proportion of the asthma remedies 
sold in the drug-stores. Thus Himrod’s powder is composed of the 
leaves of lobelia inflata, datura stramonium and ordinary tea, mixed 
with a certain proportion of nitrate of potash, while the “ Green 
Mountain Cure ” is composed of the same drugs, in somewhat dif- 
erent proportions. Probably no combination of these remedies is 
more effective than the following, from the Brompton Hospital 
Pharmacopoeia: 
Pulv. stramonii, . . . . . . 3 iv. 
Pulv. anisi, 
Potas. nitrat., . . . . . aa 3 ij. 
Pulv. tabaci, ....... grs. v. 
These powders may be burned on a plate, or smoked in an ordinary 
clay pipe. 
Still other remedies, which possess a certain amount of popu- 
larity for use in this manner, are: datura tatula, datura fatuosa, 
metel, belladonna, opium, hyoscyamus, arsenic, etc. These, how- 
ever, are usually used in combination with the stramonium and 
potash, as in the well-known Espic’s cigarettes, the formula of 
which is as follows : 
I)* Fol. belladonnae, ...... grs. vss. 
Fol. hyoscyami, 
Fob stramonii, ..... aa grs. ij f. 
Fob phellandrii aquatici, . . . gr. i. 
Extract, opii, gr. 
Aquae lauro-cerasi, . . . . . q. s. 
This is a very efficacious combination, and is also an exceedingly 
convenient method of obtaining the fumes of these drugs. Chibrac 1 
reports a case of a man, who obtained notable relief from the in- 
halation of the fumes of carbonic acid, obtained from a charcoal 
brasier, while Julius2 reports the case of a patient, who obtained 
relief by smoking cigarettes containing quarter of a grain of white 
arsenic, although she was compelled to gradually increase the dose 
up to three grains, on account of a certain tolerance produced. 
This, I believe, is a plan practised among the Chinese. I have no 
experience with either carbonic acid or arsenic, but should hesitate 
to make use of either method; certainly, the latter is open to seri- 
ous objections. It is a curious feature, in the clinical history of 
asthmatics, that the efficacy of every remedy seems to exhaust 
1 Union Medicale, 1879, vol. xxviii., p. 617. 
2 Lancet, i86i,vol. ii., p. 138. ASTHMA, OR VASO-MOTOR BRONCHITIS. 
253 
itself, to a certain extent. This is not due, I think, to any tolerance 
produced by the drug, but rather to the fact, that the longer the 
disease lasts, and the more fixed the asthmatic habit becomes in an 
individual, the greater the difficulty in affording relief to a paroxysm- 
In other words, the morbid lesion which constitutes a paroxysm, 
being a relaxation of the blood-vessels, their tonicity or power to re- 
contract seems to be lessened, according as the disease persists for 
a lengthy period of time. Hence, any of the above simple remedies 
may occasionally fail to afford relief, and it will become necessary 
to resort to internal medication. Of internal remedies, undoubtedly 
the most efficacious is opium. This should be administered, where 
necessity demands, in the form of morphine, and given hypoder 
matically, as securing the promptest effect of the drug, and in doses 
of one-eighth to one-sixteenth of a grain, repeated hourly, until relief 
is afforded. This remedy has undoubtedly been in use for a num- 
ber of years, and yet curiously enough, we find no allusion to it in 
literature until Levi1 reported notably good results from the hypo- 
dermatic injection of morphine, while subsequent observations of a 
similar character were made by Lessdorf,2 Anderson,3 and Oliver.4 
The latter, however, recommended, that it be combined with one 
one-hundredth of a grain of atropia. Under the theory that an 
asthmatic paroxysm is due to muscular spasm, morphine was ad- 
ministered for the purpose of relaxing muscular contraction. This 
theory being faulty, we must seek for the beneficial action of the 
opium in its general sedative action upon the nervous system, and 
perhaps, also, in a certain amount of sedative influence, which it 
exerts upon the circulation. In much the same way we explain 
the action of chloral, the efficacy of which was long since recog- 
nized. According to Williams,5 this is best administered in doses 
of fifteen to twenty grains, repeated every three hours, until sleep 
is produced, or in twenty to thirty grain doses, repeated once or 
twice during the night. The advantage of combining this drug 
with bromide of potassium, as suggested by Lamadrid,6 is recog- 
nized by all, and hence to each dose of the chloral we may add an 
equal amount of the bromide. If the paroxysms be very severe, 
we may resort to the administration of chloroform, as was recom- 
mended as early as 1849 by Birdsall,7 or of ether, as recommended 
by Willis,8 although these remedies should be used with a certain 
amount of hesitation, and with the anticipation of giving but tern- 
1 Gior. Veneto di Sc. Med., Venezia, 1866, 3d series, vol. iv., p. 603. 
2 Deut. Klin., 1871, vol. xxiii., p. 15. 3 Practitioner, 1875, vol. xv., p. 321. 
4 Practitioner, 1876, vol. xvi., p. 137. 5 Brit. Med. Jour., June 13th, 1874,p. 772. 
6 Phila. Med. Times, 1874, vol. iv., p. 760. 
7 Lancet, 1849, vol. i., p. 336. 
8 Lond. Med. Gaz., 1847, n- s., vol. iv., P- 271. 254 
DISEASES OF THE NASAL TASS AGES. 
porary relief. The latter is especially objectionable, on account of 
its peculiar irritating action upon the mucous membrane of the 
upper air-passages. When Duncan 1 first suggested the use of ni- 
trite of amyl, its use was resorted to with a considerable degree of 
enthusiasm, as it seemed to give most excellent results, although 
subsequently it has fallen into disuse, on account of the very dis- 
tressing symptoms referable to the head to which it gives rise. In 
the same category we may place the iodide of ethyl, recommended 
by See.2 
In former times, I found excellent results, in many instances, 
from counter irritation applied to the spine, either in the form of a 
mustard plaster, or a blister from two to four inches square, over 
the fourth and fifth dorsal vertebrae. This of course is somewhat 
objectionable, and in view of the prompt action of the remedies 
first noted, I have not resorted to this measure in recent years. 
Probably better and prompter action would be obtained from ap- 
plying cold to the spine, either in the form of an ice-bag in the same 
region, or perhaps better still, the long Chapman’s ice-bag, over the 
whole of the spine, its action being probably much the same as 
that experienced by its use in hay-fever cases, as recommended by 
Kinnear.3 The use of the galvanic current has been recommended 
for the relief of the asthmatic paroxysm by Caspari,4 and it is an 
excellent suggestion, although scarcely available in most instances. 
We have thus given, somewhat in the order of preference, the vari- 
ous measures to which we may resort, in our attempts to relieve the 
paroxysm, all of which undoubtedly possess notable merit, and yet, 
as a rule, I think we shall find, in most instances, the best results 
from the simple measures first enumerated, notably the local ap- 
plication of cocaine, and the inhalation of the fumes of stramonium 
and nitrate of potash, in some one of their various combinations. 
General Treatment.—While I believe the local treatment of a dis- 
eased condition of the air-passages the most important part of our 
therapeutic measures, none will question the marked effect of the in- 
ternal administration of drugs, in this disease. Hence I think we 
are rarely justified in depending entirely on local measures alone, but 
when our patients first come under observation, they should be im- 
mediately put on a course of internal medication also. Of internal 
remedies, the one which experience has shown us to possess the most 
notable efficacy in the control of asthma, is undoubtedly iodide of 
potassium. Its value in this disease was recognized very soon after 
1 Mich. Univ. Med. Jour.. 1872-3, vol. iii., p. 588. 
2 Gaz. Med. de Paris, 1878, 5th series, vol. vii., p. 79. 
s Loc. cit. 
4 Wien. Med. Woch., 1868, vol. xviii., p. 333. ASTHMA, OR VASO-MOTOR BRONCHITIS. 
255 
its first discovery. Casey1 found excellent results from the admin- 
istration of from two to five grains, three times daily, while Deane 2 
found it of value, administered in doses of from two to five grains 
every two hours, as controlling the severity of the paroxysm. Sub- 
sequent to this, we find a number of similar observations in litera- 
ture, with no very specific directions for its systematic administra- 
tion until See3 suggested a definite plan for its administration, in 
following which, I am disposed to think, we will obtain our best 
results. He commences with the administration of ten grains, well 
diluted in wine or water, which is to be given three times daily, 
after meals, for from five to seven days, after which he doubles the 
dose, and continues it for an equal period. This latter dose usually 
produces iodism, as evidenced by the metallic taste in the mouth, 
when he reduces the dose to seven grains, three times a day, 
for a somewhat long period of time, occasionally interrupting its 
administration for a day or two, but still continuing to give it 
for a prolonged period, or until its efificacy has been thoroughly 
tested. As regards other remedies, such as lobelia, recommended 
by Andrew,4 nitric acid, as recommended by Hopkins,5 belladonna, 
in large doses, suggested by Wood,6 or the hypodermatic use of 
atropine, as suggested as early as 1859 Courty,7 valerianate of 
atropia, as suggested by Michea,8 veratrum viride, found efficacious 
by Winch,9 platinic chloride, recommended by Dr. Huss,10 sulphur 
baths, as recommended by Courtin,11 local application of nitrate of 
silver to the larynx, as advocated by Bowditch,12 quinine, as sug- 
gested by Dawson,13 leonurus cardiaca, as recommended by Spottis- 
wood,14 compressed air, as recommended by Bertin 15 and Guttman,16 
and glonoin, as suggested by Fraser,17 I have little experience, but 
am disposed to think that they have been found efficacious in excep- 
tional cases, and are scarcely to be recommended as available in a 
1 New York Journal of Medicine, 1845, vol. iv. 
2 Stethoscope and Virginia Med. Gaz., 1851, vol. i., -. 572. 
3 Gaz. Me'dicale de Paris, 1878, 5th series, vol. vii., pp. 69 and 79. 
4 Glasgow Medical Journal, 1830, vol. iii., p. 190. 
s American Journal of Med. Sciences, 1850, vol. xx., p. 549. 
6 Philadelphia Med. Times, 1874, vol. iv., p. 804. 
7 Gaz. des Plopitaux, 1859, p. 531. 
8 Gaz. des Hopitaux, 1856, vol. xxix., p. 579. 
9 Chicago Med. Journal, 1863, new series, vol. vi., p. 511. 
10 Jour, des Connais. Med. Chir., October, 1851. 
11 Gaz. Med. de Paris, 1847, vol. ii., p. 961. 
12 Boston Medical and Surgical Journal, vol. lvii., p. 159. 
13 Western Med. Journal, 1848, third series, vol. i., p. 285. 
14 Med. and Surg. Reporter, 1879, vol. xl., p. 152. 
15 Montpellier Medicale, i860, vol. iv., pp. 201, 419, 506. 
16 Wien. Med. Presse, 1878, vol. xix., p. 764. 
17 American Journal of Med. Sciences, October, 1887, and Feb., 1888. 256 
DISEASES OF THE JVASAL TASS AGES. 
very large class of patients. In late years, there have come into 
use two remedies, which possess noted value, these are grindelia 
robusta and quebracho. The first of these was first recommended 
by Gibbons,1 who found excellent results from its administration, 
in a flattering number of cases, an observation which has been con- 
firmed by a number of other observers. A larger experience, how- 
ever, seems to show that whereas the grindelia robusta undoubtedly 
has a powerful effect in controlling the disease when first admin- 
istered, it seems, at the end of a few months, to lose its efficacy 
almost entirely. The same I think can be said of the quebracho. 
We find, therefore, that our constitutional treatment of this dis- 
ease will depend, as far as internal medication is concerned, largely 
upon the administration of iodide of potassium, after the manner 
above detailed. 
Our systemic treatment, however, is not necessarily confined 
to the administration of drugs, for very much can be accomplished 
by certain general hygienic rules. The most important of these is 
the daily use of the cold bath, either in the form of a plunge or 
shower, or where this is not tolerated, the daily sponging of the 
skin. In addition to this, careful attention must be paid to those 
general rules of living, which have already been clearly indicated in 
the chapter on hay-fever, such as the regulation of the clothing, a 
certain amount of outdoor life and exercise, attention to diet, etc. 
Asthma is not one of the diseases wherein we can give an abso- 
lutely favorable prognosis, in all cases. In other words, it is not one 
of the diseases that we can cure in every instance. Hence, our ther- 
apeutic resources failing, our final resort will consist in advising our 
patient to seek relief in change of climate. Unfortunately, asthma 
is, moreover, a somewhat fickle disease, and hence a climate which 
is favorable in one case, will prove unfavorable in another, and we 
may be at times somewhat at a loss, just what advice to give. In 
general, however, we may say that those cases of asthma which are 
associated with hay fever will find the greatest relief by residence 
at the sea-shore, while those which are purely neurotic, such as we 
have termed cases of bronchial asthma, will seek mountainous re- 
sorts, or high altitudes. Why high altitude should prove beneficial 
in these cases, it is difficult to say. Certainly it is not in the di- 
minished atmospheric pressure, for this would tend to increase 
vascular plethora. Possibly the beneficial effect of high altitudes 
lies in the general tonic effect of the pure air, which we find in these 
regions. Whatever it may be, certainly clinical experience teaches 
us, that the best climate for the purely nervous asthmatic is the 
mountain regions. Thus, we find that asthmatics do well in the 
1 Pacific Medical and Surgical Journal, 1867, vol. ix., p. 237. ASTHMA, OR VASO-MOTOR BRONCHITIS. 
257 
White Mountains, the Adirondacks, Catskills, or in any elevated 
region, although complete relief is only obtained, probably, at an 
elevation of between 3,000 and 4,000 feet. This we find in Colorado, 
which affords a climate better adapted for the larger number of 
cases than any region found, probably, in this country. It should 
be said further, in regard to the effect of climate, that whereas re- 
lief is obtained immediately upon our patients resorting to these 
regions, and as long as they remain there, yet the disease is not 
cured, in that they become, as a rule, subject to their asthmatic 
attacks as soon as they return to the lower level. Hence, we must 
consider the climatic treatment of asthma as purely palliative, and 
warn our patients, that permanent relief is only to be obtained by 
permanent residence in the exempt regions. CHAPTER XVI. 
NASAL HYDRORRHGEA. 
THIS is a term which we use to designate a curious form of dis- 
ease which is occasionally met with affecting the nasal passages, in 
which the prominent symptom consists of a profuse watery dis- 
charge from the nose, and which, while presenting many of the 
symptoms of an ordinary attack of hay-fever, occurs at all seasons 
of the year. There is, however, a certain amont of periodicity 
about it, in that while occurring every day, it comes on in many 
instances only at certain definite times each day, while in other 
instances it seems to persist during the whole twenty-four hours. 
The disease is an exceedingly rare one, and as we find but few 
instances recorded in medical literature, perhaps a better apprecia- 
tion of the peculiar features of the affection will be obtained by a 
brief resumd of these cases. 
The first observation on the subject is the report of a case by 
Rees,1 although long previous to this Ammannus2 had recorded an 
instance, the details of which are not sufficiently clear to warrant 
its being embraced in this category. 
Case I.—Rees’s case was that of a woman, aged 52, who suffered from a con- 
stant dropping of a clear watery fluid from the left nostril. The dropping 
persisted during the whole of the twenty-four hours, and was especially dis- 
tressing on lying down, when it caused attacks of suffocation. The general 
health was notably affected, and the patient suffered from general anasarca, 
which would indicate that the affection may have been dropeical in its nature 
although the full details and ultimate result are not stated. Treatment was 
unavailing. 
Case II.—Reported by Forster.3 A young woman presented with a history 
of having suffered for six years with repeated attacks of profuse watery dis- 
charge from both nostrils, which persisted through the whole twenty-four hours, 
during considerable periods of time, although there were occasional intervals 
of three or four weeks’ duration, when the discharge ceased entirely. Her 
general health was somewhat impaired, although not in a notable degree. 
The atmosphere of the city aggravated the affection, while the cool air of the 
country always gave a certain amount of relief. Hot weather also seemed to 
1 London Medical and Surgical Journ., 1834, vol. iv., p. 823. 
2 Misc. Acad. Anat. Curios., 1671 : Francof. et Lips., 168S, vol. ii., p. 2S2. 
3 New York Medical Times, 1852, vol. ii., pp. 113-115. NASAL HYDRORRHCEA. 
259 
exercise an unfavorable influence. She was treated with nitrate of silver both 
internally and locally without avail. 
Case III.—Reported by Elliotson.1 A female aged 26 was suddenly seized 
with a profuse watery discharge from the left nostril, which persisted for 
eighteen months, when it terminated somewhat abruptly, recurring again at 
the age of 40, coming on somewhat slowly now, and persisting for twenty- 
three months. The amount of water discharged was usually two quarts daily, 
although on one occasion it was three quarts. The fluid was of 1.010 specific 
gravity, and contained sodium chloride and sulphate, a small amount of mucus, 
and traces of calcium and phosphoric acid. The first attack seemed to have 
been brought on by an exposure to cold, which resulted in violent headache 
and which was only relieved by the sudden onset of the watery secretion. She 
was treated by means of blisters, leeching, blood-letting and various other 
measures without avail, the disease disappearing apparently of its own accord. 
The second attack came on without any apparent cause, and only attained ids 
full activity at the end of two weeks. Again various remedies were tried 
without avail, until Brodie advised the internal and local use of sulphate of 
zinc, soon after which the dropping ceased. According to Brodie this was 
the result of treatment, although it is far more likely that the cessation was 
spontaneous, as in the first attack. 
Case IV.—Reported by Davies.2 This was the case of a male, aged 50,who it is 
stated had syphilis fifteen years previously, although in what form, or with 
what manifestations is not stated. He was attacked with an abscess at the 
root of the second molar tooth of the left side, which discharged both into 
the mouth and through the antrum into the nose. The oral discharge ceased, 
but the nasal discharge had continued at the time of the report for two years 
and a half, and consisted of a somewhat profuse, thin, yellow, acrid fluid. It 
was worse in damp weather, and seemed to be aggravated by mental exertion. 
No addition to these somewhat meagre details is given, and the question still 
remains, as to whether this was really a case of nasal hydrorrhoea, or whether 
it may not have been a case of ordinary purulent catarrh of the antrum. 
Case V.—Reported by Tillaux.3 This case was that of a male, who, follow- 
ing the removal of a nasal polypus, commenced to suffer from a profuse watery 
discharge from the nose, which persisted during the whole twenty-four hours, 
excepting that, when in the recumbent position, the discharge ceased, while if 
the head were bent forward, it seemed to be increased. The amount secreted 
in twenty-four hours was about nine ounces. An analysis of the fluid showed 
it to be identical with arachnoid fluid, and Tillaux was led to suppose that in 
the extraction of the polypus, the cribriform plate of the ethmoid was broken, 
and that the source of the discharge was the arachnoid cavity.* 
Case VI.—Reported by Paget.4 In November, 1876, a lady aged 48, while 
in the enjoyment of perfect health, received a blow over the left frontal sinus. 
It was a trivial accident and would have been forgotten but that in January, 
1877, she had an attack of severe headache, lasting a few days, and in the fol- 
lowing February she received a severe mental shock. In May of the same 
1 Medical Times and Gaz., London, 1857, vol, xv., p 290 ; also, Brown’s Archives, 
vol. iii., p. 665. 
2 Lancet, 1870, vol. ii., p. 592. 
3 “ Traite d’anat. topograph.” Second edition, Paris. 1878, p. 52. 
4 Medical Press and Circular, London, 1878, n. s. xxvi., p. 432 ; also Transactions 
Clinical Society of London, 1879, p. 43. 260 
DISEASES OF THE NASAL PASSAGES. 
year, she began to suffer from a profuse watery discharge, confined entirely to 
the left nostril, which continued over a year and a half, with the exception of 
an intermission of a fortnight in May, 1878, when she had an attack of bron- 
chitis, for which she took morphine, and during one night, when it also ceased 
spontaneously. With these exceptions, the fluid was constantly dropping 
during the twenty-four hours, the amount being from about eight to ten 
ounces a day. It was notably increased by mental distress, and also by exer- 
tion. At night, during sleep, it would collect in the nostril, pouring out only 
when the position of the head was changed. In specific gravity it varied from 
1.004 to 1.010, and it was composed of 1.015 of solid matter to one hundred parts 
of the fluid ; the solid matter consisting of albumin, chloride of sodium, traces 
of carbonate of soda and phosphoric acid. Paget prescribed for this patient 
one grain of sulphate of zinc three times a day, and to increase the dose grad- 
ually to twice that quantity, and also made a local application of a solution of 
the same salt, three grains in an ounce of water. This plan was followed for 
six weeks, when the symptoms subsided in a notable degree, and at the end of 
three weeks longer had completely disappeared. The patient remained per- 
fectly well for a month, when, as the result of exposure to cold and great men- 
tal distress, she was attacked with a severe headache with vomiting, followed 
by restlessness, delirium, and other evidences of brain disease, and died coma- 
tose at the end of three days. Post-mortem examination revealed evidences 
of meningitis, involving a large part of the convexity of the brain. The base 
of the skull was healthy. In addition to this, there was found in the left an- 
trum, a number of small rounded polypi, from one-half to two-thirds of an inch 
in diameter, projecting from its floor and outer wall. 
The following case is one on which Althaus has built a most 
interesting study on the “ Physiology and Pathology of the Fifth 
Pair of Cerebral Nerves” and is interesting in this connection, in 
that one of the symptoms consisted in a profuse discharge from the 
nose, evidently largely composed of serum tinged with mucus. 
Case VII.—Reported by Althaus.1 P. G., aged 27, unmarried, a farmer, 
lived in Australia, had always enjoyed good health until in June, 1866, he was 
subjected to serious exposure in riding across the plains in the face of a high 
wind. While thus exposed, he was attacked with severe pain in the left side 
of the head, eyes, and face. At first the sensation was as if the face was frost- 
bitten, but subsequently it became of a dull throbbing character, and continued 
for five weeks. Some time afterward, as the result of a similar exposure, the 
right side of the face became involved in the same manner. The pain was not 
severe, and the attack did not last so long. After the disappearance of the 
pain, the following conditions set in : the corneaeof both eyes became covered 
with a thick opacity, resulting in complete loss of sight in the right, and im- 
paired vision in the left. The skin and mucous membrane of the face became 
quite numb. After a period of some months in the hospital, without much 
change in his condition, he went to England and placed himself under Althaus’s 
care, who found complete paralysis of sensation, involving all parts to which 
the trifacial nerve on each side was distributed. The sense of smell was nor- 
mal. The vision was obstructed by thick glaucoma of both corneae, although 
1 British Medical Journal, 1S78, vol. ii., p. 831; also, Med. Chir’l Trans., vol. lii., p.29. NASAL HYDRORRHCEA. 
261 
the optic nerve was not affected, the eye symptoms being due entirely to the 
condition of the corneae. Sensation of the face and scalp was entirely lost, 
the sense of temperature, touch, and locality being completely ablated. The 
conjunctiva was entirely anaesthetic, as well as the mucous membrane of the 
nose and the mouth. From the nose there poured forth such an abundance of 
acrid “mucus,” that on running down upon the lips, it produced severe excoria- 
tions, together with complete destruction of the hair follicles of the moustache. 
Under treatment, which was confined entirely to the systematic application of 
the galvanic current, the improvement at the end of three months was most 
striking, and Althaus expressed the conviction that an entire recovery would 
ensue by the prosecution of this line of treatment. 
Case VIII.—Reported by Fischer.1 Fischer noticed in one of his hospital 
cases, a male aged 42, under treatment for a fractured limb, that while in the 
hospital, he developed a severe attack of headache, followed by a profuse dis- 
charge from the left nostril, of a thin milky fluid, which was poured out to the 
amount of about half a pint. The discharge seemed to give relief to the head- 
ache. The fluid was of 1.003specific gravity, and contained traces of albumin, 
sodium chloride, and phosphates. No echinococcus hooks were found. There 
was no neuralgia of the fifth pair of nerves. The patient had had two at- 
tacks before, no details of which are given, but he stated that the headache was 
relieved in each case upon the appearance of the discharge. 
Case IX.—Observed by the author. Dr. H , aged 58, came under my 
observation in June, 1882, with the following history. Two months previously 
he caught what appeared to be an ordinary cold, characterized by nasal steno- 
sis, sneezing and watery discharge, but these had continued ever since, appar- 
ently in a periodical manner as follows : He wakens every morning, quite free 
from every symptom, but usually about nine o’clock, there comes on a feeling 
of formication about the bridge of the nose, followed by intense sneezing and 
profuse discharge. It always comes on very suddenly, and persists for from 
three to six hours, although during the remainder of the day he is not entirely 
free from his symptoms. Occasionally, although rarely, the attack intermits a 
single day. The discharge seems to be of an absolutely pure watery character, 
and in the course of a daily seizure amounts to several ounces. Examination 
showed it to contain a small amount of chloride of sodium, with traces of 
phosphates and lime. This gentleman was seen occasionally, for a period of 
several years, during which time he was subjected to various plans of internal 
and local treatment, until the fall of 1884, when the discovery of cocaine placed 
in his hands a measure which gave more relief than anything which had pre- 
viously been used, and to this day, he has continued the use of this drug, se- 
curing such relief as it affords, now a period of five years. 
It is interesting to note in this connection, that when I first ex- 
amined this patient, two months after the onset of his disease, I 
found no notable evidence of any chronic lesion of the nasal cavi- 
ties, although subsequently he developed ordinary mucous polypi 
in the nasal chambers, which for the time seemed to aggravate his 
symptoms, and the removal of which gave a certain amount of re- 
lief, although limited. 
The development of the polypi was undoubtedly due to the 
1 Deutsche Ztschr. fiir Chir., Leipzig, 1879, vol. xii., p. 369. 262 
DISEASES OF THE NASAL PASSAGES. 
fact that the mucous membrane became sodden and infiltrated with 
serum in its escape from the turbinated tissues. In other words, it 
became so far water-soaked, as it were, as to lead to myxomatous 
degeneration. It might be stated in this connection also, that a 
certain amount of relief was given by the application of the galvano- 
cautery to the turbinated tissues; the action of this remedy being 
due to the fact, that the superficial cauterization deposited, as it 
were, upon the surface of the membrane a superficial and inelastic 
coat, which temporarily gave support to the blood-vessels, and for 
a time arrested the serous exosmosis. It might be further noted 
also, that a full trial of a continuous current in this case was made 
without relief, although a stronger current than that afforded by 
seven cells was not tolerated by the patient, on account of the 
severe pain. 
Case X.—Observed by the author. Dr. D , aged forty, consulted me 
on April 7th, 1882, with the following history. For twelve months he had suf- 
fered from a profuse watery discharge from the nose, which had been a source 
of such distress to him as to almost incapacitate him for business. The dis- 
charge was not persistent through the day. but came on usually twice, viz., in 
tlje morning at 8, lasting about one hour, and again in the evening, from 5 to 
6. The appearance of the discharge was preceded by a sense of intense for- 
mication about the bridge of the nose, followed soon by the dropping. The 
amount during the hour usually was about one ounce. On damp days, how- 
ever, the discharge was persistent throughout the whole day, when its amount 
was usually a pint. With few exceptions, the discharge ceased during the 
night. Dry hot weather seemed to give relief. There was a history of inter- 
mittent fever twenty years before, and again eight years before. Up to twelve 
months before consulting me, he had been a sufferer from facial neuralgia. 
This, however, ceased with the setting in of the discharge. An examination 
showed his nasal cavities to be in a state of perfect health. The discharge 
was a clear white watery fluid, of a salty taste, and feebly alkaline, and con- 
tained a small amount of chloride of sodium, as shown by chemical test. I 
advised the use of quinine, which he took to the extent of ten grains each night, 
for three weeks, with the result of absolutely arresting the trouble. A week 
after, however, he ceased the use of the drug, and the discharge commenced 
again. He resumed his quinine, now without the slightest effect. During the 
following summer, he had an additional daily attack of an hour’s duration, from 
12 to 1 o’clock. At this time he tried the effect of various remedies. Atropia 
seemed to aggravate the difficulty. Townsend’s remedy1 was absolutely of no 
avail; tincture of elfrasia (a homoeopathic remedy for hay fever) seemed to give 
notable relief for a time, in doses of eight minims every four-hours. Ergot, in 
combination with digitalis, also was used without avail. In the fall he com- 
menced to suffer at night for the first time, and as the cooler weather set in, 
he resumed the use of quinine with a certain amount of relief, although the 
continuance of his attack seemed now to have a notable effect on his nervous 
system, and he commenced to suffer from extreme mental depression. Occa- 
1 A proprietary remedy for hay fever which attained a considerable notoriety at one 
time, being erroneously reported to have cured Ilenry Ward Beecher of his hay fever. NASAL H YDRORRHCEA. 
263 
sional doses of quinine now seemed to relieve him during the fall months, and 
on through the winter. The subsequent history of this case consisted in a cer- 
tain amount of relief from the occasional use of quinine, and the trial of vari- 
ous other remedies without effect, until on February ist, 1884, he commenced 
the use of the galvanic current from a battery of ten cells, with very marked 
relief, an electrode being applied on either nasal bone. This was continued 
until July 20th with the result apparently of curing him entirely. At this time 
he went to the mountains, and while in Saratoga he had an attack of a very 
severe character, lasting the whole day. He immediately returned home, and 
resorted to the use of electricity without avail, and in despair, concluded to 
abandon all treatment, when at the end of a few days, the discharge ceased as 
suddenly as it had come on, since which time he has enjoyed entire immunity 
from the affection. 
It is interesting to note, in connection with this case also, that 
after the disease had persisted for something over a year, mucous 
polypi developed in the nasal cavities, which had heretofore been 
entirely healthy, and, as suggested in the previous case, due en- 
tirely, I think, to the profuse escape of watery fluid into the mucous 
membrane. The presence of these growths did not seem to nota- 
bly increase the discharge, nor did their removal seem to amelior- 
ate the symptoms. It should be stated in this connection, that 
this patient, in addition to the use of electricity, subjected himself 
to a systematic course of Turkish baths, followed by the cold 
sponge, together with vigorous massage three times each week, 
during a considerable period of time, in connection with the elec- 
trical treatment. 
In addition to the above two cases which came under my own 
observation, I have in my note-book five others, the details of 
which, however, are somewhat meagre, and are scarcely worthy of 
record, other than as illustrating the fact that this disease is by no 
means so rare as one would suppose, when we consider the small 
number of cases that have been reported in current medical litera- 
ture. Of these five additional cases, one was a maiden lady, aged 
forty, engaged in literary life, and of a decidedly neurotic temper- 
ament, whom I saw but once. The second, a young lady of 
twenty-eight, in the enjoyment otherwise of fairly good health, in 
whom no treatment was of any avail, although under occasional 
observation during a period of two years. The third was a physi- 
cian of about forty, whom I saw but once, and who suffered from 
hay-fever during four months, while during the rest of the year he 
suffered from almost daily attacks of watery discharge from the 
nose, which was aggravated by intense cold, wind, dust, etc. The 
fourth was a gentleman aged fifty-one, who had suffered for a year 
with daily attacks, coming on early in the morning, from one to 
four o’clock, and lasting several hours, during which time there 264 
DISEASES OF THE NASAL PASSAGES. 
was discharged about half a pint of clear watery fluid. This patient 
I saw but a single time. The fifth was a maiden lady, aged thirty- 
five, whom I have seen but twice, and who consulted me in regard 
to a watery discharge from the nose, attended with violent irrita- 
tion and sneezing, and which came on daily, lasting two or three 
hours at a time. 
Case XI.—Reported by Speirs.1 This case was that of a male, aged 58, who 
for nine months had been troubled with a discharge of watery fluid from the 
nostrils. The attack came on with sneezing, and was at first thought to be 
due to an irritating dust, arising from the coarse flannel upon which he had been 
working. Change of employment, however, had no influence on the discharge. 
The fluid was clear, watery, and did not stiffen the handkerchief, apparently 
containing no albumin, and did not excoriate the lip or nostril. The fluid 
was discharged drop by drop, as a rule, but sometimes it poured in almost a 
continuous stream from the nostrils. Exercise in the open air seemed to lessen 
the discharge. The sense of smell was unimpaired. At night he was obliged 
to sleep in almost an upright position, since when in a recumbent position, the 
fluid would overflow into the throat, exciting cough. Tannin and glycerin 
applications were without avail, but the discharge was permanently arrested 
by keeping the nostril filled with goose grease. Speirs was of the opinion that 
this application blocked up the passage from the nose into the antrum, which 
cavity he thought was the source of the discharge, and thus damming back 
the fluid, caused such changes to take place in the membrane lining this cav- 
ity, that it no longer secreted so profusely. 
Case XII.—Reported by Leber.2 Leber reports the case of a young 
woman, 2o]/2 years of age, who had suffered from hydrocephalus from birth, 
and who, in addition to headache and frequent epileptiform seizures, was an- 
noyed by the dripping of a watery fluid, at first from the left nostril alone, but 
later the discharge would frequently cease from the left side, and affect the right. 
The quantity of fluid discharged varied from 4 to 22 cc. in the twenty-four hours. 
An opthalmoscopic examination revealed atrophy of both optic discs. Although 
the discharge would occasionally intermit, as did the headache and epilepti- 
form seizures (though no coincidence was noticed), it never ceased permanently. 
Case XIII.—Reported by Nettleship.3 This writer reports a rather curious 
case of this affection, the clinical history of which differs decidedly from those 
already reported. The patient was a young lady aged 23, subject to hysteria and 
to palpitation, who was attacked rather suddenly with headache, prostration, and 
what was apparently a mild amnesic aphasia, forgetting words so that she was 
obliged to give up her position. During this illness, the eyes were said to have 
become prominent. There was some muscular weakness, particularly on the left 
side. There was no vomiting. During her illness the sight became very much 
impaired but subsequently improved. There was no emaciation. Eighteen 
months later Nettleship found post-papillitic atrophy of both optic discs, with 
contraction of the field of vision, especially at its outer part, the left eye being 
more affected. Two months before Nettleship made this examination, fluid began 
to drop from the nose. The symptom was less aggravated when she was in bed, but 
was not affected by abstinence from fluids for an entire day. The secretion of 
fluid was entirely confined to the left nostril, the mucous membrane of which 
1 Lancet, 1S81, vol. i., p. 369. 2 Graefe’s Arch., vol. xxix., I, 273. 
3 Ophth. Review, London, 1883, vol. ii., pp. 1 to 3. NASAL H YDRORRHCEA. 
265 
was swollen and excoriated. The fluid was neutral in reaction, and contained 
chlorides, traces of phosphates and sulphates, with a small quantity of albumin 
and mucin; hence it was probably nasal and not meningeal. One month 
later, the fluid became less in quantity from no apparent cause. At this time 
the patient developed a loud, ringing cough, and examination of the fauces 
revealed that the palate reflex was entirely lost. The case seems particularly 
interesting on account of the evidence of hysteria, together with exophthalmos 
and palpitation. The termination of the case is not given. 
Cases XIV. and XV. reported by Priestley Smith1 are some- 
what similar to the last. 
Case XIV.—Was that of a male aged 28, who one month after an attack of 
small-pox, began to have severe headache and vomiting, soon after which the 
sight began to fail, and he became blind. The pain in the head remained nu- 
changed, and four years later fluid began to drop from the left nostril. After 
continuing four months, the quantity of fluid diminished, and a week later 
stopped altogether. During this last week the pain in the head became de- 
cidedly worse, and the patient wras very drowsy. On one occasion he slept for 
36 continuous hours, and for nearly a week after was constantly falling asleep. 
At length he brightened up, and the discharge of fluid from the nose returned, 
this time from the right nostril. The discharge was diminished at intervals, 
and at these times the pain in the head would be much aggravated, and the 
patient would be more or less drowsy. These attacks gradually grew more and 
more severe, and in the later attacks there were some convulsive movements. 
He died two years after the exhibition of the nasal symptoms. There was no 
autopsy. Ophthalmoscopic examination during the illness had revealed an 
atrophy of both optic discs. Examination of the fluid showed its specific grav- 
ity to be 1.007. It contained alkalies, albumin and mucin, and did not reduce 
copper. Its source, then, was probably the nose and not the arachnoid space. 
Case XV.—Was a male aged 22, who five years before, after prolonged mental 
exertion, which had made him very subject to headache, suddenly had a cere- 
bral attack from which he fell forward, lost consciousness, and developed in- 
ternal strabismus. For many months consciousness was imperfect, and he was 
subject to fits of delirium, severe pain in the head and vomiting. He became 
blind, and ophthalmoscopic examination revealed double optic neuritis, which 
subsequently passed into atrophy. For fourteen or fifteen months the lower 
extremities were completely paralyzed. Two and a half years after the begin- 
ning of the attack, fluid began to drop from the right nostril. Some months 
later, this became stopped with a polypus, subsequent to which time, fluid 
came from the left nostril. The polypus was removed from the right side, but 
soon recurred. The amount of fluid varied from twelve to fifteen ounces in 
twenty-four hours. When the discharge of fluid became less, he felt pain in 
the back, between the shoulders, which would gradually creep up toward the 
base of the skull, leaving the frontal region free from pain. Exercise increased 
the flow. His mother noticed that when the nasal secretion became diminished, 
urinary secretion became more free. The fluid was essentially the same as in 
the first case. The author was inclined to explain this occurrence by an ob- 
scure nasal growth, destroying the cribriform plate, or pressing upon it. 
Case XVI.—Reported by E. B. Baxter.2 A female, aged 35, had been in 
1 Ophth. Review, London, 1883, vol. ii., p. 4. 
2 Brain, vol. iv., p. 525. 266 
DISEASES OF THE NASAL PASSAGES. 
perfect health up to the time of her marriage. Five months afterward, she 
had been subjected to considerable worry and anxiety, and began to suffer 
from certain nervous symptoms, which steadily increased, until she was first 
seen two months after. She at first suffered from headaches, but shortly after- 
ward a clear watery fluid, sometimes rather offensive, and occasionally tinged 
with blood, began to come away from the right nostril. The headache, which 
was very severe, usually began at the right of the nose, and also involved the 
temporal region. Ophthalmoscopic examination showed double optic neuritis. 
The teeth in the upper jaw were decayed. There was uniform soft hypertrophy 
of the thyroid body of ten years’ duration. Three years after the symptoms 
began, the patient died. A rather imperfect autopsy revealed no nasal lesion, 
and no lesion of the brain. 
Case XVII.—Reported by Mathiesen.1 The patient was a thirteen-year-old 
boy, who had a severe fall, following which he was unconscious for some time. 
The following night he suffered from vomiting and epistaxis. About two 
months after the accident, he came under observation on account of the dis- 
charge of a thin watery secretion of a salty taste from the left nasal cavity. In 
the course of two hours twenty-five centimetres of this fluid were collected. 
His general health was good. Five days later the discharge ceased. Micro- 
scopical examination of the fluid revealed white blood-corpuscles, a few threads 
of mucus, and pavement epithelium. The fluid was of a specific gravity of 
1.006, and of alkaline reaction, and otherwise corresponded to a cerebro-spinal 
fluid. The writer was in doubt whether the source of the discharge was the 
cerebral or the nasal cavity. , 
Case XVIII.—Reported by Vieusse.2 Vieusse reports the case of a young 
man, who consulted him eight days after a severe fall upon the head, which 
had caused unconsciousness, and a discharge of blood from the left ear and 
nose. When seen by Vieusse, he complained' of severe headache, and there 
was a serous discharge from the nostril. On examination later, it was found 
that the serous fluid came either from the nostril or left ear according to the 
position of the head. About two drops were discharged each second. Death 
occurred, from meningitis, eighteen days after the accident. An autopsy re- 
vealed a fracture of the base, involving the cribriform plate of the ethmoid. 
In addition to these we find cases reported by C. J.3 and Lin- 
gard4 as examples of this disease, the former of which seems to have 
been an ordinary case of idiosyncratic coryza, while the latter was 
a case in which the symptoms were due to the excessive use of the 
cold-water douche. Lingard’s idea seems to have been, that the 
watery discharge was due to the fact that the accessory sinuses 
became filled during the use of the douche, and hence the dripping 
which followed it, was really the water escaping from these cavi- 
ties. Whatever may have been the cause, the symptoms disap- 
peared on abandoning the use of the douche. If Lingard’s view 
was a correct one, which I very much doubt, the case is certainly 
quite unique. 
1 Norsk. Magazin for Laegevidenskaben, p. 41, Jan., 1887. 
2 Gaz. Hebd., 1879, No. 19, p. 298. 3 British Medical Journ., 1879, vol. i., p. 175. 
4 British Medical Journ., 1878, vol. ii., p. 921. NASAL H YDRORRHCEA. 
267 
ETIOLOGY.—We have here a collection of exceedingly curious 
cases, and at first sight it would seem to be by no means a simple 
matter to give an explanation of the phenomena which they mani- 
fest, other than pure speculation, and yet I think there is much that 
is exceedingly instructive. The first feature which strikes us per- 
haps is the fact, that in a certain class of cases, the escape of 
watery fluid is purely passive and painless, while in the other, the 
flow of water gives rise to symptoms of intense irritation, such as 
we observe in ordinary cases of hay fever. This one symptom will 
serve to divide these cases, then, into two classes. In the first of 
these, the essential lesion consists of an ablation of function of the 
trifacial nerve, which, as we know, exercises an inhibitory action 
upon the serous exosmosis which takes place normally in the nasal 
mucous membrane. In connection with the paralysis of this nerve, 
of course, there occurs paralysis of sensation, and hence the trans- 
udation of fluid takes place without consciousness on the part of 
the sufferer. This feature was particularly noticeable in Althaus’s 
case, in which the pathological lesion seems to have been thor- 
oughly recognized, and the diagnosis established, of neuritis involv- 
ing the fifth nerve of both sides. The question arises whether the 
disease is due to a neuritis, as in this case, or to some other lesion, 
affecting either the nerve trunk, or the central ganglia, as there is 
good ground to think existed in Priestley Smith’s two cases, as well 
as in Nettleship’s, although neither of these authors adopted this 
view. In Paget’s case, an autopsy revealing the existence of polypi 
in the antrum of the side affected, these were accepted, without 
question, as the cause of the watery discharge. A more rational 
view, it seems to me, is that the polypi-were the result of the affec- 
tion, and that the essential lesion consisted of some obscure condi- 
tion at the base of the brain, which gave rise subsequently to an 
attack of acute meningitis, to which the patient succumbed. Cer- 
tainly it is difficult to understand how the existence of polypi in 
an antrum should cause the symptoms, while, on the other hand, 
it is very easy to see how a vaso-motor paresis with profuse watery 
discharge should give rise to myxomatous degeneration, whether 
in the antrum or in the nasal cavity, in the same manner as oc- 
curred in two of my own cases which are reported in full.1 In an- 
other class of the cases, we see that the watery discharge gives rise 
to an intense irritation of the nasal mucous membrane, as mani- 
fested by the peculiar formication and sneezing which becomes a 
source of exceeding great distress This, of course, can only occur 
in cases where the general and special sensibility of the Schneider- 
ian membrane is intact, or in other words, in cases in which the 
1 Cases IX., X. 268 
D IS EASES OF THE JVASAL PASSAGES. 
integrity of the trifacial nerve is preserved. We must, therefore, 
seek for a cause of the hydrorrhoea in these cases, in some cause 
other than a lesion of the trifacial. We content ourselves with the 
statement, that the lesion here consists of some disturbance or irri- 
tation, involving the sympathetic system of nerves. Whether this 
is peripheral or central, can only be a matter of speculation. It is 
a noticeable fact, in these cases, that there is no evidence of cere- 
bral disturbance whatever, other than an occasional headache, 
which is relieved by the setting in of the watery discharge. The 
headache is easily explained, in that it is probably an ordinary 
plethoric headache, which is relieved by the local exosmosis, in 
much the same manner as we frequently see headaches relieved by 
the relief of nasal hyperaemia. This latter class of cases, therefore, 
is very closely analogous to ordinary cases of hay fever. More- 
over, we see in them a certain diurnal periodicity, which wTould 
seem to indicate that the causes which act to produce the symp- 
toms, are operative only under certain atmospheric conditions. In 
a number of these cases, the membrane seemed to be exceedingly 
sensitive to the action of cold, wind, dust, or other causes, thus 
manifesting a condition which is almost always present in hay fever, 
in that a large majority of patients who suffer from autumnal at- 
tacks of this disease, are peculiarly sensitive, at all seasons of the 
year, to the action of smoke, dust, or irritating vapors. Sex would 
seem to have but little influence on the affection, in that of the 
twenty-three cases given above, thirteen were males and ten 
females. It belongs essentially to adult life, as the ages of these 
patients were from twenty-two to fifty-two, with the exception of 
Mathiesen’s case, which was a boy of thirteen, who in all probability 
suffered from fracture of the base of the skull. Traumatism, as a 
possible remote cause, is mentioned in several of the histories, al- 
though a careful reading of the cases fails to establish any clinical 
connection between the injury and the hydrorrhoea. In Tillaux’s 
case, I think the suggestion of fracture of the ethmoid is quite 
superfluous, in that the existence of the polypi seems to have been 
quite sufficient to establish some antedating and efficient cause for 
the watery discharge. Davies’s case was undoubtedly one of sup- 
purative disease of the antrum. The neurotic element seems to 
have been present in many of these cases, in much the same way 
as we find it in hay fever, which brings us to the question, as to 
what relation the one disease bears to the other. Certainly, as re- 
gards the cases dependent on lesion of the trifacial, I doubt if there 
is any connection, but in those in which the trifacial was not in- 
volved, and which we refer to some obscure lesion of the sympa- 
thetic, I think there can be no doubt that the disease is very closely NASAL H YDR ORRHCEA. 
269 
allied to hay fever, in that it is dependent, to a large extent, on 
what we call the neurotic habit. The other two essential causes of 
hay fever, viz., a diseased condition of the nasal mucous membrane, 
together with the impact upon it of the pollen of flowering plants, 
are not present. In my own cases, no lesion was found in the 
naval cavities. We can only say, then, of these cases, that in con- 
nection with an intensely neurotic temperament, the nasal mucous 
membrane is rendered sensitive to some obscure atmospheric con- 
dition, under the action of which vaso-motor control of the blood- 
vessels, whose special function is the exosmosis of serum in the 
normal process of respiration, becomes paralyzed, and that this 
exosmosis takes place to an abnormally large extent. Under the 
term neurosis, of course, in our ignorance of essential pathological 
lesions, we must include some probable organic lesion of the nerve- 
trunk, or ganglionic centres of the sympathetic system. That 
there is an atmospheric condition which excites the attacks in some 
instances, I think we must accept on clinical grounds, in that they 
occur daily, at about the same time, and in each individual case 
persist for the same period. This view is, furthermore, strength- 
ened by the fact that dampness, heat, and other atmospheric con- 
ditions, have a marked influence in aggravating or alleviating the 
severity of the symptoms. 
Symptomatology.—The symptoms of the affection are clearly 
indicated in the histories above given, and consist essentially in a 
dropping of clear, transparent watery fluid from the nose, which 
may either come on gradually, or abruptly, and while it lasts, con- 
sists of a constant flow of water from the nostril, which may be 
attended with a violent sense of irritation or not, according as 
the disease is dependent upon a morbid condition in the sympa- 
thetic control of the blood-vessels of the nasal mucous membrane, 
or of the trifacial. This dripping may continue during the whole 
twenty-four hours, or it may manifest a certain diurnal periodicity.. 
Where it occurs during the night, it is usually somewhat dimin- 
ished, although in many cases it continues during the sleeping 
hours, accumulating in the cavity of the nose, and pouring out, as 
it were, on a change of position. If it passes into the pharynx, it 
may give rise to cough, or even attacks of spasm of the glottis, as 
occurred in Rees’s case. In Althaus’s case, the discharge poured out 
upon the upper lip, producing excoriation, and ultimately almost a 
cicatricial condition of the skin. If the attack is accompanied by 
sneezing, etc., it may become a source of very great distress and 
even suffering to the patient. Where, however, sensation is abol- 
ished in the nasal cavity, the condition is merely one of discomfort 
and annoyance, as far as the watery discharge itself is concerned. 270 
DISEASES OF THE NASAL PASSAGES. 
PROGNOSIS.—In those cases which are essentially a neurosis 
of the sympathetic, and which are so closely allied to hay fever, the 
prognosis is somewhat unfavorable, in that we have difficulties to 
contend with here, even greater than those with which we have to 
contend in hay fever. Now, this latter disease, as we know, is an 
exceedingly fickle one, and in many cases will resist every effort 
to afford relief, although we have here a definite local lesion in the 
nose, as a prominent factor in causation, and the removal of which 
presents a clear indication for treatment. In the disease in ques- 
tion, however, the only tangible lesion with which we have to deal, 
is the neurosis, and this in most cases will seriously tax our thera- 
peutic resources. Of seven cases of this variety which were under 
my own care, but one was cured, although but three of them were 
under my care for any prolonged period of observation. More- 
over, in the one case which was cured, it is somewhat doubtful 
whether the fortunate termination was the direct result of any 
therapeutic measures. As regards the cases dependent upon a 
lesion of the trifacial, no prognosis can be given, unless the special 
lesion which has caused the disease can be definitely ascertained, in 
which case the prognosis will be based entirely on this information. 
Treatment.—The indications for treatment are twofold, viz., 
the use of such local applications in the nose as control vascular 
turgescence, and second, the resort to such therapeutic resources 
as we possess, for the remedying of the morbid lesion in the nerve 
trunk. The first indication is better carried out by the resort to 
cocaine, whose local action in controlling vascular turgescence is 
prompt and certain, beyond any other drug which we possess. 
The patient should be provided with a proper atomizer, and com- 
mencing with a four-per-cent solution, gradually reduce it, until he 
finds the weakest solution which will afford him relief, when he is 
allowed to obtain such comfort as may be afforded by its applica- 
tion, as frequently as may be demanded. I think it is very ques- 
tionable, on reading the reports given above, whether internal rem- 
edies have proven of much avail. Elliotson’s case seems to have 
been cured by the internal and local use of zinc, yet I think it an 
open question, whether either the local or internal use of this drug 
had the slightest influence on the attack. Paget’s case was very 
similar. In Althaus’s case, the diagnosis was made, and clear indi- 
cations carried out, with a good result. In the second of my own 
cases, after the use of numberless drugs, the patient was finally 
cured by the use of the galvanic current, locally applied, a method 
of treatment which seems in every way rational, and apparently 
clearly indicated, and yet in my first case, this resort was not only 
of no avail in giving relief, but seemed to aggravate the disease. NASAL HYDRORRHCEA. 
271 
The best then that we can say in regard to treatment, is that where 
we can definitely ascertain the cause of the disease, the indications 
for treatment are clear. Where the cause of the disease is obscure, 
as is the case in the large majority of instances, any plan of treat- 
ment must be to a large extent experimental, and governed by 
such indications as may be found to exist upon a careful study of 
each individual case. CHAPTER XVII. 
ANOSMIA. 
DISTURBANCES of the function of olfaction may manifest them- 
selves in an increased activity of this sense, giving rise to what is 
usually designated as hyperaesthesia of the olfactory nerve, by the 
action of which odors are appreciated with a very high degree of 
sensitiveness. This condition, is almost invariably met with in con- 
nection with hysteria, and presents no point of special clinical in- 
terest. Cloquet,1 however, has observed it in connection with dis- 
ease of the intestines, testicles and uterine organs. Again, we not 
infrequently meet with a curious perversion of this function, termed 
parosmia, or paraesthesia of the olfactory nerve, under the action 
of which, imaginary impressions are received, usually of a disagree- 
able kind, which are purely subjective, and are the result of some 
pathological lesion in the olfactory bulb, nerve, or of some central 
brain lesion. Or, again, it may be purely subjective, as in a case 
observed by Berard,2 in which the patient complained of unpleasant 
and offensive odors. An autopsy was performed subsequently and 
the olfactory nerves were found completely destroyed. 
From a clinical point of view, this condition perhaps occurs 
most frequently as a subjective hallucination in cases of insanity, 
although it may occur in connection with any form of organic brain 
disease. Our main interest, however, in this connection, lies in the 
consideration of that form of perversion of this function, which is 
characterized by an impairment or total loss of the sense of smell, 
usually designated as anosmia. 
Etiology.—This symptom may arise from any condition which 
either interferes with the entrance to, and impact of odorous par- 
ticles upon the mucous membrane lining the upper portion of 
the nasal cavity, called the olfactory tract, or from any morbid 
condition of the nerve itself, which prevents its full appreciation of 
the odorous character of those particles. Under this latter head 
may be embraced lesions of the terminal filaments of the nerve, 
lesions of the trunk of the nerve, or lesions of the bulb. Under 
the former class may be embraced acute rhinitis, hypertrophic 
1 OsphrEesologie, Paris, 1821, p. 749. 
2 Froriep’s Notizen, vol. xi., p. 151. ANOSMIA. 
273 
rhinitis, fractures or deformities of the septum, nasal polypi and 
other forms of neoplasm. In much the same way, tumors of the 
pharynx or palato-pharyngeal adhesions, give rise to anosmia, in 
that the inspiratory current of air through the nose is interfered 
with. In these cases, the symptom is due to purely mechanical 
causes, and yet, while a nicer use of the term anosmia would sug- 
gest that it would be confined entirely to cases of purely neurotic 
origin, yet it is customary to group them all under the same con- 
sideration. Among the causes of the disease, which lie in a mor- 
bid condition of the nerve itself, are embraced, atrophy of the bulb 
or of the trunk of the nerve, as in cases observed by Prevost1 and 
Notta,2 or the nerve may be absent, as in cases reported by 
Dubreuil,3 Pressat,4 Blandin,5 Despres,6 de San Juan7 and Bernard.8 
In addition to these, several congenital cases have been re- 
ported by Notta.9 Traumatism also plays an important part in 
the production of the symptom, giving rise to fracture of the base 
of the skull, as observed by Notta9 and Molliere,10 or in a separation 
of the bulb from its branches, as they enter the cribriform plate of 
the ethmoid, as Ogle 11 suggests, and as probably occurred in Legg’s 12 
case, where the injury resulted in permanent loss of the sense of 
smell, although in a very similar case reported by Rotch,13 whicli 
was attended with hemorrhage from the ears, nose, and mouth, the 
anosmia disappeared at the end of six weeks. 
In a case observed by Hamilton,14 permanent anosmia super- 
vened upon a meningitis following a blow upon the occiput. 
Tumors of the brain, it would seem, are not liable to give rise 
to complete anosmia, in that their location as pressing upon both 
nerves, would be somewhat unusual. Thus, Loder15 met with a 
case from scirrhus of the pituitary body. Oppert16 also found an 
abscess of this body, pressing on both olfactory nerves, resulting in 
loss of the sense of smell, Huguenin,17 however, in reporting two 
1 Gaz. Medicate, 1866, No. 37, p. 597. 
2 Arch. Generate, 1870, vol. i., p. 385. 
3 Gaz. Medicate, 1835, 2 s., vol. iii., p. 243. 
4 Cited by Longet, Anat. et Phys. du Systeme Nerveux, vol. ii., p. 39. 
5 Bui, de la Soc. Anat., Paris, 1827, Second Edition, 1844, vol. ii., p. 18. 
6 Bui. de la Soc. Anat., Paris, 1841, p. 140. 
7 Siglo Med., Madrid, 1857, vol. iii., pp. 21 x and 218. 
8 Cited by Althaus, Lancet, 1881, p.771. 9 Loc. cit. 
10 Lyon Medicate, 1871, vol. viii., p. 385. 
11 Med-Chir. Trans., 1870, vol. liii.. p. 263. 
12 Lancet, Nov. 8th, 1873, vol. ii., p. 659. 
13 Boston Medical and Surg. Journ., 1878, vol. xcix., p. 130. 
14 Trans, of the Col. of Physicians, Philadelphia, 1870, n. s., vol. iv., 362. 
15 Observatio Tumoris Scirrhosi in basi Cranii reperti, Jen., 1790. 
16 Dissertatio inaug. de Vitiis Nervorum Organicis, Berol., 1815. 
17 Correspondenzblatt ftir Schweizer Aertze, 1882, vol. xii., pp. 257 and 295. 274 
DISEASES OF THE NASAL PASSAGES. 
such cases, has found that this symptom is due rather to a basilar 
meningitis, excited by the presence of the neoplasm. There can 
be little doubt that very many cases of cerebral hemorrhage or 
neoplasm result in a destruction of functional activity in the olfac- 
tory nerve on one side, and yet this condition is probably so far 
masked by the more serious symptoms which result from the cen- 
tral lesion as to escape notice. The main point of interest in this 
connection, is that this condition always occurs on the left side, 
and is associated with aphasia and paralysis of the right side of the 
body as observed by Hughlings Jackson,1 Ogle - and Fletcher.3 
In an interesting case observed by Althaus,4 this symptom de- 
veloped in the second stage of an attack of locomotor ataxia, 
about six years after the onset of the disease, while in one of 
Molliere’s4 cases, it was due to cerebral syphilis, as also in Rom- 
berg’s 5 case. 
Those cases, in which the affection is the result of a morbid 
condition of the terminal filaments of the olfactory nerve, are 
probably also to be classed as neurotic. In this category are to 
be embraced those cases in which permanent anosmia results from 
the inhalation of irritating or highly offensive gases, or powerful 
odors. Thus, Graves6 reports a case, in which a man subjected 
himself to the exceedingly offensive and irritating gases which 
emanated from a cesspool, for a period of several hours’ dura- 
tion, with the result of permanent loss of the sense of smell, and 
again in a case reported by Strieker,7 the same accident happened 
to an entomologist from working several hours a day in an at- 
mosphere surcharged with ether, which he used in the prepara- 
tion of his specimens. It is a noticeable fact, in these cases, that 
the anosmia only occurred after the terminal filaments of the nerve 
had been subjected to the irritating action of these agents, for a 
somewhat prolonged period of time, for while, as we know, if we 
subject the olfactory tract to the irritating effects of strong am- 
monia, for instance, the sense of smell is abolished temporarily, 
although no permanently deleterious effects occur. Its prolonged 
action, however, must undoubtedly give rise to some definite mor- 
bid change. It may be that the physiological irritability of the 
nerve is destroyed simply by prolonged and excessive irritation, or 
possibly a localized inflammatory process arises about the terminal 
filaments. A more plausible suggestion, however, is that of Alt- 
haus,4 that a capillary hemorrhage occurs in the nerve itself. 
1 London Hospital Reports, vol. i., p. 410. 2 Loc. cit., p. 273. 
3 Brit. Med. Journ., April, 1861. * Loc. cit. 
5 “ Klinische Ergebnisse,” p. 18. 6 Cited by Notta, loc. cit. 
7 Virchow’s Arch., vol. xli., p. 291. ANOSMIA. 
275 
Atrophic rhinitis, or ozaena, in its late stages, is attended with 
more or less complete loss of the sense of smell. This may be due 
to the fact, that the crusts and scales of dry mucus which lodge 
upon the surfaces of the turbinated bodies, prevent the approach 
of olfactory particles, or it may result from the fact, that the ter- 
minal filaments of the nerves are destroyed in the process of atro- 
phy, which, as we know, results in a condition verging on sclerosis 
of the mucous membrane, the atrophy of the nerve filaments being 
due entirely to pressure. It is probable, however, that the anosmia 
is due to a combination of both these factors. 
A somewhat curious suggestion is made by Mackenzie,1 that 
anosmia occurs in connection with paralysis of the seventh nerve, 
and that the orbicularis muscle being paralyzed, the tears flow 
over the cheek, instead of through the nose, thereby leading to an 
abnormal dryness of the nasal mucous membrane. It is scarcely 
necessary to suggest, that tears flowing through the lachrymal 
canal, in no way approach the olfactory tract, and furthermore, 
the nasal mucous membrane receives its moisture from the turbin- 
ated bodies, rather than from the tear-duct. Allusion has already 
been made2 to the importance which Ogle attributes to the pres- 
ence of pigment in the olfactory region, in the physiology of olfac- 
tion, the corollary of which is, that its absence may be an import- 
ant factor in the impairment of this function. Ogle substantiates 
his view by the report of a case in which a colored boy underwent 
a process of bleaching, as it were, until all parts of his body, which 
were not exposed, became white, while at the same time, the sense 
of smell gradually became impaired, and finally almost completely 
disappeared. He instances also a number of analogies, both in 
man and among the lower animals, showing that the sense of smell 
is more highly developed in the colored races, and furthermore in 
animals with a pigmented skin. The argument is ingenious, and 
admirably sustained, and yet it is certainly impaired by the fact, 
that albinos, both in man and the lower animals, are not univer- 
sally anosmic, yet even these, as Ogle shows, afford ground for 
his argument, in the fact, that among the lower animals, the acute- 
ness of the sense of smell seems to bear a certain proportion to 
their general pigmentation. 
Symptomatology.—The close relation between the sense of 
smell and the sense of taste has already been fully discussed in 
connection with the physiology of olfaction, where it was shown, 
that the sense of taste consisted only in the ability to appreciate 
1 “ Diseases of the Throat and Nose,” American Edition, Philadelphia, 1884, vol. ii., 
P- 455- 
2 Chapter VI., on the Physiology of the Nose. 276 
DISEASES OF THE NASAL PASSAGES. 
the bitter, sweet, salt and acid qualities of substances brought in 
contact with the mucous membrane of the tongue and palate, and 
that the more delicate elements of the sense of taste were due 
entirely to the appreciation of their odor, by the olfactory nerve. 
A loss of the sense of smell, therefore, is always accompanied by a 
deterioration of the sense of taste, and it is through this latter de- 
ficiency, that anosmia really is recognized, in the majority, if not in 
all Instances. There seems to be a connection between the olfac- 
tory properties of the upper nasal passages, and general sensation, 
although Magendie1 entertained the view, that olfaction was de- 
pendent upon the branches of the fifth pair, a view which Bernard 2 
supports, by reporting a case, in which the disagreeable odors of 
an outhouse were complained of by a patient, in whom the cribri- 
form plate, together with the olfactory nerves, were found absent 
on post-mortem examination. This may have been a case of par- 
osmia, similar to that of Berard’s,2 or more probably, as Althaus 
suggests, the disagreeable odors were largely made up of ammonia- 
cal effluvia of the fetid hydrogens, which could easily be appreci- 
ated by the general sensation of the mucous membrane. From a 
clinical point of view, however, the two properties are distinct, and 
in no way interdependent, in that the anosmia may be complete 
while the general sensation is in no degree impaired. In the ma- 
jority of instances, however, the condition is not one of complete 
anosmia, but rather a more or less notable impairment of the func- 
tion. Especially is this true of those cases in which the condition 
is due to an obstructive lesion in the nose, which prevents the 
entrance of odorous particles, as in nasal polypi and other tumors, 
acute rhinitis, hay-fever, etc., the extent of the anosmia bearing a 
close relation to the patency of the cavity. Where, however, the 
affection is due to a nerve lesion, the anosmia is usually complete, 
although it is noticeable in this form of the disease, that, in many 
cases, the complete loss of function is preceded by certain disturb- 
ances, such as hyperosmia or parosmia. Thus, in a case reported 
by Lockeman,3 the primary stage of the affection was marked by 
the appreciation of disgusting odors, while Althaus2 has observed 
a case, in which the odor of phosphorus was a source of great 
annoyance to a patient, who subsequently developed complete 
anosmia. 
PROGNOSIS.—The differential diagnosis between essential and 
symptomatic anosmia is a matter of some importance, as regards 
prognosis, in that while recovery from the former is exceedingly 
rare, in the latter, we may usually give a favorable opinion, de- 
1 Jour, de Phys. exper., Paris, 1824, vol. iv., p. 169. 
3 Cited by Althaus, loc. cit. 
2 Loc. cit. ANOSMIA. 
277 
pendent upon our ability to remove such local obstructive lesion in 
the nose as rhinoscopic inspection reveals. Perhaps the only 
cases in which a favorable opinion can be given in essential an- 
osmia, are those dependent on syphilis. In a case reported by 
Raynaud' the anosmia seemed to be due to malarial poisoning, in 
that it was intermittent, recurring every day at five o’clock; more- 
over it was entirely cured by the administration of quinine. A 
nice question arises here, as to how long the olfactory nerve will 
retain its integrity, while its function is affected by an obstructive 
lesion of the nasal cavity. It is an almost universal rule in the 
economy, applying alike to gland structures, muscles, and probably 
to nerves, that when their function is ablated, they show a tendency 
at least to degenerative changes of an atrophic character. Hence, 
if the function of the olfactory nerve is suspended by some lesion 
of the nose, which absolutely prevents the approach of odorous 
particles, this tendency manifests itself, and if the lesion remains for 
a sufficient period of time, the nerve will have undergone such 
atrophy as that its integrity cannot be restored by the removal of 
the obstruction. Perhaps no definite period can be stated, during 
which this nerve may retain its functional activity, and probably it 
varies in different individuals. I have never seen a case, for in- 
stance, of nasal polypi, in which both cavities were completely filled 
with polypi without relief for ten years, in which complete and 
permanent anosmia did not supervene. I have seen, in many in- 
stances, cases in which the sense of smell was abolished for four to 
six years, from this cause, and yet ultimate recovery ensued. 
Notta2 has seen a case of anosmia due to polypi, in which recovery 
took place at the end of fifteen years. We can only state then, 
that perhaps six or eight years of total ablation of function will 
result in a permanent loss of the sense of smell, probably as the 
result of degenerative changes, either in the olfactory trunk, or at 
the nerve centres. It is not to be understood that the prognosis is 
unfavorable in all cases of anosmia due to brain lesions. Thus, in 
a case reported by Ogle3 dependent on apoplexy, there was ulti- 
mate recovery. A like conclusion also resulted in Rotche’s cases, 
in which there was probably a local extravasation at the base of 
the brain; and in three of Notta’s cases, where there was fracture 
of the base of the skull. These cases, however, are somewhat ex- 
ceptional. Dubreuil4 reported a case, in which the anosmia oc- 
curred in connection with a cleft palate, and where post-mortem 
examination showed absence of the olfactory nerves, which would 
suggest an explanation of the symptoms occasionally met with in 
1 Union Medicale, July loth, 1879, p. 58. 
3 Loc. cit., p. 273. 
2 Loc, cit., p. 405. 
4 Loc. cit. 278 
DISEASES OF THE JVASAL PASSAGES. 
connection with the deformity, in that a cleft palate is very fre- 
quently associated with a malformation or deficiency of the brain. 
Pathology. — It is impossible to describe any pathological 
lesion as belonging essentially to anosmia, in that the disease is a 
symptom of a variety of diseases, rather than a disease itself. 
Thus, it may be dependent upon a tumor of the brain, pressing 
upon, or involving the olfactory centre in or near Broca’s convolu- 
tion ; or involving, or perhaps pressing upon, the nerves in their 
continuity; or upon the bulbs themselves. It may be due to con- 
genital absence of the bulbs and nerves. In Oppert’s1 case, there was 
an abscess of the pituitary gland, and in Bonet’s2 cases there was 
pus formation in the olfactory bulbs themselves. Again, the nerve 
may become involved in local inflammatory changes in connection 
with meningitis. The only special interest which attaches to this 
branch of the subject, however, is in connection with the changes 
which may occur in the olfactory region. I know of no observa- 
tions bearing on this subject, and yet it seems clear, that, in many 
cases, we must concede that the diseased condition of the brain 
itself is responsible for the loss of the sense of smell. Aside from 
those conditions in which the approach of odorous particles to the 
terminal filaments of the olfactory nerve is prevented, this condi- 
tion probably consists of some atrophic change, occurring in the 
terminal filaments of the nerve, due, either to the pressure of local 
inflammatory deposits, or to a deficiency of circulation, this latter 
condition being the one which exists in the ordinary forms of atro- 
phic rhinitis; or, again, it may possibly be connected with the de- 
generative changes which occur in old age. Thus, Prevost1 in an 
examination of a large number of cases, has found certain degener- 
ative changes in the olfactory nerve trunk, as belonging especially 
to advanced life, in which the trunk of the nerve is less bulky, and 
fills a relatively smaller space in the groove of the ethmoid, while 
the nerve fibres themselves are diminished in number, their place 
being supplied, as it were, by increased numbers of amyloid cor- 
puscles. In more frequent instances, however, we must look for 
local inflammatory changes, as the source of the condition. Thus, 
in an ordinary acute rhinitis, we may have anosmia persisting for 
many days after the inflammatory process undergoes resolution; 
while in hay-fever, in which the local inflammatory action persists 
for a still longer period of time, there may result an anosmia, of 
even months’ duration. The same thing also occurs in croupous and 
diphtheritic rhinitis, especially in the latter, where the symptom is 
the result of local changes, rather than of blood poisoning. 
DIAGNOSIS.—The essential importance of the diagnosis consists 
1 Loc. cit. 
2 Sepulchretum, Geneva, 1700, lib. i., sec. xx., obs. 1., p. 441. ANOSMIA. 
279 
in the determination, as to whether the symptom be due to a local 
condition of the nasal chambers, or a diseased condition of the 
nerve. In other words, whether we have to deal with an essential 
or symptomatic anosmia. This can only be determined by a care- 
ful examination of the nasal cavity, and by the elimination of any 
possible local cause there. This, taken in connection with the his- 
tory of the case, and the concomitant symptoms, ordinarily will 
suffice to establish, with a considerable degree of certainty, the 
existence or non-existence of any central disease. We eliminate, 
then, from consideration, brain tumors, hemorrhages, abscesses, 
meningitis, tabes and all diseases of this character, in that, in such 
cases, an anosmia becomes a symptom of the most trivial character, 
in the presence of an exceedingly grave organic affection, and only 
interest, as serving as a possible, though unimportant aid to diag- 
nosis, in that, as Hugueinin1 observes, anosmia may occur in con- 
nection with brain lesions, even remote from the olfactory centres. 
The simple test for olfaction consists in the use of odorous 
substances. In the selection of these, however, one should always 
make use of a substance which is recognized purely by its odorous 
qualities, the most delicate test, of course, being the fragrant odors, 
whereas the disagreeable odors are often deceptive, in that what is 
unpleasant, often is not necessarily a genuine odor. If it is desired 
to accurately and determinately ascertain the condition of the 
olfactory nerve it will be necessary to resort to the use of the gal- 
vanic current, Althaus having shown that this nerve affords a direct 
response to the electrical stimulus, when healthy. A current from 
a thirty-five-cell battery being passed as nearly as possible through 
the course of the nerve, gives rise, according to the integrity of the 
nerve, to a well-marked subjective odor of phosphorus. Unfor- 
tunately, the application of this test may be exceedingly limited, in 
that, except in rare instances, where there is paralysis of the fifth 
pair of nerves, a current of this strength will be too painful for 
endurance. The existence of a unilateral essential anosmia, al- 
though not easily recognized, can be determined by delicate tests, 
and ordinarily should be regarded as evidence of brain lesion. A 
determination of the loss of smell, on one side alone, would require, 
of course, a very careful and complete closure of the opposite cav- 
ity, both before and behind. 
TREATMENT.—Clinical observation has failed, as yet, to afford 
us any very notable suggestions for the successful treatment of an 
essential anosmia. Our interest in this connection mainly centres 
on those cases in which this function is to a greater or less degree 
enfeebled, as the result of some obstructive lesion in the nasal cav- 
1 Loc. cit. 280 
DISEASES OF THE NASAL PASSAGES. 
ity. In the larger majority of instances, the indications for treat- 
ment are nothing further than the removal of the organic lesion 
in the nose. In certain instances, however, where after this has 
been successfully accomplished, the sense of smell is found still 
notably impaired, it becomes necessary to resort to measures for 
its restoration. For this purpose, we may use in a routine way, 
perhaps, preparations of strychnine, arsenic, phosphorus, or any of 
the ordinary remedies, which are supposed to possess specific prop- 
erties in restoring tone to the nerves. I confess that I have never 
seen any directly recognizable good results, from the administra- 
tion of any of these drugs. Mackenzie1 advises the local adminis- 
tration of strychnine, by means of insufflation, giving from one- 
twenty-fourth to one-sixteenth of a grain twice daily. It should 
be borne in mind, that the alkaloids are absorbed by the nose with 
more readiness even than by the stomach, and that the full physio- 
logical effect of the drug is thus obtained almost as rapidly as by 
means of a hypodermatic injection. Notta* suggests the use of 
local insufflation of powders containing veratria, in the proportion 
of one to one hundred and twenty. 
Our most reliable measure, however, will be the use of the gal- 
vanic current, commencing with daily applications of a weak cur- 
rent, and increasing the strength according to tolerance. In some 
cases, faradization will give even better results than the continued 
current. I think in many cases, where the nerve has become en- 
feebled by long-continued disease, we may stimulate it into func- 
tional activity, by forcing it, as it were, to fulfil its normal duties. 
This can be accomplished by using not irritating but agreeable 
odors, of as powerful a kind as are easily obtainable, and rrequently 
changing them. The choice of odors will be such as the patient’s 
fancy may dictate, but these should be frequently changed, a half- 
dozen different ones being used in the course of the same day, and 
applied frequently, first to one nostril and then to the other. In 
this way, we may obtain even better results than by the use of 
electricity, or the internal administration of strychnine, or the other 
nervines. 
1 “ Diseases of the Throat and Nose,” American Edition, Philadelphia, 1884, vol. ii., 
p. 461. 
3 Loc. cit. CHAPTER XVIII. 
DEFORMITIES OF THE NASAL SEPTUM. 
DEFORMITIES of the nasal septum, either as a result of trauma- 
tism or inflammatory action, are probably the most frequent of all 
the exciting causes of catarrhal inflammation in the nasal mucous 
membrane. Hence it becomes a matter of no little importance 
that we should thoroughly appreciate, not only their method of 
development, but also the rationale of their action upon the lining 
membrane of the nasal cavities, as well as their influence upon its 
respiratory functions. 
In health, we find the nasal septum presenting simply as a bony 
and cartilaginous wall, dividing the nasal passages into two sym- 
metrical cavities. It thus possesses no very important function in 
the economy, although on its upper portion there is found a site 
for the distribution of filaments of the olfactory nerve, while in the 
lower and posterior portion we find imbedded in the mucous mem- 
brane certain vascular structures, which probably contribute some- 
what to the great respiratory function of the nose. In diseased 
conditions, however, we find present in this structure certain ab- 
normalities of contour, which undoubtedly have a marked influence 
in the production of an ordinary catarrhal inflammation. The first 
to recognize a deformity of this structure was Quelmalz,1 who de- 
scribed septal deflections, attributing their existence to the habit of 
putting the finger into the cavity. 
Morgagni,2 making a more special investigation of these parts, 
attributed the deflections which he found, to excessive growth of 
the septum, as a result of which it became too large to fit in its 
bony framework, thereby becoming warped. 
Coming down to our own day, we find Theile3 making a statis- 
tical study of the subject. He examined 117 skulls, in only twenty- 
nine of which was the septum symmetrically placed. Similar 
results were obtained by Semeleder, who, in examining forty-nine 
skulls, found the septum bent to the left in twenty, to the right in 
1 “ Programma de narium earumquoe septi incurvatione,” Lipsice, 1750, p. 7. 
2 “ De sedibus et causis morborum,” i. xiv., 16. Batav., 1767. 
3 Zeitschrift fur rationelle Medizin, 1855, Neue Folge, vol. vi., p. 242. 282 
DISEASES OF THE JVASAL PASSAGES. 
fifteen, and a sigmoid deformity in four, while Harrison Allen,1 in 
fifty-eight skulls, found narrowing of the left side in nineteen, and 
of the right side in twenty-one; in six of the latter, there was con- 
tact between the superior and middle turbinated bones and septum. 
These statistics are all based on an examination of the dry skull, 
where, it should be remembered, there may be a source of error 
due to the warping which is liable to take place in thin bones. 
Zuckerkandl,2 who has made perhaps the most thorough study of 
this subject, bases his statistics largely, I take it, on an examination 
of the cadaver, which I think unquestionably affords us more accu- 
rate data. Out of 370 crania, he found 123 symmetrical and 140 
asymmetrical nasal septa. Of the last, the septum was deviated to 
the right in fifty-seven cases, to the left in fifty-one, and was sig- 
moid in thirty-two. 
Loewenberg3 after examining several hundred skulls, makes the 
statement, that only in about one case in seven do we find the 
septum absolutely straight in all its parts, while Mackenzie,4 in an 
examination of 2,152 skulls in the museum of the Royal College of 
Surgeons, found 1,657 cases in which the septum presented in a 
more or less asymmetrical position. In 834, the deviation was 
toward the left side, in 609 toward the right, in 205 the deflection 
was sigmoid in character, while in five the irregularity was what he 
called zigzag. It is noticeable here, that the examination of the 
dry skull shows a percentage of deviation in seventy per cent and 
upward, of the cases examined, while the study of the cadaver 
brings this percentage down to less than forty per cent, as in Zuck- 
erkandl’s investigations. The probable source of error here, has 
already been suggested. A study of the living subject gives us still 
further information, Heymann 5 going so far as to state that ninety- 
nine per cent of all cases examined will show deformities. This 
would seem rather an extravagant statement. If we only recognize 
those deformities which give rise to morbid symptoms, certainly 
this percentage should be very much reduced. 
A notable difference as regards race is observed by Zuckerkandl, 
in that one hundred and three of his cases were barbarous or semi- 
barbarous people, and in these only twenty-four were asymmetri- 
cal. This observation was confirmed by Mackenzie, who in four 
1 American Journal of Medical Sciences, Jan., 1880, p. 70. 
2 “Anatomie der Nasenhohlen,” Wien, 1882, p. 45. 
3 “Anatomical Researches on'Deviations of the Nasal Septum,” Archives of Otology, 
vol. xii., No. i, March, 1883 p. 25. 
4 “ Diseases of Throat and Nose,” American Edition, Philadelphia, 1884, vol. ii., p. 
424. 
5 Sixtieth meeting of the German Naturalists and Physicians, 1887. DEFORMITIES OF THE NASAL SEPTUM. 
283 
hundred and thirty examples of symmetrical septa, found only 
22.6 per cent in the superior races. Harrison Allen also found, in 
ninety-three skulls of negroes, deformity of the septum in only 21.5 
per cent. 
Classification.—Various classifications have been made, based 
largely on the character of the deviation, which occurs both in the 
bony and cartilaginous portions of the septum. Thus Loewenberg 
divides these cases into vertical, horizontal, and irregular devia- 
tions. and the horizontal subsequently into superior horizontal and 
inferior horizontal. Other classifications have been made by John 
Mackenzie,1 and Ingals.2 
When we remember that no two of these cases are alike, it would 
seem that any attempt at classification is immediately confronted 
with obstacles, which are difficult to overcome. Furthermore, its 
practical value is not very obvious. In a general way, we find the 
nasal septum, as the result of a fracture, presenting certain typical 
appearances which are easily recognized. Thus we may have the 
cartilage of the septum broken in the vertical line in such a way 
that the projecting ridge presents in one passage, with a corre- 
sponding depression in the opposite side. More rarely, we have 
the cartilaginous septum broken in a line more or less nearly ap- 
proaching the horizontal. These fractures occasionally involve 
the vomer in such a way that the horizontal ridge extends through 
both the cartilaginous and bony portions of the septum, examples 
of which are seen in Figs. 82 and 83. In another class of cases, 
the injury results in a dislocation of the articulation between the 
vomer and the superior maxillary bone in such a way that the 
lower border of the septum is shifted, as it were, to one side, thus 
encroaching on the lumen of the nares. Here we have Loewenberg’s 
lower horizontal deviation as seen in Fig. 84. Another form of 
deviation is what has been described'by many writers as sigmoid, 
shown in Fig. 85, a condition which would seem to confirm Mor- 
gagni’s view as to redundancy of growth. Here we have the lower 
portion of the cartilaginous septum and vomer bulging on one side, 
while above the perpendicular plate of the ethmoid, and the upper 
portion of the vomer, it turns to the opposite side, as a rule, coming 
in contact with the middle turbinated bone, thus involving largely 
the anterior two-thirds of the septum. Again the whole carti- 
laginous and bony septum may bulge, as it were, into one or the 
other cavities, as seen in Fig. 86, giving the impression, of its being 
too large to fit into its bony framework. A deflection involving 
1 “ Deflection of the Nasal Septum and its Treatment,” Trans. Med. Society of Vir- 
ginia, 14th session, 1883. 
2 “ Deflections of the Septum Narium,” Arch. Laryngology, vol. iii., No. 4, p. 291. 284 
DISEASES OF THE NASAL PASSAGES. 
Fig. 82.—Horizontal Deviation of the Septum, probably the result of a Fracture. (Zuckerkandl.) 
Fig. 83.—Horizontal Deviation of the Septum. (Zuckerkandl.) DEFORMITIES OF THE NASAL SEPTUM. 
285 
Fig. 84.—Dislocation between the Lower Border of the Septum and the Superior Maxilla. (Zuckerkandl.) 
Fig. 83.—Sigmoid Deflection of the Septum, probably the result of Fracture. (Zuckerkandl.) 286 
DISEASES OF THE NASAL PASSAGES. 
the posterior extremity of the vomer I have never seen. Schaus,1 
however, has found the deflection extending to the posterior nares, 
producing asymmetry in these openings. He bases his observation 
on digital examination rather than on rhinoscopy. It is character- 
istic of all these deviations, that, in every case, an angular or a 
rounded projection of the septum into one nostril, is attended with 
a corresponding depression on the opposite side. 
In addition to this, we find a large number of cases, in which 
there is present a more or less prominent deformity on one side of 
the septum, which is not accompanied by this corresponding de- 
pression. This condition is always found along the sutural lines 
Fig. 86.—Bulging of both Cartilaginous and Bony Portions of Septum into Right Nasal Cavity. 
(Zuckerkandl.) 
of the septum, and consists in a more or less well-developed angular 
prominence or ridge, which, projecting into the nasal passage, acts 
to obstruct normal respiration. These ridges are found, first, and 
most frequently, along the junction of the vomer with the superior 
maxillary bone; second, along the junction of the anterior border 
of the vomer with the cartilage of the septum; third, along the 
whole of the anterior border of the vomer, including its union with 
the cartilage of the septum, and the posterior border of the perpen- 
dicular plate of the ethmoid; fourth, and most rarely, at the junc- 
tion of the cartilage of the septum with the perpendicular plate of 
the ethmoid. In most instances, these ridges are confined to one 
1 Archiv ftir klin. Chirurgie, Band 35, Heft I, 1887. DEFORMITIES OF THE JVASAL SEPTUM. 
287 
side of the septum. In other cases, we find them occurring sym- 
metrically on either side of the suture, thus constituting a condi- 
tion, not properly classified under deviation or deflection of the 
septum. These were first described by Langenbeck1 who gave to 
them, mistakenly I think, the name exostoses, a term which is fre- 
quently used even at the present day. Subsequently they were 
recognized and described by Theile, Harrison Allen, John Mac- 
kenzie, Zuckerkandl, and others. 
Etiology.—The causation of these deformities has been the 
subject of no little discussion, and various theories have been ad- 
vanced to account for their occurrence. As regards those devia- 
tions which are due to fracture of the septum, of course there can 
be no question, they are due to a direct blow upon the nose. When 
we come, however, to discuss the causes of the sigmoid flexure, or 
unilateral bulging of the septum, as also the sutural ridges, a pretty 
large field for discussion is opened up. Quelmalz2 believed that 
deviations might be produced by the action of astringents, drying 
up the membrane, causing it to contract, and thus drawing the 
cartilage down upon itself, a view also entertained by Schultz. 
Cloquet3 obscurely states that these deviations are due to some 
defect in the primary laws of organization. Allusion has already 
been made to Morgagni’s view, that these deflections are due 
to excessive development of the vomer. This also was advocated 
by Chassaignac.4 In the same line is the view that the septum may 
be crowded up by a highly arched palate, a view suggested by 
Trendelenberg,5 who first called attention to the frequent asso- 
ciation of these two conditions. Jarvis6 has reported four cases 
in which this association occurred, all in the same family, which 
would seem to suggest that there might be an hereditary or 
systemic habit pre-existing, to account for the bony deformity. 
According to Schaus2 and Welcker,7 certain abnormal conditions 
of facial development are frequently associated with deformities of 
the septum. The first investigations in this line were made by 
Welcker,2 who describes certain changes in the shape of the an- 
terior nares, occurring in cases of septal deformity, which from 
their resemblance to the shape of the elm leaf, he denominates as 
pteleorrhin. In this condition, the two nares are asymmetrical, 
one being wider in a horizontal and the other in a vertical diameter. 
1 “ Handbuch der Anatomie,” Gottingen, 1842. 
2 Loc. cit. 
3 “ Osphresiologie,” Paris, 1821. 
4 Bulletin de la Societe de Chirurgie, 1851-2. 
s Cited by Schaus, loc. cit. 
6 New York Med. Record, March 14th, 1885. 
f “ Die Asymmetrie der Nase und des Nasen-Skelets,” Stuttgart, 1882. 288 
DIS EASES OF THE JVASAL TASS AGES. 
The less deeply cut nostril and the deviation of the crista nasalis 
always lie on one and the same side. Welcker also found, that, 
in the large majority of these cases, there was deformity of the 
nasal bones, and that the less deeply cut nostril lay on the side to 
which the bones deviated. While Welcker’s investigations show 
essentially a difference in shape of the external nose and of the 
nostrils, in cases of septal deformity, Schaus’s observations go to 
show that, in a large number of these cases, there is a faulty devel- 
opment of a large part of the facial skeleton. In other words, we 
may have scoliosis, as it were, of the whole face. The orbits may 
lie on different levels, thus giving rise to serious ocular trouble. 
The most marked changes, however, are seen in the development 
of the superior maxillae. The palatine arch is always high, the 
alveolar processes, instead of forming a wide arch, come together 
at a comparatively acute angle, the incisor teeth frequently over- 
lap, the palate is asymmetrical, the smaller half corresponding to 
the narrower nostril, and the alveolar processes are of unequal 
length, the longer alveolar process usually lying on the side to 
which the septum deviates. The cause of the deformity Schaus 
believes to be a faulty development of the facial skeleton, in exactly 
what manner it is impossible to say. With reference to rachitis 
as a possible cause, he says that the majority of the cases are not 
rachitic. Notwithstanding this conclusion, I think Schaus has drawn 
such a graphic picture of a rachitic case, that we must differ with him 
as to the conclusion, and say that where these conditions present, we 
have to do with a case of mollities ossium. This, however, explains 
but a very small proportion of cases which we observe. 
Now with regard to these various views, I think a larger clini- 
cal observation would lean to the view, that traumatism is by far 
the most frequent direct cause of septal deformities. The clinical 
history of many of these cases affords direct evidence of this, and 
even in those cases in which the direct injury is not testified to, I 
think it safe to say, that an injury has occurred, which may have 
been of so slight a character as not to have excited especial atten- 
tion at the time of the occurrence. An injury to the nose need 
not necessarily give rise to the immediate development of a notable 
deformity, as in fracture, but it may set up a low grade of morbid 
action, which going on through a number of years, will finally de- 
velop a condition by which the normal function of the nose is 
seriously hampered. In childhood or infancy while the parts are 
soft and delicate, and probably specially susceptible to injury, a 
fall on the face occurs, which perhaps ruptures some of the sutural 
attachments of the septum, or perhaps jams the septal cartilage 
against the vomer or perpendicular plate of the ethmoid, in such a DEFORMITIES OF THE NASAL SEPTUM. 
289 
way as to cause a low grade of inflammatory action. This morbid 
process developing slowly, results in an angular spur, we may say, 
along the anterior border of the vomer; possibly after five or ten 
years, or more, this will have attained sufficient size to cause notable 
obstruction to breathing, which, in a manner discussed in a former 
chapter, sets in play new forces, which, after the lapse of another 
long period of time, result in a chronic hypertrophic inflammation 
of the nasal mucous membrane. The point which I would particu- 
larly emphasize in this connection, is that, in the first place, the 
morbid lesion results from a slow process of development, and, 
secondly, that the catarrhal symptoms which ensue, develop only 
after another long lapse of time; the original injury, which has set 
in play all these forces, occurring in infancy or childhood. Zucker- 
kandl1 has shown us, that deformities of the septum never occur 
under seven years of age, while Welcker saw none before the fourth 
year. This, however, does not controvert the views that I advance, 
for, as I say, the injury may occur before either of these ages, with- 
out resulting in any notable deformitiy for many years later. Of 
course, these observations do not refer to fracture of the septum, 
which undoubtedly may occur at a very early age. Furthermore, 
these deformities, as the result of traumatism, although rarely, still 
do occur very early in life, for my own recorded cases show one 
operated upon at three years of age, and another at five. 
That inflammatory action plays some part in the deformities is 
borne out by a histological investigation of the masses removed. 
Thus in Fig. 87 is shown an illustration of the microscopic appear- 
ance in a case of sutural ridge removed by means of the saw, in 
which the perichondrium shows well-marked evidence of inflamma- 
tory action. This may be contrasted with a similar specimen 
shown in Fig. 88, probably of longer standing, in which the inflam- 
matory process, if it ever existed, has entirely subsided. That the 
injury may occur without the clinical history of traumatism, is very 
clearly shown by Robertson,2 who, in an examination of two hun- 
dred and forty cases, found abnormalities of the nose in two hun- 
dred and seventeen, while there was a clinical history of injury in 
but eighty-three cases. 
That traumatism plays an important part in the causation of 
these deformities is the view adopted by Zuckerkandl,3 who, how- 
ever, does not explain further the special method of their develop- 
ment. Miot,4 however, basing his conclusions on a microscopical 
1 Op. cit., p. 45. 2 Trans. Am. Laryngol Soc., 1885, p. 104. 
3 Op. cit., p. 48. 
4 “ Remarques sur certaines obstructions nasales,” Revue Mensuelle de Laryngologie, 
May, 1888, p. 245. DISEASES OF THE NASAL PASSAGES. 
290 
examination made by Duret, finds that these prominences consist 
essentially of plastic infiltration, thus establishing the fact that they 
Fig. 87.—Transverse Section of Deformity of the Septum. D, Duct of mucous gland; it, stratified 
epithelium thickened, F, hyperplastic fibrous connective tissue due to subacute inflammation; G, acinous 
mucous glands, scanty;/5, perichondrium, thickened by chronic plastic perichondritis; C, hyaline cartilage. 
Fig. 88.—Transverse Section of Deformity of the Septum. E, Ciliated columnar epithelium; F. capil- 
lary blood-vessel; G. acinous mucous glands; V, large vein; /’. perichondrium; C, hyaline cartilage. 
are inflammatory in their origin, constituting true perichondritis. 
Bresgen,1 Volkmann,2 Onodi,3 Gottstein,4 Hopmann,4 Heymann,4 and 
1 Wien. Med. Presse, Nos. 7, 8, 1887. 
2 Sixteenth Congress of the German Surgical Society. 
3 Sixtieth meeting of German Naturalists and Physicians. 
4 Idem. DEFORMITIES OF THE NASAL SEPTUM. 
291 
others, content themselves with simply assigning a traumatic origin 
to most cases, which would seem to indicate that the deviation 
occurred at the time of the injury. The point on which I would 
lay special emphasis, is that the deformity is primarily the result 
of traumatism, and secondarily of a slow inflammatory process, 
which results therefrom. Combining the views of the writers above 
quoted, with the investigations by Duret, who has so clearly shown 
them to be due to an inflammatory process, I think this view is still 
further strengthened by the investigations of Zuckerkandl,1 who 
has shown that, in many cases, there lies between the perpendicular 
plate of the ethmoid and the superior border of the vomer a nar- 
row strip of cartilage, apparently due to incomplete ossification 
of the temporary cartilages. Zuckerkandl thus accounts for the 
prominent ridges which are seen running from the nasal spine to 
the rostrum of the sphenoid. Those spurs or ridges which run along 
the lower border of the vomer, at its junction with the superior 
maxillary, probably, in many cases, occur at the time of the original 
injury, although here we must undoubtedly recognize the fact, that 
a chronic inflammatory process contributes much to their subse- 
quent development into more prominent deformities. 
How far syphilis is involved in the causation of these deformi- 
ties, is rather a nice question. My own impression is that all 
syphilitic lesions in the nasal fossae run a somewhat rapid course, 
and develop very soon into ulceration with necrosis, although 
Trelat asserts that many cases are of syphilitic origin. Rickets has 
been supposed by some, notably by Loewy,2 to be the cause of septal 
deformities. No doubt deformities of the septum are frequently 
associated with rickets, in the same manner that facial deformity is 
so associated. There is, however, no good reason for supposing 
this to be an exciting cause. With reference to the curious facial 
deformities noticed by Schaus and Welcker, in connection with 
deformities of the septum, it might be stated that Ziem 3 has shown 
by a series of experiments, that occlusion of one nostril in young 
animals, will produce similar facial deformities. It is a question, 
therefore, whether deviations of the septum may not play a certain 
part in the causation of facial deformity, instead of being only a 
concomitant condition or a result. 
Most writers mention the fact that septal deformities may be 
congenital. This is undoubtedly true, as the child in utero, as well 
as in the process of delivery, is not exempt from traumatism of a 
sufficiently violent character to do no little damage to the delicate 
tissues which form the nasal septum. 
1 Op. cit., p. 44. 2 Berliner klinische Wochenschrift, 1886, No. 47. 
3 Monatsschrift flir Ohrenheilkunde, 1883, Nos. 2, 3, 4, and 5. 292 
DISEASES OF THE NASAL TASS AGES. 
SYMPTOMATOLOGY.—From an objective point of view, nasal 
deformities may occasionally be recognized by a deformity of the 
external nose. This may show itself in two forms. In the one 
form we have what Welcker1 calls a scoliotic nose, in which the 
nasal bones are displaced in one direction, while the tip of the nose 
is turned toward the opposite side, thus forming an angle at their 
point of junction. In the other form, the whole nose is deflected 
bodily to one side. These external deformities may be so marked 
as to notably disfigure the face, or of so slight a character as to 
escape observation. It is worthy of note, that deformities of the 
external nose are of far more frequent occurrence than is generally 
supposed, for if we examine a given number of individuals with a 
plumb line, we will find the tip of the nasal organ deviating from 
the median line of the face, in quite a large proportion of cases. 
A third external deformity might be mentioned, which consists 
in a lack of symmetry of the two nostrils, met with in connection 
with deflection of the lower border of the cartilaginous septum, or 
displacement of the columnar cartilage, producing distortion of the 
columna nasi. In addition to these, there may be present, in a 
certain proportion of cases, the peculiar facial expression of nasal 
stenosis, which is more fully discussed in connection with hyper- 
trophy of the pharyngeal tonsil. 
Subjectively, the primary symptom to which these deformities 
give rise, is simple nasal stenosis, with interference with normal 
nasal respiration. Secondarily, however, there is set up in the nasal 
fossae, as the direct result of the deformity, a series of changes in 
the nasal mucous membrane, which so far interfere with its func- 
tions as to produce symptoms referable to the whole upper air- 
tract, constituting what is popularly designated as a chronic nasal 
catarrh. As already stated, I regard septal deformities as responsi- 
ble, in the large majority of cases, for the whole train of symptoms, 
direct and indirect, which are embraced under the very general 
term of chronic nasal catarrh, or to give it a more specific name, 
chronic hypertrophic rhinitis. The methods by which this develops, 
is so thoroughly discussed in the chapter on hypertrophic rhinitis, 
that it needs but a brief reference here. As the result of stenosis, 
either in one or both nares, the air immediately behind the point of 
deflection is rarefied with each act of inspiration, consequently the 
soft spongy membrane covering the turbinated bones is subjected 
to a sort of dry cupping process, as it were, by which its vessels 
become permanently dilated as time progresses. The direct result 
of the chronic hypersemia is, naturally, increased nutrition; all the 
nutritive processes of the membrane become stimulated to such 
1 Op. cit. DEFORMITIES OF THE NASAL SEPTUM. 
293 
an extent, that the membrane grows rapidly in all its parts, and 
becomes notably thickened; this thickening being due to an in- 
crease in the calibre of the blood-vessels, together with a deposit 
of connective tissue in the intervenous tissues. We thus have 
established all the elements necessary to the production of what 
we call a chronic catarrh. If the deformity has been such as to 
completely occlude one nostril, the function of the membrane in 
that passage is naturally abolished, and the membrane itself col- 
lapses, and is seen to be in an almost bloodless condition. It is 
necessary for the development of these hypertrophic changes that 
air should pass through the fossa. We therefore find it an invari- 
able rule, that the greatest extent of hypertrophy develops on that 
side which is most open, for in no case of a deflected septum is the 
extra width of the one passage competent to supply the deficiency 
of the other. In other words, the combined calibre of the two 
nasal passages, where deformity of the septum exists, is unequal to 
the purpose of the normal respiratory function. We thus find in 
those deflections characterized by prominence on one side, and 
concavity on the other, that the turbinated tissue on the concave 
side not infrequently grows out, as it were, into enormously en- 
larged masses, fitting themselves into the concavity of the septum. 
The statement is made by Baumgarten1 and reiterated by Seiler2 
that these deflections are produced by the hypertrophy of the tur- 
binated tissues. I am disposed to think that these writers have 
mistaken cause for effect; for, if this were true, in those cases in 
which we have notable hypertrophy of both turbinated bodies to 
the extent of contact with the septum, as suggested by Lowey,3 we 
should naturally expect to find atrophy of the septum or, as Bres- 
gen3 suggests, even perforation. 
Where the deformity produces stenosis in or near the nostril, a 
sinking in, during the act of inspiration, of the ala of the nose will 
often be noticed. The air entering the narrowed orifice in a rapid 
current, according to the extent of the stenosis, causes the nostril 
to collapse, in many cases producing complete occlusion. Deform- 
ity of the septum, probably more than any other single cause, gives 
rise to attacks of epistaxis, due to the fact that the irregularities of 
the surface of the septum present certain prominences, which are 
exposed to the ingoing current of air, laden with particles of dust 
and other impurities, whose action is something in the nature of 
the sand blast. These small particles, striking against these prom- 
inences, cause minute erosions, by which the mucous membrane is 
1 Deutsche Med. Wochenschrift, 1886, No. 22, p. 313. 
2 New York Med. Journal, Feb. 18th, 1888, p. 180. 
3 Loc. cit. 294 
DISEASES OF THE NASAL PASSAGES. 
broken, the walls of the capillaries are denuded or injured, thus 
becoming the source of more or less violent and profuse attacks of 
hemorrhage without apparent cause. Again the symptoms may 
arise from the habit of the patient of picking off with his finger the 
small crusts or scabs which form. 
The prominent subjective symptoms, then, of a deflected septum, 
are catarrhal inflammation of the nasal mucous membrane, with its 
resultant laryngitis, bronchitis, the various forms of otitis, asthma, 
hay fever, etc. A very notable symptom in those cases, and one 
which I regard as almost pathognomonic of deflection of the sep- 
tum, is alternating stenosis of the two passages, by which, while the 
one side may be completely stopped, the other will seem to be 
quite pervious, followed rapidly by the vice-versa condition. This, 
of course, is only met with in those cases where the deformity pro- 
duces partial occlusion of either passage, but it seems to me, it 
strengthens in a very notable manner the line of argument followed 
above, in explanation of the method of development of symptoms, for 
I think that the first morbid lesion which results in the nasal mucous 
membrane from septal stenosis is dilatation of blood-vessels, with a 
weakening of their muscular coat, thereby inducing a tendency to 
the occurrence of sudden turgescence, either in the one side or the 
other, under which the muscular control of the calibre of the blood- 
vessels on one side is maintained for a short period, followed by a 
sudden letting go, as it were, and their filling, with the concomitant 
relief of the opposite side. The stenosis, it must be borne in mind, 
is produced by a swelling of the mucous membrane both on the 
turbinated bones and on the septum. That there is a connection 
between the two sides is well shown by the fact, in these cases, 
that when lying down, a complete closure of the upper passage in 
the recumbent position may be relieved by the blood sagging down, 
as it were, into the tissues of the lower fossa. 
The voice may be affected by a deformity of the septum in two 
ways. Its tone is impaired in much the same way as it is in hyper- 
trophic rhinitis, from the fact that the nasal chambers, which play 
so important a part in the production of the overtones, are to an 
extent closed. The voice, therefore, loses to a degree its nasal 
tone, and is thereby weakened. The speaker, in his effort to sup- 
plement this deficiency, is liable to strain the vocal muscles, thus 
producing either laryngeal hyperaemia, or what many writers call 
mogiphonia, i.e., impairment of voice. A still further source of 
impairment of voice is in the catarrhal condition of the larynx and 
trachea, which sooner or later develops in connection with hyper- 
trophic rhinitis, to which the septal deformity may give rise. 
A still further symptom, which is frequently observed in these DEFORMITIES OF THE NASAL SEPTUM. 
295 
cases, is met with where the deflection occurs in the region of the 
middle turbinated bone, producing a narrowing of the middle meatus 
by which this rarefaction of the inspired air acts more forcibly on 
the middle turbinated tissues. As a consequence, we have developed 
conditions which present certain characteristics resembling the 
nasal neuroses, by which sneezing with watery discharges becomes 
a prominent feature of the trouble. The explanation of this is in 
the fact that we have here a nerve supply, enriched by the distribu- 
tion of the terminal filaments of the olfactory nerve, and thus a 
hyperaemic condition of the membrane renders it more delicately 
sensitive. It is in these cases, moreover, that we not infrequently 
meet with hay fever, asthma and the other reflex neuroses, com- 
plicating intra-nasal disease. 
The various ear-troubles already discussed, as dependent upon 
hypertrophic rhinitis, may equally well arise from septal deformities, 
but here I think, without question, we not infrequently find ear- 
symptoms developing, even before the catarrhal inflammation has 
progressed to any serious extent; the conditions which tend to de- 
velop impaired hearing, as already stated in the chapter referred 
to, being dependent rather on the nasal stenosis than on the in- 
flammatory process, or its extension to the tympanic cavity. This 
point I regard as one of no small importance, for in a number of 
cases which have come under my own observation, I have seen 
very marked impairment of hearing completely removed by the 
removal of a septal obstruction in the nasal passages, where there 
existed no hypertrophic changes which required treatment. This 
would seem also to substantiate the opinion already expressed, that 
catarrhal disease of the middle ear is not necessarily due to an ex- 
tension of the inflammatory action. 
DIAGNOSIS.—Recognition of these deformities is based entirely 
on examination anteriorly, posterior rhinoscopy giving us absolutely 
no information. I fully concur with Mackenzie 1 that these deform- 
ities never extend to the posterior nares. An examination should 
be made with a good light, sunlight being used if possible, which 
should bring well into view any deviation from the normal line or 
contour that may exist, cocaine having first been applied, to thor- 
oughly contract the mucous membrane, and open up the passage 
for thorough inspection. Care should be taken, in making this ex- 
amination, to tilt the tip of the nose thoroughly to one side, so as 
to bring the plane of the normal septum into as nearly a direct 
right line with the observer as possible. The examination, of 
course, being made through both passages should enable us to 
1 “ Diseases of the Throat and Nose,” American Edition, Philadelphia, 1884, vol. ii., 
page 426. 296 
DISEASES OF THE NASAL PASSAGES. 
recognize the extent and character of the deformity. Additional 
information is afforded by the use of a slender probe, wrapped with 
a small pledget of cotton, which is easily tolerated if the passage is 
thoroughly anaesthetized, and which can be passed over the sep- 
tum as far as the deformity will permit, in such a way as to give 
much information. Seiler1 has devised a septometer for measur- 
ing the thickness of the septum at various points, which may be of 
service, although much the same end may be accomplished by plac- 
ing a speculum in each nostril, and while throwing the strongest 
light into one, observing the translucency of the tissue through the 
other. The shadows thus formed, and the opacities or semi-opaci- 
ties thus displayed, often afford information which may be of value. 
The probe affords us a means of testing the character of the prom- 
inences which may exist, and solves the question as to whether 
they are bony or cartilaginous on the one hand, or glandular on 
the other, the vascular prominences being eliminated by the use of 
cocaine. 
Zuckerkandl2 has described a somewhat rounded mass of glands, 
first alluded to by Morgagni, which are found in a normal condi- 
tion, in a line about opposite the middle turbinated bone, especially 
at its anterior extremity and about the lower margin of the olfac- 
tory region. Creswell Baber3 describes this prominence as the 
tuberculum septi. It consists essentially of a mass of muciparous 
glands, soft to the touch, which need not lead to error in diagnosis. 
It would seem that the diagnosis of deformity of the septum would 
present few difficulties, and yet I have frequently had sent me 
patients with the diagnosis of nasal polypus, in which the red mass 
or face of the projecting portion of the deflected septum occluding 
the nostril, gave rise to this error. It need only be borne in mind 
that a polypus or fibroma is more or less freely movable on the 
impact of the probe, and soft to the touch, while the deflected sep- 
tum is rigid and immovable. The same may be said of abscess or 
angioma of the septum. Enchondromata, ecchondromata, and ex- 
ostoses also present a hard resisting mass to the probe, but these 
tumors are somewhat distinct from the septum. Furthermore they 
are among the rarest of diseases. Malignant disease possesses few 
characteristics which could possibly lead to any confusion in diag- 
nosis. Syphilitic perichondritis presents a bulging mass on the sep- 
tum, is bright red in color, somewhat soft to the touch, but presents 
evidences of active inflammatory action, which is rarely met with 
in connection with simple deformities. 
PROGNOSIS.—Those cases which have not led to the develop- 
1 “Diseases of the Throat," Philadelphia, 1883, p, 83. 2 Op. cit-, page 44. 
3 “ Examination of the Nose," Amer. ed., pp. 17 and 20. DEFORMITIES OF THE NASAL SEPTUM. 
297 
ment of complicating disorders, such as catarrhal inflammation of 
the upper air-passages, ear-disease, etc., of course, only demand a 
restoration of the normal respiratory freedom for entire relief to 
symptoms. In other cases, in which, as the result of multiple frac- 
ture, the septum is crumbled, as it were, into a shapeless affair, 
complete restoration cannot be promised. Where ear-disease has 
set in without the interposition of a catarrhal rhinitis, the results 
of treatment are as a rule most gratifying. Where the symptoms 
developed are merely those of catarrhal inflammation of the upper 
air-passages, the successful operation on the nasal septum goes far 
toward giving relief to the catarrhal symptoms, and yet, as a rule, 
more or less subsequent treatment will be demanded for the relief 
of this condition. As regards the influence on the voice, where 
the voice has become impaired without the intervention of a 
rhinitis, its complete restoration may be promised by a successful 
operation. In hay fever and asthma, the course is so far compli- 
cated by other elements as to render our prognosis exceedingly 
uncertain, and yet where these neuroses exist in connection with a 
deformity of the septum, it is extremely doubtful if any relief can 
be afforded until the operation has been successfully done, and 
perhaps no single measure in these diseases gives more satisfactory 
results. 
Treatment.—The essential feature of these deformities, which 
demands correction, is the stenosis, as from this, as has been 
shown, arise all the sequelae and complications which accompany 
them. Where the deformity has occurred as the result of a fracture, 
this may be attempted, either by removing the projecting portion 
of the deviation, or by restoring the fragments to their normal 
plane. The earliest effort in this direction, of which we have 
knowledge, is the measure recommended by Quelmalz, who di- 
rected that the patient himself should, by digital manipulation, 
repeated many times during the day, press the parts, so far as pos- 
sible, into their normal position, and hold them there. Dieffen- 
bach1 on the other hand, advised that the projections should be 
sliced off with a knife. A still more intricate procedure was 
adopted by Heylen,2 who first dissected the mucous membrane 
carefully from the surface of the deformity, and then removed the 
projecting portion with scissors, thus seeking to preserve the 
mucous coating. Chassaignac3 adopts a somewhat nicer surgical 
procedure, in first dissecting up the mucous membrane, and then 
making a number of incisions through the deflected portion, by 
1 “ Die Operative Chirurgie,” Bd. I. Leipzig, 1845. 
2 Annales de la Soc. de Med. d’Anvers, Gaz. Med., 1847, p. 810. 
3 Gaz. des Hopitaux, 1851. p. 420. 298 
DISEASES OF THE NASAL PASSAGES. 
which it is rendered pliable, thus enabling him to restore it again 
to its normal plane, where it is maintained in position by the inser- 
tion of plugs into the cavity, until it has solidified. Ingalls1 de- 
scribes a still nicer manipulation, by which, after dissecting up the 
mucous he excises a V-shaped piece from the deflected 
cartilage, and subsequently brings the parts together by sutures, 
thus recognizing the redundancy of tissue which is usually present 
in these cases, while Heymann2 removes the projecting portion by 
means of an ordinary carpenter’s chisel, a method also adopted by 
Seiler.3 Demarquay4 still further complicates the operation by 
opening the cavity by an incision along the ridge of the nose, in the 
median line, for the purpose of gaining free access to the parts, 
after which he dissects the mucous membrane from the prominences, 
which he removes with a knife, and then unites the membrane over 
the part by sutures, subsequently closing his external wound in the 
same manner. A somewhat similar operation was done by A. C. 
Post, of New York, as quoted by Robinson.5 He opened the nose 
externally by Dieffenbach’s operation, by an incision along the alar 
fissure, while Richet, as quoted by Miot6 opens the nasal cavity by 
separating the columna from the lip and also from the lower border 
of the septum, which is thus thoroughly exposed, enabling him to 
remove the projection. It need scarcely be added, that an opera- 
tion which involves incision of the facial integument is rarely if 
ever justified for the relief of these deformities. Linhart,7 going 
further, deems it necessary to dissect up the mucous membrane on 
both sides of a deflected cartilage before removing the projecting 
portion. 
It will be noted that Quelmalz, Chassaignac and Ingall’s opera- 
tions are designed only for cases of deflected septum, while the 
others are done both for deflections and for those cases characterized 
by bony or cartilaginous ridges along the sutural lines, or by hyper- 
trophy of the tuberculum septi. 
An instrument which was based on a thorough recognition of 
clinical indications, was the punch devised by Blandin8 shown in 
Fig. 89, which consisted simply of a modification of the ordinary 
shoe-punch, by the use of which he was enabled to remove one or 
more small discs of the projecting portions of cartilage. Blandin’s 
idea was simply to ablate the projecting portion of the deflected 
1 Arch, of Laryngology, vol. iii., p. 297. 
2 Berliner Klinische Wochenschr., 1886, No. 20, p. 329. 
3 Loc. cit. 4 Gaz. des Hopitaux, 1859, p. 470. 
5 “ Nasal Catarrh and Allied Affections,” 2d ed., N. Y., 1885, p. 189. 
6 Loc. cit., p. 250. 
7 “ Compendium der Chirurgischen Operationslehre,” Wien, Braumuller, 1826, p. 516. 
8 “ Compendium de Chirurgie,” T. iii., page 33. DEFORMITIES OF THE NASAL SET TDM. 
299 
septum, recognizing the fact that the perforation did not necessarily 
constitute a morbid lesion. The punches designed by Ruprecht1 
and Roser- differ in no essential manner from that of Blandin. 
The punch is easy of manipulation, and in many cases, where 
the deflection presents an angular prominence, accomplishes the 
Fig. 89.—Blandin’s Septal Punch. 
purpose of removing the stenosis in a fairly satisfactory manner. 
Steele3 has devised a punch (see Fig. 90) in which the cutting 
blades radiate from a centre, in such a manner as to produce a 
stellate incision in the septum. The object of this device is To 
produce a series of triangular flaps, which will allow of the deflected 
portion being brought down to the normal plane. John Mackenzie 4 
gives priority in this device to Dr. James Bolton,5 of Richmond, 
who published a case of deflected septum, which he operated upon 
by producing these stellate incisions by means of an instrument 
Fig. 90.—Steele’s Septal Punch. 
resembling a buttonhole-scissors, a better instrument, it seems to 
me, for accomplishing the purpose than Steele’s punch, for in my 
hands, I have never been able with this instrument to make in- 
cisions sufficiently deep to render the septum pliable; although, as 
regards priority, the principle was first suggested by Chassaignac,6 
1 Wien. Med. Wochenschr., 1868, p. 1157. 
2 Berliner Klinische Wochenschr., 1880, No. 45. 
3 St. Louis Courier of Med., May, 1879. 
* “ Deflection of the Nasal Septum and its Treatment,” Transactions of the Medical 
Society of Virginia, 14th Session, 1883. 
3 Richmond Med. Journal, vol. v., April, 1868, p. 241. 6 Loc. cit. 300 
DISEASES OF THE NASAL PASSAGES. 
who made use of the bistoury, which to me seems a more rational 
method than either the punch or the scissors, in that its move- 
ments can be directed in a far more intelligent manner. The op- 
eration which came most largely into vogue after its publication, 
was that of Adams1 who advised that the septum should be seized 
with a forceps, shown in Fig. 91, and crushed, as it were, or re- 
fractured, in such a manner that it could be restored to its normal 
Fig. 91.—Adams’ Forceps for Refracturing a Deflected Septum. 
plane, after which a clamp (see Fig. 92) was to be worn, for a period 
of three days, followed by the use of a pair of ivory plugs (Fig. 93), 
which were to be worn during the day and removed at night, until 
firm union had taken place. 
Jurasz2 has modified this instrument, by combining forceps and 
clamps in a single instrument, in such a manner that, after crush- 
ing the septum, the handles are removed, leaving the clamps in 
position, to hold the fragments in a straight line. 
Where there is considerable distortion of the external nose, due to 
a bending of its cartilaginous portion, I think Adams’s operation is 
often indicated, as serving to remedy the facial deformity, although 
I think it is not usually successful in removing the stenosis, for it 
Fig. 92.—Adams’ Nasal Clamp. 
Fig 93.—Adams’ Nasal Plugs. 
must be remembered that, where we have fracture of the septum, 
there is invariably a considerable degree of thickening at the point 
of the original fracture, which renders refracturing in this line 
almost impossible. Moreover, the operation is an exceedingly 
painful one, and the subsequent treatment in wearing clamps and 
plugs subjects the patient to a period of great discomfort and even 
suffering. Where the facial deformity involves a deflection or dis- 
tortion of the nasal bones, Adams’s operation is inadequate. I think 
1 British Med. Journal, October 2d, 1875. 
2 Berlin. Klinische Wochenschr., 1882, No. 4. DEFORMITIES OF THE NASAL SEPTUM. 
301 
the prominent indication, both in deflections and deformities, is the 
removal of the projecting portion, and the restoration of the sep- 
tum to a plane as nearly approaching the normal as possible. This 
indication was recognized by Dieffenbach, Heylen, Richet and most 
of the writers already quoted, but I think their operative measures, 
as a rule, were inefficient. In most of these cases, we encounter 
bone as well as cartilage, hence a knife is utterly inadequate to 
thoroughly remove the obstruction. The scissors, also, I think, fail 
in most cases, for the same reason. Furthermore, I deem it of the 
greatest importance, in removing these obstructions, that a thor- 
oughly smooth surface should be left, for when a jagged, uneven 
surface remains, the result is unsatisfactory, and the period of heal- 
ing occupies an unnecessarily long time. The device suggested by 
Fig. 94.—Jarvis’ Cutting Forceps for the Removal of Septal Deformities. 
Jarvis1 of transfixing the projecting portion with a needle, and 
subsequently removing it by a snare, is open to the objection of 
leaving a jagged surface, and furthermore, his needle can only 
transfix cartilage, while I regard the removal of the bony projec- 
tion as of even more importance. The same objection, it seems 
to me, lies against this writer’s cutting forceps2 shown in Fig. 94. 
Moreover this instrument is too fragile to serve an efficient pur- 
pose. The use of various forms of burrs, such as'are shown in Fig. 
95, operated by an ordinary dental engine, or the electro-motor, is 
advocated by Seiler3 and others, while Holbrook Curtis4 has de- 
vised a series of small trephines (shown in Fig. 96), which work by 
an electro-motor, whose use he advocates for the removal of de- 
formities of the septum. The objection, I think, lies against these 
1 Arch, of Laryngology, vol. iii., p. 300. 
2 Medical Record, vol. xxvii., p. 167. 
3 “ Diseases of the Throat,” 2d ed., Philadelphia, 1883, p. 248 et seq. 
4 New York Med. Journal, May 28th, 1887. 302 
DISEASES OF THE NASAL TASS AGES. 
devices, that they fail to leave a smooth, unbroken surface, which 
is a matter of no small importance. 
For those cases which present a horizontal ridge projecting into 
the cavity from the lower portion of the septum. Seiler 1 in a later 
Fig. 95.—Various Forms of Burrs for the Removal 
of Septal Deformities. 
Fig. 96.—Curtis’ Nasal Trephines. 
publication advises cutting through the mucous membrane above 
and below the ridge, with a small knife, and subsequently removing 
the bone and cartilage by means of delicately constructed chisels 
or gouges (see Fig. 97) operated by the hand or by a small mallet. 
Fig. 97.—Seiler’s Nasal Chisel and Gouges. 
As giving a clean-cut surface, and going readily through both 
bone and cartilage, the saw would naturally suggest itself as an 
efficient instrument. Some years since, Woakes made use of this 
1 Op. cit., 3d ed., p. 320. DEFORMITIES OF THE NASAL SEPTUM. 
303 
device, recognizing its value, and subsequently Seiler 1 recommended 
the use of a metacarpal saw for removing the bony projections, 
or “ exostoses.” 
The essential features of a saw which will render its use feasi- 
ble, are such thinness of blade, and fineness of teeth, as will enable 
it to enter the tissues even at an acute angle—in other 
words, that it shall take hold readily. 
The instruments above noted, failing in my hands, I 
resorted to various devices for securing a proper model, 
till finally I had one constructed as follows: the blade 
as thin as possible, consistent with strength, one-eighth 
of an inch wide, five inches long, with a cutting edge 
of three inches, with thirty teeth to the inch, each 
tooth an exact equilateral triangle, with no cross-cut 
and no set to the teeth, the handle being three inches 
long, of sufficient size to be easily grasped by the hand, 
and attached to the blade at an angle of forty-five de- 
grees, in order that the hand should in no way obstruct 
the view while operating. These saws were constructed 
in two forms, one with the cutting edge upward and 
the other with the cutting edge downward. This in- 
strument (shown in Fig. 98) simply removes the present- 
ing portion of deformities and deflections of the sep- 
tum, the end in view being to cut as nearly as possible 
in the plane of the normal septum. In other words, to 
saw out a new septum, as it were, as one would saw a 
board from a log. removing those deformities which 
may be found in either fossa. When this in- 
strument was first made public2 I reported a 
series of one hundred and sixty-six operations. 
Since that time, I have made almost daily use 
of it, and regard it as by far the 
best device we possess, for the re- 
moval of these obstructions. The 
mode of operation is as follows: 
First, with a Delano atomizer 
a twenty-per-cent solution of co- 
caine is sprayed into the nostril, 
both on the obstructed and on the 
open side. At the end of two minutes a probe, wrapped with 
cotton, is dipped into the same solution and swept over the pro- 
jecting portion of the septum, the membrane being by this time so 
nearly anaesthetized as to tolerate a thorough probing. The cotton 
Fig. 98.—The Author's Nasal Saw. 
1 Op. cit., p. 254. 
2 N. Y. Med. Record, January 29th, 1887. 304 
DISEASES OF THE NASAL PASSAGES. 
pellet is used to bring the cocaine in more thorough contact with 
the septum, and also for a more thorough exploration of the extent 
and character of the deviation. At the end of six minutes the 
parts are thoroughly anaesthetized. The saw is now introduced, 
and fixed in such a position that, in cutting, the whole of the pro- 
jecting portion will be removed, the object being kept in view 
always to reduce the septum as far as possible to its normal out- 
lines. In other words, it is to be sawed down, as we saw a board 
out of a log. After the instrument has entered, the sawing is done 
with as rapid a motion as it is possible to give the hand, care being 
taken to make a straight cut without bending the instrument* In 
this way the saw is carried directly down through both bone and 
cartilage until it emerges at the lower edge. Occasionally I have 
used the reverse manipulation, and sawed from below upward, 
where the deflection was of such a character as to interfere with 
entering my instrument well above the point where the projection 
bent from the median line. 
After cutting, the piece is generally easily removed by the for- 
ceps, or, if not thoroughly cut through, it can be removed by slip- 
ping the loop of the snare over it. The bleeding is profuse for two 
or three minutes, but in no case have I had any serious annoyance 
from hemorrhage. In two instances, I think, I have been compelled 
to plug, but in only two. Hemorrhage is arrested by clot, and I 
simply direct my patient not to expel the clot for three hours, 
when I think all danger of hemorrhage has ceased. 
In regard to the operation, in only a single case of all the opera- 
tions which I have performed have I cut through the septum, which 
illustrates the fact of its marked thickness at the point of fracture, 
and, furthermore, explains why Adams’s operation for straightening 
is so often unsuccessful. 
Objection has been made to these operations that they result in 
ulceration. Now I wish to say, in as positive a manner as possible, 
that in no case have I had any such result. The subsequent treat- 
ment is nothing. The healing process requires no attention. The 
parts heal up kindly, and, as a rule, with no unpleasant symptoms 
during the process. It has been charged that bad cicatrices result. 
Again I say that I have seen no such result in any case. The 
mucous membrane reforms over the cut surface, and at the end of 
two months it would be difficult to recognize the fact that any cut- 
ting had been done. Too much importance cannot be laid on the 
necessity of a perfectly straight, smooth-cut surface. In one or 
two instances in operating I bent my saw, which is exceedingly 
flexible, in such a way as to make a hollow cut, sawing in a curve, as 
it were, leaving a depression on the surface of the septum. When- DERORMITIES OF THE NASAL SEPTUM. 
305 
ever I have made such a mistake there has been exceedingly great 
annoyance from delayed healing, owing to the fact that mucus and 
bloody pus accumulated in the depression and formed crusts, and 
thus markedly interfered with the healing process. And herein, it 
seems to me, lies an objection to the rougher operation oi the 
gouge and the forceps in removing these obstructions, as leaving 
an irregular surface for the lodgment of mucus and secretions. 
This, however, does not form ulceration. We meet with no ulcera- 
tions in the nasal cavity, except as the result of syphilis or some 
blood-poisoning. Delayed healing may occur, but not ulceration, 
after the operation; and delayed healing, I am positive, can only 
be the result of unskilful operating. 
I will only add, with regard to the operation, that it should 
always be done, if possible, with the use of sunlight or some equally 
powerful illuminator, as it is of the utmost importance that the 
movements of the saw should be kept under as close ocular inspec- 
tion as possible, in order that the line of cutting shall not deviate 
from that of the plane of the normal septum, and this can only be 
secured by the aid of thorough and powerful illumination. 
Roe 1 has attached the blade of this instrument to an electro- 
motor, claiming certain advantages for this procedure. It seems 
to me, a nicer manipulation and more accurate direction can be 
given by the hand. Dr. John B. Roberts has devised a somewhat 
ingenious operation, which consists in making a linear incision with 
the bistoury along the prominent line of a deflection, in such a man- 
ner as to enable him to press the parts into their proper position, 
after which he imbeds a long steel pin in the septal tissues in such a 
manner as to hold them in line, until they have become so far solidi- 
fied as to maintain their position without this aid; if necessary, 
more than one pin being used. I have never been able to obtain 
Dr. Roberts’s success by this method of procedure, although I have 
found these pins of great value in those cases in which we have a 
rounded bulging deflection, confined to the cartilaginous portion 
of the septum, and which is easily replaced by the forefinger, but 
springs back, as it were, the instant the pressure is removed. In 
these cases, firm pressure being made on the convexity of the de- 
flection and the cartilage made to bulge on the opposite side, the 
pin is passed directly through the septum, and returned again at 
about a quarter of an inch beyond the first perforation, the head 
of the pin remaining on the side of the original concavity. In this 
manner the pin is not imbedded in the tissues, but remains really 
on the outside. An ordinary brass pin answers an excellent pur- 
pose, and remains in position a week or longer, giving rise to no 
1 Trans, of the Amer. Laryngol. Assoc., 1887, p. 241. 306 
DISEASES OF THE NASAL PASSAGES. 
special inconvenience, and is removed when the parts have become 
fairly solidified. There is no objection to the loss of mucous mem- 
brane in any of the operations above alluded to, as this renews itself 
very rapidly, although many of the earlier operators, as will have 
been noticed, went to no small pains to preserve this, by dissecting 
it before removing the cartilaginous or bony obstructions. 
In this connection should be mentioned the ingenious operation 
suggested by Dr. Weir, of New York, for correcting the facial de- 
formity caused by a deflection of the bony portion of the external 
nose. These deformities are embraced under two general varieties. 
In the one, the bony frame-work is displaced laterally, while in the 
other the bridge of the nose is flattened, resulting in a bulging, as 
it were, of the two nasal bones. In the operation for lateral dis- 
placement 1 he commences, by making a bevelled incision a quarter 
of an inch long, immediately over the naso-maxillary articulation 
on the side toward which the displacement occurs. A small car- 
penter’s chisel is then inserted, and the two bones separated through 
the whole length of the articulation. He then makes an effort to 
fracture the opposite articulation by digital manipulation, or pry- 
ing with the chisel or by means of a forceps introduced into the 
nasal cavity. When this is accomplished, the nose is held in posi- 
tion by pads, secured in situ by adhesive plasters. In a subsequent 
article, Dr. Weir2 describes a method of restoring a traumatic flat- 
tening of the bony portion of the nose, the steps of the operation 
being the same as those previously described, with the additional 
suggestion, that if necessary the chisel should be carried directly 
through the primary incision, to the opposite side of the nose, for 
the purpose of separating the entire maxillary suture of that side, 
where this is not easily fractured by the simpler manipulations 
before described. The two nasal bones are then brought into 
place, by crowding them together, and subsequently held in situ 
by a pin passed directly through both bones, and further strength- 
ened by iodoform-pads laid on the outside. 
Dislocation of the Columnar Cartilage. 
In addition to the deformities of the septum already described, 
two cases have come under my observation and have been reported 
in a former paper3 in which the deformity was so peculiar that I 
give them somewhat in detail. 
We find lying immediately below the cartilage of the nasal 
1 New York Med. Record, March 13th, 1880, p. 279. 
2 Philadelphia Med. News, March 5th, 1887. 
3 “ Illustrated Med. and Surg.,” vol. i., p. 25. DEFORMITIES OF THE NASAL SEPTUM. 
307 
septum, and parallel with its lower border, a small oblong plate of 
cartilage, not usually mentioned in our text-books on anatomy, 
the purpose of which seems to be to act as a support for the in- 
tegument of the columna. This may be designated as the columnar 
cartilage. 
The first case was that of a gentleman, who reported that for 
two years he had noticed something growing in his right nostril. 
The deformity, slight at first, had continued to increase, until when 
I saw him there was a considerable 
degree of closure of the nostril. The 
facial expression was considerably 
altered by the deformity, and also 
by the anxiety to which it had given 
rise. On examination, the columnar 
cartilage was found to. be displaced 
laterally and at the same time tilted 
upward, in such a manner that the pos- 
terior angle projected upward into the 
nostril. It could be restored to posi- 
tion by pressure, but when this was re- 
laxed the deformity reappeared. The 
appearance is well shown in Fig. 99. 
The second case presented no points of difference from the first, 
except that the deformity was on the left side, which would suggest 
that the cause of the affection was the pressure of the thumb in 
using the handkerchief, since the first patient was left-handed, while 
the second was right-handed. After the deformity had been once 
produced, vigorous efforts at clearing the nostril by closing the 
other passage, would only increase the deformity. 
The treatment in each case consisted in dissecting out the 
cartilage through a small incision made over it, resecting the re- 
dundant portion of mucous membrane, and uniting the edges with 
fine sutures. The result was satisfactory in each case. 
Fig. 99.—Dislocation of the Columnar Car- 
tilage of the Nose into the right nostril. 
Perforation of the Septum. 
Perforation of the nasal septum may take place through either 
the bony or the cartilaginous portions. In the former case, it is 
probably due, in the very large majority of instances, to an ulcera- 
tive and necrotic process, the result of syphilis, scrofula, or one of 
the graver constitutional dyscrasiae, although in rare instances I 
have seen it occur from traumatism, the injury having caused a 
comminuted fracture of the vomer, with the subsequent sloughing 
away of the small fragments, by which a permanent opening 308 
DISEASES OF THE NASAL PASSAGES. 
between the two cavities was established. Schmiegelow 1 reports 
a somewhat unique case in which perforation of the bony septum 
followed an attack of idiopathic periostitis. 
Perforation of the cartilaginous portion of the septum, on the 
other hand, is in most instances due to purely local causes, al- 
though this region, of course, is not exempt from the invasion of 
syphilis and other systemic dyscrasiae. The most common cause of 
this form of perforation is to be found in the existence of a projec- 
tion of the cartilage into one or the other passage, whereby its 
prominent portion becomes subjected to the current of inspired air, 
laden as it is with dust and other impurities, whereby a process of 
erosion is established, under which the cartilage is gradually worn 
away until an opening occurs. This is a purely local process and 
involves no suspicion of a systemic taint. The existence of the 
erosion is attended with an annoying crust formation over its site, 
causing a frequent picking at the nose, by which the process of 
erosion is much hastened. 
This process, as we see, is really a conservative effort on the 
part of nature to relieve the patient of an obstructive lesion in the 
nose, and one, moreover, which I have frequently seen attended 
with signal success, since the removal of the obstruction seems to 
be the primary effect of the process, while the establishment of a 
perforation is to an extent adventitious. I cannot agree with 
Zuckerkandl2 in the view that these cartilaginous perforations are 
due, in the large majority of instances, to an ulcerative or inflam- 
matory action, in that the simple erosion in my experience is 
never attended with either of these processes. Schmiegelow3 has 
seen one case in which the perforation in this region was congenital 
and which involved a very large portion of the septal cartilage. 
This would seem, without much question, to be a case of arrested 
development, although Zuckerkandl3 does not believe this is the 
case. Similar cases have been observed by Hildebrandt4 and Hyrtl.5 
The frequency of these perforations is well shown by Zucker- 
kandl,3 who in one hundred and fifty autopsies found eight cases. 
As will be inferred from what has been said, I am disposed to think 
that the clinical significance of openings though the septal carti- 
lage is comparatively trivial. They cause no inconvenience and in- 
dicate the existence of nothing other than a simple local process of 
erosion. Nor do they give rise to any symptoms, except in those 
1 Hospitalstidende, 1886, 3 Rackke, iv., Bd., no. 42. 
2 “Anatomie der Nasenhbhlen,” Wien, 1882, p. 99. 
3 Loc. cit. 
4 “ Lehrbuch der Anatomie,” Wien, 1802, vol. iii., p. 162. 
5 “Handbuch der Topographischen Anatomie,” Wien, 1871, I. Bd., p. 316. DEFORMITIES OF THE NASAL SEPTUM. 
309 
rare instances when the opening occurs in a septum which is bent 
somewhat diagonally across the passage, whereby the respiratory 
current of air gives rise to a whistling sound, on its entrance and 
exit; while the erosion exists, hemorrhage is liable to occur, but 
this is rarely serious in character. The clinical significance of 
openings through the bony portion have already been sufficiently 
indicated. 
The erosion, however, soon heals up, leaving a smooth rounded 
border to the opening which is easily recognized on inspection 
Fig. ioo.—Perforation of the Cartilaginous Septum. (Zuckerkandl.) 
through the anterior nares. This is well illustrated in Fig. ioo. 
There are no special indications for treatment. If the edge of an 
opening projects into one or the other passage it is to be removed. 
If erosion exist, giving rise to epistaxis or annoying crust forma- 
tion, it is easily controlled by local application of vaseline, cold 
cream, or any simple emollient, applied two or three times daily. 
There is a somewhat prevalent idea that these perforations so weaken 
the supports of the nose as that they may eventually cause an ex- 
ternal deformity. This is, I think, an entirely mistaken idea, as I 
have never seen such an accident occur, except in the case of syphili- 
tic ulceration and necrosis which was active and progressive. CHAPTER XIX. 
EPISTAXIS. 
This term epistaxis, meaning properly a dropping, was used by 
older writers to define milder attacks of hemorrhage, which were 
characterized by a mere dropping of blood from the nose. In our 
day, however, it is used to define all varieties of nasal hemorrhage. 
Etiology.—Bleeding from the nose, while in most cases a com- 
paratively trivial affair, in others may involve grave danger to 
health, and even to life. As a rule, it is due to some unimportant 
local lesion, while in other cases, it may arise as the result of some 
systemic condition. Epistaxis maybe the result of (\) traumatism; 
(2) constitutional or systemic conditions; (3) vicarious menstruation 
and (4) local morbid conditions of the nose. 
Traumatic.—The most frequent injury which gives rise to an 
epistaxis, is a direct blow upon the nose, causing a rupture of some 
of the blood-vessels, more frequently of the septum. Just how this 
acts, it is not easy to determine. Probably, however, there is a 
solution of continuity, at some of the sutural junctions. Where the 
blow is sufficient to cause fracture of the septum, the hemorrhage 
is apt to be of rather a violent character, while the simpler injuries 
give rise, as a rule, to but trivial loss of blood. Among the rarer 
injuries which cause an epistaxis may be mentioned fracture of the 
base of the skull, involving its anterior fossa. In some cases, the 
escape of blood may be entirely beneath the mucous membrane, 
giving rise to a haematoma, which may attain sufficient size, as sug- 
gested by Schech,1 to protrude from the nostril. Under the same 
head should be classed those cases of bleeding which are excited 
by the introduction of irritating substances into the nose, as is the 
common habit with young children. 
Diathetic.—Among the diathetic conditions which may cause 
bleeding from the nose, maybe enumerated: plethora, anaemia both 
simple and pernicious, the hemorrhagic diathesis, purpura hemor- 
rhagica, organic disease of the heart, and disease of the liver and kid- 
neys. It may also occur in certain acute diseases, such as typhoid 
1 “Diseases of the Mouth, Throat and Nose,” Engl, ed., Edinburgh, 1886, p. 256. EPISTAXIS. 
311 
and relapsing fevers, and according to later writers, it occurs some- 
times in pneumonia. 
Vicarious.—Under this head we include those curious cases, in 
which hemorrhage from the nose is substituted for the normal 
menstrual flow. In the same way, nasal hemorrhage at the meno- 
pause may be regarded as to a certain extent vicarious. B. Fran- 
kel1 has collected a number of cases of vicarious menstruation, 
which bring out some exceedingly interesting points. Thus, in a 
case of Kussmaul’s,2 there was periodical nasal hemorrhage in a 
woman with total absence of the uterus, while in a case reported 
by Fricker,3 violent hemorrhage recurred at intervals of six weeks, 
in a girl of nineteen who had never menstruated, resulting finally 
in the death of the patient. Still another case was observed by 
Sommer4 in which monthly hemorrhage occurred from the nose 
in a woman, during the whole period of a fifth pregnancy, while 
Obermeier 5 records the instance of a young woman in whom reg- 
ular menstruation occurred once at the age of fifteen, after which 
she had a monthly recurrence of nasal hemorrhage, lasting three 
or four days, ceasing only when she was pregnant. Frankel also 
quotes the observations .of Puech,6 who found in ninety-nine cases 
of vicarious menstruation, that the seat of hemorrhage was the 
nasal mucous membrane in eighteen, the lungs in twenty-four, the 
breast in twenty-five, and the stomach in thirty-two. 
Joal7 lays special stress upon the intimate relation which he 
believes to exist between the sexual apparatus and the turbinated 
bodies. He believes that many cases of epistaxis in young persons 
come from masturbation, congestion of the turbinated bodies at 
the time of the catamenial flow, or some other form of irritation 
affecting the sexual apparatus. 
Local Lesions.— Slight deformities of the septum are probably 
the cause and source of an epistaxis more frequently than any 
other lesion met with in the nasal cavity, the apex of the project- 
ing portion becoming the seat of a slight erosion, probably as the 
result of attrition by the dust-laden current of the inspired air. In 
this manner, the walls of the blood-vessels become thin, while at 
the same time the eroded surface forms a site for the formation of 
dry crusts. When these crusts are picked away by the finger, as 
is the habit, hemorrhage is very liable to ensue. Again, on the 
concavity of a deflected septum, there is this same tendency to 
1 Ziemssen’s “ Cyclopaedia,” vol. iv., p. 152. 
2 “Vom Mangel der Gebarmutter,” Wurzburg, 1859. 
3 Wi'irtemberg Med. Correspond., 1844, No. 21. 
4 Heidelberger Ann., x., 3. 5 Virchow’s Arch., vol. liv., p. 435. 
6 Gaz. des Hopitaux, 1863, p. 1.88. 7 Rev. mens, de laryngol., 1888, Nos. 2 and 3. 312 
DISEASES OF THE NASAL PASSAGES. 
crust-formation, producing an eroded surface, which bleeds upon 
the removal of the crusts. It is often stated 1 that epistaxis is met 
with as the result of erosions, which occur in connection with the in- 
crustations on the septum in atrophic rhinitis. Neither ulceration 
nor erosion ever occur, I think, in atrophic rhinitis, and furthermore, 
the incrustations, as a rule, do not form upon the septum. Epis- 
taxis I regard as one of the rarest of symptoms in this disease. 
The same, I think, may be said in regard to the ulcerations which 
occur in connection with syphilis and tuberculosis, the ulcerative 
processes in these affections rarely invading the blood-vessels. 
Neoplasms, with the exception of mucous polypi, may become the 
source of violent attacks of epistaxis. This is especially true of 
fibroid tumors and the angio-sarcomata, and also of the fibro- 
and myxo-sarcomata, though probably in a much less degree. In 
carcinoma of the nose, also, hemorrhage is a frequent symptom. 
Foreign bodies in the nasal passages may give rise to occasional 
mild attacks of epistaxis, although this is somewhat rare. 
PATHOLOGY.—The hemorrhage in these cases, in the large ma- 
jority of instances, is undoubtedly from blood-vessels, ruptured 
either by traumatism, an erosion, or by an .ulcerative process. Oc- 
casionally, as in the case of an angio-sarcoma, the hemorrhage may 
occur directly from the tumor itself. In fibroma and carcinoma, 
however, the source of the blood is in erosions, caused by the 
pressure of the growth, although in the late stages of carcinoma, 
blood-vessels may be opened, as the result of ulcerative action. 
The source of the hemorrhage, in the very large proportion of 
cases, is in the septum. Thus, Chiari2 states that in twenty-two 
cases out of twenty-five, the bleeding point was found on the sep- 
tum, while Baumgarten3 found the more frequent site to be the 
septum, next the floor of the nose, and least frequently, the tur- 
binated bodies. A similar view is expressed by Robinson.4 Mac- 
kenzie,5 on the other hand, states that the site of the hemorrhage, 
is most frequently on the outer wall of the nose, while Moure6 
more guardedly asserts that the hemorrhage may occur from the 
turbinated bodies. The soft spongy membrane covering the tur- 
binated bodies does not present the conditions favoring the develop- 
ment of an erosion, such as we find in the thin mucous membrane 
stretched, as it were, over the bony or cartilaginous structures of 
the septum. Hence, I think we must regard Mackenzie’s state- 
1 B. Robinson: N. Y. Med. Journal, September 24th, 1887. 
2 Wiener Medicin. Zeitung. 
3 “Treatment of Epistaxis,” Vienna, 1886. 4 Loc. cit. 
5 “ Diseases of the Throat and Nose,” Amer. ed., Phila., 1SS4, vol. ii., p. 346. 
6 “ Manuel Pratique des Maladies des Fosses nasales,” etc., p. 227. EPISTAXIS. 
313 
ment as open to question. The same, I think, may be said of 
Sajous’s1 assertion that hemorrhage may occur from the glands in 
the vault of the pharynx. 
Symptomatology.—The bleeding may be somewhat trivial in 
character, dripping slowly from the nose, or so profuse in amount 
as to run in a continuous stream. As the blood pours out, clotting 
necessarily occurs in the side from which it starts, and may gradu- 
ally occlude this passage, as the result of which it becomes filled 
with blood, which pouring over the septum, escapes from the op- 
posite side. The character of the blood is usually of a dark color, 
though occasionally we may have the rupture of a minute artery on 
the septum, giving rise to arterial hemorrhage. Profuse arterial hem- 
orrhage from the nose, however, rarely occurs, except as the result 
of ulceration from a malignant growth. If the bleeding occurs in 
connection with the hemorrhagic diathesis, this is usually elicited 
by a history of former hemorrhages, and also may be fairly deter- 
mined by the failure of the blood to form clots. The bleeding 
generally occurs from one nostril. Habitual bleeding from the 
same side would rather indicate a local lesion of that cavity, while 
hemorrhage from both sides would point probably to some sys- 
temic condition. Certain prodromic symptoms are occasionally 
met with, characterized by a feeling of fulness in the head, vertigo, 
throbbing of the temples, headache, disturbance of vision, etc. 
These symptoms usually occur in individuals of plethoric habit, in 
whom an epistaxis is to be regarded as a conservative effort of 
nature, although certain febrile affections may be preceded by an 
attack of bleeding from the nose. Dangerous epistaxis may occur 
as the result of traumatism, or from the presence of tumors, and 
also in the hemorrhagic diathesis, disease of the kidneys and heart, 
vicarious menstruation, and the continued fevers. Semon,* ob- 
serving an epidemic of relapsing fever, met with epistaxis as a criti- 
cal symptom in thirty per cent of the cases, and in one extremely 
exhausted case, it was the actual cause of death. 
The general symptoms, which result from epistaxis, depend 
entirely on the amount of blood lost. Thus, if this is excessive, 
faintness or complete syncope may ensue. This symptom is usu- 
ally attended by a diminution or complete arrest of the bleeding, 
although it should always be borne in mind, that, when syncope 
occurs, the blood may continue to flow into the air passages below, 
involving the danger of a new complication. 
Diagnosis.—The prominent point of interest involved in the 
question of diagnosis is in those cases in which slight hemorrhage 
1 “Diseases of the Nose and Throat,” Phila., 1886 p. 207. 
2 “Zur Recurrens-Epidemie in Berlin,” 1871-72 Inaug. Dissert.. 1873. 314 
DISEASES OF THE NASAL TASS AGES. 
has occurred, in the night perhaps, and the blood, passing into the 
fauces, is hawked or coughed up, giving rise to apprehension, on 
the part of the patient, of pulmonary disease. An anterior or pos- 
terior rhinoscopic view, as a rule, will serve to establish this source 
of the hemorrhage, by the shreds of clotted blood still to be ob- 
served, either in the nasal cavity, or the vault of the pharynx. 
Furthermore, the venous character of the expectorated blood 
would indicate the nose or throat as its source. 
Treatment.—Where the attack is of a mild character, it will 
ordinarily be sufficient to make an application of ice to the side of 
the nose from which the bleeding occurs, while at the same time a 
small piece may be held in the mouth, the object being to produce 
direct contraction of the blood-vessels. Indirectly, this may be 
accomplished also by cold applied to the spine, as in the well- 
known domestic remedy of applying a cold key to the back of the 
neck; the vascular contraction, in this case, being due to a reflex 
action. This is undoubtedly best accomplished by cold applica- 
tions, although Chapman’s bags filled with water at the tempera- 
ture of one hundred and five degrees have been used for the same 
purpose. The position of the patient is of importance, I think, the 
best being that suggested by Moldenhauer1 who advises that the 
patient should be placed on his side, with the head turned forward, 
to allow the blood to escape from the nostril. This position is cer- 
tainly preferable to the sitting posture recommended by Moure.2 
Placing the patient absolutely on the back, as advised by Sajous,3 
would seem to be objectionable, as permitting the blood to flow 
into the throat. In every case where feasible, an attempt should 
be made to locate the bleeding point, and in many cases this will 
be successful, as in the majority of instances the source of the 
hemorrhage is near the nostril, and can be easily brought under 
inspection, when a pledget of cotton can be inserted, and pressure 
made by the finger on the outside of the nose. Mackenzie4 ad- 
vises pressure on the outer wall of the nose by means of the finger 
inserted into the nostril, after the manner of Valsalva. As before 
stated, however, I think the rule is that the bleeding surface is 
some point on the septum. The same writer advises that pressure 
be made on the facial artery, as it passes over the ramus of the 
inferior maxillary bone. Pressure on the septum by the finger 
inserted Into the nostril may be efficacious in directly controll- 
ing the hemorrhage by pressure on the bleeding surface, or as 
1 “Die Krankheiten der Nasenhohlen,” Leipzig, 1886, p. 132. 
2 Op. cit., p. 230. 
3 “ Diseases of the Throat and Nose,” Phila., 1886, p. 208. 
4 Opi cit., p. 346. EPISTAXIS. 
315 
Cohen1 suggests, by occluding the septal artery. Keetley 2 finds 
the external application of hot water, of a temperature of one 
hundred and twenty to one hundred and twenty-four degrees, an 
efficacious measure. Contraction of blood-vessels in one of the 
cavities, by the external application of heat and cold, is I think, 
undoubtedly a reflex phenomenon, and therefore is induced by 
the direct external stimulus or shock. Hence, I think, we should 
regard the cold application as a more powerful agent, and our 
efforts should be exerted with the idea of making an impression of 
a very decided character. Mackenzie3 quotes a case in which an 
epistaxis was arrested by plunging the body into a cold bath. Cer- 
tain revulsive agents, for determining the blood to the extremities, 
are recommended by all writers, such as a mustard plaster to the 
calves of the legs, immersing the feet in hot water, etc. Virtually 
the same effect is accomplished by a firm ligature applied around 
all the extremities, as suggested by Patrick.4 A curious case has 
been reported by Verneuil in which an epistaxis was arrested by a 
blister over the hepatic region, in a case of cirrhosis of the liver. 
A similar case is also quoted by Eccheverria,s in which no hepatic 
disease is mentioned. 
Simpler measures failing to arrest the hemorrhage, resource 
should be had to local applications to the nasal cavity. The sim- 
plest of these is the injection of cold water by means of a syringe, 
or the insertion of a pellet of ice into the cavity, or, as accomplish- 
ing the same purpose, hot water may be used. Dr. Stewart,6 of 
Minneapolis, reports a case in which an epistaxis was arrested by 
passing hot water through the nasal fossae, by means of the Thudi- 
chum douche, the operation being continued until the water flowed 
from the opposite nostril unstained by blood, thus arresting the 
hemorrhage, and at the same time leaving the nasal passages un- 
obstructed by clotted blood. 
Astringent applications naturally suggest themselves to any 
one endeavoring to arrest an epistaxis, and for this purpose, tannin 
or alum, in powder and solution, the various iron preparations, and 
perhaps other drugs of the same class may be used. These may 
be applied by means of the syringe or spray, or carried into the 
cavity on a pledget of cotton. I have always been averse to using 
these so-called haemostatics in the nasal cavity, both on account of 
1 “ Diseases of the Throat and Nasal Passages,” 2d ed., Phila., 1879, p. 378. 
2 The Practitioner, February, 1879, cited by Mackenzie, op. cit., vol. ii., p. 346, 
3 Op. cit., p. 346. 
4 New York Med. Journal, March 19th, 1887. 
5 El Dictaman, June 30th, 1887. 
6 New York Med. Record, September 8th, 1883, vol. xxiv., p. 262. 316 
DISEASES OF THE NASAL PASSAGES. 
the unsatisfactory results obtained, and also from the fact, that 
their local action on the healthy membrane forms an exceedingly 
disagreeable feature of the treatment. Moreover, the resulting 
mass of clotted blood, combined with the medicament used, ob- 
scures the inspection of the parts, and at the same time hampers 
further measures of treatment. These agents are best used by 
immersing a pledget of cotton in the fluid, or sprinkling the pow- 
ders on its surface, and carrying it well into the cavity. I question 
if what good results are obtained, be not from the plug, rather than 
from the drug with which it is medicated. The combination of 
iron with blood forms an exceedingly disagreeable mass, and one 
also through which blood will flow, hence I think it is rarely neces- 
sary to make use of this agent. The same objection, though in a 
lesser degree, lies against tannin. Alum, however, is not especially 
objectionable, and in many cases will be of service. It is best used 
in the strength of twenty grains to the ounce of water, either in 
the form of a spray, or with a syringe, or it may be applied with 
cotton pledgets. Lavrand1 has found antipyrin an efficacious 
remedy; a watery solution, of a strength one part to thirty, being 
carried in on pledgets of cotton. This is a remedy of undoubted 
value, but is better, I think, applied in the form of a powder, either 
insufflated, or blown in with a tube. Of all local remedies, how- 
ever, we have none whose action is so striking and so unvarying as 
that of cocaine, provided that we can apply it directly to the mem- 
brane, and secure its absorption to a sufficient extent to produce 
its characteristic action on the muscular coat of the blood-vessels, 
by which their calibre is so markedly diminished. I believe cocaine 
to be the only drug in our pharmacopoeia which possesses an abso- 
lutely certain constringent action on the blood-vessels. This action, 
furthermore, is best obtained by the weaker solutions, a four-per- 
cent strength being preferable. It may be applied with pledgets of 
cotton, carried well into the cavity, one after the other, or better 
still, I think, in an oily emulsion as follows: 
Cocain. hydrochlorat., ..... grs. xx. 
Aquae, . . 3 ss. 
M. ft. sol. et adde 
Ol. voschano (see p. 115) 
Vel Ol. petrolati (zero) vel ol. olivi, . ad § i. 
M. 
This combination is easily atomized by the hand-ball atomizer 
(shown in Fig. 47) and may be sprayed into the cavities. In this 
manner, we secure a more permanent action of the cocaine, in that 
1 Journal de Medecine et de Chirurgie Pratique, Nov., 1885. EP1STAXIS. 
317 
it is not washed out by the flowing blood as rapidly as a watery 
solution, and furthermore, the oily fluid seems to exercise a certain 
mechanical action in arresting the hemorrhage. 
If the foregoing measures fail to arrest or markedly modify the 
severity of the hemorrhage, plugging should be resorted to, before 
constitutional symptoms of excessive loss of blood supervene. A 
number of mechanical devices have been suggested for plugging 
the nose, in the form of air or water-bags. The earliest of these 
was the suggestion of J. P. Frank,1 who used a portion of the intes- 
tine of a hog, which, after insertion into the nasal cavity, was dis- 
tended with water. Similar devices were suggested by St. Ange2 
and Cooper Rose,3 air being used for the inflation of the bags; 
while Antoni4 has modified the instrument, by inserting within the 
outer bag a rubber tube, open at both ends, through which the 
patient may be allowed to breathe, after the outer bag has been 
inflated in the nose. This modification would seem scarcely neces- 
sary or practicable, as the breathing 'tube would undoubtedly be 
collapsed by the pressure in the outer tube necessary to fill the 
cavity. The ordinary rubber toy-balloon, sold on the streets, would 
probably answer quite as good a purpose in an emergency as any 
of the devices above mentioned, but I am disposed to think this 
measure somewhat impracticable, and furthermore, the apparatus 
is rarely at hand. A much simpler and more efficacious method is 
plugging with pledgets of cotton, or the single large tampon. The 
tampon possesses the advantage of being easily removed after it 
has served its purpose, and yet I think is less efficient than pledgets 
of cotton, packed one after the other through the nostril, as large 
a plug as can be well inserted being placed behind, well into the 
posterior nares, followed by smaller pledgets, packed directly 
against it, and above it, until the whole cavity is filled. The diffi- 
cult part of this procedure is the insertion of the first plug, which 
should be an inch to an inch and a half long, of the size of the 
forefinger. This should be grasped in its whole length by a pair 
of slender forceps and carried through the middle meatus and well 
backward until near the posterior nares, when it should be packed 
down firmly on the floor of the nares, with the closed blades of 
the forceps. The only difficulty about this procedure is in the 
subsequent removal of the plugs. To overcome this, it may be 
well to tie a string to the first plug only, although Schech5 advises 
1 “ De Curandis hominum morbis,” Mannhemii, 1807, lib. v., pars ii., p. 144. 
2 Lapeyroux, These de Paris, 1836, No. 314. 
3 Mackenzie, op. cit., vol. ii., p. 281. 
4 Bolletino delle Malattie dell’ orecchio, della gola, etc., No. 3, 1886. 
5 “ Diseases of the Mouth, Throat, and Nose,” English ed., Edinburgh, 1886, p. 258. 318 
DISEASES OF THE NASAL TASS AGES. 
that a separate string be tied to each plug. A better device still, 
perhaps, is that of Moure,1 of a kite-tailed tampon, made up of 
pledgets of cotton, inserted at varying distances, in the continuity 
of a single cord. An excellent suggestion is made by Ingalls,2 who 
advises the use of a strip of iodoform gauze as a tampon, for the 
decomposition which takes place in these plugs, after remaining in 
situ for one or two days, may give rise to unpleasant symptoms. 
The continuous tampon possesses an undoubted advantage, in that 
many cases are met with in which hemorrhage is not arrested by 
this measure, hence the rapid removal of the plugs is of importance, 
in order to proceed to our last resort in controlling the epistaxis, 
viz.: by plugging the posterior nares. The first step of this manipu- 
lation requires the passing of a cord through the nares, and out 
through the mouth. In former times this was done by the aid of 
Bellocq’s canula. This instrument is an awkward, cumbersome 
device, and usually constructed.with a curve entirely inappropriate 
for insertion into the nasal cavity. By far the best instrument for 
carrying a cord through the nose is a soft-rubber or English cathe- 
ter, of small size, which will readily pass through the lower meatus 
to the pharynx, where it can be seized with the forceps, or thrown 
forward into the mouth by a hawking effort on the part of the 
patient. If necessary, the stylet may be inserted into the catheter 
for the purpose of introducing it, although, as a rule, this is not 
necessary. After the catheter is in position, a stout cord should be 
fastened to either end, and drawn through the cavity. A pledget 
of cotton sufficiently large to completely fill the posterior nares, 
perhaps the size of the last phalanx of the thumb, should be tied 
firmly into the continuity of the cord, and drawn up behind the 
palate, and firmly fixed in the posterior nares. As a rule, it will 
be well to facilitate the passage of the plug to its position, by the 
left forefinger inserted behind the palate, to prevent the plug from 
becoming engaged against the velum. The remaining step consists 
in plugging the anterior nares firmly. The two ends of the cord 
are now fastened together, and may be carried, for convenience, 
over the ear. The object of leaving the cord in the mouth, of 
course, is to enable the operator to remove the plug when neces- 
sary. I have seen several cases where this cord was cut close to 
the tampon; as a consequence the removal of the plug became a 
somewhat difficult matter, and in one case it became necessary to 
leave it in situ for three weeks, until it became loosened and dropped 
into the pharynx spontaneously. Robinson,3 in a similar dilemma, 
passed a flexible catheter into the pharynx through the nares, and, 
1 Op. cit., p. 233. 2 Medical News, July 23d, 1887. 
3 New York Pathological Society, April 27th, iS8i. Medical Record, July 16th, 1881. EPIS TAXIS. 
319 
attaching to it the nasal extremity of the cord, drew it down into 
the pharynx, and extricated the plug. Moure 1 suggests that where 
the nasal cavities are obstructed by tumors, deformities of the sep- 
tum, or other causes, the posterior nares may be plugged by car- 
rying a pledget of cotton behind the palate, with a pair of properly 
curved forceps. This procedure is a difficult one, and will be 
materially aided by digital manipulation. 
The plugs should be allowed to remain in position not longer 
than forty-eight hours, when they may be with safety removed. I 
have never seen any accident follow plugging of the posterior nares, 
although Mackenzie2 cites a number of instances, in which the pro- 
cedure caused extensive gangrene of the face, tetanus, pyaemia, 
facial erysipelas, and in some cases resulted in death; while Gelle3 
reports a case of double purulent otitis media resulting from this 
procedure. 
Too much emphasis cannot be laid on the importance of search- 
ing for the bleeding point in every case of epistaxis, before any 
measures are employed for arresting the hemorrhage. If this is 
done by means of a head-mirror and a good light, the nostril being 
well dilated, probably in the large proportion of cases the bleeding 
surface can be thus brought into view, by cleansing the membrane 
from the flowing blood by means of a pledget of cotton, when 
measures for the arrest of the hemorrhage become comparatively 
simple. When the bleeding point has been located, the hemor- 
rhage may be arrested, as a rule, by simple pressure, although in 
certain cases a local application is preferable, in avoiding the dis- 
comfort attendant upon the insertion of plugs. Chiari4 expresses 
preference for the galvano-cautery in these cases, while Robinson 5 
condemns it, justly I think, for certainly a simple stick of nitrate 
of silver, or crystal of chromic acid, will often answer the purpose 
equally well, and is much more easy of manipulation, or if these 
fail, the ordinary silver probe, heated with a spirit lamp to a dull 
heat, offers most of the advantages of the galvano-cautery and, 
moreover, is always available. 
In addition to local measures, there are certain internal reme- 
dies which are regarded as possessing the property of controll- 
ing hemorrhage. These remedies act either directly upon the 
blood or on the blood-vessels, diminishing in one case the fluidity 
of the blood, and in the other, acting on the muscular coats of 
the blood-vessels, in such a way as to contract their calibre. Tan 
1 Op. cit., p. 234. 2 Op. cit., p. 348. 
3 Societe Franijaise de Laryngologie, October, 1886. 
4 Wien. Med. Zeitung ; Medical Record, August, 1883. 
5 New York Med. Journal, Sept. 24th, 1887. 320 
D IS EASES OF THE NASAL PASSAGES. 
nic and gallic acid, acetate of lead, and sulphuric acid, and the 
various preparations of iron, are supposed to diminish the hemor- 
rhagic tendency; while ergot, belladonna, digitalis, hamamelis, 
and antipyrin act to diminish the calibre of the blood-vessels. I 
see no objection to the administration of any of these remedies in 
severe cases of hemorrhage, as aids to the local measures resorted 
to, although I think little reliance can be placed upon them. Cer- 
tainly my own experience has failed to demonstrate their useful- 
ness. The use of ergot has been somewhat warmly advocated by 
Mackenzie 1 and probably few of us, in severe cases of hemorrhage, 
would consider our whole duty fulfilled without the hypodermatic 
administration of twenty minims of the fluid extract of this drug, 
repeated according to circumstances. Opium, also, in some of its 
forms, may well be given, both on account of its supposed action in 
contracting the blood-vessels, and also on account of its anodyne 
effect, wherein I think lies its chief value. I should fully agree 
with Mackenzie2 in regard to the tincture of opium, as the best 
form for its administration. Frankel3 cites instances in which 
periodic attacks of epistaxis, which he regards as having been due 
to malarial origin, were cured by the administration of quinine. 
Harvey4 also reports a somewhat similar case, in which the epistaxis 
recurred daily at 3 P.M. for seven days, when it was finally arrested 
by the administration of anti-periodic remedies. In this case, there 
was no evidence pointing to malarial poisoning other than the perio- 
dicity. Where the loss of blood is very great, transfusion or infusion 
naturally suggests itself, as a means of restoring the vitality of the 
patient, rather than for the arrest of the hemorrhage, and yet Mac- 
kenzie5 cites a case reported by Mosler, in which the hemorrhage 
was arrested by the transfusion of blood. The infusion of a saline 
solution or of warm milk would probably answer the same purpose. 
1 Op. cit.. p. 248. 2 Op. cit. 
3 Ziemssen’s “Encyclop.,” Amer. ed., vol. iv., p. 152. 
4 New York Med. Record, May 20th, 18S2, vol. xxi., p. 541. 
s Op. cit., p. 349. CHAPTER XX. 
FOREIGN BODIES IN THE NASAL PASSAGES. 
Either by accident or the curious instincts of childhood, a 
foreign body in the nose is a not infrequent condition, demanding 
surgical interference. In the large majority of instances these 
bodies are inserted through the nostril intentionally, by mischievous 
children or hysterical females, while others make their way into 
the cavities through the posterior nares, in an oftentimes obscure 
and rather a curious manner. Thus, in the act of vomiting, a por- 
tion of the contents of the stomach is frequently thrown into the 
nasal fossae, and some parts of it may remain. Thus, not long since, 
I removed a deciduous tooth from the nasal cavity, in a gentleman 
aged thirty-seven, which had been the cause of a purulent catarrh 
for twenty-five years. In this case, the tooth, becoming loosened 
in its socket, had been swallowed at the age of twelve, and probably 
afterward thrown into the nasal cavity, in the act of vomiting. A 
somewhat curious case is reported by Lowndes,1 in which a ring 
was found impacted in the posterior nares of a child fifteen months 
old, which was too large to have made its way through the nostril, 
and which probably had been swallowed and subsequently thrown 
into this locality by vomiting. Of course, soft particles of food, 
ejected from the stomach into the nasal cavities, are easily expelled, 
and prove but ephemeral sources of irritation. Moldenhauer2 
mentions the liability of lumbricoid worms, pills, fruit stones, etc., 
to reach the nose in the act of vomiting, and furthermore, that this 
accident is facilitated by paralysis of the palate. Mention has 
already been made, in the chapter on epistaxis, of tampons being 
left in the nasal cavity by plugging. As a rule, these loosen them- 
selves, and come away spontaneously, although, in one case, I re- 
moved a tampon which had been inserted for the purpose of con- 
trolling an epistaxis, and which had been the source of an exceed- 
ingly offensive purulent discharge from one of the nasal cavities for 
two years. Similar accidents are alluded to by Moldenhauer3 and 
1 British Med. Journal, September, 1867, p. 206. 
2 “Die Krankheiten der Nasenhohlen,” Leipzig, 1886, p. 122. 
3 Loc. cit. DISEASES OE THE NASAL PASSAGES. 
322 
Moure.1 The objects which are inserted into the nose anteriorly, 
are shoe-buttons, beans, pebbles, and, in fact, any object whose size 
the nostril admits. When inserted in this way, they usually lodge 
just within the nostril, against the anterior extremity of the lower 
turbinated bone, although occasionally they lodge midway in the 
lower meatus. Entering from behind, they lodge as a rule well 
back in the lower meatus, although Moure2 states that, when enter- 
ing in this direction, they lodge in the middle meatus, an assertion 
which does not coincide with my own observation. Among rarer 
accidents are those in which a foreign body makes its way into the 
nasal cavity through the external walls of the nose, as in the case 
quoted by Moldenhauer3 in which a splinter of wood made its way 
through the canine fossa, and was removed from the inferior meatus 
a month later. In the same way a spent bullet, fragments of iron 
or other objects may make their way into the nasal cavity by 
penetrating the bones of the face. Interesting cases have recently 
been reported by Noquet,4 Coupard,5 and Lastra.6 
Symptomatology.—The immediate effect of the presence of 
any foreign body in the nose, is to excite more or less profuse sero- 
mucous discharge, which is soon converted into a muco-purulent 
or bloody discharge, as the result of the ulcerative process which 
its presence causes in the mucous membrane, against which it is 
lodged. Hence, the prominent and characteristic symptom to 
which it gives rise, is an offensive muco-purulent discharge. The 
presence of the object itself, causes more or less stenosis of the 
passage, which is greatly increased by the swollen condition of the 
mucous membrane which it causes, and still more by the muco- 
purulent secretions accumulating in the cavity. Moure7 makes 
the point that sneezing, with a sense of oppression and interference 
with olfaction, is a characteristic symptom, where the body is lodged 
anteriorly. This I do not think is the case, for the olfactory region, 
the most sensitive area of the nose, is not encroached upon by the 
foreign body as a rule. In fact, wherever the foreign body lodges, 
the membrane becomes to a certain extent tolerant of it, in that 
reflex symptoms, such as sneezing and watery discharges, are not 
excited by its presence. Olfaction, furthermore, is not liable to be 
affected, in that the entrance of odorous particles is not necessarily 
interfered with, and even if they were, their appreciation by the 
healthy membrane of the opposite passage would render the dis- 
1 “ Manuel Pratique des Maladies des Fosses nasales,” etc., Paris, 1886. 
2 Op. cit., p. 147. 3 Op. cit., p. 123. 
4 Bull. Med. du Nord, Sept., 1887. 5 Soc. Med. Pratique, Mch. 15th, 1888. 
6 Rev. de Med. de Seville, 1887, Tome xi., No. 6. 
7 Op. cit , p. 149. FOREIGN BODIES IN THE NASAL PASSAGES. 
323 
covery of any impairment of olfaction in the occluded side some- 
what improbable. The morbid process set up in the membrane, 
furthermore, is not that which leads to the development of ear 
symptoms, hence, impairment of hearing is probably rarely, if ever, 
an accompaniment. Facial neuralgia is occasionally present, and 
may prove an exceedingly distressing symptom. Erosion of the 
nostril and lip, as mentioned by Schech 1 is not infrequently caused 
by the acrid discharges from the nose. This is especially observable 
in young children. The same writer includes epiphora, conjunc- 
tivitis, and allied affections among the symptoms of foreign bodies 
in the nose. These I should regard as somewhat rare. 
Diagnosis.—The occurrence of a chronic purulent discharge 
from one nostril should always give rise to the suspicion that it is 
due to the presence of a foreign body, for in those diseases of the 
nose which are characterized by a purulent discharge, the rule is 
almost universal that it is bilateral. Syphilis may cause an offen- 
sive discharge from one side, but this disease makes itself known 
by other and concomitant symptoms, which would render a mistake 
in diagnosis almost impossible. Disease of the accessory cavities 
of the nose is almost always unilateral, but in these cases, stenosis 
is the rare exception, while it is always present to a more or less 
extent in the case of a foreign body, and moreover, it is a disease 
of adult life. The presence of myxoma and fibroma does not cause 
a purulent discharge, while in sarcoma and carcinoma it is the rule. 
These growths, however, make their presence known by symptoms 
not to be mistaken. Furthermore, the discharge caused by the 
presence of a foreign body in the nose is somewhat peculiar, in 
that mixed with the pus are found small flocculent whitish masses 
of inspissated mucus, presenting a somewhat cheesy appearance, 
which is characteristic. The ulceration in the nasal cavity is not 
progressive, and rarely, I think, extends through the thickness of 
the mucous membrane. Occasionally the pressure may produce 
perforation of the cartilaginous septum, but never a true necrosis 
of bone. If the foreign body is of sufficient size and lodged an- 
teriorly, external deformity will be noticed in the region of the ala. 
The diagnosis can only be definitely made by the use of a probe. 
Cocaine should always be applied, after cleansing the cavity as 
thoroughly as possible by means of a syringe or spray, when thor- 
ough probing is easily tolerated. In the case of young children, I 
think it is always wise to administer a few whiffs of chloroform, 
sufficient to produce primary anaesthesia, before any attempt is 
made at exploring the cavity, for thus a quiescent condition of the 
child is obtained, which will enable the operator to ascertain the 
1 “ Diseases of the Mouth, Throat, and Nose,” English ed., Edinburgh, 1886, p. 260. 324 
DISEASES OF THE NASAL TASS AGES. 
presence and locality of the foreign body by an exceedingly brief 
exploration with the probe, without injury to the soft parts, which 
would be almost an impossibility with a struggling child. 
Treatment.—As before stated, if the patient is a child, a gen- 
eral anaesthetic should always be given, in order to secure its thor- 
ough quiescence, as advised by Mackenzie,1 Schech,2 and others, 
although Moldenhauer,3 on the other hand, strongly objects to this 
agent, preferring that the child should be held by two assistants. 
In adults, general anaesthesia will rarely be necessary. If the body 
is small, and lodged anteriorly, it will usually be easily seized 
by a pair of mouse-toothed forceps. If not easily grasped by 
this, it is sometimes feasible to slip the loop of a snare around 
it, drawing it tightly, and thus firmly engaging the object. If the 
object prove too large to extricate through the nostril, it is quite 
feasible to cut it in two by this instrument, or crush it and re- 
move it piece-meal, thus avoiding the necessity of forcing it through 
into the pharynx, as would otherwise be incurred, or of enlarging 
the nostril by the Rouge or Dieffenbach operation, although if 
the object be too hard to crush with the snare, and tod large to 
withdraw through the nostril, one of these procedures may be 
necessary. If the object be a shoe-button, its removal is rendered 
quite simple by the insertion of a hook into its eye. If the mouse- 
toothed forceps is too small to grasp it, a larger forceps may be 
used. Durham4 has devised a pair of forceps with an obstetric 
lock, by which a better grasp of the object may be secured, while 
Rastelli5 has devised a fenestrated hook, based on the principle of 
the obstetric vectis. These devices, I take it, complicate unneces- 
sarily what is usually a simple manipulation. A simpler instrument 
is the curette devised by Gross. This instrument has also on its 
outer extremity a small screw, for insertion into the object, an in- 
genious device, provided the screw can be inserted without forcing 
the body back into the nasal cavity. In those cases in which the 
object is lodged in the posterior nares, it may be dislodged with 
the finger in the pharynx worked in connection with the probe 
through the nose, or seized by a pair of curved forceps, passed 
behind the palate, directed either by the finger or by the rhino- 
scopic mirror. The use of douches to dislodge a foreign body is 
not only of questionable efificacy, but probably involves a certain 
amount of risk, in that the ordinary dangers of the douche are in- 
creased by the obstruction. Temain6 avoids the dangers of the 
1 Op. cit., p. 434. 2 Op. cit., p. 261. 3 Op. cit., p. 125. 
4 Holmes’s *' System of Surgery,” 1870, vol. iv. 
5 Raccoglitore medico, No. 4, 1887. 
6 Revue mensuelle des maladies de l’enfance, Paris, Feb., 1887. FOREIGN BODIES IN THE NASAL PASSAGES. 
325 
douche, by passing a catheter through the nose beyond the foreign 
body, and projecting a stream of water against it from behind, in this 
manner endeavoring to force it out. Many writers mention the 
use of snuffs to excite sneezing, in the hope of thereby dislodging 
the object, purely on theoretical grounds, I take it, for certainly a 
more vigorous expulsive effort can be made in blowing the nose 
than ever occurs in the act of sneezing. In very young children, 
who cannot blow the nose vigorously, this may be done for them 
by the use of a Politzer’s bag, blowing into one nostril, or by blow- 
ing into the child’s mouth; although either of these procedures 
should be carried out very carefully. After all, however, a foreign 
body will be usually extracted by means of the forceps or snare, 
and these supplemental methods need rarely be called into use. CHAPTER XXI. 
RHINOLITHS. 
WHEN a foreign body has become impacted in the nasal cavity, 
and remains for a lengthened period of time, there are oftentimes 
deposited upon it the saline constituents of the mucous secretion, 
giving rise to a nasal calculus, or, as it is more generally termed, a 
rhinolith. The earliest instance of this we find recorded by Joseph 
Mathias de Gardi1 who relates that one of his confreres removed 
from the nasal passages a calculus as large as a fir-cone. Subse- 
quently Bartolini2 reports two cases, in one of which a calculus 
was formed about a cherry-pit as a nucleus, while the other appar- 
ently was produced spontaneously. Similar cases have been re- 
ported by Clauder,3 Kern,4 and Vitus Riedlinus.5 Still later, a 
very curious case was reported by Wepfer6 in which the calculus 
was completely imbedded, and covered by the mucous membrane. 
A case has been noted by Ruysch7 in which a piece of amber 
formed a nucleus for the calculus, while Plater,8 in discussing the 
causes of their formation, takes the ground that they are due to 
certain changes in the mucous secretion. Additional cases were re- 
ported by Horn,9 Saviales,10 Graeffe,11 Thouret,12 and Brodie.13 Per- 
haps the most exhaustive study of these formations was that made 
by Demarquay14 who not only made a full study of all the recorded 
cases, to which I am much indebted for the references given, but also 
entered into a full discussion of their causation. The frequency with 
1 “ Pratica Venise,” 1502, post ii., cap. xiv., p. 308. 
2 “ Hist. Anat. rara,” 1654, Cen. i., Hist. 33, p. 47 ; et Ibid., Cent, iv., Hist. 85, p. 
404. 
3 “ Ephem. curios.,” 1685, dec. 2, An. 13, obs. 78. 
4 “ Ephem. cur. natur.,” 1700, dec. 3, An. 5 and 6, obs. 46, p. 100. 
s “Ephemer.,” 1706, dec. 3, an. 9 et 10, observ. 145, p. 268. 
6 “ Ephem.,” 1727, obs. 192, p. 905. 
7 “Obser. Anat.,” Amsterdam, 1733, obs. 44, p. 42. 
8 “ De olfactus lesione,” 1736, lib. i., cap. 9, p. 264. 
9 Dans Smuker, 1788, obs. 22, p. 289. 
10 Bulletin de la faculte de medecine, 1814, t. iv., p. 44. 
11 Annales d’oculistique, 1828, t. viii., liv. iv. and v., p. 203. 
12 Arch, generale de med., 1829, t. xix., p. 27. 
13 Annales de therapeut. med. et chir., May, 1844, No. ii. 
14 Arch, generale de med., 1845, vol. viii., p. 174et seq. RHINOLITHS. 
327 
which nasal calculi are reported in our later literature would seem to 
indicate their somewhat common occurrence. Thus we find obser- 
vations recorded by Mackenzie,1 who also quotes reports of cases by 
Cooke,2 Kotlin,3 Rouyer,4 W. N. Brown,5 Verneuil,6 West,7 Roe,8 Her- 
ing,9 and Nourse.10 Still later observations were made by Erichsen,11 
Clark,12 Bettman,13 Beach,14 Bovill,15 Hendley,16 Bigelow,17 C. Creswell 
Baber,18 Nolte,19 Moure,20 Ferre,21 Schoetz,22 Seifert,23 Rindfleisch,24 
Silitch,25 Morelli,26 and Clay.27 
The formation of the nasal calculus is governed by the same 
laws which direct the formation of calculi in other portions of the 
body, that is, a foreign body is impacted in the nasal cavity, and 
serves as a nucleus, about which there are deposited the solid con- 
stituents of the fluid in which it is immersed, namely the normal 
secretion of the nasal mucous membrane. In most of the cases 
above enumerated, a nucleus was observed and recognized. In 
other cases, no apparent nucleus was detected, and yet I think there 
can be no question that the nucleus must-have existed, and subse- 
quently disappeared, as in the case of a large rhinolith removed by 
the author, which, on section, showed a small cavity which appar- 
ently had been occupied by a kidney bean, of which scarcely any 
trace was left. A small mass of hardened mucus, as suggested by 
1 “Diseases of the Throat and Nose,” Amer. ed., 1884, vol. ii., p. 438. 
2 Ranking’s “Abstract,” 1847, vol. vi., p. 132. 
3 Wiirtemberg. Corresp. Blatt, 1854. 
4 Bull, de la soc. Anat. de Paris, 1857, p. 60. 
5 Edinburgh Med. Journal, 1859, vol. v., p. 50. 
6 Gaz. des Plopitaux, 1859, p. 25. 
7 London Lancet, 1872, vol. i., p. 147. 
8 Arch, of Laryngology, 1880, vol. i., No. 2, p. 149 et seq. 
9 Monatsschrift fur Ohrenheilkunde, 1881, No. 5. 
10 British Med. Journal, October, 1883, p. 728. 
11 “ Science and Art of Surgery,” 7th ed., Phila., 1881, vol. ii., p. 390. 
12 Albany Med. Annals, 1883, vol. iv., p. 34. 
13 Journal Amer. Med. Association, Sept. 6th, 1884. 
14 New York Medical Record, July nth, 1885, p. 38. 
15 British Med. Journal, October 16th, 1886, p. 718. 
16 British Med. Journal, December nth, 1886, p. 1,161. 
17 Albany Med. Annals, 1887, p. 178. 
18 London Lancet, April 16th, 1887, p. 772. 
19 Allg. Med. Cent.-Zeit., 1887, p. 1,180. • 
20 journal de med. de Bordeaux, 1887. 
21 Ibid. 
22 Deut. Med. Zeit., 1887, p. 21. 
23 Ibid., p. 86 (also Sitzungs-Bericht der Physikalisch-medicin. Gesellschaft zu Wurz- 
burg, 1885, p. 112). 
24 Ibid. 
25 Vratsch, 1887. , 
26 Pesther Med. Chir. Presse, 1887. 
27 British Med. Journal, Feb. 12th, 1887, p. 328. 328 
DISEASES OF THE NASAL TASS AGES. 
Cohen,1 or a blood-clot as suggested by Moldennauer, may be the 
starting point in one of these formations, of which probably little 
trace would be left. In Baber’s case, a rag was found as the nucleus, 
while in one of Seifert’s cases a metallic button was the nucleus, 
and in another a piece of bone, while in Bigelow’s case a piece of 
dried mucus was demonstrated to have been the nucleus. As a 
rule, these formations are met with singly, the only exception to 
this which is found being a case reported by Axmann ’ in which 
the patient, suffering from periodic headache, was relieved by the 
spontaneous expulsion of a number of rhinoliths. 
Their shape is somewhat dependent on the character of the 
nucleus, as modified by the contour of the cavity, but in general 
they are elongated, and of an irregular ovoid form. In some cases, 
they constitute a thin shell, deposited upon a foreign body in the 
nose; while in others, they form a somewhat dense and almost 
homogenous solid mass, as in the case of Hendley, where the mass 
measured two inches in length by seven-eighths in breadth, weigh- 
ing seven hundred and twenty grains, and was of almost the density 
of ivory. In Rindfleisch’s case, the rhinolith consisted of a calcare- 
ous lamella deposited upon the convexity of a deflection of the car- 
tilaginous septum, this deflection being due to inflammatory action. 
The question arises here, whether this may not have been a case of 
calcareous degeneration of the mucous membrane described by 
Virchow4 and Kolliker,5 a view which would seem to harmonize 
more closely with clinical observation of these formations. In the 
same category, probably, should be placed Erichsen’s cases, where 
the calcareous deposit formed a lamella in the mucous membrane 
of the ala of the nostril. The cause of these formations, then, in 
all cases, I am disposed to think, is a foreign body in the nose, act- 
ing as a nucleus, around which the calcareous material is deposited. 
Whether any constitutional diathesis acts as a predisposing cause, 
seems to me somewhat doubtful. Certainly, in the majority of 
cases, it is difficult to demonstrate this, although Graefe believes 
that the gouty diathesis acts as a predisposing factor, a view also 
entertained by Sajous; while Demarquay, in fifteen cases, finds this 
diathesis presenting in but one case. This writer believes that a nar- 
rowing of the inferior meatus is a predisposing cause to the forma- 
tion of rhinoliths and, furthermore, that an alteration of secretion has 
some influence. It would seem that there must be some factor of 
1 “ Diseases of the Throat and Nasal Passages,” Philadelphia, 1879, P» 39°- 
2 “ Die Krankheiten der Nasenh6hlen,” Leipzig, 1886, p. 123. 
3 Amer. Journal of Med. Sciences, 1829, old series, vol. v., p. 204. 
4 “ Cellular Pathologie,” iv. Aufl., Berlin, 1871, p. 453 and note ff. 
5 “ Gewebelehre, Geruchsorgan.” RHINOLITHS. 
329 
this kind, as in a case alluded to by the author, in the chapter on 
foreign bodies, a tooth was retained in the nasal cavity twenty-five 
years, which, when removed, showed no deposit whatever. Mac- 
kenzie 1 regards chronic inflammation of the nasal mucous mem- 
brane as predisposing to the formation of rhinoliths. The presence 
of a rhinolith naturally excites a certain amount of inflammatory 
reaction, which would render it somewhat difficult to draw a nice 
distinction between cause and effect in these cases. 
An analysis of these formations shows them to contain the 
ordinary saline constituents of nasal mucus, which according to 
Robin contains in 1,000 parts: 
Chlorides of sodium and potassium, . . . 5.60 
Phosphates of lime and magnesia, . . . 3.50 
Sulphate and carbonate of soda, . . . .90 
Schech2 states that they consist of phosphates and carbonate of 
lime, and a small quantity of iron, together making up eighty per 
cent, and that they contain twenty per cent of organic material. 
In Nolte’s case iron was also found. 
Symptomatology.—A consideration of the symptoms due to 
the presence of rhinoliths involves mainly questions already dis- 
cussed in the chapter on foreign bodies, with the additional factor, 
that a rhinolith growing within the nasal cavity attains a large de- 
velopment, which consequently involves certain additional symp- 
toms, due to the mere presence of the growth. In Hendley’s case, 
the nose was greatly swollen, while a sinus opened externally, dis- 
charging pus; while in Bovill’s case, the left side of the face was 
swollen, there was left facial paralysis, ptosis and epiphora of the 
left eye, the nose and the septum were deviated to the right side, 
and the hard palate was distorted. In Nolte’s case, the hard palate 
was perforated at its junction with the soft palate. In Baber’s 
case the lower turbinated bone was atrophied, and the nose and 
cheek deformed. We find then these additional symptoms, due to 
the progressive development of the growth, much in the same 
manner as a fibroma develops, crowding the soft parts and even 
bone before it, while at the same time extensive ulceration occurs, 
giving rise to a profuse purulent discharge, oftentimes of a exceed- 
ingly offensive character, which makes its exit through the nostril, 
into the fauces, or through an artificial opening in the external face, 
or in the palate. The neuralgia and paralysis which accompany 
the development of a rhinolith are, of course, dependent on pressure 
either on the nerve trunk or peripheral filaments. In Axmann’s 
1 Op. cit., p. 436. 
2 “ Diseases of the Mouth, Throat, and Nose,” English ed., Edinburgh, 1886, p 258. 330 
DISEASES OF THE NASAL PASSAGES. 
case, the neuralgia assumed a periodic form. In Bettman’s and 
Clark’s cases, mucous polypi developed, in much the same manner, 
probably, as they occasionally develop around the ragged edges of 
a syphilitic ulcer. 
DIAGNOSIS.—The development of these formations is some- 
what slow, and hence they are usually met with in adult life, 
although in Clark’s case the patient was but six years of age, while 
Baber’s was twelve; for while it is in young children that foreign 
bodies are most frequently met with in the nose, the conditions 
favorable to the development of a calcareous deposit do not seem 
to obtain, in most instances, until later in life. The diagnosis is 
usually easy and depends mainly on investigation by means of the 
probe, cocaine being applied as thoroughly as feasible. The impact 
of the probe will reveal the location, and to an extent the size of 
the rhinolith, while the characteristic grating sensation will deter- 
mine its character. The only source of error would be in the pres- 
ence of necrosis of bone, or calcareous degeneration of the mucous 
membrane. These conditions, however, should be easily recognized, 
since their location is on the walls of the nasal cavity. 
Treatment. treatment of a rhinolith is essentially the 
treatment of any foreign body. As a rule, these formations are 
entirely too large, to extract through the nostril, and hence crush- 
ing becomes necessary. In many instances, this is easily done by an 
ordinary duck-bill forceps, or the snare ccraseur may be used, as 
suggested in connection with foreign bodies. This is applicable to 
soft formations, and those in which the nucleus is large, and the 
outer incrustation is thin. Where the formation is dense and solid, 
more powerful mechanism will be required for crushing them. For 
this purpose, any of the ordinary lithotrites designed for crushing 
urinary calculi are applicable. The crushing of a hard nasal cal- 
culus is by no means a trivial operation, and in most cases will 
require a general anaesthetic. Its dangers are not necessarily great, 
and yet Mackenzie1 states that extensive hemorrhage attended his 
operation, together with the development of facial cellulitis on the 
following day. In Hendley’s case, the rhinolith was removed by 
dividing the external nose, while in Nolte’s case it was extracted 
by enlarging the opening in the palate. 
1 Op. cit., p. 438. CHAPTER XXII. 
PARASITES IN THE NASAL CAVITIES. 
ALTHOUGH the various forms of living creatures which either 
make their way into the nasal cavity, or are developed from ova 
deposited there, are not, in the strict sense of the term, parasites, 
yet this is the term used by most writers, in describing this curious 
condition which, while one of the rarest events in temperate regions, 
is of somewhat frequent occurrence in tropical climates, involving 
in many cases extensive local destruction of tissue, with impaired 
general health, and even death. 
While we find reports of isolated cases of this affection scat- 
tered through the literature of the last two centuries, no general 
resume of the subject was made until Mackenzie’s1 work ap- 
peared, in which the literature of this affection has been most 
thoroughly and exhaustively collated, whence our knowledge on 
this branch of the subject is mainly derived. The earliest cases 
reported are those of Gahrlieb,2 Behrends3 and Wohlfahrt,4 in 
which patients suffering from apparently a severe cold in the head, 
with violent headache, were treated by hot inhalations of various 
kinds, resulting in the expulsion of large numbers of maggots 
from the nose, which were found to be the larvae of flies, the 
patients recovering. A much more serious case was reported by 
Cloquet,5 in which a man, after sleeping in an open field, was 
brought into the hospital suffering from violent frontal pains, with 
a swollen condition, involving the whole face and head, with worms 
crawling out of the nostrils and ears. The swellings were opened, 
and in the course of the treatment three plates full of these crea- 
tures were removed. The patient recovered with the loss of both 
his eyes. McGregor’s6 case is interesting, as being the earliest ob- 
servation of a case occurring in British India, while a more thorough 
1 “ Diseases of the Throat and Nose,” vol. ii., pp. 439 et seq. 
2 ” Ephem. Nat. Curios..” dec. 3, ann vii. and viii., observ. 141, p. 260. 
3 Scharschmid’s Med. et Chir. Nachrichten, Berlin. 1743, Jahrg. 1, p. 214. 
4 “ Obser. de Vermibus per Nares Excretis,” Halae Magdeburgise, 1768. 
5 American Journal of Medical Sciences, May. 1828, p. 228. 
6 London Med. and Physical Journal. 1830, vol. 44. p. 498 et seq. 332 
DISEASES OF THE NASAL TASS AGES. 
study of the affection in India was made by Lahory 1 who collated 
ninety-one cases, of which two were fatal. Coquerel,2 of Cayenne, 
reports five cases occurring in French Guiana, of which three died, 
the prominent symptoms in all being similar to those in Cloquet’s 
case; the fatal cases, however, developing meningitis. The disease 
in Mexico, as studied by Morel3 and Weber,4 presents no features 
worthy of special note. Further observations were made by 
Frantzius5 in Costa Rica, Petrequin6in Italy, Mankenwitcz7 in Ger- 
many, Urbanek8 and Moquin-Tandon9 in France, and Prince 10 and 
Schmitt11 in the United States. The above-cited authors all quote 
cases in which the larvae of different varieties of dipterous insects 
had developed in the nasal fossae, from ova deposited by the parent 
fly after making its way into the cavities. 
Frankel12 states that patients suffering from ozaena are more 
liable to this invasion in temperate climates, while in tropical 
regions it occurs not infrequently in patients in whom the nasal 
membrane is quite healthy. This is easily explained, since the 
odor in ozaena is undoubtedly due to decaying animal matter, and, 
therefore, naturally proves attractive to different varieties of insects. 
Moreover, the cavities in this disease are large and cavernous, and 
usually lined with dry crusts, hence the entrance of the insect is 
very little obstructed. In ordinary hypertrophic catarrh, the pas- 
sages are narrowed, and the membrane coated with moisture, hence 
this condition would naturally serve as a protection from the in- 
vasion of insects. The diptera, which deposit their ova in the nasal 
cavity in temperate regions, are the musca vomitoria, musca car- 
naria, and probably in certain cases the oestrus, or gad-fly; in 
tropical climates the lucinia hominivora is the most active. 
The warm cavity of the nose provides a favorable surrounding 
for the hatching of the ova, hence the larvae or maggots develop and 
become active in twenty-four hours after the deposit of the ova, 
and commence their work of destruction, invading the whole nasal 
cavity, and making their way into the accessory sinuses and com- 
municating passages, destroying not only the mucous membrane, 
1 Edinburgh Med. Journal. Oct., 1856, vol. ii., pp. 371 and 372. 
. 2 Arch, generate, May, 1858. 
3 Recueil de Med. Milit., 1865, 3e serie, t. xiv., p. 516 et seq. 
4 Ibid., 1866, 3e serie, t. xvii., p. 58 et seq. 
5 Virchow’s Arch., Bd. 43, p 98. 
6 Fricke u. Oppenheim’s Zeitschr. f. d. gesammte Med., 1838, p. 276. 
7 Virchow’s Arch., 1868, vol. xliv., p. 375. 
8 Wien. Med. Presse, No. 7, 1878, p. 209. 
9 “ Elem. de Zoologie Medicate,” Paris, 59, p. 212. 
10 Philadelphia Med. News, October 14th, 1S82, vol. xli., p. 445. 
11 Daniel’s Texas Med. Journ., Aug., 1887, p. 46. 
12 Ziemssen’s “ Encyclopedia,” Amer. ed., vol. iv., p. 178. PARASITES IN THE NASAL CA PITIES. 
333 
but the periosteum also, and so giving rise to bony necrosis. If 
not arrested, they travel still farther, making their exit from the 
nose, and invading the cellular tissue of the face and scalp. Their 
exit from the nasal cavity is probably through the cartilages of 
the nose. In some of the cases reported by Coquerel, not only the 
septum, but the whole nose was nearly destroyed, which would 
indicate that bony tissue offered no very formidable bar to the 
progress of their destructive invasion. 
Symptomatology.—The earliest symptom due to the presence 
of maggots in the nose is a sense of formication, followed soon by 
frontal headache, which, increasing in severity assumes an exceed- 
ingly distressing character. Frankel1 quotes Weber, as stating 
that the agony of the pain in this affection has been so great that 
the victims have been driven to commit suicide. Muco-purulent 
bloody discharges set in very soon, and increase with the progress 
of the destructive operations of the larvae. Epistaxis, oftentimes 
of a very serious character, may occur, probably as the result of 
invasion of some of the blood-vessels. Swelling of the nose and 
face occurs, as the maggots escaping from the nose burrow in these 
tissues. These swellings assume the character of localized ab- 
scesses, which may open spontaneously, or may be opened by in- 
cision, when masses of the creatures are removed, together with 
an escape of blood and pus. 
In the commencement of the attack, constitutional symptoms 
are not marked, though on the second or third day, as the destruc- 
tion goes on, general shock is present, as evidenced by the marked 
depression of the vital powers. Pus formation in the cellular tissue 
is evidenced by the occurrence of chilly sensations, dr a well devel- 
oped chill. The effect on the general system is shown in the rapid 
and feeble pulse, with fever setting in early, and as the disease pro- 
gresses, this often shows a temperature of 102° to 103° or even higher. 
A fatal termination of the disease is due, probably in all cases to 
the supervention of meningitis, although it would seem that the 
very extensive suppuration going on in the cellular tissue of the 
face and scalp might result in a septic condition, sufficient to pro- 
duce death without the occurrence of inflammation of the meninges. 
Meningitis in many cases is probably due to extension of the in- 
flammatory process by continuity of tissue, after the invasion of 
the ethmoidal or sphenoidal sinuses. 
DIAGNOSIS.—The diagnosis is comparatively simple, and one 
should be able to recognize the presence of these creatures, before 
any serious damage has been done, although in most of the grave 
cases the patients did not come under observation until serious mis- 
1 Op. cit., p. 179. 334 
DISEASES OF THE NASAL PASSAGES. 
chief had resulted. While the maggots confine their activity to 
the nasal passages alone, their further progress can be arrested 
easily. When, however, they have invaded the accessory sinuses, 
or the cellular tissue, they are far more difficult to deal with. 
These cases relate entirely to the larvae of the diptera. The 
other insects which are found in the nasal cavity, are compara- 
tively harmless. Thus Cochran1 reports a case, in which the 
expulsion of about fifty screw worms from the nose gave entire 
relief to a patient, suffering with apparently a severe influenza, 
with high fever; while Thiedemann 2 has collected evidence of the 
existence in the nose of centipedes, earwigs and larvae of the bea- 
con beetle. Another case of centipede in the nose was reported 
by Packard,3 in which no marked symptoms resulted from its pres- 
ence, although in a case reported by Mar£chal as cited by Moquin- 
Tandon,4 violent headache and profuse epistaxis occurred, resulting 
from its presence. Leeches have been found in the nose as cited 
by Mackenzie,5 while lumbricoids have been ejected into this cavity, 
in the act of vomiting. 
Treatment.—In early days various drugs were recommended 
for use in these cases with probably little effect. During the inves- 
tigations which Morel made in Mexico, on the subject of maggots in 
the nose, Dauzats, an apothecary’s assistant, suggested the use of 
chloroform. This was diluted with an equal amount of water, and 
injected into the nose, with the result of destroying the larvae in 
every case in which it was tried, where the creature had not bur- 
rowed beyond the reach of the drug. Mackenzie6 suggests that this 
agent might be used in full strength, although the patient should be 
anaesthetized first, as otherwise the application would be too pain 
ful. Cloquet’s case seems to have been cured by inunctions of mer- 
cury, even after the maggots had invaded the cellular tissues of 
the face and skin, and destroyed the eyes. Moldenhauer7 suggests 
the use of a solution of bichloride of mercury. The immediate 
effect derived from the use of chloroform is so satisfactory, that 
the trial of other remedies will rarely be justified. In connection 
with this, the thorough disinfection of the cavity, with the use of 
douches and syringes for washing away, as far as possible, the larvae 
themselves, together with the debris following their destructive 
process, is naturally of much importance. 
1 College Clinical Record, Phila., vol. iii., p. 245. 
2 “ Von lebenden Wurmern und Insekten in den Geruchsorganen des Menschen,” 
1844 
3 Med. and Surgical Reporter, August 3d, 1878, p. 100. 
4 Op- cit., p. 217. s Op. cit., p. 450. 6 Op. cit., p, 448. 
7 “ Die Krankheiten der Nasenhohlen,” Leipsic, 1886, p. 127. PARASITES IN THE NASAL CAVITIES. 
335 
When the maggots have reached the accessory cavities, these 
should be opened if necessary and feasible. Thus, it may become 
necessary to trephine the frontal sinus or to open into the antrum. 
This latter operation would preferably be done by the supra-alevolar 
operation. Localized abscesses on the face or scalp will be treated 
under the ordinary rules of surgical procedure. CHAPTER XXIII 
SYPHILIS OF THE NASAL PASSAGES. 
The manifestations of syphilis that are met with in the nasal 
cavity, from a clinical standpoint are, (1) the primary lesion, (2) 
erythema or coryza, (3) the mucous patch, (4) the superficial ulcera- 
tion, and (5) the gummy tumor leading to (6) deep ulceration and 
necrosis. 
The division of syphilitic lesions into secondary and tertiary is 
a purely arbitrary distinction, in that the mucous patch and the 
superficial ulcer, which are usually regarded as secondary lesions, 
not infrequently occur in the later stages of the disease, while the 
gummata, with their resulting deep ulceration and necrosis, not in- 
frequently occur quite early in the history of the malady. 
The Primary Lesion. 
Chancre of the nose is naturally one of the rarest of lesions, 
and could only occur as the result of a most untoward accident. 
Thus in 2,244 cases observed by Bassereau, Clerq, Lefort, Four- 
nier and Ricord, the lesion was found in the nose twice. In 292 
cases observed by Fournier and Martineau, in no instance was 
the nasal mucous membrane the seat of the lesion. MacCarthy1 
cites one case of indurated chancre of the nose, while Rollet claims 
to have observed three cases, in which the primary lesion was 
situated at the entrance of the nares. The ordinary method in 
which this accident occurs, is by conveying the virus on the fin- 
ger nail, as for instance, in a case reported by Moure,2 the virus 
seems to have been inoculated upon the nasal septum by the 
finger nail, the source of the virus being a syphilitic lesion in a 
lewd woman, while in a case observed by Watson3 the disease 
was contracted in the same manner by a wet-nurse. The source 
of the virus, however, in this instance, was in an affected nurs- 
ling. The location of the chancre in these cases, as would be the 
natural inference, is upon the cartilaginous septum, in that it is in 
1 These de Paris, 1844. 2 Revue Mensuelle de Laryngologie, 1887, No. 7, p. 385. 
3 Med. Times Gazette, April 16th, 1881, p. 428. SYPHILIS OF THE NASAL PASSAGES. 
337 
this portion of the nasal cavity that abrasions are more frequently 
met with, which permit the introduction of the virus. In Watson’s 
case, however, the chancre developed on the inner aspect of the 
ala. It would seem that when the nasal passages become the seat 
of a primary syphilitic lesion, the infective process assumes a 
somewhat more efflorescent character, and moreover, that the gen- 
eral febrile movement which attends the onset of the disease is of 
a far more aggravated character; as, in Moure’s case, the ulcer 
presented a large granular mass, which bled easily upon touch, and 
which not only produced notable stenosis, but also pressed against 
the ala of the nose to such an extent as to produce external de- 
formity, while in Watson’s case the base of the chancre presented 
the appearance of a hard cartilaginous tumor, with an ulcerated 
surface which bled easily upon touch, and projected so far into the 
nostril as to produce notable stenosis. 
Diagnosis of the Primary Lesion.—Our clinical knowledge 
of chancre of the nose is based on so few recorded cases, that 
definite positive conclusions cannot be well drawn. The diagnosis, 
however, may be based on the gross appearance of the ulcer, in 
connection with the constitutional disturbance. The existence of 
an ulcer in the nose, with a peculiarly hard base, and granular sur- 
face, bleeding easily on touch, and limited in extent, would suggest 
either tuberculosis, malignant disease, or syphilis. Tuberculosis 
of the nose only occurs as secondary to a pulmonary deposit, and 
furthermore, an examination of the discharge would show the ex- 
istence of the characteristic bacillus. Malignant disease, whether 
carcinoma or sarcoma, is rarely stationary, which is the case with 
chancre, and furthermore its development is liable to be attended 
with attacks of profuse epistaxis, a symptom not met with in chan- 
cre. The enlargement of the submaxillary glands on the side 
affected, always attends the development of a chancre, and is not 
usually met with except late in the clinical history of cancer, and 
rarely at all in sarcoma. The constitutional disturbance in these 
cases is very marked, and is characterized by febrile movement, 
general malaise, and depression of spirits, together with a peculiar 
cachexia which occasionally marks the onset of syphilis. Of 
course, the diagnosis is completely established if the characteristic 
cutaneous eruption comes on at the end of from six weeks to three 
months. 
Syphilitic Coryza or Erythema. 
This occasionally occurs in the early stage of syphilis, but pre- 
sents no prominent features which enable us to recognize it as due 
absolutely to the specific virus, although in many cases, it would 338 
DISEASES OF THE NASAL PASSAGES. 
seem that the turgescence of the mucous membrane presents a 
somewhat purplish or dark tinge, indicative of a venous congestion, 
while at the same time its surface presents a dryer aspect than that 
usually observed in connection with an acute rhinitis, the mucous 
coating itself being of a gray, somewhat brownish character, rather 
than the peculiar watery discharge, met with in an ordinary cold. 
The diagnosis as a rule, however, will depend on the clinical history 
of the case. 
It occurs from three weeks to six months after the primary 
sore, and usually in connection with a roseola, although I think 
there can be no doubt that we may have a coryza in connection 
with the latter development of syphilitic disease, such as mucous 
patches, periostitis, or the superficial ulcer. It is present probably 
in but a small proportion of cases, although undoubtedly it is liable 
to be overlooked, in that it gives rise to but trifling annoyance to 
the patient, whose attention and apprehension are far more closely 
confined to the discovery that he has contracted constitutional 
syphilis. 
The Mucous Patch. 
This manifestation of syphilis shows an unmistakable tendency 
to develop in the region of muco-cutaneous junctions, such as 
the anus, the lips, or the vulva, hence we would naturally expect 
to find it about the margins of the nostrils, yet, as a fact, this 
is an exceedingly rare location for a mucous patch. Davasse and 
Deville 1 in reporting 186 cases of this lesion occurring in females, 
have found that in only eight cases was.the nasal mucous mem 
brane invaded, while Bassereau2 showed that out of 130 cases 
of this lesion observed in males, the nasal mucous membrane was 
not affected in a single case. I am disposed to think, that there 
may be an element of uncertainty in this report of Davasse and 
Deville, in that there are various conditions in the nasal cavity 
which might simulate the appearance of a mucous patch, and 
render the diagnosis somewhat obscure. Thus a slight angular 
projection of the septum, with an erosion at its apex, I have seen 
present appearances almost identical with those of this lesion, 
or again, we occasionally see on certain irregularities on the sur- 
face of hypertrophied mucous membrane covering the turbinated 
bones, appearances far back in the cavity, which on first inspection 
might warrant the suspicion of syphilitic disease. Moreover, these 
writers made their report at a time when our methods of examin- 
1 Arch. Generale de Med., 1845. 
2 Quoted in Internat. Encyclop. of Surg., vol. ii., N. Y., 1888, p. 403. SYPHILIS OF THE NASAL PASSAGES. 
339 
ing and treating the nasal passages were exceedingly primitive. 
Certainly in my own experience, I have never seen a nasal lesion 
in which I felt warranted in making the diagnosis of a mucous 
patch. If the lesion should occur, however, I take it, it should be 
recognized, as presenting the same appearances as a mucous patch 
when seen in other portions of the air tract. Its existence, how- 
ever, would probably be marked by no notable symptoms, in that, 
whereas a mucous patch in the oral cavity is liable to be a source 
of no little annoyance, on account of the constant functional activ- 
ity of the parts, and the irritating action of food and drink, in the 
nasal cavity, thoroughly protected by its bony walls, and subjected 
to no functional movements, it would give rise probably to no 
notable subjective symptoms. 
The Superficial Ulcer. 
In the superficial form, we meet with an ulcerative process 
in the nasal cavity, commencing apparently in the surface of the 
mucous membrane, which invades the tissue by a slow process 
of destruction, spreading laterally, and also to a very slight ex- 
tent deeply. This is an exceedingly rare lesion, although un- 
doubtedly met with. It occurs usually in what is called the sec- 
ondary stage, namely from one to three years after the primary 
sore, and its occurrence is explained by the breaking down of a 
mucous patch. Now, as already shown, a mucous patch in the 
nose is not only a very rare, but a somewhat dubious occurrence. 
I am disposed to think that a superficial ulcer belongs to a later 
stage of syphilitic disease, and that it is due to the breaking down 
of a superficial gummatous deposit. That we have an ulceration 
of this form, differing not only in its gross appearances, but in its 
clinical history, from the deep ulcer, cannot be questioned, and be- 
longing, as before stated, to the later stages of the disease, I think 
we must assume that we may have a gummatous infiltration of the 
superficial layers of the mucous membrane, which breaking down, 
gitfes rise to this form of ulcerative action. The microscopic appear- 
ances, moreover, of a section of this form of ulceration, as shown 
in Fig. ioi, would seem to confirm this view. The primary gumma- 
tous infiltration being superficial in character, would give rise to no 
notable symptoms, which should call attention to a disease going 
on in the membrane, and furthermore, would present no notable 
appearances on direct inspection, hence our attention is first di- 
rected to the fully developed ulcer. This form of ulcer is usually 
met with on the septum, although occasionally it may be found on 
the floor of the nose, or on the surface of the turbinated bodies. 340 
DISEASES OF THE NASAL PASSAGES. 
Its borders are moderately well defined, and the mucous membrane 
surrounding it perfectly normal in appearance, there being no 
areola of redness. The edges of the ulcer are neither sharply cut 
nor depressed. Its surface, however, is somewhat depressed in the 
centre, although its periphery is usually flush with the surrounding 
membrane. Its surface is covered with a coating of thick, stringy 
and grayish-yellow muco-pus, usually discolored by the deposit of 
impurities from the inspired current of air. If this is removed, the 
cleansed surface would show a grayish-pink color. It is feebly 
sensitive to the touch, and bleeds easily. It shows no marked ten- 
dency to extend, and its destructive activity is exceedingly feeble. 
Occasionally, the superficial ulcer would seem to extend deeply, 
and result in an involvement of the periosteum and an exposure of 
Fig. ioi.—Syphilitic Ulcer at Muco-cutaneous Junction. E, Stratified epithelium; C, fibrous connec- 
tive tissue with inflammatory nests; U, ulceration penetrating the connective tissue; G, Gummatous in- 
filtration with scanty blood-vessels; A, artery invaded by syphilitic endarteritis; B, remnants of connec- 
tive tissue bundles. 
bone. I doubt if this is really due to an extension of the ulcerative 
process, because, as before stated, as a rule, the superficial ulcer 
does not extend, but contents itself with the mischief accomplished 
by the breaking down of the original gummatous deposit in the 
superficial layer of the membrane. This destruction of deeper 
tissues, with the resulting necrosis of bone, is due, as has been so 
clearly demonstrated by Schuster and Sanger,1 to the fact that co- 
incident with, or even later than the superficial gummatous deposit, 
there occurs a gummatous deposit in the deep layer of the mem- 
brane, which results in the breaking down of the deeper tissues 
and the setting in of an ulcerative process there, after the super- 
ficial ulcer has fully developed. 
That the superficial ulcer is due to the eummy deposit, I think, 
1 Vierteljahresschrift fur Derm, und Syph., Jahrg. iv. Wien, 1S77, lift. I. & II., p. 92. SYPHILIS OF THE NASAL PASSAGES. 
341 
is further shown in the fact, that the administration of mercury has 
but feeble influence in controlling the morbid process, but that it 
yields promptly to the administration of iodide of potassium, as is 
the case with the deeper gummatous deposits. 
The Gummy Tumor. 
Under this designation ought to be included those manifes- 
tations of late syphilis which indicate an exceedingly active con- 
dition of the specific virus in the system, and under which the 
mucous membrane becomes the seat of a deposit of gummatous 
material, which thoroughly infiltrates the whole thickness of the 
membrane, involving both its superficial and deep layers, result- 
ing in the development of a large tumefaction in the membrane. 
No portion of the nasal cavity is free from this deposit, although, 
in the large majority of instances, the deposit occurs on the 
septum, involving both the bony and the cartilaginous portions. 
It may also occur on the turbinated bones, or the floor of the 
nose, no portion of the cavity being exempt from its invasion. The 
gummatous deposit shows a more or less well-marked tendency 
to rapid degeneration into an ulcerative process, depending some- 
what on the locality of the deposit. Thus, in the pharynx, owing 
to its exposed situation, and to the fact that the parts are subjected 
to constant functional activity, the development of the gummatous 
deposit into an ulcerative process is so rapid, that a gummy tumor 
is rarely observed in this region. In the nasal cavity, on the other 
hand, a gummy tumor is so thoroughly protected from any extra- 
neous influence, that the morbid process is exceedingly slow, and 
the existence of the tumor is usually recognized before ulcerative 
action has taken place. This lesion belongs essentially to what is 
called the tertiary stage of syphilis, namely that from five to fifteen 
years after the primary lesion. 
Symptomatology of the Gummy Tumor.—Where the de- 
posit occurs upon the septum, it does not usually give rise to any 
marked pain, although there is usually a more or less well-marked 
sense of discomfort, with nasal obstruction. When the deposit 
occurs on one of the turbinated bones, on the other hand, the pain 
is apt to be more marked, and assumes the same character which 
accompanies a like process in other portions of the body, namely 
in being notably aggravated at night. The pain is of a deep boring 
character, and is usually very distressing. During waking hours, 
there is a marked diminution, and in many cases complete relief from 
this symptom. Ordinarily the symptoms are sufficiently prominent 
to direct the attention of the patient to the part. 342 
DISEASES OF THE NASAL PASSAGES. 
DIAGNOSIS.—A gummy tumor of the turbinated tissues is not 
easily recognized on gross inspection, in that they are usually small 
in size, and situated well back in the nasal cavity. In these cases, 
the diagnosis will be based on the previous history of syphilis, in 
connection with stenosis, deep-seated pain, extending to the side of 
the face, with nocturnal exacerbations, together with the existence 
of a tumefaction over one of the turbinated bones, usually the 
lower, which, on inspection, presents simply the round swollen 
aspect of hypertrophied tissue. The impact of the probe, how- 
ever, reveals the tumefaction to be of a more solid character than 
turbinated hypertrophy. 
When the morbid process develops upon the septum, as before 
stated, it attains a much larger size than when it occurs in other 
portions of the cavity, and presents as a large, rounded, prominent 
mass, projecting from the wall of the septum, and more or less com- 
pletely occluding the nasal passages, the prominence of the mass 
often impinging upon the turbinated tissues of the opposite side. 
In contour, it is round and smooth, and covered with a mucous 
membrane, usually of a normal tint, or, on the other hand, the mem- 
brane may present a bleached appearance, due to the fact that the 
tumor developed underneath it, so far stretches the covering mem- 
brane, as it were, as to produce an exsanguinated condition. In 
other cases, we may find it showing evidence of deep venous injec- 
tion, giving rise to a reddish or purplish hue. This, however, is 
more characteristic of the smaller growths. In a certain propor- 
tion of cases the lesion is found occupying both faces of the sep- 
tum, although, as a rule, I think, it is unilateral. There is no 
marked tenderness on pressure, and the growth to the touch pre- 
sents a somewhat hard, semi-elastic, cartilaginous condition. The 
mucous membrane covering the growth is intact, unless, possibly, 
there be evidence of slight erosion, not specific in character, at the 
apex of the tumor. There are two conditions with which a gum- 
matous condition of the septum may be confused, namely, deflected 
septum and sarcoma. In the case of a deflected septum, the pre- 
senting tumor is much more hard and dense to the touch, and, 
furthermore, will show a corresponding concavity on the opposite 
side, which is not present in the case of a gumma. These cases, 
however, frequently present appearances which very closely simu- 
late a sarcoma, and in one case, certainly, in my own experience, a 
diagnosis of sarcoma was ventured upon, until the microscope re- 
vealed the mistake. As a rule, however, a sarcoma presents a 
softer, more pedunculated mass, bleeding easily upon touch, and is 
somewhat movable. Moreover, its attachments are apt to be much 
higher up in the cavity. An absolute diagnosis can only be made SYPHILIS OF THE NASAL PASSAGES. 
343 
by the removal of a portion of the tumor for examination, together 
with the clinical history of sarcoma, especially with reference to 
epistaxis, which is a characteristic of malignant disease, and never 
occurs in connection with a gummatous deposit. Moreover, a 
gumma is usually a sessile tumor. 
It would scarcely seem possible to mistake a gumma for a 
fibrous tumor, and yet Van Domelin1 reports a case of fibrous 
polypus, attached to the outer wall of the nasal cavity, which dis- 
appeared completely under the administration of the iodide of 
potassium. There can be little question that the diagnosis was 
incorrect, and that he had to do with a case of syphilitic gumma, 
especially as he states that subsequently there was necrosis of the 
bones of the nose. 
PATPIOLOGY.—The essential pathological lesion, which consti- 
tutes a gummatous deposit, is an infiltration of the mucous mem- 
brane with small round cells, or inflammatory corpuscles, which 
invade not only the epithelial layer, but also the mucosa proper 
and the deep layers of the membrane or periosteum, and even the 
bone tissue itself. The extent and distribution of this infiltration 
would seem to depend somewhat on the activity of the specific 
virus in the system. Thus as we have seen, where the activity of 
the virus is limited, the cell infiltration only invades the epithelial 
layer of the membrane, giving rise to the superficial ulcer, the 
ulcerative process being due to the crowding together, as it were, 
of the inflammatory corpuscles in this layer, thus causing a localized 
necrotic process, in other words, the ulceration is confined to the epi- 
thelial structures of the membrane. On the other hand, where we 
have a greater activity of the specific virus in the system, the cellu- 
lar infiltration, which we call a gummatous deposit, invades the 
whole thickness of the mucous membrane, giving rise to more or 
less prominent tumefaction. The membrane is crowded, as it were, 
with these small round cells, which so far encroach upon the peri- 
glandular structures, as to obliterate the glands, probably by pres- 
sure, thus resulting in their destruction and the exfoliation of their 
lining epithelium. In addition to this, the same process invades 
the vascular structures of the membrane, more especially the nutri- 
ent arteries, giving rise to an infiltration of the arterial coats, and 
particularly the inner, by which their calibre is markedly diminished, 
and finally completely obliterated, partly, perhaps, as the result of 
pressure from without, but, in the main, as the result of a genuine 
endarteritis obliterans which is set up by their presence. According 
to Sanger,2 we occasionally find, in the deep layers of the mem- 
brane, in addition to the small round-cell infiltration, a certain 
1 Jour, des Conn. Med. Prat, et Pharm., 1S58-9, vol. xxvi., p. 425. 
2 Loc. cit. 344 
DISEASES OF THE NASAL PASSAGES. 
number of spindle cells, deposited in or near the periosteal layer. 
Sanger further states, that, as the result of the obliteration of the 
arteries, we have a damming back of the blood, which may give rise 
to a hyperaemic condition of the tissues beyond, and that this is 
followed by localized extravasations of blood, and, as an occasional 
ultimate result, small cyst formations. 
COURSE AND Duration.—A gummy tumor in the nasal pas- 
sages runs a somewhat chronic course. This is due largely to the 
fact of its location, lying as it does in the inclosed cavity of the 
nose, where it is subjected to neither the irritation of functional 
movements nor external influences. It develops somewhat rapidly, 
attaining its full growth in probably a very few days. The syphili- 
tic explosion, however, seems to expend itself in the development 
of the lesion, for after the growth has attained its full size it may 
remain quiescent for weeks and even months. In one case which 
came under my own observation, the tumor had existed for twelve 
months, apparently without great change, giving rise merely to the 
ordinary symptoms of nasal stenosis with nocturnal pains, and 
some occasional coryza. This disposition, however, is not to be 
relied on, as I think the tendency is to break down much earlier 
than this. Probably a duration of six months is to be regarded as 
beyond the average. As the result of the peculiar anatomical 
features of the deposit, already described, by which the normal 
structures of the membrane are crowded upon, as it were, by the 
inflammatory corpuscles, but more especially as the result of the 
obliteration of the arteries, the subsequent history of a gummatous 
deposit consists of a breaking down at its centre, which, gradually 
extending to the surface, results in the development of an ulcerative 
process. This is due directly to the fact that the blood supply to 
the part is completely arrested. This necessarily must be a some- 
what slowly developing process, for as we have seen a gummy 
tumor may last for three months or even longer. Hence, we 
naturally infer that the endarteritis is a progressive lesion, and that 
the complete obliteration of the arteries is only a final result. 
When this, however, occurs, nutrition is arrested in the mass, 
necrosis ensues, and the whole of the tissue, whose nutrition de- 
pended previously on the blood supply from the diseased artery, 
becomes necrotic, breaks down and sloughs away, leaving the char- 
acteristic broad crater-like ulcer which we recognize as the deep 
ulcer of syphilis. 
The Deep Ulcer of Syphilis, and Bony Necrosis. 
This lesion, arising directly from a gummy deposit, presents the 
same clinical history as regards its location and as to the time of SYPHILIS OF THE NASAL PASSAGES. 
345 
its occurrence following the primary lesion as that of the condition 
from which it arises, and belongs, therefore, essentially to the ter- 
tiary stage of the disease. It occurs usually from ten to fifteen 
years after the primary sore, although among races in whom syphi- 
lis has been prevalent for ages without the controlling influence of 
proper treatment, it seems to possess a special virulence, and hence 
runs a more rapid course. Thus Chinese syphilis is commonly re- 
garded as one of the most virulent forms of the disease, as far as 
clinical observation shows it as contracted by members of the Euro- 
pean races, and hence runs an exceedingly rapid course, the tertiary 
symptoms developing very early. Furthermore, Spillmann1 has 
made a similar observation with reference to the disease as con- 
tracted by French troops in Mexico, who presented at the Val de 
Grace Hospital on their return, where tertiary lesions set in, in one 
case six months after the primary lesion, and in two cases within 
twelve months. Mackenzie2 makes a like observation with regard 
to the Arabs. This peculiar feature of syphilis, however, is ex- 
ceedingly rare among the European races, although Mauriac3 has 
observed a deep ulceration, followed by necrosis of the nasal bones, 
seven months after the primary lesion. 
Its most frequent location is fortunately upon the septum, in 
that, when occurring on the turbinated bones, it is less amenable to 
treatment, pursues a more chronic course, and results in more ex- 
tensive destruction of tissue. The first effect of the breaking down 
of the gumma is to involve the whole thickness of the mucous 
membrane, and the periosteum as well, in the ulcerative process. 
The ulceration does not necessarily at first involve all the tissues 
which were affected by the gummatous deposit, but only such tis- 
sues as receive their nutrition from the artery involved in the 
obliterating process, and which thus become necrotic. After the 
ulcerative process, however, becomes established, there is shown a 
tendency to extend by a slow process of destruction, both laterally 
and deeply, resulting thus in the destruction of neighboring tis- 
sues, and the involvement of the bone beneath. Or, in case that 
there has been a primary gummatous deposit in the bone, we have 
a bony necrosis, coincident with the breaking down of the gumma 
and the establishment of the ulcerative process in the mucous 
membrane. Or, again, the deposit may be primarily in the bone, 
and the breaking down of the bony gumma maybe the direct cause 
of the ulcerative process in the softer tissues. The destruction of 
tissue is by no means rapid, and the extension of the ulcer is prob- 
1 Quoted by Mackenzie, “Diseases of the Throat and Nose,” vol. ii., Amer. ed., 
Phila. 1884, p. 391. 
2 Op. cit., p. 391. 3 Quoted by Mackenzie, op. cit., p. 391. 346 
DISEASES OF THE NASAL TASS AGES. 
ably due, to a large extent, to the subsequent breaking down of 
those portions of the membrane which have previously become in- 
filtrated with the gummatous deposit, and in which the ultimate 
obliteration of arteries occurs later than in the tissues involved in 
the earlier ulcerative action. For I think it is exceedingly doubt- 
ful if we ever have a further gummy deposit, after the first deposit 
occurs, the syphilitic explosion, as we may call it, expending itself 
when the first gummy tumor develops, as before stated. After all 
the tissues involved in the original gummy deposit have taken on 
the ulcerative process, there is very little tendency for the ulcer to 
extend, and furthermore I have never known a deep ulceration of 
syphilis in the nose to take on anything like serpiginous action. An 
additional feature which I think is characteristic of the deep syphi- 
litic ulcer, is that it shows a marked hesitancy in transgressing an- 
atomical boundaries. This, probably, is due to the fact above 
stated in regard to the ulcerative process being limited by the ori- 
ginal gummy deposit. Certainly these ulcers do not extend be- 
yond the nostril to the skin, nor do they extend beyond the poste- 
rior nares into the pharynx. 
Symptomatology of the Deep Ulcer.—With the breaking 
down of the gumma, the peculiar boring pains with nocturnal ex- 
acerbations disappear, and the prominent symptoms now consist of 
those due to the ulcerative process, namely a profuse sanguino- 
purulent discharge mixed with the blackened shreds of necrotic 
tissue. These show a tendency to accumulate on the face of the 
ulcer in large masses, which, drying up, form crusts which are dis- 
charged periodically in the shape of casts, as it were, of the crater- 
like cavity of the ulcer. These crusts are exceedingly offensive, of 
a most nauseating appearance, and are attended with an odor 
which is intolerable, especially where the disease has extended to 
the bone, giving rise to necrosis, in which case the odor is charac- 
terized by a penetrating stench that is almost unendurable. This 
odor is present about the person of the patient, not only at the time 
of the discharge of these crusts, but at all times, and is quite char- 
acteristic, differing in every way from the odor of an ozaena de- 
pendent upon atrophic rhinitis which, as we have already seen, is 
not due to necrosis, but simply to the decomposition of mucus. 
Here we have the odor of decomposing animal matter, which can- 
not well be described, but when once experienced is not easily for- 
gotten. Occasionally there are discharged with the bloody crusts 
small spiculae of bone, and where the disease has existed for a long 
time, even large sequestra may be expelled, either through the nose 
or through the pharynx. As the ulcer extends, the crusts which 
adhere upon its surface become, of course, much larger, and their SYPHILIS OF THE NASAL PASSAGES. 
347 
discharge becoming more difficult, there finally ensues a condition 
of things in which the cavity is largely blocked up with a great mass 
of bloody pus and necrotic tissue, which the patient cannot void, 
and hence it remains in the cavity, giving forth a hideous odor 
until relief is obtained by the interference of the surgeon. 
The sensibility of the nasal cavity seems to be notably dimin- 
ished in syphilitic disease, in that the presence of these crusts seems 
to give rise to no special symptoms, such as sneezing or watery 
discharge. Spencer Watson 1 reports a case in which lachrymation 
was quite a prominent symptom, due to the fact that the lachrymal 
duct was involved in the ulcerative process and thereby obstructed. 
The sense of smell is usually abolished or markedly impaired, sim- 
ply as the result of the occlusion of the nasal passages by the ac- 
cumulation of crusts, thereby obstructing the approach of odorous 
particles to the olfactory tract, although this might be explained 
by the involvement of the olfactory nerves in the syphilitic lesion, 
as has been observed by Gros Lancereau.2- A similar case has been 
reported by Bayle and Kergaradec.3 
Deep syphilitic ulceration, unless arrested very early in its 
career, results in necrosis of the bony tissue or cartilage beneath. 
If it occurs upon the turbinated bones, the necrosis involves no ex- 
ternal deformity, but confines itself simply to the destruction of 
such portion of the bone as may be involved in the original gum- 
matous deposit. Where the ulceration occurs upon the cartilagin- 
ous septum, necrosis occurs very early, and runs a somewhat rapid 
course, usually involving the whole of the cartilaginous portion of 
the septum in the destructive action. The result of this is that the 
tip of the nose is thus so far robbed of its support that it sinks in, 
producing the peculiar deformity so easily recognized as the result 
of this lesion. In certain cases, although exceedingly rare, the de- 
struction of the cartilaginous septum is attended with a destruction 
of the columna of the nose, thus converting the two nostrils into 
one single orifice upon which the sunken tip of the nose falls over 
like a flap, as it were. This, however, is an exceedingly rare acci- 
dent, for, as before stated, syphilitic ulcers show a marked hesitancy 
in transgressing anatomical boundaries, and the ulcerative process 
is limited to the destruction of the cartilage alone. If the original 
gummatous deposit is circumscribed in extent, the mischief done is 
confined merely to producing a perforation of the septum without 
causing any external deformity. Where the ulceration and necro- 
sis involves the bony septum, it may confine itself to the destruc- 
1 Med. Times and Gaz., 1871, vol. i., p. 58. 
2 “Affections Nerveuses Syphilitiques. ” 
3 Cited in the “ International Encyclop. of Surgery,” vol. ii., p. 415. 348 
DISEASES OF THE NASAL PASSAGES. 
tion of a portion of the septum, or complete destruction of the 
vomer may take place without any external deformity. In other 
cases, however, the nasal bones are also involved in the morbid 
process, probably as the result of the original deposit of gummatous 
material in the bones themselves, and not to an extension of the 
diseased action from the vomer. Where the nasal bones are de- 
stroyed, we have resulting an external deformity quite as noticeable 
as the one previously described, yet differing from it in a very 
marked degree. The bridge of the nose now sinks in, leaving the 
tip of the nose intact. The sinking in of the bridge, is attended 
with a certain amount of atrophy of the tissues of the external nose, 
and there is left simply a rounded elevation representing the origi- 
nal bony bridge, which thus throws the unchanged nasal tip into 
greater prominence. I have never seen this form of external de- 
formity result from gumma of the nasal bones alone, if such a thing 
ever occurs. The process, in every case that has come under my 
observation, involved the complete destruction of the bony septum 
in connection with the nasal bones. The nasal processes of the 
superior maxillae are usually also involved to a certain extent in the 
same necrotic process which attacks the nasal bones. 
Schech1 mentions erysipelas as a complication of syphilitic 
necrosis in the nose. This is, certainly, a most rare complication, 
and not one to be anticipated, as the morbid processes are in no 
way connected from a clinical standpoint. 
Diagnosis of the Deep Ulcer.—After the ulcerative pro- 
cess has commenced in a gummy tumor, the destruction of tissue 
goes on very rapidly, until the whole growth has broken down, and 
developed into the characteristic deep ulcer, or tertiary ulcer of 
syphilis, which now presents appearances so typical in character as 
to render the diagnosis comparatively easy, although the subjective 
symptoms are usually sufficient to establish the diagnosis beyond 
much question. It is a deep, excavating ulcer with ragged over- 
hanging edges. The mucous membrane surrounding it is reddened, 
and the arteries congested. The surface of the ulcer is covered 
with dark, offensive-looking crusts, composed of blood and pus, 
mixed with black necrotic tissue, the removal of which reveals the 
characteristic excavation. The surface of the ulcer will now be 
shown to be covered with dirty-looking yellow pus, in considerable 
quantities. The areola of the ulcer is characteristic in its exceed- 
ingly bright and glassy-looking red color, which extends some dis- 
tance beyond its border. The gross appearances are quite sufficient 
to establish the diagnosis. 
It has already been shown that the deposit extends very deeply 
1 “Dis. of the Mouth, Throat, and Nose” Eng. ed., Edinburgh, 1886, p. 248. SYPHILIS OF THE NASAL PASSAGES. 
349 
through the mucous membrane, and usually involves the deep layer 
or periosteum. Hence, the bone is usually found to be denuded—a 
fact which is easily established by the use of a probe, which should 
always be used both for determining the existence of denuded or 
necrosed bone, and furthermore to establish the extent of tissue 
which the ulcerative process involves. If the disease has existed 
for a sufficient length of time to result in the formation of a seques- 
trum, this fact is also determined by means of the probe, as the 
mobility of the mass is thus easily determined. Schuster1 suggests 
as a further aid to diagnosis, that the patient be anaesthetized, and 
that the nasal cavity be explored by means of the finger passed 
through the anterior nares. I doubt if this is ever necessary or ad- 
visable, as all the needed information can be better obtained by 
means of ocular inspection, and the use of the probe. The ragged 
tissue about the edges of the ulcer occasionally develops a typical 
myxoma, though small and stunted in size, or in rare instances, 
groups or masses of polypi will develop, which for a time may ob- 
scure the diagnosis. Their removal is easily accomplished, when 
the diseased action beneath is readily made manifest. In addition 
to this, a certain exuberant granulation-tissue is noticed in the 
majority of cases, more or less efflorescent in character, develop- 
ing upon the ragged ulcerating edges, and extending over the dis- 
eased surface of the ulcer. This is somewhat rapid in growth, and 
in many cases very exuberant, more or less completely filling the 
crater-like cavity of the ulcer. This presents the typical appearance 
of granulation tissue, except that it is somewhat redder, and is usu- 
ally covered with the offensive secretion from the ulcer. It is of a 
somewhat yellowish color, and bleeds easily on being touched with 
a probe. 
Another appearance quite characteristic of the tertiary ulcer in 
the nose is the accumulation of a peculiar, clear-white substance, 
having much the appearance of potted cheese. This is found above 
and beyond the ulcerative process, and seems to consist of mucus 
which has been imprisoned in the narrow portion of the nasal cav- 
ity, and has undergone cheesy degeneration. This comes away in 
large flakes upon cleaning the ulcer. This condition is almost 
pathognomonic of a syphilitic ulcer, as I have rarely seen it in any 
other form of diseased action on the nose. 
Course and Duration of the Deep Ulcer.—As before in- 
timated, I am disposed to think that the deep ulcer of syphilis sim- 
ply involves those tissues which had originally been the seat of the 
gummy deposit, and that there is no tendency to the involvement 
of neighboring tissues by the extension of the ulcerative process. 
1 Vierteljahresschrift fur Derm. u. Syph., Wien, 1878, p. 213. 350 
DISEASES OE THE NASAL PASSAGES. 
The disease runs an essentially chronic course, after the ulcer has 
been established, owing to the fact that the morbid process has ex- 
tended to the bone, resulting in its denudation and subsequent ne- 
crosis. Certainly, if there is any extension of the ulcer itself, it is 
due to the fact of the existence of necrosed bone, acting as an irri- 
tant, or foreign body, which keeps up this slowly progressing ulcer- 
ative action in the mucous membrane covering the bony seques- 
trum. Whether the original gummy deposit be in the bone, or is 
simply confined to the mucous membrane or the periosteum, the 
necrosis is a necessary result. In the former case, however, it would 
involve a larger, and perhaps more rapid ulcerative action, in that 
the deposit in the bone-tissue itself would indicate a greater activ- 
ity of the syphilitic virus in the system. 
If the disease is located upon the vomer, it may result finally in 
producing simply a bony sequestrum, which causes a perforation 
of the vomer, or it may involve the whole bone, giving rise to its 
complete destruction, and thereby the introduction of a new ele- 
ment in the disease, in that, as the result of the destruction of the 
vomer, a certain portion of the hard palate is involved in the pro- 
cess, resulting in perforation, and the appearance of the disease in the 
roof of the mouth. I am disposed to think that this complication 
arises as the result of the original gummy deposit involving a small 
portion of the floor of the nose, or the upper surface of the hard 
palate, and not to an extension of the disease, although it possibly 
might be accounted for by the pus secreted by the ulcerative pro- 
cess on the vomer, making its way downward beneath the perios- 
teum and the floor of the nose, and thus producing a denudation 
of bone and subsequent necrosis there. 
As regards the danger of external deformity resulting from 
syphilitic disease in the nose, this I think is clearly indicated by 
the extent of the original lesion. Thus, deformity may arise from 
the destruction of the bony or cartilaginous septum, or the nasal 
bones, or both. If the original gummy tumor has involved these, 
and ulcerative action has resulted, giving rise to denudation of 
bone and necrosis, an external deformity is inevitable. In other 
words, all means of affording nutrition to the bone have been de- 
stroyed, and it is only a question of time, before the bone breaks 
down. The only time when this tendency can be arrested is in the 
stage of gummy deposit, and possibly the very early stage of ulcer- 
ative action. The prognosis, then, as regards external deformity, 
depends entirely upon the location and extent of the ulcer. Thus 
even a small ulcer involving the nasal bones would result in defor- 
mity, while a large ulcerative process, located upon the posterior 
portion of the vomer, involves no danger whatever of such an SYPHILIS OF THE NASAL PASSAGES. 
351 
accident. Again, an ulcer of considerable size, located upon the 
central portion of the cartilaginous septum, may produce a large 
perforation, leaving a mere ring of cartilage. If, however, this ring 
is complete anteriorly, an external deformity need not result. If, 
on the other hand, the disease extends to the anterior edge of the 
cartilaginous septum, a sinking in of the tip of the nose is inevita- 
ble. As before intimated, syphilitic disease shows a marked hesi- 
tancy in transgressing anatomical boundaries. Original syphilis of 
the nose, as a rule, remains a syphilis of the nose. An extension, 
for instance, through the anterior nares to the integument never 
directly occurs. The same, I think, can be stated, in regard to any 
extension into the pharynx. As we have already seen, apparent 
extension to the oral cavity is the result of an accident, and is not 
really an extension of the disease. Baratoux1 has reported a some- 
what remarkable case, in which syphilitic disease gave rise to the 
destruction of the septum, both lower and middle turbinated bones, 
and the whole body of the sphenoid, the latter being expelled 
through the fauces. This, of course, is not to be regarded as an 
extension of the disease, since all of these parts were the original 
seat of a gummy deposit, which resulted in ulceration and necrosis. 
An interesting question, in this connection, is the danger of septic 
absorption, from the exposed bone, constantly bathed, as it is, in a 
purulent fluid. This is ordinarily regarded as constituting a con- 
dition especially favorable for the production of septic infection, 
and yet as a matter of clinical observation I think this complication 
is an exceedingly rare one. Herman Weber,2 however, has re- 
ported a case of syphilis of the nose, in a man aged twenty-four, in 
whom a certain cessation of the sanious discharge from the nose 
was followed by rigors, headaches, somnolency, carphologia, ptosis, 
and finally hemiplegia, ending,in death at the end of thirteen days. 
Postmortem examination revealed thrombosis commencing appar- 
ently in the left ophthalmic vein, and extending to the sinuses at 
the base of the brain, and purulent meningitis with secondary ab- 
scesses in the lungs, liver, and purulent effusion in the pleural cav- 
ity. This case of Weber’s establishes beyond question the possi- 
bility of a general septic infection, having its origin in necrosis in 
the nasal cavity, and yet in Baratoux’s case the exposure of bone 
was enormous in extent, while there were no recorded evidences 
of septic poisoning or cerebral symptoms. While undoubtedly 
cerebral symptoms present in many cases of syphilis of the nose, I 
quite agree with Schuster3 in his statement, that these are usually 
to be regarded as reflex manifestations, rather than as evidence 
of brain lesion. 
1 Revue mensuelle de laryngologie, 1883, p. 225. 
2 Med. and Chir. Trans., vol. xliii., p. 182. 
3 Loc. cit., p. 232. 352 
DISEASES OF THE NASAL PASSAGES. 
Treatment. 
The Primary Lesion.—In dealing with a hard chancre in the 
nose, there are no indications for treatment, other than the use of 
simple lotions, merely for the purpose of keeping the parts clean. 
If the ulcerative process is active, this may be controlled by the 
local application of iodoform or iodol, either in the form of an oint- 
ment or in the form of a powder of the strength of one drachm to 
the ounce. If the diagnosis has been fully established by the ap- 
pearance of the characteristic syphilitic eruption, the patient should 
be put on a course of mercurial treatment. Caustics should not be 
used, in that no good purpose is thus accomplished. Furthermore, 
internal medication should not be resorted to, until the diagnosis is 
fully established, by the appearance of the secondary symptoms. 
This is of special importance, in that the diagnosis of a nasal chan- 
cre must necessarily be to an extent uncertain. 
The Coryza or Erythema.—A syphilitic coryza subsides readily 
under the use of general medication, and as a rule requires no local 
treatment. If, however, it should prove obstinate or persistent, 
resort may be had to the same methods of treatment which govern 
cases of simple acute rhinitis. 
The Mucous Patch.—The indications for the treatment of a 
mucous patch here, as elsewhere, consist in its thorough and com- 
plete destruction, by means of chromic acid or some equally effi- 
cient caustic, applied daily until the morbid process is completely 
arrested. 
The Superficial Ulcer.—The essential feature of treatment in this 
form of ulceration consists in the administration of iodide of potas- 
sium, commencing with a dose of fifteen grains, three times daily, 
after meals. Its efficacy is easily tested by watching the progress 
of the ulcer. If the morbid process is not immediately brought 
under control, the dose should be increased on the third or fourth day 
to twenty grains, and if necessary at the end of a week to twenty- 
five grains, although cases are very rare in which the administration 
of doses larger than fifteen grains will be demanded in this form 
of ulcerative action, as I am disposed to think a superficial gumma- 
tous deposit indicates that the specific virus in the system is not 
specially active. In connection with the iodides, either the bichlo- 
ride or biniodide of mercury is to be administered, in doses of one- 
sixteenth of a grain three times a day. After the ulcer is com- 
pletely healed, the further administration of the iodides is not 
indicated. The mercurial treatment, however, of course, should 
be continued for from eighteen months to two years. SYPHILIS OF THE NASAL PASSAGES. 
353 
The patient should be seen daily and the progress of the disease 
watched with care, not only to test the efficacy of the general re- 
medies, but also to guard against the very possible mistake of re- 
garding a deep ulcer as one of the superficial variety. The surface 
of the ulcer should be kept thoroughly clean by the use of some 
simple cleansing and disinfectant lotion, and its surface daily pow- 
dered with iodol or iodoform. 
The Gummy Tumor.—The early recognition of a gummy tumor 
is of special importance, in that, if recognized before the ulcerative 
process commences, its treatment is attended with the best of re- 
sults. Few lesions in syphilis are more directly amenable to inter- 
nal medication than this manifestation, in that its disappearance 
under the administration of iodide of potassium is rapid and com- 
plete. I do not entirely agree with those who advocate the use of 
this drug in extremely large doses. Certainly in this lesion, as 
manifested in the nasal cavity, my own experience goes to show 
that the administration of twenty grains of iodide of potassium, 
three times daily, is quite sufficient to accomplish the desired end. 
I do not say that all cases can be controlled by this amount. The 
administration of the remedy, however, should be commenced with 
this dose, administered three times daily. The manifestation of 
the disease is so directly under immediate ocular inspection that 
the effect of the remedy can be easily watched. If at the end of 
the second day a notable subsidence in the tumor is not observed, the 
dose should be increased to thirty grains or even to forty. As a 
rule, however, the twenty grain dose will prove sufficient. This 
remedy is always somewhat irritating to the stomach. I think, 
however, this is often due to the fact that it is not sufficiently well 
diluted in its administration. The amounts above given, should be 
administered in at least a wineglass of water to each dose. The 
administration of the full dose of the iodide is to be continued 
until every vestige of the gummy deposit has disappeared, and 
then it is to be given in ten-grain doses, administered three times 
daily, for ten days. Occasionally we find that even small doses of 
the iodides are not tolerated, on account of the excessive irrita- 
bility of the stomach which it causes. This may be overcome by 
administering each dose of the drug in a wineglass of milk. If this 
is not sufficient, it may be given for a certain period by the rectum, 
although this can be continued for but a short time, as the drug 
exhibits the same irritating qualities in this region. Better results 
in this direction, I think, can be obtained by attention to the diet. 
Perhaps the best plan is to restrict as largely as possible the use of 
vegetable food, putting the patients mainly on an albuminous diet, 
while at the same time the use of tea and coffee is to an extent re- 354 
DISEASES OF THE NASAL PASSAGES. 
stricted, and indulgence in alcohol and tobacco entirely interdicted. 
Or, we may place the patient largely or exclusively on a milk diet 
for a time, the object being, that while nourishment is administered 
in thoroughly ample quantities, the stomach shall be taxed as little 
as possible. 
In rare cases, a change of climate seems to overcome this intol- 
erance, but it is not an infrequent experience, to find that this in- 
tolerance of the iodides resists all our ingenuity in devising methods 
for overcoming it. We may, therefore, with good results, occa- 
sionally intermit the administration of the drug, and put the patient 
under a course of general tonic treatment for a week or ten days, 
giving one of the following: 
$ Ferri et quin, cit., ...... 3 iiss. 
Elixir, simplicis, . . . . . . § iv. 
M. S. Teaspoonful three times a day before meals. 
Ferri et ammonii citratis, . . . .3 iij. 
Liquor, sodii arseniatis, . . . . .3 iss. 
Syrupi, ........ § iss. 
Aquae, . . . . . . ad 3 iv. 
M. S. Teaspoonful three times daily after meals. 
5 Ferri et strych. phosphatis, ... 3 ij. 
Tinct. calumbae, . . . . . ad § iv. 
M. S. Teaspoonful three times a day before meals. 
Another serious obstacle, occasionally met with in the adminis- 
tration of the iodides, is the production of iodism, which I have 
seen resulting from the administration of even small doses, giving 
rise to an intense irritation of the mucous membrane of the whole 
upper air-tract as well as of the conjunctivae. This difficulty, how- 
ever, is readily overcome in most cases by adding to each dose of 
the iodide, ten grains of the bromide of potassium. 
I am disposed to think mercury has but very little effect upon 
a gummy tumor, and although there is good authority for the doc- 
trine, that in this stage of the disease its administration should be 
combined with that of the iodides, I am disposed to think it had 
best be avoided, until the iodides have fully accomplished their 
purpose, when, of course, it should be administered, after the 
manner to be described later. There is no local treatment spe- 
cially indicated in the management of a gummy tumor. Seiler1 
has reported two cases of. gumma of the septum, in which the 
tumor was removed by means of the curette. The first operation 
was done under the mistaken idea that he was dealing with a sar 
coma; the second was operated upon designedly. I see no special 
1 International Journal of Surgery and Antiseptics, vol. i., No. 2, April, 18S8 p. 65. SYPHILIS OF THE NASAL PASSAGES. 
355 
objection to this, nor do I see anything to be gained. In a case 
which came under my own observation in 1886, a gummy tumor 
completely obstructed one nasal passage, and was operated upon 
with the nasal saw, under the impression that I was dealing with a 
deflected septum. My mistake was immediately recognized, when 
I found my saw going- through the growth, almost at a single cut, 
so soft did I find it, which led me immediately to suspect the exist- 
ence of sarcoma. The subsequent history of the case showed that 
it was syphilis. No untoward result followed, and yet I am quite 
confident that the tumor might quite as easily have been dissipated, 
by the administration of proper remedies, without involving the 
necessity of a complete restoration of the mucous membrane over 
a somewhat broad area of the septum following an operation. 
The Deep Ulcer.—The treatment of the deep ulceration de- 
mands the thorough cleansing of the part, by the removal of all 
obstructing crusts, by the use of the douche or syringe, using for 
the purpose any simple carbolized wash. If the crusts are large 
and not easily removed, a probe should be used with a large pledget 
of cotton to detach the masses, or they may be withdrawn by means 
of the forceps. After the ulcer is thoroughly cleansed, any necrosed 
tissue which is found, should be removed by means of the snare or 
a sharp spoon. If polypi be found, they also should be removed 
in the same manner. After this, the ulcer should be filled, by 
means of the insufflator, with powdered iodoform, or better still, 
as avoiding its exceedingly offensive odor, iodol, which is equally 
prompt of action on ulcerated surfaces. This procedure should be 
repeated daily, until healthy action is established in the diseased 
tissues. At the same time, the patient should be directed to make 
use, three or four times daily, by means of the nasal douche, or by 
simple insufflation from the palm of the hand, of a cleansing lotion, 
as follows: 
Acidi carbolici, . . . . . grs. vi. 
Sodii biborat., ...... grs. xxv. 
Aquae, . . . . . .ad 3 viij. 
Or, 
B Potassii permanganat., . . . . 3 i. 
Aquae, . . . . . . ad § viij. 
An exceedingly nice way of using a lotion is by means of the 
hand-ball atomizer, shown in Fig. 47. Schuster1 advises that these 
ulcers should be thoroughly scraped out by means of the sharp 
spoon, or else cauterized by means of nitrate of silver. I doubt the 
propriety of resorting to any destructive measures in the treatment 
1 Loc. cit. 356 
DISEASES OF THE NASAL PASSAGES. 
of this lesion, in that the excessive loss of tissue from the ulcera- 
tive action is the essential condition which we desire to control. 
Much of the tissue is of course diseased, but a better result can be 
obtained by converting this into healthy tissue, rather than by its 
total ablation. This is accomplished by the local applications above 
indicated, together with the internal administration of the iodide 
of potassium. In this stage of the disease, much smaller doses are 
required than in the primary stage of gummatous infiltration, in 
that much of the gummatous material has been entirely destroyed, 
and but a small portion of it is left to be affected by remedies; 
hence, I think a larger than a twenty-grain dose of the iodides is 
rarely indicated. This should be administered until there is evi- 
dence that the disease is well under control, and that such ulcera- 
tive action as remains is due only to the existence of necrosed 
bone. There is no objection to the commencement of the admin- 
istration of mercury in this stage of the disease, and this may be 
given in connection with the iodides, using either the bichloride or 
biniodide, in doses of one-sixteenth of a grain three times daily. 
If the probe reveals the existence of necrosed bone beneath the 
ulcer, the indications are that this should be removed, for in many 
cases this undoubtedly keeps up the diseased action, by its mere 
presence, as of a foreign body. It is important, however, to distin- 
guish between necrosed bone, and exposed bone, for in the latter 
case, the probe often gives indications which may very closely 
simulate those of necrosis, and yet the disease may not have gone 
so far but that it may be still amenable to prompt and efficient 
measures of treatment, under which its integrity may be completely 
restored. The impact of the probe upon necrosed bone gives rise 
to a hard, dry, gritty sensation, which is notably different from 
that of merely exposed bone, where there is a slight suggestion of 
softness, and moisture in connection with the gritty feeling. If the 
part is completely necrosed, and a loose sequestrum has formed, it 
is to be removed by means of a stout pair of forceps. If it is too 
large for removal, it should be broken up with a proper crushing 
instrument, or better still by the snare, the loop of which may easily 
be placed around it, when it can be crushed, or cut in halves. 
If the sequestrum has not fully separated itself, I am disposed 
to think it is well to wait until this has taken place, for separation 
follows rapidly the necrotic process. Certainly I do not approve 
of the burr and dental engine which have been used so much of 
late in these cases, in that these devices accomplish their work en- 
tirely in the dark, and do not admit of that nice manipulation and 
ocular direction which should govern all our operations in the nasal 
cavity. I have seen no case of necrosis of the bones of the nasal SYPHILIS OF THE NASAL PASSAGES. 
357 
cavity in which a sufficiently accurate diagnosis of the size and 
locality of the sequestrum could not be made by means of the eye 
and the probe, as to render its removal comparatively simple, and 
that without that injury to neighboring parts which is so liable to 
occur from the use of the burr. 
The General or Constitutional Treatment of Syphilis. 
—After the local lesion has been satisfactorily disposed of, the 
further indication, and by far the most important one, is to elimin- 
ate the syphilitic poison from the system, by a prolonged course of 
mercurial treatment. I know of no special preparation of mercury 
which possesses any notable superiority in the accomplishment of 
the purpose. It has been my practice to administer the bichloride, 
in doses of one-sixteenth of a grain, three times daily, continuing 
this for three months. Its administration is then stopped for two 
weeks, when it is resumed in the same doses, and its administration 
continued thereafter for two months, followed by a period of rest 
for one week. At the end of eight months, the dose is reduced to 
one-twentieth of a grain, and this is to be continued until two years 
have elapsed, from the last appearance of the specific lesion, with 
weekly periods of rest at the end of each two months. It is under- 
stood that we administer mercury after the syphilitic lesions have dis- 
appeared, the indications for treatment of the specific lesions having 
already been fully considered. Keyes,1 in laying down a specific plan 
of treatment of syphilis, places special emphasis on the tonic influ- 
ence of this drug, substantiating his view by a series of exceedingly in- 
teresting experiments, wherein he demonstrated, that under the long 
continued administration of mercury in syphilis, the number of red 
blood-corpuscles increases, as shown by the haematometer. Hence, 
Keyes’s plan of treatment is generally known as the “tonic” plan. 
His observations are undoubtedly correct, but I think there is 
reason to regard this increase of blood-corpuscles as the result of 
the general improvement of all the nutritive processes in the sys- 
tem, as the syphilitic virus becomes eliminated by the direct action 
of the mercury. This drug is simply a specific in syphilis. Its 
tonic effect is purely secondary. Keyes prefers the use of the pro- 
toiodide of mercury, which he gives in the form of granules, each 
containing one-sixth of a grain, in the following manner: “ let him 
take one standard dose of mercurial (one granule of the protoiodide, 
for example) after each meal for two or three days. On the fourth 
day one extra standard dose is added at the mid-day meal. Now 
1 “ The Effects of Small Doses of Mercury Modifying the Number of Red Blood- 
corpuscles in Syphilis.” Amer. Jour, of Med. Sciences, January, 1876. Also “ Internal 
Treatment of Syphilis,” Trans. Internat. Medical Congress, Phila., 1877. Also, “Tonic 
Treatment of Syphilis,” N. Y., 1877. Also “The Venereal Diseases,” N. Y., 1880. 358 
DISEASES OF THE NASAL PASSAGES. 
four standard doses (granules) are taken daily and this is to be 
continued for three days when a fifth is added. On the succeed- 
ing fourth day another standard dose is added, two standard 
doses being now taken after each meal — six granules a day.” In 
this manner, the dose is increased every third or fourth day, until 
slight symptoms of salivation are manifested, when it is reduced 
one-half, and kept at this point permanently, unless symptoms 
reappear, when it is gradually increased again, the idea being to 
find just exactly the amount of mercury that will absolutely con- 
trol any manifestations of the disease. This plan of Keyes’s is 
certainly a most excellent one, and yet as regards syphilis of the 
upper air-passages, I regard even slight salivation as a condition 
always to be avoided with the greatest care, as not only subjecting 
the patient to great annoyance, but as directly exercising a de- 
pressing influence upon the general system. 
Of course, it is to be understood that, in dealing with the deep 
ulcer, followed by necrosis, the administration of mercury is not to be 
postponed until all the nasal symptoms disappear, for really with the 
breaking down of the gummy tumor in syphilis of the nose, the 
syphilitic lesion, viz., the gummatous infiltration, to a large extent 
disappears, and the long-continued ulcerative process which it leaves 
behind is largely due to the presence of necrosed bone, and persists 
until the sequestrum separates and has been discharged or removed. 
That the mercurial treatment is not to be regarded as really a tonic 
treatment, is shown by the fact, that in many cases, where there is 
notable impairment of general health, it becomes absolutely neces- 
sary to administer barks and iron, or cod-liver oil, in order to im- 
prove general nutrition. The indications for these remedies are 
always very clear, and their administration governed by ordinary 
rules. The main obstacle to the administration of mercury lies in 
the intestinal irritation which it very frequently produces, in the 
form of griping pains and loose, watery stools. I believe that the 
bichloride is freer from this objection than any other form of mer- 
cury, and for this reason I give it preference, although in many 
cases it will be found that no form of mercury is free from this 
effect. Our main reliance in these cases would be in the adminis- 
tration of small doses of opium, in connection with the mercury. 
For this purpose, it is well to order pills containing one-quarter of 
a grain of the extract of opium, and administer one of these with 
each evening dose, and if necessary successively add it to the noon 
and morning doses. If this is not sufficient, a second opium pill 
can be added to the evening dose, and so on, until the intestinal 
irritation is controlled. It is an excellent suggestion of Keyes’s in 
these cases, to administer blue mass in doses of half a grain, in SYPHILIS OF THE NASAL PASSAGES. 
359 
combination with quarter of a grain of dried sulphate of iron. In 
spite of all changes in the form of mercury, and the administration 
of correctives, it will oftentimes be necessary to abandon, for a 
time, its internal exhibition, and resort to inunctions or fumiga- 
tions. Inunction is not a nice way to administer mercury, but it is 
certainly very efficient. For this purpose, preference should always 
be given to the oleates, as being less objectionable than mercurial 
ointment. We may order from twenty to thirty minims of a 
twenty-per-cent oleate, rubbed on the thighs or forearms daily. 
Fumigation is usually resorted to, as a rapid method of bringing 
the system under the influence of mercury, and yet I have occa- 
sionally ordered a mercurial bath, of from seventy to one hundred 
grains of the sulphuret of mercury, twice or three times weekly, as 
a substitute for the internal administration of the drug, with most 
excellent results, continuing its use for several weeks at a time, 
until the intestinal irritation, which was caused by its internal ad- 
ministration, subsided.. 
In case any of the above nasal lesions of syphilis appear during 
the mercurial course of treatment, they of course will necessitate 
a resumption of the plan of treatment already laid down. The 
time during which the mercury should be administered, must in 
all cases, 1 think, be extended fully to the end of two years from 
the date of the last serious lesion. Few cases, nowadays, of the 
late lesions of syphilis appear, without the patient having pre- 
viously been subjected to treatment, but that this previous course 
of treatment has been inefficient, I take it, the reappearance of the 
disease is sufficient evidence. Hence, I think, we must act on the 
ground that all previous treatment has been of no effect. Whether 
this be true or no, I certainly am of the opinion, that it is our duty 
to subject the patients to a thorough course of antisyphilitic treat- 
ment, viz., mercurial, for the full length of two years after the last 
unmistakable lesion. CHAPTER XXIV. 
CONGENITAL SYPHILIS OF THE NASAL PASSAGES. 
Syphilis in the father or mother is exceedingly liable to be 
followed by syphilis in their offspring. Whether a syphilitic father 
can transmit syphilis to the offspring without infecting the mother, 
or whether the mother must first be infected, and thereby transmit 
the disease to the child, is still a matter of discussion among 
syphilologists. Again, it is still an open question as to how long, 
after the primary lesion, the father or mother can transmit the dis- 
ease. The weight of opinion, however, I think, leans decidedly to 
the view that the limit of transmission in either the father or the 
mother is certainly within three years after the contraction of the 
disease. These problems, however interesting, need not be dis- 
cussed in the present chapter. 
As a result of inherited syphilis, the foetus in utero may become 
syphilitic, giving rise to premature birth, or the child may be still- 
born at the end of the full term; or, again, the manifestation of the 
disease may be delayed until after birth, although, if the disease is 
present, it shows itself very soon. Thus Von Rosen 1 found that, 
out of sixty-eight cases, in all but nine the disease manifested itself 
earlier than three months after birth; while Kassowitz,2 out of one 
hundred and twenty-four cases of hereditary syphilis, found symp- 
toms presenting in eleven cases in the first week, twenty-one in the 
second, thirty-four in the third and fourth, forty in the second 
month, and eighteen in the third month; while Roger,3 out of two 
hundred and seventy-two cases of hereditary syphilis, found that 
the symptoms presented in one hundred and twenty-two cases in 
the first month, one hundred and twenty-eight cases in the second 
and third, and only thirty-two later. Baumler4 comes to much the 
same conclusion, in making the general statement, that nearly half 
the children are attacked in the first month of life, one-third in the 
second, about one-eighth in the third, and only one-eleventh at a 
later period, although he adds, however, that the symptoms very 
1 Behrend’s “ Syphilidologie,” new series, iii., 1861, pp. 223, 226. 
2 “ Die Vererbung der Syphilis,” Vienna, 1876. 
3 “ Recherches cliniques sur les maladies de l’enfance,” vol. ii., 1883, p. 1. 
4 Ziemssen’s “ Cyclopaedia,” vol. iii., p. 240. CONGENITAL SYPHILIS OF THE NASAL PASSAGES. 
361 
seldom begin in the first week, and not infrequently in the second; 
while Diday 1 makes the statement, that he has seen a few cases as 
late as four months, and one case, in which the disease did not 
appear until the child was nearly two years old. This last state- 
ment is somewhat unique, and it is not improbable that this child 
may have acquired the disease after birth, as it scarcely harmonizes 
with our knowledge of the action of syphilitic virus, that it should 
remain latent for two years in the nursling. 
The present consideration is confined entirely to the discussion 
of hereditary syphilis, which is occasionally treated of under the 
designation of congenital syphilis. Now, the latter term may be 
used to describe a form of syphilis which is acquired at birth, 
namely, by infection from an existing lesion in the genital passages 
of the mother. In this case, I am disposed to think that the dis- 
ease runs an entirely different course from that to be described in 
the present chapter, probably differing in no very marked degree 
from the ordinary type of acquired syphilis, although these cases 
are so exceedingly rare, that the data upon which any general 
statement is based, must necessarily be, to a certain extent, limited; 
hence, when Simon2 makes the statement that “ Congenital syphilis 
not infrequently manifests itself for the first time after weeks, 
months, or, in certain instances, not until the age of puberty, and 
even after many years,” I think if, by congenital syphilis, he 
means the hereditary form of the disease, the statement must be 
accepted with considerable reservation. If, however, he alludes to 
syphilis acquired at birth, his assertion may undoubtedly be cor- 
rect, with reference to the very late manifestation of the disease, 
although even here, there is an element of doubt, in that syphilis 
can be acquired in irregular or accidental ways, and the primary 
lesion escape observation; for, in cases where the disease is ac- 
quired at birth, we should usually expect a more rapid course of 
development than in adult life, although by no means so rapid a 
course as is met with in the hereditary form of the disease. 
The earliest manifestation of congenital syphilis in children is 
either in a coryza or in some form of cutaneous eruption. In still 
rarer cases, we have iritis, deafness, or some obscure brain symptoms. 
I know of no statistics bearing on the frequency of the special 
lesion, although, unquestionably, in the large majority of cases, the 
first manifestation of syphilis in children occurs in the form of a 
coryza, which, manifesting itself by the ordinary symptoms of nasal 
stenosis with watery discharge, as the disease progresses, gradually 
develops into a muco-purulent discharge of a somewhat acrid char- 
1 “ Traite de la syphilis des nouveaux-ne's et des enfants a la mamelle,” Paris, 1854. 
2 Virchow’s “Spec. Path. u. Therapie,” art. Syphilis, Band ii., Abth. 2, p. 577. 362 
DISEASES OF THE NASAL TASS AGES. 
acter, giving rise to irritation of the muco-cutaneous junction and of 
the upper lip, together with crust formation about the margins of the 
nostrils. The essential lesion consists of an inflammation of the 
mucous membrane lining the nose, apparently a non-specific rhinitis. 
We probably have no means of making a definite diagnosis in these 
cases, in that the examination of the nasal cavity is not only ex- 
ceedingly difficult in young children, as revealing any easily recog- 
nizable condition, but. moreover, if an examination were feasible, 
it is questionable if the morbid appearances would afford any spe- 
cial light in directing attention to the existence of syphilis. The 
diagnosis must depend in part on the clinical history of the case, 
and the concomitant appearances, but mainly on the general ap- 
pearance of the child, who shows very marked evidence of mal- 
nutrition, the skin presenting a pale, somewhat earthy color, while 
the general facial expression gives to the child a somewhat pinched 
and old-man face, as it were. In connection with this, in the ma- 
jority -of cases, either concomitant with the development of the 
nasal symptoms, or soon after, there appears the ordinary eruption 
on the skin, which verifies the diagnosis. This makes its appear- 
ance usually about the anus or buttocks, and afterward spreads 
over the body. This is usually papular in character, presenting 
the typical copper color. The further manifestation of the disease 
in the nose consists in the deposit of gummatous material, either 
in the superficial or deep layers of the membrane, which, breaking 
down rapidly, results in an ulcerative process. This phase of the 
disease is manifested by an increase of the pus discharge, which 
has now assumed a somewhat offensive character, and is mingled 
with blood and shreds of black necrotic tissue. The secretions 
from the ulcerative surfaces form hard incrustations, which drying, 
by a somewhat rapid process of accretion, obtain such size as that 
they cannot be expelled from the cavity, and hence form an addi- 
tional source of irritation, in that they may give rise to reflex brain 
disturbances, which may lead to the suspicion of the existence of 
some form of brain-syphilis. In most cases, probably, however, 
this is due simply to the fact that the incrustations accumulate to 
such an extent as to completely block the passages, and prevent 
the escape of the purulent discharge. Herman Weber1 has re- 
ported two cases of infantile syphilis, in which epileptiform convul- 
sions, followed by coma, developed coincidently with the cessation 
of the sanious discharge from the nose, the nervous symptoms dis- 
appearing, however, immediately upon the reestablishment of the 
escape of pus from the nose. A fair inference might be here, that 
the damming back of the pus might have given rise to septic infec- 
1 Med. Chir. Trans., vol. xliii., p. 188. CONGENITAL SYPHY LIS OF THE NASAL PASSAGES. 
363 
tion, but septicaemia is one of the rarest of complications in nasal 
syphilis, even where extensive necrosis has resulted from the dis- 
ease. A true explanation of the development of the brain symp- 
toms in these cases is to be found in the fact, that in young chil- 
dren the retention of the crusts produces reflex disturbances of the 
nerve-centres. 
Congenital syphilis of the nose in young children runs an ex- 
ceedingly rapid course, the ulceration following rapidly on the 
coryza, which very soon leads to exposure of bone, and subse- 
quent necrosis, as external deformity shows itself very early in 
the history of the case, evidencing the fact that the whole of the 
bony septum, and probably some portion of the nasal bones, have 
been destroyed. In a case reported by Hawkins,1 nasal syphilis 
developed in a child six weeks after birth, resulting in complete 
destruction of the vomer, with sinking in of the nose four months 
later. We thus find the clinical history of the development of 
syphilis in children, differing from that of adults in a very striking 
degree. This is not to be explained by the view, that inherited 
syphilis is a more active poison than the acquired form of the dis- 
ease, but rather to the fact, that small children possess a compara- 
tively slight power of resisting the inroads of any disease: hence, 
the syphilitic virus makes a very powerful impression from the 
onset upon infants, giving rise to a general impairment of all the 
nutritive powers, as evidenced by their general cachexia already 
described, this general cachexia not being necessarily a direct, but 
an indirect result of the disease. 
DIAGNOSIS.—The diagnosis of nasal syphilis ought to be com- 
paratively easy in all cases, in the early stage, where it is charac- 
terized by a simple coryza. It should be remembered that the 
turbinated tissues are in a very early stage of development at birth 
and for some months later, hence an acute idiopathic rhinitis is an 
exceedingly rare disease at this age. Furthermore, if by any 
chance such a disease exists, it would run the ordinary course of a 
few days, and undergo resolution, whereas in syphilis it progresses 
rapidly toward the development of a discharge, of such a decidedly 
purulent character as to eliminate the possibility of its being an 
acute rhinitis even in its late stages, wherein the discharge never 
obtains an absolutely purulent character. In a purulent rhinitis in 
children, in the early stage of atrophy, the disease never develops 
earlier than from three to four years of age, and in its earlier stages, 
is an exceedingly mild affection, and not characterized by any nota- 
ble stenosis, or great swelling of the mucous membrane. Hence 
in a given case of coryza, in the first few months of life, suspicion 
1 “ Contributions to Path, and Surgery,” vol. i., p. 229. DISEASES OF THE NASAL PASSAGES. 
364 
should always be excited of the existence of inherited disease. If, 
in addition, the child is small, illy-nourished, and presents the ordi- 
nary appearance of anaemia, together with an earthy tint of the 
skin, and old-man look in the face, we have still further confirma- 
tion of this suspicion. The appearance of the characteristic erup- 
tion, however, renders the diagnosis complete, and this should be 
easily recognized from its gross appearances. According to Baum- 
ler,1 this usually presents in the typical copper-colored elevated 
papules, present on the buttocks or about the anus, which very 
soon assume the appearances of mucous patches. In still rarer 
cases, the eruption may be of the macular character, although 
Romberg2 and Van Harlingen3 assert that the smooth macular 
eruption is the more frequent. In either case, however, of course, 
the minute extravasations are characteristic of syphilis, as shown by 
the copper-colored tint of the eruption. Still later developments, 
as bloody pus mixed with necrotic tissue, in connection with the 
characteristic fetor which attends an ulcerative process in the nose, 
of course, leave no possibility of mistake in diagnosis. Baumler4 
alludes to the characteristic appearance of the external nose, in 
these cases, which consists mainly in a depression or flattening of 
the nasal bridge, together with a protrusion of the frontal sinuses. 
This feature is oftentimes noticeable, and is not to be regarded as 
an evidence of any distortion of the nasal bones as the result of 
disease, but is rather due to the fact, that in consequence of the 
stenosis, the alae of the nose are sunken in, and the nostrils to a 
certain degree collapsed, as a result of which, the bridge of the 
nose presents a somewhat bulbous or swollen appearance, which is 
heightened by the emaciation of the child, the features being 
pinched, as it were, and the subcutaneous cellular tissue being ab- 
sorbed, and the thin flabby skin drawn firmly, as it were, across the 
nose, giving it a misshapen aspect which, as before stated, is only 
an appearance, and not an absolute condition. 
In addition to these objective symptoms, much light can also 
be thrown on the matter of diagnosis, by making close inquiry as 
to the possibility of syphilitic disease in either the father or mother. 
A patient may oftentimes attempt to deceive a physician, where 
the inquiry is made in regard to acquired syphilis in his own person. 
When, however, a man is confronted with the possibility of having 
transmitted a terrible disease to his offspring, he is usually disposed 
to answer questions with absolute candor and honesty. Hence, 
1 Loc. cit., p. 238. 
2 “ Klin, Ergebnisse,” Berlin, 1846, s., 178. 
3 “International Cyclopedia of Surgery,” vol. ii., p. 453. 
4 Loc. cit., p. 239. CONGENITAL SYPHILIS OF THE NASAL PASSAGES. 
365 
this clinical feature of the disease can usually be investigated very 
thoroughly, and the facts of the case established with a fair degree of 
certainty. The same considerations, I take it, apply with equal force 
to the mother, who in a matter of this kind, will confide the truth 
to the physician, even if she have something to conceal from her 
husband. As a matter of clinical observation, any father or mother 
who has had a primary syphilitic lesion within three years pre- 
ceding conception, is liable to transmit that disease to the offspring. 
Whether this possibility of transmission occurs later, is still an open 
question. Clinical facts, however, I think are rather against it, and 
hence our investigations should be made on this basis. Still an- 
other interesting question is as to the possibility of the father 
transmitting syphilis to his child, without first infecting the mother. 
Clinical facts are about equally distributed in supporting one or 
the other side of this question, and yet, on purely physiological 
grounds, it is not easy to understand why this may not be; espe- 
cially as the possibility of inheriting the rheumatic, gouty or turber- 
cular diathesis from.the father remains unquestioned. 
PROGNOSIS.—The early development of syphilis in children is 
to be regarded as an evidence of the activity of the specific virus 
in the system. Thus, in a case where the evidences of the disease 
are presented at birth, the prognosis is simply bad, as those cases 
are rarely amenable to treatment—one of the most serious features 
of the case being, that the nasal disorder so far interferes with 
nursing, as to lead to the very early development of mal-nutrition 
or marasmus, and the children usually succumb, largely as a result 
of this complication. On the other hand, we may state it as a rule, 
that the later the development of the disease, the more favorable 
the prognosis, in that the child has had an opportunity of gaining 
vigor and strength to combat the blood poison when it manifests 
itself, and furthermore, I think it may be stated as a rule, that the 
later the disease manifests itself, the slower its progress, hence 
the better the opportunity for establishing the diagnosis, and plac- 
ing the child under proper remedial measures. In the ordinary 
run of cases, namely, in those cases in which the coryza of syphilis 
sets in from four to six weeks after birth, the prognosis is based 
largely on the general condition of the child, many children show- 
ing at this age very marked evidence of marasmus. In these cases, 
the prognosis is bad. If, on the other hand, we have to do with a 
fairly well-nourished child, at four to six weeks of age, who develops 
syphilitic coryza, when we consider the fact that we possess a spe- 
cific remedy in mercury, and that children come readily under the 
influence of this drug, the prognosis may be considered favorable, 
if the disease is recognized, and the remedies administered. If ul- 366 
DISEASES OF THE NASAL PASSAGES. 
ceration, with resultant necrosis, has developed before the disease 
is recognized, this does not in itself modify the prognosis as regards 
ultimate recovery, other things being equal. In other words, if a 
syphilitic child has developed necrosis at six months without treat- 
ment, and still shows no very marked evidence of general mal- 
nutrition, there is no reason for giving an unfavorable prognosis, in 
that the syphilitic explosion, as it were, which leads to the deposit 
of gummatous material in the mucous membrane lining the nose, 
seems to have exhausted itself in this deposit, and the further 
progress of the disease is largely a local process, in that the mass 
breaks down into an open ulcer, under which all the gummy mate- 
rial which formed the original deposit is thrown off. The necrosis 
of bone which results, entails a much longer process for its exfolia- 
tion. This process, however, does not necessarily lead to any im- 
pairment of the general health, except so far as it interferes with 
the normal function of the nose—interfering with nursing, and 
thereby producing impaired nutrition. If what has now become a 
local disease, acts to impair the general health, it acts indirectly 
and not directly. As we have already seen, syphilitic disease of 
the nose in children, runs an exceedingly rapid course, but still ad- 
heres to the same rules which govern the manifestations of syphilis 
in the adult. It shows a marked hesitancy in transgressing ana- 
tomical boundaries, and does not extend, therefore, to the integu- 
ment anteriorly, nor into the pharnyx behind. If it produces de- 
struction of the hard palate, it is due to an original deposit of 
gummy material in the bones forming this structure, or if the 
ethmoid or sphenoid bones are involved, this involvement is due to 
original syphilitic disease. In those cases, of course, where the 
extent of involvement of tissue in a necrotic process is very great, 
the prognosis must necessarily be, to a certain extent, rendered 
more grave, in that the general health must suffer in a young child, 
with so large an extent of diseased tissue. We come then to the 
conclusion, that a fairly correct prognosis can be made at the time 
the disease is recognized, and is based on the time at which the 
disease develops, the extent of tissue involved, and lastly, but .of 
most importance, on the general condition of the child. 
Treatment.—The local treatment of the coryza is a matter of 
some importance, if thereby we are enabled to restore the passages 
to their normal patency, and thus allow the child to take its nour- 
ishment in proper amounts, from the breast. For this purpose we, 
perhaps, possess no remedy which is as efficacious as cocaine, 
which should be used in the form of a spray, in about half-per-cent 
solution, as follows: CONGENITAL SYPHILIS OF THE NASAL PASSAGES. 
367 
B Cocainae hydrochloratis, .... grs. iij. 
Sodii biborat., ...... grs. vi. 
Aquae, ad 3 i. 
Or perhaps better still, in the form of an emulsion with some oily 
substance, such as the following: 
IJ Cocainae hydrochloratis, .... grs. iij. 
Aquae, . . . . . . . . iq x. 
M. ft. sol. et adde 
Ol. menth. pip., . . . . . . t\[ v. 
Ol. amygdalae, . . . . . . § i. 
M. S. Shake well before using. 
Either of the above can be used in the hand-ball atomizer, shown 
in Fig. 47 and placed in the hands of the attendant, to be applied 
to each nostril, every two or three hours. Astringents possess no 
value in this condition. The integument about the margins of the 
nostrils is always exceedingly tender, and should therefore be pro- 
tected by the local application of vaseline or cold cream. A certain 
amount of good is undoubtedly done in these cases, by anointing 
the external nose either with mutton tallow, or better still, the 
well-known domestic remedy, the tallow of a goose. After the 
disease has progressed to' the ulcerative stage, our efforts are di- 
rected entirely toward keeping the parts thoroughly cleansed by 
means of a wash, after the membrane has been reduced, and the 
passages opened as far as possible by one of the cocaine sprays 
already alluded to. For the purpose of the wash, any simple alka- 
line lotion may be used. The difficulty, of course, in cleansing 
the nose in an infant, is that the child cannot blow its own nose. 
This is fairly well accomplished for the child, by simply fitting the 
nozzle of the spray apparatus into the nostril, and blowing, the 
reservoir of the spray being empty, the theory being, that if you 
blow into one nostril of the child, the palate is immediately thrown 
up against the posterior wall of the pharynx, and that orifice 
closed. Hence, the current of air blown into one nostril escapes with 
considerable force through the other, carrying with it such mucus 
or pus as may lie in the cavity. If this is not successful, there is 
no serious objection to using a cotton pledget, firmly fixed on the 
end of a probe, as after the use of cocaine, the parts are by no 
means sensitive. If ulceration has set in, the efforts should be 
toward controlling this, in that the disease runs an exceedingly 
rapid course, and bony necrosis must necessarily occur, unless the 
ulcerative process is arrested, for we are justified in believing that 
a gummy deposit does not always extend deeply into the mucous 
membrane, and hence bony necrosis is not always an inevitable 368 
DISEASES OF THE JVASAL PASSAGES. 
result of an ulcerative action. Our best method of controlling 
ulcerative action is by the use of iodol or iodoform. 
This should be applied, after the parts are thoroughly cleansed, 
by insufflation in the form of a powder. Neither of these drugs is 
irritating, and hence they can be used in full strength. By far the 
most important treatment of nasal syphilis, is to bring the child as 
rapidly as possible under the influence of mercury, the administra- 
tion of which must be regulated by much the same rules as govern 
its administration in adults. If, for any reason, the administration 
by the mouth cannot be well managed, inunctions answer an ex- 
cellent purpose, the amount to be used of mercurial ointment being 
about five grains daily, or else the oleate is used, two or three 
minims daily, of a twenty-per-cent strength. Ordinarily, however, 
I think its internal administration is preferable, and for this pur- 
pose we may use either mercury with chalk, or calomel, in doses 
of one grain twice or three times daily, or the protoiodide in doses of 
one-eighth or one-tenth of a grain. In children, as in adults, the 
administration of iodine is liable to cause disturbance of the bowels. 
This, however, can be regulated by the administration of a small 
quantity of opium, or it may necessitate the abandonment of in- 
ternal medication, and compel us to resort to inunctions, or mer- 
curial baths. The mercurial bath may be prepared, by dissolving 
eight or ten grains of corrosive sublimate, in four or five gallons of 
tepid water, into which the child is placed, and allowed to remain 
from ten to fifteen minutes, care being taken to exclude water from 
the eyes, mouth, and nose. If ulceration exists in the nasal cavity, 
or evidence of gummy deposit, it is well to administer small doses 
of iodide of potassium, for a limited period of time, its duration 
being governed by the toleration of the child, and the impression 
which the remedy makes upon this special feature of the disease. 
The dose, however, cannot ordinarily well be increased above pos- 
sibly two grains, given three times daily. This, however, must be 
given in connection with some form of mercury; in this case, it is 
probably wiser to confine the administration of mercury to either 
the biniodide or bichloride, as in this manner any danger is avoided 
of forming a poisonous combination in the system, of the iodine 
with mercury, although this objection to the combined administra- 
tion of these two remedies has probably been overestimated. In 
addition to the constitutional treatment, the general condition of the 
patient ordinarily demands the administration of tonics, and espe- 
cially the use of cod-liver oil, while, at the same time, the most scru- 
pulous care must be exercised, in the observation of the utmost 
cleanliness in the child’s surroundings, the daily administration of 
the cold bath, and by subjecting the child to the best of general 
hygienic influences. CHAPTER XXV. 
TUBERCULOSIS OF THE NASAL PASSAGES. 
TUBERCULOUS disease invades the nasal passages with greater 
rarity than any other portion of the respiratory tract. Thus 
Willigk,1 in four hundred and seventy-six autopsies of tuberculous 
cases, found but one case in which the nasal membrane was in- 
volved, while Weichselbaum 2 found two cases in one hundred and 
sixty-four autopsies. If the theory that tuberculosis is a germ dis- 
ease, and therefore infectious, has any foundation in fact, we can 
easily understand how the nasal mucous membrane should fail to 
afford a lodgment for the floating germ, in that any particle lodging 
upon its surface, would be washed away by the constant flow of serum 
in the process of respiration. The same is true, not only of tuber- 
culosis, but of all the infectious diseases, the germs of which, as we 
know, find a more favorable lodgment in the fauces. The first to 
recognize the disease during life was Laveran3 who reported two 
cases, in which advanced tuberculosis was complicated by a low 
form of sluggish ulceration upon the septum, which Laveran con- 
sidered as due to a tubercular deposit. In one of these cases, the 
diagnosis was confirmed by autopsy, while in his second case, there 
was some question whether the disease was genuinely tuberculous 
in character. 
In a rather curious case reported by Riedel,4 the ulceration on 
the nasal septum persisted for twenty-seven years, and while the 
lungs were entirely healthy, a microscopical examination of tissue 
removed from the affected surface, revealed the existence of tuber- 
cular disease, as occurred also in a second case reported by Riedel,5 
where an ulcerative process on the septum, of one and a half year’s 
duration, was shown on microscopical examination to be due to 
tuberculosis. In this case also, the lungs were declared to be 
healthy. Spillman,6 in reporting a case, gives an exceedingly 
1 “ Sections-Ergebnisse an der Prager. Path. Anat. Anstalt von i. Feb. 1850 to 1. 
P'eb. 1852.” Prag. Viertaljahresschrift, vol. xxxviii., p. 4. 
2 Allg. Wien. Med. Ztg., 1881, xxvi., 268. 
3 Union Medicale, 1877, No. 36, p. 501. 
4 Deut. Zeit. fur Chir., Leip., 1878, vol. x., pp. 56-58. s Loc. cit. 
6 As quoted by Cartaz, La France Medicale, 1887, No. 85, p. 1,020. 370 
DISEASES OF THE NASAL PASSAGES. 
graphic description of the characteristic appearances of the tuber- 
cular ulcer, as involving the lower portion of the nasal septum, in a 
patient suffering from pulmonary phthisis, with tubercular ulcera- 
tion of the nose, although the diagnosis was not confirmed in this 
case by autopsy. A case reported by Tornwaldt1 is interesting, 
in that it is the first record of the disease as invading the mucous 
membrane covering the turbinated * bodies. In this case, the 
disease manifested itself in the form of a small raspberry-shaped 
excrescence, about the size of a pea, at the anterior termination 
of the lower turbinated body. A smaller mass was also found in 
the upper surface of the soft palate, while there were granular 
erosions on the septum. In reporting two additional cases, Weich- 
selbaum 2 enters into a somewhat elaborate discussion of the whole 
subject of nasal tuberculosis, mainly from a pathological point of 
view. In his first case, a boy of fifteen, suffering from general 
tuberculosis, there was on either side of the septum a number of 
small grayish-yellow ulcers, which an autopsy revealed to be tuber- 
cular in character. In his second case, the disease developed in the 
form of small gray ulcers on the lower and middle turbinated 
bodies of one side, while on the other, there was a small tubercular 
mass on the middle turbinated, just commencing to take on ulcer- 
ative action. This diagnosis was also confirmed by autopsy. Mil- 
iard,3 in a case of acute miliary pharyngeal tuberculosis, found 
tubercular nodules, as large as a millet seed, in the nasal mucous 
membrane. In a case reported by Riehl,4 tubercular disease, in- 
volving the integument covering the nostril, nose and lip, seems to 
have extended to the nasal septum, resulting in infiltration, with 
ulceration of both surfaces. The diagnosis was confirmed in this 
case by autopsy, which also showed advanced disease of the lungs. 
Demme5 reports two cases in children. The first case was that of 
a child, one year of age, whose nose was stopped with brownish 
crusts. When these had been removed, there were found, on the 
septum, the characteristic nodules and ulcers of tubercular disease. 
The base of the ulcers appeared dirty yellow, and they were cov- 
ered with thin yellowish pus. There was no history of congenital 
syphilis. The child died later, of pulmonary tuberculosis. 
His second case occurred in a child, aged eight months, with no 
specific or tubercular family history. The child, however, was 
cared for by a family in which the father died of tuberculosis. At 
1 “ Ein Fall von Tuberculose der Nasenschleimhaut.” Deut. Arch. f. Klin. Med., 
Leip. .1880, xxvii., 586-591. 
2 Loc. cit. 3 Bull, de la Soc. Med. des Hop., 1881. 
4 Wien. Med. Woch., 1881, No. 4., p. 1261. 
5 Berlin. Klin. Woch., 1883, No. 15 p. 217. TUBERCULOSIS OF THE NASAL PASSAGES. 
371 
the age of six months, and two months after entering this family, 
the child began to suffer from a foul-smelling nasal discharge. An 
examination of the right nasal cavity revealed the characteristic 
tubercular nodules and ulcers on the septum. Tubercular bacilli 
were found in the discharge from the nostril. The child died later, 
of tubercular meningitis. The case is especially interesting, from 
the fact that the author favors the opinion that the child became 
infected from living in a tubercular family. 
Berthold,1 in reporting an instance of the disease, has failed to 
give the history of his case sufficiently in detail to make it of any 
interest. Cartaz2 cites the case of Sokolowski, in which the ulcera- 
tion on the septum showed a tendency to extend to the upper lip, 
and, furthermore, was exceedingly painful. This diagnosis was 
based on the discovery of the tubercular bacillus in the secretions. 
Schaffer’s3 experience certainly has been somewhat unique, in that 
out of four hundred and fifty cases of tumors of the nose, he has 
met with eight cases of tubercular disease, six of which he has re- 
ported somewhat in detail. In all of these, the disease assumed a 
neoplastic form, and as a rule, was located upon the septum. In 
four of his cases, the diagnosis was based on gross inspection, there 
being no microscopical examination made, and furthermore, in 
three of these, the lungs were perfectly healthy. In the fifth and 
sixth cases, the condition of the lungs is not given, although the 
character of the ulcerations was determined by the microscope, 
which revealed the presence of bacilli and also the characteristic 
tubercular tissue. Cartaz,4 in reporting a case, enters into quite 
an elaborate discussion of the whole subject of tuberculosis in the 
nose, and gives an analysis of all cases reported up to date. In 
Cartaz’s case, a large rounded tubercular ulcer made its appearance 
on the septum, the patient suffering from advanced phthisis. A 
case of nasal tuberculosis was presented by Juffinger,5 a detailed 
account of which is not given. 
Hajek6 presented a case of the same disease, before the same 
society, the details of which are as follows: 
A male, set. thirty, presented with the history of a bloody dis- 
charge from the right nostril, the source of which was found to 
to be ulcer on the cartilaginous septum. Potassium iodide was ad- 
ministered without benefit. At a later examination, a growth was 
1 Berlin Klin. Wochenschr., 1884, No. 40, p. 644. 
2 I.oc. cit. 
3 Deut. Med. Woch., 1887, vol. xiii., pp. 308-310. 
4 La France Medicale, Nos. 84, 85, 86 & 87, 1887. 
3 In der Sitzung der Gesellschaft der Aerzte in Wien vom 30. Nov. 1888. Wien. 
Klin. Wochenschr., 1888, No. 36, p. 748. 
6 Ibid. 372 
DISEASES OF THE NASAL PASSAGES. 
discovered in the naso-pharynx. After the removal of the growth, 
it was found that its surface was ulcerated, and a microscopical ex- 
amination revealed tubercle bacilli. A fragment was now removed 
from the septal ulcer, and bacilli were found in the deeper parts. 
The treatment consisted in scraping the ulcer, and the subsequent 
application of lactic acid. The benefit was only temporary, recur- 
rence always following at the end of a few weeks, and finally the 
disease invaded the opposite side. The termination of the case is 
not given. 
Kikuzi1 reports a case, under the care of Bruns, at the Tubin- 
gen Clinic, in a male thirty years of age, in whom there was no 
hereditary history of tuberculosis. At the time of examination, 
there was no evidence of tubercular disease of any of the internal 
organs, syphilis, or lupus. The disease had produced perforation 
of the cartilaginous septum, and assuming the neoplastic form, had 
caused complete stenosis of the right nostril, and narrowing of the 
left. An external operation was done and the disease eradicated. 
Five months after, there was a partial recurrence, which was treated 
with the currette and galvano-cautery. The tubercular nature of 
the disease was confirmed by microscopic examination. 
Luc2 reports the case of a male, suffering from a profuse muco- 
purulent discharge from the right nostril, and pain on deglutition, 
confined to the left side of the throat. Examination revealed a 
small ulceration, behind the left pillar of the fauces, which was 
proven to be tubercular. In the right nasal fossa, a similar ulcera- 
tion was found on the inferior turbinated bone. There were evi- 
dences of infiltration at the left apex, and of tubercular orchitis. 
Both ulcerations were scraped with the curette, and cauterized 
with the galvano-cautery. The ultimate result was good. Tenne- 
son3 reports a case of ulceration in the nasal cavity, which was 
probably tubercular in its origin. The ulcer had lasted four months; 
its borders being soft and injected. There was consolidation at the 
apex of the right lung, together with diarrhoea, and albuminuria. 
We find then twenty-seven cases of nasal tuberculosis reported 
in literature. A review of these cases, however, I think warrants us 
in excluding a certain number of them, in that the diagnosis is not 
sufficiently established. In Weichselbaum’s very elaborate study 
of the disease, he excludes one of Laveran’s cases as unproven, 
while he also questions Riedel’s cases, in which, while the micro- 
scope seemed to indicate the existence of tuberculosis, we have the 
disease in his first case lasting twenty seven years, in a man enjoy- 
1 “ Beitrage zur Klinischen Chir.” Tubingen, 1888, lid. iii., Heft 3, p. 49.3. 
2 Archiv. de laryng., fevrier, 1889, No. 1, p. 19. 
3 Ann. de Dermat. et deSyph., March 25th, 1889, p. 214. TUBERCULOSIS OF THE NASAL PASSAGES. 
373 
ing perfect health, and again in Schaffer’s four cases, which were 
based entirely on ocular inspection, I think we are justified in 
seeking a better confirmation of the diagnosis. We thus have left, 
twenty cases, on which, I think, our knowledge of the clinical his- 
tory of the disease must be based. 
Etiology.—The disease occurs either in connection with pul- 
monary or general tuberculosis, exceptions to this rule being the 
two cases of Riedel’s in which the diagnosis is doubtful, and a 
single case of Schaffer’s in which no pulmonary disease was recog- 
nized. Hereditary influence is shown to exist in a large propor- 
tion of cases of the disease. How far the local condition of the 
nasal cavity may affect the ulcerative process cannot be deter- 
mined, although, undoubtedly, it has some influence in that direc- 
tion. Aside from this, we recognize no conditions which stand in a 
causative relation to nasal tuberculosis, other than those which we 
recognize in connection with the same morbid process as affecting 
other regions of the body. 
PATHOLOGY.—A tubercular process in the nasal mucous mem- 
brane manifests itself in two forms. In the one case, it develops 
in the ordinary tubercular ulceration, very similar to that observed 
in other portions of the air-tract. In other cases, it shows a ten- 
dency to hyperplasia, in the form of small tumors, varying in size 
from bird-shot to a pea, presenting a somewhat mammillated or 
raspberry-like surface, the growths being attached to the parts 
beneath by a broad base. The ulceration, in the majority of in- 
stances, shows itself on the septum or floor of the nares, while the 
neoplastic form, on the other hand, is more frequently found on the 
turbinated bodies, although occasionally found on the septum also. 
Examination will determine whether the form be neoplastic or ul- 
cerative. A section of the growth exhibits a fine basement mem- 
brane of connective tissue, richly infiltrated with round nucleated 
cells (lymph cells), together with larger nucleated epithelial or en- 
dothelial cells, and sometimes, but not always, true giant cells. 
The normal gland structure of the membrane is more or less modi- 
fied, the glands may appear normal, or they may be distorted by 
the pressure of the surrounding inflammatory products. The gland 
epithelium may degenerate, or it may simply be pushed off, as it 
were, by the infiltration of the tissues by the round cells. The 
tissue immediately about the ulcer or tumor, as the case may be, 
shows an abundant round-cell infiltration. By appropriate staining, 
tubercle bacilli may be found, but if so, they are usually present in 
rather small numbers. 
SYMPTOMATOLOGY.—If the disease takes on the ulcerative form, 
the prominent symptom will be the discharge of grayish mucus, DISEASES OF THE NASAL TASS AGES. 
374 
more or less profuse, according to the extent and size of the ulcera- 
tion. If the ulceration is on the septum, especially if near the nos- 
tril, crust formation will prove a source of annoyance to the patient. 
In these cases also, slight hemorrhage is liable to attend the dis- 
lodgment of the crusts. Pain is rarely present, either subjectively 
or as the result of pressure. In the neoplastic form of the disease, 
the prominent symptom attendant upon the presence of these 
small growths is obstruction with a moderate amount of secretion 
and occasional hemorrhage. 
Diagnosis.—A tubercular ulcer, wherever it may be, presents a 
certain characteristic appearance, which distinguishes it from any 
other form of ulcerative action. Its surface is of a whitish-gray 
color, flush with the surface of the mucous membrane surrounding 
it. In other words, there is no apparent loss of tissue. The out- 
line of the ulcer is somewhat irregularly rounded, while the mucous 
membrane surrounding the ulcer presents no characteristic distinc- 
tive features, there is no discoloration or, in other words, there is 
no areola, the color of the ulcer merging into the color of the 
mucous membrane beyond, in a way that oftentimes obscures the 
exact boundary of the diseased process. The secretion from the 
surface of the ulcer is usually a whitish-gray mucus, mingled with 
a few epithelial cells, not however in sufficient numbers to render 
the secretion notably opaque. The tubercular ulcer rarely, if ever, 
secretes pus. These peculiar characteristics of this form of ulcera- 
tion are somewhat changed in the nose, owing to the fact that the 
impurities of the inspired air tend to irritate the diseased process 
in this region, and furthermore they lodge upon, and discolor the 
ulcerated surfaces. Hence, we notice a slight tendency to bleeding, 
together with a certain amount of congestion of the blood-vessels. 
The hyperplastic form presents, on inspection, small rounded 
projections from the mucous membrane of the nose; as a rule they 
are found on one of the turbinated bodies, and are of a reddish- 
gray tinge and mammillated contour, presenting very much the ap 
pearance of a papillomatous growth, differing, however, from a 
papilloma, in that they are usually much smaller, more flattened, 
and are of a more regularly rounded contour. Occasionally, when 
the surfaces of these growths take on ulcerative action, the appear- 
ance is that of the ordinary tubercular ulcer, already described. 
PROGNOSIS.—Apparently, tubercular disease of the nose gives 
rise to no very marked symptoms, and, furthermore, does not seem 
to very greatly affect the prognosis of the general or pulmonary 
disease to which it is secondary. I think, as a rule, that the nearer 
a tubercular process involving the air passages approaches to the 
external world, the more virulent and hopeless the disease seems TUBERCULOSIS OF THE IVASAL TASS AGES. 
375 
to be. Thus the fatality of pulmonary, laryngeal, pharyngeal, 
palatal and lingual tuberculosis, seems to show an increasing ratio 
of gravity in the order given. This is not true of the nasal disease. 
Here the ulceration is perfectly protected by bony walls, and is sub- 
jected to no disturbance or motion, as is the fact in the larynx and 
mouth, where it is subjected to continual irritation, by the move- 
ments of mastication, deglutition, etc. These ulcers show no 
marked tendency to extend in the nose, and indeed grow very 
slowly. As regards their curability, however, the prognosis is un- 
favorable. Local measures have accomplished little in the way of 
controlling the diseased process. The total extirpation of the dis- 
ease seems to have arrested it in certain cases, although, as a rule, 
there has been a recurrence. 
Treatment.—The indications for treatment, locally, consist in 
the use of cleansing and disinfecting washes, together with the local 
application of iodoform in powder. If pain be present, this should 
be combined with morphia. The neoplastic form demands extir- 
pation by means of the snare or the curette, as suggested by 
Schaffer, after which the base is cauterized, either by a chemical 
agent or the galvano-cautery. That form of treatment which seems 
to have afforded the best results, is the total extirpation of the dis- 
ease, where this is feasible, as is especially easy of accomplishment 
where the disease is located on the septum. Cartaz recommends 
the use of lactic acid after the method suggested by Krause in the 
treatment of laryngeal phthisis. CHAPTER XXVI. 
LUPUS OF THE NASAL PASSAGES. 
LUPUS of the nose consists of a deposit in the tissues of the 
nasal mucous membrane, of what is probably a specific virus, which 
not only produces primarily certain local changes of an inflamma- 
tory character, and subsequently ulcerative action, but also leads, 
by a sort of migration of the virus, to the development of new 
centres of morbid activity in the neighboring tissues, giving rise to 
a crop, as it were, of what are generally termed lupus-nodules. 
The disease belongs essentially to the skin, and in the majority of 
instances, invasion of the nasal mucous membrane is due to the 
extension of the disease from the surrounding integument. In 
rare cases, however, the disease commences in the nasal cavity, and 
although not in every instance extending to the tissues beyond the 
muco-cutaneous junction, this tendency is usually clearly manifest. 
The disease has been the subject of an excellent monograph by 
Moinel,1 while cases have been reported by Rigal,2 Collis,3 Reed,4 
Starke,5 Shurley,6 Rough,7 Schmiegelow,8 Van Santvoord,9 Cozzo- 
lino,10 Clutton,” Bresgen,12 Rafin,'3 and Kikuzi,14 the total number of 
cases here recorded amounting to twenty. Many of these, however, 
are given with insufficient data, while in others the diagnosis is 
open to serious question. Nevertheless, many valuable deductions 
can be drawn from an analysis of those cases in which the diagnosis 
has been established, and of which full reports have been given. 
Etiology.—The origin of the disease is obscure, although it is 
1 “ Essai sur le lupus scrofuleux des fosses nasales,” Paris, 1877. 
2 Revue Medicale et Etrangere, 1829, vol. iv., p. 401. Reported as a can- 
cerous ulcer of the interior of the nose, but undoubtedly a case of lupus. 
3 Dublin Quarterly Journal Med. Science, 1866, vol. xlii., p. 324. 
4 Canada Med. Journ., 1871, vol. vii., p. 154. 
5 Ibid., 1872, vol. viii., p. 109. 
6 Archives of Laryngology, 1882, vol. iii., p. 307. 
7 Lancet, Feb. 10th, 1883, vol. i., p. 232. 
8 Hospitals-tidende, Marto, 1885. 
9 New York Med. Journ., December 5th, 1885. 
10 Archivio italiano di Laringologia, vi., fasc. i., 1886. 
11 Clinical Society’s Transactions, London, 1887, vol. xx., p. 264. 
12 Deut. Med. Woch., No. 30, 1887, p. 663. 
13 Lyon Medicale, 1887, vol. lvi., p. 382. 
14 “ Beitrage zur Klin. Chir.,” Tubingen, 1888, Bd. iii., Heft 3, p. 427. LUPUS OF THE NASAL PASSAGES. 
377 
generally associated with a notably impaired condition of the gen- 
eral health, and in some instances, with unmistakable evidences of 
the strumous diathesis. It is usually said to occur more frequently 
in females than in males, although, in the above list of cases, about 
forty per cent of the sufferers were males. It is furthermore stated 
that it is essentially a disease of youth. This is not the rule, for 
although Kough’s case was a child of six months, and Reed’s, Van 
Santvoord’s, Glutton’s, and one of Shurley’s cases occurred at the 
ages of from fourteen to sixteen, with these exceptions, the average 
age was thirty-six, the oldest case occurring at the age of fifty-two. 
Probably, in the majority of instances, the nasal affection is due to 
an extension from the external nose, which was the case in about 
forty per cent of those reported, but it should be borne in mind 
that undoubtedly a very large number of cases occur in which the 
skin affection so far overshadows the disease of the nasal cavity 
that no note is made of the latter, the notable cases being those in 
which the origin of the disease is the mucous membrane. 
SYMPTOMATOLOGY.—A moderate amount of nasal stenosis, ac- 
cording to the extent of the disease, always attends its development, 
this symptom being aggravated by the marked disposition which 
the ulcerated membrane shows to the formation of crusts on its 
surface. This would seem to be a rather notable symptom of the 
disease, as specially noted by Kaposi,1 these crusts having usually 
the character of broad, flat, brownish-colored scales. The forcible 
removal of these may be attended with slight bleeding, although 
this is never a prominent symptom of the disease. The discharge 
from the surface of the ulcer is of a thin sero-mucous character, 
and is never large in amount. Odor is rarely ever present, unless 
possibly where the disease is situated well up in the nasal cavity, 
and the crusts which cover the surface of the ulcer are retained for 
a sufficent length of time to undergo decomposition. While pain is 
not a prominent symptom of lupus of the skin, it may be present 
when the disease invades the nasal cavity, owing to the fact, prob- 
ably, that the mucous membrane here is so much more sensitive to 
external impressions, although, even here, it never becomes a very 
distressing feature of the disease. According to Neisser,2 a very 
frequent complication of lupus is erysipelas, in consequence of the 
ulcerated surface favoring the development of erysipelas cocci. 
Clinical observation, however, as regards nasal lupus, would scarcely 
favor this view. 
1 “ Hebra on Diseases of the Skin,” Sydenham Society Edition, London, 1875, vol. 
iv., p. 67. 
2 Ziemssen’s “Handbook of Skin Diseases,” American Edition, New York, 1885, 
p. 296. 378 
DISEASES OF THE NASAL TASS AGES. 
Pathology.—The pathological changes which take place in the 
mucous membrane, consist essentially of a deposit in the tissues, or 
their infiltration with small, round corpuscles of granulation tissue, 
which imbed themselves between the bands of connective tissue 
and the glands, and show a tendency to follow the course of 'die 
blood-vessels. This infiltration, instead of occurring in a diffuse 
form, shows a marked disposition to gather itself into small masses, 
giving rise to the so-called lupus-nodules (see Fig. 102). An ex- 
amination of these nodules, in many cases, will show the presence 
of giant cells. We have here, then, merely a number of independent 
centres of inflammatory action, which would seem to indicate that 
the disease is due to the entrance of this specific virus, as stated by 
Neisser,1 each point of invasion becoming the seat of a localized 
Fig. io2.—Lupus from the Inner Surface of the Ala of the Nose. A', Stratified epithelium; L,L,L, 
lupus nodules (avascular); C, fibrous connective tissue with injected blood-vessels; //, transverse section of 
hair. 
inflammatory process. In aadition, however, we notice the presence 
of giant corpuscles. These, as we know, may occur in tuberculosis, 
syphilis or scrofula, hence their pathological significance remains 
still a disputed question. The further changes which take place in 
the membrane, consist either in the re-absorption of the granula- 
tion tissue, or its progress toward the surface of the membrane, 
resulting in a breaking down of tissue there, and the establishment 
of an ulcerative process, which possesses somewhat peculiar char- 
acters, in that while the waste of tissue from the surface is by no 
means rapid, the building-up process, as it were, or the proliferation 
of round cells, continues; hence we have an ulcerative process, in 
which, instead of a loss of tissue, there is really an excess of tissue, 
the contour of the ulcer projecting above the normal surface of the 
1 Loc. cit. LUPUS OF THE NASAL PASSAGES. 
379 
mucous membrane. Schuller1 has observed small, round bodies or 
micrococci, imbedded between the granulation cells, and extending 
in the form of irregular chains of micrococci, into the neighboring 
connective tissues. Neisser,2 on the other hand, seems to think that 
Schuller is mistaken, and that the virus which causes the disease, 
will sooner or later be demonstrated to be the tubercular bacillus. 
DIAGNOSIS.—In those cases in which the disease is due to an 
extension of lupus from the external integument, of course the di- 
agnosis should be attended with but little difficulty. Where, how- 
ever, the starting point is within the nose, its recognition is at- 
tended with no little difficulty, for as Billroth3 has pointed out, the 
gross appearance of the ulcer varies somewhat, and it is not only 
“ pardonable, but even unavoidable ” to mistake the disease for a 
syphilitic lesion. As a rule, our attention is only called to the dis- 
ease, after the ulcerative process becomes established. At this 
time, an inspection of the cavity will reveal the existence of a gran- 
ular mass, projecting above the surface, of a reddish or brownish 
color, and covered by a brownish-gray crust, the removal of which 
will show the ulcer beneath, covered with grayish or whitish tena- 
cious mucus. Further investigation will show, that, upon the impact 
of the probe, the tissue is exceedingly soft, and that the instrument 
penetrates readily, without exciting much pain or hemorrhage. If 
the disease is located upon the septum, the probe will readily pene- 
trate through the cartilage, or if this has been destroyed, it passes 
completely through to the opposite cavity, showing the mass to be 
of a soft, pulpy, and easily-yielding consistency. A positive diag- 
nosis, however, cannot be based simply on the gross appearance of 
the mass. The essentially chronic character of the disease, and the 
fact that it does not yield to anti-syphilitic treatment, add much to 
our information, while the positive differential diagnosis between 
lupus, sarcoma, carcinoma and tuberculosis, the only other diseases 
with which it may be confounded, must be based on the micro- 
scopic characters of the tissue. 
COURSE and Prognosis.—Lupus of the nasal mucous mem- 
brane would seem to be a much less serious affection, and more 
amenable to treatment, than lupus of the skin, if we are to accept 
the cases reported, in that while it runs an essentially chronic 
course, the destruction of tissue is by no means so rapid, and 
furthermore, that its progress can be so promptly arrested. Why 
this should be, it is difficult to state, unless it is that the reparative 
force in a mucous membrane is more active than in the skin, as 
shown by the fact, that, whereas any extensive destruction of the 
1 Centralblatt fiir Chir., Nov. ioth, 1881, p. 721. 
3 “ Surgical Pathology,” Am. Edition, New York, 1883, p. 490. 
2 Loc. cit. 380 
DISEASES OF THE NASAL PASSAGES. 
skin is followed by a slow process of healing, and furthermore a 
cicatrix is likely to be very intractable, as in the case of a burn, in 
a mucous membrane, on the other hand, a cicatrix is a very great 
rarity, if it ever occurs, and even extensive destruction of tissue is 
followed by complete restoration of the part to its normal condi- 
tion. Whatever the cause may be, the fact certainly exists, that 
unless the disease has invaded too large an amount of tissue a cure 
may be expected. In the cases above referred to, one of Shurley’s 
is reported unimproved, while in Van Santvoord’s case, that of a 
boy aged fourteen, death occurred, owing to the fact that the dis- 
ease had invaded the nose, upper lip, hard and soft palate, pharynx 
and larynx. Aside from these two cases, I find no record of other 
than a cure. The duration of the disease would seem to have some 
influence, as Shurley’s unimproved case lasted four years, although 
in Rafin’s case a cure was effected at the end of eight years. The 
age of the patient does not seem to influence the prognosis. 
Treatment.—It should be borne in mind that the disease ex- 
tends both by the piling-up, as it were, of an original lupus-nodule, 
and also by the development of new centres in the surrounding 
tissues, this process, however, being characterized by an extremely 
slow stage of progress. The probabilities, however, are that the 
virus which produces the original disease reproduces itself, and 
that its progress is due exclusively to a re-inoculation. Hence it 
becomes important, in dealing with the disease, that every possible 
seat of infection should be thoroughly eradicated. In Rigal’s case, 
this was accomplished by the excision of the ala and septum of the 
nose, the disease being both external and internal. Excision, 
however, is not usually demanded, as all that is necessary can be 
accomplished by either scraping or scarification, as recommended 
by Volkmann, or the use of some caustic agent. For this latter 
purpose, Bresgen made use of chromic acid, but found it not so 
efficient as the potential cautery, while Rafin used an eighty-per-cent 
solution of lactic acid. Each individual case, however, will afford 
ample opportunities of testing the efficacy of any caustic used, and 
since there seems to be no danger of stimulating a renewed activity 
in the growth by these agents, they may be pushed to the full ex- 
tent. Certainly, in most cases, Volkmann’s spoon will be the first 
resort, as the tissue is of a soft and grumous character, and there is 
no danger of encroaching upon healthy parts. As before stated, 
the disease is accompanied by a notable impairment of the general 
health, and hence it scarce needs be added, that the indications for 
general tonic remedies are always present. Hunt,1 seems to regard 
arsenic as a specific, although this observation lacks clinical support. 
1 British Med. Journ., 1862, vol. i., p. 8. CHAPTER XXVII. 
RHINO-SCLEROMA. 
It seems to be a somewhat prevalent popular idea, that there 
is some intimate connection or sympathy between mucous mem- 
branes and the cutaneous structures. Clinical observation, how- 
ever, fails to confirm this idea, as it is the almost invariable rule, 
that a diseased process in the mucous membrane shows no ten- 
dency to pass over the muco-cutaneous junction, and involve the 
integument in a like morbid activity. An exception to this rule, 
however, is found in that very curious disease, first described by 
Hebra,1 to which he gave the name rhino-scleroma, and which 
consists essentially in the development, in the deeper layer of the 
mucous membrane or integument, of hard, dense plates, as it were, 
with somewhat rounded edge’s, which make their appearance either 
in the mucous membrane within the nostril, or in the integument 
of the alae or upper lip, the starting point usually, being not far 
from the margin of the nostril. After inception the disease 
extends by a slow but irresistible progress, either by the enlarge- 
ment of the original plates, or by new centres of development. 
Hebra’s original description of the disease was based on the ob- 
servation of nine cases. Subsequent to this, contributions to our 
clinical knowledge of the disease were made by Tanturri,2 Geber,3 
Ricchi,4 Mickulicz,5 Billroth,6 Cornil,7 Frisch,8 Semon,9 Cornil and 
Alvarez,10 Davis,11 M. Stukowenco,12 Schulthess,13 Doutrelepont, 
1 Wien. Med. Wochenschr., 1870, No. 1, p. 1. 
2 II Morgagni, 1872, Anno xiv., Dispensa I. 
3 Arch, fiir Derm. u. Syph., 1872. 
4 II Raccoglitore Med., xxxvi. (1873), 22, S. 104. 
s Arch. f. Klin. Chirurgie, 1877, p. 531. 
6 Quoted by Kaposi, “ Path. u. Therapie der Hautkrankheiten,” Zweite Auflage, Wien 
u. Leipzig, 1883, Zweite Halfte, pp. 632-637. 
7 Progres Medicale, July 28th, 1883, p. 587. 
8 Wien. Med. Wochenschr., 1885, p.965. 
9 Brit. Med. Journ., March 7th, 1885, p. 485. 
10 Annal. de Derm, et Syph., 1885, p. 202. 
11 Brit. Med. Journ., May 29th, 1886. 
12 Med. Obosr., No. 20, 1887. 
13 Arch, fiir Klin. Med.. Bd. 41, Heft 1 and 2, 1887. 
14 Deut. Med. Woch., 1887, No. 5, p. 85. 382 
DISEASES OF THE NASAL PASSAGES. 
and Dietrich,1 based on the observation of one or more cases, which 
would seem to indicate that the disease is not of so rare occurrence 
as was at first supposed, in that many cases have been unrecognized, 
from mere lack of knowledge of the existence of such an affection. 
Thus Weinlechner, as cited by Mickulicz, failed to recognize sev- 
eral cases which came under his own observation, until his attention 
was especially called to the disease, regarding them as obstinate 
cases of syphilis. 
Etiology.—Our clinical knowledge of the disease fails to throw 
any light whatever on the cause of the affection, in that it ap- 
parently develops upon patients in perfect health, and usually at a 
time of life, moreover, when the vital powers are at their best, as 
most of the cases occurred before the age of forty. In Semon’s 
case it occurred in a boy aged fourteen. Mackenzie2 suggests that 
the climate or conditions of life in Southeastern Europe may have 
some influence as a predisposing cause of the affection, which would 
seem to carry the suggestion that it bears a certain analogy to goitre 
in Switzerland, and leprosy in the Orient, and yet I think the fact 
of so many cases being reported as occurring in the neighborhood 
of Vienna, is to be explained on the ground of the great activity of 
the study of skin diseases so characteristic of that city, and the inter- 
est excited by Hebra’s original paper, inasmuch as later reports indi- 
cate that it is met with in most distant parts of the globe; Alvarez’s 
cases having occurred in San Salvador, while Semon’s case was that 
of a Guatemalan, and Davis’s case occurred in Egypt. The possi- 
bility of the syphilitic origin of the disease is very thoroughly ex- 
cluded by the large number of reported cases, in which antisyphilitic 
treatment proved absolutely of no avail. 
Symptomatology.—Subjectively, the disease gives rise to no 
notable symptoms, in that its slow progress is attended with no 
local disturbances. There is usually some tenderness on pressure, 
but aside from this, no pain attends its development. If, however, 
the growth encroaches upon the respiratory tract so far as to inter 
fere with respiration, of course considerable discomfort arises from 
this cause. Or again, when it extends backward toward the fauces, 
or possibly into the larynx, laryngeal stenosis becomes an exceed- 
ingly grave condition, as occurred in Schulthess’s case. Again, if 
the disease encroaches upon the oral cavity, it may be a source of 
infinite distress, as in one of Mickulicz’s cases, the oral orifice was 
so nearly obliterated, that an external operation became necessary, 
while in another of Mickulicz’s cases, the soft palate became ad- 
herent to the wall of the pharynx, necessitating an operation in 
1 Zeit. fiir Heilkunde, 1887. vol. iii., p. 252. 
2 “ Dis. of the Throat and Nose," Amer. ed., 1884, vol. ii., p 407. RHINO-SCLEROMA. 
383 
this region to relieve the difficulty. Aside from these extreme 
conditions, the prominent symptoms to which the disease gives 
rise, consist mainly in a certain amount of deformity, together with 
a feeling of stiffness and general discomfort about the integument. 
The progress of the disease is characterized essentially by infiltra- 
tion of tissue, and no other morbid process is superadded. There 
is no tendency whatever to a breaking down, or to the formation 
of an ulcerative process. 
Pathology.—According to the original observation of Hebra, 
the essential pathological lesion which constitutes the disease, con- 
sists of an infiltration of the chorium or papillae of the skin, or when 
it occurs in mucous membranes, an infiltration of the deep layer of 
the mucous membrane with small round cells. As the result of 
this infiltration, the normal structures of the tissue are so far en- 
croached upon as to give rise to an atrophic process, simply as the 
result of pressure involving the gland-structures, the connective 
tissue, and in fact, all the normal elements of the membrane and 
integument. This would seem to indicate that the morbid process 
is inflammatory in character, a view entertained by Mickulicz,1 al- 
though, from a clinical standpoint, there are no evidences whatever 
of an inflammatory process. Still further changes are observed by 
Mickulicz, which consist in a transformation of the round cells into 
spindle cells, and finally into a dense fibrous connective tissue. 
Tanturri1 makes the statement that the disease is essentially epi- 
thelial in character, and yet this view is probably based on an ex- 
amination of a very superficial portion of the tissue removed, as he 
is entirely unsupported. Cornil1 finds a small, rod-like bacillus in- 
closed in a hyaline capsule, closely resembling Friedlander’s pneumo- 
coccus, from which he draws the conclusion, that the disease is 
parasitic in its nature, although Dietrich, accepting the view that 
the disease may perhaps be due to a microbe, whether Cornil’s or 
some other, yet asserts that it results more probably from a mixed 
infection than from a specific germ, and that the existence of the 
microbe is entirely adventitious, and not essential to the disease. 
Frisch' finds a small rod-shaped bacillus in the round cells, espe- 
cially in those which have undergone retrograde metamorphosis. 
He believes that the connective tissue is the result of inflammation 
set up by the bacteria. 
It is interesting to note, that the disease has been reproduced 
in animals, from cultures of the bacilli, by Stepanow.2 The special 
changes which take place in the tissues are shown in Fig. 103. 
Diagnosis.—The disease makes its appearance in small, rounded, 
flattened nodules, which may project beyond the skin, giving rise 
1 Loc. cit 
2 Moaatsschrift ftir Ohrenheilk., 1889, vol. xxiii., p. 5. 384 
DISEASES OF THE NASAL TASS AGES. 
to slight tumefaction, or it may be entirely beneath the skin or 
mucous membrane, without marring its normal contour. The 
tissue covering it may be of a healthy color, although ordinarily it 
is of a dusky-red tinge. These nodules may occur in considerable 
numbers, entirely separated from one another, or they may be con- 
tiguous. They develop by an exceedingly slow progress of growth, 
both in size and superficial area, extending to neighboring tissues. 
The extension of the growth is usually laterally, although it may 
pile itself up, as it were, into irregular masses. It is hard to the 
touch, usually tender, but does 
not give rise to any pain. The 
tissue surrounding the growth 
presents an absolutely normal ap- 
pearance, there being no areola 
of redness, or indeed any vascu- 
lar engorgement, unless, as occa- 
sionally occurs, the tissue over 
the surface of the tumor is slight- 
ly reddened. There is never any 
oedema, or swelling of the tissues 
beyond the growth. The growth 
itself presents to the touch a 
hard, dense, cartilaginous feeling, 
or even, in advanced cases, it 
gives the impression of bone. 
The only affections with which 
it might be confounded are sar- 
coma, carcinoma, and syphilis. 
The characteristic appearance of 
malignant disease is a soft gru- 
mous mass, bleeding readily on 
touch, in connection with an 
acrid discharge, which in all cases 
makes the diagnosis clear. The only manifestation of syphilis with 
which it might be confounded in the nasal cavity, is a gummy 
tumor, whose smooth outline differs essentially from the nodular- 
character of rhinoscleroma, while the latter presents a character- 
istic stony feeling, never met with in the syphilitic manifestation. 
Any doubt in the diagnosis, is, of course, quickly dispelled by the 
administration of anti-syphilitic treatment. 
PROGNOSIS.—The disease is essentially intractable, and is usu- 
ally regarded as absolutely incurable. With the exception of 
Doutrelepont’s1 case alone, no remedies or therapeutic measures 
Fig. 103.— Rhinoscleroma. E, Thickened epi- 
dermis; L, broadened stratum lucidum; E, rete mu- 
cosum; I\ papillary layer; C, tracts of dense fibrous 
connective tissue; I. /, smallcellular infiltration of 
derma. 
1 Loc. cit. RHINO-SCLEROMA. 
385 
have ever been resorted to, which seemed to have the slightest 
effect in controlling its progress. This case, however, possesses 
the special interest of having been cured, and is therefore reported 
somewhat in full as follows: 
A male, aged 34, previously he&lthy and with no syphilitic history, presented 
with the history of having noticed a small, round, knotty swelling on the right 
upper lip, near the nasal orifice, which commenced seven months previously, 
and had slowly extended, until it involved the whole of the upper lip, and had 
invaded the nasal cavity, attacking the lower portion of the septum and the 
right ala. When seen, the upper lip was swollen to the thickness, of the 
thumb, while the whole circumference of the nostril was thickened, the infiltra- 
tion presenting a hard, bony sensation to the touch, while the surface showed 
a glistening appearance, of a reddish-brown color. A small portion was re- 
moved for microscopic examination, and found to present the characteristic 
round-cell infiltration of rhino-scleroma, together with Cornil’s bacillus. 
Local applications were made, of a one-per-cent corrosive sublimate ointment 
in lanolin twice daily, resulting in the complete disappearance of the disease 
in three months and a half, with the exception of a small nodule on the 
septum. 
If this case be accepted without question, it does not harmonize, 
in its clinical history, with the other cases reported, in that so rapid 
a development, and so large an invasion of tissue at the end of 
seven months is quite unusual. The question arises, then, whether 
this may not have been a syphilitic lesion, cured by mercurial inunc- 
tion. Certainly, if this case is unquestioned, it affords the only 
justification for looking upon these cases as other than utterly 
hopeless as regards any expectation of either arresting or even cur- 
tailing the progress of the disease. 
As regards life, however, the prognosis is favorable, as the dis- 
ease is purely a local one, for its onset does not necessarily impair 
the general health, and involves no tendency to death, except where 
it interferes with important functions by its mere location, as for 
instance when it extends to the larynx, giving rise to stenosis and 
threatened suffocation. With this exception, the disease apparently 
does not shorten life, and simply continues a source of discomfort 
to the victim until death occurs, usually from intercurrent disease. 
Thus in Schulthess’s 1 case the disease had extended so far at the 
end of twenty-four years, as to involve the integument of the ex- 
ternal nose, upper lip, the upper and lower pharynx and the larynx, 
giving rise to stenosis of the larynx, demanding tracheotomy, the 
patient being still living at the time of the report. This would 
appear to be the limit to which the disease ever extends. As hav- 
ing its origin in or near the nostril, it extends to the external nose, 
upper lip, and in rare cases encircles the mouth. After entering 
1 Loc. cit. 386 
DISEASES OF THE NASAL PASSAGES. 
the nasal cavity, it travels slowly backward, involving the pharynx, 
soft palate and larynx, after which its lateral extension seems to 
cease, while its remaining energy is expended in adding to the 
already existing tumefaction. 
Ganghofner,1 however, believes that the disease may sometimes 
originate and develop in the larynx and trachea, giving rise to 
stenosis, without the nose and mouth being affected. 
Treatment.—Experience has fully demonstrated, that the ex- 
tirpation of these growths exercises no influence whatever in arrest- 
ing their extension. Furthermore, their destruction by caustic 
agents is equally futile, although neither of these measures seems 
to have any deleterious effect in stimulating the activity of their de- 
velopment. The only indication, then, for surgical resort, is where 
it is demanded as a remedial agent, as for instance, when the nasal 
passages become occluded, it becomes necessary to remove the 
growths in order to re-establish nasal respiration. Internal medica- 
tion is of no avail. The one suggestion that can be made, then, in re- 
gard to radical treatment, is found in the successful result in Dou- 
trelepont’s case, by the application of corrosive sublimate, although 
the suggestion of Voltolini2 as to the use of electrolysis may be of 
value. 
1 Zeit. fur Heilk., 1880, i., p. 350. 
1 “Die Krankheiten der Nase,” Breslau, 1888, p. 258. CHAPTER XXVIII. 
NASAL POLYPUS, OR MYXOMA. 
This term nasal polypus is usually given to a variety of growths 
which are met with in the nasal cavity far more frequently than 
any other form of neoplasm. They are so designated, on account 
of their fancied resemblance to the aquatic polyp, a low order of 
zoophite. They occur either singly or in groups, and present a 
grayish, semi-opaque appearance, with a moist glistening surface, 
not unlike the pulp of a grape. They have been recognized and 
well described by all medical writers from the earliest times. These 
growths occur more frequently, I think, than is generally recognized, 
although I can scarcely agree with Zuckerkandl1 who makes the 
somewhat startling statement, that he finds either polypi or poly- 
poid hypertrophies (polypose Wucherungen) in one of every eight 
or nine autopsies. Under this latter term, he undoubtedly em- 
braces many cases which would scarcely be recognized during life 
as true polypus, but should be regarded probably as cases of hyper- 
trophic rhinitis. My own experience, however, shows that of one 
thousand four hundred and eighteen cases of ordinary catarrhal 
disease seen in private practice, exclusive of my hospital cases, one 
hundred and thirty-four showed the presence of fully developed 
polypi, or about one case of polypus for every eleven cases of ordi- 
nary catarrhal trouble. 
Zuckerkandl, in his classification of these growths, describes five 
forms. His first form he calls hypertrophy of the mucous mem- 
brane, a condition which he asserts occurs only in the respiratory 
region and which he describes as follows:2 
Group ist. “The mucous membrane is thickened, swollen, and 
largely interspersed with dilated glandular pro- 
liferations,” differing, as we see, essentially from 
an ordinary hypertrophic rhinitis. 
Group 2d. True polypi, (a) with small, (b) with broad pedicles. 
Group 3d. Small and warty, or mound-like tumors on the ex- 
ternal wall of the nose, and on the lips of the hia 
tus semilunaris. 
1 “ Normaleund Pathologische Anatomie der Naserhohle,” Wien, 1882, p. 76. 
2 Loc. cit., p. 76.  388 
DISEASES OF THE NASAL TASS AGES. 
Group 4th. Polypoid proliferations, (a) on the turbinated bones, 
(b) on the septum. 
Group 5th. Papillomata. 
From a careful reading of Zuckerkandl’s text, I think the infer- 
ence can be drawn, that in his fourth group of polypoid prolifera- 
tions, he describes what has been already alluded to in the chapter 
on hypertrophic rhinitis as hypertrophy of the mucous membrane 
covering the posterior termination of the lower turbinated bone. 
Furthermore, I think papillomatous growths are hardly to be classi- 
fied as polypi. Hence, we easily understand how Zuckerkandl 
should have made his curious statement, as to the frequency of 
polypoid disease. The term polypus, I think, should properly only 
be used to describe the typical myxomatous growths. They occur 
as pedunculated or sessile growths, and vary in size from that of 
bird-shot to the limit of the nasal cavity. 
Pathology.—The prevailing type of these tumors is that of 
pure myxoma, with certain more or less well-marked variations, at- 
tendant, probably, either on their immediate origin, or perhaps on 
certain adventitious features of their subsequent development, sur- 
roundings, or life. According to pathologists, the external surface 
of the tumor is covered by the epithelial layer of the mucous mem- 
brane lining the nasal passages, the epithelium frequently being 
ciliated. Within this envelope, we have true hypertrophy of the 
structures of the mucous membrane, namely the glandular and con- 
nective-tissue elements, with no increase in the vascular elements. 
The tumor may be very rich in glands, or may be absolutely with- 
out glandular structure, and consists simply of a delicate reticulum 
of connective tissue, in which we find imbedded the characteristic 
stellate myxomatous cells, the embryonic connective-tissue cell, the 
bulk of the tumor being made up of a gelatinous intercellular sub- 
stance containing very largely of mucin (see Fig. 104). 
Billroth1 classes nasal polypi among the adenomata, while 
Erichsen2 considers these tumors as myxomata. Butlin3 takes the 
same view, and further4 states that adenoma of the nose is almost 
invariably polypoid, and that it differs only slightly in appearance 
from those polypi which contain no glands, although it is firmer in 
consistency than the ordinary mucous polyp, and is covered with 
normal mucous membrane. 
I think we find here the same confusion which has already been 
noted in regard to Zuckerkandl’s classification of these growths, as 
1 “ General Surgical Pathology and Therapeutics,” Amer. ed. N. Y., 1883, p 748. 
2 “Science and Art of Surgery,” Amer. ed., Phila., 1881, vol. ii., p. 738. 
3 “ International Encyclop. of Surgery,” vol. i., p. 856. 
4 Ibid., p. 904. NASAL POLYPUS, OR MYXOMA. 
389 
to what really constitutes a nasal polypus, both from a pathologi- 
cal and clinical point of view. The inference is clear, that these 
observers are describing growths which, from a purely clinical 
point of view, are not to be regarded as typical nasal polypi. Thus 
Zuckerkandl1 describing his fourth group, gives an accurate de- 
scription of hypertrophy of the extremity of the lower turbinated 
body. 
While cystoma, as will be seen when we come to the discus- 
sion of that form of tumor, is met with very rarely in the nasal 
cavity, cystic metamorphosis is probably a not infrequent occur- 
rence in nasal polypi. This would seem therefore, to go far toward 
Fig. 104.—Myxoma, or Nasal Polypus. M, M, Myxomatous tissue; C, wide capillary bltfod-vessel; V, 
vein in transverse section. 
demonstrating that glandular structure is present in the myxomata; 
according to Robin,2 cystic degeneration is due to a general hyper- 
tophy of the acinus, together with an atrophy of its duct, as the 
result of which there is an increased secretion, which failing of free 
exit, collects in the gland, whose walls gradually yield to the pres- 
sure and become dilated. That this process is not constant, how- 
ever, has been shown by Billroth,3 who states that cystic degenera- 
tion does not necessarily depend always upon obstruction of the 
gland duct, but may result from certain changes in the epithelial 
cells lining the glands, their ducts remaining patent. From a clini- 
1 Loc. cit., p. 76. 
2 Gazette des Hopitaux, 1852, p. 46. 
3 “ Ueber den Bau der Schleimpolypen,” Berlin, 1855. 390 
DISEASES OF THE NASAL PASSAGES. 
cal point of view this form of degeneration is illustrated in a case 
reported by Moure,1 who cites a case of “cystic polyp” partially 
occluding the posterior nares of the left side, in a patient suffering 
from mucous polypi in the right nostril. After several unsuccess- 
ful attempts to remove the tumor with the snare, the pedicle, which 
was located in the posterior part of the middle meatus, was de- 
tached by means of a polypus forceps and the growth expelled 
through the mouth in the form of a pouch, the liquid having 
already been discharged. The cyst when distended was about the 
size of a small egg. The author looks upon this growth as a mu- 
cous polyp, a portion of which had undergone cystic degeneration, 
a condition which he does not consider uncommon, especially where 
Fig. 105.—Cystic Degeneration of Ordinary Nasal Polypus, or Myxoma. E, Columnar ciliated epithe- 
lium; M, myxomatous tissue; A, acinous gland; C, C, glands, transformed into cysts. 
polypi pass through the posterior nares into the pharynx. This 
degeneration is well shown in Fig. 105. 
Attachment.—All authorities unite in the statement that these 
growths spring, as a rule, from the mucous membrane covering the 
middle turbinated bone. It remained for Zuckerkandl,2 however, 
to make such a thoroughly exhaustive study of this feature of the 
disease, that little can be said, other than to quote the following 
statistics as regards the location of the growths, in thirty-three cases 
which he examined post mortem. 
(a) The lips of the hiatus semilunaris, . . 15 
(b) In the infundibulum, ..... 1 
(c) In the ostium ethmoidale, 1 
(d) In the ostium frontale, or maxillare, . . 1 
1 Journal de Med. de Bordeaux ; 1886-7, vol. xvi., P- 64. 
2 Op. cit., p. 78, et seq. NASAL POLYPUS, OR MYXOMA. 
391 
(e) On the edge of the middle turbinated bone, 
(the median and lateral edge of its lower 
border), ....... 4 
(f) On the lips of the accessory fold which some- 
times lies on the medial side of the middle 
turbinated bone, ...... 3 
(g) In the bulla ethmoidalis, .... 2 
(h) In the ethmoidal cells, ..... 3 
(i) On the septum, especially in the respiratory 
portion of the nasal cavity, .... 3 
We thus find thirty of his cases had their origin upon or in the 
immediate neighborhood of the middle turbinated bone, the other 
three cases springing from the septum. All of these last, it should 
be stated, were of a sessile character, while Heymann,1 out of two 
hundred and ninety-seven cases, found seven springing from this 
site, without specifying the character of the growths. These latter 
statistics were based on an observation of thirty-nine cases. Seven 
of them, however, were cases of irregular hypertrophy, and should 
not, I think, be included in this category. Zuckerkandl’s investiga- 
tions were made on the cadaver, and hence the exact site of the 
growths could be determined with a degree of accuracy which it is 
impossible to attain by an inspection during life, which would ac- 
count for the probable inaccuracies of the statement of Petrequin 2 
and of Voltolini,3 that these growths sometimes spring from the 
roof of the nasal cavity, or that of Wagner,4 that they may spring 
from the lower turbinated bones. Schech3 is alone I think in the 
statement, that these growths may spring from the floor of the 
nasal cavity. 
Etiology.—It is difficult to assign any definite cause for the 
occurrence of mucous polypi. They are certainly not due to any 
impairment of general health or constitutional diathesis, for, as a 
rule, they occur in patients in vigorous health. Sajous6 says that 
“ they are usually considered to be due to chronic inflammation of 
the Schneiderian membrane,” a view which Mackenzie7 very prop- 
erly controverts, on the ground that while catarrh is very common 
among children, polypus is very rare before the age of sixteen. 
Moldenhauer8 also takes this view, on the ground that catarrhal 
1 Berlin. Klinische Wochenschrift, Nos. 32 and 36, 1886. 
2 “ Traite d’anatomie topographique,” Paris, 1857. 
3 “ Die Anwendung der Galvanokaustik,” Vienna, 1871. 
4 “ Diseases of the Nose,” N. Y., 1884, p. 117. 
5 “ Diseases of the Mouth, Throat and Nose,” Eng. ed., Edinburgh, 1886, p. 262. 
6 “ Diseases of the Nose and Throat,” Phila., 1886, p. 137. 
7 “ Diseases of the Throat and Nose,” Amer. ed., 1884, vol. ii., p. 352. 
8 “ Die Krankheiten der Nasenhohlen,” Leipzig, 1886, p. 138. 392 
DISEASES OF THE NASAL P ASS AGES. 
inflammation most frequently involves the mucous membrane cov- 
ering the lower turbinated bones, which is never the site of a mu- 
cous polypus. 
I am disposed to think that the most rational explanation of 
the development of these growths, is in the fact that the mucous 
membrane covering the middle turbinated bone is of very soft, 
delicate consistency, and is actively concerned in the respiratory 
function of the nose, viz., serous exosmosis, and that as a result of 
this serous transudation, the membrane becomes saturated or water- 
soaked as it were, in such a manner as to lead to the development 
of this peculiar myxomatous condition. As to what peculiar 
nutritive disturbance in the meshes of this tissue predisposes to 
this form of degeneration, I have no suggestion to make. The 
view is based entirely on the fact of the frequent development of 
nasal polypi in those curious cases of profuse watery discharge from 
the nasal mucous membrane, already described in the chapter On 
Nasal Hydrorrhoea (pp. 261-263), which occurs, not as the result of 
the impact of vegetable spores upon the nasal mucous membrane, 
as in hay-fever, but is perennial and diurnal, that is, it occurs usually 
at certain hours every day, through the whole year. In the early 
stages of the attacks, no morbid condition of the mucous membrane 
can be discovered, as a rule, but in a number of instances which have 
come under my observation, after the disease has persisted for a 
certain length of time, typical mucous polypi have developed on 
the membrane covering the lower border of the middle turbinated 
bone, which after development, subject as they are to the action of 
gravitation, together with the traction influence, of blowing the 
nose, and the to-and-fro movement of the current of air in respira- 
tion, gradually sag down as it were, and becoming filled with serum, 
drag on their original attachment to the membrane above, until 
a pedunculated tumor is developed (see Fig. 106). A somewhat 
similar view is suggested by Hopmann,1 who thinks the primary 
lesion which leads to the development of the growths, is in some 
impairment of circulation in the efferent vessels, resulting in an 
cedematous condition of the membrane. Billroth,2 whose views as 
to the glandular character of these growths is adopted by Zucker- 
kandl, considers that the tumor originates as an adenoma, but during 
development some of the ducts become occluded, resulting in a 
myxomatous degeneration of the glandular tissue. A case has 
been reported by Gerdy3 in which the development of these growths 
was dependent on a fracture of the vomer, an observation which 
would seem to harmonize with what is frequently observed in con- 
1 As cited by Moldenhauer, op. cit., p. 138. 
3 “ Des polypes et de leur traitement,” Paris, 1883. 
2 Loc. cit. NASAL POLYPUS, OR MYXOMA. 
393 
nection with syphilitic necrosis either of the vomer or of the tur- 
binated bones, where we not infrequently find mucous polyps de- 
veloping on the edges of the ulcerated surfaces. 
They are more common in males than in females. Mackenzie, 
in two hundred cases, finds one hundred and twenty-three in men 
and seventy-seven in women. Erichsen2 is alone, I think, in his 
statement that they are more frequently found in females. Of one 
hundred and twenty-four cases recorded by myself, seventy-eight 
were males and forty-six were females. As to age, they occur 
Fig. 106.—Nasal Polypi. (Zuckerkandl). b, Infundibulum; c, cyst of the mucous membrane. 
most frequently between twenty and thirty. They rarely occur 
before the age of fifteen, after which they develop with decreas- 
ing frequency after thirty, up to seventy, or even later. Lennox 
Browne 3 is undoubtedly fully justified in making the broad state- 
ment that “ polypi may occur at almost any age.” He states that 
he has operated on patients as young as seven and as old as eighty. 
Beverley Robinson4 cites a case of nasal polypi occurring in a boy 
three years of age, the growth being successfully removed with the 
forceps, while a very curious instance of the disease has been re- 
1 Op. cit., p. 353. - K Op. cit., p. 386, 
3 “ The Throat and its Diseases,” 2d ed., London, 1887, p. 520. 
4 “Nasal Catarrh,” 2ded., N. Y., 1885, p. 251. 394 
DISEASES OF THE NASAL PASSAGES. 
ported by Krakauer,1 in which he removed twelve polypi from the 
right nasal fossa in a child of four and a half months. 
Heredity would ordinarily seem to have little influence on the 
development of these tumors, and yet Heymann2 has observed the 
following curious case: The patient suffering from this trouble was 
the father of four children, each of whom had polypi, one married 
son had six children, and three of these suffered from the same 
neoplasm. Somewhat similarly, I had recently under treatment 
two brothers with nasal polypi, whose sister had a myxo-fibroma, 
while from the son of one I removed a fibroma. These cases, 
however, I should be disposed to regard as mere coincidences, 
rather than as showing evidence of heredity, as the causation for 
these growths. 
A deformed septum is not infrequently associated with the exist- 
ence of nasal polypi, and probably exercises an important causative 
influence in their development, in the same manner, probably, as in 
the development of hypertrophic rhinitis. In these cases the 
tumors are usually found in the more roomy cavity, though in rarer 
cases they occur on the obstructed side. 
Symptomatology.—The first and earliest symptom that occurs 
in connection with these growths, is intense irritation in the upper 
passages of the cavity, manifesting itself in more or less violent 
attacks of sneezing, accompanied with watery discharge, although 
Lennox Browne 3 makes the broad and somewhat curious statement 
that “ sneezing is seldom exhibited, immunity from this disagree- 
able symptom being doubtless due to a blunting of the sensibility 
of the nerve-endings.” Notwithstanding this assertion, I do not 
hesitate to say that no symptom is more constantly and invariably 
present in these cases, and it is due to the intense sensitiveness of 
the mucous membrane, especially over the middle turbinated bodies, 
which is caused by the presence of the growths. The watery dis- 
charges, which accompany the attacks of sneezing, have their source 
in the mucous membrane proper, and not in the polypus as is often 
asserted. This symptom is due probably to a paresis of the vaso- 
motor control of the respiratory exosmosis, under the action of 
which there occurs an excessive serous transudation. This fluid, 
making its way through the membrane, produces an abnormal irri- 
tation of the parts, causing burning or itching sensations, referable 
to the bridge of the nose. As the growth develops in size, nasal 
stenosis sets in, which is at first most marked in the upper portion 
of the cavity, a form of stenosis which is oftentimes more distress- 
ing in the nervous irritability which it causes, than if the obstruc- 
1 Revue Medicale, August 22d, 1885. 
3 “ The Throat and its Diseases,” 2d ed., London, 1887, p. 521. 
3 Loc. cit. NASAL POLYPUS, OR MYXOMA. 
395 
tion were in the lower pasages, on account of the sense of fulness, 
with the distention, which it causes in the more sensitive olfactory 
region. The stenosis in this region is due more to the swelling of 
the membrane excited by the presence of the polypi, rather than 
by the polypi themselves. As they increase in size, however, ob- 
structions occur in the lower passages, which eventually become 
totally closed as the result of their presence. They commence, as 
a rule, in one fossa, but I think it is the rare exception that they 
do not develop sooner or later on the other side. The cause of 
this is not obscure. The obstruction on the one side resulting 
from the growths, compels the opposite passage to do double duty, 
with the result of diminished air-pressure, which acting on the soft 
tissues covering the middle turbinated bone, already under the in- 
fluence of whatever constitutional predisposition may have led to 
the primary development of the neoplasms, necessarily results in 
the same morbid process here. Mackenzie1 finds the growths bi- 
lateral fifty-nine times in two hundred patients, which would indi- 
cate merely that the disease was recognized and subjected to treat- 
ment before it had extended to the opposite side, in more than 
two-thirds of his cases. 
Loss of the sense of smell occurs early in the development of 
the disease, not entirely as the result of obstruction due to the 
presence of the growth, but rather to a certain disorganization which 
occurs in the mucous membrane lining the olfactory region. The 
stenosis, due to the presence of the growths, varies notably under 
varying atmospheric conditions, which has given rise to the asser- 
tion by probably a majority of writers, that these growths possess 
a certain hygroscopic character, under the action of which they 
absorb moisture and become swollen on damp days. I do not 
think a myxomatous growth posessses the power either of ab- 
sorbing moisture, or of giving it forth in any marked degree, but 
should attribute this symptom to the swelling of the mucous mem- 
brane lining the nose, owing to the excessive irritability caused 
by the presence of the growths. By this irritability, we mean es- 
sentially an intense hyperaemia due to a weakness of vaso-motor 
control. Wherever this exists, as in hay-fever and allied affections, 
the terminal filaments of the nerves are in a state of constant irri- 
tability, and thus become exquisitely sensitive as the direct result 
of this persistent hyperaemia. As a consequence,- these patients 
become exceedingly susceptible to changes in the weather, all the 
symptoms being notably aggravated during the cold and damp 
days of spring and fall, while the milder seasons afford notable 
relief. The discharge from the nose is usually rather profuse, and 
1 Op. cit., p. 354. 396 
DISEASES OF THE NASAL PASSAGES. 
while the disease is confined to the nasal cavity proper, is of a thin 
watery character; or when the nasal membrane is much irritated, 
it may be of a grayish semi-transparent color, and consist largely 
of a mucous or semi-mucous discharge. 
In cases of long standing we not infrequently find a profuse 
discharge setting in, which consists of bright-yellow, fluid pus. I 
doubt very much if a mucous polyp ever gives rise to a purulent 
discharge, whose source is in the nasal cavity proper, hence I think 
that a discharge of this kind should always be understood as in- 
dicating the supervention of purulent disease of the antrum, or of 
one of the accessory cavities. The method of development of 
this complication is quite simple. The orifices of these cavities 
having become occluded by the presence of the growths, the normal 
secretion accumulates to such an extent that a purulent inflamma- 
tion is the natural result, for as stated before, wherever we have 
inflammation of the mucous membrane lining a closed cavity, sup- 
puration necessarily ensues. Occasionally a mucous polyp may 
develop in the antrum, or possibly it may make its way into the 
antrum from the nose. In a case reported by Pedro Verdds1 a 
growth made its way into the antrum, completely filling it and 
protruding below the lower eyelid, causing an external deformity 
The growth was successfully removed, but the question arises 
whether this was not a case of myxo-fibroma, for as a rule, simple 
myxomatous growths in the antrum merely fill its cavity, without 
producing facial distortion. 
As already stated in the discussion on nasal reflexes, no morbid 
lesion of the nasal cavities is more frequently the source of reflex 
disturbances than nasal polypus; hence, asthma and hay fever are 
associated with these growths in a not inconsiderable proportion of 
cases, although Hack2 considers polypi as rather an infrequent 
intra-nasal condition, in cases of this disease. This question, how- 
ever, is more properly discussed elsewhere. For the same reason, 
ocular symptoms not infrequently occur in connection with the 
presence of these growths. The aural symptoms due to nasal 
polypi are to be regarded not as reflexes, but as direct symptoms 
due to stenosis with interference of normal respiration, their method 
of development being identical with that described in the chapter 
on hypertrophic rhinitis. These symptoms consist mainly in the 
development of chronic catarrhal otitis media, which, according 
to my experience, is almost invariably present in a more or less 
well-marked degree, where the growths have attained sufficient 
1 Revista di laringologia, otologia y rinologia, May, 1887. 
Wien. Med. Wochenschr., 1883, No. io, p. 279. NASAL POLYPUS, OR MYXOMA. 
397 
size to produce notable stenosis, although Woakes1 somewhat 
guardedly states that patients with nasal polypi rarely complain of 
deafness, due, as he says, to the fact that these growths rarely ex- 
tend to the lower meatus, which is really the auditory passage. 
This statement is undoubtedly correct, but the various other dis- 
comforts attendant upon nasal polypi are so great, that the patients 
do not, as a rule, complain of prominent ear-symptoms, and yet by 
careful test, as before stated, every case will show marked diminu- 
tion of the hearing distance. 
Suppurative otitis I have not seen, although this complication 
has been observed by Barth.2 Tinnitus aurium also is mentioned 
by Robinson3 as a complicating symptom. Laryngitis, and bronchi- 
tis, are very liable to occur sooner or later as the result of the nasal 
stenosis. The voice is affected according to the extent of the nasal 
obstruction, its resonance being destroyed. To one familiar with 
these cases, I think the voice presents characteristics which enable 
us to recognize a case of nasal polypus almost immediately on hear- 
ing the voice. It is a peculiar dead voice, and yet with something 
more of resonance than the dead voice of an adenoid—a dead 
voice, perhaps with a faint nasal tone in it. The facial expression 
is also characteristic, in that there is that peculiar thickness about 
the bridge of the nose which always suggests nasal stenosis, whether 
from a cold in the head or other causes. Deformity of the external 
nose is never present in a pure myxoma, the growths as they fill 
the cavity oozing out, as it were, from one or the other nostril, 
rather than pressing against the lateral walls. 
DIAGNOSIS.—The recognition of a nasal polypus depends en- 
tirely on ocular inspection, which should always be made with sun- 
light, or an equally powerful illuminator, for I am confident that 
these growths are often overlooked when the ordinary gas-jet is 
the source of light. With proper illumination, therefore, I do not 
hesitate to say that the growth may be recognized, provided there 
is no marked deformity of the nose, in its very earliest stages, and 
even before it protrudes from beneath the middle turbinated bone. 
Of course if the growths have extended down into the lower meatus, 
they can then be recpgnized by the unaided eye, but in very early 
stages, I think, their recognition becomes a matter of exceeding 
importance, in that the polyp-breeding tissue at this time is very 
limited in extent, while in the latter stages of the disease, the whole 
of the mucous membrane covering the middle turbinated bone may 
become degenerated. As an aid to diagnosis we should always 
1 “ Post-Nasal Catarrh,” Am. ed., Philadelphia, 1884, p. 190. 
2 Revue mensuelle de laryngologie, No. 4, p. 208. 
3 “ Treatise on Nasal Catarrh and Allied Diseases,” 2d ed, N. Y., 1885, p. 254. 398 
DISEASES OF THE JVASAL PASSAGES. 
make use of cocaine, to thoroughly contract the blood-vessels and 
open up the cavity for thorough inspection. When this is accom- 
plished, if a polypus is present it will be seen to present a striking 
contrast in color with the normal nasal mucous membrane of the 
passage, while it also presents a tumefaction not belonging to the 
normal contour of the cavity. The color, furthermore, of a polypus 
resembles no other growth or abnormality that is found in the 
nasal cavity. It is of a bluish-gray color, with a bright, shining, 
glistening surface, not unlike, as before suggested, the pulp of a 
grape, but with the addition of a bluish rather than a greenish tint. 
If the growth has developed so far as to protrude below the 
middle turbinated bone, we have an additional aid to diagnosis, in 
the fact that it becomes freely movable in the cavity; hence, in 
these cases a probe should always be used, to test this mobility, or 
it may be seized with a pair of small mouse-toothed forceps, such 
as are shown in Fig. 112, and the attempt made to pull it forward 
or downward. Furthermore, on the impact of a probe it is easily 
indented, showing a certain resiliency, by which the indentation 
disappears readily on the removal of the probe. A mistake in di- 
agnosis I think need never occur with a proper illuminating appara- 
tus. Its gross appearances are so strikingly in contrast with either 
sarcoma or carcinoma, in its smooth, glistening, semi-opaque surface, 
as to render it unnecessary to indicate the points of differential di- 
agnosis. It differs essentially from a fibroma, in that this form of 
neoplasm is hard, dense, and of a bright, pink color and is, as a rule, 
immovable. Moreover, hemorrhage is never a direct symptom of 
the nasal polyp, although very frequently met with in connection 
with the denser tumors. A deflection of the septum presenting 
near the nostril might be mistaken by the inexperienced for a nasal 
polyp. Its density and immobility is always sufficiently evident to 
render such a mistake unnecessary. The same may be said of 
ecchondromata and exostoses. Abscess of the septum may very 
closely simulate a mucous polyp, but this affection presents a soft, 
fluctuating tumor, whose character can easily be ascertained by 
careful manipulation of the probe, or better still by puncture with 
a bistoury. As a rarely possible source of'error Moure1 refers to 
a meningocele projecting into the upper part of the nasal cavity, 
although its reducibility and compressibility, together with the 
cerebral symptoms which accompany it, should enable one to avoid 
any-such error in diagnosis. A case of this kind was found by 
Cruveilhier,2 on post-mortem examination, protruding through the 
cribriform plate of the ethmoid bone, presenting a soft, fluctuating 
1 Op. cit., p. 475. 
2 As quoted by Mackenzie, op. cit., p. 360. NASAL POLYPUS, OR MYXOMA. 
399 
tumor in the nose, closely resembling in appearance and outline a 
mucous polyp. 
PROGNOSIS.—The existence of nasal polypi involves no serious 
danger to life other than in their involvement of the integrity of the 
mucous membrane of the whole air tract, giving rise to bronchitis, 
asthma, hay fever, etc., whereby the general health may become 
somewhat impaired. If not subjected to treatment they develop 
with increased rapidity, as the polyp-breeding surface increases in 
area, and the nasal cavities become completely stenosed. There is 
no tendency to a spontaneous cure, hence the prognosis is mainly 
dependent upon the success of treatment. A question of perhaps 
more interest is, whether a myxomatous tumor preserves its origi- 
nal type, or whether it may undergo changes of a malignant char- 
acter. This question is naturally much confused, in that it may 
be that those cases which have undergone malignant degenera- 
tion, have been largely the result of crude methods of extirpation, 
rather than of any inherent tendency of the myxomatous tumor to 
undergo this form of degeneration. Billroth1 states that the view 
that these growths may take on carcinomatous degeneration, has 
been accepted as an article of faith, rather than proven, since the 
only absolute proof that we could have of such a change, would be 
to find a case in which the same tumor, beginning as a mucous 
polyp, would subsequently develop into one of the malignant type, 
and such a case to his knowledge does not exist. In this same 
work, however, he cites a case which from its history seems to have 
been at first one of mucous polyp, which after operation apparently 
took on a carcinomatous degeneration. He also reports a second 
case which may possibly have been an early stage of a similar 
change. In a subsequent work,2 however, he goes so far as to state 
that the tissue found in nasal polypi is frequently adeno-sarcoma- 
tous, but is somewhat vague as to the clinical significance of this 
tissue. J. W. Hulke3 reports a case of nasal polyp, which after 
operation at varying intervals of time, developed into malignant 
disease, although the report of the case is unsatisfactory. Sajous4 
makes the general statement, without further comment, that nasal 
polyps occasionally degenerate into sarcoma. A search through 
the literature of the subject fails to reveal on what grounds this 
statement has been made, and yet a somewhat vague impression of 
this sort seems to prevail in the minds of most observers. Thus, 
Lennox Browne,5 after asserting that after operation these polyps 
1 “ Ueber den Bau der Schleimpolypen,” Berlin, 1855, p. 34. 
2 “ General Surgical Pathology and Therapeutics,” Amer. ed., N. Y., 1883, p. 748. 
3 Ophthalmic Hospital Reports, vol. iv. 
4 “ Diseases of the Nose and Throat,” Phila., 1886, p. 139- 5 Op. P’ 523- 400 
DISEASES OF THE NASAL PASSAGES. 
assume more of a fibrous character, states also that they frequently 
show under the microscope evidences of sarcomatous structure. 
Now Butlin 1 makes the statement that it is impossible to distin- 
guish microscopically between round-celled sarcoma and normal 
granulation tissue, which would seem to infuse an additional ele- 
ment of obscurity into the question. Beyer 2 who has made a 
somewhat laborious study of this question, reports one case under 
his own observation, of a man fifty years of age, operated upon by 
the galvano-cautery for “ nasal polypus,” who two months later 
had developed cancerous papilloma (Zottenkrebs). Schmiegelow3 
cites a case, reported by Schaffer, of a man forty-two years of age 
with nasal polypi and naso-pharyngeal fibro-sarcoma, in which the 
polypi in the course of a year took on sarcomatous degeneration. 
An interesting case bearing on this point came recently under my 
own observation. A German, aged forty-eight, who for a year had 
suffered from nasal polyps, which had been operated upon a num- 
ber of times with forceps, followed by their rapid recurrence, came 
under my care November nth, 1887. I removed a number of small 
polypi, and came down upon a soft, grumous-looking mass spring- 
ing from beneath the middle turbinated bone, which bled profusely 
on the slightest manipulation. A small portion was removed, and 
under the microscope the growth was shown to be angio-myxo- 
sarcoma. This patient was seen a number of times, at intervals of 
a fortnight, and the whole growth successfully extirpated by means 
of the cold wire snare. When last seen he had gone six months 
without a recurrence. The microscopic character of the neoplasm 
in this case (see Fig. 107) would seem to lend weight to the view 
that a myxoma may take on sarcomatous degeneration. I think 
Schaffer’s case may be excluded, as throwing no special light on 
the question under discussion. The other cases, however, it seems 
to me, afford undoubted evidence that these tumors may undergo 
not only sarcomatous but probably carcinomatous degeneration, 
probably, however, only as the result of operative interference, and 
yet when we remember the very large number of cases of mucous 
polypi which are subject to exceedingly crude and harsh methods of 
removal, I think the statement may safely be made, that this tend- 
ency toward malignant degeneration is a somewhat feeble one. As 
far as f know, there is no well-established case in literature, of nasal 
polypus having undergone malignant degeneration spontaneously. 
1 Loc. cit., p. 881. 
2 “ Ueber die Transformation von Schleimpolypen in bosartige (krebsige oder sar- 
komatose) Tumoren.” 
3 “ Tumeurs malignes, primitives du nez.” Revue mensuelle d'Otologie de Laryn- 
gologie et de Rhinologie, 1885. NASAL POLYPUS, OR MYXOMA. 
401 
Treatment.— The successful treatment of mucous polypi in 
the nose depends upon their complete ablation, either by destruc- 
tion or extirpation. The destruction of a polypus in situ has always 
been a subject of considerable interest, due undoubtedly, I think, 
to the very unsatisfactory results obtained from the use of surgical 
measures in vogue up to comparatively recent years. Local appli- 
cations have the indorsement of good authority, for we find Bryant1 
representing that insufflations of powdered tannin possess a certain 
amount of efficacy, while better success is obtained from the local 
application of nitrate of silver in the hands of Nelaton.2 Erich- 
sen 3 cites a case, in which a large mucous polyp was destroyed by 
the injection of a strong solution of chloride of zinc. Robinson4 
Fig. 107.—Myxoma, Changing to Myxo-Sarcoma. A/, Myxomatous tissue; .S, myxo-sarcomatous tissue 
V, vein in transverse section; C, capillary in transverse section. 
had good results from the use of tincture of chloride of iron. I 
seriously question, however, notwithstanding the weight of author- 
ity in their favor, whether any local applications to nasal polypi 
have any other than the most ephemeral action. 
For their destruction certain chemical agents are recommended 
to be introduced directly into the mass, by means of a hypodermic 
syringe, or by simple puncture. Thus, Frank Donaldson5 advises 
that chromic acid be carried directly into the body of the tumor 
by means of a pointed glass rod, while Bell6 accomplished the same 
purpose, by injecting into each growth, by means of a hypodermic 
1 “ Practice of Surgery,” p. 552. 
2 “ Pathologie Chirurgicale,” Paris, 1S74, 2ded., vol. iii., p. 748. 
3 “Science and Art of Surgery,” vol. ii., p. 386, Amer. ed., Phila. 1881. 
4 Op. cit., p. 259. 
s Archives of Laryngology, vol. iv., p. 175. 
6 Canada Medical Review, February, 1884. 402 
DISEASES OE THE NASAL PASSAGES. 
syringe, a solution of tannic acid, twenty grains to the ounce. In 
the same manner Maxwell1 has met with success by the injection 
of tincture of iron. The destruction of a polyp in situ, after these 
methods, may undoubtedly be successful, but it results in a necrotic 
mass of tissue, which remains in the cavity, a putrid, offensive body, 
until it sloughs away. We can easily understand how, in those 
cases in which twenty, thirty, or even more separate growths occur, 
this method might involve an unnecessarily long and distressing 
course of treatment. I think it offers no advantage whatever, 
sufficient to warrant our subjecting patients to it. We reach the 
conclusion, then, that the only successful method of dealing with 
these growths is in their extirpation by surgical means. The evul- 
sion of nasal polypi by means of forceps is certainly the oldest, and 
probably is the one which has come into widest use. Various 
forms of this instrument have been devised by different writers, all, 
however, agreeing in the same general characteristics. Thus, 
Erichsen 2 directs that, by means of the instrument itself, the loca- 
tion of the polyp is to be ascertained, when its pedicle is to be 
seized, and by a slightly rotary motion, twisted off. The same 
writer advises that the instrument should be long and of very slen- 
der construction. Perhaps the best instrument constructed on this 
principle is that of Simrock, in which the blade is toothed through- 
out the whole extent of its bite. Gross’s duck-bill forceps, which 
are evidently designed to seize the growth itself, are altogether 
objectionable, on account of the size of the blades. A modification 
of this instrument has been devised by Mackenzie, which consists 
in fitting the blades to the handle at such an angle as to remove 
the hand below the line of vision in operating. The blade, further- 
more, is fitted with a small ridge or punch, which, when approxi- 
mating its fellow, inserts itself into a fenestra, thus forming a 
cutting instrument. This instrument is adapted for much nicer 
work than the ordinary forceps operation. A still more delicate 
instrument is the tube-forceps of Seiler3 the shaft of which is made 
flexible, enabling the operator to carry it to any portion of the 
nasal cavity, the growth being seized by drawing the small blades 
within the tube. I think, however, in regard to the use of any 
forceps in the nasal cavity, that it is a procedure which should 
never under any circumstances be resorted to, unless absolute 
necessity exists, in the absence of any other of the many better 
devices. As regards special directions for searching for the 
polypus, and for seizing its pedicle, I am confident that no operator 
ever possessed either the skill to differentiate, by touch with the 
1 New York Med. Record, October ist, 1868. 
2 “ Science and Art of Surgery,’’ Amer. ed., Phila., i860. 3 Op. cit., p. 269. NASAL POLYPUS, OR MYXOMA. 
403 
forceps, a nasal polypus from the mucous membrane, or sufficient 
manual dexterity to enable him to seize the pedicle. The instru- 
ment, at its best, cannot be sufficiently delicate to allow large 
freedom of action in the nose. As a rule, it will be carried in with 
its blades open, and then be closed upon whatever may happen to 
fall within its grasp. Furthermore, its use is often attended with 
an unnecessary injury of healthy tissue. We are told on good 
authority that this is not only justifiable, but oftentimes de- 
manded, as for instance so careful a writer as Mackenzie, indorses 
the precaution frequently given by earlier writers, that a piece of 
the turbinated bone should be removed in operating on nasal 
polypi with the forceps, in order to prevent a recurrence of the 
growth. Now the origin of the tumor is not in the bone, but in 
the mucous membrane. Furthermore, when the whole of the 
growth is removed, in the large majority of cases the whole of the 
disease is extirpated. I know of no condition which either calls for 
or justifies the removal of a portion of the turbinated bone in a 
case of nasal polypi. Furthermore, operation by the forceps rarely 
results in a cure of the disease, but is rather followed by a recur- 
rence of the growth, not only with increased activity, but with a 
neoplasm, as a rule, of a different character, in that it is more dense 
in structure, and contains largely of connective tissue, a result un- 
doubtedly due to the harsh usage attendant upon the forceps 
operation. The essential feature of any operation for the extirpa- 
tion of nasal polypi is that they shall be removed without injury to 
the healthy tissues. Now, for the accomplishment of this purpose 
I know of no measure comparable to the cold wire snare. In this 
instrument the loop of wire is slipped over the polypus, carried as 
far toward its base as possible, and then drawn within the tube, 
and the growth severed. For devising and rendering popular the 
cold snare e'craseur, much credit is due to Dr. Jarvis,1 who first 
made us familiar with the advantages of steel wire. Now, there is 
nothing new in the use of the snare, but a snare mounted with a 
steel wire is a very different instrument from one carrying annealed 
wire. The steel wire gives us a loop of sufficient stiffness to enable 
us to carry it to any portion of the nasal cavity, and over any 
growth which it is desired to seize. Jarvis’s original snare ecraseur 
(see Fig. 76) being somewhat slow in its action, led me to advise 
the instrument shown in Fig. 108, the manipulation of which will 
be readily appreciated at a single glance. The loop being placed 
in position over a growth, is drawn home by a single motion, and 
the tumor severed from its attachments. 
The galvano-cautery, since its introduction by Middledorpf2 and 
1 Archives of Laryngology, vol. ii., p. 164. 
2 “ Die Galvanokaustic,” Breslau, 1*854. 404 
DISEASES OF THE NASAL TASS AGES. 
its extended use by Voltolini,1 has had many advocates for its use 
in the removal of these tumors. By this agent, a growth may be 
directly destroyed or its attachments severed by the galvano- 
caustic loop. This latter method, it is noticeable, was somewhat 
enthusiastically advocated by earlier writers notably Votolini, 
Fig. 108.—The Author’s Snare. 
Bruns, Michel, and especially Walston a of Edinburgh, who, how- 
ever, uses the iron wire in place of the platinum. Of late years I 
think this device finds little if any indorsement, those who use the 
chemical cautery contenting themselves with making use of it to 
cauterize the base of a growth, after its removal by other methods, 
although not a few still make use of it for the destruction of the 
growth itself, notably Mackenzie,3 who advises that a flat spatular 
electrode should be passed along the surface of the mucous mem- 
brane from which the polypus grows. As regards the galvano- 
cautery loop, all that it accomplishes is in the severing of the growth 
from its attachments, and it requires no little skill to put a soft and 
pliable platinum wire loop around a polypus, especially when it is 
mounted in the somewhat unwieldy cautery handle in common use 
(see Fig. 109). Furthermore, even when the loop is in position, I be- 
lieve it a better procedure to separate the polyp by means of the 
wire alone, without turning on the electric current, as the heated wire 
only adds an element of danger to the operation, as causing more 
Fig. 109.—Galvano-cautery Snare. 
or less inflammatory reaction. As regards the destruction of the 
growth, as advocated by Mackenzie, it is necessarily a slow process, 
as mentioned by himself. Moreover it is not cleanly, and necessa- 
rily involves more or less of inflammatory reaction, and I am con- 
fident that were all clinical experiences with this instrument frankly 
1 '* Die Galvanokaustic,” Breslau 1867. 
2 Report of British Med. Assoc., August, 1886. 
3 Op. cit., p. 374. NASAL POLYPUS, OR MYXOMA. 
405 
recorded, we should have many repetitions of the case reported 
by Daly,1 where suppurative otitis with threatened mastoid disease 
followed the use of the potential cautery in the nose I think we 
may safely say, then, of this agent that its advantages are few and 
its dangers and disadvantages many, hence, as we should naturally 
expect, we find it abandoned in favor of the cold wire snare by a 
large number of writers such as, Moure,2 Lennox Browne,2 Robin- 
son,2 Moldenhauer,2 Schech,3 and others. I do not hesitate, there- 
fore, to say that the cold wire snare should be preferred, both as 
affording the most efficient and least painful method of operating, 
and also as more completely avoiding any dangers or complica- 
tions that may arise, than any other device. The instrument 
already figured as the author’s, possesses the advantage of delicacy 
of construction and ease of manipulation, while, at the same time, 
Fig. iio.—Mackenzie’s Snare. 
it affords an unobstructed view of the manipulation of the loop in 
the nasal cavity. The still further advantage, I think, should be 
mentioned, of the three-fingered manipulation, which undoubtedly 
affords the nicest adjustment of the loop over the growth, and the 
quickest abscission of the tumor, for it is properly a cutting instru- 
ment rather than a snare. Similar instruments have been devised 
by Schech,4 Moldenhauer,5 Mackenzie6 (see Fig. no), Sajous,7 and 
Wright.8 The latter instrument, however, is a somewhat heavier 
snare, and designed more especially for growths of denser structure. 
Its working is easily appreciated by reference to Fig. hi. 
Operation.—In operating on nasal polypi, the use of cocaine 
is indispensable, both as producing local anaesthesia, and so far con- 
tracting the blood-vessels of the mucous membrane as to largely 
eliminate the possibility of hemorrhage. For this purpose, a 
1 Arch, of Laryngology. Vol. ii., April ist 1881, p. 147. 2 Op. cit. 
3 “ Diseases of the Throat, Mouth, and Nose,” English ed., Edinburgh, 1886. 
4 Op. cit., p. 267. 5 Op. cit., p. 143. , 6 Op. cit., p.,271. 
7 “ Diseases of the Nose and Throat,” I'hila., 1886, p. 142. 
8 N. Y. Med. Record, vol. xxxiii., March 17th, 1888, p. 315. 406 
DISEASES OF THE NASAL TASS AGES. 
twenty-per-cent solution should be used as producing most rapid 
and complete insensibility. This should be applied by means of 
an atomizer. In cases where the cavities are more or less com- 
pletely filled with the growths, the thorough anesthetization of the 
membrane is impossible, although in those cases, much can be ac- 
complished by the delicate manipulation of a pledget of cotton 
on a probe, dipped in the solution, and carried in as far as possible. 
Where a mucous polyp is visible, I think it in all cases feasible to 
carry a loop over it. Now, it is not a matter of importance whether 
the whole polyp is extirpated at the first operation or not. Bear- 
ing in mind, that, as a rule, its attachment is beneath the middle 
turbinated bone, the loop is carried in between the growth and the 
septum, its lower border being below the lower end of the tumor, 
when it should be turned to a horizontal plane and by a gentle to- 
Fig. hi.—Wright's Snare. 
and-fro motion slipped upward, until as much 
of the polyp as possible is engaged within its lu- 
men, when the loop should be drawn home. Pro- 
ceeding in this manner, I think in the majority 
of instances it will be found an easy matter to 
clear one or both cavities of all presenting growths 
at a single sitting, provided there are no obstruct- 
ing deformities of the cavities, such as a deflected 
septum. If the polyps are numerous, and the cavity well filled, the 
complete inspection is much hampered by the profuse sero-mucous 
secretion, which seems to ooze from beneath the growths, and which 
it is necessary to constantly wipe away with pledgets of dry cotton. 
Hemorrhage rarely if ever attends this method of operating in the 
hands of a skilful manipulator, and therefore need not complicate 
the procedure, for the blood-supply in the polypus itself is exceed- 
ingly scanty, and the mucous membrane itself, the usual source of 
bleeding, need not be injured. As the operation proceeds, and 
deeper portions of the cavity are opened up, it is well to repeat 
the applications of cocaine, as, of course, much discomfort is saved 
the patient in anaesthetizing the free portion of the cavity, even if 
the anaesthetic does not reach completely the part filled by the 
growth. Where the tumor lies well back in the passage, and cannot 
be easily reached by the snare, although visible, the manipulation 
will be much aided by the use of McKay’s slender ear forceps, 
shown in Fig. 112. By this instrument the growth can be easily NASAL POLYPUS, OR MYXOMA. 
407 
seized, its bite being mouse toothed, and drawn down into full view, 
when the loop can be readily adjusted over it. As before stated, it 
is usually quite feasible to thoroughly open up the passages by the 
removal of all visible polyps at one sitting. The removal of these 
growths, however, seems to loosen, as it were, those tumors which 
have been apparently crowded up in the sinuosities beneath the 
middle turbinated bone, so that they are enabled to drop down 
into the cavity. Hence, it is best to repeat the sitting at the end 
of a week, when oftentimes quite a number of apparently new 
growths will have shown themselves. These are not new polyps, 
however, but have simply allowed themselves to come into sight, 
and moreover have undoubtedly filled up and enlarged simply from 
the fact that space has been afforded them. These weekly sittings 
should be continued until an inspection shows a cavity entirely free 
from polypi, after which the patient should be seen once a month 
for probably four or five months, at the end of which time a radical 
cure, in the large majority of cases, can be assured. Moure,1 
Schech,2 Robinson,3 and others, attach a certain amount of impor- 
tance to the cauterization of the base of the growth, to prevent its 
recurrence, giving preference for this purpose to the galvano- 
cautery. I have never been able to recognize the base from which 
a polyp has been severed, and therefore think it unwise to subject 
healthy tissues to injury, in the blind attempt to cauterize a region 
that cannot be seen. Furthermore, I do not believe it is necessary, 
for as before intimated, if we thoroughly extirpate the growths they 
do not recur. Mackenzie4 advises the ablation of the lamella of 
bone from which the polypus springs as “the most certain method 
of preventing any fresh development of the growth,” and further- 
more shows that this is necessary, in order to reach well up beneath 
the middle turbinated bone, a region otherwise inaccessible. Now, 
a polypus does not spring from the bone, and secondly I believe it 
perfectly feasible to carry the steel wire loop completely to the 
base of a growth, no matter how far it extends beneath the middle 
turbinated bone. The removal of bone or healthy mucous mem- 
Fig. 112.—McKay’s Forceps. 
1 Op. cit., p. 188. 
3 Op. cit., p. 265. 
2 Op. cit., p. 268. 
4 Op. cit., p. 370. 408 
DISEASES OF THE NASAL PASSAGES. 
brane I think is never justifiable or necessary. The assertion that 
in a recurrence of these growths they take on a new development, 
in the fact of their being more dense and consisting largely of con- 
nective tissue, has already been referred to. Seiler,1 in speaking of 
this change in development, notes also the fact that they assume a 
telangiectatic form. A similar observation has been made by 
Joaquin Berrueco.2 In a large number of cases which I have fol- 
lowed, some as the result of neglect and failure of attendance, ex- 
tending through two and three and even four years, I have in no 
single instance observed any such tendency, after operating with 
the cold snare, the polypus at the end of four years showing the 
same type as the original virgin growth. I am confident that this 
fibrous development is entirely the result of traumatism in the use 
of forceps or the galvano-cautery, as every case which has come 
under my observation which had been subjected to these harsh 
measures, showed marked evidence of this change, in the denser 
character of the tumors, and in the fact of their bleeding freely 
upon removal. I make this assertion broadly, for it is based on a 
large experience, in which no single exception to the rule has been 
observed. In closing, mention should be made of the use of elec- 
trolysis for the ablation of nasal polypi, as alluded to by Sajous3 
and Robinson.4 In this procedure, the positive pole of the battery 
is attached to a needle which is inserted into the polypus, while 
the negative pole is attached to a sponge-electrode placed over the 
nose, the current being allowed to pass for about fifteen minutes, 
the sitting being repeated every three or four days. This is a 
somewhat unnecessarily tedious procedure, and as shown by Ber- 
rueco,5 is only applicable to the smallest growths. 
1 Op. cit., p. 265. 
2 Anales de otologia y laryngologia, No. 3, 1887. 
3 Op. cit., p. 146. 4 Op. cit., p. 266. 
s Loc. cit. CHAPTER XXIX. 
FIBROMA OF THE NASAL PASSAGES. 
A CURSORY examination of the literature of nasal growths, 
would seem to suggest that a fibrous tumor in the nasal cavity is 
an exceedingly rare event. Thus Mackenzie’s 1 study of the sub- 
ject is based on an analysis of three cases, one of which occurred 
in his own practice. A more careful investigation, however, shows 
us, that whereas this form of neoplasm is met with more frequently 
in the naso-pharynx than in any other portion of the upper air- 
passages, its location in the nasal cavity proper is by no means an 
uncommon occurrence. Moreover, the establishment of this fact 
is not in any way due to the development of an interest in diseases 
of the upper air-passages, because a majority of the cases found in 
literature, were reported long before the diseases of the nasal cav- 
ity became the subject of that industrious investigation, which char- 
acterizes the present day. Thus, we find reports on the subject by 
Syme,2 Mott,3 Gerdy,4 Figuiere,5 Verhaeghe,6 Gomez,7 Syme,8 Pepin- 
ster,9 Fisher,10 Van Dommelen,11 Mougins,12 Fischer,13 Dickson,14 Dol- 
1 “ Diseases of the Throat and Nose,” American Edition, Philadelphia, 1884, vol. ii., 
P- 375- 
2 Edinburgh Med. and Surg. Journ., 1832, vol. xxxviii., pp. 322 to 324. 
3 Am. Journ. of Med. Sciences, 1843, n. s., vol. v., pp. 87-91. 
4 “ Des Polypes et de leur Traitement,” Paris, 1833, p. 19. 
3 Bull, de la Soc. Anat. de Paris, 1843, vol. xviii., p. 294. 
6 Annal. Soc. med-chir. de Bruges, 1844, 214-217. 
7 Gac. Med.. Madrid, 1850, vol. vi., p. 272. 
8 Monthly Journ. of Med. Sciences, 1852, vol. xv., p. 274.. 
9 Arch. Beiges de Med. Mil., Bruxelles, 1856, vol. xvii., p. 342. 
10 Am. Med. Monthly, 1857, vol. viii., p. 15. 
11 Jour, des Connaissances Med. Prat, et Pharm., 1858-9, vol. xxvi., p. 425. (Though 
the history of this case would lead to the suspicion, that it may have been a gummatous 
tumor of the lower turbinated bone.) 
12 Revue de Therapeutique Med-Chir., Paris, 1861, p. 621. 
13 Mitth. aus der Chirurg. Univ. Klin, zu Gottingen, 1861, p. 290. 
14 Brit. Am. Journ., 1861, vol, ii., p. 545. 410 
DISEASES OF THE NASAL PASSAGES. 
beau,1 Bryk,2 Maisonneuve,3 Hodgen,4 Steiner,5 Smith,6 Hitchcock,7 
Lichtenberg,8 Perez y Jimenez,9 Gay,10 Kempf,11 Jarvis,12 Chiari,13 
Buchanan,'4 Cozzolino,'5 Jacquemart,'6 Seiler,'7 Chatellier,'8 Villar,'9 
Kirtikar,20 Casselberry,21 and Ingals,22 the whole embracing a study 
of 41 cases of the disease. 
ETIOLOGY.—Morbid processes in the nasal mucous membrane 
are essentially those which involve connective-tissue changes, hence 
the highly vascular character of the pituitary membrane, together 
with the intense functional activity which belongs to it, would seem 
to provide especially favorable conditions for the development of 
fibromata. It is a well-known fact, that the uterus is the most fre- 
quent site of fibroid development, which Billroth23 very ingeniously 
explains, on the theory that fibromata arise from the nerve sheaths, 
and the adventitia of the small arteries, the nerves disappearing, 
while the arteries remain, and hence the uterus, whose nerves and 
vessels undergo such great changes during menstruation and preg- 
nancy, offers a favorable site for this form of morbid growth. The 
daily and hourly changes in the turgescence of the blood-vessels of 
the nasal membrane, together with its exceedingly rich nerve dis- 
tribution, would seem to show the existence of a certain predispos- 
ing cause of the disease under consideration in this region also. 
The immediately exciting cause, however, is not so easily explained, 
although in Steiner's case, an inflammatory process seems to have 
been the active cause of the morbid growth, while in Buchanan’s 
1 Gaz. des Hopitaux, 1862, vol. xxxv., p. 530. 
a Wien. Med. Halle, 1862, pp. 223 et 276. 
3 Gaz. des Hopitaux, 1863, vol. xxxvi., p. 521. 
4 St. Louis Med. and Surg. Journ., 1S65, vol. ii., p. 97. 
s Wien. Med. Woch., 1868, vol. xviii., p. 1082. 
6 Brit. Med. Journ., 1869, vol. ii., p. 557. 
7 Trans. Med. Soc. Mich. (1870), Lansing, 1871, p. 94. 
8 Lancet, 1872, vol. ii., p. 773. 
9 Genio. Med. Quir., Mad., 1875, vol. xxi., p. 346. 
10 Buffalo Med. and Surg. Journ., 1875-6, vol. xv., p. 301. 
11 Louisville Med. News, 1879, vol. vii-, p. 65. 
12 Med. Record, New York, Sept. 2d, 1882, vol. xxii., p. 270. 
13 Wien. Med. Jahrbuch, 1882, p. 481. 
14 Glasgow Med. Journ., 1882, vol. xvii., p. 211. 
15 Archivii Ital. di Laryngol., 1883-84, Number iff., p. 97. 
16 Annal. des Mai. de I’Oreille, May, 1883, p. 69. 
17 Trans. Pathological Society of Philadelphia, 1884, vol. xi., p. 126. 
18 Annal. des Mai. de l’Oreille, 1886, vol. xii., p. 473. 
19 La France Medicale, 1886, vol. i., p. 374. 
20 Transactions of the Medical and Physical Society. Bombay (1886), 1887, (III.) S., 
x., p. 59- 
21 Journ. Am. Med. Ass’n, April 21st, 1888. 
22 Journ. Am. Med. Ass’n, Chicago, Dec. 8th, 1888, p. 803. 
23 Langenbeck’s Arch., vol. iv., p. 545. FIBROMA OF THE NASAL PASSAGES. 
411 
case, the development seems to have been due to traumatism. In 
the negro races, as we know, fibroma of the uterus is exceedingly 
common. As regards the nasal cavity, however, race would seem to 
have no influence. Sex, on the other hand, would seem to have a 
notable influence in predisposing to the disease, in that rather more 
than two-thirds of the cases reported occurred in males. Age 
would seem to exercise a certain influence also, in that the disease 
belongs to the earlier periods of life, usually from fifteen to thirty, 
the youngest case being that of Gerdy, at 13, while the oldest case, 
Seiler’s, occurred at the age of 68, Gomez’s case being 60, while 
Kempf’s was 58. 
SYMPTOMATOLOGY.—As already noted, the disease probably 
commences in the nerve sheaths and blood-vessels, the nerves being 
destroyed, while the vessels remain. Moreover, in this region, the 
disease develops in the sheaths of the vaso-motor nerves. Hence, 
pain is rarely a symptom in the early part of the disease, although 
it may develop later, as the result of pressure. It is never, how- 
ever, a prominent symptom. Epistaxis, on the other hand, is per- 
haps one of the most constant and frequent evidences of the dis- 
ease, due in most instances, undoubtedly, to the vascularity of the 
growth itself, the surface of the tumor becoming eroded, although 
this erosion may occur in the mucous membrane lining the nasal 
cavity, giving rise to hemorrhage from this source. In the large 
majority of instances, however, the source of the bleeding is in the 
tumor itself. This symptom recurs with considerable frequency, 
and may become an exceedingly grave symptom, on account of its 
persistency, and frequent occurrence. Nasal stenosis, with a more 
or less profuse muco-purulent discharge mixed with blood or clots, 
is of course a frequent attendant upon the development of these 
growths. Nasal stenosis is present, according to the size and loca- 
tion of the growth. Perhaps no form of neoplasm develops and 
spreads with a more unrelenting progress than a fibroma, neither 
tissue, cartilage, nor bone seems to offer the slightest hindrance to 
its growth. Hence, according to its original location, and the di- 
rection of its growth, external deformity sooner or later develops. 
This, however, is not present in all cases, in that in certain instances, 
where it makes its exit either from the nostril or through the pos- 
terior nares, it would seem to expend its force in these directions. 
In most cases, it has its origin in the roof or upper portion of the 
nasal cavity, and hence, extending forward, it gives rise to the 
peculiar facial expression which we call frog face, which consists 
of a spreading of the nasal bones, with an apparent flattening of its 
ridge. In Steiner’s, Maisonneuve’s, Dolbeau’s, and Seiler’s cases, 
exophthalmos was produced, by the growth obliterating the eth- 412 
DISEASES OF THE NASAL TASS AGES. 
moid or sphenoid sinuses, and encroaching upon the orbital cavity. 
In Hitchcock’s case, the antrum on one side was obliterated by 
encroachment of the growth, while on the other side, the same ob- 
literation occurred by the septum being crowded and pressed 
against it. Headache seems to have been present in a number of 
these cases, probably of a neuralgic character. Anosmia occurs in 
the majority of instances, as the direct result of stenosis, while, as 
its indirect result, slight impairment of hearing is present in all 
cases, and in many, this symptom is very prominent, due probably 
to the interference with normal nasal respiration, although, if the 
growth extends into the naso-pharynx, there may be direct pressure 
upon the orifice of the Eustachian tube, while, as the result of this 
extension, the movements ’of the pharynx in deglutition may be 
seriously interfered with. 
Pathology.—Fibroma of the nose, from a pathological point 
of view, differs in none of its essential features from the same form 
of neoplasm as found in other regions of the body. It is composed 
of a dense network of fibrous tissue, containing within the meshes 
or interspaces, scattered here and there, either between the bun- 
dles of fibres, or between individual fibres, spindle-shaped or stel- 
late cells, together with a finely granular homogenous basement 
substance. The density of the tumor varies to a certain extent, 
dependent somewhat on the relative proportion of the cellular sub- 
stance, and the fibrous tissue. Thus, in Dolbeau’s case, in certain 
portions of the tumor, the fibro-plastic elements were even in excess 
of the fibrous tissue. In connection with the white fibrous tissue, 
a few yellow elastic fibres may be found. The starting-point of 
the growth, as Billroth1 has shown, is in the nerve sheaths and 
adventitia of the small arteries. As the tumor develops, the nerves 
are destroyed, while the arteries remain intact. This observation 
is supported by clinical experience, as regards a nasal fibroma, in 
that while the growth of the tumor is not attended with pain, it is 
highly vascular, its progress being attended by repeated attacks of 
epistaxis, while the operations for its removal are attended with 
excessive hemorrhage. In this respect, the nasal neoplasm differs 
in a notable degree from the same form of growth in other portions 
of the body. 
Sarcomatous degeneration is a not infrequent occurrence in 
these cases, and yet the presence of spindle cells is not always to 
be regarded as an evidence of this change, in that this element may 
persist for a long period of time, and even increase, and yet the 
growth itself, from a clinical point of view, show no evidence what- 
ever of malignancy. Thus, Ingals1 operated on a pure fibroma, 
1 Loc. cit. FIBROMA OF THE NASAL PASSAGES. 
413 
which recurred at the end of five years. The tissue removed by 
the second operation proved to be in part composed of from one- 
fifth to one-half cellular elements. 
In making a microscopic examination, it is a matter of some 
importance, that a number of specimens be studied, in order to 
establish the definite relation between the fibrous and the cellular 
elements, as these growths may not only undergo sarcomatous 
degeneration, but there may be a mixed growth from the onset. 
Aside from sarcoma, we have fibrous tissue combined with other 
elements, giving rise to a myxo-fibroma, adeno-fibroma, chondro- 
fibroma and osteo-fibroma. Of these forms, myxo-fibroma is not 
infrequently met with in the nose. Probably, in most cases, this 
growth is the result of harsh surgical measures, for the relief of 
simple myxoma. Dixon’s case, as far as I know, is the only in- 
stance on record of a chondro-fibroma. Of the other varieties, no 
cases have been reported as occurring in the nasal cavity. 
DIAGNOSIS.—With our present means of exploring the nasal 
passages, by depleting the blood-vessels through the action of co- 
caine, a fibroma whose origin is in the nasal cavity proper, should 
ordinarily be brought under ocular inspection through the anterior 
nares, even when situated well back in the chambers, if the secre- 
tions be deftly removed, by means of a cotton pledget, and the 
parts thoroughly cleansed. If this is not feasible, it can be brought 
under inspection, by means of a rhinoscopic mirror in the fauces. 
When seen, its gross appearance is characteristic, and usually rec- 
ognized with facility. The surface of the growth is irregularly 
rounded or tabulated, smooth and glistening in appearance, and 
presents a decidedly reddish-pink color. In some cases, the blood- 
vessels can be recognized coursing near its surface, being thrown 
into somewhat prominent relief, by the whitish background of the 
fibrous tissue of which the tumor is composed. These growths are 
usually sessile in character, and firmly imbedded, as it were, in 
the cavity, and do not yield on pressure with the probe. In other 
cases, a to-and-fro motion to the touch can be observed, as show- 
ing that the tumor is somewhat pedunculated, as occurred in Pep- 
inster’s case. As before stated, the growth of a fibroma is relent- 
less, in that it appears to crowd all tissue before it, and yet its 
shape is, to an extent, modified by the shape of the bony cavity, 
so that it seems to send prolongations forward toward the anterior 
nares, or backward into the pharynx. The growth is of a dense, 
resisting character, and need not usually be mistaken for any other 
neoplasm, the diagnosis being based on the subjective symptoms 
of stenosis, and much aided by external deformity, where it exists, 
together with the repeated attacks of epistaxis, which are charac- 
teristic, and the peculiar color, and gross appearance. 414 
DISEASES OF THE NASAL TASS AGES. 
The only neoplasms in the nose with which it might be con- 
founded, are osteoma or chondroma. Osteoma is exceedingly rare 
in this region, usually arising from the accessory sinuses, and should 
be recognized by the probe or needle. Chondroma is even rarer 
tha-n osteoma, and its recognition will be dependent, either on the 
use of the needle, or the removal of a piece for microscopic exami- 
nation. While the diagnosis of the character of the growth is 
quite easy, the determination of its origin requires a more careful 
examination. It is a matter of no little importance, to determine 
whether the growth springs from the nasal cavity proper, or from 
the vault of the pharynx, for, as we have seen, nasal fibromata are 
comparatively rare, while the upper pharynx is a somewhat frequent 
site for their development, the operative procedure indicated in 
the one case, being very different from that in the other. A 
pharyngeal fibroma usually gives rise to bilateral stenosis, while in 
its early stage, and usually till the tumor has grown to considera- 
ble size, a nasal fibroma causes unilateral stenosis. Dolbeau 1 seems 
to attach considerable importance to this diagnostic symptom, but 
takes the ground, that the unilateral stenosis characterizes the naso- 
pharyngeal growth. I am disposed to think, however, that a tumor 
springing from the base of the skull will give rise to obstruction of 
both posterior nares, as it grows downward, forming a curtain, as it 
were, much earlier than the nasal tumor having its origin in one 
passage. Furthermore, the peculiar frog-face already mentioned, 
is a characteristic of the nasal growth, a feature usually not so 
prominent in the pharyngeal disease. The determination, then, of 
the site, must be based on such careful study of the parts as the 
size of the growth permits, both by rhinoscopic examination, and 
palpation, together with the use of the probe, in connection with a 
careful estimate of the subjective symptoms. In the majority of 
cases, the growth springs from the upper portion of the cavity, 
either from the ethmoid bone, or from the region of the superior 
turbinated, although in Dixon’s, Pepinster’s, and one of Ingals’s 
cases, its origin was in the floor of the nares, while in Fischer’s and 
Dolbeau’s cases, it sprang from the septum. 
PROGNOSIS.—On account of its location, and its nearness to vital 
parts, a fibroma of the nose will eventually prove fatal, unless sub- 
jected to successful operative interference. That, however, a favor- 
able termination may be expected from this interference, is very 
strikingly shown, by the results of the cases above alluded to, in 
that of those in which the full details are given, we find that in 
twenty-three, the growth was successfully extirpated, while in four, 
death occurred, in all cases as the result of the operation, for in 
1 Loc. cit. FIBROMA OF THE NASAL PASSAGES. 
415 
Gerdy’s and Seiler’s cases, death occurred on the operating-table, 
while in Syme’s and Dolbeau’s cases, death occurred respectively 
in a day and a half, and five days after operation, and apparently 
as the result of it. Gerdy’s and Syme’s cases were boys of thirteen 
and fifteen years of age, in which the disease had lasted respec- 
tively eighteen and twelve months, while in Dolbeau’s case the 
disease had lasted for twelve years, in a man of forty-one years of 
age, probably having produced notable impairment of general 
health. In Seiler’s case also, the disease had existed for a num- 
ber of years, in a man aged sixty-eight, rendering him probably an 
unfavorable case for operation. 
Treatment.—No local treatment has ever been demonstrated 
to possess any power whatever in arresting the growth of these 
tumors, unless, perhaps, we except electrolysis, used successfully 
in Ingal’s hands, in notably reducing the size of the growth 
in one of his cases, thus enabling him to use the ecraseur with 
more facility, by which he completed his operation. Used in 
this manner, and for this purpose, electrolysis might prove an ex- 
ceedingly valuable measure. Whether the size of the larger tumors 
can be modified in this way, or whether any growth can be fully 
eradicated, still remains to be demonstrated. Certainly, in the ma- 
jority of instances, a surgical operation for the removal of the 
tumor is indicated, and will be required. If the growth can be 
embraced in the loop of a cold wire snare, or the galvano-cautery 
Ecraseur, probably we possess no better method for its removal, and 
with our present improved methods of working in the nasal cavity, 
and also with the great advantages of the use of cocaine, this is far 
more feasible than in former times. The choice of the cold or the 
heated wire, of course, will be dictated largely by the individual 
preferences of the operator. The steel wire, however, owing to its 
resistance, and facility of manipulation, certainly affords a device, 
by which a loop can be placed around a growth with far greater 
facility than the platinum wire of the galvano-cautery. After the 
wire is in position, it becomes a question, whether the simple ecra- 
seur will not accomplish all that the cautery does, without subject- 
ing the patient to the inflammatory reaction, which usually follows 
the use of the potential cautery, in that when the loop is slowly 
contracted, hemorrhage is completely avoided; thus, in Jarvis’s 
case, five hours were consumed in closing the loop. It has been 
almost the universal practice, to use the No. 5 steel piano wire in 
the snare. It certainly would be wiser, in fibroma of the nose, to 
make use of the larger sizes, in order to avoid the possibility of 
any accident happening, as did in Seiler’s case, by the breaking of 
the wire. If the growth is of large size, there is no objection to 416 
DISEASES OE THE JVASAL PASSAGES. 
removing it piecemeal, if this is feasible. Where, however, this 
cannot be done, Casselberry’s device can be resorted to, which con- 
sists in incising the growth by means of the galvano-cautery knife, 
after which, the snare can be easily adjusted over the two tongues, 
as it were, which are thus produced. In Smith’s, Gay’s and 
Gomez’s cases, evulsion was practised, and apparently with success, 
but it is a method of operation, which would scarcely be considered 
a proper surgical procedure at the present day. In man)' cases, 
however, one of the operations alluded to in the chapter on the 
External Surgery of the Nose, will be necessary. In Fisher’s case, 
the soft palate was slit, and the growth dragged down, and cut 
with a knife, while in Dolbeau’s, access to the cavity was obtained, 
by opening through both the soft and hard palate ; this latter pro- 
cedure, however, was resorted to through a mistaken idea that the 
growth was naso-pharyngeal. 
The great danger which attends an operation on a nasal fibroma, 
lies in the excessive hemorrhage. Thus, in both Gerdy’s and 
Seiler’s cases, this was the cause of death, which occurred on the 
operating table. We possess no means of eliminating this danger, 
as it is a concomitant of this form of tumor, and must be managed 
by the rules which govern general surgical procedure. CHAPTER XXX 
OSTEOMA OF THE NASAL PASSAGES. 
Many writers classify osteomata as exostoses and enostoses, a 
distinction which, from a clinical point of view, I think best to be 
discarded, as regards the nasal cavity. A careful reading of the 
reports of cases of exostoses, warrants the conclusion, that this 
term is used to describe that form of outgrowth, so frequently 
met with at the sutural junction, between the vomer and the pala- 
tal process of the superior maxilla, already described in the chapter 
on deformities of the septum, and which are not to be regarded as 
osteomata properly. The term osteoma, then, we should restrict 
to that very grave form of osseous neoplasm, which, having its origin 
in the upper portion of the nasal cavity, or in one of the accessory 
sinuses, extends slowly, but with a relentless progress which nothing 
withstands, until it invades neighboring parts, or projects beyond 
the cavity, producing oftentimes most unsightly external deformity. 
In most cases, these tumors, in their development, retain connec- 
tion with the parts from which they originate, constituting what 
are ordinarily called, living osteomata. In other cases, this con- 
nection may be severed, as the result of a blow, or some unknown 
cause, and the fragment remain imprisoned in the cavity, as a 
source of irritation, constituting what is known as a dead osteoma. 
While it is not an especially rare occurrence, for the nasal cav- 
ity to be invaded by an osseous tumor, which has its origin in parts 
beyond, a neoplasm of this form, developing primarily in this 
region, is much less frequent. Their occurrence is evidenced by 
such unmistakable signs, that we can easily understand how they 
should have been recognized by the earliest writers on medicine, 
and yet their observations were so lacking in definite data, as to 
add little to our clinical knowledge of the disease. For this, we 
must depend largely on the observations of later date. Thus we 
have reports by Morgan,1 Hilton,“ Duka,3 Michon,4 Verneuil,5 
1 Guy’s Hospital Reports, 1836, vol. i., p. 403. 
2 Ibid., p. 493. 
3 Path. Trans., London, vol. xvii., p. 256. 
4 Bui. de la Soc. de Chir. de Paris, Seance Jan. 9th, 1850, vol. i., p. 505. 
s Comptes Rendus de la Soc. de Biol., 1851, p. 80. 418 
DISEASES OE THE NASAL PASSAGES. 
Mott,1 Legouest,2 Pamard,3 Ollivier,4 Gaubert,5 Rendu,6 Richet,7 
Dolbeau,8 Arnold,9 Michel,10 Knapp,11 Bornhaupt,12 Habermaas,13 
Knapp,14 Tillmanns,'5 Sprengle,16 and Fenger.17 
ETIOLOGY.—It is difficult to assign any direct cause for these 
growths, and any suggestion would be merely speculative. They 
ordinarily commence somewhat early in life, usually at from fifteen 
to twenty, although Tillmanns’s case manifested its first symptom 
at the age of forty-five. In the majority of instances they occur 
in males, although why this should be, it is difficult to say. In six 
of the cases collected by Bornhaupt, as well as in Fenger’s case, a 
clinical history of an injury was obtained, although neither of these 
writers seems to think that this exerted any direct causative influ- 
ence upon the development of the growth. 
SYMPTOMATOLOGY.— External deformity seems to be the earli- 
est symptom to which these growths give rise, in the majority of 
cases this feature presenting, even before nasal stenosis is recog- 
nized. This is due to the fact, that the growth has its origin in 
the upper portion of the nasal cavity, and extends toward the face, 
even before it involves the lower meatus. Thus in Morgan’s case, 
after a duration of nine years, the tumor seemed to cover the whole 
of one side of the face, causing a most unsightly deformity. In 
the same way, it very early shows a disposition to invade neighbor- 
ing cavities, its most frequent track, perhaps, being through the 
ethmoid cells to the orbit, giving rise to exophthalmos, as occurred 
in Hilton’s, Fenger’s, Mott’s and Tillmanns’s cases. Epistaxis does 
not usually occur. Pain, however, due to pressure on some of the 
sensory nerves, is of frequent occurrence. Nasal stenosis is of 
course dependent upon the size and direction which the growth 
1 Am. Journ. of Med. Sciences, 1857, p. 35. 
2 Gaz. Iieb., 1863, vol. x., p. 854. 
3 Bull, de la Soc. de Chir., 1866. 
4 Th£se de Paris, 1869. 
5 These de Paris, 1869. 
6 Arch. Generate de Med., August, 1870, ii., 214. 
7 Bull, de l’Acad. de Med., Paris, 1871, vol. xxxvi., p. 564. 
8 Bull, de la Soc. deChir., Paris, 1872, p. 5; Bull, de l’Acad. de Med., 1866, vol. xxxi., 
p. 1,076. 
9 Virchow’s Archiv, Bd. lvii., p. 145. 
10 Gaz. Heb., 1873, 2 s., vol. x., p. 380. 
11 Archives of Ophthalmol., 1880, vol., ix., p. 464. 
12 Langenbeck’s Arch., 1881, Bd. xxvi, p. 589. 
13 “ Mittheilungen aus derChirurg. Klinik zu Tubingen,” herausgeg. von Paul Bruns 
Tubingen, 1884, S. 376. 
14 Archives of Otology, 1884, vol. xiii., p. 51. 
15 Verhandlungen der Deutschen Gesellschaft fur Chirurgie, Berlin, 1885, p. 72. 
16 Arch, fur Klin. Chir., Bd. 35, H. 1, 1887, p. 224. 
'7 Tourn. Amer. Med. Ass., August nth, 1888, p. 185. OSTEOMA OF THE NASAL PASSAGES. 
419 
takes. Discharge from the nose is not usually a prominent symp- 
tom, although suppuration, as the result of ulcerative processes, or 
death of the osteoma, occasionally occurs. In both Tillmanns’s 
and Fenger’s cases, there was an external fistula, due probably to 
bony necrosis, as the result of pressure by the neoplasm. 
Pathology.—These tumors are met with in two varieties, the 
hard and soft. In one case the growth being made up entirely of 
compact tissue, while in the other it is made up of cancellous 
tissue, covered by a thin shell, as it were, of hard bone. The 
starting-point of the morbid process in these tumors is still some- 
what a matter of speculation. They may arise from the ossifica- 
tion of the islands of cartilage, which are occasionally found as 
survivals of the original process, by which the bones of the skull 
are formed; or their starting-point maybe in the minute centres 
of calcification, which Verneuil has demonstrated to exist in the 
mucous membrane. Whichever of these theories may be true, the 
source of these growths is undoubtedly in the periosteum. There 
is good ground for supposing that their primary origin is always 
in one of the accessory sinuses. Thus, Tillmanns thinks, that in 
the large majority of instances they have their origin in the eth- 
moidal cells. This is confirmed by Bornhaupt, who, in an investi- 
gation of forty-nine cases of osteoma of the nose and accessory 
cavities,' finds this origin in thirty-four cases. In Legouest’s and 
Richet’s cases, the tumor developed from the inferior turbinated 
bones, while Michel's sprang from the septum. We must, then, 
accept Dolbeau’s view, that they may arise from any portion of 
the mucous membrane, either of the nose or accessory cavities; 
their frequency in the accessory cavities, and especially in the eth- 
moid, being closely connected with the peculiar tendency to cal- 
careous degeneration alluded to in the discussion of the pathology 
of disease of the antrum. 
The surface of these tumors is irregularly lobulated, and cov- 
ered with normal mucous membrane, the deep layer of which forms 
the periosteum. The outer layer of the tumor is invariably formed 
of compact bone tissue, differing in no essential degree from nor- 
mal bone of this character. In many cases, the entire tumor is 
composed of this tissue, while in others, as we penetrate beneath 
the surface, we come upon the cancellous tissue, still preserving 
the normal type, and differing from it only in that the Haversian 
systems are somewhat distorted, and perhaps, in most instances, 
crowded together, as it were, into a denser tissue than the normal. 
At its onset, the development of these tumors is equal and periph- 
eral, giving rise to a cylindrical and rounded contour. As they 
impinge upon the bony walls of the cavity, this rounded shape is in- 420 
DISEASES OF THE NASAL PASSAGES. 
terfered with in such a way, that the surface becomes nodulated, and 
furthermore, prolongations develop in the direction in which their 
progress is least impeded, as in Legouest’s case, one prolongation 
extended well back into the pharynx, while another presented near 
the nostril, while in Duka’s case, the prolongations were respectively 
toward the anterior nares and the antrum. As the tumor develops, 
the point of original attachment occupies an area which bears a 
somewhat small relation to the whole size of the growth. Now, 
when we remember that the pedicle is composed of spongy tissue, 
it is easy to understand, how a spontaneous separation may occur 
at this point, giving rise to a dead osteoma. This separation may 
occur in one of two ways. The growth may be broken off, as the 
result of traumatism, or, as Tillmanns suggests, it may occur from 
a process of atrophy, due to pressure at the point of attachment, 
giving rise to suppuration and ultimate necrosis; or, if the tumor 
has attained a large size, and still depends for nutrition upon a 
comparatively small pedicle, it may not be impossible, that the 
separation may occur as the result of interference with free circu- 
lation through the nutrient arteries. 
DIAGNOSIS.—The existence of the growth is recognized, pri- 
marily, by the interference with normal nasal respiration, which, 
calling for an examination of the parts, should enable us to recog- 
nize the existence of the tumor at a comparatively early stage, 
when its character should be made manifest by its gross appear- 
ances, and the resisting surface; the presence of bone, probably in 
every case, being easily determined, by means of the probe, or, 
where feasible, the insertion of the finger. If there be any doubt 
as to its structure, the exploring-needle is sufficient to remove this. 
The nicer points of diagnosis, such as between an osteoma and an 
osteo-sarcoma, can only be determined by the removal of a portion 
of the tumor, and subjecting it to a microscopical examination. 
The growth is firm and absolutely immovable, except in those 
cases where spontaneous separation has occurred, hence its mo- 
bility must always be accepted as evidence of this occurrence. If 
the tumor has remained in the cavity for a prolonged period of 
time after separation, it may present the appearance of a rhinolith, 
in that its mucous membrane undoubtedly will have sloughed away, 
and its presence be attended with a profuse and offensive discharge. 
In this case, the diagnosis would only be cleared, after the removal 
of the growth. 
PROGNOSIS.—After spontaneous separation, there is no tendency 
to recurrence, the only condition to deal with, being the removal 
of what is now merely a foreign body in the nose. Where this 
fortunate accident does not occur, these growths may attain large OSTEOMA OF THE NASAL PASSAGES. 
421 
size, and involve very serious external facial deformity, and yet 
the prognosis seems to be favorable in the very large majority 
of cases, in that surgical interference is usually attended with com- 
plete success. 
Treatment.—In most instances, the usual difficulty which the 
treatment of these growths involves, is found in those cases in 
which the tumors are of the hard variety, and of considerable size, 
owing to the fact that the density of the growth is in many cases 
so great as to resist any form of instrument used for either crush- 
ing or cutting. Hence the object must be, to obtain access to the 
pedicle, which, as before stated, being of cancellous structure, is 
easily cut through, when reached. An external operation in most 
instances therefore will be required, the special features of which 
will be determined largely by the form and size of the tumor. 
This will often demand free incisions, and the extensive removal 
of such bony structures as may stand in the way of free access to 
the pedicle. When this is reached, the separation is easily accom- 
plished by means of the chisel, crushing forceps, or the saw. The 
only serious accident that may occur, in connection with the opera- 
tion, is excessive hemorrhage, which is fortunately somewhat rare, 
although, in one of Dolbeau’s operations, this was of a most alarm- 
ing character. CHAPTER XXXI. 
PAPILLOMA Ob' THE NASAL PASSAGES. 
Papillomata or warty growths, as affecting mucous mem- 
branes in general, would seem to find, certainly, a predisposing 
cause in the movements t’o which the part is subjected by its 
normal functional activity; hence the nasal cavity, protected as it 
is to a large extent by its bony walls, and endowed with cer- 
tain functions which are carried on in a state of absolute quies- 
cence, we should naturally infer, would be to a large extent 
exempt from the invasion of this form of neoplasm, a fact which 
clinical observation fully confirms ; for, I take it, that a certain 
allowance is to be made for the enthusiasm manifested by Hop- 
mann 1 in the study of these growths, which he was the first to 
investigate, when he finds seventy-eight cases of papillomata, in a 
total of four hundred and thirty cases of benign nasal tumors. In 
a later paper, Hopmann2 states that Schaffer, in one hundred and 
eighty-two cases of nasal polypi, observed twenty instances of 
papillomata. Schmiegelow,3 on the other hand, in seventeen cases 
of nasal tumors, found but one case, while Zuckerkandl4 observed 
only one case of papilloma in thirty-nine cases of polypi. It is 
certainly not easy to harmonize these observations of Hopmann 
and Schaffer with ordinary clinical experience, unless we recognize 
the fact that these are, in the large majority of instances, 
entirely overlooked. My own records include something over two 
hundred cases of benign tumors of the nose, but one of which was 
a case of papilloma, that of a girl aged thirteen, in which a growth, 
the size of a raspberry, springing from the lower turbinated body 
in front, was removed by means of the snare, without recurrence; 
there was no other morbid condition. The only conclusion then 
to be drawn is, that we have been in the habit of overlooking these 
cases, for when we consider the thoroughly exhaustive and scholarly 
manner in which Hopmann has written up the subject, I take it we 
1 Virchow’s Archiv, vol. xciii., Sammlung Ivlinischer Vortrage, No. 315. 
2 Wien. Med. Presse, 1883, xxiv., 1227-31. 
3 Hospitalstidende, Marto. 1885. 
4 “ Anatomie der Nasenhohle,’’Wien, 1882, p. 70. PAPILLOMA OF THE NASAL PASSAGES. 
423 
are not at liberty to question his results, to which still further 
weight is given by the subsequent observations of Mackenize,1 
Butlin,2 Aysaguer,3 Verneuil,4 Cozzolino,5 Gamperz6 and Noquet.7 
Besides these cases, published after the first of Hopmann’s elaborate 
articles, researches in literature afford us two other examples of 
what were in all probability instances of this disease. Thus, Ward8 
reports a case of follicular tumor of the nose, which was probably 
a papilloma; and the same can be said of the case reported by 
Testelin,9 as a condylomatous polyp of the nasal fossa. 
ETIOLOGY.—It is not easy to assign any definite cause for the 
occurrence of this form of neoplasm in the nose. Hopmann gives 
prominence to atrophic rhinitis as exciting their growth, a patho- 
logical condition, which on general principles one would suppose 
would protect the membrane in this region from their develop- 
ment, rather than excite it. His suggestion that the irritation of 
the respiratory current might have some influence, is purely specu- 
lative. 
SYMPTOMATOLOGY.—The development of these growths is at- 
tended with no prominent subjective symptoms, other than the 
interference with normal nasal respiration, which exists according 
to the size of the growth. Their presence excites but little irrita- 
tion, and hence excessive discharge does not usually exist, either 
from the growth itself, or from the membrane surrounding it. 
Hemorrhage occasionally occurs, probably due to erosion of the 
mucous membrane, rather than to a rupture of blood-vessels in the 
tumor. Their growth is neither rapid nor vigorous, hence when 
they even completely fill the nasal cavity, they are not capable of 
producing notable external deformity. Their presence, therefore, 
gives rise simply to the ordinary symptoms which attend the de- 
velopment of the softer non-malignant growths. 
Pathology.—According to the usually accepted view, papillo- 
matous growths of the nasal mucous membane, consist essentially of 
an hypertrophy of all the elements which enter into the formation 
of the normal papilla; of the membrane, this hypertrophy involving 
these elements uniformly, or the greatest activity of the morbid 
1 “ Diseases of the Throat and Nose,” Am. Edition, Philadelphia, 1884, vol. ii., p. 
377- 
2 St. Bartholomew’s Hospital Reports, 1885, vol. xxi., pp. 147-152. 
3 Annal. des Mai. de l’Oreille, No. 5, Nov., 1885. 
4 Bull, et Mem. de la Soc. de Chirurg., Paris, July 28th, 1886, p. 658. 
3 Revista Clinica e Terapeutica, Naples, 1887, vol. ix., p. 75. 
6 Monatsschrift fiir Ohrenheilk., Feb., 1889. 
7 Revue de Laryngologie, July 1st, 1889, p. 369. 
8 Lancet, 1854, vol. ii., p. 480. 
9 Journal de Med., Chirurg. et Pharm., Brux., 1S59, p. 147. 424 
DISEASES OF THE NASAL PASSAGES. 
process may develop in a single element, such as either the connec- 
tive tissue or the blood-vessels. This process, commencing beneath 
the surface, encroaches upon and elevates the superficial structures, 
while at the same time it involves them in a certain morbid activity, 
by which the epithelial elements are notably increased, the initial 
point of morbid activity thus being in the deeper layers. Auspitz,1 
on the other hand, reverses this order and argues that the morbid 
process commences in an activity of the epithelial structures, and 
extends to the tissues beneath, and thus stimulates or sets up the 
hypertrophic process in the papillae, a view which would seem to 
more closely harmonize with clinical observation, if we accept the 
teaching that papillomatous growths result from external irritation. 
Microscopic examination shows each individual papilla to be com- 
posed of a framework of more or less richly distributed connective 
tissue, containing usually a single vascular loop, and the whole 
covered with epithelial cells. Gland tissue is rarely present, and 
when present, shows itself in a disorganized or atrophied condition. 
At the base of the papillae, the glandular elements of the 
membrane show a tendency to proliferation. If we examine a 
cross-section of the papilla, the microscope will show the central 
blood-vessels separated by the delicate connective-tissue structures, 
and surrounded by a ring, as it were, of epithelial cells. 
According to Hopmann, papillomata of the nose occur in two 
varieties, a hard and soft form. This classification would seem to 
be based on the location of the growth, in that where it occurs near 
the muco-cutaneous junction, its surface is coated with squamous 
epithelium, hence it presents a somewhat dense consistency; 
whereas, when it occurs higher up in the nasal cavity, its epithelial 
covering is of the columnar variety, and hence the growth presents 
a soft and yielding contour. 
DIAGNOSIS.—The small growths which appear near the margin 
of the nostril, afford something of the ordinary appearance of a 
warty growth as seen on the integument, in that they present a 
grayish pink tinge, and mammillated contour. In this region the 
growths are usually of Hopmann’s hard variety, and do not ordi- 
narily attain any very great size, although in Butlin’s case the nos- 
tril was almost completely obstructed. This case, moreover, was 
pedunculated, thus differing from all the other cases occurring in 
this region, which were sessile in character. When they occur 
higher up in the nasal cavity, they are of a softer consistency, 
of a more decidedly pink color, and attain a much larger size, 
and while the whole growth is usually sessile in character, the 
individual papillae may hang down in a somewhat pendulous 
1 Arch, fur Derm, und Syph., 1870, vol. ii., p. 25. PAPILLOMA OF THE NASAL PASSAGES. 
425 
manner, so as to give rise to an appearance of pedunculation. 
Thus while the individual papillae may obtain considerable size, 
and present the appearance of an ordinary mucous polyp even, 
the whole growth presents an exceedingly irregular surface, not 
unlike perhaps the surface of a raspberry, in which each seed folli- 
cle projects, and becomes to a certain extent pendulous. 
The gross appearances of the tumor in either region, should be 
sufficiently characteristic to render a diagnosis easy. Any doubts, 
however, can easily be cleared up by removing a portion of the 
growth, and subjecting it to a microscopic examination. They 
seem to be more frequent in females than in males, and belong to 
Fig. 113.—Papilloma of the Nasal Mucous Membrane. (Zuckerkandl.) 
early adult life, although no age is exempt from them. According 
to Hopmann, the soft variety is much more common, and arises 
invariably from the lower turbinated bodies. The hard variety, 
as before stated, occurs near the muco-cutaneous junction, and 
may spring from the septum, floor, or the inner face of the ala. 
The gross appearance of a small soft papilloma is well illustrated 
in Fig. 113. 
PROGNOSIS.—These growths develop somewhat slowly, and in- 
volve no serious danger either to health or to life. In Ward’s case, 
death resulted from pneumonia twelve days after the growth was 
operated upon, while in Verneuil’s case, death seems to have re- 
sulted from an extension of the tumor. With these exceptions, 426 
DISEASES OF THE NASAL PASSAGES. 
the treatment of these cases has always been successful. Verneuil’s 
case, although unique, is of interest in showing how even so benign 
a tumor may involve very grave danger. The patient was a female 
aged twenty-nine, in whom the growth had existed for two years, 
giving rise merely to stenosis, without any other notable symptoms. 
Access to the tumor was obtained by an incision through the ala 
of the nose, and the growth removed by a curette and sharp spoon. 
Recurrence taking place three months later, the superior maxilla 
was partially resected, and the growth again removed by scraping. 
The patient reappeared sixteen months later, with a recurrence of 
the tumor in the nose, together with a pulsating tumor at the inner 
angle of the orbit, probably an encephalocele, which forbade further 
operative procedure. 
Treatment.—The soft tumors are to be treated in much the 
same manner as an ordinary nasal polypus, in that they are to be 
thoroughly extirpated in such manner as shall do the least injury 
to healthy structures, while at the same time any possible danger 
of stimulating the tissues to renewed morbid activity should be 
avoided. I think there is no question that this can be best accom- 
plished by means of the cold snare, in that it is more easily manip- 
ulated, accomplishes its work more thoroughly, and avoids the 
reaction which not infrequently attends the use of the galvano- 
cautery. The question of cauterizing the base of the growth, I 
think, should be governed entirely by a close observation of each 
individual case, and the recognition of any tendency to recurrence, 
although Aysaguer seems to attach a certain amount of importance 
to this procedure. With our present methods of working in the 
nasal cavity, and the great facility of manipulation and exploration 
afforded by the use of cocaine, and, furthermore, when we consider 
that all these growths are attached to, or near the lower turbinated 
bone, it is not probable that any case of papilloma cannot easily be 
brought under inspection and within reach of the snare. In the 
small hard variety, situated near the margin of the nostril, the 
growth is easily removed by the cold snare. If the snare cannot 
be used, there is no objection to . the use of either the scissors or 
knife. In this variety, it will probably be found best, in most in- 
stances, to cauterize the base of the growth. For this purpose, 
perhaps chromic acid or acetic acid will give the best results, in 
that they are the least irritating of the chemical agents used for 
this purpose. Furthermore, cauterization will often become neces- 
sary to control hemorrhage. 
In Ward’s and Verneuil’s cases, access to the cavity was ob- 
tained by means of an external operation. This is an exceedingly 
rare contingency, and was rendered necessary in these cases, largely 
by the long neglect of the patient in seeking professional advice. CHAPTER XXXII. 
ADENOMA OF THE NASAL PASSAGES. 
The nasal mucous membrane does not seem to be a favorable 
site for the development of this form of neoplasm, in that this tissue 
is but scantily endowed with glandular structures. As we have 
already seen, the special function of the glands and follicles in the 
mucous membrane, is to furnish it with sufficient moisture to keep 
it soft and pliable. The demand for this is exceedingly limited 
in the nasal cavity, whose lining is constantly bathed by the 
serous exosmosis, which constitutes the respiratory function of the 
nose. Hence, with an exceedingly small number of glands, whose 
function is by no means active, the tendency to the develop- 
ment of glandular tumors would naturally be but very slight, and 
in fact, it is a nice question, if from a clinical standpoint, they are 
ever met with in this region. An investigation of the literature of 
the subject shows us observations by Gosselin,1 and Pugliese.2 
Gosselin reports the following case: 
A man, aged 43, presented with the following history. Early in the year 
1857, he developed nasal stenosis, for which he sought relief at the hospital, 
early in the April following, when a number of polypi were removed. A second 
operation of the same character was done in October. In February, 1858, he 
was seen by Gosselin, who found the right nasal passage completely closed by 
a tumor, which presented at the nostril, and also projected into the pharynx, 
It was of firm consistency, and grayish in color, the surface being soft and 
pultaceous. It was attached in front and above. An operation being decided 
upon, access to the cavity was obtained by external incisions, and the growth 
extracted by means of forceps, and digital manipulation. The operation was 
attended with but slight hemorrhage. Microscopic examination showed the 
growth to be composed of “ abundant epithelial cells, with glandular cul-de- 
sacs,” on which the diagnosis of a glandular tumor was based. The operation 
was successful, and the patient left the hospital apparently cured. 
In reporting his case, Gosselin alludes casually to two others of 
a similar kind, which had been under his care, and in which there 
was a recurrence of the growth. Hence the question arose in his 
mind, as to whether tumors of this class were to be regarded as 
possessing any malignant tendency. Robin,3 writing on glandular 
tumors in general, refers to one of these cases of Gosselin, in which 
1 Moniteur des Hopitaux, No. 34, 1858, p. 275. 2 These de Paris, No. 68, Paris, 1862. 
. 3 Gaz. des Hopitaux, 1852, No. 12, p. 46. 428 
DISEASES OF THE NASAL PASSAGES. 
after recurrence, the tumor successively invaded the bodies of the 
ethmoid and sphenoid, the patient finally succumbing to an attack 
of meningitis. 
Pugliese, under the title “Adenomata of the Nasal Cavity,” re - 
ports a case which came under the observation of Verneuil, as 
follows: 
A female, aged 65, presented with the following history: Eighteen months 
before, she noticed a slight tumor over the left lachrymal sac, which, slowly in- 
creasing in size, had resulted, at the time she came under observation, in pro- 
ducing exophthalmos, together with divergent strabismus, and was the seat of 
considerable pain. The skin over the growth was discolored, and the nasal 
process of the superior maxilla was eroded. There was no nasal stenosis, 
epistaxis, or discharge. An external operation was done, and the growth ex- 
tirpated, it having invaded the external wall of the nasal cavity, and the 
antrum of Highmore. The microscope revealed the greater portion of the 
tumor to be composed of large numbers of tubular racemose glands, lined with 
nucleated epithelium somewhat crowded together, giving rise in some portions 
to a distention of the glands, verging on cystic degeneration, but the whole 
tissue showing evidences of nothing but true glandular hypertrophy, although 
in some parts, the extensive cell-proliferation had resulted so far in disorganiz- 
ing the gland structure, as to give rise to the suspicion, that the growth might 
be epithelioma. An operation was successful, and no recurrence was reported. 
It cannot be questioned, that this case was one of glandular 
tumor, although not properly of the nasal cavity, for it undoubt- 
edly commenced in the lachrymal sac. 
As regards Gosselin’s cases, we have a history of recurrence in 
two, while there is no further record of his last case after leaving 
the hospital. There are two views to be taken in regard to this. 
One is that these were cases of Billroth’s cylindroma, or glandular 
epithelioma, or that they were adeno-sarcoma. The rapid devel- 
opment of the growth, however, would seem to militate against the 
view that they were cylindroma, as the clinical history of this form 
of neoplasm usually extends over a long period of years. I think 
then that we must conclude that they were cases of adeno-sarcoma, 
a view which entirely harmonizes with the clinical history of the 
cases, and the pathological descriptions given in the reports, espe- 
cially when we consider that this diagnosis was made between 
thirty and forty years ago, at a time when the classification of 
tumors, based on microscopic examination, was exceedingly im- 
perfect. Certainly, until further clinical evidence of the fact has 
been established, we must conclude that unmixed adenoma does 
not occur in the nasal cavity, and that where glandular tissue is 
met with in a neoplasm, it is purely adventitious, and the clinical 
significance of the growth is to be determined by the preponderance 
of other elements, as in adeno-sarcoma, adeno-carcinoma, adeno- 
fibroma, adeno-myxoma, etc. CHAPTER XXXIII. 
CYSTOMA OF THE NASAL PASSAGES. 
A CYSTIC tumor, as involving the mucous membrane in the 
upper air-passages, probably arises in all cases from the adenoid 
tissue of the membrane, either as the result of degenerative changes, 
or from retention of the normal secretion. Now, as we have 
already seen, morbid changes in the glandular structures of the 
pituitary membrane, from a clinical point of view, scarcely ever 
occur. Hence, we can easily understand how a cystic tumor in 
this region is among the rarest of occurrences. The only record 
I find of such a neoplasm having been met with are those reported 
by Johnson,1 Watson 2 and Lefferts.3 
The first of these occurred in a male, aged 24, who had suffered for two years 
from nasal obstruction, with moderate symptoms of ordinary catarrhal disease, 
which an examination revealed to be due to the existence of a grayish semi- 
opaque tumor, the size of a marble, which was pendent from the posterior ex- 
tremity of the middle turbinated bone, projecting somewhat into the pharynx. 
It wras lacerated and emptied, by means of the forceps, and found to contain a 
glairy fluid, resembling the white of an egg. The mere crushing seemed to 
completely dissipate the growth, in that there was no recurrence at the end of 
ten years. 
Watson’s case was that of a girl, 15 years of age, who had been troubled 
with a discharge from the left nostril for several years, together with steadily 
increasing stenosis of this side. Examination revealed a polypus, which arising 
in the region of the middle turbinated, had displaced the nasal process of the 
superior maxilla outward, to a certain extent. The growth was removed with 
the snare, and was found to be a multilocular cyst, some of the cavities being 
as large as a split pea. These cavities contained mucus and columnar epithe- 
lium. No regular lining membrane could be made out. It is of interest to 
note, that, after some time, a tumor appeared high up in the opposite nostril. 
No operation was performed, and the patient was lost sight of. 
Lefferts’s case occurred in a young woman, and differed in no 
respect from Johnson’s. 
This form of neoplasm would, therefore, seem to be simple in 
character, and easily dealt with, giving rise to no notable subjective 
1 Brit. Med Journal, May 23d, 1874, p. 677. 
2 Proceed. Med. Soc., London, vol. iii., p. 134. 
3 Medical News, Phila., December 15th, 1883, vol. xliii., p. 65-3. 430 
DISEASES OF THE NASAL PASSAGES. 
symptoms, other than stenosis with catarrhal discharge. It appar- 
ently presents no appearances which render it easy to distinguish 
it from an ordinary nasal polypus, other than the fact that it occurs 
singly, although perhaps a careful examination will reveal the fact 
of its containing fluid contents. In this connection, however, there 
should be borne in mind the possibility of the occurrence of a 
meningocele, as in a case reported by Cruveilhier,1 where the men- 
inges of the brain protruded into the nasal cavity, giving rise to the 
appearance of a nasal polyp, the true condition being only recog- 
nized after death. The presence of pulsation in the growth, to- 
gether with the existence of cerebral symptoms, should be suffi- 
cient to excite suspicion. It would seen from a clinical standpoint 
that they are to be treated in much the same manner as an ordinary 
nasal polypus, without requiring the nicer manipulation necessary 
in dealing with myxoma, to prevent recurrence. 
1 “ Anatom. Pathol, du Corps Humain,” Paris, 1835-1842, t. ii., livraison xxvi., 
PP- 5, 6. CHAPTER XXXIV. 
ANGIOMA OF THE NASAL PASSAGES. 
CONSIDERING the highly vascular character of the nasal mucous 
membrane, together with the activity of its functional processes, 
we would naturally suppose it to be a favorable site for the de- 
velopment of angiomatous tumors, yet as a matter of clinical fact, 
they occur very rarely in this region, if the paucity of the literature 
on the subject is to be accepted as evidence. The records embrace 
only observations by Verneuil,1 Wagner (two cases),2 Steinbriigge,3 
Seiler,4 Richet,5 Roe,6 who has given us an excellent resumb of the 
subject, Jarvis,7 Vanderpoel,8 and Burckhardt.9 In addition to these, 
we find embraced in Roe’s tables, reports of cases by Nelaton,10 
Huguier,11 Panas,12 Guyon,73 Dumenil,14 a second case by Richet,15 
and a case by Delavan.16 
An examination of the original papers, however, fails to justify 
Roe in reporting them as angiomata, as in no single instance did 
these writers even suggest this diagnosis. The growths apparently 
were cases of highly vascular myxomata or fibromata, with the 
exception of Panas’s and Richet’s cases, in which the post-mortem 
examination demonstrated a connection between the nasal growth 
and the cavernous sinus, indicating the tumor to be probably a 
varix, rather than an angioma. We thus find our clinical knowl- 
1 Annal. des mal. de l’oreille, vol. i., p. 169. 
2 “ Diseases of the Nose,” N. Y., 1884, pp. 149, 150. 
3 Zeit. fur Ohrenheilkunde, vol. viii., p. no. 
4 American Specialist, Phila., 1881, vol. ii., p. 7. 
5 Cited by Debrie, These de Paris, No. 5, 1882. 
6 Trans, of the Amer. Laryngological Assn., 1885, p. 94. 
7 International Journal of Antiseptics, vol. i., p. 1. 
8 Cited by Jarvis, loc. cit. 
9 Bericht fiber die Chirurgische Abtheilung des Ludwigs-Spitals, Charlottenhilfe 
(1884), 1885, 11. 
10 Cited by Beuf, These de Paris, No. 69, 1857, pp. 21, 25. 
11 Bull, de la Soc. de Chir. de Paris, 2 S. i., p. 7 ; seance of January 4th, i860, 
12 Bull, de la Soc. Anat. de Paris, 1872, vol. xlvii., p. 435. 
13 Bull, de la Soc. de Chir. de Paris, 3 S. vol. ii., p. 356 ; seance of June 25th, 1873. 
14 Ibid., p. 339, seance June 18th, 1873. 
15 Cited by Debrie, op. cit. 
16 Arch, of Laryngology, vol. iii., p. 174. 432 
DISEASES OF THE NASAL TASS AGES. 
edge of this form of neoplasm, must be based on the records of 
but ten cases, indicating an exceeding rarity of occurrence. 
ETIOLOGY.—The essential pathological lesion, which seems to 
govern the development of this form of neoplasm, does not seem 
to be primarily in a disturbance of the circulation, or in any con- 
dition which leads to a distention of the normal blood-vessels, but 
it is rather to be looked upon as due to some disturbance in the 
process of nutrition in the vascular walls themselves. Hence, the 
suggestion of Steinbriigge, that interference with the return circu- 
lation may be a cause, is scarcely to be accepted, nor that of John 
Mackenzie,1 who suggests that a plethoric condition of the turbi- 
nated tissues may act as a predisposing cause, especially when we 
consider the great frequency of turgescence of these tissues, and 
the exceeding rarity of angiomatous tumors. We are unable, there- 
fore, to assign any definite cause, either active or predisposing, for 
the development of these neoplasms. Of the cases reported, eight 
wrere males, and but two were females. Most of the cases occurred 
during the earlier period of life, although no age seems to be ex- 
empt, Roe’s case occurring in a man aged sixty-eight. 
Symptomatology.—The symptoms which arise from the pres- 
ence of these growths in the nose, are largely mechanical, nasal 
respiration being interrupted, according to the size of the tumor, 
while its presence also excites a certain amount of muco-purulent 
discharge. As would be naturally inferred, their presence is at- 
tended with frequent attacks of epistaxis, although this rarely 
seems to be of a violent character, and yet its frequent recurrence 
may lead to a notable impairment of the general health. Exter- 
nal deformity, dependent on any dislocation of the hard parts, is 
never present, although where the growth projects near the nostril, 
a spreading of the soft parts may occur. In short, an angiomatous 
tumor of the nasal cavity gives rise to the same train of symptoms 
which would be met with in connection with any benign growth, 
of soft and yielding consistency. 
PATHOLOGY.—This form of tumor is composed almost entirely 
of blood-vessels, held together by a slight network of connective 
tissue. Their mode of development is not known. Their start- 
ing point may be in a primary dilatation of the normal vascular 
structures, or what is more probable, we may have an excessive 
activity of the normal nutritive processes, by which the normal 
blood-vessels are formed. This process results in the formation 
of a tumor, in which nutritive activity expends itself, as it were, in 
developing the walls of the blood-vessels, leaving no energy for the 
development of the other elements of the tissue. The vascular 
1 Trans. Amer. Laryngological Assn., 1885, p. 98. ANGIOMA OF THE NASAL PASSAGES. 
433 
walls produced in this way, are necessarily feeble, and possess slight 
powers of resistance. The course of each blood-vessel is marked 
by dilatation, and the formation of even large spaces, as it were, 
scattered throughout the growth. An examination of the tissue 
under the microscope (see Fig. 114), will show a network of wavy 
connective tissue, in some places densely packed together, and in 
other places of exceedingly delicate structure; these bands sur- 
rounding spaces, as it were, of varying sizes, each space indicating a 
blood course, and yet ordinarily the blood-vessels in their continuity 
cannot be traced. Many of these blood spaces are lined with epi- 
thelium, while in others this element is entirely absent. The outer 
surface of the tumor shows evidences of the development of a 
Fig. 114.—Cavernous Angioma with Glandular Hyperplasia of Nasal Mucosa. E, columnar ciliated 
epithelium; C, C, hyperplastic fibrous connective tissue, with capillary blood-vessels; A, hyperplastic 
acinous mucous glands; V, V, cavernous veins, partially filled with blood. 
capsule, which seems to be of later growth, while above this, we 
find the superficial layer of the mucous membrane, the gland struc- 
tures seeming to have undergone partial or complete degeneration. 
No portion of the nasal cavity seems to be exempt from these 
growths, in that they may spring from either the lower or middle 
turbinated bodies, or from the septum, but they usually occur 
rather nearer the anterior nares. 
DIAGNOSIS.—These growths usually present appearances suf- 
ficiently characteristic to make their recognition comparatively 
easy. Their surface .is somewhat irregularly rounded, and presents 
a reddish or purplish hue, which indicates unmistakably their highly 
vascular character, a lighter red color, indicating usually, a larger 
element of arterial blood in the growth. The fluid character of 
the contents of the growth is further evidenced by manipulation 
with the probe, which shows them easily indented. This matter DISEASES OF THE NASAL LASS AGES. 
434 
of examination, however, should be accomplished with great care, 
in that they are easily punctured by the probe, whereby hemor- 
rhage of an exceedingly troublesome character may supervene. If 
they are within reach of the finger, or even by ocular inspection, 
pulsation of a more or less decided character may be recognized. 
There is probably no growth which might lead to an error in diag- 
nosis, unless possibly as in Panas’s and Richet’s cases, that of a 
varix, springing from the base of the brain. This condition, how- 
ever, would be indicated by the existence of symptoms referable 
to the brain. 
COURSE AND Prognosis.—These growths develop slowly, and 
run a somewhat protracted course, of usually from two to five years. 
They involve usually no danger to life, and are ordinarily amena- 
ble to surgical treatment, their removal not being attended with 
any great danger, while there is no tendency-to recurrence. In 
Verneuil’s case, death occurred four years after the removal of the 
growth, from extreme cachexia, but probably not as the result of 
the tumor, while in Richet’s case, death occurred twelve days after 
an attempt at removal of the tumor by means of forceps, which 
was attended with profuse hemorrhage, an accident which was, per- 
haps, due in part to the use of the forceps. 
Treatment.—These growths can easily be removed through 
the natural passages, a procedure which ordinarily is attended with 
no great difficulty. The only danger to be anticipated lies in the 
excessive hemorrhage which may attend the operation. Hence, 
the prominent indication is to remove them by such means as will 
best avoid this accident. It is scarcely necessary to say, that the 
forceps never should be used. Perhaps no device will accomplish 
their removal more safely than the snare, either the cold wire or 
the galvano-cautery, and of these two devices, on every ground, 
Jarvis’s cold wire dcraseur should be preferred, in that it can be 
manipulated with greater ease, and after the loop has been placed 
in position, the attachments can be severed by so slow a move- 
ment as that much of the hemorrhage can be avoided. This is a 
point on which Jarvis laid special emphasis in reporting his case, 
he having occupied three hours in tightening his loop, thus accom- 
plishing the manipulation with the loss of but a few drops of blood. 
Furthermore, if possible, it is a matter of some importance that 
the loop should be adjusted well down upon the pedicle of the 
tumor, in that, of course, there is greater danger of hemorrhage in 
cutting through the body of the growth, although this may occa- 
sionally become necessary, on account of the size of the tumor. CHAPTER XXXV. 
CHONDROMA OF THE NASAL PASSAGES. 
THIS is a term which seems to have been used somewhat care- 
lessly in late years, since the nasal cavity, and especially the mor- 
bid conditions of the nasal septum, have become the subject of so 
much active investigation, and undoubtedly many cases which are 
called enchondroma, or ecchondroma, are nothing other than sim- 
ple deformities or deflections of the nasal septum. Thus, in treat- 
ing this subject, Mackenzie1 refers to a case of this character re- 
ported by Erichsen,2 which, without question, was one of deflected 
septum. The same can be said of Bryant’s,3 Ure’s,4 Richet’s,5 and 
Durham’s6 cases. 
The use of this term should be restricted to that large, round, 
nodulated tumor, so very rarely met with in the nose, which pre- 
sents all the clinical characteristics of a fibroma, and yet which, on 
examination, is found to contain hyaline cartilage. Undoubted in- 
stances of this form of growth have been reported by Verneuil,7 
Devalz,8 Ashhurst,9 and Mackenzie.10 
We find, therefore, that the nasal cavities do not present favor- 
able conditions for the development of cartilaginous tumors. Thus, 
Weber, out of three hundred and seven cases of solid tumors of the 
upper jaw, found enchondroma but eight times, and in two hun- 
dred and sixty-seven cases of cartilaginous tumors in all portions 
of the body, the upper jaw was involved in but eight cases. 
We can assign no cause for the development of these growths, 
although they seem to belong to the period of adolescence, viz., 
from eleven to seventeen years of age. When present, they give 
rise to much the same train of symptoms as are met with in fibroma, 
viz., nasal stenosis, muco-purulent discharge which may be offen- 
1 “ Diseases of the Throat and Nose,” Am. ed., Phila., 1884, vol. ii., p. 379. 
2 Lancet, 1864, vol. ii.. p. 153. 3 Lancet, 1867, vol. ii., p. 225. 
4 Lancet, 1861, vol. i., p. 411. 5 Cited by Casabianca, These de Paris, 1877. 
6 Holmes’s " System of .Surgery,” London, 1876, vol. iv., p. 319. 
7 Cited by Spillman: 11 Diet. Encyc. des Sciences Medicales.” second series, vol. xiii., 
p. 184. 
8 Gaz. Med. de Bordeaux, 1873, p. 105. 
s Tr. Path. Soc., Phil., vi., 146. 10 Op. cit., p. 380. 436 
DISEASES OF THE JVASAL PASSAGES. 
sive as the result of retention, together with marked external de- 
formity, although neither epistaxis nor pain occurs. Their devel- 
opment is even slower than that of fibroma. In Mackenzie’s case, 
there was no external deformity, although in Verneuil’s case, after 
a long lapse of time, the facial deformity was very marked. In 
structure, they are composed of hyaline cartilage, usually com- 
bined with white fibrous, and some yellow elastic tissue, generally 
distributed on its surface. In Verneuil’s case the tumor was sessile 
in character, while in Mackenzie’s it was somewhat pedunculated. 
They are easily recognized by their exceeding great density, and 
also by their immobility. They are of a yellowish pink color, ir- 
regularly nodulated surface, and present a hard cartilaginous sen 
sation to the touch. They can be readily distinguished from an 
osteoma by means of the needle, although they may easily be con- 
fused with a fibroma, recognition only being made by an exami 
nation of a portion of the growth, after removal. In discussing 
these tumors in general Devalz states, that in most instances they 
occur in young subjects, and are usually not larger than a grain of 
corn, but may attain sufficient size to seriously impede respiration. 
They are ordinarily situated at the junction of the cartilaginous 
septum with one of the alar cartilages, that is, at the anterior, infe 
rior angle of the cartilaginous septum. He mentions this situation, 
and the form of the tumor, as points in differential diagnosis be- 
tween this affection and deviations of the septum. 
The prognosis is usually good, in that the growth appears to 
be quite amenable to surgical interference. In Verneuil's case an 
external operation was done, with entire success, while in Macken 
zie’s case the tumor was extirpated by means of the cold snare, 
manipulated through the natural passages. They seem to show no 
disposition to recurrence. The method of removal is to be deter- 
mined by the size and character of the growth. Of course, where 
feasible, this should be done by means of the cold snare, although 
the curette, or even gouge, can be used with impunity, as the oper 
ation is never complicated by hemorrhage from the growth itself. CHAPTER XXXVI. 
SARCOMA OF THE NASAL PASSAGES 
While the early writers on medicine included all varieties 
of neoplasms of the nose under the general head of polypi, 
they found little difficulty in making a distinction between their 
malignancy and non-malignancy. Thus Hippocrates described 
five varieties of polypi, one of which he regarded as a kind of can- 
cer, a classification of nasal growths which was adopted up to the 
time of Ambrose Pare. Under this general term of cancer, how- 
ever, were embraced all forms of malignant tumors, including the 
various forms of carcinomata, as well as what are now termed sar- 
comata. The distinction which has been made, in our day, between 
carcinoma and sarcoma, becomes a matter of no little importance, 
for whereas they both are to be regarded as malignant growths, 
they differ in a marked degree, not only in their course and clini- 
cal history, but also in their prognosis. Sarcoma is by no means 
frequently met with in the nasal passages, and its literature is 
somewhat limited. I have thought it wise, therefore, to give a 
brief resume of all the cases reported, with the view, that, in this 
manner, we shall obtain a better and fuller comprehension of its 
clinical significance, history, and tendencies. In many of the cases, 
when the diagnosis has been obscure, I have been compelled to 
assume the responsibility of assigning the case to either the sarco- 
matous or carcinomatous group, according to my own estimate of 
its clinical history. 
Case I.—Reported by Pelleta.1 This was the case of a young man who died 
in coma, having previously suffered from severe pains in the head, the source of 
which does not seem to have been suspected. Post-mortem examination, how- 
ever, revealed the existence of a large tumor, which springing from the septum 
had completely filled the right side of the nose, destroying the cribriform plate 
of the ethmoid and invading the cranial cavity, where a tumor the size of an 
egg was found, that had pressed upon and partly destroyed the right lobe of the 
cerebrum. The case was originally reported as one of polypus, but Casabianca 
regarded it as an undoubted case of sarcoma. 
1 “ Exercit. Pathology’ Milan, 1820, p. 7. (As cited by Casabianc-a.) These de 
Paris, 1877. 438 
DISEASES OF THE NASAL PASSAGES. 
Case II.—Van Buren1 has reported a case, as cancer of the nose, which so 
strikingly illustrates the characteristic clinical features of sarcoma, as to show 
with little question that the growth was really a sarcoma. The microscope, 
moreover, revealed the tumor to be composed of spindle cells. The patient 
was a woman, aged 34, who eight years previously had a violent attack of epis- 
taxis, followed by a similar accident a year later, together with notable ste- 
nosis. Shortly after this, a number of polypi were removed, the operation being 
attended with hemorrhage of a dangerous character. For four years following, 
the progress of the tumor seems to have been controlled by the application of 
caustics, after which it took on a renewed activity, resulting in great deformity 
of the nose, with absorption of the nasal bones. Ligation of the right common 
carotid was finally resorted to, with the hope of arresting the growth, appar- 
ently with success, for the size of the tumor seemed to diminish notably, 
although the patient died eighty-two hours after the operation. An autopsy 
showed the growth to have sprung from beneath the lower turbinated bone, 
and to have filled the nasal cavity, successively invading the antrum and eth- 
moid cells. 
Case III.—Reported by Michaux ;2 this was the case of a male, forty years 
of age, in whom a nasal tumor, which had existed for about nine months, 
giving rise to stenosis of the right nostril, frequent attacks of epistaxis, facial 
neuralgia, and displacement of the eyeball with consequent diplopia, was re- 
moved successfully, after extirpation of the superior maxilla. The patient is 
said to have been cured, although apparently not seen later than forty days 
after the operation. 
The case is reported as one of cancer, but its clinical history seems to in- 
dicate that it was more probably one of sarcoma. 
Chassaignac3 reports the following case, which both from its 
clinical history and the microscopical appearances of the growth, is 
evidently one of sarcoma. 
Case IV.—A male, aged 40, ip February, 1851, had a violent epistaxis, fol- 
lowed by a similar attack eight months later. Four months afterward, he 
discovered a tumor in the nasal cavity, which was operated upon in March, 
1852. A recurrence occurred in the following July, as evidenced by nasal ste- 
nosis, with headache, and repeated attacks of epistaxis. In May, 1853, there 
was complete stenosis. A second operation was done in September of that 
year, with relief to all the symptoms, although six weeks later, the return of 
the tumor was evidenced by the return of his headaches. The growth devel- 
oped rapidly now, resulting soon in complete stenosis, with notable deformity 
of the external nose. In January, 1854, he was seen by Chassaignac, at which 
time both nasal cavities were completely filled with a soft fungoid growth, 
which could be seen anteriorly, and felt by the finger in the posterior nares. 
This case is of interest also, in the fact that Chassaignac here devised and 
first put in practice his operation for gaining free access to the nasal passages, 
by tilting the external nose to one side. The entire growth was extirpated, 
and found to involve the nasal cavities, together with the frontal and maxillary 
sinuses. The tissue was found to be fibro-plastic in character. The patient 
left the hospital a month later ; the further history not being reported. 
1 New York Journal of Medicine, 1849, vol. ii.. p. 297. 
2 Gaz. Med. de Paris, 1849, No, 48, p. 931. 
3 Moniteurdes Hopitaux, Paris, 1854, vol. ii., p. 266. SARCOMA OF THE NASAL PASSAGES. 
439 
Case V.—Gosselin 1 reports the case of a female, aged 38, who presented 
with a history of nasal tumor, dating back seven years, which had given rise to 
violent attacks of epistaxis. When seen, the tumor completely filled the nasal 
cavity, and extended to the pharynx behind, and gave rise to facial deformity 
and exophthalmos. Access to the cavity was obtained by splitting the nose in 
the median line, after which the growth was extirpated, and found to have had 
its origin in the floor of the nares. No recurrence.had taken place at the end of 
seven months. The diagnosis of sarcoma was based on the gross appearances 
of the tumor. 
Case VI.—Erichsen2 reports as sarcoma, a case of intra-nasal tumor, occur- 
ring in a male, 42 years of age, in whom the growth, arising from the nasal 
process of the superior maxillary bone, had in three months completely filled 
the left nostril. The growth had given rise to nasal stenosis and epistaxis. 
There was no glandular enlargement. The tumor was extirpated by an exter- 
nal operation. The subsequent history is not given. 
Case VII.—In 1868 we find recorded the history of a case by Fayrer,3 in 
■which a large growth was removed from the nasal cavity by Dieffenbach’s 
operation, in a woman aged thirty. Its origin was from the septum. The 
growth had existed for three years, and gave rise to considerable deformity of 
the external nose. The microscope showed the tumor to be composed of ger- 
minal cells. This was probably the first instance in which this form of nasal 
growth was recognized, in contradistinction from carcinoma. The result of 
the operation was not published. 
Case VIII.—Rabitsch4 reports a case of Dittel’s, in which the patient, a 
female about 15, had suffered for five months from a tumor in the throat, 
pressing the palate forward, and interfering with respiration. 
Five years before this, she had had a severe attack of epistaxis, and during 
the five succeeding years, she had been operated upon ten or twelve times for 
nasal polypi. 
On examination, the tumor was found to be pedunculated, and attached to 
the right upper turbinated body. It was removed through the nose, by means 
of the galvano-cautery snare. A microscopic examination showed it to be a 
branching-celled sarcoma, with considerable glandular tissue. No subsequent 
history of the case is given. 
Case IX.—A few years later we find Viennois3 reporting two cases. His 
first case was a woman, aged 43, in whom a myxo-sarcoma of the size of an egg 
was removed by Ollier’s operation, of depressing the nose. In this case, there 
was an extremely fetid discharge from the nose, with very severe suborbital 
pain, and exophthalmos. There was no recurrence at the end of seven years. 
His second case was that of a melano-sarcoma, in a woman aged 63, on whom 
the same operation was done, for a growth which had given rise to distortion 
of the external nose, with exophthalmos and intense supraorbital pain. This 
patient succumbed eight days later, to pyaemia. 
Case X.—A case is reported by Mason,6 of a myeloid sarcoma, which oc- 
curred in a woman aged 60, in whom the prominent symptom was hemorrhage. 
The growth was removed by means of forceps, and was found attached to the 
1 Gaz. des Hopitaux, 1856, xxix., p. 175. 
2 Lancet, 1864, vol. ii., p. 153. 
3 Med. Times and Gaz., July 4th, 1868, p. 3. 
4 Allg. Wien. Med. Zeit.. 1869, p. 382. 
5 Lyon Medicale, 1872, No. 18, p. 8. 
6 Med. Times and Gaz., 1875, vol. i., p. 552. 440 
B/SEASES OF THE NASAL PASSAGES. 
septum on one side. A recurrence took place at the end of two weeks. A 
second operation was now done, consisting of slitting up the nostril, and re- 
moving a portion of the nasal process of the superior maxilla, after which the 
growth was dissected out, and the base cauterized with chloride of zinc. Still 
another recurrence, two months later, necessitated the removal of a portion 
of the upper lip. At the end of four months there was no recurrence. 
Case XI.—In the same year we find Osio 1 reporting a case of melanotic 
sarcoma, occurring in a man aged 55, in which the tumor had apparently ex- 
isted for eight months. It had its origin in the outer wall of the right nasal 
passage, and subsequently invaded successively the opposite side, the antrum 
of Highmore, the orbit, and the sphenoidal sinuses, giving rise to deformity of 
the external nose, nasal stenosis, pain, exophthalmos, and injection of the con- 
junctiva. A radical operation was attempted, followed, at the end of seven 
days, by the death of the patient from meningo-encephalitis. 
Case XII.—In the same year Kolaczek2 operated on a case of round-celled 
sarcoma, in a man aged 54, which had existed for a year, and given rise to a 
considerable distortion of the external nose. His operation consisted in slit- 
ting up the nose in the median line, and removing the growth by the curette. 
Case XIII.—Weinlechner3 reports a case of a boy, aged 14, in which a sar- 
coma, starting in the nose, invaded successively the pharynx, orbit, and oppo- 
site side, giving rise to stenosis and exophthalmos. Death occurred as the result 
of the growth, no operation being attempted. 
Case XIV.—Grynfeldt4 has reported a case, in which a sarcomatous tumor 
was observed in a female, aged 26, which had apparently existed for six months, 
giving rise to repeated attacks of epistaxis. When first observed, it presented 
a small mass about the size of a pea, attached to the septum, just within the 
nostril. It was removed writh the forceps and scissors, and the base cauterized 
with chloride of zinc paste. A recurrence at the end of twenty days, demanded 
a second cauterization, and a similar recurrence a month later, was followed by 
a third repetition of this procedure. The disease recurring a third time, Gryn- 
feldt removed a section of the septum, operating through the natural passages, 
and cauterized the edges, which seems to have completely eradicated the dis- 
ease. The tumor was a mixed round and spindle cell sarcoma. 
Case XV.—Weinlechner3 reports a case of a male, aged 39, in which he 
removed a growth from one nasal cavity, which had existed for a year and a 
half, and produced a moderate amount of distention of the external nose, 
without noticeable deformity. The growth was removed by the curette and 
spoon, manipulated through the natural passages, and was found to be around- 
celled sarcoma. There was no recurrence at the end of a month. 
Case XVI.—Weber6 cites a case of a child, who died as the result of a sar- 
coma, which had been allowed to develop without operative interference. 
The autopsy revealed that the growth, springing from the region about the 
right middle turbinated bone, had extended along the lachrymal canal to the 
right orbit, while an independent centre of development was established on 
the opposite side, giving rise to a tumor over the left infra-orbital foramen. 
1 Rev. de Cien. Med., Barcel., 1875, vol. i.. p. 312; 1876, vol. ii., p. 22. 
2 Arch. f. Klin. Chir., Berlin, 1875, xviii., 344-346. 
3 “ Bericht der k. k. Krankenanstalt Rudolph-Stiftung in Wien” (1875), 1876, p. 350. 
4 Montpellier Medicale, 1876, vol. xxxvii., pp. 307 and 511. 
5 ‘'Bericht der k. k. Krankenanstalt Rudolph-Stiftung in Wien ”(1876), 1877, p. 314. 
6 “ Handb. der Allg. und Spec. Chir.,” Pitha and Billroth, vol. iii., p. 201. SAX COMA OF THE NASAL PASSAGES. 
441 
Case XVII.—Duplay1 cites a case of. fibro-sarcoma, in a woman aged 52 
years, in which the growth had apparently existed for twelve years, producing 
considerable distention and distortion of the nose. The cavity was opened by 
slitting up the nostril, and the tumor entirely eradicated. According to the 
report, there was no recurrence. 
Case XVIII.—In a case reported by Gallozzi,2 a sarcomatous tumor, which 
had existed for seven months, gave rise to an external deformity, with absorp- 
tion of the nasal bones, and the nasal process of the superior maxilla. The 
cavity was opened, by dividing the nose in the median line, a modification of 
Pean’s operation, and the growth extirpated, its attachment being to the ex- 
ternal wall. The subsequent history was not reported. 
Case XIX.—In a case reported by Sargent3 as having occurred in Pean’s 
clinic, the history would seem to indicate, that the starting point of the disease 
was in nasal polypi, the symptoms of which had existed for ten years, and for 
which the patient had been subjected to operative procedure, respectively 
three years, and nine months, previous to his appearance in the clinic, at which 
time a grumous-looking mass was found filling the left nasal passage, present- 
ing anteriorly, while posteriorly it filled both choanae. The patient was a male, 
aged forty-three. Free access was gained to the nasal cavity by Pean’s usual 
operation, and the growth extirpated. It was found that the tumor had in- 
vaded the antrum, which necessitated the removal of the anterior wall of the 
superior maxilla. The whole mass was eradicated, and the cribriform plate of 
the ethmoid bone scraped. The patient was discharged a month later, the 
subsequent history not being recorded. The growth was found to be a myxo- 
sarcoma. 
Case XX.—A somewhat unique clinical history is given in a case reported 
by Verneuil, as follows : A young man, aged 19, presented a history of repeated 
attacks of epistaxis, together with nasal stenosis, dating back six months. 
When first observed, the tumor was discovered filling the right nasal fossa. 
The removal of a piece, showed the growth to be sarcomatous in character. 
The internal administration of iodide of potash, together with local astrin- 
gents, seemed to diminish the size of the tumor, in that the nose became per- 
meable, while the epistaxis was less frequent. About this time, a slight ex- 
ophthalmos developed, followed soon by the formation of an abscess at the 
inner canthus of the right eye, together with headache, and some obscure 
brain symptoms, which afterward becoming more marked, the patient suc- 
cumbed. The autopsy revealed the fact that the orbital abscess communicated 
with a large abscess at the base of the brain, which was the result of extension 
of the sarcomatous disease through the cribriform plate. 
Case XXI.—Richet4 operated on a young man, aged 19, for a growth in 
the right nasal fossa, which had existed for four years, and gave rise to no 
marked symptoms, other than distention and deformity of the external nose*. 
The tumor had been previously operated on by forceps, but had recurred. 
Access to the cavity was obtained by means of Chassaignac’s operation, after 
which the growth was extirpated by means of a blunt hook. The subsequent 
history of the case was not published. 
Case XXII.—Mo3 has reported a case of fibro-sarcoma, occurring in a 
1 “ Traite Elem. de Pathologic Externe,” Paris, 1877, t. iii., p. 846. 
2 II Morgagni, 1878, vol. xx., p. 565. 3 These de Paris, 1881, No. 316, p. 41. 
4 Ann. des Mai. de l’Oreille et du Larynx, Paris, 1881, vii., 327-331. 
5 L’Osservatore, Gazetta delle Cliniche di Torino, 1882, vol. xviii., pp. 641-673 and 705. 442 
DISEASES OF THE NASAL PASSAGES. 
woman, aged 22, which had existed for one year, giving rise to nasal stenosis, 
sanious discharge, etc., and of late, notable deformity of the external nose, with 
facial neuralgia and exophthalmos. Access to the cavity was secured by 
means of Bruns’s operation, and the whole growth removed, no recurrence 
having occurred at the end of two months. 
Case XXIII.—An exceedingly interesting case was reported by Hopmann,1 
of a tumor which had existed for two years in a man, aged 44, occupying 
mainly the right side, although extending posteriorly into the left. The 
prominent symptoms were stenosis, with recurrent attacks of hemorrhage. 
Free access to the cavity was obtained by performing Bruns and Demarquay’s 
operation, after which the growth was thoroughly extirpated, by means of the 
curette. Its recurrence at the end of a month demanded a second operation, 
a third operation three months later, a fourth two months later, and a fifth 
five months later, finally resulting in the radical extirpation of the growth, no 
recurrence being reported. It should be stated, however, that Hopmann does 
not report this as a case of sarcoma, simply stating that the histological char- 
acter of the growth coincided closely with the “ Zottenkrebs” of Billroth, namely, 
an epithelial growth, with sarcomatous elements scattered through it, although 
Mackenzie2 and Moure3 included this case in their list of sarcomatous tumors. 
Case XXIV.—Trelat4 reports a case of sarcoma, in a man, aged 63, which 
had existed for two years, giving rise to epistaxis and deformity, in which 
pieces of the tumor were expelled spontaneously, which, on examination, were 
shown to be composed mainly of embryonic and glandular tissue. No opera- 
tion was performed in this case. 
Case XXV.—Burckhardt5 reports a case of melano-sarcoma of the nasal 
cavity, occurring in a woman aged 43. The patient had suffered from nasal 
stenosis, severe pain, and frequent hemorrhages. The growth involved both 
nasal cavities. Access to the growth was obtained by splitting the nose, and 
the growth was removed by means of the sharp spoon, and the finger. The 
subjective symptoms were improved for a short time, but there was recurrence 
five months after the operation. 
Case XXVI.—Terrier6 reports a case of a man, aged 45, in whom nasal ste- 
nosis existed for two years, due to a growth in the left nasal fossa, which was 
found to be a spindle-cell sarcoma, by the removal of a small piece, for micro- 
scopic examination. The prominent symptoms were external deformity, with 
fetid d ischarge, and severe neuralgic and epiphora. The cavity was opened 
by splitting the nose in the median line, and the growth removed. There was 
no return at the end of two months. 
Case XXVII.—Butlin reports a case of sarcoma in a woman, aged 78, 
which produced notable deformity of the external nose, with stenosis and 
epistaxis. Po.tions of the growth were removed by the galvano-cautery loop, 
but it was never thoroughly extirpated. 
Case XXVIII.—A case reported by Lincoln8 is interesting, in that two 
1 Arch, fiir Path. Anat., Berlin, 1883, Bd. xciii., p. 235. 
2 Op. cit. 3 Revue Mensuelle de Laryngol., 1886, pp. 417-425. 
4 Gaz. des Hopitaux, 1883, lvi., p. 210. 
5 “ Bericht fiber die Chir. Abtheilung des Ludwigs-Spitals Charlottenhilfe im Jahre 
1884.” p. 12. 
6 Ann. des Mai. de l’Oreille et du Larynx, Paris, 1884, x., 279-282. 
7 “St. Bartholomew’s Hospital Reports,” 1885, No. 21, pp. 147-152. 
8 Trans. Amer. Laryngological Assn, for 1885, N. Y., 1886, pp. 92-94. SARCOMA OF THE NASAL PASSAGES. 
443 
operations had been previously done, followed by recurrence, at intervals of 
two and eight months, for a melano-sarcoma, which had existed for three 
years, giving rise to epistaxis and fetid discharge, with external deformity. 
An operation was done by means of the galvano-cautery loop, the patient 
being under an anaesthetic, and the whole growth extirpated. Its attachments 
were found to be from the middle and lower turbinated bones and the floor of 
the nares. This patient was kept under observation for several months, for 
local cauterization and other treatment, with the result of the complete eradi- 
cation of the disease. 
Case XXIX.—Schmiegelow1 had an opportunity of seeing a case of sar- 
coma in a girl, aged 14, within two or three weeks after its development, 
which, at that time, presented a small, rounded, pulsating mass, attached to 
the septum, which he removed with his finger. The growth, however, recurred 
rapidly, causing almost complete stenosis in a few weeks, after which it was 
removed by means of the galvano-cautery. It was a round-cell sarcoma, and 
at the end of seven months it had not recurred. 
Case XXX.—In the same paper Schmiegelow2 reports a case, communi- 
cated to him by Max Schaffer, in which a man, aged 42, with mucous polypi in 
the nose, suffered also from a fibro-sarcoma of the naso-pharynx, which was 
removed by the galvano-cautery snare. An interesting feature of the case was 
that the mucous polypi took on sarcomatous degeneration, and showed a 
hemorrhagic tendency so great that the patient eventually died from epistaxis. 
There were also sarcomatous deposits in the viscera. 
Case XXXI.—Higgins3 reports a case of a male, aged 66, who fourteen 
years before had a severe attack of epistaxis; seven years later he had another 
attack which confined him to the house for four weeks. After this time, he 
had recurrent hemorrhages at intervals of four to six weeks. About six weeks 
before he came under observation, a tumor appeared at the inner cantlius of 
the left eye. On examination, the left nostril was found to be completely 
blocked by a neoplasm, while the tumor at the canthus of the eye was at this 
time about one inch in diameter, and was pulsating, although there was no 
bruit. The patient continued to suffer from hemorrhages until his death 
from pneumonia, which occurred one month after admission to the hospital. 
No operation was attempted. An autopsy revealed that the tumor was sar- 
comatous in nature, and had commenced in the nose, and spread along the 
lachrymal canal, and invaded the frontal minuses, the roof of the orbit having 
been entirely absorbed. 
Case XXXII.—The rapidity which a sarcomatous growth may take on, even 
in its early stages, is well illustrated in a case reported by Fowler,4 in which a 
growth of this character was observed in a boy, aged 16, which apparently 
had existed but for two weeks, and which in that time had developed notable 
deformity of the external nose, while the tumor protruded from the nares. A 
piece was removed, which showed the tissue to be an alveolar sarcoma. Its 
removal by means of the snare was followed by a recurrence at the end of 
two weeks, when Fourneaux-Jordan’s operation was done, with the result, 
apparently, of the complete eradiction of the growth, although the subsequent 
history of the case has not been reported. 
1 “ Tumeurs malignes primitives du nez Revue Mensuelle de Laryngologie, Paris, 
1885, pp. 421 and 482. 
* Loc. cit. 
3 “ Guy’s Hospital Reports,” 1884-5, London, 1886, third series, vol. xxxiii., pp. 91- 
102. 4 Lancet, 1885, vol. ii., p. 992. 444 
DISEASES OF THE NASAL TASS AGES. 
Case XXXIII.—Moure 1 was fortunate enough to observe a case, from very- 
early in its history, and to follow the entire progress of the disease to its ter- 
mination. A woman, 43 years of age, had suffered for about a year with suc- 
cessive attacks of epistaxis, and discharge of dry scales or crusts from the nose. 
She complained of no pain, and there was no external deformity. Anterior 
rhinoscopy revealed a tumor about the size of a cherry stone, attached to the 
right middle turbinated anteriorly, touching the septum but not adhering to 
it. The patient declined operation, and visited the sea-shore for her general 
health. The local symptoms, however, became worse, and when she presented 
herself a year and a half later, nasal respiration had become decidedly ob- 
structed, and there was a muco-purulent discharge from the affected nostril. 
Examination now showed the tumor completely occluding the nostril. Access 
to the cavity was obtained by Dieffenbach’s operation, and the neoplasm re- 
moved by means of the forceps and curette, and the base thoroughly scraped 
with the curette. There was no history of recurrence, at the end of seven 
months. 
Case XXXIV.—Calmettes and Chatellier2 report a case of a young woman, 
aged 30, who had suffered from epistaxis, with slight nasal stenosis, in infancy. 
These symptoms did not again present themselves until her twenty-third year, 
when they recurred, and the patient noticed a little excrescence in the left 
nostril. On examination, a tumor, the size of a cherry stone, was observed in 
the left middle meatus, attached to the cartilaginous septum. The growth 
was removed by the galvano-cautery snare, and measured 1 l/z centimetres in 
diameter. A portion of the surface was somewhat ulcerated. Microscopically, 
the mass of the tumor was made up of fusiform cells, and some fine fibrillae, 
thus identifying the growth as a spindle-celled fibro-sarcpma. The ulcerated 
surface was made up of a large number of round cells, with very little inter- 
cellular substance. The surface of the tumor was covered with flat epithelium. 
There was no recurrence at the end of eleven months. 
Case XXXV.—Weir3 cites a case of a fibro-sarcoma of the nose, occurring 
in a male, 42 years of age, who had been troubled for a year with nasal stenosis 
on the right side, and recurrent epistaxis. A tumor had existed in the right 
nostril, to his knowledge, for two months. On admission, the naso-pharynx 
was found free, the right side of the nose being occupied by the tumor. Ac- 
cess to the growth was obtained by Chassaignac’s operation, and a portion of 
it removed by means of the curette. It, however, was found to involve the 
sphenoidal and ethmoidal sinuses, and it was deemed unsafe to attempt com- 
plete extirpation. The patient recovered from the operation in two weeks, 
but six weeks later there was a recurrence of the tumor in the nose, and also 
extension of the growth into the cranial cavity. 
Case XXXVI.—Routier4 reports a case of a man, aged 24, who suffered at 
first with what he thought was an acute coryza, the symptoms, however, did not 
disappear, and the discharge gradually became tinged with blood. Nasal ste- 
nosis soon became complete, and he began to have severe attacks of epistaxis, 
especially after violent exercise. The sense of smell became entirely lost. Ex- 
amination revealed a tumor blocking up both nasal cavities, more especially 
the left. It could also be felt with the finger behind the palate. The disease 
1 Revue Mensuelle de Laryngologie, etc., 1886, pp. 417-425. 
2 Annal. des Mai. de l’Oreille, etc.. March, 1887, vol. xiii., pp. 89-92. 
3 N. Y. Med. Jour., March 12th, 1887, vol. xlv., p. 282. 
4 Revue de Chir., 1887, p. 62. SARCOMA OF THE NASAL TASS AGES. 
445 
had existed about thirteen months when he came under Routier’s observation. 
The growth wras removed by means of a curette, the finger being introduced 
through the mouth into the posterior nares, the palate having been divided 
vertically. Hemorrhage was profuse, but was controlled by pressure. There 
was no recurrence at the end of the month ; no subsequent history of the case 
is given. It is interesting to note that ozaena developed after the operation; 
this being explained by Routier by the fact that the pressure of the growth 
had caused atrophy of the turbinated tissues, and in consequence the nasal 
cavities were more open than normally. 
Case XXXVII.—Ficano1 reports a case of a patient aged 24, who had suf- 
fered from epistaxis for three months. Examination showed a moderate-sized 
pedunculated tumor, attached to the cartilaginous septum. The growth was 
not ulcerated, but bled easily on being touched. Its removal was effected by 
means of the cold snare. Microscopically, it was covered by a superficial layer 
of flat epithelium, the mass of the tumor being made up of spindle cells. 
Case XXXVIII.—Major2 reports a case in which a growth the size of a 
pigeon’s egg was removed from the triangular cartilage by means of the snare. 
The seat of origin was destroyed with the galvano-cautery. Microscopic ex- 
amination revealed the growth to be a spindle-celled sarcoma. There was no 
recurrence at the end of four months. 
In addition to these, the following cases have come under my 
own personal observation. 
Case XXXIX.—Was a male, aged 45, who came under my observation with 
a history of a growth in the nose, of comparatively slow development, which 
had existed for three years, and had been subjected to various plans of treat- 
ment, without arresting its development. Latterly there had been more or 
less violent attacks of epistaxis. When first seen, the nose was distorted, and 
completely blocked up by a dark bluish-gray, grumous-looking mass, which 
protruded from the left nostril. In connection with this, there was an offen- 
sive sero-sanguinolent discharge. Each attempt at removal was attended with 
violent hemorrhage. Notwithstanding this, the whole mass was removed by 
means of the cold snare, and the operations repeated at intervals of a week, 
until, at the end of six months, all tendency to recurrence had apparently dis- 
appeared. Four months later, however, recurrence took place, and the tumor 
grew with such rapidity that it became necessary to devise a more radical 
method ci removal. He returned, therefore, to his home in Philadelphia, 
where he was subjected to Ollier’s operation by Dr. Keen, and the growth 
extirpated. Recurrence took place at the end of about six weeks, death fol- 
lowing soon after, from exhaustion. The growth was a round-cell sarcoma, 
attached at first to the left side of the perpendicular plate of the ethmoid, but 
subsequently extended to the cribriform plate, the turbinated bones, and to the 
tissues in the opposite nares. 
Case XL.—Was a male, aged 48, who for a number of years had had nasal 
polypi. He consulted me November 4th, 1887, with the history of an offensive 
discharge from the right nostril, together with a tendency to repeated attacks 
of hemorrhage, which had existed for eight months. Several polypi were 
removed in this case by the snare, when a dark, grayish, grumous mass was 
discovered, attached apparently beneath the middle turbinated bone of the 
1 Gazz. d’osp., Milano, 1888, ix., No. 12, p. 90. 
2 Journal of Laryngology and Rhinology, vol. iii., p. 164. 446 
DISEASES OE THE NASAL TASS AGES. 
right side, which bled excessively with the slightest disturbance. In this case, 
after most of the growth was removed, it became necessary to abandon the 
snare, and resort to the galvano-cautery, on repeated applications of which 
the tumor was completely eradicated. At the end of a year, there has been 
no recurrence. The character of the growth was angio-myxo-sarcoma. 
Case XLI.—Was a gentleman, aged 47, who came under my care, with a 
history of having commenced to develop, two years previously, notable nasal 
stenosis, in connection with' frequent attacks of epistaxis. This had been 
found to be due to the existence of a sarcoma, which had been operated on 
upon two occasions, followed by recurrence at the end of from three to six 
months. When first seen by myself, there was very extensive deformity of the 
nose, with a large reddish-yellow mass protruding from the nostril in front, 
and also extending into the naso-pharynx. Under the influence of ether, this 
growth was eradicated, as far as possible, by means of digital manipulation, in 
connection with the curette, the operation being attended with excessive hem- 
orrhage. Subsequently, the passages were thoroughly gone over under ocular 
inspection, and every portion of suspicious tissue removed by the snare. This 
patient was kept under occasional observation, and no evidence of recurrence 
could be detected six months after the last operation. The character of the 
growth was an adeno-sarcoma, the attachment being upon the floor and outer 
wall, the turbinated bones being completely obliterated by pressure. 
The above cases have been detailed somew hat at length, with 
the idea that a rapid glance over the salient features of these cases, 
offers much of information on a subject, which has not been ex- 
haustively studied heretofore. 
In addition to the above it should be stated that Kuhn’ has 
reported a case, which occurred in the practice of Theulot, in 
which a large growth had existed in the nasal passages for thirty 
years, in a man aged sixty-eight, which for five years had projected 
from the nostril, hanging down as far as the chin. Kuhn reports 
this as a case of sarcoma, which was completely cured by an oper- 
ation, although the diagnosis is open to serious question. 
The same, I think, is to be stated in regard to Dalrymple’s2 
case, also cited by Kuhn, in which a similar growth was observed 
hanging from the nostrils, down to the upper lip, and which had 
existed for eleven years, the patient being a man aged forty-five. 
A radical operation is reported to have resulted in a complete cure. 
Etiology.—As regards the etiology of the affection, these cases 
afford but little information. In the second of my own cases, the 
sarcoma seemed to develop after the polypi had been operated on 
rather harshly, by means of forceps, while in Schaffer’s case the 
same conversion had taken place, apparently spontaneously, which 
1 “ De tumoribus narium sarcomatosis.” Vratislaviae, 1835. 
2 Im Magazin der auslandischen Literatur der gesammten Ileilkunde und Arbeiten 
des arztlichen Vereines zu Hamburg. Herausgegeben von Dr. G. H. Gerson, Marz, 
April, 1835. SARCOMA OF THE NASAL PASSAGES. 
447 
would seem to indicate the possibility of a spontaneous conver- 
sion of myxoma into sarcoma. 
That catarrhal inflammation of the nose may predispose to sar- 
coma, is possibly true, and, furthermore, would seem to be indi- 
cated in the fact that out of thirty-eight of the above cases, 
twenty-two are males, and sixteen are females, catarrhal disease 
being more common in males, owing to the greater exposure to 
which they are subject. 
A very noticeable feature of sarcoma of the nose, furthermore, 
is the age at which it seems to develop. Thus, in the above cases 
we find, while there were a few instances in elderly people, the 
very large proportion of them occurred earlier than the age of 
forty, the average being something less than thirty-nine, differing 
in this respect, in a very marked degree, from the clinical history 
of cancer, which develops, as a rule, late in life. We find, how- 
ever, that the average duration of the above cases was three and 
two-thirds years, which would bring down this percentage some- 
what, and also would seem to show that sarcoma runs a somewhat 
slow course when it develops in the nose. 
PATHOLOGY.—The structure of sarcoma of the nose differs in 
no essential respect from the same morbid process as developed 
in other portions of the body, except in so far as it is modified by 
the special tissue from which it develops. It should be easily rec- 
ognized by microscopical examination, and yet it must be borne in 
mind, that the normal membrane of the nose is exceedingly rich 
in lymphoid tissue, which oftentimes bears a somewhat confusing 
resemblance to the structure of round-celled sarcoma. In the third 
of my own cases (Case XLI.) the microscopic appearances were as 
follows: The growth was made up of connective tissue and of 
cells. The cells were of two kinds, round and ovoidal, and large 
granular cells. In some parts, the connective tissue fibres sur- 
rounded the cells in a manner suggestive of nests. This arrange- 
ment, however, was by no means constant, and on closer inspection, 
these nests were found to be lobules of the tumor. The surround- 
ing connective tissue constituted the trabeculae, dividing these 
lobules from each other. The mass of the growth, then, was made 
up of cellular elements. In certain portions, the normal gland struc- 
ture of the membrane had undergone a proliferation. In other 
words, a portion of the growth presented all the characteristics of 
an adenoma. The growth was therefore an adeno-sarcoma. See 
Fig. 115- 
In the second case (Case No. XL.) the growth was composed 
almost entirely of cells, some round, others the characteristic stel- 
late mucous cell. In this case, the walls of the blood-vessels were 448 
DISEASES OF THE NASAL PASSAGES. 
entirely lost, their place being supplied by large vascular spaces, 
running between the cells, the growth corresponding in microscopi- 
cal character to angio-myxo-sarcoma, apparently much the same 
thing as Kolaczek 1 designates as a perivascular sarcoma. 
In my first case (Case No. XXXIX.) the appearances found on 
microscopical examination were as follows: In some places, the 
tissue consisted of tubular glands, lined by columnar ciliated epithe- 
lium, closely packed together, to such an extent that but little con- 
nective tissue was seen between the tubules. This connective tis- 
sue was convoluted in all directions, and carried scanty capillary 
blood-vessels. This portion of the tumor was therefore an ade- 
noma. Other portions, however, showed the connective tissue 
Fig. 115.—Adeno-Sarcoma of the Nasal Mucosa. Case III. of the author (Case No. XLI.) G, G, 
hyperplastic glands; A’, A’, globular sarcoma corpuscles; A, Spindle-shaped sarcoma corpuscles; M, mem- 
brana propria transformed into spindle cells. 
between the tubular glands much augmented, and crowded with 
globular sarcoma corpuscles in all stages of development; a section 
from this portion of the growth is shown in Fig. 116, still other 
portions exhibited but scanty remnants of tubular glands. It is 
interesting to note, that as the case progressed, subsequent histo- 
logical investigation showed that the glandular elements entirely 
disappeared from the growth, which assumed the appearance of a 
typical, round-cell sarcoma. 
The ordinary round-celled or spindle-celled sarcoma, differs in 
no essential respect from the above, other than in the absence, in 
the one case, of the glandular, and in the other, the myxomatous 
elements. 
In the so-called melano-sarcoma, the color is due to the deposit 
of pigment in the cells, and in part, perhaps, to minute blood ex- 
1 Loc. cit. SAX COM A OF THE NASAL PASSAGES. 
449 
travasations, while in fibro-sarcoma we have a mixture of sarcoma- 
tous cells, with fibrous connective tissue, in varying proportions. The 
surface of the growth is sometimes covered with flattened epithe- 
lium, as in Calmettes’ and Chatellier’s case, which might prove mis- 
leading, did we not recognize the fact, that this appearance is due 
to the mechanical pressure upon the normal columnar epithelium. 
SYMPTOMATOLOGY.-1—The prominent symptom of the presence 
of a sarcomatous growth, as of every nasal tumor, is in the obstruc- 
tion of nasal respiration. Coincident, however, with this symptom, 
in the large majority of cases, occurs epistaxis, of a more or less 
violent character. This symptom seems to be strikingly character- 
Fig. 116.—Round-cell Sarcoma. Case I. of the author. (Case No. XXXIX.) X, S', globular bodies of 
varying sizes; J, scanty tracts of fibrous connective tissue; C, capillary blood-vessel. 
istic of sarcoma, as also of fibroid. In both these forms of growth, 
the hemorrhage is probably due, in many cases, to an erosion of 
the mucous membrane of the nose,, by the pressure of the tumor. 
In the sarcoma, however, I believe it is not infrequently due to an 
escape of blood from the growth itself, especially where the tumor 
presents a prominent angiomatous character. 
The discharge from the nose is of a sero-sanguinolent character, 
and usually gives rise to quite an offensive odor. The fetor is un- 
doubtedly due to retention of secretion, with decomposition of its 
organic constituents; while the source of secretion is mainly in the 
mucous membrane of the nose, and possibly, in part due to trans- 
udation from the growth itself. 
Deformity of the nose depends on the size and consistency of 450 
DISEASES OF THE NASAL PASSAGES. 
the growth, although a very soft and flabby tumor may produce no 
inconsiderable deformity, crowding the septum to one side, and 
forcing out the lateral walls of the external nose, both the cartila- 
ginous and the bony. 
DIAGNOSIS.—The gross appearance of the growth presenting 
in the nasal cavity, is a bluish-gray surface, with a soft flabby con- 
sistency, which should in all cases excite suspicion of the existence 
of a malignant disease, especially in connection with the repeated 
hemorrhages, which so frequently occur in these cases. The diag- 
nosis, however, will always depend upon the microscopic examina- 
tion of a portion of the growth, which will reveal not only its char- 
acter, but to a certain extent, the clinical tendencies. Furthermore, 
impact upon the growth with a probe will show it to be, to a cer- 
tain extent, movable in the nasal cavity, as the tumors are invaria- 
bly pedunculated. Mackenzie1 makes the statement that their 
usual attachment is to the septum, but we find them springing with 
about equal frequency from both the outer and the inner wall of 
the cavity. They occur, usually, as a single tumor, although 
Weber2 makes the rather curious statement, that sarcoma is usually 
accompanied by several deposits of the same neoplasm, in neighbor- 
ing regions. Certainly, there is no clinical evidence to support 
this view, and moreover, at the time Weber made this statement, 
the whole literature of nasal sarcoma was based on but few cases. 
PROGNOSIS.—An analysis of the cases above reported, would 
seem to indicate that about half of the cases recovered, and yet I 
am disposed to think that the prognosis is not so favorable, as our 
knowledge of the subsequent history of those cases is not suffi- 
ciently definite to warrant us in the conclusion that the disease 
was eradicated. Thus, in Mason’s case, our latest report is four 
months after the operation; in Weinlechner’s, one month; in Ter- 
rier’s two months, etc., and, furthermore, in some of the cases 
reported as cured, the time which had elapsed since the operation 
is not given at all. Hence, I think it is scarcely safe to say that so 
large a proportion of cases recovered, as a result of the operation, 
and yet sarcoma in the nose apparently does not present the same 
malignant tendencies as it does when found in other localities. In 
many instances, its progress is extremely slow, and apparently is 
arrested with ease. It should be stated in regard to many of the 
cases above reported, that even good results were accomplished by 
operative measures, which were not done with the nicety of man- 
ipulative skill which we now possess in treating cases of intra-nasal 
disease. Age seems to exercise a certain amount of influence on 
the prognosis of these cases, in that in advanced life the disease is 
1 Op. cit. 
2 Loc. cit. SARCOMA OF THE NASAL TASS AGES. 
451 
less amenable to operative interference than in youth. Aside from 
these considerations, our prognosis must be based on the extent of 
the disease, its duration, and especially on its apparent rapidity of 
growth. The character of the growth has an important bearing 
on the prognosis, in that a round-cell sarcoma is to be regarded as 
more malignant in its tendencies than the other varieties. Thus, 
in the cases reported above, all of those in whom a cure was 
effected, and where the microscopic character of the growth was 
known, were composed of other than round-cell tissue. In those 
cases where we find the sarcomatous elements intermingled with 
the normal tissue elements, as in fibro-sarcoma, myxo-sarcoma, 
adeno-sarcoma, etc., the prognosis is rendered less grave as the 
proportion of the normal elements increases in the tumor. The 
melanotic or angiomatous character of the neoplasm does not mod- 
ify the prognosis, otherwise than that the latter growth may be at- 
tended with excessive hemorrhage. 
Treatment.—There are no local applications which have the 
slightest effect on a sarcomatous tumor in the nose. The only 
treatment is the thorough and complete eradication of the growth, 
and this at the earliest period possible, without regard to the 
character of the tissue. If there is a marked hemorrhagic disposi- 
tion, as in the angiomatous tumors, the operation should be pro- 
ceeded with as rapidly as possible, without regard to the hemor- 
rhage, as this complication can be controlled, when its arrest 
becomes necessary. Furthermore, I think, ordinarily, the growth 
should be removed through the natural passages when it is feasible, 
although if better access to the nasal cavities is demanded, an oper- 
ation on the external nose does not necessarily complicate the final 
result. The growth may be extirpated by the curette, spoon, the 
cold snare, or the galvano-cautery loop. As a rule, these growths 
are exceedingly soft and friable, and their removal is not a thor- 
oughly surgical procedure in its details. Probably the cold wire 
loop, properly manipulated, affords the best method of removing 
the small tumors, and the larger growths, even, may be removed 
piecemeal by this method. This manipulation, certainly, is easier 
of accomplishment than the application of the galvano-cautery 
loop; and furthermore, I think it is a nice question oftentimes, 
whether the galvano cautery should be used, as I am convinced, 
from my own personal experience, that it may stimulate a sarco- 
matous tumor to renewed activity of growth. The essential thing 
is to get rid of the growth, and that as rapidly as possible, and the 
special instrument used is not a matter of great importance, but 
will be dictated by the choice and special manipulative skill of the 
operator. The most serious obstacle met with in these operations, 452 
DISEASES OF THE JVA SAL TASS AGES. 
is always the excessive hemorrhage. This is probably true in all 
varieties of sarcoma, and especially so of the angiomatous growths. 
The source of the hemorrhage is always from the tumor itself, and 
the indications are to get the growth out as rapidly as possible, and 
to get down to its attachments. When this part is reached, the 
hemorrhage, as a rule, ceases at once. In a rapid operation, then, 
either bimanual manipulation, by means of one finger in the 
nostril and one in the nares, will be resorted to, or the curette will 
be used through the nostril, its manipulation being aided' by the 
finger in the posterior nares. Routier,1 in order to facilitate this 
manipulation, made an incision through the soft palate; entirely 
unnecessarily, I think. In operating in this way it is necessary that 
the mouth should be held open by a mouth-gag, while an assistant 
stands ready to prevent the blood from flowing down into the larynx 
and trachea; although in many cases the choanae are sufficiently 
plugged by the growth itself, until the posterior attachments are 
thoroughly severed, after which, by tilting the head forward, the 
blood makes its escape from the anterior nares. After the growth 
has been removed, the subsequent hemorrhage is easily controlled, 
by packing the nose with one or more small sponges. 
The primary operation on these growths I regard as but the 
commencement of treatment, the more important part being the 
subsequent close watching of the cavity, to arrest and control any 
tendency to a reappearance of the growth. This watchfulness 
should be maintained for a prolonged period of time, at intervals of 
from one week to a month, until certainly from one to two years 
have elapsed. In those cases where the growth develops rapidly 
after operation, these minor operations must be repeated with 
greater frequency, according to circumstances. 
As regards the advisability of cauterizing the base of the tumor, 
by means of the galvano-cautery, or some one of the various chem- 
ical agents, I think this is oftentimes not only uncalled for, but 
mischievous, while in other cases their use would seem to be at- 
tended with the best of results. The only indication here, then, 
will be that any caustic agent for the control of sarcomatous re- 
currence, must be used with the greatest possible care, and its im- 
mediate effect watched. 
The primary operation is usually accomplished with a consider- 
able degree of rapidity, and hence, if a general anaesthetic becomes 
necessary, the first stage of chloroform anaesthesia is quite suffi- 
cient in duration for the accomplishment of the procedure. Of 
course, where the growth is smaller, local anaesthesia with cocaine 
is all that will be required. 
1 Loc. cit. CHAPTER XXXVII. 
CARCINOMA OF THE NASAL PASSAGES. 
It would seem that there is nothing in the morbid process which 
constitutes catarrhal inflammation, which favors the development 
of malignant disease, for while inflammatory action of the nasal 
mucous membrane is one of the most frequent of diseases, I think 
Grynfeldt’s1 view must be accepted, that a malignant disease in 
this region is one of the rarest conditions. That it does occur, 
however, as a primary disease in the nasal cavity, can scarcely be 
questioned, notwithstanding the assertion of Cornil and Ranvier2 
that there is no well-authenticated case of primary carcinoma of 
the nose. That it should be so rare in this region is probably due 
in some degree to the fact that the nasal mucous membrane, in- 
closed within its bony walls, is so thoroughly protected from any 
constantly acting traumatic or difectly irritating influences. Thus, 
as we have seen in regard to the mild form of malignant disease, 
which takes the direction of a sarcomatous tumor, the whole litera- 
ture of the subject embraces but a limited number of cases, while 
as regards carcinomatous disease, the number of cases which the 
literature affords is even smaller. As was done in the chapter on 
sarcoma, so in treating carcinoma, a brief resume of the cases re- 
ported is given, as affording perhaps a more graphic account of the 
disease in its various clinical features. That carcinoma may have 
its primary origin in the nasal cavity, I think, cannot be questioned, 
in face of the testimony of the following cases: 
Case I.—Reported by Seeliger.3 A male, aged 60, presented with a history 
of a growth in the nose, dating back about three months, which had given 
rise to stenosis and moderate discharge, together with severe left facial neu- 
ralgia. No attempt at removal was made, and the growth slowly developed, 
giving rise to marked facial deformity, together with attacks of epistaxis, 
and an exceedingly offensive discharge. The patient died a year after the 
first appearance of the growth. The malignant character of the disease was 
evidenced by its clinical history. 
1 Montpellier Medicale, 1876, vol. 37, p. 515. 
2 “ Manuel d’Histologie Pathologique,” Paris, 1869, p. 656. 
3 “ Beobachtungen und Abhand. aus dem Gebiete prak. Heilk. von Oesterr. Aerzten,” 
Wien, 1824, vol. iv., p. 469. 454 
DISEASES OF THE NASAL PASSAGES. 
Case II.—Reported by Earle.1 A male, aged 48, by occupation a sailor, 
was admitted to St. Bartholomew’s Hospital, with a history of epistaxis eigh- 
teen months previously, followed soon by the discovery of a tumor in the nose, 
which was removed by forceps, an operation which had been repeated twenty- 
three times, previous to his admission to the hospital, at which time there was 
external deformity, with a grumous mass protruding from the nose. Access 
to the cavity was obtained by splitting the external nose in the median line, 
and the tumor removed and its base cauterized. Recurrence took place at the 
end of forty days, followed by death a month later. The autopsy showed the 
tumor to have had its origin in the vomer, cribriform plate, and superior turbi- 
nated bone. The growth was designated as a fungoid tumor, although its car- 
cinomatous character was clearly evidenced by the fact that secondary depos- 
its were found in the liver, lungs, cellular tissue of the abdomen, and peri- 
nephritic tissues. 
Case III.—Reported by Hecker.2 A female, aged 46, presented with a his- 
tory of nasal stenosis, dating back three years, as the result of a tumor, which 
had given rise to repeated attacks of epistaxis, with notable neuralgic pains. 
Several operations had been done, followed by a recurrence. The nose was 
opened by external incisions, and the growth extirpated by means of the scis- 
sors and knife. It was found to be attached to the septum, extending well 
forward, involving the ala of the nose. Recurrence took place in the nasal 
cavity at the end of a few months, and the disease rapidly extended to the lip 
and cheeks, rendering further operative procedure hopeless. 
Case IV.—Reported by Pemberton.3 A boy, aged five, presented with a 
history of nasal polypi, dating back eleven months, and which had been oper- 
ated on with forceps previous to h'is admission to the hospital. When first 
seen, both nostrils were completely filled with a grumous mass, which projected 
into the pharynx posteriorly. The growth was removed by means of the for- 
ceps, and had the appearance of a medullary cancer. At the end of .three 
weeks the disease recurred, and was again operated on, followed by the death 
of the patient on the operating table. Post-mortem examination showed that 
the tumor had its origin in the nasal passage, and had successively invaded 
the antrum, ethmoid and sphenoid cells. This case was reported as a case of 
medullary cancer, although the diagnosis is open to serious question, as from 
the age of the patient it is more likely to have been a case of sarcoma. No 
microscopic examination was made of the tissue. 
Case V.—Reported by Lawrence.4 A male, aged 64, presented with a his- 
tory of a growth in the nose, dating back six months, which resulted in com- 
plete stenosis of both nostrils, with notable external deformity. Access to the 
cavity was obtained by a modification of Chassaignac’s operation, and the 
growth extirpated. It had produced absorption of the nasal bones, and was 
found to be confined entirely to the nasal cavity. Recurrence took place at 
the end of a month, the subsequent history not being given. The diagnosis 
of carcinoma was made from the gross appearances. 
Case VI.—Reported by Neudorfer.5 A female, aged 31, presented with a 
history of nasal stenosis, of eleven years’ standing, with notable external 
1 London Med. Gaz., 1827-28, vol. i., pp. 159-161. 
aArch. fur Physiologische Heilkunde, 1844, iii., p. 260. 
3 Provincial Med. and Surg. Journal, 1850, p. 519. 
4 Lancet, 1856, vol. i., p. 455. 
3 Oesterreich. Zeitschrift fur prakt. Heilk., Wien, 1858, iv., p. 305. CARCINOMA OF THE NASAL PASSAGES. 
455 
deformity, dating back three years. On examination, there was found a dense 
tumor, apparently continuous with the septum, completely occluding both 
nares, giving rise apparently to stenosis, with anosmia and deafness. The 
glands at the angle of the jaw were notably enlarged. Access to the cavity 
was gained by an external operation, when the tumor, about the size of a small 
walnut, was removed, which was found, upon microscopic examination, to con- 
sist of medullary carcinoma. The subsequent history was not given. 
Case VII.—Reported by Liebl.1 A male, aged 50, received an injury of the 
external nose, at the age of 37, which healed within two years, leaving an ulcer- 
ation at the angle of the right eye, which was operated upon unsuccessfully ; 
soon after which, a growth appeared in the nasal cavity proper, as evidenced 
by pain, external deformity, and nasal stenosis with exophthalmos. Access to 
the cavity was obtained by an external operation, and the growth removed. 
The subsequent history is not given. The diagnosis of medullary cancer was 
made, based on the gross appearances of the tumor. 
Case VIII.—Reported by Fleury.2 The patient was a male, 20 years of age, 
with no family history of malignant disease. In July, he was suddenly seized 
with pain in the right side of his face, and a few days after, noticed an increase 
in size of the nose, in the region of the right ala. Steadily increasing nasal 
stenosis became a prominent symptom, and in September there was exophthal- 
mos, and the neoplasm could be felt by the finger passed behind the palate. 
In the latter part of September, a violent cellulitis of the face supervened, 
giving rise to an abscess at the root of the nose, from which there was purulent 
discharge. The patient grew steadily worse, there was difficulty in deglutition, 
symptoms of compression came on, and the patient died on the 5th of October. 
An autopsy revealed a tumor, involving the cribriform plate and lateral masses 
of the ethmoid, and the body of the sphenoid. Pressure on the brain in this 
region had given rise to the symptoms of compression. The frontal sinus was 
opened, and the orbital and cranial cavities communicated in this way. There 
was no glandular enlargement. No microscopic examination was made of the 
growth, which was called a “polype fungeux ” (cancereux). 
Case IX.—Reported by Gosselin.3 This was the case of a male aged 58, 
who for several years had suffered from a tumor in the nose, which had given 
rise to attacks of violent epistaxis, with nasal stenosis and external deformity, 
together with exophthalmos. Two operations had been done, followed by 
recurrence. Gosselin split the nose in the median line, and extirpated the 
growth, which was found to consist of an epithelio-glandular polyp. The sub- 
sequent history was not reported. 
Case X.—Reported by Waldeyer.4 This is a case of a female, aged 50, 
operated upon by Middledorpf, for a tumor the size of a walnut, involving the 
septum narium, which the microscope showed to be typical carcinoma. The 
further details were not published, this being simply one of the illustrative 
cases which Waldeyer made use of, in his well-known series of papers on the 
development of cancer. 
Case XI.—Reported by Watson.3 A female, aged 60, presented with a his- 
tory having suffered apparently from ordinary nasal polypi, of some years’ 
1 Allg. Wien. Med. Zeit , 1861, vol. vi., p. 188. 
2 Gaz. des Hop., 1863, p. 522. 
3 Gaz. des Hopitaux, 1865, vol. xxxviii., p. 46. 
4 Virchow’s Archiv, 1872, vol. lv., p. 93. 
s “Diseases of the Nose,” London, 1875, p. 287. 456 
DISEASES OF THE NASAL PASSAGES. 
standing, which gave rise to a muco-purulent discharge. A few months pre- 
viously, there had developed exophthalmus, with lachrymal abscess. A portion 
of the polypoid mass was removed, which was found to be epithelioid in char- 
acter. No radical operation was done, and the patient died within the year. 
There was no autopsy. 
Case XII.—Reported by Watson.1 Watson also reports a case of a child, 
four years old, from whose nasal cavity Brodie removed a malignant tumor. 
The disease reappeared in various parts of the body, resulting in death at the 
end of six months. An autopsy revealed the growth to have originated within 
the nasal cavity, and successively to have invaded the antrum, cerebral surface 
of the frontal bone, the sphenoid, and the cribriform plate. The brain was 
healthy. 
Case XIII.—Reported by Agnew.2 A boy, aged eight, presented with a 
history of nasal tumor, dating back one month, giving rise to external deform- 
ity, with exophthalmos, and enlargement of the veins of the face. The case 
was hopeless when first seen, and portions of the growth were removed by for- 
ceps, as a palliative measure. The diagnosis of encephaloid cancer was made. 
No subsequent history is given. 
Case XIV.—Reported by Pean.3 A female, aged 42, presented with a his- 
tory of a nasal tumor dating back eighteen months, giving rise to frequently 
repeated attacks of violent epistaxis. An operation was done, and the growth 
removed by forceps, followed by recurrence. When first seen by Pean, there was 
complete stenosis, with external deformity, exophthalmos and severe headache. 
A modified Ollier’s operation was now done, and the growth extirpated, fol- 
lowed by sudden death from brain symptoms, two months later. The autopsy 
showed that the tumor had invaded the frontal sinus, the posterior wall of 
which was perforated, giving rise to pressure on the brain. No microscopic 
examination was given, but the carcinomatous character of the tumor wTas 
evidenced by the secondary deposits in the liver and kidneys. 
Case XV.—Reported by Casabianca.4 A male, aged 52, had noticed for 
two years a prominence in the left nostril, which gave rise at first to a pricking 
sensation, but later to stenosis. Fifteen days after the tumor appeared, he 
noticed an enlargement of the left submaxillary gland. Seventeen months 
later, the nasal growth had given rise to ulceration, and a purulent discharge 
from the nostril. The nose was opened by Verneuil’s operation, and the tumor 
extracted, and the infiltrated gland was also removed. Recurrence took place, 
and the patient finally succumbed, without further interference being attempted. 
Case XVI.—Reported by Pean.5 A female, aged 64, for five months had 
suffered from a tumor in the right nostril, situated on the septum, which had 
given rise to sneezing, stenosis, and later, to anosmia. This growth contin- 
ually increased in size, giving rise to external deformity, especially of the right 
side. The nasal cavity was opened by Linhart’s operation, and the growth 
extirpated, but recurred at the end of four months, giving rise to very great 
deformity, together with violent headache and cachexia. A second operation 
was done, during which the septum, portions of the nasal bones, and the supe- 
rior maxilla, were taken away. The operation was unsuccessful in extirpating 
all of the growth, and the patient succumbed soon after. 
Case XVII.—Reported by Eder.6 A male, aged 66, in December, 1876, 
1 Op. cit., p. 286. 2 Phila. Med. Times, vol. v., 1S75, p. 612. 
3 Lancet, 1876, vol. ii., p. 85. 4 These de Paris, 1877. 
s Cited by Casabianca, op. cit. 
6 Aerzt. Bericht der Privat-Heil-Anstalt des Dr. Eder, 1S77, Vienna, 1878, p. 46. CARCINOMA OF THE NASAL PASSAGES. 
457 
commenced to suffer from exophthalmos and double vision, followed by anos- 
mia. A few months later, he had a violent attack of epistaxis from the left 
nostril, after which he was seen by Eder, who discovered a tumor in the nasal 
cavity, which having its origin on the left side, had extended to the opposite 
side, apparently around the septum. There was also discovered a small orbital 
tumor at the inner canthus of the left eye. Access to the cavity was obtained 
by chiseling away a portion of the nasal and lachrymal bones, together with the 
nasal process of the superior maxilla, when the growth was removed with a 
sharp spoon. It was found to involve the frontal, ethmoidal, sphenoidal, and 
maxillary sinuses. Examination revealed the tumor to be a melanotic carcino- 
ma. The patient died two days later, of meningitis. 
Case XVIII.—Reported by Weinlechner.1 A male, aged 56, presented with 
the history of nasal stenosis, of three years’ standing, due to the presence of a 
growth, which had given rise to epistaxis, and latterly to exophthalmos. Two 
attempts at removal had been made through the natural passages, without 
success. An external operation was decided upon. Access to the nasal cavity 
was obtained by the removal of a portion of the anterior wall of the superior 
maxilla, and the growth removed, and found to be a melanotic carcinoma, 
springing from the outer wall of the nose, and invading successively the sphe- 
noid, ethmoid, maxillary, and orbital cavities. Recurrence took place, which 
required a second operation, eight months later, which was incomplete, on 
account of the danger of invading the cranial cavity. The patient left the 
hospital in a week, and no further history was recorded. 
Case XIX.—Reported bjr Heurtaux.2 A male, aged 40, presented with the 
history of a nasal growth, dating back twelve months, which had given rise to 
repeated attacks of epistaxis. A tumor was removed from the nasal cavity, 
and found to be an encephaloid carcinoma. 
Case XX.—Heurtaux3 gives a very imperfect history of another case, in 
which, as the result of a fall, a tumor developed in the left nostril, its attach- 
ment being the septum. It was found to be a lobulated epithelioma, made up 
of large nucleated cells. 
Case XXI.—Reported by Pepper and Shakspeare.4 A female, aged 73, pre- 
sented with a history of having suffered some months from a discharge from 
the naso-pharynx, which soon assumed a sero-sanguinolent character, followed 
soon by a growth which pressed against the soft palate, causing a notable pro- 
tuberance. This was treated by injections of ergot, with a moderate amount 
of relief, although subsequently the general health became notably impaired, 
attended with limitation of the field of vision of the right eye, with weakness 
of the ocular muscles, together with deafness in the right ear. Death occurred 
seven months after the tumor was first noticed, no operation having been 
attempted. The post-mortem examination showed that the growth, which 
was a lobulated epithelioma, involved the right nasal fossa, sphenoid and eth- 
moid cells, and the meninges of the brain. 
Case XXII.—Reported by Campbell.5 A male, aged 54, following an injury 
to the right eye, three years previously, had developed a tumor in the nose, 
1 Bericht der k. k. Krankenanstalt Rudolph Stiftung in Wien (1877), Vienna, 1878, 
P- 315. 
2 Soc. Anat. de Nantes, Seance March 13th, 1878 ; Bull. Soc. Anat. de Nantes, 
Paris, 1879, p. 87. 
3 Op. cit., p. 68, Seance Feb. 12th, 1879. 
4 Trans. Path. Soc. of Phila., 1880, vol. ix., pp. 138-144. 
5 Brit. Med. Journ., 1880, vol. i., p. 325. 458 
DISEASES OF THE JVASAL TASS AGES. 
attended by external deformity with swelling of the face, together with a sero- 
sanguinolent fetid discharge. When first seen, the nasal growth completely 
filled the right nostril, and protruded into the pharynx. Access to the tumor 
was obtained by removal of the superior maxilla, together with the hard palate 
and orbital plate. The growth was enucleated, and found to be a glandular 
carcinoma, having its origin in the upper portion of the nasal cavity. There 
was no recurrence at the end of six months. The microscope revealed the 
neoplasm to be composed of mucous glands, lined with cylindrical epithelium, 
or the glandular carcinoma, first described by Billroth, which, he asserts, pos- 
sesses no marked disposition to recurrence. 
Case XXIII.—Reported by Heurtaux.1 Heurtaux presented as a specimen 
before the Pathological Society of Nantes, a tumor, which he had removed 
from the nasal cavity of a woman, aged 57, the growth having, according to 
the report, persisted for fourteen years. He describes the growth as a tubular 
epithelioma. This also was probably the cylindrical carcinoma of Billroth. 
The subsequent history was not given. 
Cases XXIV., XXV. and XXVI.—Reported by Schaffer.2 A male, aged 45, 
suffered from an epithelial carcinoma of the anterior nares, which was removed 
by means of the curette, followed by death a year later. Schaffer’s second case 
was a man, aged 28, who suffered from an epithelial carcinoma of the mucous 
membrane of the left inferior turbinated, which was operated upon in 1879. 
Recurrence took place in 1880, followed by death in 1881. In his third case, 
there was epithelial carcinoma of the right side, extending to the lachrymal 
canal, in a man, aged 57, complicated by the existence of mucous polypi *on 
both sides. 
Case XXVII.—Reported by Delstanche.3 A male, aged 53, presented at 
the clinic on account of nasal stenosis and deafness, with no other notable 
subjective symptoms. Examination revealed the presence, in the left naris, of 
a reddish, liver-like mass, which completely filled the cavity, and bled easily to 
the touch. A piece of this was removed, and subjected to microscopical exam- 
ination, which revealed it to be a pavement-cell epithelioma. No operation 
was attempted, and the patient lingered on, and finally died, eighteen months 
later, having developed in this time considerable deformity of the external 
nose and face, with exophthalmos, together with a sanious discharge. An 
autopsy showed that the growth had its origin in the roof of the left nasal 
cavity, and had invaded successively the sphenoid and ethmoid cells, and the 
base of the brain. 
Case XXVIII. — Reported by Butlin.4 A male, aged 44, presented with a 
small, wart-like growth, about the size of a hazelnut, attached to the inner 
aspect of the ala of the nose, about two-thirds of an inch from the muco-cuta- 
neous junction. This was removed with the snare, followed by a recurrence, 
three weeks later, when the whole ala of the nose was removed. Examination 
revealed the growth to be a squamous-celled epithelioma. The subsequent 
history is not given. 
Case XXIX.—Reported by Schmiegelow.5 A male, aged 51, presented with 
1 Bull. Soc. Anat. de Nantes, Paris, 1881, p. 96, Seance Nov., 1880. 
2 Cited by Schmiegelow, loc. cit. (I fail to find any report of these cases, although 
Schmiegelow notes them as having been published in the Deut. Med. Wochenschrift, 
,1882, No. 3.) 
3 Annal. des Mai. de 1’Oreille, etc., July, 1884, No. 3, vol. x., p. 129. 
4 St. Bartholomew’s Hospital Reports, vol. xxi., 1885, pp. 147-152. 
s Rev. Mens, de Laryngologie, 1885, v., 421. CARCINOMA OF THE NASAL PASSAGES. 
459 
the history of an apparent cold in the head three months previously, which was 
followed by the development of a growth, giving rise to stenosis in the left side. 
It was attended with a puro-sanguinolent, acrid discharge. When first seen, 
Schmiegelow discovered the lower turbinated on the affected side to be par- 
tially destroyed, and partially transformed into a tumor, the size of a nut, while 
the middle turbinated, and the upper portion of the septum, were found to be 
transformed into an ulcerated mass of the same character. The diseased tissue 
was removed by means of the cold snare, together with free use of the galvano- 
cautery. The process involved a course of treatment of seventeen days. At 
this time the patient was discharged. Four months later, examination revealed 
the passage to be in a fairly healthy condition. Schmiegelow reports the 
growth to have been a cylindrical-celled carcinoma. It was, most probably, 
the glandular carcinoma of Billroth. 
The following case came under my own observation. 
Case XXX.—A male, aged 56, presented with the history of violent pains, 
involving the whole left side of the head, dating back six months, while two 
months previously, there had set in complete stenosis of the left naris, with 
Fig. 117.—Scirrhus of the Nasal Cavity. Case No. XXX. observed by the author. E, Columnar 
epithelium ; M, mucosa transformed into dense fibrous connective tissue; iV, epithelial nests; C, loose 
fibrous connective tissue between cells, showing incipient infiltration. 
muco-sanguinolent discharge, of a decidedly acrid character. The general 
health was somewhat impaired, and for a month back the patient had noticed 
a swelling in the left submaxillary region, which he thought was somewhat on 
the increase. Examination of the nose showed the left passage to be filled 
with a growth, which seemed to have its attachment beneath the middle tur- 
binated bone, which, apparently by pressure, had given rise to necrosis of the 
vomer. The rhinoscopic mirror showed the posterior nares of that side com- 
pletely filled with a soft, grumous-looking mass. In the submaxillary region, 
there was a large mass of enlarged glands, which presented the peculiar dense, 
nodulated feeling, characteristic of secondary cancerous infiltration. A piece 
of the growth was removed by the cold snare, and being subjected to micro- 
scopic examination, it was found to consist of a connective-tissue frame-work, 
inclosing nests of large flat epithelial cells, as shown in Fig. n 7. This frame- 
work was so abundant, that in many sections the epithelial structure was not 
found. The preponderance of connective tissue classed the growth as an 460 
DISEASES OF THE NASAL PASSAGES. 
epithelioma of the scirrhus variety. The case seemed to be one in which an 
operation was unwarranted; hence, the patient returned to his home, where 
he died, three months later, from exhaustion. No autopsy was made. 
ETIOLOGY.—It is a very easy matter, after malignant disease 
has developed, to trace its origin back to some injury received in 
previous years, and yet to connect the injury in a direct positive 
relation with the development of the cancer, is by no means so easy 
a matter. Hence, when we say that a cancer may be due to trau- 
matism, it is a suggestion, not clearly warranted by clinical obser- 
vation. In Liebl and Campbell’s cases, the disease would seem to 
have been the result of injury, and yet not directly, for in the 
former, the injury to the nose resulted in a fracture of the nasal 
bones with necrosis, which produced a long-continued ulcerative 
action, which finally assumed a malignant character, although in 
Campbell’s case the carcinoma would seem to have been really the 
direct result of the injury. This, however, is entirely too rare an 
event, to warrant the conclusion that traumatism acts as other than 
a possible predisposing cause of malignant disease. 
In none of the cases above reported, has hereditary influence 
been mentioned, and yet we all recognize the fact, that this ele- 
ment is the one powerful predisposing cause of the disease. Aside 
from this consideration, I do not think we know why malignant 
disease occurs. 
The question of the transformation of a benign into a malig- 
nant growth, has already been discussed in the chapter on nasal 
polypi and need not be entered upon in this connection, further 
than to repeat, that whereas there is a certain amount of clinical 
evidence to show that a nasal polyp may be transformed into a 
sarcoma, when subjected to unwarrantably harsh interference, such 
as with the forceps, yet there is no ground for supposing that a 
carcinomatous transformation ever takes place. In Pean’s case, 
there might be a suggestion of this transformation, and yet the 
clinical history would seem to indicate that the carcinoma devel- 
oped primarily, and that the growth of the nasal polypi was an ad- 
ventitious feature of the cancerous development. 
As regards the age at which the disease develops, cancerous 
deposits in the nose follow the same course as in other parts of the 
body, occurring, as a rule, after middle life. 
In Cases IV., XII., and XIII., the disease occurred in childhood, 
presenting rare exceptions to the rule; aside from these, and the 
rather doubtful cases of Neudorfer (VI.) and Schaffer (XXV.), we 
find that the disease occurs from forty to sixty years of age, the 
majority being above fifty. 
PATHOLOGY.—Carcinoma of the nose, from a pathological point CARCINOMA OF THE NASAL PASSAGES. 
461 
of view, presents no characteristics which differ from the same 
form of tumor in other portions of the body. Hence, a full de- 
scription of the minute pathology of these growths need not be 
given here. An interesting clinical observation is made by Ver- 
neuil,1 who states that a malignant growth, occurring within half 
an inch from the muco-cutaneous junction, is liable to be of the 
squamous epithelial variety, whereas, if it occurs beyond this line, 
it is of the epithelio-glandular variety. Inasmuch as the recogni- 
tion of a cylindroma throws a great deal of light, not only on the 
prognosis, but clinical indications, a full description of this form of 
neoplasm becomes of importance. Whereas, the typical epithelioma 
is composed essentially a connective-tissue framework, wherein the 
alveoli are lined with either epithelium or endothelium, in a cylin- 
droma, on the other hand, the connective-tissue structure seems to 
be obliterated almost entirely. The tumor is alveolar in structure, 
and yet the alveolar walls are composed almost entirely of epithe- 
lial structures, whereas the spaces represented by the alveoli are 
filled up with colloid material. In addition to this, there will be 
observed little tooth-like processes, as it were, of the epithelial 
structure, encroaching upon or projecting into the central colloid 
masses. We have thus a structure, not unlike a sponge, the spaces 
of the sponge being represented by the colloid masses, whereas the 
solid portion of the sponge is represented by the epithelial struc- 
tures. 
SYMPTOMATOLOGY.—There is nothing in the development of a 
malignant growth in the nose, to specially suggest the character 
of the disease other perhaps than the peculiar sero-sanguinolent 
acrid discharge. Epistaxis occurs in a certain proportion of cases, 
but perhaps not so frequently as is the case with sarcoma of the 
nose. Pain, which is usually so prominent a symptom of the devel 
opment of cancer elsewhere, does not seem to be characteristic of 
the disease when met with in the nasal passages. Nasal stenosis, 
with deformity of the external nose, of course, is present, according 
to the duration and extent of the disease. As the tumor invades 
the sphenoid and ethmoid cells, we have the symptoms character- 
istic of disease in these cavities, such as exophthalmos, impairment 
of vision, etc. 
Enlargement of the lymphatic glands does not seem to be a 
frequent concomitant of the disease, although noted in Cases VI. 
and XXX., thus following the rule observed in connection with 
cancer of the larynx; although the direct connection between the 
cervical glands and the nasal mucous membrane is probably more 
1 Gaz. des Hopitaux, Paris, 1885, vol. lxviii., p. 269. 462 
DISEASES OF THE NASAL PASSAGES. 
direct than is the case with the larynx. Maisonneuve 1 does not 
find the submaxillary glands enlarged in intra-nasal carcinoma, un- 
less the antrum is involved, with infiltration of the skin in the in- 
fraorbital region. The cancerous cachexia is to be observed, of 
course, late in the disease, although not constituting a symptom of 
any special value. 
In Cases II. and XII., secondary carcinomatous deposits were 
found in certain of the viscera on autopsy, although not giving rise 
to any symptoms which led to their recognition before death. 
Diagnosis.—The ordinary symptoms of malignant disease of 
the nasal cavities are of sufficient prominence to render the diag- 
nosis, based on the objective symptoms, a comparatively easy 
matter. With our present methods of examining the nasal cavities, 
however, a growth should always be recognized very early in its 
development, when a small portion can be removed for examination 
with the microscope, which will reveal its character. This removal 
should in all cases be accomplished by means of the cold wire 
snare, as avoiding any unnecessary harshness in manipulating the 
growth, whereby a renewed activity of development might be 
stimulated. As we have seen, in sarcoma secondary enlargement 
of the cervical glands is never present. In carcinoma, however, 
this symptom seems to be present in a few cases, as is shown in 
Neudorfer’s case, as well as my own. In Neudorfer’s case, this 
seemed to be developed late in the disease, whereas in my own, 
this symptom manifested itself quite early. The absence, then, of 
secondary infiltration would seem not to possess any special diag- 
nostic significance. Epistaxis would seem to be quite as charac- 
teristic of carcinoma as of sarcoma, although in the former disease 
ulceration of the surface of the tumor is more frequently met with, 
and hence this lesion is more liable to be the seat of the hemor- 
rhage than in sarcomatous growths. 
PROGNOSIS.—The prognosis of carcinomatous deposits in the 
nasal passages is essentially grave. It becomes, however, an inter- 
esting point, as to how far the location of the disease affects the 
progress of the growth. In cancer, in general, we usually accept 
the view, that the average duration of life is three years. From a 
glance at the cases, however, above reported, it would seem that 
the nasal cavity presents a rather unfavorable location, in that, 
with the exception of the cases of cylindroma, the disease seems 
to, in many cases, run a somewhat rapid course, three years being 
the longest duration, while in twelve cases, in which the record is 
complete, the average duration of life was twelve months. Fur- 
thermore, the time of life seems to have a certain influence, as it 
* Gazette des Hopitaux, 1863, p. 521. CARCINOMA OF THE NASAL PASSAGES. 
463 
would appear that where the disease develops late in life, it runs a 
very rapid course, although this may possibly be accounted for by 
the fact, that, in advanced years, the vital forces are diminished, 
and the individual falls a more readily victim to the encroachments 
of the malignant process. The character of the tumor does not 
seem to modify the prognosis in any marked way, for while we find, 
in the above cases, many varieties of carcinoma, the special charac- 
ter seems to have had no influence. It is to be noted, however, 
that in Case XXII. a tumor composed of mucous glands, lined with 
epithelium, after a duration of three years, was cured by an opera- 
tion, while in Case XXIII., a typical epithelioma was operated 
upon at the end of fourteen years. 
Again, in Case XXIX. we find the disease eradicated at the end 
of a few months, in a case of what Schmiegelow reports as carci- 
noma cylindriformis. These cases are all undoubtedly instances of 
cylindroma, a form of tumor which seems to be somewhat vaguely 
classified by pathologists, and which, while presenting certain his- 
tological evidences of malignancy, from a clinical point of view 
manifests but very slight malignant tendencies, and perhaps, there- 
fore, should not be regarded as a malignant disease. Thus, Wag- 
ner 1 states that probably many cases of cylindroma do not belong 
to cancer, while Billroth2 states that this form may belong either 
to sarcomatous or carcinomatous tumors. Joiion,3 in discussing 
this matter, makes the statement, that epithelioma of the mucous 
membrane shows a tendency to take on the tubular form, and un- 
dergo mucoid degeneration, thus giving rise to a neoplasm which 
is essentially benign in character, and which may run an exceed- 
ingly prolonged and slow course, without developing malignancy. 
Whereas, therefore, the prognosis of ordinary forms of carcinoma 
becomes exceedingly grave, in cylindroma, if recognized sufficiently 
early, and before the disease has invaded inaccessible parts, such 
as the sphenoid or ethmoid cells, the prognosis as to the successful 
arrest of the disease is to be regarded as favorable. The cause of 
death, in most of these cases, is exhaustion, unless death follows 
immediately upon an operation. The malignant process, having 
its origin in the nasal cavity proper, successively invades the ac- 
cessory sinuses, and in still rarer cases, the cranial cavity, as is 
shown in Cases XIV., XVIII., XXI., and XXVII.; while in Case 
XVII. meningitis set in after the operation, probably as the result 
of pyaemia or septic infection. 
Treatment.—If the microscopic examination shows that the 
1 “ Manual of General Pathology,” Amer. ed., N. Y., 1883, p. 489. 
2 “ Surgical Pathology,” Amer. ed., 1883, p. 746. 
3Bull. Soc. Anat. de Nantes, 5th year, Seance of Feb., 1881, Paris, 1882, p. 22. 464 
DISEASES OF THE NASAL PASSAGES. 
disease with which we have to deal, consists of cylindroma, treat- 
ment may be undertaken with every promise of success; but 
this should be borne in mind, I think in all cases, that in any treat- 
ment which is instituted, we should avoid, as far as possible, any 
harsh or irritating measure whereby a greater malignancy of growth 
might be developed. Hence, in these cases, the growth should be 
removed preferably by means of a cold snare, and possibly the 
curette, and the base cauterized, perhaps, but the caustic applied 
with great care, and somewhat sparingly, the action of the agent 
being closely observed. Schmiegelow’s case would seem to clearly 
show the good result of this slow procedure. Where the growth 
has obtained considerable size, a more radical and rapid operation 
becomes necessary. Thus in Campbell’s case, the growth was ex- 
tirpated with apparent success, after excision of the superior max- 
illary bone. If we have to do with carcinoma, it becomes a nice 
question, how far life may be prolonged by the radical operation. 
I know of no well-authenticated case of the successful removal of 
a carcinoma of the nose, through the natural passages. In the 
majority of instances, the growth has its origin in the upper and 
narrower portion of the nose, in close proximity to the superior 
turbinated bones, hence, even when early recognized, it has in- 
vaded regions almost inaccessible by the simpler manipulations. 
Of course, if the growth is small, and within reach, it becomes our 
duty to remove it in this manner if possible. As a rule, however, 
a radical operation becomes unavoidable, if it is deemed justifiable 
to attempt any operation. The records of the cases above given, 
certainly offer a most discouraging outlook. In Cases V., VI., 
VII., and IX., the reports are too vague and incomplete to base 
any data upon. Aside from these, there is no radical operation re- 
ported, which seems even to offer any justification for operative 
interference in carcinoma of the nose. Of five radical operations 
done, death occurred respectively two days and two months after 
the operation in Cases XVII. and XIV., while in Cases II., V., and 
XVI., recurrence took place, followed by death, respectively in 
forty days, thirty days, and four months. It is a fair inference, 
therefore, that surgical interference, in these cases, shortened rather 
than prolonged life. CHAPTER XXXVIII. 
DISEASES OF THE ACCESSORY SINUSES OF THE 
NOSE. 
Under this consideration is included a study of the diseased 
conditions which are met with as involving those cavities which are 
found in certain of the bones of the face and skull, and which com- 
municate with the nasal passages by one or more small openings. 
These cavities are: The antra of Highmore, or the maxillary si- 
nuses; the ethmoidal sinuses; the sphenoidal sinuses; and the fron- 
tal sinuses. Disease of these cavities is usually treated under the 
general head of Disease of the Accessory Sinuses. A better 
knowledge of their clinical history and significance, however, will 
be arrived at by their consideration under separate and distinct 
headings. 
Disease of the Antrum. 
This term is used to designate a not infrequent complication or 
concomitant of catarrhal inflammation of the nasal mucous mem- 
brane, which is characterized by an inflammatory process in the 
mucous membrane lining the antrum of Highmore, which subse- 
quently degenerates into the purulent process, as is the almost 
invariable rule, where a chronic inflammation of a mucous mem- 
brane occurs in a closed cavity. This pus secretion, accumulating 
in the cavity of the antrum, makes its exit through the ostium 
maxillare, and escapes into the nasal cavity, giving rise to a more 
or less profuse pus discharge from the nose. 
ETIOLOGY.—Zuckerkandl1 takes the ground, that the most fre- 
quent cause of the disease lies in an extension of the inflammatory 
process from the nasal cavity, a view also entertained by Schiffers,2 
Chatellier,3 and Krause.4 In a previous chapter, this question 
of extension of catarrhal inflammation has been discussed some- 
what at length, and the ground taken that catarrhal inflammation 
1 “ Normale und Pathologische Anatomie der Nasenhohle,” Wien, 1882, p. 137. 
2 Revue Mensuelle de Laryngologie, June, 1887. 
3 French Soc’y of Otology and Laryngology, April 13th, 1887. 
4 Berlin. Klin. Wochenschr. 1887 No. 13, p. 228. 466 
DISEASES OF THE NASAL PASSAGES. 
shows a notable hesitancy in extending from one anatomical region 
to another. A catarrhal inflammation of the nose is the result of 
local conditions, which do not, in any degree probably, operate in 
the maxillary sinuses. In other words, so-called nasal catarrh is a 
perversion of function of the normal respiratory apparatus of the 
nose, and its causes only operate on those tissues, and would have 
no effect on the delicate membrane lining the antrum. Hence. I 
think it is an exceedingly rare event, that disease of this cavity re- 
sults by an extension of inflammation through continuity of tissue. 
This view, it seems to me, is notably strengthened, when we con- 
sider the large number of individuals who suffer from chronic rhini- 
tis, and the very small proportion of these in which antral disease 
occurs. That hypertrophic rhinitis is the cause of the disease, in a 
large number of cases, is undoubtedly true, but not by extension, but 
rather owing to the fact that the hypertrophic process develops in 
such a manner as to produce stenosis or complete occlusion of the 
ostium maxillare. Furthermore, as we know, this orifice varies 
greatly in different individuals. Quite extensive hypertrophy in 
one case might fail to produce any notable stenosis, while in others, 
a moderate degree of thickening of the membrane might produce 
complete obstruction. The closure of this orifice would naturally 
act, in the first place, to produce moderate hyperaemia of the 
mucous membrane lining the sinus, resulting necessarily in a cer- 
tain increase of secretion. Now, in health, this membrane secretes 
just sufficient mucus to keep its own surface moistened and no 
more, a fact long ago observed by Burns,1 who attaches a certain 
amount of importance to the nice balance which must exist be- 
tween the mucous secretion and the absorption by the lymphatics. 
Another element enters into this consideration, as pointed out by 
Zuckerkandl,2 in that in a patulous condition of the ostium maxil- 
lare, no inconsiderable amount of moisture is dissipated by evapo- 
ration, hence, we can readily perceive, that when this orifice is 
closed, there would necessarily be an accumulation of secretion, 
even were the membrane in a healthy state. Add to this, hyper- 
aemia, with hypersecretion in the lining membrane, and it would 
become apparent how the secretion must accumulate in the sinus. 
The necessary result of this is a catarrhal inflammation, which 
eventually degenerates into one characterized by a purulent dis- 
charge, for, as has already been stated, I regard it as an invariable 
rule that a catarrhal secretion in a closed cavity must give rise, 
sooner or later, to a purulent discharge. 
It is a very ancient tradition,.that decayed teeth are a frequent 
1 “ Anat. des Halses und Kopfes,” aus dem Engl., Halle, 1821. 
2 Op. cit., p. 141. DISEASES OF THE ACCESSOR Y SINUSES OF THE NOSE. 
467 
source of purulent disease of the antrum. When we consider that 
the first and second molar teeth usually project into the floor of 
the cavity, and occasionally penetrate it (see Fig. 118) we can easily 
understand, as Moldenhauer1 states, how caries of these teeth 
might act to produce suppuration in the cavity. That this is 
almost the only cause, as stated by Louis,2 or is even the most fre- 
quent cause is doubtful, although this latter view is entertained by 
Frankel,3 Baratoux,4 Noquet,5 Boucheron,5 Garel,5 Gelle,5 Beverley 
Fig. 118.—Transverse Section of the Maxillary Sinuses, showing the Roots of the Molar Teeth pro- 
truding into the cavities through the floor. (Zuckerkandl.) 
Robinson,6 Lennox Browne7 and Garretson.8 That carious teeth 
are a frequent source of the disease, cannot be questioned; that 
they are the most frequent, is probably not easy to decide. From 
my own point of view, I should say not, and yet we can easily un- 
derstand why the last quoted writer should assert this broadly, and 
1 “ Die Krankheiten der Nasenhohlen,” Leipzig, 1886, p. 185. 
2 “Obs. on Surg. Dis. of Head and Neck,” Sydenham Soc. Pub., London, 1848, 
p. 167. 
3 Berliner Klinische Wochenschrift, 1887, No. 16, p. 273. 
4 “ French Society of Otology and Laryngology,” April 13th, 1887. 
5 Ibid. 
6 Trans. Amer. Laryngological Assn., 1886, p. 181. 
7 “ The Throat and its Diseases,” London, 1887, pp. 508, 528. 
8 “System of Oral Surgery,” 1884, p. 747. 468 
DISEASES OF THE NASAL PASSAGES. 
with emphasis, since cases due to carious teeth, as a rule, fall into 
the hands of the dentist or oral surgeon, while those cases depend- 
ent on other causes, naturally fall into the hands of the throat 
specialist. Watson 1 states that nasal polypi may produce the dis- 
ease, a cause not usually mentioned by other writers, and yet I re- 
gard this as one of the most frequent sources of suppurative in- 
flammation of the antrum. This, it seems to me, can easily be 
understood when we consider the fact that mucous polypi have 
their origin, in the large majority of cases, in the immediate region 
of the ostium maxillare, and very early in their development, act 
to produce occlusion of this orifice. I am disposed to think, that, 
in many cases, the involvement of the antrum is overlooked, in the 
somewhat more prominent symptoms to which polypi give rise, 
and furthermore, that its purulent discharge, becoming mingled 
with, and diluted, as it were, by the sero-mucous discharge excited 
by the polypus, fails of recognition as a distinct pus secretion. Cer- 
tainly in those cases in which the polypi have developed to the ex- 
tent of completely filling the nasal cavity, producing complete 
stenosis, I think it is almost the exception, that the maxillary sinus 
does not become the seat of a suppurative inflammation. This 
complication, however, only becomes evident after the nasal pas- 
sages have been thoroughly cleared of the polypi. I am disposed 
to regard this, then, as perhaps the more frequent cause, hyper- 
trophic rhinitis next, and least frequently, carious teeth. In the 
same manner, an attack of acute rhinitis is not infrequently at- 
tended with symptoms referable to the maxillary sinus, and hence 
may be an exciting cause of suppurative disease of that cavity. 
That this accident is not of more frequent occurrence, is probably 
due to the fact, that the acute rhinitis subsides in natural course, 
before mischief of a sufficiently permanent character has been done 
to the membrane lining the antrum, to lead to the development of 
the chronic lesion. The same may be said of croupous and diph- 
theritic inflammation of the nasal cavity. Furthermore, it should 
be mentioned that Zuckerkandl2 has stated, that the mucous mem- 
brane lining the antrum does not present the anatomical character- 
istics which favor the development of a fibrinous exudation, and 
hence, an inflammation of this membrane would be of a simple 
catarrhal character, even in the event of its being excited by the 
croupous or diphtheritic lesion in the nose. A rather unique case 
is reported by John A. Wyeth,3 in which a supernumerary tooth 
developing within the antrum, and acting as a foreign body, caused 
suppurative inflammation of the cavity. The symptoms had con- 
1 “ Diseases of the Nose,” London, 1875, P- 156. 
3 New York Med. Record, December 8th, 1883, p. 633. 
2 Op. cit., p. 139. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 
469 
tinued for thirteen years, and followed immediately upon an attack 
of scarlet fever. 
Among the somewhat rare causes of the disease may be men- 
tioned traumatism. Thus in two cases as cited by Watson 1 the dis- 
ease was supposed to have arisen from an accident attendant on 
parturition, while Langenbeck2 has seen two cases of suppurative 
disease of the antrum following Malgaigne’s operation for division 
of the infraorbital nerve. Schech 3 states that it may occur as the 
result of an attack of facial erysipelas. I believe it to be purely a 
local disease, and due to local causes, although Watson4 makes the 
broad statement that the general health is almost always at fault, 
and that the exciting cause would not produce suppuration, unless 
some general dyscrasia were present. 
PATHOLOGY.—At the onset of the affection, the mucous mem- 
brane is hyperaemic, slightly swollen, and with its surface dotted 
over with minute points of ecchymosis, due to the fact that the 
blood-vessels coursing through the membrane, possess exceedingly 
thin, delicate walls which rupture easily, giving rise to slight local- 
ized hemorrhages. As the disease progresses, the membrane be- 
comes swollen to ten or fifteen times its normal thickness, this 
swelling being largely due to an cedematous condition, which pre- 
sents somewhat irregularly, giving rise to small, localized, rather 
than to diffuse, tumefactions, producing a somewhat mammillated 
contour. This infiltration involves not only the superficial, but the 
deep layer of the membrane, which in this region constitutes the 
periosteum of the bony walls of the sinuses. In connection with 
this, there is a somewhat profuse serous exudation, under which 
the blood-vessels unload themselves, and the swollen membrane to 
an extent subsides, followed by a more or less profuse secretion of 
sero-mucus, together with blood, and this in the course of time, 
occupying weeks or perhaps months, results finally in a discharge 
of pure, laudable pus. The later stages of the disease are charac- 
terized by a certain activity in the deep layers of the membrane or 
periosteum, under which there are formed lamellae or spiculae of new 
bone, which may project into the cavity, or may form thin plates, 
crossing it in such a way as to divide it into two or more small 
chambers. This perversion of function may go so far as to lead to 
the formation of small bony tumors within the cavity, entirely sepa- 
rated from its walls. This process is probably closely allied to the 
calcareous degeneration of the mucous membrane described by 
Virchow, Kolliker, and Verneuil.5 
1 Op. cit., p. 157. 2 Arch, fur Klin. Chir., Berlin, 1869, Bd. xi. 
3 “ Diseases of the Mouth. Throat, and Nose,” Eng, edition, Edinburgh, 1886, p. 278. 
4 Op. cit., p. 156. 5 Comptes Rendus de la Soc. de Biol., Paris, 1851, p. 80. 470 
DISEASES OF THE NASAL PASSAGES. 
Symptomatology.—At the onset of the disease, if the cavity 
becomes filled with serum or sero-mucus, whose exit is prevented 
by an obstruction of the ostium maxillare, pain referable to the 
region becomes a prominent symptom, together with a sense of ful- 
ness and weight below the orbit. Unless relief is soon given, this 
pain may become of a most agonizing character, extending over 
the whole side of the face. The pain over the cheek bone involves 
the upper teeth, which give the impression of being elongated, and 
crowded out of their sockets, mastication thus becoming painful. 
In connection with the facial neuralgia, there is liable to be more or 
less general hyperaesthesia of the face, with tenderness on pressure 
over the trunks of the nerves, as they emerge from the foramina. 
This sense of fulness may also be felt in the roof of the mouth, 
which may be crowded downward from up above, and bulged into 
the oral cavity. Schech1 states that protrusion of the eyeball, with 
atrophy of the optic nerve, may occur in connection with antrum 
disease; while Ziem 2 has reported a case of purulent disease of the 
antrum, in which the affection had caused narrowing of the field of 
vision, which disappeared as soon as the pus was evacuated from 
the maxillary sinus. These symptoms, however, would rather indi- 
cate disease of the ethmoidal or possibly the sphenoidal sinuses. 
These sensations may persist for several days, and are relieved 
spontaneously, or at the hands of the surgeon. If spontaneous 
relief occurs, it is usually with a profuse discharge of ill-smelling 
pus from the nasal cavity of the side affected, mixed with a certain 
amount of minute blood-clots. The escape of pus may be either 
through the normal opening, or by an artificial opening through 
the thin lateral wall of the cavity, and in still rarer cases, the 
spontaneous evacuation may take place through the alveolus, cheek, 
or orbit. Among the rarer events is the extension of the disease 
to neighboring cavities. Thus in the case reported by Maier 3 even 
after opening the antrum through the alveolus, the disease invaded 
successively the ethmoidal sinuses, the orbit and the cephalic 
cavities, resulting in meningitis and death. 
After this spontaneous evacuation of the cavity, the pus dis- 
charge continues, for, it may be, a lengthened period of time, flow- 
ing freely from the nasal passage, when obstruction again occurs, 
and with its attendant symptoms of pain and sense of fulness 
about the maxillary region ; these symptoms, however, being not 
so well marked, as a rule, as in the case of a primary attack, the 
further progress of the disease being characterized by these inter- 
mittent attacks of retention. In most cases, perhaps, the disease is 
1 Op. cit., p. 277. 2 Berlin Klin. Wochenschr., 1888, No. 37. 
3 Edinburgh Med. Journal, May, 1886, p. 1,009. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 47 x 
chronic from the onset, the ostium maxillare remaining patulous, 
and the course of the disease never marked by an attack of pus 
retention. Where this occurs, the prominent symptom is a dis- 
charge, from one nasal cavity, of a more or less profuse purulent 
secretion, which shows a certain amount of diurnal intermittence. 
On waking in the morning, a large amount is discharged, which has 
accumulated over night, while through the day, the evacuations 
are in smaller quantities, the patient soiling perhaps three or four 
handkerchiefs, the pus being of a bright-yellow color, and emitting 
no marked odor, except, perhaps with the first discharge in the 
morning. In connection with this, neuralgic pains of a mild char- 
acter, referable to the side of the face affected, are often noticed, 
which occasionally extend also to the teeth. In the late stages of 
this form of the disease, the teeth whose roots project into the 
floor of the antrum may become carious as the result of periostitis 
and necrosis involving the thin bony plates covering them, as shown 
by Zuckerkandl.1 
This would suggest that the carious teeth, which in many cases 
are said to be the cause of the antrum disease, may rather be the 
effect of it. Although there may be no obstruction to the escape 
of the pus, the cavity is probably most of the time full, up to the 
level of the opening, hence in many cases, as the result of the thin- 
ning of the anterior wall, which as Moldenhauer2 says may become 
almost parchment-like, a slight bulging, with fluctuation, may be 
observed over the canine fossa, although Ziem3found no facial 
deformity in a large number of cases under observation. As the 
purulent secretion passes into the nasal cavity, it retains its fluid- 
ity, and is expelled in the same condition. Crust formation is 
never a feature of this disease, nor is the mucous membrane of the 
nose in any way affected by the presence of the pus. Front is4 
reports two cases, in which cough was a prominent symptom. This 
may have been greatly due to the diseased condition of the an- 
trum, but more probably, I should say, to the purulent secretion 
making its way into the pharynx and upper air passages, as it oc- 
casionally does, especially on waking in the morning, and in that 
way becoming an exceedingly disagreeable and oftentimes a dis- 
tressing symptom. In the same manner, I should attribute any 
symptoms referable to the upper air-tract to a concurrent disease 
of the nasal mucous membrane, rather than to the direct influence 
of the antral affection. 
Diagnosis.—A pus discharge from but one nasal cavity should 
1 Op. cit., p. 142. 
3 As cited by Moldenhauer, op. cit., p. 187. 
4 North Carolina Med. Journal, January, 1887. 
2 Op. cit., p. 186. 472 
DISEASES OF THE NASAL PASSAGES. 
always excite suspicion of the existence of suppurative disease of 
one of the accessory sinuses. The sources of a pus discharge from 
the nose are, the purulent rhinitis of children, syphilis, the pres- 
ence of a rhinolith or foreign body, a neoplasm, nasal diphtheria, 
and disease of the accessory sinuses. Now, of these affections, the 
only ones which give rise to a unilateral pus discharge are foreign 
bodies, syphilis, and neoplasms, in all of which the accompanying 
symptoms are so prominent, that a differential diagnosis should 
never be difficult. Furthermore, the character of the pus discharge 
in antrum disease, in all cases probably, is that of a uniformly 
bright yellow, cleanly secretion. The odor, furthermore, I think 
is somewhat characteristic, being that of sulphuretted hydrogen, and 
never presenting the intolerable fetor characteristic of syphilis, or 
the musty graveyard odor of ozaena. Furthermore, the odor is 
only present when pus is evacuated after being retained for a day 
or longer. 
In making an examination of the nasal cavity, a four-per-cent 
solution of cocaine should first be applied, to contract the tissues, 
after which, on ocular inspection, there will be found a small mass 
of bright-yellow, canary-colored, or perhaps straw-colored pus, 
lying on the lower border of the middle turbinated bone, about 
midway of its course. If the discharge in the nose is free, the 
secretion will be found coating the lower turbinated body, and 
possibly lying upon the floor of the nares. If, however, this be 
wiped away with a pledget of cotton, the origin of the pus will 
easily be detected, as oozing from beneath the middle turbinated 
body. If, furthermore, a probe wrapped with a small pledget of 
cotton be pressed up against the point from which the pus appar- 
ently issues, the manipulation will be followed by a flow of pus, 
directly from the cavity, which now will emit, if the pus discharge 
is free, the characteristic odor of fetid hydrogen. The question of 
differential diagnosis now arises, to determine from which of the 
accessory sinuses the pus issues, and this involves some exceed- 
ingly nice questions, which are not always easily decided. Molden- 
hauer 1 makes the statement, that placing the head in different posi- 
tions, will enable us to determine the source of the pus discharge, 
but he is somewhat indefinite as to his directions, while Schech* is 
equally vague on this question. Frankel,3 on the other hand,'di- 
rects that after removing the pus that is visible on inspection, the 
head should be placed well down between the knees for some mo- 
ments. If now, on a reinspection, the pus is observed beneath the 
middle turbinated body, the indication is that its source is the max- 
1 Op. cit., p. 186. 
3 Berlin. Klinische Woch., 1877, No. 16, p. 273. 
2 Op. cit., p. 277. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 
473 
illary sinus, as, in this position of the head, it cannot well flow from 
any of the other cavities. A still better procedure is to direct 
the patient to lie down on the unaffected side, a position in which 
discharge from the antrum would be facilitated, while there would 
be little or no tendency to the escape of pus from any of the other 
sinuses, hence keeping the patient in this position for ten minutes 
or longer, especially if the erect position had been maintained for 
several hours beforehand, the exit of pus from the maxillary sinus 
would be obtained, if suppurative disease existed there. Percus- 
sion of the two sides should always be resorted to, as suggested by 
Frontis,1 for by this means we may detect a dulness over the 
affected side, as well as a certain amount of sensitiveness. Wat- 
son 2 suggests tapping the teeth of the upper jaw successively, and 
if tenderness be discovered, that the pulp-chamber should be ex- 
amined with reference to a diseased condition. Moldenhauer3 
states, that by means of a syringe with a properly curved nozzle, 
fluids may be injected, not necessarily into, but against the orifice 
of the antrum, when pus will be brought away. Even if this 
manipulation were successful, I do not think it possible to deter- 
mine thereby the source of the pus discharge. Tenderness on 
pressure over the canine fossa, or above the alveolar process in 
the oral cavity, might constitute a symptom of some diagnostic 
value, although it is not usually present. Puncture of the antrum 
by means of an exploring needle, or with the aspirator, is a com- 
paratively simple test, against which there lies no objection, other 
than the danger of breaking the needle, if the bone be thick or 
dense. This exploration should preferably be made through the 
outer wall of the antrum, an incision being made through the 
ginglivo-labial fold, above the second molar tooth. Schmidt4 ad- 
vises that such an exploratory puncture be made in doubtful cases, 
by means of a strong, curved, aspirating needle, piercing the inter- 
nal wall of the antrum, in the inferior meatus of the nose. If either 
the first or second molar tooth is carious, it should be extracted, 
and access to the cavity for exploratory purposes is easily obtained 
through the alveolar process, although I question the propriety of 
extracting a sound tooth for this purpose, considering the ease with 
which the cavity may be entered at the points above mentioned, 
Schech5 makes the point, that in those cases where air obtains ac- 
cess to the cavity through a patulous ostium maxillare, a succussion 
sound can be obtained by the ordinary manipulation. This, I take 
to be somewhat theoretical, as the cavity would scarcely be large 
enough to produce any splashing of its purulent contents against 
1 Loc. cit. 2 Op. cit., p. 160. 
4 Berlin. Klin. Wochenschr., 1888, No. 50. 
3 Op. cit., p. 187. 
3 Op. cit., p. 276. 474 
DISEASES OF THE NASAL PASSAGES. 
the soft and thickened membrane which forms its walls. At best, 
the diagnosis of these cases is oftentimes quite obscure, and can only 
be obtained by exclusion, and a careful study of symptoms, the 
only absolute diagnostic sign being in gaining access to the cavity. 
PROGNOSIS.— These cases rarely involve any danger to life, un- 
less, as may happen, the disease extends to the sphenoidal and 
ethmoidal sinuses, and yet their diagnosis and treatment occasion- 
ally present difficulties, which, although not insurmountable, often- 
times tax the therapeutic resources of the surgeon, and weary the 
patience of the sufferers. Garretson 1 states with a considerable 
degree of emphasis that “ diseases of the antrum are for the most 
part simple in character, easy of diagnosis, and as a rule not at all 
difficult of treatment.” This is the point of view of the oral sur- 
geon, whose cases are mainly dependent on carious teeth, and 
which, therefore, yield readily to treatment, by the simple measure 
of removing the cause, when oftentimes a cure ensues without fur- 
ther treatment. Cases which result from intra-nasal disorders or 
traumatism, yield less readily, and often require a somewhat pro- 
longed course of treatment. Spontaneous resolution of chronic 
suppurative disease of the antrum probably never occurs. In an 
acute catarrhal attack from an acute rhinitis, spontaneous resolu- 
tion is perhaps the rule. 
Treatment.—The essential feature of the treatment of a case 
of suppurative disease of the antrum, consists in opening the cavity 
for proper drainage, and subsequently its thorough cleansing and 
disinfection. If it occurs in connection with nasal polypi, hyper- 
trophic rhinitis, deformity of the septum, or other obstructive 
lesion, I think it is important that these lesions should be removed 
as far as possible, by a proper mode of treatment, before further 
measures are resorted to. The removal of the nasal obstruction 
offers the hope, that the normal orifice of the cavity may be found 
patulous, in which case a freer drainage will be afforded. In ad- 
dition to this, disinfecting lotions should be used by the patient 
several times daily, to prevent the ostium from becoming blocked 
by accumulated secretions. For this purpose there may be used 
a solution of carbolic acid, three grains to the ounce, boracic acid, 
twenty grains to the ounce, to which may be added bicarbonate or 
biborate of soda in the proportion of five grains to the ounce. This 
can be used by means of the small atomizer (see Fig. 47). After 
the thorough cleansing of the parts, I have seen excellent results 
from the use of the following, as a spray: 
5. Terebene, ....... 3 ss. 
Ol. petrolati (Zero), . . . . . § i. 
1 Op. cit., p. 747. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 
475 
This process, however, involves a long and somewhat tedious 
course of treatment, with exceedingly doubtful results, for in re- 
moving the cause of the disease, it is questionable whether we 
succeed in even modifying the morbid process, which has fixed 
itself upon the mucous membrane lining the cavity, and further- 
more it is not probable that fluids injected into the nasal cavity 
reach to any extent the diseased sinus, although Moldenhauer1 
thinks that projecting medicated solutions in the direction of the 
orifice by a properly curved syringe, is sufficient to insure their 
penetration. This is not sufficient, I think, for we not only re- 
quire penetration of the cavity, but its thorough cleansing. Hart- 
mann2 believes ordinary politzerization to be an efficient method of 
opening the antral orifice, while Ziem 3 uses a curved nozzle, passed 
behind the palate, for the same procedure, in order to avoid blow- 
ing putrefactive particles into the Eustachian orifices. The practical 
value of these procedures I seriously question. Wolfram4 reports 
a case of antrum disease of six months’ standing, cured by the use 
of the steam atomizer, from which, after the parts were cleansed 
with the nasal douche, a two-per-cent solution of tannin and gly- 
cerine was inhaled twice daily, and subsequently acetate of alum, 
a cure being'effected in a few weeks. Storck5 treats his cases by 
local medication through the nose. The nozzle of a syringe is in- 
serted directly into the antral orifice, in those cases in which this is 
feasible. Where this cannot be seen, he uses a syringe with a 
straight nozzle, the dfstal opening of which is closed, and a perfora- 
tion made in its side. Now, by moving this along the middle 
meatus, he claims that when the jet enters the antrum, the pa- 
tient is conscious of it, and in this way the location of the opening 
is ascertained, and its distance from the margin of the nostril re- 
corded by a mark on the tube of the syringe. In order to gain 
freer access to the parts, he states that the nasal passages may be 
dilated, by packing them with pledgets of cotton, previous to the 
use of the syringe. I know of but one way to dilate the nasal cav- 
ity, and that is to contract the tissues by the application of cocaine, 
as in all forms of mechanical dilatation the stenosis recurs by the 
return of the blood-flow, immediately after the removal of the 
dilator. 
In the large proportion of cases, a successful cure of disease of 
the maxillary sinus requires that an artificial opening be made. If 
the first or second molar tooth is carious, or loosened, there can be 
no questiqn that the access to the cavity is better obtained by its 
1 Op. cit., p. 187. 2 As cited by Schech, op. cit., p. 282. 
4 Berliner Klinische Wochenschrift, April 21st, 1879, p. 227. 
5 Wien. Med. Wochenschrift, No. 43, 1886. 
3 Ibid. 476 
DISEASES OF THE JVASAL PASSAGES. 
removal. In some cases, this procedure will reveal the existence 
of an opening, while in others, it will be necessary to drill upward 
through the tooth cavity, until the antrum is reached. The pene- 
tration of the sinus should be followed by an escape of pus. We 
thus have established two openings into the cavity, one of which 
being situated in its most dependent portion, presents the condi- 
tions essential for its proper drainage. The indications now are, 
the thorough cleansing of the diseased part, while at the same time 
a patulous condition of the artificial opening is maintained. Cleans- 
ing is accomplished by syringing through the artificial opening 
daily, until the solution escapes through the nasal orifice. The 
fluids adapted to this, are any of those already mentioned. After 
the cavity is thoroughly cleansed, there should be injected a mild 
and unirritating astringent, such as sulpho-carbolate of zinc, grs. v. 
to the ounce; resorcin, grs. v. to the ounce; hydro-naphthol, gr. ss. 
to the ounce, nitrate of silver, grs. v. to the ounce, etc. Astier1 ad- 
vises that the cavity be touched by lunar caustic fused on the end of 
a probe; a procedure of doubtful propriety. Tincture of iodine may 
Fig. ng.—Silver Drainage Tube for the Antrum, full size. 
be used in the strength of fifteen minims to the ounce of water, al- 
though Schech2 has seen iodism produced by the injections of weak 
solutions of this agent. To prevent a closure of the artificial open- 
ing, it will be necessary to insert a drainage tube (see Fig. 119). 
The best form of this is a silver tube three-fourths to one inch long, 
and one-eighth of an inch in diameter, which should be provided 
with a collar or flange, as first used, I believe, by Bordenave,3 by 
means of which it is attached, by a silk thread, to a neighboring 
tooth. Salter4 suggests that a vulcanite plate be made to fit the 
gum, into which the drainage tube is inserted, of just sufficient 
length to reach the orifice. The lower end of the drainage tube is 
so constructed as to accurately fit the nozzle of the syringe, which 
is used for injecting into the cavity. During intervals of treatment 
this author suggests that a small cork should be worn in the drain- 
age tube, to prevent the constant discharge of the offensive pus 
into the mouth, and also to prevent particles of food getting into 
1 Revue Generate de Clinique et de Therapeutique, July, 1887. 
2 Op. cit., p. 283.' 
3 “ Dis. of the Maxillary Sinus/’ Mem. Royal Acad, of Surg., France, Sydenham. 
Soc. Pub., London, 1848, p. 145. 
4 Holmes’s “ System of Surgery,” Amer. ed., Phila., 1881, vol. ii., p. 571. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 
477 
the antrum. Experience has taught me that this precaution 
is unnecessary. In case the patient wears artificial teeth, any 
dental surgeon can easily attach a small piece to the plate, which 
pressing against the flange of the tube, will hold it in place. 
Any small syringe, fitted with a proper nozzle, is adapted for use in 
these cases. I usually direct the patient to provide himself with 
an ordinary dental syringe, or an Anel’s lachrymal syringe (Fig. 
120); with this the cavity is to be cleansed at least twice daily. In 
some instances patients have acquired the habit of cleansing the 
cavity without the use of a syringe, simply filling the mouth with 
a solution of salt water, or some other simple lotion, and forcing it 
through the tube by the lips, cheeks, and tongue, the head being 
held over a proper receptacle, into which the lotion falls from the 
nose. The retention of the tube must be continued according to 
Fig. 120.—Anel’s Lachrymal Syringe, for use in Disease of the Antrum. 
the duration of the pus discharge. In one of Bordenave’s 1 cases, a 
cure was effected and the tube removed at the end of two months, 
while in another 2 it was retained for two years, before it could be 
removed with safety. 
When the cavity is first opened, it is important that it should 
be thoroughly explored by means of the probe, in order to detect 
the existence of necrosed bone, or other unusual conditions, as 
thus, in Wyeth’s case, already alluded to, a supernumerary tooth 
was the source of the suppuration, while in a case cited byGiraldes3 
local medication failed to arrest the suppurative process, until the 
existence of a bony septum traversing the cavity was discovered, 
and broken up by means of a probe. In those cases in which no 
evidence of diseased teeth is discovered, the question arises as to 
the propriety of sacrificing a sound tooth. The only advantage of 
1 Loc. cit., p. 146. 2 Loc. cit., p. 147. 
3 “ Des Maladies du Sinus Maxillaire,” Paris, 1851. 478 
DISEASES OF THE NASAL PASSAGES. 
this lies in the fact, that we thereby establish an artificial opening 
in the most favorable position for securing drainage, viz,: in the 
dependent portion of the cavity. I do not think the advantage of 
this opening is sufficient to warrant the sacrifice of a sound tooth, 
when we consider the simplicity and efficacy of the operation first 
suggested by Mickulicz,1 of opening into the antrum through the 
inferior meatus. This is done by an instrument, which consists of 
a spear-pointed knife, mounted on a shaft, curved to a right angle, 
and fitted with a shoulder, about three-eighths of an inch from the 
point, in such a manner as to regulate the depth of the cut. The 
instrument being carried within the nostril, the incision is made at 
a point in the lower meatus, immediately below the normal orifice 
of the antrum, the direction of the incision being upward, backward, 
and outward, in order to avoid the hard, bony tissue at the lower 
border of the septum, which could not be easily penetrated. A 
diamond-shaped opening is thus established, which is sufficiently 
near to the floor of the antrum to afford ample drainage facili- 
ties, and is also easily accessible for subsequent cleansing and 
medicating procedures, which are essentially the same as those 
mentioned in connection with the alveolar opening. The hemor- 
rhage attending the operation is but trivial, and can easily be con- 
trolled. Mickulicz states, that the operation is impracticable if 
the entrance is very narrow, or the bones very hard, or where 
there is extreme hypertrophy of the lower turbinated bone. It 
need scarcely be stated that the operation should be done with the 
use of cocaine, which in every case, I think, would so far eliminate 
the turbinated hypertrophy, by contracting the tissues, as to over- 
come any obstacle that that condition might present. If deflection 
of the septum hamper the manipulation, it can easily be removed 
by means of the saw. If the bone is found to be sufficiently hard 
to resist penetration by the knife, a burr or drill, or perhaps Curtis’s 
trephine, can be manipulated by the dental engine or electro- 
motor. An artificial opening to the antrum through the nasal 
cavity is by no means new, for in the last century, we find Hunter2 
recommending this operation, but advising, however, that it should 
be done in the middle meatus; on what grounds it is not easy to 
determine, unless the idea was to re-establish the normal orifice. 
The very serious objection lies against it, however, that it does not 
establish drainage, and moreover the normal orifice is quite patu- 
lous in many cases of suppurative disease of the antrum, and yet 
the suppurative process persists. I see, therefore, but little ad- 
1 Zeitschrift fur Heilkunde, 1886, p. 257. 
2 “Practical Treatise on Diseases of the Teeth,” London, 1771. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 
479 
vantage to be gained from the operation, although it is indorsed 
by Jourdain,1 Schiffers,2 and Zuckerkandl.3 Mickulicz’s operation 
does not open the antrum at its lowest portion, yet it is sufficient 
practically to afford ample drainage of the sinus, and I fully agree 
with Frankel4 in the view, that the antrum should be opened in 
the lower meatus, in preference to any other locality, unless a cari- 
ous molar tooth invites the alveolar opening. There may be con- 
ditions rendering it necessary to make the opening through the 
canine fossa, such as ankylosis of the jaw, preventing the removal 
of a tooth, in connection with insuperable objections to Mickulicz’s 
operation. An opening in this region offers no special advantages, 
while the wearing of a drainage tube in this locality might prove 
a source of considerable annoyance, and furthermore, it is usually 
a matter of some difficulty to keep the opening patulous. La Mo- 
rier5 as early as 1740 resorted to this operation in a case in which 
there was a somewhat extensive necrosis of the alveolar pro- 
cess, and which had existed for several years. He made the 
opening sufficiently large to admit the little finger into the cavity, 
by means of which its walls were subjected to digital exploration. 
In this case the opening remained patulous, giving rise to a defect 
in articulation similar to that of cleft palate, which was only rem- 
edied by wearing artificial plugs. The suppurative disease was cured, 
however, in a few weeks. In those cases in Which, as the result of 
the long retention of pus, the anterior wall of the antrum has be- 
come thin, and the pus shows a tendency to point upon the cheek, 
this disposition should be corrected as soon as possible, by an arti- 
ficial opening elsewhere, since it is probably never wise to open 
the antrum through the cheek, as, in that case, a permanent fistu- 
lous opening is liable to form. 
Disease of the Ethmoidal Sinuses. 
In these sinuses, we meet with catarrhal inflammation, and also 
the suppurative process. In the former instance, it is probably, in 
most cases, a complication of an attack of acute rhinitis, and hence 
its symptoms are, to an extent, masked by those of the inflamma- 
tory process in the nasal cavities. The only feature of the attack, 
which should direct prominent attention to the ethmoidal sinus, 
is simply pain, referable to that region, of an intensity and per- 
1 Hyrtl, “ Topographische Anat.,” Wien, 1871. 
2 Revue de Laryngologie, June, 1887. 
3 Op. cit., p. 143. 
* Berliner Klinische Wochenschrift, No. 16, 1887, p. 273. 
s Mem. Acad. Fr., 1743. 480 
DISEASES OF THE NASAL PASSAGES. 
sistence not usually characteristic of an ordinary cold in the head. 
It usually subsides spontaneously, as the inflammatory process in 
the nose undergoes resolution. Suppurative disease of the eth- 
moidal sinuses, on the other hand, is an affection of far more seri- 
ous import, involving as it does, symptoms of a more troublesome 
and even dangerous character, in that its tendency is toward caries 
and necrosis of the bony structures underlying the mucous mem- 
brane. 
ETIOLOGY.—It may develop from a simple catarrhal process, 
complicating an acute rhinitis, as in the following case reported by 
Schaffer:1 
A soldier, 23 years old, after the ordinary symptoms of a cold in the head, 
commenced to suffer from a swelling of the eyelids on the right side, together 
with right exophthalmos; at the same time there set in an ill-smelling, muco- 
purulent discharge from the right nasal cavity ; an orbital abscess finally devel- 
oped, from which pus was evacuated by incisions. By injections through these 
incisions, the fluid flowed freely from the right nasal cavity. Death finally 
occurred from meningitis, and the post-mortem examination revealed a sup- 
purative patch of the size of a walnut in the ethmoidal cells, wdth ulceration of 
the osseous tissue. 
The disease may also develop in connection with a chronic rhi- 
nitis, the hypertrophic process gradually extending toward, and 
occluding the ostium ethmoidale, in much the same way as has 
been noticed in connection with disease of the antrum. This ap- 
parently was the primary origin of the attack in Hartmann’s2 case, 
as follows: 
A man, aged 26, was seized with a violent pain over the frontal region, which 
increased in severity, and gradually extended over the whole of the left side of 
the face, while at the same time protrusion of the left eyeball became notice- 
able, and slowly increased. At the 'end of two weeks, marked febrile move- 
ment set in. Soon after the exophthalmos became apparent, a more or less 
profuse purulent discharge made its appearance from the nasal cavity, which 
the patient himself noticed was increased by pressure upon the eyeball. Three 
weeks after the onset of the attack, he was admitted to the hospital, presenting, 
in addition to the foregoing symptoms, immobility of the left eyeball in all direc- 
tions, with diplopia. The ophthalmoscopic appearances, and pupillary reaction, 
were normal, the field of vision being free. Under the use of disinfecting lo- 
tions and palliative measures, the case progressed favorably, and two months 
after the onset of the attack, a bony sequestrum was removed, and the patient 
was discharged cured two weeks later. 
In rare instances, the disease may develop from traumatic causes, 
as from a blow upon the nose, giving rise to a fracture of the' 
vomer, or a sutural dislocation in the neighborhood of the ethmoid 
1 Prag. Med. Wochenschrift, 1883, No. 20. 
2 Quoted by Berger and Tyrman, “ Die Krankheiten der Keilbein-Hohle und des Sieb- 
bein-Labyrinthes,” Wiesbaden, 1886, p. 14. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 
481 
plate, the inflammatory process attending the accident causing 
occlusion of the ostium ethmoidale, or possibly the disease may 
arise from an extension of the morbid lesion. In still rarer in- 
stances, the os planum itself, or the labyrinthine walls, may be 
fractured as the result of external injury. The ulcerative processes 
accompanying syphilis, tuberculosis, and possibly scrofula, may un- 
doubtedly give rise to a suppurative disease of the ethmoid cells, 
as stated by Berger and Tyrman,1 yet such cases do not constitute 
properly an attack of suppurative disease of the ethmoid sinuses, 
being simply an adventitious complication, the symptoms of which 
are entirely overshadowed by the graver disease, which has given 
rise to them. 
The well-known action of phosphorus on the bones of the face, 
would naturally suggest this as one of the causes of disease of the 
ethmoid cells. I am not aware that the ethmoid cells have ever 
been primarily attacked from this cause, although Scobell Savory2 
has reported the case of a young man who worked in phosphorus, 
and who died as the result of disease contracted therefrom, in 
whom the post-mortem revealed the ethmoid bone almost com- 
pletely destroyed by the necrotic process, which also involved the 
sphenoid, and most of the facial bones. 
The development of nasal polypi, with its accompanying nasal 
obstruction, may give rise to ethmoid disease, in much the same 
manner as that described in connection with disease of the antrum, 
although the latter cavity is far more liable, I think, to be the site 
of suppurative disease from this cause. Woakes3 endeavors to 
trace a very close connection between mucous polypi in the nose, 
and what he terms necrosing ethmoiditis, going so far as to state 4 
that “ the two pathological conditions run on side by side, experi- 
ence confirming, that when polypus exists necrosis is also present, 
but the converse position cannot be maintained, necrosis being 
demonstrable earlier, and occurring much more frequently, than 
does myxoma.” This remarkable statement I cannot indorse, as 
I regard ethmoid disease as one of the rarest complications of nasal 
polypi. 
Berger and Tyrman5 mention facial erysipelas as a possible 
cause of the disease. There seems to be some question, however, 
whether in these cases the erysipelas be due to an acute rhinitis, or 
the acute rhinitis the result of erysipelas. Weichselbaum,6 after a 
1 Op. cit., pp. 13 and 27. 2 Med. Chirurgical Trans., 1874, vol. Jvii., p. 187. 
3 Nasal Polypus,” Amer. ed., Phila., 1887. 
4 Op. cit., p. 23. s Op. cit., p. 13. 
6 “ Phlegmonose Entzlindung der Nebenhohlen der Nase.” Wr. Med. Jahrb., 1881, 
p. 227. 482 
DISEASES OF THE NASAL PASSAGES. 
somewhat careful analysis of ten such cases, finds himself still in 
doubt as to this point. In either case the ethmoid disease develops 
as the result of the nasal inflammation. 
We thus find, in the large majority of instances, the disease de- 
velops from causes in the nasal cavity. Occasionally, however, we 
find it occurring as the result of disease in the orbital cavity, as in 
the case reported by Vossius1 in which the extraction of a molar 
tooth gave rise to a thrombosis of the accessory orbital veins, and 
the subsequent development of an abscess in the orbital cavity, 
which penetrated the os planum, and set up suppurative disease of 
the ethmoid. 
PATHOLOGY.—The morbid process here develops in essentially 
the same manner as that already described in connection with dis- 
ease of the antrum. The hyperaemia results in a sero-mucous ex- 
udation, which, owing to the fact that the cavity is closed, soon de- 
generates into a suppurative inflammation. The accumulation of 
pus soon follows, and distends the cells, while at the same time the 
inflammatory process in the mucous membrane, extending to its 
deep layers, which constitute the periosteum of the thin, bony walls, 
results in the development of a true periostitis. The necessary 
consequence of this is the early occurrence of necrosis and exfolia- 
tion of bone. We see, therefore, that the tendency in all cases, and 
the result in the large majority of instances, of a suppurative in- 
flammation of the ethmoid cells, is necrosis of bone, hence Woakes’s 
newly invented term of necrosing ethmoiditis, would seem to be 
scarcely called for, since all ethmoiditis tends toward, and usually 
develops sooner or later into, necrosis. 
SYMPTOMATOLOGY.—The earliest symptom of ethmoid disease 
is pain referable to the lower frontal region, and generally confined 
to one side. As the disease progresses, the pain increases in sever- 
ity, and may extend to the whole side of the face, but being most 
intense as a deep-seated orbital or frontal pain. The discharge of 
pus from the nasal cavity of the side affected, sets in early in the 
attack, and has a bright yellow color and laudable appearance. 
The pus discharge at first may be attended with the characteristic 
fetid hydrogen odor. If the flow becomes established, however, 
this disappears to a great extent, returning in the course of one or 
two months, with the development of necrosis, when it assumes the 
characteristic fetor of dead bone. Its character, also, is now 
changed, in that it may contain shreds of necrotic tissue, or the 
debris from the process of bony destruction. With the disten- 
tion of the cells from pus, a giving-way occurs on the side of least 
1 “ Ein Fall von Orbitalphlegmone bei Thrombophlebitis der Orbitalvenen, etc.,’’ v. 
Grafe’s Archlv, vol. xxx. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 
483 
resistance, which is toward the orbit, hence, a bulging of the eye of 
that side may occur very early in the disease, accompanied with 
functional symptoms attendant upon ocular dislocation, such as 
immobility of the eye, and impairment of vision with diplopia. 
Allusion has already been made to the fact, that in a certain num- 
ber of cases, the direct connection between the exophthalmos and 
the pus discharge can be demonstrated, from the fact that pres- 
sure upon the eyeball causes a flow of pus into the nasal cavity. 
Febrile movement occurs early in the course of the disease, and 
shows the usual remittent type characteristic of pus formation, 
showing a daily variation of from one to two degrees, the evening 
exacerbation of fever rarely developing a temperature above 102°, 
while the morning temperature will not vary greatly from ioo°. 
Chills or chilly sensations do not occur, except in connection with 
an unusual access of febrile movement. A pus discharge, although 
almost an invariable rule, is not always present, as in a case reported 
by Vernujne,1 a girl sixteen years of age, suffering from naso-pharyn- 
geal catarrh since she was five years of age, probably the result of 
scarlet fever, was attacked with the ordinary symptoms of ethmoid 
disease, with the exception of the purulent discharge. Vernujne 
made a diagnosis of retention cyst in the ethmoid cells, basing this 
conclusion on a somewhat similar case observed by Knapp,2 in 
which a pus sac formed in the ethmoid, and crowding the os planum 
before it, presented at the inner canthus of the eye, apparently as 
an osteoma, which, however, upon being opened with a chisel was 
found to contain pus. 
DIAGNOSIS.—An examination of the nasal cavity will reveal a 
discharge of bright-yellow healthy pus, making its way from be- 
neath the middle turbinated body of the side affected, which always 
indicates the existence of suppurative disease of one of the acces- 
sory sinuses. The question to determine now is, which of these 
cavities is the source of the discharge. Ingals 3 makes the point, 
that in antrum disease, the pus flows down over the middle of the 
lower turbinated body, while in ethmoid disease, it is found on its 
posterior termination. This condition is not greatly to be depended 
upon, as whatever be the source of the discharge, if it is large in 
amount, it diffuses itself pretty generally over the whole of the 
lower turbinated body, and moreover, the direction of the flow 
would be determined somewhat by the position of the body. Nor 
is much information afforded by Frankel’s suggestion, already al- 
1 Amer. Journal of Ophthalmology, 1884, vol. i.. No. 5, p. 129. 
2 Fifth Ophthalmological Congress, N. Y., 1876, p. 55. 
3 “ Suppurative Inflammation of the Antrum,” Journal Amer. Med. Association, July 
30th, 1887. 484 
DISEASES OF THE NASAL PASSAGES. 
luded to in the chapter on disease of the antrum, that by lowering 
the head, the flow is promoted from the antrum, while the erect 
position facilitates the discharge from the other sinuses. Our diag- 
nosis, then, must be made on the co-existence of a pus discharge 
from beneath the middle turbinated body, in connection with deep- 
seated pain and exophthalmos, the latter symptom being the one 
which points most directly toward disease of the ethmoidal laby- 
rinth. Berger and Tyrman1 mention emphysema of the orbit as 
occasionally present in these cases, its existence being due to necro- 
sis of the os planum. This condition can be recognized by the 
peculiar cracking sound produced by pressure on the eyeball. It 
would only exist, however, in connection with exophthalmos. 
PROGNOSIS.—The simple catarrhal disease of the ethmoid si- 
nuses, which usually occurs in connection with an attack of acute 
rhinitis, undergoes resolution in the large majority of instances with- 
out treatment. Suppurative disease, on the other hand, runs a de- 
cidedly chronic course, and shows little tendency to spontaneous 
resolution. While the disease confines itself to the ethmoid sinuses, 
it involves no serious danger to life, but in those rarer cases in which 
the diseased action extends to the cranial cavity, the prognosis be- 
comes exceedingly grave, and almost necessarily fatal. Probably 
in the majority of instances, where the disease extends to a neigh- 
boring cavity, the orbit is the part invaded. So marked is this, 
that the existence of an orbital abscess should in all cases suggest 
the existence of ethmoidal disease as its source, as in a case re- 
ported by Sonnenberg2 the pus discharge from the nose was not 
present, until after incision of the abscess in the orbit. Owing to 
their close and intimate anatomical relation, invasion of the sphe- 
noidal sinuses is a not infrequent complication of ethmoidal disease, 
although not one which can be recognized by any diagnostic signs. 
The suppurative disease confined to the ethmoid cavities, runs a 
somewhat slow course, and eventually leads to necrosis, which first 
involves the labyrinthine plates, which may undergo spontaneous 
expulsion, as in Hartmann’s case already cited, or may extend to the 
os planum, and the cribriform plate, and thus involve the neighbor- 
ing cavities. In either instance, the labyrinthine walls become 
subject to the process of caries, under which the destruction goes 
on very slowly, and the disease runs a course, which may be pro- 
longed into months or even years. 
Treatment.—The indications for the treatment of ethmoid 
disease are naturally the same as those in disease of the antrum. 
1 Op. cit., p. 28. 
2 “ Beitrag zur acuten Zellgewebs-Entziindungen der Augenhohle,” Deutsche Zeit- 
schrift fur Chirurgie, 1877, vol. vii., p. 500. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 
485 
They consist essentially in thoroughly cleansing and disinfecting 
the nasal cavity, and subsequently in establishing proper drainage 
from the diseased sinuses. In most instances, probably, it will be 
necessary to resort to surgical interference, although occasionally 
it may be possible by simple measures, such as disinfecting sprays 
and douches in the nose, and the subsequent use of cocaine to con- 
tract the tissue, to so far open the nasal passages, and gain access 
to the normal orifice, as to facilitate the pus discharge, and estab- 
lish free drainage. Thus, in Hartmann’s case, already alluded to, 
this was the only measure of treatment applied. Unfortunately, 
such good fortune cannot always be anticipated, and hence more 
active measures are demanded in the majority of cases. These 
consist in establishing an artificial opening into the sinus. This 
opening must necessarily be made above the middle turbinated 
body, and hence is an exceedingly delicate and difficult manipula- 
tion. Ziem, who was the first to open these sinuses, advises that 
this should be done, after removing a portion of the middle turbi- 
nated bone, thus gaining a freer access to the superior meatus, 
where the posterior ethmoidal cells are to be opened by means of 
a probe or injection needle carried obliquely along the junction 
of the bony and cartilaginous septum, upward and backward, and 
directly into the cells. Schech,1 recognizing the difficulty of gain- 
ing access to this region through the nostril, suggests that a freer 
manipulation, and a better view may be obtained, by splitting open 
the external nose. Ziem seems not to have been especially suc- 
cessful in his operation, and hence it seems to me, that if it becomes 
advisable to open the ethmoid cells, it should only be attempted 
after the external operation as suggested by Schech, although for 
this purpose, it would be wiser to tilt the nose to one side by means 
of Boeckel’s operation, or to drop it downward, after Ollier’s 
method, after which, the cavity being brought thoroughly and 
widely into view, the cells may be opened by means of a probe or 
drill, and necrosed bone, if it be present, removed by the curette 
or gouge. It is only candid to state, however, in regard to this 
operation, that the literature of ethmoidal disease contains no cases 
which were treated with notable success in this manner. In most 
instances, the treatment has consisted in the • persistent use of 
cleansing and disinfecting lotions, and the use of politzerization, 
after the manner of Hartmann or Ziem. Whenever complicating 
lesions manifest themselves, their treatment is to be directed by 
general surgical rules. If orbital abscess occur, it is to be opened 
at the earliest moment, and efficient drainage established. 
1 Op. cit., p. 284. 486 
DISEASES OF THE NASAL PASSAGES. 
Disease of the Sphenoidal Sinuses. 
Simple catarrhal inflammation of the mucous membrane lining 
the sinuses of the sphenoid bone, occurs probably not infrequently 
as a complication of an acute rhinitis, as is the case with the other 
accessory sinuses. This, however, is not evidenced by any very 
marked symptoms, and may undergo resolution, with the subsidence 
of the nasal disorder. Suppurative disease in this region, however, 
constitutes an affection of very serious import, in that, as in the 
other sinuses, it manifests but little disposition to undergo a spon- 
taneous cure, but on the contrary gradually extends to the deep 
layers of the membrane and the periosteum, resulting in a bony 
necrosis. 
ETIOLOGY.—The course and development of the morbid pro- 
cess here is much the same as we find it in the other accessory si- 
nuses, and probably arises primarily from obstruction of the ostium 
sphenoidale, resulting in a retention of secretion, with consequent 
suppurative inflammation. This obstruction may result from the 
encoachment of hypertrophic inflammation of the mucous mem- 
brane lining the nasal cavities, the existence of polypi or other 
tumors, the presence of foreign bodies, or some deformity of the 
nasal cavity, which acts to occlude the normal orifice. Zucker- 
kandl1 raises the question, whether in some certain cases the necro- 
sis may not be primary, and the pus discharge a resultant symp- 
tom, although favoring the view that in the majority of instances 
the necrosis is the result of a morbid process in the mucous mem- 
brane. Schech2 states that purulent accumulations in these sinuses 
have been observed in connection with cerebro-spinal meningitis, 
this complication resulting probably from contiguity of structure, 
or this may possibly serve to substantiate the recent view enter- 
tained in regard to spotted fever, that it is the result of a germ, 
taken into the system by inhalation through the nasal passages. 
Berger and Tyrman3 enumerate among the causes of the disease, 
syphilis and scrofula, giving the former as its more frequent cause, 
although I am disposed to regard intra-nasal disorder, as already 
stated, as more liable to produce the disease. Zuccarini,4 in an in- 
vestigation of the relation of facial erysipelas to typhus fever, has 
found sphenoidal disease in a post-mortem on one patient, in whom 
1 f‘ Anatomie der Nasenhohle,” Wien, 1882, p. 174. 
2 “ Diseases of the Mouth, Throat, and Nose,” Eng. ed., Edinburgh, 1886, p. 280. 
3 “ Die Krankheiten der Keilbein-Hohle und des Siebbein-Labyrinthes,” etc., p. 22. 
4 “ Gesichtsrothlauf in Verlaufe des Typhus,” Wien. Med. Wocheftschr., 1853. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 
487 
these two affections co-existed. A similar case has come under the 
observation of Weichselbaum.1 
Pathology.—The pathological changes which take place in the 
mucous membrane of these sinuses, consist essentially in a catar- 
rhal inflammation, gradually extending to the deeper tissues, which 
here constitute the periosteum, as the result of which, the nutrition 
of bone is so far interfered with, that necrosis occurs in precisely 
a similar manner to that already described in the discussion of 
ethmoidal disease, the simple catarrhal inflammation being converted 
into a suppurative process, as the result of obstruction to the ori- 
fice, and resultant accumulation of the secretions. Hence, we can 
easily see how, as noted by Ziem,2 the anatomical situation of the 
orifices of the sphenoidal sinuses and the antrum, favor the devel- 
opment of suppurative inflammation, being situated on the lateral 
wall of the sinus, thus differing from the ethmoidal and frontal 
sinuses, whose orifices admit of freer drainage, while Zuckerkandl3 
singles out the ostium sphenoidale, as being located in a manner 
particularly unfavorable to the free escape of accumulated secre- 
tions. 
SYMPTOMATOLOGY.—More or less profuse purulent discharge 
from the nasal cavity is a prominent symptom of the disease, this 
pus being the same bright-yellow healthy pus which is characteris- 
tic of suppurative disease of all of the accessory sinuses. The dis- 
charge makes its way backward, as a rule, dropping into the pharynx. 
Lennox Browne4 makes the statement that “sphenoidal discharges 
may be the forerunner, and possibly the excitant, of obstinate post- 
nasal catarrh.” This is scarcely a correct observation. Certainly 
the discharge excites no morbid condition in the mucous membrane 
over which it passes, and moreover, a pus secretion does not occur 
in what is ordinarily termed a post-nasal catarrh. Deep-seated pain 
is always present, referable to the side affected, and in some cases 
may be of a most distressing character, radiating through the whole 
side of the face, involving all the branches of the trigeminus, as in 
a case observed by Rouge,5 the dental branches of the superior 
maxillary nerve became the seat of a neuralgia of so intense a na- 
ture, as to lead Rouge to make a diagnosis of disease of the antrum, 
for which he performed resection, the death of the patient occur- 
ring soon afterward. An autopsy revealed an accumulation of 
cheesy pus in the sphenoidal sinuses, while the maxillary sinus was 
1 Wien. Med. Jahrbuch, 1881. 
* Monatsschr. fur Ohrenheilkunde, 1886, No. 3, p. 82. 
3 Op. cit., p. 173. 
4 “ The Throat and its Diseases,” London, 1887, p. 529. 
5 Cited by Berger and Tyrman, op. cit., p. 23. 488 
DISEASES OF THE NASAL PASSAGES. 
perfectly healthy. Owing to the proximity of the sphenoidal 
sinuses to the optic foramina, ocular symptoms might naturally be 
expected, and hence impairment of vision or complete blindness may 
occur, as the result of pressure on the optic nerve; as, in the case 
reported by Horner 1 of a girl fifteen years of age, who, after having 
complained of headache for some time, suddenly became blind in 
the right eye ; at the same time there was exophthalmos and im- 
mobility of the eyeball; the ophthalmoscopic examination showed 
slight swelling of the optic nerve ; there was no swelling of the eye- 
lids. Two months after the blindness came on, the patient died of 
meningitis. The autopsy showed necrosis of the sphenoidal sinuses. 
The chajiges were most marked about the right optic foramen. 
The cellular tissue of the orbit was infiltrated with serum. A 
similar case reported by Post2 presents the additional- point of 
interest, in the ultimate recovery of the patient, who in the course 
of the disease developed both exophthalmos and amaurosis, de- 
pendent upon necrosis of the lesser wing of the sphenoid. Extrac- 
tion of the sequestrum was followed by a return of the eye to its 
normal position, but the amaurosis was not relieved. The exoph- 
thalmos in this case may have been due to serous exudation, caused 
by obstruction to the return circulation, by pressure on the orbital 
veins in their passage through the sphenoidal fissure as in Horner’s 
case, or the diseased process of the body of the sphenoid may have 
extended to the great wings, where they form a portion of the 
outer and superior wall of the orbit, thus leading to the develop- 
ment of an orbital abscess, and resultant protrusion of the eye as in 
the case reported byPanas3 where, as the result of an ostitis of the 
sphenoid, sudden blindness set in, followed by the development of 
an abscess in the orbit. The notable symptoms then, we find, are 
a pus discharge with pain, followed, as the disease progresses, by 
a somewhat sudden occurrence of blindness, and in a certain pro- 
portion of cases the development of orbital abscess, or serous exu- 
dation into the cellular tissue of the orbit. 
Berger4 calls attention to a peculiar feature of the amaurosis 
occurring in connection with cases of sphenoidal disease, in that 
the peripheral field of vision is invaded before the central field is 
affected. This is explained by the fact, as first observed by $amel- 
sohn, that the central fibres of the optic nerve are distributed to 
the macula lutea, while the peripheral fibres are distributed to the 
outer portion of the retina. 
1 Klin. Monatsbl. f. Augenh., P'ebr., 1863. 
2 London Lancet, May 6th, 1882, p. 734. 
3 Gaz. des Hopitaux, 1873, p. 1148. 
4 Revue Mensuelle de Laryngologie, July, 1888, p. 400. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 
489 
DIAGNOSIS.—A diagnosis of suppurative disease of one of the 
accessory sinuses having been established by the existence of a 
discharge of bright-yellow healthy pus from one of the nasal pas- 
sages, the attention would necessarily be directed toward the sphe- 
noidal sinus as the seat of the disease, by the fact of the pus pour- 
ing over the surface of the middle turbinated bone, and that its 
source can be traced to the superior meatus, provided the nasal 
passages are sufficiently patulous to admit of a thorough explora- 
tion. It should be stated, however, that this nice localization of a 
purulent discharge in this region is very rarely possible by an ex- 
amination anteriorly, although it may occasionally be accomplished 
by posterior rhinoscopy. In those cases of ethmoidal disease in 
which the posterior group of cells is involved, we may also have a 
pus discharge into the superior meatus. In these cases, the recog- 
nition of the disease will necessarily be based on a consideration of 
concomitant symptoms, although it should be stated, that proba- 
bly, in the majority of cases in which the posterior group of eth- 
moidal cells is the seat of the disease, the sphenoidal sinuses are 
involved in the same morbid process, owing to their close anatomi- 
cal relation, and the fact that the orifices both of the sphenoidal 
and posterior ethmoidal cells open together into the superior mea- 
tus, and hence the same causes which would operate to produce 
suppurative disease in one group, would act equally on the other. 
The pus discharge makes its way into the pharynx, giving rise to 
symptoms of ordinary so-called naso-pharyngeal catarrh, although 
the character of the secretion differs essentially from the ordinary 
inspissated mucus which is found in the pharyngeal vault in that dis- 
ease. Suppurative inflammation of the pharyngeal bursa, the so- 
called Tornwaldt’s disease, gives rise to a pus discharge into the 
pharyngeal vault. This affection, however, I regard as an exceed- 
ingly rare one, and furthermore, a rhinoscopic examination should 
easily establish the source of the purulent secretion. Ziem 1 has re- 
ported a rather interesting case, in which a somewhat profuse puru- 
lent discharge into both the pharyngeal vault and the nasal cavities, 
had its origin in a cyst of the pharyngeal bursa, the removal of which 
seemed for a while to arrest the disease, although subsequently it be- 
came necessary to open the antrum, on account of suppurative in- 
flammation of that cavity. Further diagnostic signs pointing to sphe- 
noidal disease, consist of deep-seated pain, exophthalmos, paralysis of 
the optic nerve, or paresis of any of the motor nerves passing through 
the sphenoidal fissure. The deep-seated pain is characteristic both 
of sphenoidal and ethmoidal disease, and presents no points espe- 
cially indicative of either affection. Exophthalmos is present in a 
1 Monatsschr. f. Ohrenheilkunde, 1886, Nos. 2, 3. and 4. 490 
DISEASES OF THE NASAL PASSAGES. 
large proportion of cases, but is probably not so constant a symp- 
tom of this affection, as of ethmoidal disease. One of the earliest 
effects of distention of the sphenoidal sinus by pus, would be pres- 
sure on the optic nerve, in its passage through the optic foramen, 
hence the sudden onset of amaurosis occurs in probably a large 
proportion of cases. An exarqination by the ophthalmoscope in 
these cases should reveal the characteristic swollen disc. Still fur- 
ther diagnostic indications are furnished by the results of pressure 
on the nerves passing through the sphenoidal fissure, causing ptosis, 
strabismus, or immobility of the eyeball. 
COURSE AND Prognosis.—The prognosis of these cases, as a 
rule, is grave, as owing to the depth and inaccessibility of the parts 
affected, and the difficulty of reaching them with proper remedial 
measures, suppurative inflammation sooner or later leads to a ne- 
crosis of bone, which extending slowly, invades the orbital cavity, 
producing paralysis of the optic nerve. Death may occur as the 
result of meningitis as in Horner’s case, or as the result of invasion 
of the cavernous sinus by an erosion of its wall, as in the case re- 
ported by Scholz 1 whose patient, twenty-one years old, suffered 
from delirium tremens, developing facial phlegmon, subsequently 
going on to abscess of the cheek. After several days, there was a 
discharge of pus into the mouth, behind the last upper molar tooth. 
The patient suffered from frequent rigors. Ten days after the be- 
ginning of the illness, there were spasmodic contractions of the 
extremities, with coma; about twenty-four hours after, left-sided 
ptosis; on the evening of the same day, there was profuse hemor- 
rhage from the mouth and nose, of which the patient died. The 
autopsy showed the cause of death to be an erosion of the cavern- 
ous sinus, and a destruction of the bony substance of the body of 
the sphenoid on the right side, thus establishing direct communi- 
cation between the sphenoidal cells and the cavernous sinus. In 
this case, the primary seat of the disease was in the sphenoidal 
cells. Blachey2 and Lloyd, as cited by Berger and Tyrman,3 re- 
port cases of thrombosis of the circular and cavernous sinus and 
of the ophthalmic veins. A somewhat unique case is reported by 
Baratoux,4 in which nature effected a cure by the spontaneous ex- 
pulsion of the whole body of the sphenoid through the nose, the 
singular feature of the case being, that during the course of the 
disease, there were no symptoms of meningeal irritation or impair- 
ment of vision. 
TREATMENT.—The same palliative measures are indicated here, 
1 Berlin. Klin. Wochenschr., 1872, No. 43, p. 516. 
2 Gaz. Hebd., 1863, x., p. 44. 
4 Progres Medicale, 1883, p. 826. 
3 Op. cit., p. 26. DIS EASES OF THE ACCESSORY SINUSES OF THE NOSE. 
491 
as noted in the directions for treatment of ethmoidal and antral 
disease. These consist in the use of cleansing and disinfecting 
sprays and washes, together with politzerization, either anteriorly, 
or posteriorly according to Ziem’s method. These should be used 
frequently and with every thoroughness, in order to secure as effi- 
cient drainage of the diseased cavity as is possible in this manner. 
The indications for the radical treatment of the disease consist 
simply in opening the cavity for the discharge of pus in its early 
stages, and the removal of necrosed bone where feasible, in its later 
development. Zuckerkandl1 advises the opening of the sphenoi- 
dal sinus through the nasal cavity, at its anterior and dependent 
portion, whereby the most efficient drainage may be secured. He 
directs that the trocar shall be introduced along the septum, pass- 
ing upward and backward, across the middle turbinated bone, 
about at the junction of its posterior and middle third, until it 
reaches the anterior wall of the sphenoid cells, when it is pushed 
directly into the cavity. Zuckerkandl’s advice is based entirely on 
anatomical study of the cadaver. The first to perform Zucker- 
kandl’s operation on the living subject was Schaffer2 who succeeded 
in opening the sphenoidal cells, making use of a spoon-shaped in- 
strument instead of the trocar, by means of which he also removed 
small fragments of necrosed bone. It is scarcely necessary to state 
that this operation demands not only a high degree of manipula- 
tive dexterity, but also exceeding great care, as it is not unattended 
with a certain amount of risk of entering the cranial cavity. Indeed 
so great is this danger that Schech3 regards the operation as unad- 
visable, preferring to approach the cavity through the vault of the 
pharynx, making his opening through the lower plate of the body 
of the sphenoid, just behind the border of the posterior nares. In 
this connection, Schech refers to a case reported by Stoerk, which 
seems to favor this point of operation, where a spontaneous open- 
ing at this point occurred in the case of a scrofulous boy, suffering 
from sphenoidal disease. Bronner,4 however, reports a successful 
case in which the sphenoidal cells were scraped out by means of a 
sharp spoon, necrosis having been detected by means of the probe. 
The entire procedure was accomplished by manipulation through 
the nasal cavity. The case is a notable one, if we accept the cor- 
rectness of Bronner’s diagnosis, and yet I think this is open to very 
serious question, in that it would be almost impossible in most 
cases to absolutely localize the sphenoidal sinuses, by a probe intro- 
1 Op. cit., p. 174. 
2 “ Chirurgische Erfahrungen in der Rhinologie und Laryngologie Wiesbaden, 
1885, p. 4. 
3 Op. cit., p. 284. 4 Medical Press and Circular, April 4th, 1888, p. 343. 492 
DISEASES OF THE NASAL PASSAGES. 
duced through the nostrils, or to intelligently manipulate a curette 
in this manner. After an opening has been established, the further 
treatment of the disease consists in daily washing out the cavity, 
by means of cleansing and disinfecting lotions, while at the same 
time the patency of the orifice is maintained by proper means. If 
bony necrosis is found to exist, it should be removed as far as pos- 
sible, under the general rules of ordinary surgical procedure. If 
this is limited in extent, a small curette through the artificial open- 
ing would probably accomplish all that is required. If, however, 
the necrosis has extended to the body and wing of the sphenoid, its 
removal can only be accomplished by access through the orbit. 
Disease of the Frontal Sinuses. 
While simple catarhal inflammation of the mucous membrane 
of the frontal sinuses, occurs in connection with a cold in the head, 
more frequently than that of any of the other accessory cavities, 
suppurative inflammation, on the other hand, is one of the rarest 
occurrences. This is probably due to the fact, that the infundib- 
ulum opens from the most dependent portion of the cavity, thus 
affording free drainage, while, at the same time, it is probably less 
liable to become firmly occluded. We find, then, here an acces- 
sory sinus, in which the anatomical conditions favoring the devel- 
opment of suppurative disease are absent. Thus Zuckerkandl1 
states that he has never met with a single instance of uncompli- 
cated disease of this sinus. 
ETIOLOGY.—The disease may arise as the result of any condi- 
tion causing occlusion of the orifice of the sinus, such as hyper- 
trophic rhinitis, deflection of the septum, the presence of tumors 
in the nasal cavity, or any other obstructive lesion in the nasal pas- 
sages. This, however, is a exceedingly rare event. Far more 
active agents in the production of the disease are traumatism, mag- 
gots in the nose, gonorrhoea, syphilis, scrofula, disease of the eth- 
moidal sinus, or the development of tumors within the sinus itself. 
Pathology.—The changes which take place in the membrane, 
consist briefly in hyperaemia, with hyper-secretion, which, as the 
result of retention, gradually changes into a suppurative process, 
and in connection with this, the morbid process gradually invades 
the whole thickness of the mucous membrane, causing marked 
tumefaction with resultant periostitis, and the development of ex- 
ostoses or bony plates. In fact, the pathology of disease of the 
frontal sinus differs in no respect from that of disease of the an- 
trum already described. 
1 “ Anatomie der Nasenhohle,” Vienna, 1882, p. 168. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 
493 
SYMPTOMATOLOGY.—The earliest symptoms which should di- 
rect attention to a diseased condition of these sinuses, is frontal 
headache, which may develop into pain of an exceedingly distress- 
ing character, increasing as the accumulated secretions gather 
and distend the sinus. A certain amount of relief is gained with 
the escape of pus, which flowing into the nasal cavity, is discharged 
through the nose. It is bright yellow, and at first is exceedingly 
offensive in character. As the flow becomes established, however, 
the fetor in a measure disappears. The headache is usually per- 
sistent, although occasionally it may assume an intermittent type. 
It is increased by mental effort, or the use of alcohol, and at times 
assumes the character of sick headache, being attended with nau- 
sea and vomiting. If the pus accumulation in the sinus is large, 
and its exit obstructed, the roof of the orbit maybe so far crowded 
downward as to produce displacement of the eyeball with diplopia 
or amaurosis. At the same time, the anterioir wall of the cavity 
may be so far displaced as to produce notable facial deformity. 
If the posterior wall of the sinus is displaced, it will be indicated by 
symptoms referable to the brain, such as dulness or apathy, with 
increased headache, or sleepiness. The brain symptoms, however, 
are very apt to be obscure, as is usually the case when pressure 
occurs on the anterior lobes, although Otto, as quoted by Schech 1 
cites a case where displacement of the posterior wall of the sinus 
gave rise to unilateral paralysis. If the disease goes on so far as 
to produce erosion of the posterior wall, with the escape of pus 
into the brain cavity, the ordinary symptoms of meningitis super- 
vene; on the other hand, a cerebral abscess may develop without 
perforation of the bony wall of the sinus. In the same way, ero- 
sion of the roof of the orbit may occur, resulting in the escape of 
pus, and the development of an abscess in this cavity. In this con- 
nection it should be borne in mind, as stated by Zuckerkandl,2 that 
a congenital defect occasionally occurs in the development of the 
bones of the orbit, by which a permanent opening exists in this 
plate, through which pus from the frontal sinus may make its way 
into the orbital cavity, without erosion or necrosis. 
Diagnosis.—The history of the case will often afford diagnos- 
tic points, leading to the suspicion of the existence of frontal dis- 
ease, as gonorrhoea, maggots, syphilis, etc. The pus discharge 
presents the ordinary characteristics of disease of the accessory 
sinuses, and makes its appearance in the nasal cavity as a bright- 
yellow healthy pus, flowing over the middle turbinated bone rather 
nearer the anterior extremity, and is discharged usually through 
1 “ Diseases of the Mouth, Throat, and Nose,” Eng, edM Edinburgh, 1886, p. 279. 
2 Op. cit., p. 168. 494 
DISEASES OF THE NASAL PASSAGES. 
the nostril. In connection with this the diagnosis usually should 
be fairly well established, by the existence of frontal pain, tender- 
ness upon pressure, possible dulness on percussion, as compared 
with the opposite side, and if distention occurs, the gross eviden- 
ces of the disease as shown by external deformity, or displacement 
of the orbital plate. 
PROGNOSIS.—Simple catarrhal inflammation of the frontal sinus 
usually undergoes resolution spontaneously. In suppurative dis- 
ease, this tendency is not remarkable, and, although the prognosis 
is rarely grave where the disease is uncomplicated, its course is 
somewhat lengthened and tedious, unless arrested by proper reme- 
dial measures. Its tendency is not toward the development of 
necrosis, but to the accumulation of pus in the sinus, with disten- 
tion and encroachment upon neighboring cavities, as in the follow- 
ing case reported by Knapp 1: 
A woman, aged 30, had suffered for two years from headaches of a more or 
less violent character, in which the pain seemed to centre itself about the root 
of the nose at times. Six days before Dr. Knapp saw her, she was seized with 
a chill, which was followed by a slight swelling of the upper eyelid, with pro- 
trusion of the eye. On examination the outer half of the supraorbital margin 
was red, swollen, and painful on pressure, and the swelling was close to the 
bone. Ophthalmoscopic examination showed slight oedema and congestion 
of the papilla. A diagnosis of incipient abscess was made. Two days later, 
the'abscess had become very large, and was opened at the junction of the outer 
and middle thirds of the upper lid. The wound discharged for a few days, 
and the symptoms apparently disappeared. Six days after the operation, she 
was quite suddenly seized with headache, and became very weak, followed by 
vomiting, stupor, and slow pulse (50-60). These symptoms continued for 
several days, and the patient finally died of cerebral abscess of the left frontal 
lobe. On the post-mortem examination, the convolutions of the left frontal 
lobe were flattened; there was some discoloration of the base of this lobe, and 
the dura mater was adherent for an area of one cubic centimetre. The dura 
was not perforated. There was discoloration of the cerebral surface of the or- 
bital roof at the point of adherence of the dura mater, and over an area of one 
cubic centimetre on the anterior and inner roof of the orbit. The bone was 
necrotic at this point and a probe could be passed through it into the frontal 
sinus. The frontal sinus was dilated, and both the frontal and ethmoidal 
sinuses were filled with pus. The cerebral abscess probably developed from the 
patch of necrosed bone already described. It will be noticed in this case, that 
there was no purulent discharge from the nasal cavity, which would indicate 
that a complete closure of the infundibilum existed, a condition which prob- 
ably had much to do in causing the invasion of the cerebral cavity. 
Still another case was seen by Knapp,2 which presents points of 
interest, as follows: 
1 “Contribution to the Pathology of the Frontal Sinus,” Archives of Ophthalmology, 
vol. ix., No. 2, 1880. 
2 Loc. cit. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 
495 
A man, aged 30, presented with the history of having suffered from a tumor 
the size of a walnut which had existed at the inner angle of the eye, for about 
six years, and which had latterly given rise to a slight exophthalmos. The 
growth was accompanied with considerable pain, and varied notably in size at 
different periods of time, each temporary swelling being accompanied by an 
exacerbation of pain. When seen by Knapp, there had been an exacerbation 
of all the symptoms for three months. An incision of the tumor showed it to 
be an abscess, after the evacuation of which, it was found that both the frontal 
sinus and ethmoidal cells were involved, and furthermore, that there was poly- 
poid degeneration of the lining mucous membrane, the removal of which re- 
sulted in a complete cure at the end of three weeks. 
In two cases reported by Pettesohn,1 nasal discharge had been 
a symptom for some time. There was a tumor at the supra-nasal 
angle of the orbit, and oedema of the upper lid. Both cases were 
cured by incision. 
Treatment.—The primary treatment of the affection consists 
in the use of cleansing disinfectant lotions, in the nasal cavity, by 
means of the syringe or atomizer, in order to remove such secre- 
tions as may lodge in this region, and at the same time establish, 
as far as possible, free drainage through the normal opening. This, 
however, in many cases fails to accomplish all that is desired, and 
hence it becomes necessary to make an artificial opening into the 
sinus through the bony walls, of a sufficient size and accessibility 
as to admit of their thorough cleansing, and at the same time, se- 
cure free drainage. The point usually selected for this operation 
is immediately below the eyebrow, and near the bridge of the nose, 
where an incision having been made through the integument, the 
periosteum is elevated, and subsequently the perforation made into 
the frontal sinus by means of a drill, trocar, or trephine. In this 
manner, the opening is made as nearly as possible in the dependent 
portion of the cavity. Where an orbital abscess exists, of course the 
first indication is to open this by free incision, after which an explora- 
tion with a probe would reveal, in most cases, an already existing 
perforation of the orbital plate, and in those rare instances in which 
no opening exists here, the bone will be found to be in a condition 
which will easily admit of perforation. The opening here must be 
made sufficiently large to give free access to the sinus. It would 
seem that, even where no orbital abscess exists, we have at the 
upper and inner angle of the orbit, just within the supraorbital ridge, 
a site which might well be chosen for an artificial opening, in that 
the bony plate is quite thin, and the cavity would be surely and 
thoroughly opened, and furthermore, the resulting cicatrix would 
be less noticeable. Where the infundibulum is obstructed, it is a 
matter of considerable importance, even after the artificial opening 
1 “ Centralblatt fur prakt. Augenheilkunde,” Feb., 1888. 496 
DISEASES OF THE NASAL PASSAGES. 
into the frontal sinus has been established, to reopen also the nor- 
mal orifice, in order that proper through-and-through drainage may- 
be secured. Schech 1 advises the dilatation of the normal orifice 
by means of a probe passed through the artificial opening, after 
opening the frontal sinus, and if necessary the forcible passage of 
a trocar through into the nasal cavity, and the insertion of a 
drainage tube into the opening thus made. Such a procedure, 
however, would rarely be necessary. After access has been gained 
to the sinus, thorough exploration should be made with a probe, 
which should reveal the presence of necrosis or tumors, and further- 
more, would make known the involvement of the neighboring 
sinuses if such exist. Thus, in a case which came under the obser- 
vation of Welge,* the nose, orbit, antrum of Highmore, and the 
frontal and ethmoidal sinuses were all thrown into one cavity, so 
widely had the diseased process extended, as the result, apparently, 
of a primary disease of the ethmoidal labyrinth. 
In some cases it would seem that the disease may be cured by 
the removal of such obstructing lesion as may be found in the 
nasal cavity ; thus Schmiegelow3 has reported a case of suppurative 
disease of the frontal sinuses, cured by the removal of nasal polypi. 
Seiss4 goes so far as to state that in the majority of cases the dis 
ease can be controlled by “pinning down” the swollen tissues in 
the nasal cavity which occlude the normal orifice, using applications 
of chromic acid, after the manner described in Chapter IX. While 
not indorsing so broad a statement, I am yet disposed to think 
that much can be accomplished by measures of this character, and 
yet I think that the statement is fully justified, in cases such as 
Schmiegelow’s, and those referred to by Seiss, that there may have 
been a possible error in diagnosis, for in any given case of suppu- 
rative disease of one of the accessory sinuses, which is dependent 
upon some intra-nasal lesion, and which is cured by the removal of 
that lesion, I doubt very much whether it is possible in every case 
to determine with certainty, which of the accessory sinuses is in- 
volved. As stated in discussing the subject of disease of the an- 
trum, I believe that suppurative disease is set up in this cavity, as 
the result of a morbid process in the nasal cavity, far more fre- 
quently than in any of the other accessory sinuses. 
Differential Diagnosis between Disease of the Acces- 
sory Cavities. 
While the recognition of suppurative disease of one of the acces- 
sory sinuses of the nose is comparatively an easy matter, the de- 
1 Op. cit., p. 284. 
3 Hospitalstidende. Feb., 1888. 
2 “ Diss. de Morbo Sin. Frontal.,” Gottingen, 1786. 
4 Phil. Med. News, January 5th, 1889. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 
497 
termination of which cavity is affected is often involved in consid- 
erable obscurity, and hence it would seem not out of place, to group 
together here the different symptoms, with their special diagnostic 
significance. 
A pus discharge from the nose is characteristic of disease of all 
the sinuses, excluding those exceptional cases in which the normal 
orifice is completely occluded, in which case the abscess is forced, 
as it were, into neighboring regions, such as the orbital or cranial 
cavity. In antral and frontal disease, and in disease of the anterior 
ethmoidal cells, the pus makes its way anteriorly, and is discharged 
from the nostril, while in disease of the posterior ethmoidal and 
the sphenoidal sinuses, it makes its way into the pharynx. In an- 
tral disease, the discharge is intermittent, and shows a certain de- 
gree of periodicity. In disease of the other cavities it is usually 
continuous. Inclining the head well forward, or lying on the un- 
affected side, favors a discharge from the antrum, while the upright 
position favors a discharge from the other sinuses. 
Unilateral pain is present in all the affections. In antral disease, 
this is most marked in the region of the cheek-bone and teeth. In 
frontal disease, it becomes a frontal headache, while in the ethmoi- 
dal and sphenoidal affections, it is more deep-seated, and locates 
itself at the roof of the orbit. 
Exophthalmos is the rule in ethmoidal disease, but also is met 
with somewhat frequently in connection with disease of the sphe- 
noidal sinuses. It is exceedingly rare in connection with disease 
of the antrum, and only occurs where the abscess ruptures into the 
orbit. In frontal disease, bulging of the orbital plates is not a rare 
event, but in this case the eye is apt to be crowded downward and 
outward, so that the eyeball is not protruded to the same extent 
as is liable to occur in ethmoidal disease. Diplopia, when present, 
is the result of displacement of the eyeball, and therefore consti- 
tutes a diagnostic sign of no additional value. 
Sudden blindness is due to pressure on the optic nerve as it 
passes through the optic foramen and is, therefore, only met with 
as a symptom in connection with sphenoidal disease; although, as 
Ziem has shown, the field of vision may be narrowed in disease of 
the antrum. 
Ptosis is the result of pressure on the third nerve as it passes 
through the sphenoidal fissure. This also, therefore, would point 
to involvement of the sphenoidal labyrinth. 
Strabismus would be occasioned by a certain differentiation of 
the pressure on the nerves passing through the sphenoidal fissure, 
and would also indicate the existence of sphenoidal disease. 
Facial neuralgia may occur in connection with disease of any of 498 
DISEASES OF THE NASAL PASSAGES. 
the sinuses, although it is most constantly met with in disease of 
the antrum, less frequently in connection with sphenoidal disease, 
and with the greatest rarity in connection with ethmoidal and 
frontal disease. 
Fetor is present in a very mild degree in disease of all the si- 
nuses, and may possess a certain amount of intermittency as sug- 
gested by Luc,1 thus pointing more directly to disease of the 
antrum, in that the fetor probably attends the escape of pus after 
a temporary retention. 
The frequency with which the different sinuses are affected 
with suppurative disease, affords a certain amount of aid in diag- 
nosis. Antral disease is by far the most frequently met with, while 
in the order stated the disease is less frequent in the ethmoid and 
sphenoid sinuses, while suppurative disease of the frontal sinus is 
the rarest of all. 
1 Jour, de Med. de Paris, 1887. Section II. 
Diseases of the Naso-Pharynx DISEASES OF THE NASO-PHARYNX 
CHAPTER XXXIX. 
THE ANATOMY AND PHYSIOLOGY OF THE NASO- 
PHARYNX. 
That space which lies behind the posterior nares and the oral 
cavity, and which extends from the basilar process of the occipital 
bone to the upper border of the larynx, has usually been described, 
in works on anatomy, as constituting a single cavity, under the 
name of the pharynx. Writing on this subject some years since,1 I 
urged that, from a physiological point of view, this space should be 
regarded as consisting of two separate and distinct cavities, the 
upper pharynx and the lower pharynx, or using perhaps a better 
designation, the naso-pharynx and the oro-pharynx, in that the 
former belongs to the air tract with certain somewhat adventitious 
functions perhaps connected with the food tract, while the latter 
belongs essentially to the food tract, both physiologically and in its 
anatomical construction, its connection with the air tract being 
purely adventitious. The upper space has been designated, some- 
what indifferently, as the upper pharynx, the vault of the pharynx, 
the post-nasal space, and the naso-pharynx. In our consideration 
of the subject, I prefer the use of the term naso-pharynx, as more 
clearly defining the region under discussion. 
Anatomy of the Naso-Pharynx. 
This cavity consists of a somewhat quadrilateral-shaped space., 
lying immediately behind the posterior nares, and bounded as fol- 
lows: Its roof is formed by the basilar process of the occipital 
bone, together with a small part of the posterior portion of the 
body of the sphenoid, while it terminates below in an imaginary 
plane opposite the border of the palate. The posterior wall is 
formed by the spinal column, the prominence of the arch of the 
1 N, Y. Med. Record. Nov. 6th, 1880. 502 
DISEASES OF THE NASO-PHARYNX. 
atlas being often recognized at about the point where the vertex 
of the palatal arch in contraction impinges upon the pharyngeal 
wall. From this upward, the wall curves forward. The anterior 
boundary is formed by the two oval openings of the posterior nares, 
together with the posterior border of the vomer or septum, which 
presents a somewhat sharp edge below at its articulation with the 
hard palate, but expands somewhat above, to articulate with the 
rostrum of the sphenoid. Each lateral wall is marked by the open- 
ing of the pharyngeal orifice of the Eustachian tube, which presents 
as a somewhat elongated or ovoid funnel-shaped orifice, or as 
Roosa1 describes it, “ a trumpet-shaped orifice, nine millimeters 
high and five millimetres broad.” The opening of the tube is par- 
tially surrounded by a well-defined cartilaginous ridge, which is 
mainly formed by a projection of the cartilage which enters into 
the formation of the tube proper. This eminence is very well 
marked posteriorly and above, while anteriorly is it less prominent, 
and immediately below the orifice it is absent. As the mucous 
membrane is reflected over this cartilaginous ridge or cushion of 
the Eustachian orifice as it is usually termed, it is thrown into a 
fold, as it passes from the lower termination of the posterior sec- 
tion of the ridge to the pharynx below, forming what has been 
designated by Luschka as the plica salpingo-pharyngea, while by 
its reflection from the anterior portion of the ridge a less prominent 
fold is formed, which extends from the anterior border of the tube 
to the soft palate. This is called by Luschka the plica salpingo- 
palatina. Immediately behind the Eustachian orifice, and lying 
between the cartilaginous cushion and the posterior wall of the 
pharynx, is noticed an elongated depression, the fossa of Rosen- 
miiller. This fossa varies somewhat in shape and depth in differ- 
ent subjects, although it is usually elongated, and much broader 
above than below, and is mainly of interest in that in introducing 
a Eustachian catheter, its point is usually first engaged in this de- 
pression. While at rest, the Eustachian orifice is closed, and is 
only opened as the result of muscular contraction in the various 
functional movements of the fauces. 
The muscle which acts most prominently as a dilator of the 
tube, is the tensor palati muscle, or as it is generally named by 
otologists, the spheno-salpingo staphylinus, or the dilator tubae. 
It arises from the base of the internal pterygoid plate of the sphe- 
noid bone and the scaphoid fossa, and from the cartilaginous por- 
tion of the Eustachian tube throughout its whole length. It then 
passes downward, forward, and inward, and winds around the ham- 
ular process of the sphenoid, and is inserted into the soft palate. 
1 “ Dis. of the Ear,” 3d ed., 1876, p. 209. ANA TOM Y AND PH YSIOLOG Y OF THE NASO-PHAR YNX. 
503 
It enlarges the calihre of the tube by drawing its anterior cartila- 
ginous margin downward and forward. 
The levator palati, whose action is less marked than the action 
of the former in opening the Eustachian tube, and yet undoubtedly 
possessing a certain function in this direction, is a long, rounded, 
muscle, arising from the petrous portion of the temporal bone, and 
from the cartilaginous portion of the tube, from which, passing 
downward and inward, it spreads out into a broad tendon, and is 
inserted with its fellow into the median line of the soft palate, the 
fibres blending with the mucous membrane of this structure. By 
its contraction, it lifts, as it were, the lower edge of the collapsed 
tube into such a position, that its lateral walls separate, and the 
lumen becomes patulous. 
The palato-pharnygeus, which arises from the soft palate, the 
posterior portion of the hard palate, and from the cartilaginous 
portion of the Eustachian tube, passes downward to the thyroid 
cartilage, some of the fibres blending with the corresponding mus- 
cle of the opposite side. Its action is to fix the cartilaginous por- 
tion of the tube to which it is attached, and thus aid the action of 
the levator palati. 
The orifice of the Eustachian tube is usually described as open- 
ing into the anterior and lower portion of the lateral wall of the 
naso-pharynx, opposite the posterior termination of the lower tur- 
binated bone, from which it is distant about three-eighths of an 
inch, while its average distance from the nostril is, according to 
Luschka,1 two and three-quarters inches, although, according to 
Mackenzie,2 the distance is three and one-fifth inches. Kostonecki,3 
however, has shown, that there are very great variations in the 
locality of this orifice, as regards its vertical position, in that in 
many cases it is found much higher in the lateral wall of the 
pharynx than in others. This fact, however, is constantly brought 
to the notice of otologists in passing the Eustachian catheter, in 
that in many cases the tip must be carried well upward, in order to 
engage in the tubal orifice. 
The cavity of the upper pharynx differs greatly in different 
individuals, without reference to their physical development. 
Luschka’s measurements, however, are as follows: its vertical and 
antero-posterior measurements are about the same, viz., three- 
quarters of an inch, while its width is about one and three-eighths 
inches. The fibrous basement structure of the naso-pharynx con- 
sists of a thick aponeurosis, which has its attachment to the basi- 
1 “ Der Schlundkopf des Menschen,” Tubingen, 1868. 
2 “ Diseases of the Throat and Nose,” Phila., 1884, vol. i., p. 18. 
3 Arch, fiir Mik. Anat., 1887, vol. xxix., p. 539. 504 
DISEASES OF THE NASO-PHARYNX. 
lar process of the occipital bone, and the petrous portion of the 
temporal. Beneath this tissue are found certain muscular struc- 
tures, involved in the movements and support of the head.** Its 
internal surface is lined with mucous membrane, which differs in no 
essential features from the mucous membrane of the respiratory 
tract. It is richly endowed with mucous glands, both the tubular 
and racemose varieties, while its epithelial surface is covered with 
columnar ciliated epithelium. 
That however, which gives the pharyngeal vault an especial 
interest, and also endows it with certain important functions, is the 
crowding together of a large number of glands into a distinct mass, 
in the upper and central portion of the cavity, constituting what is 
known as the pharyngeal tonsil, or the third tonsil, and sometimes 
called Luschka’s tonsil, in that, this writer first gave us a complete 
anatomical description of it, although according to Cohen1 the 
mass was recognized and dissected by William Hunter in the last 
century. I find,, however, no record of this in any of Hunter’s 
writings. According to Luschka,2 there is always present in this 
region, although in varying degrees of development, a soft mass of 
tissue, of about one-quarter of an inch in thickness, spread over 
the roof and posterior wall of the naso-pharynx, covering the whole 
extent of the basilar process of the occipital bone. It extends the 
whole width of the pharynx, to the fossae of Rosenmiiller, and 
even encroaches upon the cartilaginous eminences surrounding the 
Eustachian tube. The gross appearance of this mass of glands 
varies somewhat, presenting occasionally a soft cushion-like outline 
covered with small rounded elevations, while in others it is trav- 
ersed by fissures in various directions. The most: constant appear- 
ance, however, and that seen in the largest majority of cases, is 
that in which the mass is traversed longitudinally by a series of 
fissures or indentations, of perhaps a quarter of an inch in depth, 
with a slight disposition to branch, as it were, giving rise to a sort of 
crow’s-foot appearance on the surface. (See Figs. 121, 122.) At the 
lower portion of the pharyngeal tonsil, in the median line, Luschka 
describes an opening, about the size of the head of a pin, some- 
times larger, sometimes smaller. This opening leads into a small 
sac, about three-quarters of an inch long, and a quarter of an inch 
wide, to which Luschka gave the name bursa pharyngea, a term 
already used by J. O. Meyer,3 to describe a similar anatomical con- 
dition found in the pharynges of certain of the mammalia, in that 
this sac formed a bursa between the adenoid tissue already de- 
1 “ Diseases of the Throat and Nasal Passages,” Phila., 1879, P- 253- 2 Op. cit. 
3 “ Neue Untersuchungen auf dem Gebiete der Anat. und Physiologie,” Bonn, 1842. ANA TOMY AND PHYSIOLOGY OF THE NASO-PHAR YNX. 
505 
scribed, and the basilar process of the occipital bone. The anterior 
wall of this cavity is lined with glandular tissue. The tissue form- 
ing the posterior wall, is, according to Luschka, joined by a distinct 
ligament to the basilar process of the occipital bone. Ganghofner1 
and Schwabach2 deny its existence as a distinct anatomical struc- 
ture, taking the ground that this bursa, so-called, is really the re- 
cessus pharyngeus medius, or simply the median fissure of a 
normal pharyngeal tonsil, or possibly an hypertrophied one, which 
undergoing the changes incident upon maturity, has by a process 
of unfolding, as it were, or shrinking up upon the median line, re- 
sulted in an adhesion of the super- 
ficial layers of the adenoid tissue 
over the median fissure, in such a 
way as to form this bursa-like cavity. 
It is difficult to understand why 
nature should have found it neces- 
sary to establish a bursa here, for 
any purpose of function, especially 
one of the size Luschka describes. 
Certainly there is no function of the 
pharynx which requires the pres- 
ence of such an appendix. Hence, 
the objections made by Ganghofner 
and Schwabach seem to be exceed- 
ingly well grounded, for certainly 
Luschka's original description 
scarcely strikes one as that of a per- 
manent and constant anatomical 
condition. Moreover, Luschka de- 
scribes it as a condition present in 
only a certain proportion of cases. I think, then, that we must 
abandon Luschka’s idea of a normal pharyngeal bursa in this region, 
and regard the condition he describee as the adventitious result 
of certain morbid conditions of the glandular structure in this 
region, as described by Ganghofner. 
This region derives its arterial supply from the ascending pharyn- 
geal branch of the external carotid, and the ascending palatine 
branch of the facial, together with the palatine and the spheno-pal- 
atine branches of the internal maxillary. The veins open into the 
internal jugular. The nerve supply is derived mainly from the 
Fig. 121.—The Glandular Structures at the 
Vault of the Pharynx (Luschka). i, 1, Ptery- 
goid processes; 2, vomer; 3, posterior portion of 
the vault of the nasal fossae; 4,4, Eustachian 
tubes; 5, orifice of the bursa pharyngea; 6, 6, 
Rosenmuller’s fossae; 7, median folds formed 
by the glandular tissues. 
1 “ Ueber die Tonsilla und Bursa Pharyngea.” Sitzungsbericht der k. Academie der 
Wissenschaften, Bd. lxxviii., Abth. iii., Oct. loth. 1878. 
2 Arch, fur Mik. Anat., 1887, vol. xxix., p. 61 et seq. 506 
DISEASES OE THE NASO-PHARYNX. 
second division of the fifth pair, together with branches from the 
glosso-pharyngeal and vagus. 
Physiology of the Naso-Pharynx. 
While the naso-pharynx is situated apparently in the continuity 
of the respiratory tract, and furthermore its mucous membrane shows 
the anatomical characteristics of the mucous 
membrane lining the respiratory tract, namely in 
the fact that it is covered with columnar ciliated 
epithelium, yet I am disposed to think that the 
function of the naso-pharynx has mainly to do 
with the food tract. In the ordinary process of 
deglutition, it is absolutely necessary that the 
lower pharynx should be thoroughly lubricated 
by mucus, in order that the bolus of food shall 
pass over it without hindrance. Now, as we know, 
the lower pharynx is very sparsely endowed with 
glandular structures. It is lined by a hard dense 
membrane, fitted eminently to permit without in- 
jury the passage of harsh, and oftentimes irritating 
particles of food, but it is endowed with a very 
scanty secreting apparatus. The glands neces- 
sary to furnish this region with a proper lubri- 
cant, were they imbedded in the tissue of the 
lower pharynx, would be exceedingly liable to 
injury, from the constant irritation of food in the 
act of deglutition. Hence, we find them removed, 
as it were, to the three sides of the pharynx 
most convenient for their location, namely, to the 
well-protected recess found between the two pil- 
lars of the fauces, where they form the faucial 
tonsils, and to the still better protected recess, 
the vault of the pharynx. In these three regions 
we find masses of glands, which pour out large 
quantities of mucus, whose sole and only function is to thoroughly 
lubricate the bolus of food, and facilitate its passage down into the 
oesophagus. The vault of the pharynx affording the best protec- 
tion, necessarily becomes the site of the largest aggregation of 
these glands, and as Luschka has shown us, nature has chosen this 
locality for the main distribution of the glandular structures de- 
signed for this function. 
The normal secretion from the pharyngeal tonsil consists of an 
absolutely clear, transparent, somewhat viscous mucus, of the ap- 
Fig. 122. — Glandular 
Structures of the Pharyn- 
geal Vault, seen in An- 
tero-posterior Section. ANA TOM Y AND PH YSIOLOG Y OP' THE NASO-PHAR YNX. 
507 
pearance and consistency of the white of an egg. Not infrequently, 
as we examine the lower pharynx, we will notice a large mass of 
this mucus escaping from beneath the palate, and passing into the 
pharynx below, from one to three drachms in amount, this without 
consciousness on the part of the patient. This is the healthy se- 
cretion of the glands, and the secretion of this mucus is their main 
function. The pharyngeal vault being, adventitiously as it were, a 
part of the air tract, it is of course endowed with certain anatomi- 
cal features, characteristic of the air passages. Its main function, 
however, I regard as a sort of diverticulum of the food tract, for 
the safe lodgment of these glands. 
The function of this region in connection with the auditory ap- 
paratus will more properly be discussed in a later chapter. Its 
function as a resonant chamber for the voice is also somewhat 
secondary, and possesses no point of special importance. CHAPTER LX. 
ACUTE NASO-PHARYNGITIS. 
This term is used to designate a disease, frequently met with in 
the spring and fall months, and which in many of its features 
closely resembles an ordinary acute rhinitis, or cold in the head, 
and yet differs in a notable degree from this affection, both as to 
the region involved in the inflammatory process, and in the char- 
acter of the symptoms. The disease consists essentially in an acute 
inflammation of the mucous membrane lining the vault of the 
pharynx, and hence we use the term acute naso-pharyngitis, which 
is a somewhat awkward and perhaps unfortunate designation, and 
yet I know of no better one, under which to definitely describe the 
affection. 
ETIOLOGY.—Exposure to cold we regard as the prominent ex- 
citing cause of all acute inflammatory processes involving the mu- 
cous membrane of the upper air passages. Aside from this, I know 
of no cause for the disease. As a predisposing cause, however, we 
recognize a previously existing naso-pharyngeal catarrh probably 
in all cases, adopting the same view here, as that already expressed 
in regard to chronic catarrhal affections of the nasal passages, that 
the chronic process is the first to arise, and that recurrent attacks 
of acute inflammation become one of its most prominent symptoms. 
It is met with much more frequently in adult life than in youth, in 
that at this period of life the naso-pharynx is perhaps the most 
frequent site of a chronic catarrhal process, and thereby the weak- 
est portion of the upper air-tract. An ordinary cold, as we call it, 
in very young children occurs usually in connection with adenoid 
disease of the pharyngeal vault, or with the purulent rhinitis of 
childhood. This tendency disappears at puberty or perhaps be- 
fore, after which an exposure results more commonly in an ordinary 
acute rhinitis, or a typical cold in the head. After this tendency 
has persisted for a somewhat lengthy period of time, encouraged 
perhaps by irregularities in habit of life, indiscretions, improper 
clothing and other errors of hygiene, the pharyngeal vault becomes 
involved, as a secondary result of the morbid process in the nasal 
passages, and becomes the seat of an inflammatory process in con- ACUTE NASO-PHAR YNGITIS. 
509 
nection with the attacks of acute rhinitis, and still later, the ten- 
dency to acute rhinitis disappears, and we have the colds resulting 
in an acute inflammation at the pharyngeal vault. In other words, 
chronic inflammatory processes tend to pass downward in the air 
passages, carrying with them the tendency to recurrent attacks of 
acute inflammation. Aside from these considerations, the predis- 
posing causes of the disease will be more particularly discussed in 
the consideration of the general subject of naso-pharyngeal catarrh, 
in another chapter. 
Symptomatology.—The attack comes on somewhat suddenly, 
as the result of exposure, and usually is marked by notable consti- 
tutional disturbance, as shown by a certain amount of febrile move- 
ment, as marked by flushed skin, headache, loss of appetite, etc. 
The thermometer may indicate a temperature not over perhaps ioo° 
to ioi°, and yet the general disturbance is more marked than 
would be expected from so low a degree of fever, in that the general 
malaise and feeling of illness and prostration, oftentimes will com- 
pel a patient to abandon his usual occupation, and perhaps confine 
himself to his room or even bed. 
One of the earlier sensations is a feeling of burning or dryness, 
referable to the back of the throat, or as the patient usually ex- 
presses it, in the roof of his mouth, swallowing becoming painful, 
and even to an extent difficult. This is due to the abnormal dry- 
ness of the membrane, which, as we know, characterizes the first 
stage of all acute inflammatory processes in the upper air passages. 
Now in the nose, as we know, this first stage persists usually but a 
few hours, or at the utmost, a day. In the naso-pharynx, however, 
this first stage will oftentimes last two, three, or even four days, 
constituting a period of considerable discomfort and even distress 
to the patient. In connection with this, as indicating a close con- 
nection between the naso-pharynx and the digestive apparatus, there 
is liable to be a torpid condition of the bowels, or even obstinate 
constipation, in connection with complete anorexia, and a tendency 
to nausea. 
The second stage of the attack is characterized by the setting 
in of a more or less profuse muco-purulent discharge from the 
affected region, which passes down behind the palate and into the 
fauces, from whence it is either expectorated, or passes into the 
oesophagus, and is swallowed, or, again, it may make its way into 
the nasal cavities, and is voided through the anterior nares. 
This secretion consists of a somewhat thick, grayish, opaque 
mucus, which is voided in considerable quantities. The setting in 
of the secretion seems, to an extent, to aggravate the gastric dis- 
turbance, especially giving rise to a tendency to nausea or vomit- 510 
DISEASES OF THE NASO-PHARYNX. 
ing, the appetite being, at the same time, considerably impaired. 
The mucus passing into the nasal cavities, seems to excite a certain 
amount of irritation in this region, giving rise to sneezing and per- 
haps a watery discharge from the nose, although the secretion that 
is voided anteriorly I think usually has its source in the pharyngeal 
vault. The sneezing and irritation often lead to the idea that the 
attack is one of ordinary cold in the head, and yet it is never char- 
acterized by that distressing nasal stenosis, and intense form of 
irritation, which occurs in connection with acute inflammation of 
this locality. This stage of the attack may persist from ten days 
to two weeks, with no very marked change in the symptoms, either 
of the local discharge, or of the general feeling of malaise and pros- 
tration. 
The thr'rd and last stage of the disease, consists of a gradual 
letting up of the subjective symptoms, and a diminution of the dis- 
charge. The voice is affected very early in the attack, and in a 
somewhat peculiar manner, which is almost characteristic of this 
form of cold, in that it has a curious, hoarse, metallic ring to it, 
which weakens the tone, although it is never entirely lost. This is 
due to a certain amount of sympathetic irritation or hyperaemia of 
the mucous membrane lining the larynx, which merely impairs the 
tone, the resonant chambers not being encroached upon. Pain is 
always a prominent feature of this form of cold during all stages of 
the attack. This is usually referable to the roof of the mouth, or 
upper portion of the throat, from which point it seems to radiate 
toward the angles of the jaw, and even may extend up to one or 
both angles of the face, giving rise to a facial neuralgia. This pain 
is of a purely neuralgic character, and is due probably to the in- 
volvement of the terminal filaments of the nerves in the pharyngeal 
vault. Why a facial neuralgia should so frequently complicate the 
disease, is by no means easy of explanation, unless on the ground 
that there is in the disease itself, a prominent neurotic element. 
Certainly it occurs frequently in women of a nervous and perhaps 
hysterical temperament more frequently than in others, and where 
met with in such patients, it assumes an aggravated form, and 
moreover, the nervous symptoms are more distressing. I think 
something of the same sort also is noticeable in men, especially 
those who have passed middle life, and have arrived at that age, 
when any attack of illness is watched with a certain amount of ex- 
aggerated apprehension. Pain in the back of the neck is also 
prominent in these cases, which consists of a stiffness or soreness in 
the large muscles, rather than in a neuralgic pain. Cough is rarely 
met with, although a more or less disagreeable sense of itching or 
scratching about the fauces is liable to be a prominent source of ACUTE NASO-PHAR YNGITIS. 
complaint. Furthermore, the disease does not show any marked 
tendency to extend down into the trachea and bronchial tubes, 
although it almost invariably involves the lower pharynx. This 
lack of tendency to extension is probably due to the fact that nasal 
respiration is not ordinarily interfered with, and that breathing 
takes place through the normal passages, and furthermore that the 
great respiratory function of the nose is unimpaired, which as we 
know serves very largely to protect from irritation the mucous 
membrane of the bronchial tubes and the passages below. When We 
consider that the mucous membrane of the upper and lower pharynx 
is involved in the acute inflammation, we can easily understand 
how symptoms referable to the ear should, in most cases, be a 
prominent symptom, owing to the fact that the inflammatory pro- 
cess extends to the. orifice of the Eustachian tubes, resulting in a 
temporary stenosis, with impairment of hearing, and a sense of 
dulness in that region. This symptom, however, it should be stated, 
is more characteristic of the second stage, during which there is a 
more or less profuse secretion in the pharyngeal vault. During 
the first stage, the mucous membrane is dry, and the parts which 
it covers are, as we have seen, stiff and somewhat immovable. This 
condition extends somewhat to the muscular structures which act 
upon the palate, as the result of which, the movements of the pal- 
ato-pharyngeus muscle is impaired, giving rise to the difficulty in 
deglutition, already referred to. Hence, in this first or dry stage, 
we find not infrequently that the Eustachian tubes are maintained 
in a closed condition, as evidenced by the fact that the patient 
hears his own voice with a distinctness which may be almost a source 
of distress. This symptom, however, of autophonia usually disap- 
pears with the setting in of the secretion, characteristic of the sec- 
ond stage. 
PATHOLOGY.—Any discussion of the pathology of this affection 
would be purely speculative, in that I know of no special examina- 
tions of this tissue, in a state of acute inflammation, as ever having 
been made. We can only base our conclusions on the general 
laws, which govern a manifestation of an acute inflammation as 
affecting mucous membranes in general. This point has already 
been sufficiently discussed in a previous chapter (p. 51). 
DIAGNOSIS.—These patients usually complain of a severe cold in 
the head and throat. Hence, our first impression is, that we have 
to deal with an acute rhinitis. This, however, will be completely 
eliminated by an examination through the anterior nares, which 
will reveal the turbinated tissues slightly swollen perhaps, and yet 
showing no evidence of acute inflammation. Moreover, both sub- 
jectively and on inspection, these passages will be found fairly open 512 
DISEASES OF THE NASO-PHAR YNX. 
to the current of inspired air. An examination or the fauces will 
reveal, in the first stage of the attack, an intensely hyperaemic and 
slightly swollen condition of the mucous membrane lining the 
lower pharynx, while its surface will usually present a dry and 
somewhat glazed aspect, the color being of a deep red, verging on 
a purplish hue. With the rhinoscopic mirror, the vault of the 
pharynx will present the same turgid condition, and a similar red- 
dened color, with an entire absence of any evidence of secretion. 
In the second stage, however, an examination of the fauces will 
show the membrane swollen, reddened, and coated with long stringy 
flakes of grayish opaque mucus, whose source evidently is in the 
pharyngeal vault. If we now inspect the upper portion of the naso- 
pharynx, the same hyperaemic condition will be recognized, while 
its glandular tissues will be seen covered with patches or masses of 
the same grayish mucus, as was observed in the lower portion of the 
cavity. An acute rhinitis having been eliminated, the main point 
of diagnosis, here, would be to determine the absence of an acute 
follicular inflammation. This, of course, should be determined in 
the fact, that in the exudative form of the disease, there is a lack 
of the mucous secretion, while at the same time, the characteristic 
white spots, marking the existence of a croupous exudation in the 
crypts of the follicles, is absent. Of course, this last point is only 
fully determined, after a thorough cleansing of the pharyngeal 
vault by means of a spray through the nose, or a post-nasal syringe. 
Moreover, the latter disease, it should be borne in mind, is accom- 
panied, especially in its earliest stages, by a temperature of from 
ioi° to 103°, while in the catarrhal form of inflammation, the tem- 
perature rarely exceeds ioo°. 
PROGNOSIS.—These attacks involve no special danger to life, 
although they run a somewhat prolonged course, as already stated, 
and may last from ten days to two weeks, during which time the 
patient suffers, not only from the exceeding discomfort, and even 
distress of the local affection, but also notable general malaise, with 
prostration. In fact, during the attack, the patient is apt to think 
himself, and he really is, quite ill, and even incapacitated for his 
ordinary duties. The disease, however, shows no marked tendency 
to extend to the passages below, and generally terminates in com- 
plete resolution, or if the patient has previously suffered from naso- 
pharyngeal catarrh, it simply leaves behind a somewhat aggravated 
form of the chronic disease. Mackenzie 1 who alludes very casually 
to this affection, and Sajous2 who devotes a chapter to its consider- 
ation, seem to suggest that the acute form of the disease may de- 
1 “ Dis. of the Throat and Nose,” Amer. ed., Phil., 1884, vol. ii., p. 472. 
2 “Dis. of the Nose and Throat,” Phila., 1886, p. 216. ACUTE NASO-PHAR YNGITIS. 
513 
generate into the chronic. As already stated, I think it is an al- 
most invariable rule that the chronic inflammatory process precedes 
the acute, and that recurrent attacks of acute inflammation are to 
be regarded as a prominent symptom of the chronic lesion. It 
might be stated, in this connection, that the above writers, as far 
as I know, are the only ones who refer to this form .of a cold. 
Treatment.—At the onset of the attack, the effort should be 
made to break up the cold, in much the same way as we try to 
abort an attack of acute rhinitis. For this purpose, we may give 
ten grains of quinine, while, at the same time, certain measures are 
instituted for producing diaphoresis, such as the administration of 
hot drinks in connection with the hot foot bath, preference being 
given to this simple device, rather than a warm bath or the Turkish 
bath, either of which are to be regarded as involving a certain 
amount of risk of additional cold. The simple foot bath, produc- 
ing moderate diaphoresis, should answer every purpose. 
In this connection, also, we should bear in mind the intimate 
relation between the pharyngeal structures, and the digestive ap- 
paratus, a relation which has already been referred to, in connec- 
tion with the symptoms which a cold of this kind gives rise to. 
Hence, we administer a full dose of calomel or blue mass, in con- 
nection with the quinine, usually ten grains of either being suffi- 
cient. This is given at bedtime, to be followed in the morning 
(and each morning during the existence of the cold) by a glass of 
Kissingen, Geyser, or Congress water, or indeed any of the milder 
bitter waters, the indication being to keep the bowels fairly well 
relaxed during the whole continuance of the attack, although the 
quinine and mercurial dose is usually not to. be repeated after its 
first administration. If headache is a prominent symptom, perhaps 
we have no better remedy than the administration of antipyrine in 
doses of ten grains, to be repeated every hour, until relief is ob- 
tained, although it will rarely be found necessary, and perhaps not 
wise, to administer more than a third dose. Pain, as before stated, 
is always a prominent symptom, and for the relief of this, we ad- 
minister some preparation of aconite, and, of these, none is so 
prompt and efficient in its action as the alkaloid aconitia, which 
is conveniently administered in the form of the tablet triturates or 
in granules, preference always being given to Duquesnel’s prepara- 
tion, as being, perhaps, the most reliable. This should be adminis- 
tered in doses of °f a grain every hour, in the case of a male, 
and every two hours, in that of a female, until the pain is relieved, 
or the constitutional effect of the drug is manifested, as shown by 
numbness and tingling about the fauces or lips, vertigo, or faint- 
ness. In administering so powerful a remedy as this, one of course 514 
DISEASES OF THE NASO-PHARYNX. 
needs to exercise considerable care, and where it is impossible to 
see a patient soon, I have usually directed the drug in the above 
doses, to be taken every hour for three hours during the early 
morning until three doses have been taken, and to repeat the same 
process in the early afternoon, and again in the evening, if necessary. 
I have rarely seen a case of acute naso-pharyngitis, with prom- 
inent neuralgic symptoms, in which the aconitia did not afford 
striking relief, and not only does it seem to control pain, but it 
seems to exercise a beneficial effect on the inflammatory process, 
and not infrequently it acts to completely arrest the attack. 
The above measures go far toward supplying us with all the 
therapeutic methods necessary, in the management of an attack of 
acute naso-pharyngitis, although where the symptoms are persist- 
ent, and the attack prolonged, much aid will be afforded by the 
resort to local measures, and, of these, I should place as of the first 
importance, especially in the first stage of the attack, the reduction 
and control of the plethoric condition usually present in the tur- 
binated tissues of the nasal cavity. This is accomplished by the 
local application of a strong solution of cocaine, for depleting the 
blood-vessels, after which, an application of chromic acid should be 
made after the manner already described in the treatment of hyper- 
trophic rhinitis. This application will not only exercise a beneficial 
effect on the inflammatory process in the naso-pharynx, during the 
first stage, but it also serves to modify the nasal hyperaemia which 
complicates the attack. As soon as the stage of secretion sets in, 
and the excessive discharge from the pharyngeal vault makes its 
way into the nasal cavity, giving rise to irritation of these parts, 
local applications to the primary seat of the attack in the pharyn- 
geal vault are always grateful, and afford a certain amount of relief. 
For this purpose, the ordinary nasal douche, with water as hot as 
can be borne (which is made saline by the addition of common 
salt), is of no little value, or the post-nasal pipe, in connection with 
the nasal douche is, perhaps, still better, as directing the stream 
immediately against the primary seat of the disease. This may be 
repeated as often as three or four times a day. Where the douche 
is not available, the spray, with any simple cleansing wash (mak- 
ing use of any of the formulae already given in the chapter on hyper- 
trophic rhinitis) will always be grateful to the patient. Snuffs and 
powders are of but little service in this form of disease, and may 
even be a source of annoyance. A two or four per cent solution of 
cocaine is always grateful, and affords relief to tlie painful symp- 
toms for two or three hours, and possibly also modifies the inflam- 
matory process. There is no possible objection to its use, and a 
preparation should always be placed in the hands of the patient, to 
use as freely as may be desired. CHAPTER XLI. 
NASO-PHARYNGEAL CATARRH. 
THIS is a term used to designate a disease, characterized by an 
excessive secretion of mucus or muco-pus from the glandular struc- 
tures of the vault of the pharynx, and which, passing down behind 
the palate, diffuses itself over the lower pharynx, where it gives rise 
to more or less irritation, and excites a constant hawking and ex- 
pectoration in connection with an annoying nasal screatus. This 
term of naso-pharyngeal catarrh is a somewhat unfortunate one, 
and yet it is difficult to suggest a better term. According to 
Mackenzie it was first described by Frank in 1794, although in our 
own day, attention has been notably directed to it by Horace 
Dobell1 who based his observations largely on clinical study, with- 
out making any definite suggestions as to the pathological character 
of the disease. Subsequently we have observations on the same 
subject by Wendt,2 who first described two varieties, a hypertrophic 
and an atrophic, a classification subsequently adopted by Lennox 
Browne.3 These writers, however, fail, it seems to me, to make any 
distinction between catarrh of the naso-pharynx, and catarrh of the 
nasal passages proper. Hence, their description of the disease is 
somewhat vague and unsatisfactory. Beverley Robinson,4 how- 
ever, following the same classification, was the first, I think, to 
describe the disease as confined to the naso-pharynx proper, which 
he designates as a follicular disease of the naso-pharyngeal space, 
still, however, describing two forms, a dry and moist. Mackenzie,5 
dropping this classification, discusses the subject somewhat at 
length, but still I think in a vague and indefinite way, under the 
general head of catarrhal disease, although he devotes a separate 
chapter to rhinitis, which he designates as chronic nasal catarrh. 
All these writers fail to give a clear clinical description of catarrhal 
inflammation of the naso-pharynx, in contradistinction to catarrhal 
inflammation of the mucous membrane lining the nasal cavity, and 
1 “ Lectures on Winter Cough,” London, 1866, 1st ed. 
2 Ziemssen’s “ Handb. der Therapie,” Leipz., 1874, Bd. vii. 
3 “ The Throat and its Diseases,” London, 1878, p. 153. 
4 “ Nasal Catarrh,” New York, 1880. 
s “ Diseases of the Throat and Nose,” vol. ii., p. 472. 516 
DISEASES OF THE NASO-PHARYNX. 
furthermore, fail to indicate what special pathological changes in 
the pharyngeal vault give rise to the disease. The same, I think, 
can be said of Cohen,1 Seiler,2 Woakes,3 Schech,4 and Sajous.5 In 
1885 Tornwaldt6 comes forward in a somewhat elaborate mono- 
graph, in which he essays to prove that the very large proportion 
of cases are due to a morbid condition of the pharyngeal bursa, 
which manifests itself in two ways, (1) a chronic catarrhal inflam- 
mation of the pharyngeal bursa and (2) in a cystic degeneration of 
the bursa, with closure of its orifice. Tornwaldt bases these con- 
clusions on a very careful examination of twenty-five cases, which 
he claims demonstrated not only his primary conclusion, but also 
that many cases of pharyngitis, laryngitis, bronchitis, as well as gas- 
tric catarrh, cough, asthma, headache, pains in the chest, affections 
of the ears, hyperaemia and hyperplasia of the nasal mucous mem- 
brane, and even nasal polypi, are directly due to a diseased condi- 
tion of the pharyngeal bursa, and furthermore, that the treatment 
of the bursa is sufficient to give relief to all the foregoing train of 
concomitant affections. Following very soon after the publication 
of this monograph, Tornwaldt’s disease, as it is called, became a 
subject of a somewhat animated discussion in the journals, Bresgen 7 
Keimer8 and Lennox Browne9 taking issue with Tornwaldt’s view 
purely on clinical grounds; while, on the other hand, with equal 
positiveness, we find Broich 10 and Luc" claiming to have observed 
all that Tornwaldt observed, in their examination of the naso- 
pharynx, and to have had equal success in the treatment of the 
pharyngeal bursa, as far as the catarrhal inflammation of this region 
is concerned, although failing to notice any cases of cystic degen- 
eration. Both these writers, also, claim to have cured nasal disease 
by treatment of the pharnygeal bursa alone. Schwabach,12 discuss- 
ing the question from a purely anatomical point of view, and basing 
his conclusions on a series of investigations upon the dead body, 
comes to the conclusion that the bursa pharyngea is not a special 
anatomical formation, but is merely a portion of the pharyngeal 
tonsil, and, therefore, that it has no independent pathological char- 
1 “ Dis. of the Throat and Nasal Passages,” N. Y., 1879. 
2 “ Diseases of the Throat,” Phila., 1883. 
3 “ Post-Nasal Catarrh,” Phila., 1884. 
4 “Dis. of the Mouth, Throat, and Nose,” Engl, ed., 1886. 
s “ Dis. of the Nose and Throat,” Philadelphia, 1886. 
6 “ Ueberdie Bedeutung der Bursa Pharyngea,” etc., Wiesbaden, 1885. 
7 Deut. Med. Woch., 1887, No. 5, p. 86. 
8 Monatsschrift fur Ohrenheilk., 1886, No. 4. 
9 “ The Throat and its Diseases,” London, 1887, 2d ed., p. 509. 
10 Monatsschrift fur Ohrenheilk., 1S86, Nos. 5,6, 7. 
11 La France Medicale, 1886, Nos. 120 and 121. 
12 Arch, fur Mik. Anat., 1887, vol. xix., p. 61. NASO-PHARYNGEAL CATARRH. 
517 
acter. Notwithstanding the criticism of Bresgen and others, Torn- 
waldt’s propositions are laid down with so much clearness, and his 
clinical cases reported with so great accuracy, that I think we must 
accept them as demonstrating the fact that a certain proportion of 
cases of catarrhal disease have their source in this so-called pharyn- 
geal bursa. The question as to whether this cavity, which Luschka 
has demonstrated to exist in the pharyngeal vault, is a true bursa, 
has already been discussed in the section on the anatomy of the 
naso-pharynx, where the view was taken, that the weight of evi- 
dence goes to show that it is not a constant anatomical condition, 
but rather the result of a diseased action of the normal lymphoid 
structures found in that region. The position, then, which we are 
compelled to take in the matter, is that naso-pharyngeal catarrh is 
undoubtedly, in many cases, due to a diseased condition of this so- 
called bursa pharyngea, but my own clinical studies go to show 
that we have, in addition to this, a catarrhal disease, which gives rise 
to a secretion, whose source is in the whole pharyngeal tonsil, viz., 
that mass of glands which is found normally distributed over the 
larger portion of the posterior and upper wall of the naso-pharynx. 
It seems to me entirely too narrow a view of the case, to say that 
all cases of naso-pharyngeal catarrh are dependent on the existence 
of a bursal cavity. Wherever we have muciparous glands gathered 
together in large masses, we have an anatomical condition which 
predisposes the part to a chronic inflammatory disease, in which the 
prominent lesion consists in cell desquamation, in connection with 
an apparent increased mucous secretion. This we find in the early 
stages of atrophic rhinitis, namely in the purulent rhinitis of chil- 
dren. We also find it, to a certain extent, in chronic inflammation 
of the faucial tonsils, and I think we are bound to accept the view, 
that we may also have the same morbid condition existing in the 
glandular structures of the pharyngeal vault. A chronic inflamma- 
tory process involving these glands, and attended with a moderate 
amount of diffuse hyperplasia, may result, then, in a muco-purulent 
'discharge from the broad evenly distributed cushion of glandular 
structure, spread over the pharyngeal vault, or the hyperplasia may 
take such a form, as that the lateral lobes of the pharyngeal tonsil 
may be crowded toward the central line, and the superficial layer 
of epithelium of the one side of the central fissure, or recessus 
pharyngeus medius, may become united with the superficial layer 
of the opposite side, in such a way as to give rise to the bursa-like 
cavity of Luschka or Tornwaldt, after the manner first suggested 
by Schwabach,1 the formation of the bursa being a somewhat ad- 
ventitious incident of the morbid changes which take place in the 
1 Loc. cit. DISEASES OF THE NASO-PHARYNX. 
518 
tissue, as the result of the inflammatory process, thus adding an en- 
tirely new condition, which serves to prolong, and possibly aggra- 
vate the catarrhal affection. 
Etiology.—All chronic inflammation, involving glandular struc- 
tures, develops in two distinct directions. It may result in a rapid 
cell development, in which the newly proliferated cells become 
part of the membrane, thus giving rise to true hypertrophy, or the 
cell proliferation may take on such extreme activity, as that the 
newly developed cells are thrown off, in connection with an ex- 
cessive discharge of mucus, thus giving rise to a muco-purulent 
discharge. Now, as we know, inflammatory changes in the mucous 
membranes of young people show a marked tendency to invade 
the lymphatic structures, while in adults, it is the connective-tissue 
structures which are more especially involved. Following this rule, 
I think we must look for the primary source of the naso-pharyn- 
geal disease to the earlier period of life. Now, in the majority of 
instances, an inflammatory process in children, involving the phar- 
yngeal vault, gives rise to an hypertrophy of the pharyngeal tonsil, 
or so-called adenoid disease. Hence, it is altogether possible, that, 
in many cases, an enlarged pharyngeal tonsil in childhood, leads to 
the development, in adult life, of one of the forms of naso-pharyn- 
geal catarrh heretofore described, which, as it undergoes the atro- 
phic changes which occur at puberty, takes on a desquamative 
process, and so develops into a muco-purulent discharge from the 
naso-pharynx, or the muco-purulent catarrh may set in, without 
the existence of a pre-existing hypertrophy. In these cases, we 
undoubtedly find an active exciting cause, in some one of the ex- 
anthems, especially scarlet fever or measles. After its onset, I 
think the disease should be regarded in all cases as a purely local 
condition, and not dependent on any general dyscrasia, although 
Beverley Robinson 1 lays special emphasis on the fact, that the dis- 
ease is due, not only to a catarrhal diathesis, but may be, and fre- 
quently is attached to the “gouty, hepatic, syphilitic, scrofulous 
and tubercular diatheses, and a malarial influence may likewise be 
evident,” a statement which he repeats in the second edition of his 
work ;2 while Moure3 also gives the first place to the strumous dia- 
thesis, as the cause of the disease. Lennox Browne,4 on the other 
hand, while making the statement in his first edition, that patients 
suffering from naso-pharyngeal catarrh are generally scrofulous, 
1 “ Nasal Catarrh,” New York, 1880, p. 145. 
2 “ Nasal Catarrh,” New York, 1885, p. 140. 
3 “ Manuel Pratique des Mai. des Fosses Nasales,” etc., Paris, 1886, p. 256. 
4 “ The Throat and its Diseases,” London, 1878, p. 163. NASO-PHAR YNGEAL CA TARRH. 
519 
seems to have abandoned this view entirely in his second edition.1 
I doubt the influence of atmospheric conditions in directly causing 
the disease, although they undoubtedly have a marked influence on 
the character of the symptoms. 
As regards taking cold, I am disposed to think, that, in most in- 
stances, the chronic inflammatory process exists first, and that this 
renders the patient susceptible to atmospheric changes, with the 
result of his taking cold, and that repeated colds become a symp- 
tom of the chronic inflammation, rather than that chronic inflam- 
mation results from the repeated colds. 
The use of tobacco, it is claimed, may be the source of a phar- 
yngeal catarrh, a statement which is based, I think, on no very 
careful clinical observation. The offending element in the use of 
tobacco is the nicotine, whose action is on the nervous system, 
while the direct action of the fumes of the tobacco smoke is merely 
to cause a temporary irritation of the mucous membrane. Hence, 
I think, we may safely state, that the effect of tobacco-smoke is 
to temporarily, and perhaps permanently, aggravate an existing 
catarrhal lesion, while its causative influence in the primary pro- 
duction of the inflammatory process in the naso-pharynx is very 
limited. 
The use of alcohol, on the other hand, is undoubtedly a prolific 
source of naso-pharyngeal catarrh, owing partially, perhaps, to the 
direct local action of alcohol upon the pharynx, but mainly, I take 
it, to the fact that there is a very close and intimate relation be- 
tween the pharynx and the stomach, and that the chronic gastritis 
which so frequently results from the use of alcohol, gives rise to a 
sympathetic inflammation of the pharyngeal mucous membrane. 
The possibility of contagion causing a catarrhal inflammation 
of the nasal cavities proper, has been the subject of no little dis- 
cussion. I believe Beverly Robinson2 is quite alone in the sugges- 
tion, that a person possessing the favorable constitutional diathesis, 
may contract the disease by contagion—a view which, I think, de- 
mands for its acceptance larger clinical evidence of its correctness 
than we at present possess. 
By far the most frequent and most potent of all causes which 
lead to the development of a naso-pharyngeal catarrh, is a diseased 
condition of the mucous membrane lining the nasal passages proper. 
In the chapter on the physiology of the nose, the intricate and ex- 
ceedingly important respiratory function of the turbinated bodies 
was discussed at considerable length, and an important feature of 
that discussion consisted in the assertion that the integrity of the 
mucous membrane of the whole upper air-tract was directly de- 
1 “ The Throat and its Diseases,” London, 1887. 
2 Op. cit., 2d ed., p. 135. 520 
DISEASES OF THE NASO-PHARYNX. 
pendent upon a healthy condition of the respiratory function of 
the nasal mucous membrane. If then, we have a chronic inflamma- 
tion, with hypertrophy of the nasal membrane, interfering with the 
normal nasal respiration, and hampering the normal process of 
serous exosmosis, the very first portion of the respiratory tract 
beyond the nasal cavities, would be necessarily immediately sub- 
jected to the deleterious influence of this impaired function. And 
this, I think, is shown by clinical observation, in that, as a direct 
result of hypertrophic rhinitis, we have the normal function of the 
pharyngeal tonsil notably interfered with, and furthermore, its 
glandular structures subjected to the constant irritation arising 
thereby. As the result of this, the normal secretion of mucus is 
interfered with, cell desquamation stimulated, and the normal 
mucus, which as we have shown, is clear, white and easily fluid, be- 
comes changed into a thick inspissated mucus, largely surcharged 
with unripe epithelial cells, and, in fact, becomes transformed into 
a muco-purulent discharge, which adhering to, and clinging upon 
its surface, hangs down between the palate and pharyngeal wall in 
thick masses of stringy mucus, which are expelled with great diffi- 
culty. I think it probable that in many cases the amount of the 
secretion from the pharnygeal vault in this disease, instead of 
being increased, is to an extent decreased. In other words, while 
in health, we have a very large amount of white transparent mucus 
poured out, of which the patient is unconscious, and which passes 
down into the pharynx for lubricating the bolus of food in degluti- 
tion, in disease, this secretion is much diminished in amount, and 
lodging in the cavity, is expelled with difficulty. Especially is this 
the case, where the affection is due to disease of the nasal cavity 
proper, for if the air, passing through the nasal cavities, does not 
become saturated with moisture in that passage, it reaches the 
pharyngeal vault in an abnormally dry condition, and therefore 
robs the mucus found in this cavity of a portion of its watery con- 
stituents, thereby rendering it thick and inspissated. And herein, 
it seems to me, lies one very important feature of the influence of 
a diseased condition of the nasal cavity, in giving rise to a naso- 
pharyngeal catarrh. In atrophic rhinitis we have a condition of 
the nasal mucous membrane, in which the venous sinuses, in which 
the serous exosmosis has its source, are more or less completely 
obliterated, resulting in an abnormally dry condition of the nasal 
mucous membrane, and in which its surface is usually covered with 
dry greenish crusts. The inspired air, in passing through a nasal 
cavity in this condition, does not become surcharged with moisture, 
and hence, reaching the pharyngeal vault in this abnormally dry 
state, it exerts exactly the same influence as that 'already de- NASO-PHAR YNGEAL CA TARRH. 
521 
scribed above, in connection with hypertrophic rhinitis, only its 
influence is more marked and more direct. 
The condition of the naso-pharynx, in this disease, is one in 
which this cavity is filled and blocked with large masses of thick 
and inspissated mucus, and even may be abnormally dry, giving rise 
even to dry crusts. This condition is usually described under the 
designation of atrophic, or dry pharyngitis. I am certainly of the 
opinion, that in the very large majority of instances, this dry phar- 
yngitis is nothing more than a abnormally dry condition of the 
normal pharynx, rendered so, as the result of the air passing through 
a nasal cavity, in which the respiratory function has been abolished 
by the atrophic process. In other words, pharyngitis sicca is purely 
a symptomatic disease, and a variety of naso-pharyngeal catarrh. 
The truth of this is shown in a striking manner, in those cases of 
atrophic rhinitis in which, as the result of constant douching, the 
atrophic condition is relieved, and the serous exudation so far 
stimulated and encouraged as to keep the membrane in a fairly 
moist condition. 
Pathology.—The essential pathological lesion which consti- 
tutes a naso-pharyngeal catarrh, whether it is due to a diffuse hy- 
perplasia and cell desquamation, involving the whole of the pharyn- 
geal tonsil, or whether it may be due to the adventitious formation 
of Tornwaldt’s bursa, has already been sufficiently indicated, by 
the discussion in the early part of the chapter. It need only be 
added that, in those cases where the bursa has been formed, the 
superficial epithelial layer of the gland structures becomes now, in 
the latter form of the disease, the lining epithelium of a partially 
closed cavity, the result of which is necessarily to stimulate them 
to still more active desquamation and secretion. As we know, 
where mucus is secreted in a closed cavity, or a cavity whose 
walls are in contact, the secretion becomes a pus secretion, and the 
mere presence of the pus, constantly bathing the cyst walls, stimu- 
lates them to still greater activity, and freer secretion. As we 
have already suggested, the primary morbid lesion is identical in 
both forms of the disease, the formation of the bursa being simply 
an adventitious incident of the inflammatory process. We now 
see, how this formation of the bursa results in a very notable in- 
crease of the pus secretion. On the other hand, however, it must 
be remembered, that in those cases where a bursa is formed, it 
results in a folding in, as it were, of the outlying glandular struc- 
tures to the median line, the outlying furrows of the pharyngeal 
tonsil disappearing. Hence, the amount of secretion in Tornwaldt’s 
disease is not necessarily greater, and probably is, as a rule, much 
less than in'the diffuse‘form of the disease, for in Tornwaldt’s dis- 522 
DISEASES OF THE NASO-PHARYNX. 
ease, the source of the discharge is from this small adventitious 
cavity, while in the diffuse form, the secreting surface involves the 
whole posterior wall of the naso-pharynx, extending from one 
Eustachian tube to the other. Moure1 is responsible for the asser- 
tion, that where the pus discharge is very profuse, its source may 
be in a suppurative inflammation of the mucous membrane lining 
the sphenoidal sinus. The existence of such a complication would 
manifest itself by symptoms rather more pronounced than a mere 
naso-pharyngeal catarrh. As the result of the more or less com- 
plete closure of the orifice of the bursa, we have, in a certain pro- 
portion of cases, the formation of a retention cyst, a condition 
which Tornwaldt2 found in forty-five out of two hundred and two 
cases3 of bursal disease. Similar cases have been reported by Zahn,4 
Troeltsch 5 and Czermak.6 I regard it as a somewhat suggestive com- 
mentary on the ordinary correctness of our clinical observations, 
that Tornwaldt should assert with a considerable degree of posi- 
tiveness, that Stork’s case of sphenoidal disease7 already referred 
to in the chapter on that subject, was really a case of disease of the 
pharyngeal bursa—a view which would seem to be confirmed by 
the suggestion of Beverley Robinson,8 that the mucous membrane 
of the accessory sinuses is so very scantily supplied with glands, 
that it could scarcely be the source of a very profuse purulent se- 
cretion. 
I have removed, by mean of the curette and snare, small masses 
of the diseased tissue in the diffuse form of the disease in a number 
of instances, the microscopic character of which is fairly well shown 
in the accompanying cut (Fig. 123). In all cases, it need scarcely 
be stated, the patients from whom this tissue was removed were 
adults. The pathological conditions observed were as follows: 
The hyperplasia was characterized by the bulging of the mucosa, 
which assumed the form of small raspberry like projections, which 
gave the vault of the pharynx a somewhat mammillated contour. 
Under the microscope this feature is evidenced by the presence of 
globular protrusions between which there are furrows of varying 
depths (see Fig. 123 K). The lymph tissue is richly supplied with 
blood-vessels, and a rather dense fibrous connective tissue, the 
latter holding clusters of lymph corpuscles. The lymph follicles 
1 Op. cit., p. 259. 2 Op. cit., p. 70. 3 Op. cit., p. 70. 
4 Deut. Zeitschr. fur Chir., xxii., pp. 392-399. 
5 “ Lehrb; Ohrenheilkunde,” 1877, p. 321. 
6 “ Der Kehlkopfspiegel und seine Verwerthung,” etc., Leipz., 1863. 
7 “ Klinik der Ivrankheiten des Kehlkopfes, der Nase und des Rachens,” Stuttgart, 
1880. 
8 Op. cit., p. 123. NASO-PHAR YNGEAL CA TARRH. 
523 
are scarce and small. The accompanying figure (Fig. 123) shows 
two of these follicles, one on either side of the furrow. In none 
of the specimens examined was the presence of acinous glands 
demonstrable. In this feature, therefore, the tissue differs essen- 
tially from ordinary glandular hyperplasia, in which both the lymph 
tissue and the acinous glands are augmented in number and size. 
We are led to the conclusion, therefore, that the increased se- 
cretion in naso-pharyngeal catarrh has its source largely in the 
furrows or fissures above described, for as we know, epithelium 
situated in this manner is transformed into mucus much more 
readily, and with greater activity, than when it is located upon the 
Fig. 123.—Lymphatic hyperplasia of the Pharyngeal Mucosa, illustrating the Morbid Changes in ordi- 
nary Naso-pharyngeal Catarrh. E, Columnar Ciliated Epithelium; F, Small poorly defined lymph folli- 
cles: X, Lymph Tissue intermixed with Fibrous Connective Tissue ; K, Crypt on surface. 
surface. Our greatest difficulty in understanding this somewhat 
curious disease naso-pharyngeal catarrh, lies in the attempt to har- 
monize clinical observation with the pathological changes revealed 
by the microscope, for while increased secretion is undoubtedly a 
prominent feature of the disease, the microscope fails to reveal 
the presence of those conditions usually associated with hyper- 
secretion, namely an increase, or even the presence of acinous 
glands. We must conclude, therefore, that the increased secre- 
tion has its source in the fissures, or furrows, before alluded to, 
which present anatomical conditions not unlike ordinary mucous 
glands, and therefore take on a like functional activity. In addi- 
tion to this I think we must recognize the fact, that this activity 524 
DISEASES OF THE NASO-PHARYNX. 
is in no small degree stimulated by the presence of the lymphatic 
follicles, and the diffuse lymphatic hyperplasia, which act probably 
in much the same manner as the presence of a foreign body. 
Symptomatology.—The prominent symptom of the disease 
consists in the discharge from the vault of the pharynx, of a more 
or less profuse thick, yellow, muco-purulent discharge, which pour- 
ing out from the glands of the vault, makes its way down the 
pharyngeal wall and into the lower pharynx, or adhering closely 
to the membrane lining the vault, gives rise to more or less irrita- 
tion, with a nasal screatus, and ineffectual attempts to dislodge it. 
Now, as before stated, the character of this secretion is, in most 
instances, due to the fact that the nasal cavity itself is diseased, 
and hence the secretion from the pharyngeal glands becomes thick 
and inspissated, as the result of abnormally dry air passing over it, 
and robbing it of its moisture. It is idle to suppose that the glands 
secrete a thick, tenacious, inspissated mucus in this state. No 
glands secrete other than a perfectly fluid mucus. This abnormal 
condition of thickness and inspissation is due to changes in the 
secretion after it is poured out from the glandular structures, and 
not to changes in the secreting organs. In many cases, the prom- 
inent subjective symptom of which the patients complain, is that 
of a constant “ dropping ” in the throat, the secretion being thinner 
and more nearly normal makes its way down and drops into the 
fauces. The density of the discharge varies greatly at different 
times and in different subjects. In some cases, it is almost a fluid 
pus. Especially is this true, if the source of the discharge is in 
a bursal cavity. When its source, however, is from the broadly 
diffused hyperplastic glands of the pharyngeal tonsil, it is a thick, 
yellow, grayish, tenacious mucus in all cases. The secretion is 
usually constant, day and night, yet while through the day its dis- 
lodgment is effected by voluntary motion, and perhaps flows more 
freely as the result of the normal movements of the fauces, during 
the night it accumulates in considerable quantities, with the result 
of imposing upon the patient a prolonged effort of hawking and 
nasal screatus, by which he attempts to dislodge the accumulated 
mass in the morning upon rising. Furthermore, this nocturnal 
accumulation not infrequently produces nausea and even vomit- 
ing, by its mere presence in the fauces. As evidence of the intimate 
connection between the pharynx and the stomach, and as lending 
weight to the view that the naso-pharynx belongs properly to the 
food tract, I have very frequently observed that patients suffering 
from a catarrhal affection of this region rise in the morning in 
comparative comfort, but immediately upon taking breakfast, and 
afterward, there seems to be excited thereby a profuse muco- NASO-PHAR YNGEAL CA TARRH. 
525 
purulent secretion from the naso-pharyngeal glands, which persists 
oftentimes for several hours, apparently while digestion is going on. 
As is usual, in all cases of a chronic inflammatory process in 
the upper air-passages, its progress is marked by more or less fre- 
quently repeated attacks of subacute inflammation, as the result of 
slight exposure to cold, during which the symptoms are markedly 
aggravated for the time. Moreover, we find the disease noticeably 
subject to changes in the weather, all the symptoms being worse 
in the fall and spring months, while the summer months give more 
or less complete relief. Place of residence, also, has a marked in- 
fluence on the symptoms, in that residence in a dry and equable 
climate affords relief; while in a damp climate, especially near the 
salt water, the symptoms are notably aggravated. 
It is usually stated, that the larynx and the air-passages beyond, 
are the seat of a mild chronic inflammation, owing to the fact that 
the secretions make their way down the pharynx, and pass into 
the larynx, causing local irritation and inflammatory changes there. 
I do not suppose that the secretion from the nasal passages or the 
pharynx ever makes its way into the laryngeal cavity under any 
circumstances. All extraneous matter passing through the phar- 
ynx is taken into the stomach, by an involuntary action, which is 
usually beyond the control of the patient. Certainly the presence 
of mucus in the pharynx, if it does not excite involuntarily the act 
of deglutition, becomes such an annoyance to the patient, that he 
is constantly tempted to swallow the mass, in order to relieve the 
throat of its irritating influence. Hence, I do not believe that 
naso-pharyngeal catarrh gives rise to a laryngitis in this manner. 
Those cases of laryngitis and bronchitis, with the attendant cough, 
which occur in connection with a naso-pharyngeal catarrh, I be- 
lieve to be the direct result of a morbid condition of the nasal pas- 
sages, unless, perhaps, the disease of the naso-pharynx gives rise 
to so great obstruction to normal nasal respiration as to compel 
habitual mouth breathing, in which case, sooner or later, laryngeal 
and bronchial trouble will develop. 
Inflammation of the lower pharynx, or an ordinary pharyngitis, 
is not a concomitant of naso-pharyngeal catarrh, although I think 
this is a view usually taken by most observers. I believe a simple 
pharyngitis to be a somewhat rare affection. It is too much our 
habit to examine the fauces of a patient, and observing the tonsil 
slightly red, congested, relaxed, or flabby perhaps, to at once make 
a diagnosis of pharyngitis without stopping to question ourselves 
as to the fact of there being absolute evidence of inflammatory 
action there. As before stated, the lower pharynx belongs essen- 
tially to the food tract, and not to the air tract. It i-s involved 526 
DISEASES OF THE NASO-PHARYNX. 
sympathetically with gastric catarrh, but not, as a rule, with catar- 
rhal disease of the air-passages. Tornwaldt1 reports having ob- 
served five cases of asthma, all of which were cured by the incision, 
and subsequent treatment of cysts, which he found had developed 
in the pharyngeal vault. He makes the general statement, that 
the disease was a reflex symptom, dependent upon irritation of the 
glosso-pharyngeal, vagus, and trigeminus nerves. We have already 
discussed the causation of asthma, taking the ground that it may 
be due to any obstructive lesion in the upper air-passages. These 
cases of Tornwaldt’s are certainly unique. My own experience, 
however, has taught me to regard asthma as more closely depend- 
ent upon some disturbance of the great respiratory function of the 
nasal passages. Tornwaldt goes still further, in making the state- 
ment that hyperaemia and hypertrophy of the nasal mucous mem- 
brane are dependent upon bursal disease, or rather, as he puts it, 
that they are coincident with bursal disease, and disappear on the 
removal of the disease in the naso-pharynx. In this view he is 
supported by the observations by Luc2 and Broich.2 I confess my 
entire inability to reconcile this statement, either with my own 
clinical observations, or with my knowledge of the physiological 
and pathological processes of the upper air-tract. I can only ex- 
plain it to myself, by taking the view, that the nasal disorder was 
of an unusually mild type, and that the removal of a far more 
prominent source of distress to the patient, rendered the remaining 
nasal disorder a comparatively trivial symptom. 
Ten cases are reported by Tornwaldt, in which headache was a 
prominent symptom, and relief obtained by treatment of the naso- 
pharyngeal trouble. This also we must accept as an interesting 
contribution to clinical medicine, as confirming the teaching first 
made prominent by Hack, that in every case of cephalalgia, a thor- 
ough inspection of the respiratory tract must be made in order to 
detect any possible source of irritation or diseased action in that 
region. Whereas the relief of this distressing symptom is one of 
the most creditable of our successes in throat practice, there is no 
special symptom, in any given case of headache, which warrants us 
in the positive assertion that it is dependent on disease of the air- 
passages, and yet this distressing disease is relieved, in a large pro- 
portion of cases, by treatment directed to this region. 
It is still a very prevalent impression among otologists and 
others, that catarrhal disease of the middle ear is very frequently 
due to a morbid condition involving the naso-pharynx. Tornwaldt, 
in his monograph, indorses this view. Now, while it is an undoubted 
fact that hypertrophy of the pharyngeal tonsil is the cause of ear 
1 Op. cit., p. 49. 
* Loc. cit. NASO-PHAR YNGEAL CA TARRH. 
527 
troubles in young childern, in the very large majority of cases I 
think that this is due mainly to the fact, that the pharyngeal space 
is very largely encroached upon, and its normal functions interfered 
with, by the mere mechanical pressure of the hypertrophied lym- 
phatic tissue. In adult life, however, whether a naso-pharyngeal 
catarrh is due to Tornwaldt’s bursa, or to a diffuse hypertrophy 
covering the space, this thickening encroaches so slightly upon the 
pharyngeal cavity, that its normal function is but little interfered 
with. I do not believe that a middle-ear catarrh is ever dependent 
on an extension of the catarrhal process from the pharyngeal vault, 
but is due, either to a diminution of normal atmospheric pressure 
in the naso-pharynx, and to interference with the renewal of air in 
the middle ear, or to interference with the circulation of blood by 
the mechanical presence of enlarged glands. Hence, I think it is 
exceedingly doubtful, whether we are justified in looking for the 
source of ear disease in adults, in the pharyngeal vault, when we 
consider how far more active, and absolutely direct in its action 
upon the auditory apparatus, is a diseased condition of the nasal 
cavities proper. A morbid condition of the nasal mucous mem- 
brane then, in adult life, is the more prolific source of ear disease, 
and not the glandular structures in the vault of the pharynx. That 
we not infrequently meet with impaired hearing in connection with 
naso-pharyngeal catarrh cannot be questioned. In these cases I 
think that we must look for the source of both the ear trouble and 
the catarrhal disease in a previously existing adenoid growth. In 
other words, I think that if we carefully investigate the clinical 
history of these cases, we shall find that the catarrhal trouble of 
adult life had its origin in an adenoid during youth, and that this 
was the original cause of the deafness, which being moderate in 
extent, had only become a notable infirmity later in life. Torn- 
waldt asserts that hyperaemia and hypertrophy of the nasal mucous 
membrane, and even a persistence of nasal polypi, may be the direct 
result of a naso-pharyngeal catarrh, a view in which he is sustained, 
to a certain degree, by Broich 1 and Luc.1 This assertion I find it 
exceedingly difficult to harmonize in any way with my own clinical 
observations. That a nasal hyperaemia or hypertrophy may give 
rise to a naso-pharyngeal catarrh, has already been stated. That 
the converse is true as a general rule, I find difficult of rational 
explanation. The same must be said, also, in regard to Tornwaldt’s 
assertion that gastric catarrh may be dependent upon naso-phar- 
yngeal disease. As already suggested, there is a close and in- 
timate relation between the lower pharynx and the stomach, under 
which a catarrhal condition of the lower pharynx may be depend- 
1 Loc. cit. 528 
DISEASES OF THE NASO-PHAR YNX. 
ent upon a gastric catarrh. We undoubtedly meet with many 
cases, in which the presence of the thick tenacious mucus in the 
fauces gives rise to hawking and spitting, which may result in 
vomiting, but this does not constitute gastric catarrh, but is very 
simply explained by the fact, that the presence of the tenacious 
mucus, impinging upon the lower pharynx, acts as any foreign 
body, and vomiting is produced, much as we produce it artificially, 
by titillating the fauces with the finger. I am disposed, therefore, 
to say that Tornwaldt’s proposition must be reversed, and that if 
there is any connection observed between the naso-pharynx and 
the stomach, the latter is the offending organ, and that the naso- 
pharyngeal catarrh is dependent upon a morbid condition of the 
stomach rather than the reverse. 
DIAGNOSIS.—The recognition of this disease is based partially 
on an examination of the pharyngeal vault by means of the rhino- 
scopic mirror, and in part by the exclusion of disease of the intra- 
nasal cavity, although in many instances we shall be compelled to 
depend largely on the subjective symptoms. I think, that in no 
case can we decide that the catarrhal symptoms are directly due 
to the morbid condition of the vault of the pharynx, until the ele- 
ment of intra-nasal disease has been entirely eliminated. An ex- 
amination of the pharyngeal vault by means of the rhinoscopic 
mirror, ordinarily will reveal to us an unbroken continuity of 
smooth membrane, as we slowly change the angle of the mirror in 
order to bring successively into view the posterior wall of the 
pharynx and trace it up to the broad expansion of the septum an- 
teriorly. If, however, in making this examination, we find this 
continuity interrupted, or, in other words, if instead of the smooth 
rounded dome-like cavity of the naso-pharynx, we find projecting 
into it from the posterior wall a glandular mass, of sufficient thick- 
ness to protrude itself into the line of vision, in such a way as to 
partially shut off the direct view of the vault of the pharynx, we 
recognize this as a morbid condition, characteristic of this disease. 
Tornwaldt insists, that for a thorough inspection of the pharyngeal 
vault, the palate should be drawn forward by means of the palate 
hook. This undoubtedly enables us to use a larger mirror, and 
thus obtain a better view, in that the cavity is more thoroughly 
flooded with light. I think, however, that unless the space between 
the posterior pharyngeal wall and the edge of the palate is very 
narrow, a little experience should enable us to recognize a diseased 
condition without this procedure, especially when we consider, 
that the palate retractor is only tolerated by a comparatively small 
proportion of patients. Tying up the palate, after the manner 
already described, is, I think, usually better tolerated even than is NASO-PHAR YNGEAL CA TARRH. 
529 
the palate retractor, and unquestionably, for a thorough diagnosis 
in these cases, an inspection should be made by the aid of this pro- 
cedure, or after the manner suggested by Tornwaldt. There are 
two conditions, as already suggested, which we may recognize in 
the pharyngeal vault: one, an enlargement of the pharyngeal bursa, 
and in the other, the broad diffuse hypertrophy. The latter has 
been already described. The bursa is easily recognized, as a 
rounded, almond-shaped projection in the median line, and about 
midway between the prominence of the atlas and the dome of the 
pharynx. The noticeable condition that is characteristic of both 
forms of naso-pharyngeal disease, is the large amount of thick in- 
spissated muco-pus, which is found in this cavity. This may be 
seen, thoroughly well diffused over the whole of the posterior wall 
of the pharynx, in a thick, gray blanket, as it were, or we may find 
it hanging down from the upper portion of the glandular struc- 
tures, in yellowish-gray strings, stretching from the roof to the soft 
palate below. Tornwaldt suggests, that in bursal disease dried 
crusts are found lying immediately upon the surface of the rounded 
projection of the bursa, and that upon detaching this, its removal 
will be followed by a small string of yellow muco-pus, which is 
drawn directly from the bursal orifice. This may be true, but it 
requires very nice manipulation and delicate observation to verify 
it. We find thus, that the diagnosis of this disease ordinarily should 
be easy, as based on the direct inspection. The symptoms, how- 
ever, always should aid us very greatly, in that the dropping of 
mucus from the pharyngeal vault or its lodgment in thick, in- 
spissated masses, between the palate and pharynx, is so character- 
istic of the disease as to render the diagnosis comparatively simple, 
even when based on subjective symptoms alone. The statement 
has already been made, with a considerable degree of positiveness, 
that hypertrophic rhinitis does not ordinarily give rise to an ex- 
cessive discharge. In other words, that disease of the nasal cavities 
does not result in the formation and accumulation of mucus, either 
in the passages proper, or in the discharge which makes its way 
from the nose into the vault of the pharynx, Any excessive secre- 
tion of mucus or muco-pus in the vault of the pharynx has its 
source in the vault of the pharynx, and not in the nose. The same, 
I think, is true of atrophic rhinitis or ozsena, and nasal polypi. 
Syphilitic disease, resulting in ulceration and necrosis, may occa- 
sionally give rise to so profuse a discharge of pus, as that it may 
make its way into the pharyngeal vault, but in these cases the 
syphilitic diagnosis should be so simple that a mistake need scarcely 
ever be made. Disease of the accessory sinuses gives rise to a 
purulent discharge from the nose, which not infrequently makes its 530 
DISEASES OF THE NASO-PHARYNX. 
way into the pharyngeal vault, especially where the patient is in 
the recumbent position, as during sleep, in which case the symp- 
toms closely simulate those of the naso-pharyngeal disease. During 
waking hours, however, this pus discharge is largely voided through 
the anterior nares into the handkerchief, presenting the character 
of a bright-yellow fluid pus, not specially resembling the thick in- 
spissated muco-pus of naso-pharyngeal disease, and moreover, a 
discharge from the accessory sinuses is attended with the charac- 
teristic fetid hydrogen odor, and odor is never present in any form 
of catarrhal disease of the naso-pharynx; and, moreover, a careful 
inspection of the nasal cavities should always reveal the immediate 
source of the pus discharge. 
PROGNOSIS.—This disease involves no dangerous tendencies, 
and shows no very marked disposition to increase, although it is 
essentially a chronic affection, and moreover, shows no tendency 
whatever to a spontaneous cure. As already stated, it is not to be 
regarded as an efficient cause of laryngeal or bronchial disease, 
asthma, or deafness. Hence, I think the statement that we occa 
sionally see made, that pulmonary disorders may have their starting 
point in a naso-pharyngeal catarrh, may be dismissed, as based on 
no well-grounded clinical observation. The prognosis, as regards 
a cure of these cases, must be based mainly on our special skill in 
removing the definite morbid lesion, which our examination shows 
us to be present. In the present state of our knowledge of disease 
of the upper air-passages, I think we are in perhaps the larger pro- 
portion of cases justified in assuring our patients of a complete 
relief from all the troublesome symptoms of the disease, and it is a 
serious reflection on our special skill, if we fail to justify the prom- 
ise. At best, however, the disease is a somewhat obstinate one, 
and we must not expect the same brilliant results, which we so fre- 
quently obtain in the treatment of diseases of the nasal passages 
proper, for while in the latter region our therapeutic measures are 
followed so frequently with the most prompt and flattering results, 
in catarrh of the naso-pharynx the amelioration of symptoms is 
in most instances slow, and the cases oftentimes exceedingly dis- 
couraging. I am of the opinion that, in the very large major 
ity of cases, the disease can be cured, provided the patients are 
willing to submit to the long-continued course of treatment often 
required. 
Treatment.—The question of a systemic habit, acting as a 
predisposing or exciting cause of naso-pharyngeal catarrh, has 
already been discussed, and the view taken, that the disease was 
mainly of a local character. Hence, I am disposed to question the 
efficacy of internal medication, such as has been suggested by Bev- NASO-PHAR YNGEAL CA TARRH. 
erley Robinson,1 Moure,2 and others, although if the gouty or rheu- 
matic habit is present in these cases, there can be no question that 
the cure of the disease will be markedly facilitated by the adminis- 
tration of gouty and rheumatic remedies, and yet my own clinical 
experience does not justify the claim that a cure can be accom- 
plished by those measures alone. In this form of catarrhal disease, 
as in that involving the nasal passages proper, it scarcely need be 
stated, that general hygienic measures may be of the utmost im- 
portance, such as the regulation of the clothing, the habits of life, 
attention to the skin, bathing, and other general measures, such as 
have already been discussed in the chapter on taking cold. Rob- 
inson,3 in a number of communications on this subject, has advo- 
cated, with a considerable degree of enthusiasm, the internal ad- 
ministration of cubebs, as possessing specific properties in the 
treatment of this disease. As I understand it, he does not posi- 
tively state that it cures, but rather that it ameliorates the severity 
of the symptoms. Its action, I take it, is simply as a stimulant, by 
which a freer and, therefore, a more fluid secretion of mucus is ex- 
cited from the glandular structures in the pharyngeal vault, which 
flowing with greater readiness, is expelled more easily from the 
fauces, and thus becomes a much less annoying source of distress 
to the patient. The use. of alcohol undoubtedly aggravates an 
existing naso-pharyngeal catarrh, both by its directly irritating 
qualities on the pharynx, but more especially by its indirect action, 
in setting up a gastric disturbance which reacts somewhat unplea- 
santly upon the pharyngeal membrane. Hence, its use should be 
always interdicted. It has been the custom for many years, and 
largely as a matter of routine practice, I think, to forbid the use of 
tobacco in any form to patients suffering from catarrhal disease of 
the air-passages. I have always considered nicotine absorption to 
be the vicious factor in the use of tobacco, and that the nervous sys- 
tem mainly suffers from the use of the weed, in that the action of 
nicotine is probably altogether on this system alone. In addition 
to this, tobacco smoke contains a certain amount of ammoniacal 
vapor, and where there is wood-fibre present, as in poor grades 
of tobacco, and especially in cigarettes, a small quantity of pyro- 
ligneous acid. These substances are both, to an extent, irri- 
tating to mucous membranes. Hence, we frequently notice, that 
a patient suffering from naso-pharyngeal catarrh, is greatly in- 
convenienced, and his trouble even aggravated by smoking. In 
these cases, it is necessary that the habit should be abandoned. 
But the cases of catarrhal disease which are aggravated by smoking 
are the exception, rather than the rule, and I believe it is perfectly 
1 Op. cit., p. 139. 
2 Op. cit., p. 261. 
3 Op. cit.. p. 142. 532 
DISEASES OF THE NASO-PHARYNX. 
safe, when asked the question as to whether the use of tobacco is 
injurious, to say to those individuals, that their own experience 
must be the guide, and if they find that the use of tobacco is in- 
jurious, to stop it, otherwise, I even think that it is unwise to com- 
pel them to abandon a habit, which is a source of comfort and 
pleasure, and which, even in many cases, may be of decided benefit 
for its soothing influence upon the general system. The practice 
has come largely into vogue of late years, of treating catarrh at our 
prominent Spas, both in this country and abroad, by the internal 
administration of mineral waters, combined with their local appli- 
cation, by means of atomizers and douches. I have never seen any 
notable good results accomplished by these methods. Where a 
laxative is indicated, undoubtedly the use of a glass of mineral 
water is of advantage, taken internally, but I know of no particular 
waters which possess any special virtue in this direction. Robin- 
son 1 and Moure2 both claim, that those mineral waters which con- 
tain largely of sulphur, are of special advantage in the treatment of 
this disease. This idea is not a new one, as the practice has been 
in vogue for many years, apparently based on the idea that there 
is some analogy between the skin and mucous membranes, and that 
because sulphur waters are beneficial in cutaneous diseases, they 
should possess a certain virtue in catarrhal affections. I see no 
objection to their use, as most of our patients are benefited by the 
use of a mild alterative and laxative mineral water. Too great re- 
liance, however, should not be placed on this method of treatment. 
In this, as in all forms of catarrhal disease, climatic influences are 
very marked, in that the symptoms largely disappear by a change 
of residence to a warm and dry climate, and moreover, they are 
markedly aggravated by the damp weather of spring and fall. This 
change of residence, however, affords only temporary relief, in that 
the symptoms all return, as soon as the patient is subjected again 
to the influence of cold and damp atmospheric conditions. 
The radical cure of the disease depends, I think, altogether on 
certain local measures, applied directly to the seat of the disease. 
Astringent washes and douches, in this form of the disease, exert 
not only a palliative influence, but also exercise certain curative 
powers. The vault of the pharynx is coated, with a thick, tenacious 
blanket, as it were, of muco-pus, which is very largely the source 
of the unpleasant symptoms which characterize the disease. If 
this be thoroughly removed, twice each day, it not only mitigates 
the symptoms, but serves in a marked way to improve the charac- 
ter of the discharge, and to medicate, to a certain extent, its appar- 
ent causes, and furthermore, it removes a source of irritation, and 
1 Op. cit., p. 141. 
2 Op. cit., p. 262. NASO-PHARYNGEAL CATARRH 
533 
seems to encourage a healthier action in the gland tissues. For 
this purpose, there may be used any lotion which possesses the 
action of dissolving mucus, and at the same time of controlling cell 
proliferation. For this purpose we may use one of the following. 
$ Acidi carbolici, ...... grs. iij. 
Pot. chlorat., . . . „ . . „ § i, 
Glycerini, . . . . . . • f i. 
Aquae, . . . . . . . ad § vi. 
M. 
5 Acidi borici, 3 iss. 
Aquae, § vi. 
M. 
B Zinci sulpho-carb., ...... grs. iij. 
Acidi salicylici, . . . , , . 3 i. 
Aquae, § vi. 
M. 
B Potass, permanganat., 3 ss. 
Aquae, § vi. 
M. 
hi Aluminis aceto-tartar.,1 . . . . . § i. 
Aquae, ad § vi. 
M. 
The above drug may also be used pure in the form of a powder, 
and insufflated behind the palate. The pharyngeal vault is not 
sufficiently well reached through the nasal passages by means of 
atomizers, to thoroughly remove the mucus which lodges there. 
The ordinary nasal douche answers a fairly good purpose, although 
by far the best device for a thorough cleansing of the pharyngeal 
vault is the post-nasal syringe shown in Fig. 32. This, however, is 
not easily manipulated by the patient, and the formulae above 
given, are designed to be used night and morning, by the patients 
themselves. Hence, they should be instructed to use the little 
device, shown in Fig. 34, which, after a little practice, is easily 
manipulated. This may be used with the simple bulb attached as 
shown in the figure, or the post-nasal tip may be attached to an 
ordinary Davidson or fountain syringe, as shown in Fig. 33. As 
will be noticed, these devices direct the lotions in quite a free 
stream, directly against the diseased part, thus thoroughly washing 
1 This is I believe a German proprietary medicine and is put up in this form, and also 
as Aluminium Aceto-glycerinatum. It seems to have obtained considerable notice in the 
treatment of naso-pharyngeal catarrh, and although I'have used it in a number of cases 
with benefit, it is by no means a specific. 534 
DISEASES OF THE NASO-PHARYNX. 
away the accumulated mucus, not only from the gland surface, but 
also from the interstices or fissures which divide the ridges or emi- 
nences which make up the pharyngeal tonsil. 
In addition to the above plan of treatment, which adds greatly 
to the comfort of the patient, as before stated, still further and 
more radical measures are demanded at the hands of the surgeon, 
and these consist in the thorough destruction or eradication of the 
offending tissues. Many patients may object to radical measures 
by means of the cautery, or to surgical interference, and in these 
cases, a certain amount of reliance can be placed on the local ap- 
plication of strong drugs, stronger than those above enumerated. 
Hence, after thoroughly cleansing the part, in the manner before 
stated, there may be applied by means of a pledget of cotton at- 
tached to a bent probe, the officinal glycerole of tannin, or better 
still, the officinal or the compound tincture of iodine, the applica- 
tions being repeated at intervals of from three days to a week. Or 
we may use a solution of nitrate of silver, twenty to thirty grains 
to the ounce. The acetic acid preparations seem to possess a 
special action on this form of hypertrophy, hence their use is often 
specially indicated, preference being given to the monochlor-acetic 
acid, in its undiluted form. Lactic acid, also, is worthy of trial, and 
may be used in a solution of thirty to sixty grains to the ounce. 
In making these applications, it is necessary to avoid touching 
healthy parts, hence the palate should be controlled by means of 
the palate hook, or better still, it should be tied back, by means of 
a rubber cord, after the manner described on page 24. A very 
simple device by which this measure, which is often unpleasant to 
the patients, may be avoided, is to make use of a cotton pledget, 
twisted firmly on the end of a bent probe, the pledget being made 
sufficiently large to enable the operator to coat its posterior aspect 
only with the agent to be used. This can, by a quick manipula- 
tion, be carried to the pharyngeal vault and swept rapidly over the 
part, and then withdrawn, without the necessity of there being any 
injury done to the healthy tissues of the soft palate. A simple 
little instrument for making stronger applications still is shown in 
Fig. 124, which, as will be noticed, consists of a minute shallow 
cup, with its concave surface presenting posteriorly, mounted on a 
long steel wire, which plays in a curved tube, the distal end of 
which is enlarged sufficiently to enable the cup to be withdrawn 
entirely within its lumen. In this cup may be fused chromic acid 
preferably, or perhaps nitrate of silver, and this is carried to the 
vault of the pharynx, when the cup holding the caustic is protruded 
from the tube, by pressing upon a button at the proximal end of 
the tube, and after sweeping it over the part which it is desired to NASO-PHAR YNGEAL CA TARRH. 
535 
medicate, the cup is withdrawn into the enlarged distal end of the 
tube, when the instrument is easily removed without injuring 
healthy parts. 
The above simpler measures of local application involve a some- 
what prolonged course of treatment, and one in which the ultimate 
success is not of a most satisfactory character. As before stated, 
the radical cure of the disease consists'in the thorough destruction 
of the offending tissues. Where Tornwaldt’s bursa is shown by 
examination to exist, probably the best device for its destruction, 
is in the measure advocated by Tornwaldt himself, which consists 
in the use of the galvano-cautery electrode. For this purpose, he 
uses a pointed platinum tip, which is to be inserted directly into 
Fig. 124.—Author’s Porte-Caustique for Pharyngeal Vault. 
the opening of the bursa, the manipulation being accomplished 
with the aid of the rhinoscopic mirror in position. After the elec- 
trode is well inserted the current is closed, and the sinus is cut 
through and thus thoroughly opened, or else its cavity is destroyed 
by thorough cauterization. Tornwaldt claims, that if thoroughly 
done, one application is usually sufficient, although I think, in 
most cases, there will be required repeated applications, not only to 
destroy the sinus itself, but also to destroy the hypertrophied 
glandular structures, which go to make up the whole mass of its 
walls. I have always regarded the galvano cautery as an exceed- 
ingly awkward device for accomplishing a comparatively simple 
result, in that it is cumbersome, fickle, and always treacherous. 
There can be no question, however, that in the treatment of naso- 536 
DISEASES OF THE NASO-PHAR YNX. 
pharyngeal catarrh it possesses advantages over any other device 
that we possess. The object here is the destruction of tissue, and 
this destruction must be accomplished with a certain degree of 
nicety. The galvano-cautery enables us to carry a very harmless 
and unirritating instrument to the diseased part with ease and 
facility, which, after it has reached the part which it is desired to 
cauterize, is converted into a powerful destructive agent, by simply 
closing the electric current. After it has done its work, the circuit 
is opened, and the instrument, being allowed to cool off, is changed 
again to a state of harmlessness, and thus withdrawn without in- 
volving healthy parts. In the destruction of Tornwaldt’s bursa, as 
will be noticed, an exceedingly nice manipulation is necessary, ac- 
cording to Tornwaldt’s method. This, however, should ordinarily 
be accomplished with ease and certainty, provided the palate is 
held well under control by means of rubber cords, or Frankel’s de- 
vice of a combined tongue depressor and plate hook. 
In a certain number of cases, Tornwaldt1 injected the bursa 
with a ten-per-cent solution of nitrate of silver, making use of a 
small syringe with a long curved platinum tube, the end of which 
was inserted directly into the bursal orifice. In other cases, pure 
nitrate of silver was fused upon the end of a probe, and passed into 
the bursa, although his results were not as good as with the galvano- 
cautery electrode. Broich,2 on the other hand, depended almost 
exclusively on the injection of nitrate of silver, abandoning the use 
of the galvano-cautery on account of the intense reaction which 
seemed to follow its use, in producing violent occipital and cervical 
pains. Where the orifice of the bursa cannot be seen, the elec- 
trode is simply to be forced directly through the wall, without 
reference to a normal opening, and the cavity opened up in its long 
diameter. This closed condition may be the result of morbid action, 
or there may be a congenital cyst, as in the case reported by 
Lehmann,3 in which the cyst was extirpated by means of a pair of 
curved scissors. In those cases, in which the catarrh is dependent 
upon a broad, flat, diffuse thickening of the glandular structures in 
the pharyngeal vault, the indications for treatment are the destruc- 
tion of the glandular tissue, and for this purpose, we resort to one 
of the measures already noticed, giving preference to the chromic 
acid, by means of the little instrument shown in Fig. 124. If these 
measures fail, however, we resort to the more powerful action of 
the galvano-cautery. In this, as in all measures, the part should 
be thoroughly cleansed first, by the use of the syringe, in order to 
remove all the adherent muco-pus, after which, the palate being 
1 Op. cit., p. 8o et seq. 
3 Langenbeck’s Arch., Bd. xxxvi., Heft I. 
2 Loc. cit. NASO-PHARYNGEAL CATARRH. 
537 
held well under control by means of the retractors or cords, the 
electrode is passed well up to the upper border of the gland struc- 
tures, somewhat to one side of the median line, when the circuit 
being closed, it is drawn down in a vertical line, to a point perhaps 
a quarter of an inch above the promontory of the atlas, after which, 
if the patient tolerates the manipulation, a second and parallel 
furrow may be made on the other side. The electrode to be used 
in this manipulation may be the ordinary knife-shaped electrode 
bent to the proper angle, or as better protecting the soft parts, 
there may be used the instrument shown in Fig. 128, in which, as 
will be seen, the tip is formed by a spiral wire, covered with a hood. 
Where the manipulation behind the palate is not feasible, the 
pharynx may be reached directly through the nose by the instru- 
ment shown in Fig. 125, in which the transverse wire across the 
end of the electrode constitutes the cauterizing part. This is easily 
tolerated, and serves an excellent purpose. It can be used on both 
sides at the same sitting, the cauterization being repeated at the 
end of a week. After the use of the galvano-cautery, the douche 
or spray should be again used, in order to cool the part, and con- 
trol any tendency to inflammatory reaction. In addition to this, 
the patient himself should be directed to use the douche twice 
daily, after the manner already indicated, and report for treatment 
at the end of a week, when the same procedure may be repeated. 
As Broich discovered, the galvano-cautery, even in the pharyngeal 
vault, is not unattended with a deleterious effect, in the form of an in- 
tense inflammatory reaction with neuralgia, etc., hence its use must 
be resorted to with the greatest possible care. Furthermore, it is 
not easy to absolutely destroy living tissue rapidly by means of the 
electro-cautery, the treatment of these cases of broadly diffused 
thickening, therefore, is oftentimes obstinate. If this be the case, 
I think resort should immediately be had to the use of the curette, 
shown in Fig. 134. The palate being well retracted, the whole 
area of the pharyngeal vault may be thoroughly scraped, and the 
offending tissue removed at one sitting, although, as a rule, more 
than one will be required. The manipulation must be accomplished 
with a certain amount of rapidity, in that hemorrhage at the outset 
is rather profuse, although never persisting to the extent of being 
troublesome. The pharyngeal vault is not as easily anaesthetized 
by the use of cocaine as the membrane lining the nasal cavity, and 
yet no operation should be attempted in this region, without first 
Fig. 125.—Electrode for the Naso-pharynx, to be manipulated through the Nasal Passages. 538 
DISEASES OF THE NASO-PHARYNX. 
making a thorough application of a twenty-per-cent solution of 
this drug, allowing from five to eight minutes to elapse before 
operative procedure. This region is not particularly sensitive, 
and yet an operation here is attended with more or less pain. This 
however, is largely mitigated, although as before stated, not en- 
tirely controlled by the use of cocaine. CHAPTER XLII. 
HYPERTROPHY OF THE PHARYNGEAL TONSIL, OR 
ADENOID GROWTHS IN THE VAULT OF THE 
PHARYNX. 
This term is used as more accurately describing that condition 
of glandular hypertrophy in the upper pharynx, which has usually 
been described under the term adenoid vegetations. It may be 
defined as a true hypertrophy of the normal lymphoid structures 
found in the pharyngeal vault, and whose existence has been recog- 
nized since the days of William Hunter. The diseased condition 
in this region was first described by Wilhelm Meyer,1 of Copen- 
hagen, whose classical paper on the subject was based on the 
study of one hundred and two cases which had been under his 
personal care, and which was so thoroughly exhaustive in all its 
features, clinical and other, that it leaves little to be said on the 
subject that has not already been well considered by Meyer. It 
should be stated, however, that Czermak2 had recognized and de- 
scribed, with a considerable degree of accuracy, the same condition 
as early as i860, although he failed to recognize its clinical impor- 
tance. Following Meyer, there appeared important contributions 
on the same subject by Loewenberg,3 J. O. Roe,4 Bosworth,5 B. 
Frankel,6 Chatellier,7 Hooper,8 and others, by which, while our clini- 
cal knowledge of the disease increased, the correctness of Meyer’s 
original deductions were fully confirmed. 
ETIOLOGY. —The disease is essentially one of child-life, devel- 
oping in infancy, and probably not infrequently being congenital. 
1 “ Adenoid Vegetations in the Naso-pharyngeal Cavity,*’ Med. Chirurgical Trans., 
vol. liii., p. 191. 
2 “ Du Laryngoscope,” etc., French ed., i860. 
3 “Tumeurs Adenoides du Pharynx Nasal,” Paris, 1879. 
4 “Adenoid Growths in the Vault of the Pharynx,” Med. Record, September 13th, 
1879. 
s “ Adenomaof theNaso-pharnyx,” Journal of Otology, Jan., 1882; and, “ Growths in 
the Nasal Passages,” Med. Record, Jan. 13th, 1883. 
6 “ Ueber adenoide Vegetationen,” Deutsche Med. Wochenschrift, No. 41, 1884. 
(Pages in references refer to Separat-Abdruck.) 
7 “ Des Tumeurs Adenoides du Pharynx Nasal,” Paris, 1886. 
8 Boston Med. and Surg. Journal, March 15th, 1888. 540 
DISEASES OF THE NASO-PHARYNX. 
Like other glandular hypertrophies, these growths show a tendency 
to apparently disappear at puberty. This may be'explained by a 
diminution in the morbid activity of the tissues and a certain 
amount of shrinking which occurs in this peculiar form of growth 
at this age, and also by the fact that they occupy a relatively 
smaller space in the now more widely-developed pharyngeal vault. 
Meyer,1 in an analysis of his cases, showed that they occurred at 
the following ages: 
Under 5 years, ...... 3 cases. 
Between 5 and 10, . . . . 34 “ 
“ 10 “ 15, 25 “ 
“ 15 “ 20, 21 “ 
“ 20 “ 25, 11 “ 
“ 25 “ 30, 1 “ 
“ 30 “ 35, 4 “ 
“ 35 “ 40, 1 “ 
“ 40 “ 45, 2 “ 
Total, 102 “ 
An analysis of my own cases shows a somewhat different result 
as follows: Of 75 cases there were, 
Under the age of 10 years, ... 5 cases. 
Between 10 and 15, . . . 16 “ 
“ 15 “ 20, 27 “ 
“ 20 “ 30, 23 ” 
“ 30 “ 40, 2 “ 
“ 40 “ 50, 1 “ 
Above the age of 50, . . . . . 1 “ 
Total, 75 
It will be noticed, that the average age of Meyer’s cases is much 
less than my own. This difference is to be explained, in that I be- 
lieve that in many instances the small glandular hypertrophies 
found in adult life, are identical with those of child-life, and are to 
be treated on the same principles. I have, therefore, included in 
my tables a larger number of those broad flat growths, which con- 
stitute the essential morbid condition of many cases of so-called 
naso-pharyngeal catarrh. The predisposing cause of the disease 
lies in that general predisposition, by which in young children a 
morbid process develops and has its highest activity in the epithe- 
lial and lymphatic structures, which disappears at puberty, and 
changes to a tendency to activity in connective-tissue structures, 
1 Loc. cit. HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
541 
as is more fully des'eribed in the chapter on purulent rhinitis. The 
question arises here, how far any general dyscrasia, such as scrofula, 
syphilis, or tuberculosis may predispose to this disease. 
Lowenberg1 states that the lymphatic temperament is the 
“cause of the disease in the very large majority of the cases which 
he has seen; ” while Potain 2 states that this tendency to the in- 
volvement of the lymphatics in morbid processes, characteristic of 
child-life, or lymphatisme as he calls it, is but a normal condition, 
which, carried one step further, gives us the true pathological con- 
dition of scrofula. Lowenberg, therefore, apparently leans to the 
view of a scrofulous taint in these cases, while Meyer and all subse- 
quent writers reject this theory. The cause of these growths, then, 
is simply a tendency to hypertrophy, as the result of inflammatory 
changes, which characterize the lining membrane of the upper air- 
passages and their appendages under the stimulus of repeated 
colds, as formerly stated by myself.3 It occurs in children more 
frequently than in adults, for the same reason that all glandular 
structures in children are more prone to take on morbid changes. 
The local inflammatory changes in the region of the fauces which 
accompany eruptive fevers in children, not infrequently prove a 
starting point of changes which result in hypertrophy of the phar- 
yngeal tonsil, or stimulate into a renewed activity an already ex- 
isting growth in this region. 
Heredity has an undoubted influence, as we not infrequently 
see a number of children in the same family affected similarly, as 
noted by most observers. The publication of Meyer's paper gave 
rise to the suggestion, that the disease was peculiar to northern 
climates. Further study, however, shows us that it prevails to 
quite as great an extent in temperate regions. 
Meyer4 reported, that out of his 102 cases, 52 were males and 
50 females, but further observed, that after 15, the larger propor- 
tion were females. Of my own cases, 49 were females, and 26 
males, but my tables show the average age of my cases much older 
than those of Meyer, 21 being under 15, and 54 above that age. 
Of the large proportion of cases in which I have seen it occur, 
less than half showed any morbid condition in any portion of 
the nasal passages. A frequent condition with which it is asso- 
ciated, is hypertrophic rhinitis. In ten of my seventy-five cases, it 
was associated with marked enlargement of the faucial tonsils, 
while in a much larger proportion, there was moderate enlargement 
of these glands. In four cases, it was met with in connection with 
atrophic rhinitis, three of these having reached the stage of ozaena. 
1 Op. cit., p. 12. 2 “ Diet. Encyclop.Art. Lymphatique. 
3 “Growths in the Nasal Passages,” Med. Record, Jan. 13th, 1883. 4 Loc. cit. 542 
DISEASES OE TEE NASO-PHARYNX. 
Pathology.—A microscopical examination of the pharyngeal 
tonsil shows its construction to be as follows (see Fig. 126): 
First, it is covered by a layer of columnar ciliated epithelium 
which exhibits the features of stratified columnar epithelium. The 
single columnar cells greatly vary in height, and exhibit sometimes 
long, sometimes short, bent ciliae. Between the elongated feet of 
the epithelial cells irregular corpuscles of varying shape are visible, 
such as occur throughout the mucous layer of the aerial passages, 
the larynx, the trachea, artd the bronchi. Only in one specimen 
was one side of the tumor covered by a narrow layer of stratified 
epithelium, probably corresponding to the medial aspect of the 
Fig. 126.—Hyperplasia of Pharyngeal Tonsil or Adenoid Disease of the Vault of the Pharynx. E, 
Columnar ciliated epithelium; M, myxomatous mucosa crowded with lymph corpuscles; F, lymph follicle; 
Z, lymph vessel; Z, inter-follicular tracts. 
tumor, without cilia, with a gradual transition into columnar epi- 
thelium. 
Second, all the tumors exhibit a lobate appearance, the fissure 
between the lobes being sometimes shallow and at other times very 
deep, dividing the whole mass into a number of longitudinal ridges. 
Each ridge may again exhibit a varying number of shallow papillary 
protrusions. Under the microscope correspondingly we observe 
large protrusions, which are caused by the follicular formation of 
the tissue, and small ridges of a papillary aspect caused by narrow 
protrusions of the subjacent tissue. 
Third, the main mass of the tumors is composed of lymph tissue, 
formerly termed adenoid tissue, from the mistaken idea than this HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
543 
tissue is glandular in nature. No epithelial formations enter, how- 
ever, the structure of the tumor, save the depressions and furrows 
between the lobes, sometimes penetrating very deeply into the 
mass of the tissue, and there producing manifold secondary con- 
volutions. Beneath the epithelial cover there is no fibrous connec- 
tive tissue around the lobes, while the papillary elevations are pro- 
duced by a delicate fibrous connective tissue freely supplied with 
lymph corpuscles. 
According to the general structure of lymph follicles and lymph 
ganglia, we find in the tumors under consideration a varying num- 
ber of lymph follicles, consisting of an accumulation of lymph cor- 
puscles, and supplied with a comparatively small number of blood- 
vessels. The follicles are separated from each other and inclosed 
by what is known as inter-follicular strings. In these both a myxo- 
matous reticulum and the fibrous variety of the connective tissue 
is more developed than in the follicles, and the blood-vessels are 
somewhat more numerous. Only in one of the specimens was 
there a marked fibrous inter-follicular tissue with comparatively 
few lymph corpuscles. In all others the fibrous connective tissue 
was but little developed, which feature would account for the com- 
parative softness of these new formations. 
With high power of the microscope in all specimens, the features 
common to lymph tissue are discernible. There is a myxomatous 
reticulum ill-defined and crowded with lymph corpuscles, in the 
meshes within the follicles. There is a more developed myxoma- 
tous or fibrous reticulum, with comparatively less lymph corpuscles 
in its meshes, within the inter-follicular strings. 
In one case, a cyst was observed in the tissue near the surface, 
just perceptible to the naked eye, the size of a small pin’s head. 
This cyst was lined on one side by flattened epithelium, on which even 
ciliae were still recognizable, while the opposite side lacked an epithe- 
lial cover, but was composed of lymph corpuscles, in connection with 
a delicate myxomatous tissue, filling in part the cyst. This latter 
feature indicated that the cyst had not arisen simply from an ob- 
struction of an interlobular fissure, but was due to a transformation 
of the epithelial cover, at least on one side, into a medullary, and 
from this into a myxomatous tissue. 
The examination proves the formations under consideration are 
no tumors, in the proper sense of the word, but a hyperplasia of 
the lymph tissue, which constitutes the so-called pharyngeal tonsil. 
A difference between hyperplastic faucial tonsils and pharyngeal 
tonsils, is that, in the former, the fibrous connective tissue is, as a 
rule, far more developed than in the latter, which is usually ac- 
counted for by the fact, that while the latter lies in a region entirely 544 
DISEASES OF THE NASO-PHARYNX. 
protected from the impact of food, or other matters, the former is 
constantly subjected to pressure and irritation from this cause, a 
process which necessarily gives a density and firmness to the faucial 
growth. In the main, however, the pathological lesion is identical 
in the two, being a true hypertrophy, and so warrants the use of 
the name tonsil, as applied to both. Now all writers regard the 
morbid process which results in this form of growth, as one of true 
hypertrophy, except Woakes. The mammillated appearance which 
the surface of these tumors often presents, however, has given rise 
to the statement on the part of Woakes1 that the tissue may be of 
a papillomatous character. He divides these growths into two 
varieties, one being simply hypertrophy of the normal tissue found 
in this region, and the other he calls lymphoid papilloma. This 
view is further supported by the peculiar course which the blood- 
vessels take in their distribution through the growth, which Frankel 
describes as fan-shaped. Frankel further states, however, that the 
adenoid tissues preponderate to such an extent, that they should 
never be mistaken for papillomatous growths. Woakes, therefore, 
is quite alone in his view, all other observers regarding the growth 
as simple hypertrophy of the normal glandular structure. 
In connection with the disease in the pharyngeal vault, we often 
find a chain of enlarged follicles, extending down on either side of 
the lower pharynx, immediately below the posterior pillars of the 
fauces, and also a large number of scattered follicles over the phar- 
yngeal surface, in a state of enlargement, constituting a chronic 
follicular pharyngitis, or what is often called pharyngitis granulosa. 
Lowenberg 2 regards this as a primary stage of glandular enlarge- 
ment in the pharynx, which extends to the tissues above, while 
Roe3 makes the point, that while the disease of the lower pharynx 
is an hypertrophy of the normal glands, that in the pharyngeal 
vault is characterized by an involvement of all the normal elements 
of the mucous membrane, claiming a difference in the pathological 
processes of the two regions. We have already shown, that the 
diseased process in the upper pharynx involves mainly the lym- 
phatic structures, while the connective-tissue element plays but a 
very small part in the process. Hence, I think, we may safely say, 
that the disease of the two regions is identical. Furthermore, my 
own observation goes to show that they develop together. Follic- 
ular pharyngitis is an exceedingly common affection in childhood, 
and I think we rarely meet with a case in which the glands of the 
vault of the pharynx are not notably involved. 
Symptomatology.—The prominent and most troublesome 
symptom to which the presence of these growths gives rise, is an 
1 Post-Nasal Catarrh,” Phila., 1884, p 163. 
2 Op. cit., p. 18 
3 Loc. cit. HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
545 
excessive discharge of mucus or muco-pus. The source of the dis- 
charge is, undoubtedly, in the diseased glands themselves, their 
normal secretory function not being destroyed by the morbid 
process, which has given rise to the hypertrophy, but is, on the 
contrary, greatly increased, in the manner already discussed in 
connection with the pathology of naso-pharyngeal catarrh, the view 
being taken there that the crypts and fissures in the Surface of the 
tissues constituted a secreting membrane closely resembling muci- 
parous glands, and that the secretion was still further augmented 
and stimulated by the pressure, the hypertrophied lymphatic tissue 
acting somewhat in the manner of a foreign body. We find them, 
therefore, pouring out large quantities of mucus or muco-pus, which 
in the greater proportion of cases makes its way into the lower 
pharynx. In those cases in which the growth has attained a large 
size, the discharge makes its way through the nasal cavities proper, 
and is voided through the nostrils. It possesses the character of a 
thick, ropy, and tenacious mucus, which tends to accumulate in the 
nares, especially in young children, who find difficulty in expelling 
it, both from inexperience, and from the occlusion of the posterior 
nares by the overhanging pendulous growths. 
Another symptom which may be traced directly to the existence 
of these growths, and perhaps the first to be noticed will be the 
altered character of the voice. This is changed into what Meyer 
calls the dead voice. It is the voice of one with a cold in the head, 
that is, the nasal twang is more or less completely abolished. In 
this way “ m ” and “ n ” become “ eb ” and “ ed.” In order to give 
rise to this, the growth need not be large. It may occlude but a 
small portion of the posterior nares. In order that the voice shall 
have its full nasal resonance, the vault of the pharynx should be 
quite clear. If but a small growth projects from its wall, it seriously 
interferes with the sound-waves, which in nasal sounds, should have 
a clear field from the vocal cords to the roof of the nares. If they 
impinge upon the slight projecting shoulder of a growth, located 
in the pharyngeal vault, they are to an extent smothered, and the 
whole tone of the voice deadened. 
The manner in which the singing voice is affected by these 
growths in the pharyngeal vault, offers many points of great inter- 
est. Nature is very lavish in her endowment of the various organs 
of the body, by which their different functions are performed, and 
so supplies an organ capable of doing vastly more work than it is 
usually called upon to perform. The larynx when called upon for 
an ordinary voice, responds readily, and will supply apparently a 
clear, healthy, conversational voice for years, even when there may 
exist very marked morbid changes. Let the voice be taxed by a 546 
DISEASES OF THE NASO-PHAR YNX. 
prolonged and labored effort, as in a sermon or address, and the 
weakness soon makes itself felt. The singing voice taxes the very 
highest powers and capabilities of the larynx, and demands not 
only a healthy larynx, but a healthy condition of the whole upper 
air-tract. The recognition of this latter truth I believe to be of 
the utmost importance. The vocal waves are set in motion by the 
vibration of the vocal cords, the pitch of the tone is regulated by 
the tension of the cords, and here in the main, the function of the 
larynx ceases, unless we add, perhaps, quantity or loudness of voice. 
Those qualities of the voice which we call timbre, its character and 
resonance, are given it by the pharyngeal and nasal cavities. These 
should be entirely clear of any obstructing morbid condition, or 
changes in their lining. 
In the lower or chest register, so-called, the nasal and pharyn- 
geal cavities are of comparatively little importance. The voice 
depends largely on the larynx. In the middle register, a healthy 
pharynx is of importance, but in the head register, a healthy nasal 
and pharyngeal cavity are absolutely essential. The manner in 
which the singing voice soon breaks down under the action of a 
pharyngeal growth, is quite simple. As soon as a note in the upper 
register is attempted, the singer is conscious of something wanting, 
the tone is muffled, from the fact that the vocal waves striking 
upon the mass are suppressed, as it were, the sounding-board func- 
tion of the pharynx being destroyed. The singer, therefore, in order 
to overcome this obstacle, attempts, though generally without suc- 
cess, to increase the power or volume of the voice. The larynx is 
taxed beyond its strength, and ruptured capillaries or ruptured 
muscular fibres result, and a chronic laryngitis is the consequence. 
It is a very noticeable fact with singers, that it is the head regis- 
ter which becomes first impaired in a failing voice, and in many 
cases it is the head register alone which is weak, the middle and 
chest notes being taken with ease and in clear voice. This illus- 
trates the truth of what I have for a long time urged in my teach- 
ing. The nasal passages are the first to become the seat of catar- 
rhal disease, and the tendency is very marked for this to extend 
downward, and furthermore, that in the very large majority of in- 
stances, so-called chronic laryngitis is but a secondary condition, 
resulting from disease in the nasal cavities, the laryngitis being a 
symptom, as it were, of the disease in the parts above. 
In Meyer’s original paper, prominence was given to the occur- 
rence of ear-symptoms in connection with adenoid disease. Proba- 
bly no symptom of the disease possesses greater importance, or 
requires more thorough appreciation and study, than that of ear- 
complications, occurring, as they do, early in life, and at a time HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
547 
when their prompt recognition only, may save the patient from 
permanent loss of this important faculty. The proportion of 
cases which escape ear-trouble is probably small. Woakes1 goes 
so far as to state, that not more than five per cent of his cases es- 
caped ear-complications, while Urbantschitsch,2 out of one hundred 
and seventy-five cases of adenoid vegetations, found the hearing 
affected in one hundred and thirty. In Meyer’s one hundred and 
two cases of glandular hypertrophy, seventy-two suffered from 
aural disease, while Swinburne3 found ear-complications in twenty- 
seven cases out of forty-two cases observed of adenoid disease. In 
my own seventy-five cases, eight cases showed extreme deafness, 
and twenty moderately impaired hearing. Looking at the question 
from the reverse point of view, we find Swinburne4 making the 
statement, that out of one hundred and seventy-nine cases of 
middle-ear disease, he found that twenty-seven had adenoid vegeta- 
tions. These statistics embrace cases of all ages, and although I 
have no data to go on, other than the general result of observation, 
I think it safe to say, that if the adults were eliminated, we would 
find a still more striking connection between adenoid growths and 
aural disease. Looking at the question from both points of view, 
probably a very large majority of cases of ear-troubles in children 
under the age of twelve, are dependent upon vegetations in the 
pharyngeal vault, and furthermore, that while not adopting the 
rather startling statistics of Woakes, I think it safe to say, that a 
careful examination in children would reveal an even larger pro- 
portion of ear-complications than those already cited. The two 
aural conditions met with in adenoid disease are chronic catarrhal 
otitis, and chronic purulent otitis. The method of development of 
these two diseases I believe to be essentially the same. It is usu- 
ally stated that ear-disease from the presence of adenoid growths 
in the pharyngeal vault is due to pressure on the Eustachian ori- 
fice. These growths are of a soft, pulpy consistency, while the 
eminences which surround the Eustachian orifice are hard and 
dense; hence, any pressure exerted upon them by an adenoid 
growth, would have but slight, if any effect. I think a far more 
plausible explanation of the symptoms, is in the interference with 
the renewal of air in the middle chamber, caused by their pres- 
ence in the pharynx. Any cause which interferes with free nasal 
respiration, if continued sufficiently long, is liable to cause impaired 
hearing, by its interference with this function. The method in 
which this occurs, I take it, is that nasal stenosis, arresting the to- 
1 “ Post-nasal Catarrh,” Phila., 1884, p. 168. 
2 Cited by Chatellier, op. cit., p. 51. 
3 New York Med. Record, Oct. 6th, 1883, p. 373. 
4 Loc. cit. 548 
DISEASES OF THE NASO-PHARYNX. 
and-fro current of air though the nasal passages, causes a stagna- 
tion in the pharyngeal vault, and necessarily a certain amount of 
rarefaction of air in that region. Moreover, the free action of the 
levator palati muscles is interfered with by the presence of these 
growths, and this movement is of the utmost importance in ac- 
complishing this mechanism of air renewal. In studying these 
parts by the rhinoscope, the impression is gained that the tendency 
of muscular movement here is to force air into the middle ear. 
The constant and almost ceaseless impulse of sound-waves upon 
the tympanum, must necessarily cause a rarefaction of air in the 
middle ear, and this loss is compensated for by the mechanism 
above alluded to. 
As a result, then, of this interference with the normal respira- 
tion, rarefaction of air gives rise to a condition of hyperaemia of 
the mucous membrane extending through the Eustachian tube and 
middle ear. Now, this hyperaemia does not constitute inflamma- 
tion. Inflammation, as I take it, is attended with hypersecretion. 
Hypersecretion is not always a feature of chronic catarrhal otitis 
media, so-called. The Eustachian orifice is closed, the air in the 
middle chamber rarefied, the drum-head retracted, and further 
changes in connection with the more intricate apparatus of the ear 
results in impairment of function. In a very large number of cases 
this process continues, leading to ankylosis of the ossicles, and 
atrophy of the tympanic membrane. In the smaller proportion of 
cases, arising in the same manner from nasal stenosis and rarefac- 
tion of air in the middle chamber, we have set up a true catarrhal 
inflammation with hypersecretion. Now, as an invariable law, 
where we have catarrhal inflammation setting up in a closed cavity, 
this process is converted into one of suppuration. This is true in 
the vagina, in the urethra, in the accessory sinuses of the nose, and 
in fact in all the mucous-lined cavities of the body. As the result 
we have a chronic suppurative otitis media. Why this occurs in 
one case and not in the other I have no suggestion to make. 
Woakes1 suggests that the suppurative form is more frequently 
met with when the adenoid vegetations affect mainly the vault; on 
the other hand where the growths are fewer in number, and are 
situated on the posterior wall, the disease is more apt to assume 
the non-suppurative form. It should be stated, however, that the 
suppurative form of the disease may be developed from the non- 
suppurative in the following manner. After the chronic catarrhal 
inflammation has existed for a long time, the drum-membrane be- 
comes excessively thin and atrophic. By some unknown cause, 
frequently without doubt mechanical, this membrane is perforated, 
1 Op. cit., p. 169. HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
549 
and air admitted to the middle ear through the external canal, thus 
giving rise to a suppuration. 
That the ear-symptoms are due to an extension of catarrhal 
inflammation to the Eustachian tube, as advocated by Frankel, 
Woakes, Lowenberg, Beverley Robinson and others, I think is very 
questionable. Certainly it is very rare to find the lining membrane 
of the Eustachian orifice in a condition showing any evidence of 
catarrhal inflammation by rhinoscopic examination. Lowenberg1 
directly asserts, that the presence in the pharynx of an inflamma- 
tion, which easily spreads to the middle ear, is the cause of the ear- 
symptoms, but inflammation is not necessarily an accompaniment 
of adenoid disease in the vault of the pharynx. Most writers at- 
tribute the ear-symptoms to mechanical obstruction, which is un- 
doubtedly a very active contributing agent in their development, 
but not, I think, the most prominent one. Blake,2 of Boston, ad- 
vocates a very ingenious theory, that hyperaemia is set up in the 
middle ear, by interference with the return circulation, on account 
of the superficial pressure exercised on the pharyngeal veins by 
the morbid growth, and also on the veins coursing through the 
deep-seated tissues. 
Nasal stenosis is quitfe a prominent symptom of the affection, and 
is present even in cases where the growth has not attained an unusual 
size. This may not be so noticeable during waking hours, but during 
sleep, when the voluntary muscles of respiration are not brought into 
play, it is more prominent, and the patient sleeps with the mouth 
open. 
It is a very noticeable fact, that these growths show a marked 
change in size when examined at different periods, which would 
indicate simply, that under the influence of damp weather, or other 
causes, they are liable to become the seat of an active turgescence 
or distention of their blood-vessels, by which their size is temporarily 
increased. This occurrence, especially in children, is attended with 
an increase of secretion, with obstruction to nasal breathing; in fact, 
the child has apparently an ordinary cold in the head, attended with 
its usual symptoms. As already noted, we must bear in mind that 
an acute rhinitis is comparatively rarely met with in a child, and 
that in most instances, when a child has an apparent cold in the 
head, it is really suffering from a subacute inflammation of the 
pharyngeal tonsil. In other words, the clinical history of chronic 
inflammation or hypertrophy of the pharyngeal tonsil is marked, 
like inflammatory processes in other portions of the upper air-tract, 
by a liability to repeated attacks of acute inflammation. 
1 Op. cit., p. 35- 
2 “ Relation of Adenoid Growths in the Naso-Pharynx, to the Production of Middle- 
ear Disease in Children,” Boston Med. and Surg. Journal, March 15th, 1888. 550 
DISEASES OF THE NASO-PHAR YNX. 
Cough is present in certain cases, especially if there is much 
secretion, which has made its way down the pharynx into the 
larynx, exciting a laryngitis. The cough, again, may be the result 
of the habitual mouth-breathing. 
Headache is an occasional symptom, not perhaps occurring 
with the same frequency as it is met with in hypertrophic rhinitis. 
Frankel1 discusses this symptom somewhat at length, without, 
however, suggesting an explanation of it. It probably arises in 
much the same manner as do those cases which depend on disease 
of the nasal chambers. 
Asthma, also, may be dependent on the existence of adenoid 
growths, as noted by Frankel and Chatellier. One such case has 
come under my own observation, in which complete cure was ob- 
tained by the removal of the growth. 
Epistaxis, of somewhat trivial character, occasionally occurs, or 
the child may on awakening in the morning, discover blood clots 
in the mouth, which have resulted from a slight hemorrhage during 
sleep. 
Chatellier2 mentions nightmare, as a symptom of the disease. 
This symptom is rather an accompaniment of enlarged tonsils, a 
disease in which it occurs quite frequently. I should be disposed 
to attribute it to the enlargement of the faucial tonsils, which so 
frequently accompanies the affection under discussion. Snoring, 
on the other hand, is almost always present in disease of the 
pharyngeal vault, due probably to a certain amount of relaxation 
or weakness of the palatal supports, which accompanies the dis- 
ease. Frankel3 states that this symptom is not due to a vibra- 
tion of the palate, but is produced by laryngeal obstruction, and 
gives an exceedingly curious explanation. He says, that during 
normal respiration, the lower jaw is held in position by atmospheric 
pressure; that the nasal passages being obstructed in these patients, 
the mouth falls open, and as a result of this, the base of the tongue 
falls backward upon the epiglottis, thereby obstructing the larynx, 
and giving rise to the symptom. This is ingenious, but affords a 
better explanation of the occurrence of nightmare, than of snoring. 
In very young children, the inability to nurse, as the result of nasal 
stenosis from this or any other cause, is well known. Spasm of the 
glottis, also, from nasal stenosis, in children of neurotic habit, may 
be a very troublesome symptom of the disease. 
Both Hooper4 and Chatellier5 mention night-sweats as one of 
the symptoms of the disease. This symptom is present in a certain 
proportion of cases, but probably only in those in whom the health 
1 Loc. cit., p. 18. 
4 Loc. cit. 
2 Op. cit., p. 28. 
5 Op. cit., p. 28. 
3 Loc. cit., pp. 10, 11. HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
551 
has become deteriorated, as the result of disturbed sleep and im- 
paired nutrition. 
Most writers allude to the chest deformity, which is said to ac- 
company adenoid disease, and quote the very distressing case de- 
picted by Dupuytren in his “ Memoire sur la depression laterale des 
parois de la poitrine,” 1 of a child with enlarged tonsils, and that 
deformity of the chest which we call pigeon-breast, who fell, after 
violent and useless efforts to breathe, into a most alarming state of 
convulsions, etc. It is customary to quote the case with the com- 
ment that Dupuytren had here to deal with a case of adenoid dis- 
ease. As already stated, children with adenoid disease enjoy fairly 
good general health. Certainly no such deformity as that described 
by Dupuytren could well be pro- 
duced by enlarged faucial or phar- 
yngeal tonsils, unless there already 
existed some previous systemic con- 
dition, such as rachitis or any general 
condition which might lead to that 
curious disease of the bones which 
we call mollities ossium. 
Probably no symptom of ade- 
noid disease is more striking or char- 
acteristic, than the peculiar facial 
appearance which these patients 
present. This symptom, however, 
as a rule, is most noticeable in chil- 
dren under the age of fifteen or 
sixteen years, but so notable is it 
in these young people, that prob- 
ably in the majority of cases, a sin- 
gle glance at the patient will be sufficient for a correct diagnosis. 
This peculiar facial expression consists essentially in a broadening 
and flattening of the bridge and root of the nose. Now, add to 
this the open mouth, usually rendered necessary by the nasal 
stenosis, and- you will give to the child a curiously vacant, semi- 
idiotic look, which is very striking (see Fig. 127). Now, Meyer 
attributes this to a sinking in of the nasal bridge, owing to disuse 
of the nasal passages. David 2 enters into a full discussion of this 
question, and states that, as a result of the disuse of the nose, the 
accessory sinuses, which in health perform certain functions, fall 
also into disuse, and therefore the bones of the face fail of full 
development. In this manner, the cheeks assume a flattened ap- 
Fig. 127.—The Face of a Girl illustrating the 
Peculiar Facial Expression which is Character- 
istic of the Existence of an Hypertrophied 
Pharyngeal Tonsil. (Hooper.) 
1 Repertoire Generate d’Anatomie et de Physiologie, 1828, p. no. 
2 Cited by Chatellier, op. cit., p. 48. 552 
DISEASES OF THE NASO-PHARYNX. 
pearance, the eyebrows are depressed, and indeed the whole facial 
contour is to an extent flattened, as it were, and presents a vapid 
and featureless expression. Frankel1 suggests an additional ele- 
ment of facial distortion, in that, as a result of the habitual mouth- 
breathing, the naso-labial fold is drawn downward and backward, 
and in extreme cases, the external angles of the eyes also sink 
downward. These conditions may possibly be present in cases of 
long standing, but I think, ordinarily, the essential feature of the 
facial expression lies at the root of the nose, in its broadened and 
flattened contour, by which there is apparently a widening of the 
distance between the two eyes. The idiotic expression is perhaps 
fanciful, for the mere opening of the mouth and depression of the 
jaw gives that, although the dull expression is undoubtedly en- 
hanced by the impairment of hearing, which so frequently exists 
in these cases, for although writers allude to a certain dulness of 
intellect, which occurs in these patients, I do not think the observa- 
tion is a correct one, this dulness being due to an apparent lack of 
attention, which partially deaf children show. Frankel2 discusses 
this question quite fully, and while denying that these patients are 
naturally dull of intellect, suggests that the habitual mouth-breath- 
ing, disturbed sleep, headaches, and impaired hearing, from which 
they suffer, produce a condition of apathy, which might be called 
dulness. Certainly, in my own experience, I have never been able 
to discover that these patients were not the possessors of the ordi- 
nary brightness and alertness of intellect, of children in ordinary 
health. That there is any morbid development of the facial bones, 
as suggested by David, becomes questionable, when we remember 
how rapidly all these conditions disappear, after the removal of the 
growths, as do also the other symptoms alluded to, such as mental 
apathy, inattention, etc. Where the growths are large, and nasal 
stenosis marked, the sense of smell is necessarily impaired, from 
the imperfect manner in which odorous particles reach the terminal 
filaments of the olfactory nerve. The sense of taste also is im- 
paired, as is usually the case where the sense of smell is defective. 
A somewhat unique symptom has been noted by Scanes Spicer,3 
who observes that in a certain proportion of cases of adenoid dis- 
ease, the transverse nasal vein, which courses beneath the skin 
across the bridge of the nose, is dilated, and shows as a well-marked 
blue line. This, Spicer states, is due to pressure of the enlarged 
glands in the pharyngeal vault, on the tributary veins, as they pass 
through the palatine foramina, and disappears upon the extirpation 
of the growth. 
1 Loc. cit., p. 11. 
3 British Med. Journal, August 27th, 1887. 
2 Loc. cit., p. 15. HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
DIAGNOSIS.—The prominent symptoms of facial expression, 
dead voice, nasal stenosis, and catarrhal discharge, will ordinarily 
prove sufficient for a correct diagnosis. Examination, however, 
by the rhinoscopic mirror, gives always the additional information 
of the size of the growth. By anterior examination, nothing will 
be learned ordinarily, other than the absence of a diseased condi- 
tion of the nasal cavity, to account for the trouble. If the pas- 
sages, however, are clear, the growth in the pharynx may be fre- 
quently recognized by this examination, as stated by Frankel1 and 
Michel2 although this is disputed by Roe.3 By posterior rhinoscopy, 
with the tongue depressed, and the palate relaxed, a thorough in- 
spection of the tumor may be secured, even in the smallest chil- 
dren, if care and patience are sufficiently exercised. Instead of 
the rounded dome-like cavity of the pharynx, there will be pre- 
sented a rounded mass, of a reddish-gray tinge, with a mammillated 
surface, hanging down, as it were, and obstructing the view into 
the nasal cavities. I think the best test for the existence of an 
adenoid growth, is the ability to trace the continuity of the pharyn- 
geal wall, by inclining the mirror slowly forward, in such a way as 
to bring into the field of vision progressively, the posterior wall of 
the pharynx, gradually passing over to the broad expanded upper 
portion of the nasal septum, and tracing its converging lines, until 
it reaches the palate. Now, if in this inspection we find the view 
of the upper portion of the nasal septum obstructed in a greater 
or less degree, we recognize the presence of a growth whose uni- 
form contour and symmetrical appearance will indicate hypertrophy 
of the normal tissues, or an adenoid growth. In tracing the con- 
tinuity of smooth surface, from the pharynx to the septum, we will 
find that even a comparatively small growth will interrupt the 
view, and shadow the broad upper portion of the nasal septum. 
The size of the growth will be estimated by the extent to which 
the nasal septum is veiled on inspection by the pendent growth. 
In most cases, the growth presents itself in vertical ridges, separated 
by fissures, presenting something of the appearance of the brain- 
surface. In other cases, we find a somewhat mammillated appear- 
ance, which has given rise to the mistaken idea advocated by 
Woakes, of the papillary character of the growths. 
In adult life, the growth presents a smoother contour, the fis- 
sures having to an extent disappeared. The location of the growth 
does not, I think, vary greatly in different cases. It constitutes, 
in mild cases, a broad ridge extending across from one Eustachian 
tube to the other. If the tumor is of larger size, the centre of this 
ridge becomes enlarged and rounded, and projects further down- 
Loc. cit., p. 20. 
“ Krankheiten der Nasenhohle.” 
3 Loc. cit. 554 
DISEASES OF THE NASO-PHARYNX. 
ward and forward toward the soft palate. Meyer1 describes these 
growths as being found both in the fornix, or upper portion of the 
pharynx, and the posterior or lateral walls of the upper pharynx, 
and very rarely on the floor of the nares, where they form, as it 
were, a duplicature of the soft palate. He also describes hard 
round spots on the velum, which he considers of an identical nature. 
This glandular hypertrophy of the floor of the nares, or velum 
palati, however, I should regard as belonging to another category. 
As to the varying locality of growths in the pharynx, I should 
regard this distinction as based simply on observations of the same 
growths, which present merely variation as to their development 
or shape, just as we have variations in the extent and shape of the 
development of hypertrophy of the faucial tonsil. 
The lower pharynx presents no distinctive appearances in these 
cases, although it is an almost invariable rule that we find here a 
condition of chronic follicular pharyngitis. There is also usually 
present more or less purulent secretion, whose source is in the dis- 
eased condition of the pharyngeal vault. 
Lennox Browne2 alludes to a symptom which is usually pres- 
ent where the faucial tonsil is not enlarged, which consists of a 
“ peculiar narrowing, associated with thickening of the fauces, and 
a want of definition about the pillars.” This symptom is not, how- 
ever, present, except where the growth has attained considerable 
dimensions. 
All observers recommend a digital exploration of the pharyn- 
geal vault, as an additional aid to diagnosis. This is not a difficult 
manipulation, and is generally fairly tolerated by children, and yet 
I think is rarely necessary. Very little information is gained 
thereby which is not already obtained by the subjective symptoms 
and rhinoscopic examination ; although, where rhinoscopy is imprac- 
ticable, this should be always resorted to as giving us information 
not only of the presence of the growth, but also of its size and 
character. Lennox Browne3 makes an excellent suggestion on the 
carrying out of this manipulation, which is, that when the finger 
has reached the pharynx, the lower portion of the septum should 
be first sought, and this traced up with the tip of the forefinger, 
until the growth is impinged upon, when the exploration of the 
right and left lateral walls maybe completed. Hooper4 makes the 
statement that in children the contraction of the muscles of the 
palate against the forefinger, may give the mistaken impression of 
a protruding growth. It is simply to be remembered that the 
growth is posterior, and does not present in front. The same may 
1 Loc. cit. 
3 Op. cit.. p. 519. 
2 “ The Throat and its Diseases,” London, 1887, p. 518. 
4 Loc. cit. HYPERTROPHY' OF THE PHARYNGEAL TONSIL. 
555 
be said of hypertrophy of the posterior extremity of the lower tur- 
binated bone, which occasionally protrudes from the posterior 
nares. 
Meyer mentions also two almost pathognomonic signs of ade- 
noid disease: first, in practising inflation of the middle ear by the 
Eustachian catheter, the stream of air, after having passed freely 
into the tympanic cavity, will suddenly stop, and in a short time 
will flow on again as freely as before ; second, a gurgling or bub- 
bling sound of thick mucus, behind the nasal cavity, is heard during 
inflation, and sometimes bubbles of the same viscid mucus will 
appear at the nostril through which the catheter has been intro- 
duced. Both symptoms disappear after removal of the vegetations. 
I should scarcely attribute great diagnostic value to these symp- 
toms, although undoubtedly present in many cases. 
Schech 1 quoting Semon, advocates as an equivalent for digital 
examination of children, which is occasionally difficult and even 
painful, that the permeability of the naso-pharynx be tested by 
injecting a small quantity of warm water, by means of a ball syr- 
inge. If the water does not at once flow in a stream from the 
other nostril, but, on the contrary, escapes through the mouth, then 
it is certain that there is an obstruction in the naso-pharynx. This 
method is also recommended to prove whether or not an opera- 
tion has restored the passage. This device is a most excellent one, 
and may well be resorted to before digital exploration is practised. 
A much better device, however, is in the use of fluid cosmoline or 
sweet oil, atomized by the instrument shown in Fig. 47. As we 
know, when this is atomized it forms a cloud, as it were, of the 
density of smoke. If this is sprayed into one nostril, where the 
nasal passages and naso-pharynx are clear, it will emerge from the 
opposite side in a stream whose force and direction are almost 
equal to that with which it escapes from the tip of the atomizer. 
If, on the other hand, the naso-pharynx is obstructed, the spray 
emerges from the opposite side in a very feeble stream, or even 
fails to emerge entirely. This is, I think, without doubt our best, 
and certainly our easiest test for the existence of an adenoid groAvth 
in the naso-pharynx, and one which I regard as almost absolutely 
diagnostic. 
Graucher2 states that the presence of an adenoid gives rise to 
changes in the auscultatory sounds of the chest, which he claims 
to possess a certain amount of value, stating that when the nasal 
passages are occluded in this way, the vesicular murmur does not 
1 “ Diseases of the Mouth, Throat, and Nose,” Eng. ed., Edinburgh, 1886, p. 107. 
3 Annal. des Maladies de l’Oreille, etc., May, 1886. 556 
DISEASES OF THE NASO-PHARYNX. 
remain smooth. I should not, however, attach any great value to 
this diagnostic sign. 
PROGNOSIS.—The prognosis in these cases is always favorable, 
as regards the entire disappearance of symptoms as the result of 
treatment. It has already been stated, that there is a tendency 
at puberty for these growths to atrophy to a certain extent. The 
question arises, then, how far we may be justified in leaving mild 
cases to the natural course, when the development attending upon 
puberty may be expected in the near future. There is undoubtedly 
an atrophic process, which sets in at puberty, but this does not 
always cause an entire disappearance of the tumor. The fact that 
its symptoms are markedly ameliorated, is proba-bly due in part to 
the great development which takes place at that age, causing the 
glandular mass to occupy a relatively smaller space in the breath- 
ing passages. I think, when we consider that the treatment in- 
volves no possible risk to the patient, and furthermore that the 
growth is subject to attacks of acute inflammation, by which dan- 
ger, oftentimes of a serious character, is threatened to neighboring 
organs, that we are rarely justified in adopting the expectant course. 
It should be stated, furthermore, that these tumors do not, as a 
rule, entirely disappear at puberty, but in many cases remain as a 
permanent source of a chronic naso-pharyngeal catarrh. 
If serious ear-complications have already set in, before a case 
is subjected to treatment, I think we may lay it down as a rule, 
that in children a favorable prognosis may be given, not always 
perhaps as to the ultimate restoration of hearing, but as to im- 
provement in the majority of cases, and an arrest of further exten- 
sion of the disease in nearly all cases, provided, of course, that this 
complication is dependent upon adenoid disease, with no other 
complicating morbid lesion. This statement can be safely made 
with regard to chronic catarrhal otitis media. It is also true in 
suppurative disease, I think, with few exceptions. In those cases 
which have gone on to necrosis, we all recognize the peculiar ob- 
stinacy of the affection with which we have to deal, and yet my 
own experience teaches me that we are often warranted in giving 
a favorable prognosis, as regards improvement, even here. 
Treatment.—The simpler methods of general medication are 
probably indicated in many of these cases, on account of the im- 
pairment of the general health, which is often present, as the result 
of disturbed sleep, and imperfect oxygenation of the blood, from 
interference with normal respiratory action. These measures em- 
brace simply the administration of cod-liver oil, with general tonics. 
Most writers suggest the use of the iodide of iron, or some other 
of the iodine preparations, probably with the idea of securing the HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
557 
general tonic effect of the drug, together with its alterative action, 
but it is very doubtful if we ever promote absorption in these 
growths by any internal medication. This remedy, again, is ad- 
vocated on account of a supposed strumous diathesis, which under- 
lies these growths. As already stated, scrofula is not present, as a 
rule. We therefore may content ourselves with the administration 
of some simple form of iron, combined with barks, for its general 
tonic effect. My own preference, however, is decidedly in favor of 
cod-liver oil, where tolerated, as exercising its general tonic effect 
in these cases, with better results than any other remedy we pos- 
sess. In the majority of cases, however, probably no internal medi- 
cation is indicated. 
The question as to the value of local treatment by means of 
douches and sprays, is rather an interesting one. In the majority 
of ordinary catarrhal affections of the upper air-passages, the use 
of astringent sprays is attended with very little, if any permanent 
benefit. In glandular enlargements, however, of the kind under 
discussion, especially when we consider their very soft consistency, 
and low grade of organization, the use of astringents is attended, 
oftentimes, with the best of results, both in limiting the amount of 
secretion, and in securing an absolute reduction in the size of the 
growth. This, however, is all that is accomplished. A Cure cannot 
be looked for, unless in the very early stages of the disease, when 
the growth has attained but a limited size. Furthermore, I think 
much can be accomplished by the use of astringents in preventing 
the frequent recurrence of attacks of acute inflammation, to which 
those suffering from the disease are so liable. The only form of 
medication probably, that is adapted to the disease, is that of a 
watery solution. A well-grounded prejudice exists against the use 
of the Thudichum nasal douche in adenoid disease, although Lowen- 
berg,1 Woakes,1 Schech,1 and Moure1 recommend its use. There 
is no doubt that mischief may be done by the use of this device, in 
that the growths hanging down behind the posterior nares, so far 
occlude these openings, as in many cases to prevent the flow 
around the septum into the opposite passage. This interference 
with the flow we have already noticed as a diagnostic point made 
by Semon. Now, the nasal douche never should be used, unless 
the exit of the fluid from the nose is quite as free, if not freer, than 
its entrance, owing to the danger of its being forced into the 
Eustachian tubes. I think now that the ingenuity of our instru- 
ment-makers has placed in our hands so many and such efficient 
hand-ball atomizers at a moderate price, that preference should 
always be given to the spray, as a means of local application, over 
1 Op. cit. 558 
DISEASES OF THE NASO-PHARYNX. 
every other device, as affording a method of thoroughly reaching 
the part, in such a manner as to involve no possible injury to 
neighboring organs. We give preference then to the instrument 
shown in Fig. 47. Probably no better astringent can be used in 
these cases than tannin. My own custom is to prescribe this, in 
the following combination: 
R Acidi carbolici, . . . . . . gr. i. 
Acidi tannici, .... . . grs. xl. 
Sodii biborat., . . ... grs. xx. 
Glycerini, . . . . . . . 3 ss. 
Aquae, . ad 'l iv. 
This is to be applied twice daily at home. One of the most trouble- 
some features of the disease, is the large accumulation of mucus in 
the nasal cavities, and the difficulty the child experiences in expel- 
ling it. The above lotion is cleansing, disinfectant, and astringent, 
and being thoroughly applied at the hands of the mother or at- 
tendant, fulfils well these three indications. 
In the absence of an atomizer, a small ear-syringe is well adapted 
for medicating the parts. For simple cleansing purposes, any of 
the following solutions may be used: 
Sodii chloridum, . . . grs. x. to the ounce. 
Potassii chloras, . . . grs. x. to the ounce. 
Ammonii murias, . . . grs. ij. to the ounce. 
Sodii benzoas, .... grs. x. to the ounce. 
To which any of the following astringents or alteratives may be 
added: 
Zinci sulphocarbolas, . . grs. ij. to the ounce. 
Alumen, ..... * grs. iij. to the ounce. 
Boro-glyceride, . . . 3 i. to the ounce. 
Resorcin, ..... grs. ij. to the ounce. 
As before stated, all that can be expected by local medication, is 
a modification of the symptoms. A radical cure is dependent upon 
a thorough extirpation of the offending glands. This must be ac- 
complished, either by destructive agents, such as the chemical or 
potential cautery, or by the snare or cutting instruments. Owing 
to the prejudice against surgical operations in the minds of many 
people, we will occasionally be compelled to resort to destructive 
agents for the removal of these growths, although in all cases, I 
may state here, the complete extirpation of the growths by an op- 
eration is the preferable mode of procedure. The use of caustics 
is attended undoubtedly with successful results, although it involves 
a long course of treatment, with many repetitions of the caustic HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
559 
application. Here I think the galvano-cautery possesses a destruc- 
tive power which is far more active than are chemical agents, and 
is always to be preferred. The manipulation by which this is ac- 
com'plished, is quite simple. The only risk to be avoided is of 
burning the soft parts. The electrode should be carried to the 
parts before the current is turned on, and then allowed to cool 
before it is withdrawn, otherwise the palate or other healthy tissues 
Fig. 128.—Author’s Electrode fitted with a Shield for use in the Pharyngeal Vault, 
would be cauterized. The electrode shown i-n Fig. 128, it will be 
noticed, is fitted with a hood in such a manner as to thoroughly 
protect the palate from injury in withdrawing the instrument. 
Lowenberg1 suggests, that the cauterizing instrument should be 
adjusted by the aid of the rhinoscopic mirror, or by the finger in- 
troduced behind the palate. This is scarcely feasible in most cases, 
and is rarely necessary. In small children, it is not always feasible 
to introduce the curved electrode behind the palate, hence we are 
compelled to introduce the instrument through the nasal passages. 
If introduced in this manner, the platinum tip will usually strike 
the central portion of the mass, and a considerable destruction of 
tissue may thus be accomplished. Moreover, there is abundant 
Fig. 129.—Straight Electrodes for the Application of the Galvano-cautery to the Pharyngeal Tonsil, 
through the Nasal Cavity. 
room for a vertical movement to be permitted in this manipula- 
tion, by which successive portions of the growth may be subjected 
to cauterization. The electrodes by which this is accomplished 
are shown in Fig. 129. In the absence of the cautery-battery, 
chemical agents must be used. Of these, I should give preference 
to chromic acid fused on the end of a properly-shaped applicator, 
which may be arranged in the same manner, with a protecting 
1 Op. cit., p. 57. 560 
DISEASES OF THE NASO-PHARYNX. 
hood, as the electrode already mentioned, or the applicator may be 
concealed in a tube, as shown in Fig. 124, and protruded after the 
instrument has been passed into the pharyngeal vault. Manipula- 
tion through the lower pharynx is not always tolerated by young 
children, and in a number of cases, where the nasal passages have 
admitted of it, I have made the application directly through the 
nares, the applicator being protected by a small slender tube, and 
protruded after this has been passed through the nasal cavities. 
This manipulation has become an exceedingly simple and feasible 
one, since the use of cocaine has enabled us to thoroughly open up 
the nasal cavity by contraction of its blood-vessels. The concealed 
applicator is an old device, and one which has long been used for 
making applications to the turbinated tissues in the nasal passages. 
Fig. 130.—Meyer’s Instruments for the Removal of Hypertrophic Pharyngeal Tonsils, a, Nitrate of 
■silver applicator; 6, mouth gag; c, ring knife; d, lithotrite-like instrument for the removal of growths on the 
lateral walls. 
Lowenberg prefers nitrate of silver. Chromic acid, however, is a 
more powerfully destructive agent. Either of them are easily fused 
on the end of an applicator, and constitute convenient destructive 
agents. 
As already stated, the complete extirpation of these growths by 
a surgical operation should always be resorted to, in preference to 
any other measures. Most observers who have written on the sub- 
ject of adenoid growths, have presented instruments and methods 
of their own devising for the accomplishing of this end. Meyer1 
uses a ring-knife, consisting of a small transverse oval ring with one 
sharp though not absolutely cutting edge, as shown in Fig. 130, c. 
The patient being seated with the mouth-gag (see Fig. 130, b) firmly 
fixed in position, the ring-knife is passed through the nose, and its 
1 Loc. cit. HYPERTROPHY OF THE PHARYNGEAL TONSIL 
561 
manipulation directed by the left forefinger, passed into the vault 
of the pharynx. In this manner, the growths are removed as far 
as possible on that side, when, if necessary, the knife is transferred 
to the other nostril, and the remainder of the tumor extirpated. 
Where there are portions left on the lateral walls of the upper 
pharynx, he completes the operation by means of the instrument, 
not unlike a lithotrite, shown in Fig. 130, d. To prevent recur- 
Fig. 131.—Lowenberg’s Forceps. 
rence, which in a subsequent paper1 he said had taken place in 
thirteen of his cases, he advises a weekly application of the miti- 
gated stick of nitrate of silver, by means of the instrument shown 
in Fig. 130, a. 
The use of forceps for the removal of these growths was proba- 
bly first suggested by Lowenberg, whose instrument is shown in 
Fig. 131. It has a cutting edge on the distal extremity of the 
blades. Its movements are guided by the left forefinger in the 
pharynx or by the rhinoscopic mirror. Cohen2 recommends the 
evulsion of the growths by a gouge-cutting forceps, modelled after 
Mackenzie’s laryngeal forceps. Woakes3 modifies Lowenberg’s 
forceps by prolonging the cutting edge down on the posterior 
aspect of the blade, thus adapting the instrument to cutting on the 
Fig. 132.—Curtis’ Forceps. 
posterior wall of the pharynx; while Schech4 still further modifies 
Lowenberg’s instrument, by prolonging the cutting edge completely 
around the three aspects of the distal extremity of the blades. 
Curtis5 has made a still further change, in which the blades are 
fenestrated (see Fig. 132). 
1 Trans. International Med. Congress, 1881, vol. iii., p. 282. 
2 “ Diseases of the Throat and Nasal Passages,” 2d ed., N. Y., 1879, p. 262. 
3 Op. cit., p. 174. 4 Op. cit., p. no. 
s N. Y. Medical Record, vol. xxviii., p. 446. 562 
DISEASES OF THE NASO-PHAR YNX. 
In the above instruments the blades all operate transversely in 
the pharynx. Schutz,1 however, recommends the use of a forceps with 
a fenestrated blade operating antero-posteriorly, the only advantage 
of which lies in the fact that in this manner, perhaps, the pendulous 
masses which are occasionally found in the upper portion of the vault, 
are more easily seized, while those portions of the growth which lie 
more on the posterior wall would scarcely be grasped. Major’s ade- 
notome2 (see Fig. 133) is also constructed on this principle. Its 
mechanism is easily understood by a reference to the illustration. 
The use of a curette naturally suggests itself for the extirpation of 
these growths, as first mentioned, I think, by Lowenberg.3 His in- 
strument has a sharp cutting edge, and is attached to its handle by 
Fig. 133.—Major’s A denotome. 
an S-shaped stem. Victor Lange4 indorses this method of opera- 
tion, while Chatellier5 considers it a rather dangerous operation. 
Frankel6 advises it only in cases where the growths are not to be 
reached with the forceps. This instrument is undoubtedly avail- 
able for use when the growth is small, but is not to be recom- 
mended in the case of a large growth. It is also useful for the 
removal of the remaining fragments if the main mass has been 
removed by one of the other methods. A form of curette which I 
make frequent use of in this manner is shown in Fig. 134. It con- 
sists of an ordinary Sims’s uterine curette, with the shank bent to 
the proper angle for introduction to the pharyngeal vault. Traut- 
1 Centralblatt fur Chirurg. und Orthopaed Mechanik, 1886. 
2Canada Med. and Surg. Jour., Nov., 1887. 
3Op. cit., p. 62. 4 Deutsch. Med. Wochenschrift, 1883, p. 748. 
s Op. cit. 6 Loc. cit. HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
563 
mann advises the use of a sharp spoon, which is virtually the same 
device as the curette. 
Guye,1 of Amsterdam, dispensing with all instrumental aid, states 
that the growths can be entirely extirpated by the index finger in- 
serted behind the palate, the process being accomplished, partially 
by crushing and partly by scraping with the finger nail. Creswell 
Baber2 indorses this method, but is entirely correct, I think, in the 
assertion that their complete removal cannot be accomplished in 
one sitting, stating that it should be repeated at intervals of one 
week, till the cure is completed, which as a rule, requires four or 
five sittings. In the same category are the methods employed by 
Dalby3 and Lennox Browne, who make use of a curette, or spoon, 
attached to a thimble, which is fixed upon the end of the forefinger. 
In this manipulation, the tip of the finger is left free for explora- 
tory purposes, the shaft of the curette being attached to the pos- 
terior face of the open thimble. Michael,4 of Hamburg, has devised 
a rather ingenious instrument, which somewhat resembles Woakes’s 
forceps, excepting that the blade of the instrument shows a more 
Fig. 134.—The Author’s Sharp Cutting Curette for the Pharyngeal Vault. 
extended curve, while the hollow of the instrument extends the 
whole length of the curved portion of the blade, which is of uniform 
breadth, and presents a sharp cutting edge. In addition to this, 
the shafts of the instrument curve outward, in such a manner as to 
allow the uvula to drop between them. In addition to these sim- 
pler devices, a number of somewhat complicated instruments have 
been devised, notably that of Delstanche,5 who adapts the cutting 
forceps of Lowenberg to the mechanism of the ordinary laryngeal 
tube forceps, while Lowenberg6 seems to have found it necessary, 
in certain cases to resort to other devices than his forceps, for in a 
later contribution he has presented a device which consists of a 
flat ring-knife, with its cutting edge on the inner border of the ring. 
Over this fenestra is fitted a protecting steel-plate, manipulated 
from the handle of the instrument. When the knife has been in- 
troduced into the vault of the pharynx the protecting plate is with- 
1 Transactions of International Med. Congress, London, 1881, vol. iii., p. 290. 
2 Annales des Maladies de 1'Oreille, etc., May, 1885, p. 98. 
3 London Lancet, October 2d, 1886, vo'l. ii., p. 14. 
4 Berlin. Kliniscne Wochenschrift, 1881, No. 5, p. 67. 
5 Annales des Maladies de 1’Oreille, etc., May, 1885. 
6 Deutsche Med. Wochenschrift, 1886, No. 16, p. 265. 564 
DISEASES OF THE NASO-PHARYNX. 
drawn, and the instrument swept from one side of the pharynx to 
the other, thus severing the presenting growths, the plate being 
thrown into position again, before the withdrawal of the instru- 
ment. Still other instruments, more resembling the tonsillotome, 
have been suggested by various writers. Thus Stork adapts a 
ring knife to his universal laryngeal handle, while Delstanche ad- 
vises the use of what he calls a serre-nceud, which consists of a stout 
watch spring which is operated by a mechanism similar to that in 
his instrument already described. We thus find various writers 
advocating strikingly dissimilar methods for the extirpation of these 
growths. The question arises which is the most simple and efficient 
instrument for accomplishing the purpose, I have always enter- 
tained a prejudice against the use of forceps, as being a rather un- 
surgical method. Most of the writers \yho recommend them, also 
acknowledge that the operation cannot be completed at one sitting; 
these same writers also, as a rule, operate without an anaesthetic, 
the patient, if young, being fastened to the chair, although Hooper 1 
states that the complete extirpation of the growth may be secured 
at one sitting by the forceps-operation, with the palate thoroughly 
retracted, and the patient being under the influence of an anaesthe- 
tic, a mouth-gag also being in position. The same method is pur- 
sued by Friinkel,2 who has devised a modification of Whitehead’s 
mouth-gag, by the addition of a tongue depressor, which forms part 
of the instrument itself, and a self-retaining Voltolini palate hook. 
A similar instrument has been devised independently by Swinburne.3 
With wide access to the pharynx thus secured, we can easily un- 
derstand how a growth may be entirely extirpated at one sitting, 
were it not that the flow of blood is rather profuse at the first step 
of the operation, which will necessarily seriously hamper further 
procedure. In some cases certainly, as Hooper suggests, a suffi- 
cient time may be permitted to lapse after each introduction of the 
forceps, to allow the hemorrhage to cease. In spite of this, many 
cases will be attended with hemorrhage, sufficient to interfere with 
this method of operating. Hooper extracts the growth by means 
of a forceps (shown in Fig. 135, 1) which is very similar to that of 
Lowenberg, with the exception that the cutting edge of one blade 
slightly overlaps that of its fellow. The mouth is held open by a 
mouth gag, which differs in no essential feature from that of 
O’Dwyer (Fig. 135,2), while the palate is elevated by a Voltolini pa- 
late-hook (Fig. 135, 3). As regards Meyer’s method of operating, 
we can only say, in view of the excellence of his results, that no 
better method of procedure can be suggested, provided one possess 
1 Loc. cit. 2 Trans. International Med. Congress, 1881, p, 333. 
3 N. Y. Med. Record, vol. xxiv., p. 373. HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
565 
his manipulative skill and dexterity. It should be said, however, 
that it seems somewhat complicated, and at the best, not an easy 
operation to perform with very young children, especially when we 
consider that he operates without an anaesthetic, his patient being 
fastened to a chair. The method which will commend itself proba- 
bly to an unskilled operator, or one not a specialist in throat dis- 
eases, is either the use of the long-handled curette, or Dalby or 
Browne’s finger curette, or perhaps in a still larger number of cases, 
Guye’s suggestion of the unarmed index finger. This operation I 
think should always be done under an anaesthetic, which will afford 
Fig, 135.—Hooper’s Instruments for the removal of Hypertrophied Pharyngeal Tonsils. 1, Forceps; 2, 
mouth gag; 3, palate retractor. 
ample time for a fairly thorough disorganization of the growth, if 
not its complete extirpation. It need scarcely be added, further- 
more, that the mouth-gag should be used in all cases. By this 
method, a complete cure at one sitting need never be anticipated. 
As regards the more complicated instruments of Delstanche, Stork, 
Lowenberg and others, they possess probably equal merit, but will 
scarcely come into general use. For a rapid method of removal, 
without resort to anaesthesia, mouth-gags, or palate retractors, I 
have for a long time made use of a modification of Jarvis’s snare, 
first described some years since,1 and which is shown in Fig. 136. 
1 “Adenoma of the Vault of the Pharynx,” Araer. Journ. of Otology, vol. iv., 1882. 566 
DISEASES OF THE NASO-PHARYNX. 
It consists of an ordinary snare fourteen inches in length; the end 
of this is curved in a quadrant of a circle whose radius is one and 
one-fourth inches. This is now mounted with a No. 5 piano-wire, 
which I regard as by far the most useful size, as combining elastic- 
ity, strength, and resistance. 
Having observed the growth and 
carefully' estimated its size, a 
loop is formed which will em- 
brace it, and is then bent forward over the end of 
the instrument, in order to give it a decided kink. 
The wire is now played out of the snare about 
an eighth of an inch, and the whole loop is now 
thrown backward toward the handle of the in- 
strument, giving it another bend. As will be 
seen, it is in a position for easy introduction be- 
hind the palate, without touching the parts, and 
may be passed immediately to the base of the 
growth. The palate of course is now immediately 
retracted by reflex irritation, but only embraces 
the tube of the snare, without in any degree 
hampering the manipulation. 
The instrument is now held firmly in place, 
while the loop is rapidly drawn in by turning the 
screw. The action of the bends in the wire loop 
is now perceived. As the wire is drawn in, the 
loop is thrown backward with considerable vigor, 
and embraces and severs the growth. In this 
manner even a broadly sessile growth is easily 
seized and extirpated. There is but trivial hemor- 
rhage, but little pain or retching, and the whole 
manipulation is accomplished very easily, simply, 
and speedily. After the withdrawal of the instru- 
ment, the tumor is expelled through the nose by 
blowing. Occasionally it drops into the pharynx 
below, but this is very rare. In no case has any 
patient experienced the slightest annoyance from 
the growth dropping too far down in the air-pas- 
sages, nor do I regard this as an accident that is 
liable to happen. The operation by this method 
has rarely required an anaesthetic. 
Occasionally in the case of children, in whom the control of the 
faucial movements prevented the manipulation, I have been com- 
pelled to give an anaesthetic and resort to another method,which may 
be described in a few words. In these cases the growth was severed 
Fig. 136.—The Author’s 
Modification of Jarvis’s 
Snare-ecraseur for the re- 
moval of an Hypertrophied 
Pharyngeal Tonsil. HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
567 
by passing an ordinary straight snare through the nose. Having 
mounted the snare with the wire, the loop was bent sharply down 
over the end of the instrument, giving it a kink, and then drawn 
within the tube until a loop only remained sufficiently small to pass 
through the nares; this was passed vertically until the loop was in 
the pharynx, when the instrument was turned, bringing the loop into 
a horizontal position, with the side undermost toward which the 
larger loop had been bent. The wire was now played into the phar- 
ynx, when the bend which had already been given it threw the loop 
downward, nearly to a right angle. The whole instrument was now 
pressed firmly against the pharynx, which, as will be seen, threw the 
loop over the growth. Holding the instrument firmly pressed against 
the pharynx, the screw was rapidly turned and the growth severed. 
As soon as the instrument was withdrawn, the child’s head was drawn 
over the table with the face downward, and the trifling hemorrhage 
allowed to go on for a few moments, when the same manipulation 
was repeated through the nasal cavity of the opposite side, after 
which the child was easily aroused, when the masses were expelled 
by blowing the nose. 
In this manner, as a rule, the whole growth may be removed, 
but in the first-described manipulation portions may be left. This, 
as well as their location, is easily ascertained by examination, and 
the manipulation repeated. This may be done a number of times 
at one sitting, entailing but little annoyance or weariness to the 
patient. 
An additional advantage of the use of the snare, is in the fact 
that the hemorrhage is less than when cutting instruments are 
resorted to. Hartmann1 has also recommended the use of a snare, 
in which the wire loop is concealed in a stiff ring, which enables it 
to be carried into position before it is drawn home. The serre- 
nceud of Delstanche also is a somewhat similar instrument. 
The galvano-cautery snare as recommended by Voltolini, Michel,3 
of Cologne, Sajous,3 and others, offers no advantages over the cold 
snare, and is much more difficult of manipulation. 
The use of electrolysis, as recommended by J. R. Briggs,4 is one 
of which I have no experience, and yet it seems well worthy of trial, 
in those cases where there is a prejudice against surgical interfer- 
ence. The anode, consisting of an ordinary sponge electrode, is 
held by the patient. The cathode is an insulated gold-pointed 
needle and is thrust into the vegetations, and the current is passed 
1 Deutsche Med. Wochenschrift, 1881, No. g. 
2 Trans. Internat. Med. Congress, 1881, vol. iii., p. 333. 
* “Diseases of the Nose and Throat,” Philadelphia, 1887, p. 233. 
4 Texas Courier of Medicine, December, 1886. 568 
DISEASES OF THE NASO-PHARYNX. 
until the vegetations shrivel up. About ten elements of a Stohrer 
battery are used. Michel,1 of Cologne, in indorsing a similar 
method of procedure, rather discouragingly states that it requires 
from forty to ninety sittings to complete a cure, extending over a 
period of from six to eight months. 
The question of the administration of an anaesthetic is one which 
every operator will decide for himself, in individual cases. In 
adults, and older children, it will rarely be necessary. In young 
children, however, whatever the operation, it will be found necessary 
to administer chloroform or ether. If the operation is prolonged, 
complete anaesthesia will be necessary, and, therefore, ether is to be 
preferred. In the shorter operations, by means of a cutting instru- 
ment, or my own operation by the snare, complete anaesthesia is not 
necessary. I have always found that a few whiffs of chloroform 
answer every purpose. The child will become completely re- 
laxed, and will remain so, until the operation is completed. In this 
manner, I think, we incur none of the dangers attendant upon the 
use of chloroform, and furthermore, none of the disagreeable 
features of etherization are encountered. 
Frankel2 and Moldenhauer3 both object to the use of chloroform 
as an anaesthetic, as introducing an element of danger into an opera- 
tion otherwise unattended with risk. Both these writers, in operat- 
ing on children, advise that the arms and legs shall be thoroughly 
controlled by bandaging, and administer no anaesthetic. I think, in 
these operations, control of the limbs is of less importance than 
relaxation of the faucial and palatal muscles, which, can only be 
secured by general anaesthesia. This is secured fully in the primary 
anaesthesia, produced by the administration of chloroform, which, 
furthermore, is not attended, I think, with any danger. My plan is 
to sprinkle perhaps half a drachm of chloroform on a handkerchief, 
and seizing the child, surreptitiously, as a rule, the handkerchief is 
held firmly over the mouth and nose, while at the same time, he is 
drawn down on the lap, and held firmly. Primary anaesthesia is 
thus secured, and the operation completed, before he is aware that 
anything has been done. In all cases, probably, whether a general 
anaesthetic is used or not, it is wise to apply a ten or twenty-per- 
cent solution of cocaine, to secure such local anaesthesia as it may 
afford, together with the vascular depletion which attends its use. 
Of course, this will always be used when operating without general 
anaesthesia, and yet it should be stated, that its action upon the 
glandular hypertrophies of the pharyngeal vault is very unsatis- 
1 Monats. fur Ohrenheilkunde, 1887, No. 5. 
2 Loc. cit., p. 23. 
3 “ Die Krankheiten der Nasenhohlen,”etc., Leipzig, 1886, p. 169. HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
569 
factory. It modifies possibly the pain of an operation, but does 
not absolutely control it. 
The question of recurrence has been discussed by most writers, 
and all concur in the statement, that complete extirpation is never 
followed by a return of the growth. Meyer,1 in writing on this 
subject, eleven years subsequently to his first paper, stated that out 
of one hundred and two cases first reported, there was a recurrence 
in thirteen, although he attributed this to a lack of thoroughness in 
the treatment, agreeing with Frankel,2 who states that when recur- 
rence takes place, it is undoubtedly due to a lack of thoroughness in 
the original operation. The importance, therefore, of a thorough 
removal of all offending tissue, cannot, I think, be overestimated, 
notwithstanding that so close an observer as Lowenberg,3 both in 
his original brochure and in a subsequent paper,4 states that suffi- 
cient will have been accomplished by the operation, when free nasal 
respiration is established. 
SEQUELAE.—Hemorrhage very rarely occurs in a degree sufficient 
to demand interference. If such an accident should occur, a tampon 
inserted into the pharyngeal vault is usually sufficient to control it. 
Acute otitis media has been mentioned by Meyer, Frankel, and 
others, as occurring after an operation upon these growths. Frankel 
states that it is more liable to occur after a secondary operation, 
and especially when this is done too soon after the previous sitting. 
It is probably more liable to occur as the result of the use of the 
curette or forceps, on account of injury done to healthy tissues. 
Another accident which attends the operation in a certain propor- 
tion of cases, is the occurrence of a fibrinous exudation on the cut 
surface, giving rise to an ordinary attack of acute follicular disease 
of the vault of the pharynx, extending in many cases to the follicles 
of the lower pharynx. This is accompanied with a rapid pulse, 
general febrile motion, muscular pains, sore throat, painful degluti- 
tion, and indeed, all the local and general symptoms of an attack of 
that disease, and is to be treated in much the same manner as the 
idiopathic affection. This does not ordinarily seriously complicate 
the operation, or interfere with its success, although in a few 
instances I have thought that it seemed to stimulate the tissues to 
a renewed activity, under which a partial recurrence of the growths 
supervened. I know of no way to prevent this complication. 
1 Trans. Internat. Congress, 1881, vol. iii., p. 382. 
2 Loc. cit., p. 30. 
3“Tumeurs Adenoides du Pharynx Nasal,” Paris, 1879. 
4 Deut. Med. Wochenschrift, 1886, No. 16, p. 265. CHAPTER XLIII. 
FIBROMA OF THE NASO-PHARYNX. 
This term is used to designate a form of neoplasm of the naso- 
pharynx which is composed almost purely of fibrous tissue. Spring- 
ing from the basilar process of the occipital bone, and increasing by 
a somewhat slow process of growth, it gradually invades neighbor- 
ing cavities, sending prolongations into the nasal passages and into 
the pharynx below, while at the same time it pursues the same 
relentless course as fibroma in the nasal cavity, crowding all the 
tissues before it, and resulting in absorption both of the soft tissues 
and bony structures, which intrude themselves upon its path. 
The tumor is essentially a sessile growth from its onset and dur- 
ing its course, and although occasionally reported as a naso-phar- 
yngeal polypus, it never assumes the gross characteristics of a poly- 
pus, in that during its development its attachments spread out 
and broaden, in proportion to the increase in the size of the 
neoplasm, in contradistinction from what we usually regard as a 
polypus, in which the tumor itself attains even large proportions, 
while it is still attached to the part from which it sprang by means 
of a narrow pedicle. 
Etiology.—It is difficult to assign any active cause for the 
development of these growths, in that they arise from tissues show- 
ing no evidence of morbid activity, and in individuals apparently in 
the enjoyment of perfect health. 
In the majority of instances, they occur in males, and usually at 
about the age of puberty. Nelaton, Dolbeau, Gosselin, and other 
of the earlier surgeons, seem to have entertained the view that the 
disease was met with exclusively among males. Pluyette,1 how- 
ever, making a special investigation of this point, has collated 
twenty cases of naso-pharyngeal growth occurring in females, nine 
of which were undoubtedly true fibromata. In general, these 
growths occur from the ages of fifteen to twenty-five years, while 
in females the average age is slightly greater. Mackenzie2 suggests 
that the frequency with which these cases are reported by French 
1 Revue de Chir., 1887, vol. vii., pp. 202 and 223. 
2 “ Diseases of the Throat and Nose,’’ Amer, ed., Phila., 1884, vol. ii., p. 496. FIBROMA OF THE NASO-PHARYNX. 
571 
surgeons, might indicate their greater frequency of occurrence in 
France than in England. The same might be said in regard to 
Germany. The very abundant literature of the subject, however, 
in the French and German reports, I take it, merely indicates the 
activity of this form of investigation, characteristic of the surgeons 
of these nations. When we consider the very great frequency of 
uterine fibroids among the colored races, we might naturally antici- 
pate a similar frequency of fibromata of the upper air passages, 
and yet, as a matter of fact, I know of no recorded instance of a 
fibrous tumor of the naso-pharynx occurring in a negro. 
Symptomatology.—These growths usually manifest them- 
selves very early in the history of their development, one of the 
first symptoms, perhaps, being the occurrence of repeated attacks 
of epistaxis, which may be exceedingly violent in character. The 
source of this bleeding may possibly be from an erosion of the mu- 
cous membrane against which the tumor impinges, but probably, in 
the majority of instances, it arises from the blood-vessels coursing 
on the surface of the growth itself, for, as is usually the case in 
fibroid tumors of the upper air passages, the tumor is exceedingly 
vascular in character. These hemorrhages may consist of a slight 
oozing at times, but usually it is a persistent and long-continued 
flow of blood, oftentimes lasting many hours, and even days. Fur- 
thermore, the hemorrhage repeats itself sooner or later, and is 
especially liable to occur after violent exercise, although usually it 
comes on without any apparent cause. In two instances which 
came under my own observation, there seemed to be a disposition to 
the occurrence of the epistaxis during sleeping hours, the patients 
being awakened by the choking sensation produced by the flow 
of blood into the air passages. This bleeding also may occur be- 
fore the tumor has obtained sufficient size to produce other notable 
symptoms, although, as its size increases, the tendency to hemor- 
rhage also increases. The presence of the growth is indicated by a 
sense of fulness in the naso-pharyngeal region, with a very early 
impairment of the voice, which assumes the characteristics of the 
“ dead voice ” observed in connection with adenoid disease of this 
region, the symptom being due to the fact that the propagation of 
vocal waves into the resonant chambers of the nose is prevented 
by the mechanical presence of the tumor. As the growth increases 
in volume, it hangs down over the posterior nares, closing them as 
if by a curtain, thus giving rise to nasal stenosis. This is usually 
bilateral in character, in that the tumor springs from the central 
portion of the basilar process, and develops symmetrically until its 
progress is deflected or hampered as it impinges upon normal 
structures. 572 
DISEASES OF THE NASO-PHARYNX. 
With the occurrence of stenosis there develops, furthermore, the 
peculiar facial expression always met with in naso-pharyngeal 
tumors, which consists of an apparent broadening of the bridge of 
the nose, which, in connection with the open mouth which results 
from the interference with normal nasal respiration, gives a peculiar 
expression of vacancy or stupidity to the patient. As still further 
development occurs, and as the prolongations make their appear- 
ance in the nasal cavity, and extend, perhaps, into the accessory 
sinuses, there results a genuine facial deformity, in that the nasal 
bones, or the nasal processes of the superior maxillae, are crowded 
forward on one or both sides, thus obliterating the malo-nasal 
fold, while, at the same time, the bridge of the nose is thus broad- 
ened, and that peculiar facial deformity results which is usually 
designated as “frog face.” These prolongations into the nasal cav- 
ity may extend forward, and make their appearance at the nostril, 
or they may make their way into the accessory sinuses, distorting 
these cavities, and shovving evidence of this extension by additional 
facial deformity. A still further progress may be observed, toward 
the cavity of the orbit, giving rise to exophthalmos, this occurring 
either as the result of a direct invasion of the orbit, or in consequence 
of the lifting of the orbital plates by the pressure of the growth 
from behind. The occurrence of exophthalmos would indicate, prob- 
ably in the majority of instances, the invasion of the antrum, 
although it may be due to an invasion of the ethmoidal cells. 
A certain amount of excessive secretion results from the pres- 
ence of these growths, which consists of thick, tenacious mucus or 
muco-pus. As the result of the presence of the tumor, the normal 
movements of the fauces are notably hindered, and this secretion 
tends to become inspissated, and thus accumulates in and about 
the growth and is voided with considerable difficulty. At the same 
time, the secretions also in the nasal cavity proper become altered, 
in that normal nasal respiration is arrested, and the normal process 
of voiding mucus impaired, the secretion from the nose being of a 
sero-mucus, or even watery character, and occasionally mixed with 
the muco-pus, the source of which is in the pharynx. The secre- 
tions are at all times liable to be more or less tinged with blood, 
which, as before stated, has its source probably in the blood-vessels 
of the neoplasm itself. As the growth extends into the lower 
pharynx, it impinges upon the soft palate, crowding it forward 
into the mouth, and thus interferes, not only with the act of de- 
glutition, but also prevents the closure of the palato-pharyngeal 
space, as a consequence of which fluids are liable to be forced 
into the nasal cavity during the act of deglutition. Dyspnoea may 
occur later in the disease, owing to the extension of the growth downward, and the mechanical interference with the entrance of 
air into the lungs. 
Pathology.—These tumors are composed almost entirely of 
dense, white fibrous tissue, containing very few if any elastic fibres. 
According to Muron 1 a cross section of the growth, examined under 
the microscope, shows the presence of these fibres, displayed usually 
parallel with each other, although they show a tendency to inter- 
lace in every direction. Scattered here and there, are observed 
blood-spaces of varying sizes, the smaller ones being surrounded by 
a single layer of fusiform cells, 
while in still larger ones these 
cells are displayed in two, three, 
or four layers, according to the 
size of the spaces; while in the 
largest spaces there is found a 
fairly well developed vascular 
wall, with its three coats well 
differentiated. 
In addition to this, there 
are found scattered somewhat 
sparsely through the tissue 
numbers of fusiform cells or 
multinuclear bodies, embedded 
between the fibres (see Fig. 
137). The whole growth is in- 
closed apparently in a capsule, 
which consists probably of the 
mucous membrane covering the 
part from which the tumor 
originally sprang, distended 
and somewhat attenuated, in 
that it is composed only of the 
connective-tissue layer covered with epithelial cells. Coursing 
beneath this capsule, however, are a large number of blood-vessels, 
which are visible even on gross inspection. These probably are the 
nutrient blood-vessels of the tumor. Their walls, however, are ex- 
ceedingly thin, and rupture on very slight injury, hence, these ves- 
sels are probably the source of much of the hemorrhage, which 
occurs so frequently in connection with these tumors. 
The growth is regularly rounded in outline at its onset, while 
subsequently its shape is modified by the bony walls of the cavity 
which it invades. The origin of these tumors is probably in all 
cases from the periosteum of the basilar process of the occipital 
FIBROMA OF THE NASO-PHARYNX. 
573 
Fig. 137.—Fibroma. (Author’s case reported on page 
585.) Z., Coarse bun iles of fibrous connective tissue; 
T, bundles, cut transversely ; C, capillary blood-ves- 
sels ; G, G, multinuclear bodies. 
1 Comp. Rendu delaSoc. de Biol., 1869, Paris, 1870, 5 s., vol. i., pp. 223-225. 574 
DISEASES OF THE NASO-PHARYNX. 
bone, although it may in part arise from the body of the sphenoid 
adjoining. At their onset, they spring probably from a compara- 
tively small area, but as they develop, their point of attachment 
increases to a certain extent, proportionately with the growth of 
the tumor; and furthermore, in addition to this spreading of the 
base, new attachments arise, which oftentimes lead to confusion as 
to the original source of the neoplasm. This question, as to the 
primary origin of the tumor, becomes somewhat important, and has 
been the subject of special investigation by Beuf,1 Brevet2 and 
D’Ornellas,3 who agree essentially with Nelaton, in the view that 
these tumors invariably spring from the base of the cranium, and 
that, ip those cases in which there is an apparent origin from the 
bodies of the vertebrae, the wings of the sphenoid, or from the parts 
lower down, this is due, either to the burrowing, as it were, or 
spreading of the original attachment. As the tumor extends to 
neighboring parts and cavities, adventitious attachments are 
formed, as the result, probably, of localized inflammatory action. 
DIAGNOSIS.—A fibroma can be recognized, even at its onset, by 
an inspection of the vault of the pharynx, by means of a rhinoscopic 
mirror, when it will be seen as a small, irregularly rounded growth, 
of a light pinkish color, springing from the upper portion of the 
cavity, the gross appearances of the tumor giving the impression 
of a whitish mass seen through a pinkish veil as it were composed 
of capillary vessels, while coursing on its surface can be observed 
oftentimes the larger blood-vessels. In addition to this, in order to 
test the density of the growth, the vault of the pharynx can be ex- 
plored by means of the index finger, when the tumor will be found 
hard, dense, resisting, and to a certain extent immovable. This 
manipulation, however, should be resorted to with considerable care, 
in that troublesome hemorrhage can easily be excited. In addition 
to this, if the nasal cavities are thoroughly exsanguinated by the 
use of cocaine, it is not impossible, frequently, to observe the growth 
by direct inspection through these passages, when it also will pre- 
sent itself to the eye behind the posterior nares, in its light, pink 
hue, in notable contrast as regards color to the pituitary membrane. 
In this connection, a probe, delicately manipulated, may serve to aid 
the diagnosis, in that the very slight mobility, and the dense char- 
acter of the growth, can in this manner be recognized. As the 
tumor develops in size, in connection with the characteristic symp- 
toms of nasal stenosis, repeated attacks of epistaxis, etc., the in- 
1 These de Paris, 1857, No. 69. 
a These de Paris, 1855, No. 117. 
3 “ Anat., Path, et Traitement des Polypes Fibreux de la Base du Crane, dits Naso- 
Pharyngiens.” Paris, 1854. FIBROMA OF THE NASO-PHARYNX. 
575 
spection and palpation become a much simpler matter, and the 
diagnosis becomes comparatively clear. 
A fibroid tumor in the upper air-passages, when brought under 
inspection, presents gross appearances to the eye which resemble 
no other form of neoplasm met with in these regions. An osteoma 
can always be recognized as such, by means of the probe or the 
needle. Chondroma is exceedingly rare in the naso-pharynx, and 
presents a decidedly warmer and deeper red color, with a yellowish 
tinge, is absolutely immovable, manifests no tendency to hemor- 
rhage, and can be subjected to palpation with impunity, and finally, 
its dense cartilaginous consistency can be determined by means of 
the needle. Malignant growths present no gross appearances, 
which in any wTay need lead to confusion. The only diagnostic 
point really of importance in this connection, is as to the origin of 
the tumor from the nasal cavity proper, or from the naso-pharynx, 
its fibroid character having been recognized. This question is not 
always easy of determination, where the growth has obtained such 
proportions as to have invaded one or the other of the nasal pass- 
ages. Dolbeau 1 takes the ground, that a naso-pharyngeal growth 
produces unilateral nasal stenosis, while nasal fibroma gives rise to 
bilateral stenosis, a diagnostic point which he seems to regard as of 
considerable importance. I am disposed to think that the converse 
is true, and that a growth springing from the basilar process, and 
developing, as it usually does, symmetrically, will hang down over 
the posterior nares, in such away as to produce an equal amount of 
obstruction on both sides. Hence, I am disposed to say, that a 
fibroid tumor, which in its incipiency produces bilateral stenosis, can 
in the majority of the instances be regarded as of basilar origin, while 
a tumor which produces unilateral stenosis early in its develop- 
ment, springs from the nasal cavity proper. 
A decision, then, must be based on a careful analysis of symp- 
toms, added to such information as may be obtained by the gross 
inspection and examination of the growth with our improved 
methods of examining the nasal cavities and naso-pharynx, facil- 
itated, as they are so greatly at the present day, by the local anaes- 
thetic action of cocaine, together with its constringent effect on the 
blood-vessels. 
PROGNOSIS.—Naso-pharyngeal fibroma in itself is not necessarily 
a fatal disease, and yet, when we consider the fact that there is no 
limit to its growth, that its progress is oftentimes marked by the 
occurrence of grave complications, that it may very early in its his- 
tory encroach upon vital parts, and, finally, the very serious character 
of the operations which heretofore have been so frequently resorted 
1 Gaz. des Hopitaux, 1S62, p. 530. DISEASES OF THE NASO-PHARYNX. 
576 
to for its removal, it becomes an exceedingly grave affection. The 
principal complication during the development of the tumor, consists 
of the repeated attacks of hemorrhage, which may serve to mark- 
edly impair the general health, or may even result in a fatal termina- 
tion. These growths develop in such directions as offer the least 
obstacle to their progress. Hence, after the pharynx becomes filled 
they extend forward into the nasal cavity and downward into the 
lower pharynx, where their presence may give rise to death from 
asphyxia, as occurred in a case of a boy, five years of age, observed 
by Nelaton.1 If the cranial cavity is invaded, this occurs only dur- 
ing the latter stage of the disease, after the tumor has attained a 
very large size, and has invaded the nasal cavity, where it finds a 
more vulnerable entrance to the cranium, through the cribriform 
plate of the ethmoid, or through the sphenoidal cells, as occurred 
in a case of Nelaton’s.2 
Invasion of the cranium, as the result of erosion of the basilar 
process, probably never occurs, but the growth may send a pro- 
longation through the foramen lacerum medius, as occurred in a 
case operated on by Shrady;3 this complication having been discov- 
ered after death, the patient dying upon the operating-table, after 
resection of the superior maxilla. These growths rarely, if ever, 
develop after puberty, but during earlier years their growth is some- 
what rapid. With the attainment of puberty a notable arrest of 
development is very frequently observed, which may in rare in- 
stances go still further, and result in a retrogressive movement, 
under which a tumor may completely disappear. This spontaneous 
disappearance of a fibroma has been observed by La Font,4 in a 
young man, aged twenty-four, in whom a growth, involving the nasal 
cavity and the antrum, had existed for several years, complete dis- 
appearance taking place at the end of six months from the time of 
its greatest development. A still more interesting case was reported 
by Gosselin 5 as follows : 
A young man, aged 22 years, presented with an enormous naso-pharyngeal 
fibroma, impinging upon the base of the tongue, while at the same time send- 
ing prolongations into the nasal cavity. The great dyspnoea, and the repeated 
attacks of severe hemorrhage, had resulted in such impairment of the general 
health, as to render any radical operative procedure hopeless. An attempt was 
made to modify the growth by electrolysis, injections, and caustic applications, 
with but little success, although the patient’s life was prolonged for six months, 
when a rapid extension of the tumor occurred, giving rise to exophthalmos, 
with symptoms of brain pressure. The case being regarded now as utterly 
1 Cited by Beuf, loc. cit., p. 24. 
3 N. Y. Med. Record, Sept. 9th, 1882, p. 311. 
4 Gaz. Hebdom., 1875, vol. Xxii., p. 37. 
s “ Lemons de Clinique Chirurgicale,” Paris, 1873. 
2 Loc. cit., p. 16 ■FIBROMA OF THE NASO-PHARYNX. 
577 
hopeless, all measures of treatment were abandoned, upon which tnere super- 
vened a process of reabsorption, resulting, at the end of two years, in the com- 
plete disappearance of the tumor, and an entire restoration of health. 
The following case of Grynfeltt’s1 is interesting, in that this 
reabsorption of the tumor set in at a much earlier age, and pro- 
gressed more slowly. 
A boy, aged 14, presented with a naso-pharyngeal tumor, completely filling 
the upper pharynx, and extending to and pressing upon the soft palate, com- 
pletely closing both posterior nares. Several operations were attempted with- 
out success, and finally Grynfeldt performed partial resection of the superior 
maxilla. He only succeeded, however, in removing a portion of the tumor, 
although making several attempts at different times. Operative procedure 
being abandoned, the boy was discharged, reappearing, however, seven years 
later, perfectly restored to health, when an examination revealed a small, dense 
tumor in the pharyngeal vault, about the size of a pea, at the site of the original 
neoplasm. 
Another method, by which these tumors disappear, is by slough- 
ing, cases of this sort having been reported by Vimont2 and Birk- 
ett.3 These cases of spontaneous disappearance of the growth, 
however, are of such rare occurrence, as to scarcely modify the 
view, that we must regard this affection as one of very serious im- 
port, in that a somewhat large percentage of cases result fatally. 
And yet, I think, when we carefully examine the statistics of the 
subject, we find that death results from operative procedures insti- 
tuted for the removal of the growth, in more cases than from the 
disease itself. Of course, these patients would die if they were not 
operated upon, and, in former times, these radical operations, such 
as removing the upper jaw, etc., were fully warranted, in that they 
afforded at that period, the only available means of reaching the 
tumor. With the improved methods of our own day, by means of 
which all affections of the upper air passages are brought so com- 
pletely within reach for operative procedure, we may undoubtedly 
look for better results of treatment, in that many cases of naso- 
pharyngeal fibroma will now be operated upon, without subjecting 
the patient to the somewhat grave operation of resecting the su- 
perior maxilla. Hence, our prognosis is not to be based entirely on 
former statistics. Basing our prognosis, therefore, on cases subjected 
to the radical operations, as before stated, it becomes exceedingly 
grave. Basing our view, however, on what has been accomplished 
in more recent days, it is probably safe to give a favorable opinion 
in a fairly large proportion of cases. This view is certainly justi- 
fied by the admirable report made by Lincoln 4 who in a collation 
1 Gaz. Hebdomadaire de Montpel., 1882, vol. iv., p. 196 et seq. 
2 Cited by Brevet, loc. cit., p. 20. 3 British Med. Journal, Feb. 13th, 1858. 
4 Trans. Amer. Laryngol. Assoc, for 1883, p. 86. 578 
DISEASES OF THE NASO-PHARYNX. 
of fifty-eight cases, on whom seventy-four operations were done, 
has shown us that of these, thirty-eight operations involved opening 
the face by the resection of the superior maxilla, or similar methods, 
resulting in 
A cure in, . . . . . . . io cases 
Death from the operation in, ... 8 “ 
Recurrence in, . . . . . . II “ 
Record incomplete in, ... 9 “ 
An operation was done through the palate, in seven cases, of 
which there was 
A cure in, . * . . . . . . 2 cases 
Recurrence in, . . . . . . 2 “ 
Death on the table in, ... i case 
Records incomplete in, ... 2 cases 
Evulsion was practised in four cases, resulting in 
Cure, ....... 2 cases 
Death, ....... i case 
Report incomplete, ..... i “ 
The ligature and snare were used in three cases, resulting in 
Cure,........ i case 
Recurrence, ...... 2 cases 
Electrolysis was used in three cases, as follows: 
Cured, ....... i case 
No report in, ...... 2 cases 
Ecraseur, with recurrence, i case. Scissors and cautery, i case, 
no recurrence. Injection of sulphate of zinc, I case, no recurrence. 
Scraping with the finger curette, i case, cured. The galvano-cautery 
Ecraseur was used in 14 cases, with 
Cured, . . . . . . . 11 cases 
Recurrence, ...... 3 “ 
We thus find of the thirty-eighty severe operations done, but ten 
cases were cured, while with reference to the milder operations, the 
statistics are much more favorable. Furthermore, it will be found, 
on a careful scrutiny of the reports, that the simpler operations 
were not done on selected cases, and that even where the tumor has 
attained large proportions, and given rise to serious complications, 
we are warranted in giving a far more favorable prognosis if a 
milder operation is to be resorted to, than where the patient is to 
be subjected to the additional risk of opening the face. 
Treatment.—The surgeons of ancient times recognized tumors 
of the naso-pharyngeal cavity, and attacked them apparently by 
much the same methods as are often used at the present day. Thus FIBROMA OF THE NASO-PHARYNX. 
579 
Hippocrates, placing a loop around the growth, extracted it by 
evulsion, or cut it out by means of the knife. Albucasis ex- 
tracted them by means of the forceps, together with a sharp hook. 
Fabricius devised a special forceps with a curved blade, by which the 
pedicle could be more thoroughly seized in their removal; while 
Celsus, seizing the growth by a hook, dragged it down, while.its 
separation was facilitated by means of a two-edged spatula. Job- 
a-Meckren 1 was perhaps the first to make use of the scissors for the 
removal of these neoplasms. 
These various methods of treatment, while available in certain 
cases, in their earlier development, of course proved inadequate for 
the removal of larger growths, and it seems somewhat singular that 
more radical methods should not have been undertaken earlier, and 
yet this was not done until 1832, when Syme2 and Mott3 independ- 
ently conceived the idea of obtaining free access to tumors of this 
cavity, by the removal of the superior maxilla, and made successful 
use of this method of operating; although, it should be stated, that 
complete resection of the upper jaw had already been done by 
Gensoul in 1827, while partial excision had been practised as far 
back as 1693 by Acoluthus. 
Undoubtedly many cases occur, in which on account of the size 
of the tumor, this serious operation will be demanded, and yet 
there can be no question, as has already been shown, that the nicer 
manipulations which characterize the surgery of the present day, 
will enable us to successfully extirpate the neoplasm, in a far larger 
proportion of cases than hitherto, with the result of a very marked 
improvement in the percentage of cures. There are a number of 
devices which may be resorted to for the destruction or extirpation 
of these growths, by which the patient is saved from the danger of 
the radical operation, rendered so hazardous as it is in so many 
cases, from the fact that the patient is already depleted by the un- 
toward complications which so frequently accompany the develop- 
ment of the tumor. The use of caustics superficially applied for 
the destruction of the growth offers but little hope either of arrest- 
ing its progress, or reducing its size, in that the dense, fibrous tissue 
of which it is composed is not easily amenable to the destructive 
influences of these agents, and, furthermore, the mere size of the 
growth should discourage any such endeavor. Barthelemy4 re- 
ports the case of a fibroma, completely filling the naso-pharynx, 
and projecting into the mouth, which had recurred after a previous 
1 “Observat. Med.,” chap, xi, 
2 Edin. Med. and Surg. Jour., .1832, p. 322. 
3 Amer. Jour, of Med. Sciences, 1S43, N. S. vol. v., 89-91. 
4 Arch. Generate, 1880, p. 353, et seq. 580 
DISEASES OF THE NASO-PHAR YNX. 
operation by incision of the soft palate, which was eradicated by 
injections of a saturated solution of chloride of zinc, twelve in- 
jections having been required, while in another, and very similar 
case, having failed to extirpate the growth by means of the ecraseur, 
forceps, and other methods, he incised the palate, and made injec- 
tions of the same preparation of zinc into the body of the tumor, 
partially through the incision made in the palate, and partially 
through the nose. After each injection, a sufficient time was allowed 
to elapse, until the slough had separated. This was usually from 
ten to twelve days. The growth was destroyed by nine injections. 
Upson 1 also reports having successfully treated three cases of naso- 
pharyngeal growth, by injections of acetic acid, for which he devised 
a special syringe, consisting essentially of an ordinary hypodermatic 
syringe, armed with a long, curved needle, over which is fitted a 
canula, by means of which the depth to which the needle is plunged 
can be regulated. These results are important as illustrating the 
success of a method of treatment which is exceedingly simple and 
requires no special manipulative dexterity. The only objection, 
however, that lies against the method, is that it involves a some 
what prolonged course of treatment, during which the patient is 
subjected to the presence of sloughing tissue, with its resultant 
fetid discharge, and disagreeable odor. 
Evulsion was the method practised by the old surgeons, and is 
undoubtedly available in all cases where the growth has not at- 
tained to a very large size. It is, however, an exceedingly harsh 
method of treatment, and does not admit of any very nice surgical 
skill, and, moreover, it is open to other and very serious objections. 
Hemorrhage, not only during the development of the tumor, but 
even during measures for its removal, is always a very serious com- 
plication, and probably no method of treatment is liable to be at- 
tended by a greater loss of blood than that of evulsion. Injury to 
the soft parts and even to the bony structures during this method, 
also, may seriously complicate the operation. Furthermore, a re- 
currence is specially liable to take place after an operation by 
evulsion, partially on account of the fact that the whole growth is 
rarely removed by this method, and in addition to this, the harsh 
method of treatment stimulates the tissues to renewed morbid ac- 
tivity, although Hortoles2 reports a case, in which the tumor was 
successfully extirpated in this manner, the growth having been re- 
moved in a large number of pieces at one sitting, the forceps being 
introduced, first through the mouth, and afterward through the 
nose, the manipulation being guided by the finger behind the palate. 
1 N. Y. Med. Record, May 14th, 1881, vol. xix., p. 557. 
2 Lyon Medicale, 1878, No. 34, p. 593. FIBROMA OF THE NASO-PHARYNX. 
581 
The curette is rarely available for growths of the size to which 
these usually attain, in that its manipulations are notably hampered, 
although Menocal 1 reports a case, successfully treated in this 
manner, access to the growth having been obtained by a transverse 
incision, made with the galvano-cautery knife, through the palate, 
at the junction of the hard and soft portions, after which its attach- 
ments were separated, by means of a small, sharp, Volkmann’s 
spoon. 
Ligation is an exceedingly old method of treatment, and consists 
in tying a stout cord around the pedicle of the growth, and tighten- 
ing it daily, until the whole growth sloughs away. This method of 
operating is open to the very serious objection, that the manipu- 
lation of a flexilbe cord, in such a manner as to place it successfully 
about one of these growths, even when the pedicle can be located, 
which is by no means always an easy matter, presents obstacles, 
oftentimes insurmountable, and when we consider the greater 
facility with which the cold steel wire can be manipulated for this 
purpose, and the greater advantages which it offers, it would seem 
that ligation is a method that should very rarely be resorted to, for 
the removal of these tumors. 
Excision, by means of the knife, presents probably the most ob- 
jectionable method of treatment of any that have yet been sug- 
gested, in that the violent hemorrhage which invariably attends this 
measure, not only greatly complicates the operation, but seriously 
endangers the life of the patient. Indeed, no small number of cases 
have been absolutely sacrificed in this manner, death occurring on 
the table. 
The potential cautery, either in the form of the red-hot iron of 
the older surgeons, or in the form of the Paquelin cautery or gal- 
vano-cautery, is a method not to be recommended, in that the de- 
struction of tissue is exceedingly slow, and an ill-smelling slough is 
formed, which renders the patient a source of offence, not only to 
himself, but to those about him. 
Electrolysis in the treatment of fibromata of the naso-pharynx, 
suggested by Nelaton2 in 1864, offers a very ingenious and attrac- 
tive method of treatment, but it is still an unsettled question as to 
how far this method is successful. In a case observed by Nelaton,3 
a tumor of large size, which had been unsuccessfully subjected to 
other methods of treatment, was eradicated by electrolysis in six 
sittings. In a case reported by Bruns4 also, of a young man, 
1 Revista de medicina y cirurgia practicas, Madrid, Dec., 1886. 
2 Gaz. des Hop., 1864, No. 87, p. 345. 
3 Robin Masse : “ Des Polypes Naso-Pharyngiens,” Paris, 1864, p. 78. 
* Berlin. Klin. Wocherschr., July 1st and 8th, 1872. 582 
. DISEASES OF THE NASO-PHAR Y'NX. 
twenty-three years of age, in whom a fibroma had recurred after an 
operation by the ecraseur three years previously, the growth was 
successfully eradicated by means of electrolysis, the treatment re- 
quiring one hundred and thirty sittings, at intervals of two or three 
days. Ciniselli1 also reports a case of a tumor which filled the naso- 
pharynx, and extended to both nares, as well as the mouth, and 
which was completely dissipated by a similar course of treatment, 
which extended over two years, the applications being repeated 
only once in three weeks. A case has been reported by Fischer2 
in which a cure was effected in six treatments, the needles being 
thrust through the soft palate into the growth, and the current 
allowed to pass for about twenty minutes. The first two applica- 
tions were made within five days of each other, but the interval 
was afterward prolonged from one, to two and one-half weeks. 
Michel3 reports having completely eradicated a growth in four 
cases, by this-means, in respectively 53, 47, 90, and 47 sittings. 
It would seem, therefore, that in this measure we have an ex- 
ceedingly feasible means of eradicating these tumors, which is 
simple in its application, is attended with no danger, and ordinarily, 
with little discomfort to the patient, and which, therefore, would be 
especially applicable in those cases in which the general health has 
become so far impaired as to increase the hazard of a radical opera- 
tion, or as even to render it absolutely unavailable. Unfortunately, 
however, we cannot expect these very satisfactory results by the 
use of electrolysis in all cases. Thus Lincoln4 found it efficacious 
only in reducing the size of the tumor to such proportions as ren- 
dered a radical operation more feasible. This was also the experi- 
ence of Paquet3 as well as Ingals,6 while in Gosselin’s case, this 
method seemed not only to prove a failure in securing a reduction 
in the size of the tumor, but became so painful as to compel a 
change in the mode of treatment. This plan of treatment is carried 
out usually by means of long slender needles, attached one to the 
positive, and one to the negative pole of a galvanic battery of 
moderate strength. These are thrust deeply into the growth, one 
being inserted into the nasal prolongation, while the other is in- 
serted through the mouth. Paquet noticed, in carrying out this 
manipulation, that dry gangrene occurred around the positive 
electrode, while moist gangrene set in about the negative electrode. 
Each sitting occupied from ten to twenty minutes and is to be re- 
1 Bull. Generate de Therap., Paris, 1864, vol. lxvii., pp. 59-69. 
2 Wien. Med. Wochenschrift, 1865, No. 6i, p. 1,113. 
3 Monatschr. fur Ohrenheilkunde, No. 5, 1887. 
3 Bull, de la Soc. Anat. de Paris, 1867, vol. xlii., p. 677. 
6 Jour. Amer. Med. Ass’n, Dec. 8th, 1888. 
4 Loc. cit. FIBROMA OF THE NASO-PHARYNX. 
583 
repeated in from about five to ten days, according to circum- 
stances. 
Where it is not convenient to insert both electrodes into the 
mass of the growth, the negative electrode may be inserted into 
the neoplasm, while the positive is attached to a sponge applied to 
the back of the neck, as was done by Ingals and Michel. 
Undoubtedly the instrument which is best adapted for the re- 
moval of the larger proportion of these tumors, is the ecraseur in 
some of its forms; and under this term, we may incude the chain- 
ecraseur, the wire-snare ecraseur, and the galvano-cautery loop. 
This latter device was the one so successfully used by Lincoln, and 
it is the one preferred by many operators. The great advantage 
which this instrument is supposed to possess, is in the claim that by 
its use hemorrhage is avoided. This claim is undoubtedly true to 
a certain extent, and yet from a practical point of view, the galvano- 
cautery snare does not control hemorrhage to the extent which is 
claimed. The principle on which it operates is, that after the wire 
loop has been successfully disposed about the pedicle of the growth, 
it is drawn snugly into its position, when the current being closed, 
the wire is heated to a white heat, and the loop slowly contracted, 
burning its way through the pedicle. Now, as we know, a white 
heat does not control hemorrhage, although a red heat will do so; 
but the dense tissue of a fibroma is not easily burned through by a 
dull red heat, and I think most operators have learned, and certainly 
it has been my own experience, that the intenser heat is required 
for the operation. Hence, I question whether this method possesses 
any other advantage than a certain rapidity of operation. Further- 
more, it is by no means an easy matter to manipulate this instru- 
ment. The placing of the soft platinum wire in position is by no 
means a simple procedure, and even after the pedicle has been 
grasped by the loop, the ordinary cautery-handle, with the Ecraseur 
attachment, is a somewhat bungling instrument to manipulate. 
Still further, I think it has been the experience of most of us in 
making use of this device, to find that the platinum wire is very 
fragile, especially when heated to a white heat, and that the operator 
is not infrequently put to great annoyance by the breaking of his 
wire, with the result, that all the difficult manipulation of putting it 
in place has to be undergone a second time. It has been recom- 
mended by a number of operators, to use the steel wire loop, in 
place of the platinum, in connection with the galvanic battery, on 
the ground that the wire possesses much greater tensile strength, 
is more easily manipulated and put in position on account of its 
rigidity, and that it is quite as easily heated for burning purposes 
as the softer metal. I have had no special experience in this direc- 584 
DISEASES OF THE NASO-PHARYNX. 
tion, but certainly would suggest that its use might very greatly 
simplify the operation. 
The cold wire snare, it seems to me, offers by far the best means 
of dealing with these growths, and of these instruments, perhaps 
none possesses the advantages of the Jarvis snare, although for this 
purpose, it should be of a larger and stouter construction than the 
one usually sold in the instrument-makers’, under this name, and 
furthermore, the screw-nut should be composed of a bar, rather than 
a round disc. Jarvis, in his original description of his instrument, 
advised the use of No. 5 steel piano-wire. For fibroma, it is well to 
use one of the larger sizes. The great advantage of the steel wire, 
as already suggested, is that the loop possesses sufficient rigidity 
to enable the operator to carry it into the nasal passages, or into 
the pharynx, and force it over the tumor, as it were, even against 
considerable resistance; although, of course, if necessary this manip- 
ulation can be materially aided by means of the finger inserted into 
the pharynx, where it is designed to embrace the growth in that 
region. Still further, where the growth is of large size, and is com- 
posed of a number of prolongations or offshoots, it is often impossi- 
ble to engage the whole mass by any device. Hence, with the steel 
wire loop, we may engage one prolongation, or one portion, at a 
single sitting, the procedure being simply to engage as large a por- 
tion of the mass within the circle of the wire loop as is feasible, 
when it should be drawn in, and slowly contracted, by means of the 
screw-nut. We thus largely avoid any hemorrhage, except such as 
may be excited by the manipulation, for we may occupy two or 
three hours, or even more, if necessary, in separating the mass, thus 
permanently closing the blood-vessels as we proceed. 
In this procedure, we simply tighten the wire by two or three 
turns of the thread, every three or four minutes. When the growth 
is entirely cut through, the separated part comes away easily, when 
an additional portion may be attacked at the same sitting, or this 
deferred for another day, according as may seem wise. Of course, 
this manipulation is greatly facilitated by the use of cocaine, which 
should be applied as thoroughly as possible, by means of the spray, 
or by pledgets of cotton wrapped on the probe. In most instances, 
I think, it will be found feasible to conduct the whole operation 
through the nasal passages, since certainly the nasal prolongations 
can be best removed in this way, after which the pharyngeal growth 
can be attacked through the same channel, by the very simple device 
of fitting the 6craseur with a loop sufficiently large to embrace the 
growth, when having drawn it well into the canula, this is passed 
through the nasal passages to the pharynx, after which the wire is 
forced out of the canula, when it immediately enlarges by its own FIBROMA OF THE NASO-PHARYNX. 
585 
elasticity, into a loop of sufficient size to fit over the growth. By 
deft manipulation, this, without further aid, can be carried around 
the tumor in the pharynx, and fitted to the pedicle. If necessary 
the finger may be inserted behind the palate, in order to carry the 
loop to its proper place. When this is accomplished, the same 
manipulation as before suggested, of slowly contracting the wire, is 
gone through with. In this connection, the following case, treated 
in this manner, is of interest: 
C. W. C., male, aged 13, consulted me January 16th, 1881, with the following 
history. Fora number of years had been subject to a mild catarrhal disorder, but 
of a somewhat trivial character, and for which no treatment had been given. 
Early in September previously, there had set in a dark reddish discharge, evidently 
composed of bloody mucus, which lasted two weeks, in connection with nasal 
stenosis, followed by recovery from all the symptoms. Early in December, he 
commenced to complain of nasal stenosis again, in connection with the 
“ dead ” character to the voice. These symptoms gradually developed, until 
a week before I saw him, when he commenced to have violent attacks of epis- 
taxis, which became so severe that I was called to see him, and found the 
source of the bleeding in a fibrous tumor of the naso-pharynx. On examina- 
tion by posterior rhinoscopy, an irregularly rounded mass was seen, almost 
completely filling the upper pharynx, of a light, pinkish tinge, and coated with 
flakes of clotted blood. Digital examination showed the mass exceedingly 
hard and dense to the touch, and bleeding easily. I contented myself, for a 
fortnight, with the application of strong solutions of tannic acid, to control 
the hemmorhages, which occurred almost daily, and with apparent success, 
for on the 1st of February I was enabled to introduce the loop of a Jarvis snare 
through one nasal passage, and embrace a prolongation of the tumor, which 
projected into the posterior nares, within its lumen. This was slowly tight- 
ened, by giving a turn to the screw every few minutes, and the growth finally 
separated in two hours and a half, dropping into the pharynx, a mass perhaps 
the size of the last phalanx of the thumb. These operations were done before 
we had any knowledge of the use of cocaine, and hence were somewhat pain- 
ful, especially the tightening of the loop—the boy wincing somewhat, every 
time the screw was turned. The piece was removed, however, with but a 
trivial loss of blood, and the patient dismissed. These operations were 
repeated on February 13th and 20th, March 6th, 13th, and 27th, on April 17th 
and 24th, and May 6th, pieces of varying sizes being removed at each sitting, 
in the same manner, and without any notable loss of blood, although always 
attended with more or less pain to the patient, resulting in the complete ex- 
tirpation of the growth. These operations were all conducted through the 
nasal passages, with the exception of the last two, which were done with the 
curved snare shown in Fig. 136, passed through the mouth for the removal 
of the small remaining portions of the tumor. In no instance was it necessary 
to insert the finger in the pharynx, for placing the loop in position. An ex- 
amination of the growth showed it to be composed of white, fibrous tissue, 
containing blood spaces and numbers of spindle cells, scattered throughout its 
substance (see Fig. 137). This boy, seven years later, showed no evidence 
whatever of return of the growth. 
This case is of interest, as illustrating how the successful extirpa- 586 
DISEASES OF THE NASG-PHARYNX. 
tion of a tumor of this sort may be accomplished in the ordinary 
course of office-practice, and without the aid of an anaesthetic, either 
local or general, although it is easy to perceive how much simpler 
the manipulation would have been rendered in the present day by 
the use of cocaine. I do not intend to suggest that the removal of 
these growths piecemeal is desirable. Certainly, we should in all 
cases endeavor to remove the whole mass at a single operation if 
possible, but where this is not feasible, I see no serious objection to 
removing the growth piecemeal, especially when this can be accom- 
plished in so simple a manner as that above detailed. After all, 
each operator will select that method of procedure with which he 
is most familiar, and in which he is most skilful, and while not in- 
tending to entirely condemn the use of the galvano-cautery loop, it 
seems to me, that where one has familiarized himself with the manip- 
ulation of the cold steel wire, he will in most cases find it a prefer- 
able instrument with which to attack growths in the nose and naso- 
pharynx. As regards the chain 6craseur, the instrument which is 
usually associated in our mind with £crasment, I think no one in the 
present day will resort to so cumbrous a device, when we consider 
that the small steel wire possesses a tensile strength which is quite 
equal to the large jointed chain of the ordinary Maisonneuve 
£craseur. The only question which remains to discuss, is the advis- 
ability of measures for the prevention of recurrence. These consist 
essentially in the cauterization of the base, after removal of the 
growth. I know of no statistics bearing directly on this subject, 
and furthermore, it is one not easy to decide. A majority of opera- 
tors, after removal of the tumor, cauterize the base. In a certain 
proportion of these cases the growths recur. Many cases have 
been reported in which the base was not cauterized, and in which 
there was no recurrence. If we eradicate these tumors at the age 
in which they usually present for treatment, namely from fifteen to 
twenty, we dismiss the patient, not only relieved from the tumor, 
but having outgrown largely the tendency to the development of 
this form of neoplasm. It, therefore, becomes exceedingly doubt- 
ful, whether cauterization has anything to do with the prevention 
of recurrence. Lincoln1 lays special emphasis on this point, and 
seems to think that his repeated cauterizations of the base were 
entirely responsible for the fact that the tumors did not recur—a 
conclusion, perhaps, which cannot be established nor controverted. 
I think, however, that after the removal of any tumor, we should 
exercise a certain amount of conservatism, in subjecting healthy 
tissues to the action of caustics, whereby a renewed activity of 
morbid growth unquestionably in certain cases is stimulated. Is 
1 Trans. Amer. Laryngol. Ass’n., 1879, p, 255. FIBROMA OF THE NASO-PHARYNX. 
587 
it not better to carefully watch the site of the growth, and be gov- 
erned in our actions by the appearances of the stump, and to act 
only on the appearance of any indication of recurrence, being con- 
fident, that certainly in the majority of cases, this will not be dis- 
covered ? As to the application of milder remedies, such as Lugol’s 
solution, so highly recommended by Dauvergne,1 or some of the 
milder caustics, such as acetic or chromic acid, I see no objection, 
although I think the potential cautery should be recognized, in this 
connection, as a device capable of doing mischief. 
1 Bull, de Therap., Paris, 1872, vol. lxxxiii, p. 499. CHAPTER XLIV. 
MYXO-FIBROMA OF THE NASO-PHARYNX. 
This is a term which is used to designate a form of neoplasm, 
occurring in this region, which is composed of fibrous connective 
tissue, with a more or less copious admixture of myxomatous struct- 
ure, and which, in consequence probably of the somewhat softer 
consistency which this admixture gives to the growth, results in the 
development of a tumor, possessing a clinical history entirely dis- 
tinct from that of pure fibroma; and, furthermore, this distinction 
is still further emphasized by the fact, as clinical experience has 
shown us, that the myxo-fibromatous tumor springs from the upper 
portion of one of the oval openings of the posterior nares, where 
the mucous membrane lining the nasal cavity proper is merged into 
the structures which we find in the vault of the pharynx. True 
fibroma, fortunately, is a much rarer occurrence than the myxo- 
fibroma, for the former involves far greater danger, both to health 
and to life, than the latter; in fact, the softer tumor really exhausts 
its capacity for mischief, as a rule, in merely giving rise to a nasal 
stenosis, with a certain amount of difficulty in deglutition, and possi- 
bly some increase or perversion of the normal secretions. The fre- 
quency with which these growths occur, is scarcely to be estimated 
by the literature of the subject, in that undoubtedly large numbers 
of these cases are met with, in every-day practice, which present no 
symptoms or complications which would render them of sufficient 
importance for publication. Nevertheless, the number of cases 
which possess points of sufficient interest to warrant their being 
recorded, is by no means small. Thus we have reports on this sub- 
ject by Gosselin,1 Cutter,2 Dumenil,3 Panas,4 St. Germain,5 Trelat,6 
Labbe,7 Coyne,8 Linon,9 Peltier,10 Gangolphe,11 and Chatellier.12 
1 Gaz. des Hopitaux, 1866, No. 39, p. 453. 
2 Boston Medical and Surgical Journal, 1870, No. 83, pp. 339-341. 
3 Bull, de la Soc. de Chir., Paris, 1873, 3d Series, vol. ii., pp. 335-344. 
4 Gaz. des Hopitaux, 1873, p. 861. s Ibid., 1874, No. 47, p. 66. 
6 Bull, de la Soc. de Chir., Paris, 1874, 3d Series, vol. iii., pp. 557-560. And also, 
Ibid., 1877, vol. iii., pp. 717-19. 
7 Annal. des Mai. de l’Oreille, Paris, 1875, vol. i., pp. 49-56. 
8 Gaz. Hebdom. de Bordeaux, 1880, vol. i., pp. 15 and 42. (Cases operated upon 
by Labbe.) 9 Bull, et Mem. de la Soc. de Chir., Paris, 1881, NewSer., vii. pp. 480-4S2. 
10 Annal. des Mai. de l’Oreille, Paris, 1882, No. 8, pp. 179-181. 
11 Lyon Medicale, 1884, vol. xlvi., p. 39. 
12 Annal. des Mai. de 1’Oreille, 1886, pp. 473-481. MYXO-FIBRQMA OF THE NASO-PHARYNX. 
589 
It is difficult to assign any direct cause for the occurrence of 
these tumors, although undoubtedly their development is influenced, 
in a manner not dissimilar from that which leads to the develop- 
ment of ordinary nasal polypi, in that they occur, not infrequently, 
in connection with myxomatous tumors, as was observed in the 
cases reported by St. Germain, Trelat, Peltier and Chatellier, the 
locality at which the morbid process has its onset seeming to domi- 
nate the character of the growth—the mucous polypi developing 
where the diseased process commences in the nasal cavity proper, 
the fibro-mucous polyp developing where the growth springs from 
the junction of the nose and naso-pharynx. Now, as we know, the 
one region is the favorite site for the development of fibroma, while 
the other region is the favorite site for the development of soft 
polyp or myxoma, the morbid process, therefore, at the junction of 
these two cavities gives rise to a neoplasm partaking of the charac- 
ters of both. Sex seems to have a certain influence, in that about 
two-thirds of the cases reported occurred in females, thus, as it 
were, striking an average between the two forms, in that the fibroma 
seems to be almost exclusively a disease of males, whereas mucous 
polypus is of more frequent occurrence in females. 
It is usually met with between the ages of fifteen and thirty, 
although apparently no age is exempt from the affection. Thus, 
Panas’s case occurred in a man aged sixty-eight. 
Symptomatology.—In the early stages of the development of 
the growth, the symptoms to which it gives rise, consist merely of 
a certain degree of interference with nasal respiration on the side 
from which the tumor springs, with possibly some hyper-secretion. 
As the neoplasm increases in size, the nasal stenosis becomes more 
marked, and the voice is to a certain extent affected, in that the 
presence of the growth robs it, in part, of its normal nasal resonance. 
Owing to the presence of a large amount of myxomatous tissue in 
the tumor, its consistency is somewhat soft, and its development is 
comparatively rapid. Hence it very soon impinges upon the soft 
palate, interfering with its movements in phonation, thus giving 
rise to a very notable impairment, not only of the quality of the 
voice, but also in the clearness of articulation. Deglutition is not 
notably interfered with, in that the tumor is freely movable in the 
pharyngeal cavity, and is lifted by the movements of the palate 
during this act. 
These growths may attain considerable size, without giving rise 
to any very marked symptoms of discomfort other than the inter- 
ference with nasal respiration, although when their presence is dis- 
covered, they not infrequently become a source of mental distress, 
and anxiety to the patient. After it has found a somewhat firm 590 
DISEASES OF THE NASO-PHAR YNX. 
resting place on the upper surface of the palate, and the pedicle is 
thereby relieved from the tension of the pendulous mass, the growth 
seems to assume a lateral direction, and also in part to become ar- 
rested, in that its increase in size goes on with much less rapidity, 
and even shows a tendency to stop at this point. The tumor occa- 
sionally protrudes itself between the borders of the soft palate and 
the posterior wall of the pharynx, but it usually is thrown back 
again into the upper pharynx, by the ordinary movements of the 
palate, and rarely shows a disposition to permanently intrude itself 
into the lower pharynx, although 
one of the cases reported by 
Coyne seems to have been of this 
nature, in that the lower border 
of the tumor rested almost on the 
root of the tongue. Epistaxis is 
never symptomatic of the fibro- 
polyp, although the ordinary fau- 
cial and bronchial symptoms 
which occur in connection with 
mucous polypi, may have their 
origin in a tumor of this charac- 
ter. Thus, in one of the cases 
which came under my own ob- 
servation, spasmodic asthma 
seemed to be caused directly by 
the existence of the growth, in 
that it was entirely and imme- 
diately relieved by the success- 
ful removal of the tumor. 
Pathology.—The essential 
basis-structure of the tumor is 
composed of bundles of white 
fibrous connective tissue, branch- 
ing and crossing one another in every direction, while scattered be- 
tween the bundles of fibrous tissue, as well as between the individual 
fibres is found a large quantity of myxomatous tissue (see Fig. 138). 
In addition to this, there are numbers of fibres of yellow elastic 
tissue, scattered throughout the growth. The relative proportion, 
however, of these elements seems to vary in different parts of the 
tumor, in that the myxomatous tissue seems to dominate over the 
connective tissue in the central portion of the growth, while the 
converse is true as regards the peripheral portions, in that here 
the myxomatous tissue seems to diminish notably as we approach 
the surface, whereas the fibrous connective tissue increases. In 
Fig. 138.—Myxo-Fibroma. £, Row of columnar 
ciliated epithelium ; L, delicate fibrous connective 
tissue with numerous lymph-corpuscles ; V, blood- 
vessel ; Fy bundles of fibrous connective tissue in a 
reticular arrangement ; /, interstices between bun- 
dles holding lymph-corpuscles. MYXO-FIBROMA OF THE NASO-PHARYNX. 
591 
this portion of the growth, however, the yellow elastic tissue be- 
comes more prominent in quantity, as compared with the white. 
In the outer portions of the tumor, and also scattered between the 
fibres, are found large numbers of round and spindle cells. The 
vascular supply is fairly rich in the central and peripheral portions 
of the tumor, while in the intermediate portions of the growth it 
seems to be to a certain extent deficient. Furthermore, it is nota- 
ble, that the round-cell infiltration is greatest in the parts immedi- 
ately about the peripheral capillaries. The pedicle is composed 
mainly of connective tissue. The tumor seems to be covered by 
the mucous membrane of the part from which it sprang, distended 
and somewhat attenuated, and covered by a number of layers of 
epithelium, the outer of which, in those parts not subjected to attri- 
tion or movement, is of the cylindrical ciliated variety, while in 
those parts which impinge upon the pharyngeal wall, the ciliae are 
destroyed, and the cells have become somewhat flattened. The 
deeper layers of the epithelium are rounded or even flattened as we 
recede from the surface. The attachment of the growth is, in the 
large majority of instances, to some portion of one of the oval 
openings of the posterior nares, usually its upper portion; although 
in one of Panas’s cases, and Trelat’s cases, the attachment was to 
the septum, while Coyne’s second case was quite unique, I think, 
in that the growth sprang from the inferior turbinated bone. 
The pathological character of the growth would seem to lend 
ground to the view that in its origin it is an ordinary mucous polyp, 
which having fallen into the pharynx, and finding room for a larger 
development, attains simply an unusual size, while at the same time 
it becomes subject to irritation from the normal movements of the 
parts, resulting gradually in the development of a denser structure 
in its outer layers, composed more largely of connective tissue, for, 
as we have seen, the central portion of the tumor is composed to a 
great extent of myxomatous tissue. This view is furthermore sup- 
ported in the fact that these tumors are met with so frequently in 
connection with the ordinary nasal polypi. Nevertheless, this idea 
falls to the ground, it seems to me, absolutely, when we remember 
that the neoplasm develops invariably from the margin of one of 
the posterior nares, a region from which, as far as I know, a pure 
myxoma has never been known to develop. We must regard, then, 
the tumor as developing primarily as a fibro-myxoma, and main- 
taining this character throughout its entire career, and simply ex- 
plain this fact on the ground that it has its origin from a tissue 
which is the meeting ground of the nasal mucous membrane and 
the membrane lining the vault of the pharynx, two regions lined 
by mucous membrane differing in a marked degree in their histo- 592 
DISEASES OF THE NASO-PHARYNX. 
logical and physiological characteristics, in one of which the pre- 
vailing form of growth is a myxoma and in the other of which the 
prevailing form of growth is a fibroma. Hence, a tumor springing 
from a region in which the structures of these two cavities com- 
mingle, necessarily partakes of the character of each, as first sug- 
gested by Panas.1 
DIAGNOSIS.—Anterior rhinoscopy would scarcely avail for a 
definite diagnosis of these tumors, although undoubtedly in many 
cases they may be seen in this manner. With the rhinoscopic 
mirror in position, however, the rounded mass of the neoplasm 
should be easily brought into view, presenting a grayish-red aspect, 
of a muddy tinge, as it were, which is presented by no other form 
of growth met with in this portion of the upper air-tract. It should 
not be confounded with a true fibroid, in that a growth of this kind 
presents a whitish-pink tinge that is absolutely characteristic, 
whereas a myxo-fibroma is a grayish opaque tumor with very little 
of the reddish hue which is met with in connection with a high de- 
gree of vascularity. In addition to this, the insertion of a probe 
will easily demonstrate the mobility of the growth, and render 
the diagnosis free from all obscurity. If any doubt should remain 
as regards the character of the tumor, the insertion of the index 
finger would prove sufficient to clear this up. It scarcely seems 
possible that a growth of this kind should be mistaken for a fibroma, 
when we consider its immobility, the high degree of vascularity, to- 
gether with the almost invariable occurrence of attacks of epistaxis 
met with in connection with the one, and the freely movable char- 
acter, and the absence of vascularity of a myxo-fibroma, and yet 
Dumenil performed temporary resection of the superior maxilla 
for a case of this kind, under the impression that he had to deal 
with a true fibroma, which would suggest that there may be occa- 
sionally serious difficulties in diagnosis in these cases. It should be 
stated, however, that Dumenil’s case was a boy eight years of age, 
and therefore the diagnosis presented difficulties much less easily 
overcome than in the case of an adult. When the growth presents 
below the palate, and is brought under immediate ocular inspec- 
tion, the diagnosis of course presents even less difficulty than when 
it is beyond the line of direct vision. In addition to this, it might 
be borne in mind, that a fibro-mucous tumor never gives rise to 
hemorrhage, facial deformity, displacement or erosion of bone, or 
any of the grave complications which attend the development of 
fibroma in the naso-pharynx. 
PROGNOSIS.—As before stated, these growths develop some- 
what rapidly at first, while subsequently their growth seems to be- 
1 Loc. cit. MYXO-FIBROMA OF THE NASO-PHARYNX. 
593 
come notably retarded, or even shows a tendency to arrest, al- 
though as regards any tendency to a retrograde processor atrophy, 
as sometimes occurs in fibroma, this, I think, has never been ob- 
served, nor, as far as I know, has there ever been observed any 
disposition to their spontaneous separation or a sloughing away. 
As regards life, however, or any serious danger to the general 
health, the prognosis is quite favorable, as the procedures by which 
they are removed, present, at the present day, no very great diffi- 
culties, and are attended with no grave dangers. After removal 
they occasionally recur, although this tendency is by no means as 
marked as in the case of myxomata. 
Treatment.—These growths being pendulous in the pharyn- 
geal cavity, and attached by a pedicle usually not larger than 
three-eighths to a half inch in diameter, their successful removal 
presents no very serious or great obstacles. If they hang below 
the border of the soft palate, perhaps the simplest method of ex- 
tracting them, is to seize the pendulous portion by a stout pair of 
forceps, the blades of which are armed with teeth of sufficient size 
to prevent the tumor escaping from its grasp, when the whole 
mass is separated by twisting the forceps in the hand, until the 
tumor comes away. This process of course is much better than 
simply tearing the growth away, in that by this means the separa- 
tion is accomplished at its attachment, whereas simple avulsion 
might result in unnecessary injury to healthy parts. It is not 
always feasible, however, to extract these growths by torsion, on 
account of their size, hence in order to facilitate the manipulation, 
and to provide more room, it may be necessary to make an incision 
in the palate, as was done by St. Germain, Panas, and Labbe. Of 
course, by this procedure, a much ampler access is obtained, either 
for torsion or such other method of operation as may be determined 
upon. The peculiar shape of the growth would seem to suggest, 
as the most rational method of operating, the use of the snare or 
ecraseur, and undoubtedly this is the device which should be se- 
lected in all cases where feasible, in that it assures the separation 
of the growth at the pedicle, and with the least injury to healthy 
tissue. The main difficulty here, however, consists in the adjust- 
ment of the loop. Linon 1 made use of a rather ingenious method 
of adjusting his loop, as follows: A Bellocq canula was passed 
through the nose into the oral cavity, when the ends of the wire 
were drawn back, leaving the loop in the mouth. A thread was 
then inserted into the pendulous portion of the tumor by means of 
a curved needle, and dropped through the loop, traction being ex- 
erted on the thread and subsequently on the wires emerging from 
1 Loc. cit. 594 
DISEASES OF THE NASO-PHARYNX. 
the nose. The loop in the fauces necessarily was made to pass up 
over the growth, and to adjust itself to the pedicle, whereupon the 
tube was slipped over the wires emerging from the nose and the 
pedicle severed by ecrasement. Of course, in these cases, the chain 
dcraseur is altogether too cumbrous an instrument. Most operators 
unquestionably nowadays will prefer the wire snare dcraseur, con- 
structed on the principle of Jarvis’s snare. An instrument of this 
kind, armed with a steel wire, supplies a loop, which in the hands 
of an operator of moderate manipulative skill, can be passed 
through the nasal cavity, and slipped over a growth even of consid- 
erable size without the aid of Linon’s ingenious method. The 
snare being adjusted with a loop that can be passed through the 
nostril, is carried through the nose to the pharynx, when by turning 
it in such a manner as to bring the loop in a horizontal position, 
the wire is played through the tube, when the loop, on account of 
the highly elastic character of the wire with which it is mounted, 
enlarges in the pharynx sufficiently to admit of its being carried 
up over the growth, by the simple manipulation with one hand. 
No doubt, this may not be accomplished at first, but a few trials, I 
think, in most cases, will enable the operator to put his loop in 
position in this manner, although, of course, additional aid if neces- 
sary can be obtained, and the placing of the loop in position assured, 
by passing the finger behind the palate, catching the loop, and 
carrying it into position. 
But three cases of this kind have come under my own observa- 
tion, in all of which the growth was extirpated by this means, nad 
with comparatively little trouble. Of these three cases, two hap- 
pened to come under my observation before the introduction of 
cocaine, and the operation was in all cases done without either local 
or general anaesthesia. The importance of using local anaesthesia 
in these operations need scarcely be mentioned, nor the very great 
aid which it renders both as anaesthetizing the parts, and contract- 
ing the blood-vessels of the nasal membrane, thus providing a larger 
cavity through which the manipulation may be accomplished. I 
should regard the steel wire dcraseur as more feasible and in every 
way preferable to the use of the galvano-cautery ecraseur, in that 
the instrument is lighter, simpler, and more easy of manipulation. 
The galvano-cautery loop is by no means so easy of adjustment, 
although it presents the possible advantage of cauterizing the base. 
I question, however, if this latter is a matter of any great impor- 
tance, as fortunately these tumors show but little tendency to recur 
when thoroughly extirpated, and it is an open question, whether 
even cauterization of the base retards this tendency in any degree. CHAPTER XLV. 
CHONDROMA OF THE NASO-PHARYNX. 
OUR knowledge of this rare disease is based entirely on the 
records of two cases, the report of which is appended in sufficiently 
full detail to afford all necessary information as regards its clinical 
history, prognosis, and method of treatment. 
Case I.—Max Muller1 reports having observed a case of enchondroma of 
the naso-pharynx in a young man, aged 29, who gave the history of a tumor 
of this region which had commenced some five years previously, and which at 
its onset giving rise merely to nasal stenosis without secretion, developed by a 
somewhat slow process, gradually filling up the naso-pharynx, and sending 
prolongations into both nares, while at the same time it extended down to the 
level of the soft palate, which was crowded forward into the oral cavity. 
The subjective symptoms consisted mainly of headaches, which were of a 
very severe character, coming on in paroxysms, and lasting from two to four 
days. Later he became subject to attacks of syncope, due, probably, to dis- 
turbance of the cerebral circulation. 
Access to the part was obtained by means of Langenbeck’s operation of 
temporary resection of the superior maxilla, and the tumor successfully removed 
by means of the ecraseur. Examination revealed it to be an enchondroma 
which had its origin from the basilar process. The operation was entirely 
successful, and there was no history of recurrence. 
Case II.—Heurtaux2 cites a case of a young girl, who for five years had suf- 
fered from gradually increasing nasal stenosis, first of the left side, and later of 
the right. In connection with these, there then developed exophthalmos, amau- 
rosis and broadening of the dorsum of the nose, giving rise to a certain amount 
of facial deformity, Examination showed the right nasal fossa to be closed by a 
deflection of the septum, the result of a tumor in the left nares, impinging upon 
it. The finger introduced behind the palate discovered a hard, dense tumor 
filling the naso pharyngeal space. In spite of the firmness of the growth the 
exploring-needle penetrated it easily. An operation for its removal being 
decided upon, access to the growth was gained by the removal of the left half 
of the nose. The tumor was found adherent to the floor of the nasal cavity, 
to the septum, and to the posterior pharyngeal wall, and had invaded also the 
antrum. Microscopic examination showed the growth to consist almost 
entirely of hyaline cartilage. The patient made a rapid recovery. 
1 Arch, fiir Klin. Chirurg., vol. xii., p. 323. 
2 Bull, de la Soc. Anat. de Nantes, Paris, 1879, Seance 21st Feb., 1877, p. 30. CHAPTER XLVI. 
SARCOMA OF THE NASO-PHARYNX. 
Malignant disease having its origin in this region would seem 
to be of exceedingly rare occurrence. Of the two forms, sarcoma 
is met with much more frequently than carcinoma. And yet in 
either form, medical literature contains the reports of such a limited 
number of cases, that a brief resume of each of these is given. 
Case I.—Cited by Brevet. The patient was a female, 50 years of age, who 
had always enjoyed good health until the cessation of the catamenial flow, at 
the age of 48. At this time, she developed symptoms of a naso-pharyngeal 
tumor, which gradually occluded the posterior nares, giving rise to nasal ste- 
nosis, difficulty in deglutition, and dead voice. In addition to this, there was 
considerable pain in the left side of the head. The patient became entirely 
deaf in the left ear, and the hearing on the right side was much impaired. 
The interference with deglutition and respiration was increased by the fact 
that the motions of the lower jaw were impeded, on account of a rheumatic 
ankylosis of the left temporo-maxillary articulation ; and at last the patient 
sought surgical advice. At this time she was found to be suffering from a 
tumor, situated in the pharyngeal vault, to the left of the median line, and 
almost completely occluding the left posterior nares; the tumor was adherent 
to the soft palate as well as the posterior pharyngeal wall. The growth was 
removed after extirpation of the left superior maxilla. The patient recovered 
from the operation. The further history is not given. 
A microscopic examination showed the growth to be a sarcoma, made up 
of oval cells for the most part, with an admixture of round and spindle cells, 
together with some white fibrous and elastic tissue. The growth was 
not encapsulated, and the demarcation between healthy and diseased tisuse 
was ill defined. 
Case II.—Reported by Bryk.2 A male, aged 24, presented with the history 
of a naso-pharyngeal tumor, dating back for a number of months, and which 
in six months past had attained such proportions as to project into the lower 
pharynx, and crowd the palate forward into the oral cavity, giving rise to nasal 
stenosis and difficulty in deglutition, with marked impairment of the general 
health. For three months there had been severe attacks of dyspnoea, which 
compelled the patient to maintain the sitting posture. When first seen, the 
tumor extended down to the level of the larynx, and was of a somewhat dense 
and elastic nature. There was total deafness, although no evidence of further 
extension was shown by facial deformity or other symptoms. Preliminary 
1 These de Paris, 1855, No. 117, p. 36. 
2 Wien. Med.-Halle, 1862, vol. iii., No. 33, pp. 311, 320 and 328. SARCOMA OF THE NASO-PHARYNX. 
597 
tracheotomy was done, and the growth removed by means of the galvano- 
cautery snare eight days later, followed by death at the end of twenty-one 
days from erysipelas. The tumor was a spindle-cell sarcoma, of a medullary 
character. 
Case III.—Reported by Verneuil.1 Verneuil reports a case, occurring in a 
female, aged 40, who presented with a faucial tumor, which had existed for 
three months, and which latterly had given rise to notable symptoms of diffi- 
culty in deglutition, and gastric disturbance, together with some dyspnoea. In 
addition to these, there was tumefaction of the right side of the neck. Faucial 
examination revealed the existence of a growth, about the size of a hen’s egg, 
crowding the palate forward, and projecting into the lower pharynx. There 
was also exophthalmos, convergent strabismus, deafness, and facial paralysis 
of the same side. Headache was also a prominent symptom. No operation 
was attempted in this case, and the patient died two months later, as the result 
of pulmonary congestion. Examination showed that the tumor, which having 
its origin from the sphenoidal apophysis, had invaded the basilar process, and 
extended down the lateral wall of the pharynx, and finally made its way into 
the external tissues of the neck. The brain cavity was also invaded, by exten- 
sion from its primary point of origin. 
Case IV.—Reported by Neureuter.2 Neureuter reports the case of a boy, 
aged 8, who presented with a history of a tumor of the naso-pharynx, 
which had first manifested itself two years before, and which had assumed 
such proportions as that it completely filled the naso-pharynx, and protruded 
into the oral cavity, crowding the palate forward. There was very marked 
impairment of general health, with difficulty of swallowing, and attacks of 
dyspnoea. No radical operation was attempted, but pieces were removed by 
various methods, simply as a palliative measure. One month later, tracheotomy 
became imperative, and the patient died at the end of another month, the 
tumor having made its appearance in the neighborhood of the parotid gland 
externally. The cause of death was inanition. The tumor is reported as sar- 
coma, although the special characteristics are not given. Autopsy revealed 
that it had its origin in the naso-pharynx, and successively invaded the nasal 
passages, the orbit, and made its exit upon the cheek, through the pterygo- 
maxillary fissure. 
Case V.—Reported by Boeckel.3 A boy, aged 19, presented with the his- 
tory of nasal symptoms, dating back two months, giving rise to nasal stenosis, 
a moderate discharge of foul pus, streaked with blood, together with consider- 
able neuralgic pain, referable to the right side of the face. An examination 
revealed the pharynx occupied by a rose-colored tumor, of considerable size, 
which extended down to the border of the soft palate, which was crowded 
forward into the oral cavity. There was also some impairment of the general 
health. Temporary resection of the superior maxilla was done, and the tumor 
extirpated, which was found to have its origin in the basilar process of the 
occipital bone. The growth was found to be sarcoma. The operation was 
successful, but erysipelas supervened from which the patient recovered. Death 
occurred, a month after the removal of the growth, with pulmonary symptoms. 
An autopsy showed generalization of the disease, large masses of sarcomatous 
tissue being found in the lungs. 
1 Bull, de la Soc. Anat., .1867, p. 256. 
2 Wien. Med. Presse, 1871, xii., p. 590. 
3 Gaz. Med. de Strasbourg, July 1st, 1872, No. 2, p. 18. DISEASES OF THE NASO-PHARYNX. 
598 
Case VI.—Reported by Demarquay,1 who removed from a woman, aged 
48, a naso-pharyngeal growth, which recurring three months later, led her to 
seek his advice again, when he discovered that the tumor had not only recurred, 
but had now filled the naso-pharynx, and extended into the antrum. Some- 
what against his judgment, he operated by the removal of the upper jaw, but 
before the operation was completed, the patient died on the table, from suffoca- 
tion, blood having entered the trachea and bronchi. The autopsy revealed the 
neoplasm to be sarcomatous in character, its origin being reported as from the 
third and fourth cervical vertebrae, although it seems probable that this was 
merely an extension of its primary site from the basilar process, in much the 
same manner as occurs in fibroma, as suggested by Nelaton. 
Case VII.—Reported by Veillon.2 A male, aged 14, presented the follow- 
ing history: Two months previously he commenced to suffer with severe 
pains in the pharynx, followed soon by indications of the existence of a tumor 
in that region, which gave rise to impairment of function and voice. The 
pains increased in severity, and were marked by nocturnal exacerbations. 
There was no hemorrhage at this time, although subsequently this became a 
very prominent symptom. When first seen, the growth had attained consid- 
erable size, giving rise to external facial deformity, exophthalmos, and pro- 
truded into the pharynx in such a manner as to crowd forward the soft palate, 
while at the same time respiration was notably interfered with. There was 
no secondary glandular infiltration. An operation was commenced by Ver- 
neuil, consisting of resection of the nasal bones, with a portion of the supe- 
rior maxilla. A piece of the tumor was examined during the operation and 
discovered to be a sarcoma ; further procedure was abandoned. The patient 
subsequently developed evidences of generalization of the sarcoma, as shown 
by polyuria and haematuria, and died three months after the first symptom 
manifested itself, having developed well-marked brain symptoms. An autopsy 
showed that the tumor, having its origin in the basilar apophysis, had succes- 
sively invaded the nasal cavity, orbit, the zygomatic fossa, and the anterior part 
of the base of the brain, and also had made its appearance in the thoracic and 
abdominal viscera. 
Case VIII.—Reported by Marjolin.s A female, aged 41, presented with a 
history of a tumor in the naso-pharynx, which had existed for a year, and 
which finally gave rise to difficulty in swallowing, with obstruction to nasal 
respiration. There was also a notable amount of infiltration of the cervical 
glands. There seems to have been considerable hesitancy as regards the 
diagnosis, and the patient was subjected to general medication, in spite of 
which the tumor continued to enlarge, until it had crowded forward .the soft 
palate, and even displaced the hard palate, extending as far as the anterior 
dental arch. The general health became very greatly impaired, partially as 
the result of mal-nutrition, on account of the difficulty in swallowing, and par- 
tially as the result of the general influence of the growth. Hence, no opera- 
tion was attempted, and the patient succumbed two months later, from suffo- 
cation from the passage of food into the air tract, owing to her inability to 
swallow. An autopsy showed that the growth, having its origin in the basilar 
process, had successively invaded the pharynx and nasal cavities, and had also 
involved the glandular structures of the neck. The basilar process, and the sella 
turcica were completely destroyed, although the dura mater was found intact. 
1 Gaz. des Hopitaux, 1873, p. 805. 
3 As cited by Veillon, loc. cit., p. 27. 
2 These de Paris, 1874, No. 463. SARCOMA OF THE NASO-PHARYNX. 
599 
There seems to have been some question as to the character of 
this tumor, although Veillon reports it as an undoubted sarcoma. 
Case IX.—Reported by Veillon.1 Veillon reports a second case, as having 
occurred in Nelaton’s service, of a young man, aged 17, in whom a tumor had 
developed in the naso-pharynx, and subsequently gave rise to exophthalmos, 
and atrophy of the optic nerve. An operation was done, and that portion of 
the growth within reach, removed. This was followed by a marked improve- 
ment of the symptoms for a few weeks, after which the patient succumbed to 
invasion of the brain. 
This case was reported by Nelatonas a naso-pharyngeal growth, 
but is reported by Veillon as sarcoma. 
Case X.—Reported by Eppinger.2 He reports the results of a necropsy, 
in a male, 45 years of age, who had suffered with sarcoma of the pharynx. The 
growth arose from the pterygoid process of one side, and extended downward 
along the inner surface of the right ramus of the inferior maxilla, and along 
the left side of the bodies of the cervical vertebrae. 
The growth also extended in an upward direction, and broke through the 
base of the skull, invaded the ethmoid, and partially filled the right middle 
fossa of the skull, so that the brain was compressed, and the convolutions 
flattened. The neoplasm was an alveolar sarcoma. 
Case XI.—Reported by Depres.3 A case of a male, aged 36, who showed 
symptoms two months previously of a commencing tumor in the naso-pharynx, 
which gave rise to some nasal stenosis, which when first seen, had developed 
to the extent of completely filling this cavity, projecting into the lower pharynx, 
and crowding the palate forward into the mouth. There was considerable 
difficulty in deglutition, but no impairment of general health. The cervical 
glands were slightly enlarged, although this may have been due to the inser- 
tion of a seton, which had been made some months before. Depres proposed 
to extirpate the tumor, after an incision through the palate, but no further 
report is given. 
Case XII.—Reported by Schmid.4 A case of myxo-sarcoma, occurring in 
a female, 48 years of age, with no hereditary history of malignant disease. 
She presented with the history of having been troubled for about a year with 
naso-pharyngeal catarrh, with nasal stenosis, and severe epistaxis, and a feel- 
ing of oppression in the naso-pharynx. There was difficulty of deglutition, 
and the foul discharge from the tumor, both into the nose and throat, had 
seriously interfered with the nutrition of the patient. The growth had attained 
such a size at the time of examination as to interfere with respiration, and to 
be visible below the border of the soft palate. It was apparently pedunculated, 
and appeared to arise from the vault of the pharynx. 
Gussenbauer’s operation was performed, and the growth was found to invade 
the left antrum, but was thoroughly extirpated. Three weeks after this there 
was a recurrence which necessitated the extirpation of the superior maxilla. 
Several operations followed, at short intervals, for recurrence, until finally the 
tumor had evidently involved the base of the skull, beyond the reach of oper- 
ative interference. A microscopic examination proved the growth to be a 
myxo-sarcoma. 
1 Loc. cit. 2 Vierteljahresschrift fur prakt. Heilk., 1875, No. 2, p. 8. 
3 Revue de Tfier. Med-Chir., 1877, p. 283. 
4 Prag. Med. Wochenschr., 1881, vol. vi., p. 274. 600 
DISEASES OF THE NASO-PHARYNX. 
Case XIII.—Reported by Weir.1 Weir reports the case of a boy, aged 
8, who presented with the history of nasal stenosis, and discharge, dating 
back one year, for which he had been subjected to several plans of treatment, 
without avail, the symptoms being due to a tumor in this naso-pharynx, which 
when first brought under observation, completely filled this cavity, and sent 
prolongations into the nasal passages of both sides, and at the same time pro- 
jected into the lower pharynx, and crowded the palate forward into the oral 
cavity. Access to the tumor was obtained by Nelaton’s operation, of resection 
of the hard palate, without preliminary tracheotomy. This, however, became 
necessary during the operation, on account of the entrance of blood into the 
trachea. The operation was finished, and the growth removed, but the patient 
died almost immediately upon its completion. Examination showed the 
growth to be a fibro-sarcoma, springing from the basilar process of the occip- 
ital bone. 
Case XIV.—Reported by Burnett.2 A case of a physician, 45 years of age, 
suffering from sarcoma of the pharyngeal vault, in whom the first symptom 
which attracted the patient’s attention, was steadily-increasing deafness, 
chiefly in the left ear, together with autophony, and a sensation of fluid in the 
tympanic cavity. Examination revealed fluid in both tympanic cavities, and 
paracentesis was done, with relief of the symptoms, although the procedure 
had to be frequently repeated, as the fluid re-accumulated rapidly. In addition 
to the aural symptoms there developed some nasal stenosis, and pain in the 
back of the neck. The patient also began to emaciate. Close questioning 
elicited the fact, that almost a year before, he had suffered from several attacks 
of epistaxis, and from this time on the nasal intonation became noticeable. 
Examination revealed a hard tumor, about the size of a chestnut, on the 
left side of the pharyngeal vault, close to the left choana ; a fragment scraped 
off, and subjected to a microscopic examination, was found to be made up of 
small round cells. The patient refused operative interference, and finally died, 
four and one-half months after he was first seen, from inanition, the tumor 
interfering seriously with deglutition, and also with some evidence of cerebral 
involvement. There was no autopsy. 
Case XV.—Reported by Lincoln.3 A case of a boy, aged 16, who presented 
with the history of nasal stenosis, dating back nearly three years, in connec- 
tion with which he suffered from repeated attacks of epistaxis. On examina- 
tion, a growth was found, apparently springing from the vault of the pharynx, 
and more or less completely filling that cavity, while at the same time a pro- 
longation extended into the right nasal passage. The general health was 
notably impaired. The removal of the growth by the galvano-cautery was 
decided upon, and with this design, the wire loop was carried through the 
nasal passage, by means of a double canula, and subsequently adjusted around 
the growth, with the aid of the index finger passed behind the palate. The 
separation of its attachment was successfully accomplished, when the whole 
growth came away through the mouth. The mass weighed oz., the cut 
surface measuring 2 inches by 1An histological report of the case, by Dr. 
George R. Elliott, showed it to be a fibro-sarcoma, the fibrous tissue predom- 
inating. This case is interesting, as illustrating the exceeding slowness with 
which a tumor may develop, and also a notably successful operation, by means 
1 New York Med. Record, June 3d, 1S&2, p. 607. 
2 “A Treatise on the Ear,” Phil., 1884, p. 437. 
3 New York Med. Record, Oct. 25th, 1884, p. 455 SARCOMA OF THE NASO-PHARYNX. 
601 
of the galvano-cautery ecraseur. It is unfortunate, however, that no further 
report was obtainable, in that the patient disappeared from observation. 
Case XVI.—Reported by Massei.1 A case of a young man, aged 18, in 
whom a sarcomatous tumor developed in the naso-pharynx, which at the end 
of two years had grown to a large size, completely filling the cavity, and 
extending into the lower pharynx, crowding the soft palate forward into the 
mouth. The prominent symptoms were pain, epistaxis, difficult deglutition, 
dyspnoea, complete loss of the sense of smell, and deafness. There was an 
offensive discharge, with notable impairment of the general health. Its re- 
moval was successfully accomplished by means of the galvano-cautery ecraseur, 
the loop being placed in position with the aid of a Bellocq’s canula and the 
index finger in the fauces. No further history of the case is given. 
Case XVII.—Reported by Annandale.2 A young man, aged 20, was suf- 
fering from a large growth in the naso-pharynx, which, arising from the base 
of the skull, had crowded the soft palate forward and become adherent to it. 
The growth had attained such a size as to obstruct respiration, and operative 
interference became necessary. A preliminary tracheotomy having been 
done, Annandale performed his operation of separation of the superior max- 
illae, the soft palate having also been divided in the median line. The growth 
was removed with forceps, and the patient recovered from the operation, but 
the growth recurred. It was found, upon microscopical examination, to be a 
sarcoma. 
Case XVIII.—Reported by Bryant.3 This case is interesting, from the 
rather novel procedure adopted for its control, and the success which attended 
it. The patient was a male, 22 years of age, who, since 1884, had been con- 
scious of nasal obstruction of the left side. 
About a year later, portions of a growth were removed with forceps : from 
that time until May, 1888, portions were removed from time to time, with the 
snare or forceps. The microscope showed the tumor to be a myxo-sarcoma. 
The patient grew steadily worse, and had several severe hemorrhages which 
weakened him very much. In May, 1888, the growth was causing severe pain, 
due to pressure, the hard and soft palates were displaced, and the tumor com- 
pletely filled the pharyngeal vault, causing complete stenosis. 
On June 19th, both external carotids were tied, and at the end of a week the 
neoplasm had diminished veiy much in size from the procedure. A few days 
later, the superior maxilla was excised. The subsequent treatment consisted 
in removing portions with the snare, and also by the injection of strong car- 
bolic acid, which caused a sloughing away of portions of the neoplasm. These 
injections were soon abandoned, on account of the pain which they caused. 
From this time no treatment was pursued, and the growth has continued to 
decrease in size, and has ceased to be a source of annoyance. The operator 
believes that the improvement has been almost entirely due to the ligation of 
of the carotids cutting off the blood-supply to the tumor. 
All of the above cases seem to have been rounded masses, 
forming in many cases encapsulated growths. The following case, 
which came under the care of the author,4 seems somewhat unique, 
1 Archivii Ital. di Laringologia, fasc. iii., 1887. 
2 Lancet, Jan. 26th, 1889, p. 162. 
3 N. Y. Med. JouKnal, May nth, 1889. 
4 New York Medical Record, Jan. 17th, 1885. 602 
DISEASES OF THE NASO-PHARYNX. 
in that it was a case, which starting in the naso-pharynx as a dis- 
tinct tumor, subsequently became a diffuse sarcoma, which suc- 
cessively invaded and infiltrated the tissues of the soft palate, right 
pillar of the fauces, tonsil, and the mucous membrane lining the 
lower pharynx. It is of still further interest, with reference to the 
method of treatment, and the ultimately successful cure of the 
disease. 
Case XIX.—J. T. H , aged 42, a gentleman prominent in public life in 
one of our Western States, consulted me on June 26th, 1882, at the request of 
Dr. Henry Evans, of Sedalia, Mo., giving, the following history : When a child 
he fell, receiving a blow upon the nose which resulted in a deflection of the 
septum by which the right naris became almost completely occluded. This 
caused but little annoyance in early life, but for several years he had been 
much troubled with an ordinary nasal catarrh. During the spring of 1882 he 
was under treatment for this, but with no marked relief. About February 15th, 
1882, his physician discovered a tumor in the vault of the pharynx, which he 
regarded as a glandular hypertrophy. The patient, however, had been con- 
scious of a fulness in this region for some months previously, and had at the 
same time been conscious of an increasing faucial secretion. Local treatment 
was applied to this for about two months, until April 13th, when a portion was 
removed with the forceps, which upon examination was pronounced benign in 
character. 
He went to Missouri about May 1st, remaining six weeks. While in Sedalia, 
early in June, Dr. Evans saw him, and after a careful examination of the growth 
pronounced it malignant, and advised him to come immediately to New York. 
I might mention in this connection, that on his way to New York he saw Dr. 
William Porter, of St. Louis, and Dr. Cohen, of Philadelphia, who regarded 
the growth as malignant, and gave an unfavorable prognosis. 
By this time the discharge from the tumor had become exceedingly fetid and 
offensive, and considerable in amount. His general health also had become 
markedly impaired. 
On June 26th he came to my office. At that time he was in an exceedingly 
enfeebled condition, the walk to my house, and the climbing my steps causing 
him considerable effort. He was noticeably emaciated, the skin of a sallow, 
unhealthy color, the pulse 120, and temperature ioi°. On examination of the 
fauces there was noticed a brownish, unhealthy-looking discharge from the 
pharyngeal vault, which gave forth an exceedingly unhealthy odor. The soft 
palate was of a dark-red, mottled appearance, especially on the right half, and 
seemed to be crowded forward by a growth behind it. By palpation, a hard 
dense mass was felt, of a rounded and slightly irregular outline, which seemed to 
fill the pharyngeal cavity and extend down to the edge of the soft palate. On lift- 
ing the velum with a probe, the lower edge of the mass was brought into view, 
of a pale pinkish color, and pultaceous aspect. The palato-pharyngeal space 
was completely blocked up. Protruding between the growth and the palate 
were a number of blackened shreds of necrosed tissue. 
The whole aspect of the case was most discouraging, as I felt convinced 
that the tumor was malignant. Furthermore, any question of a radical 
operation was not to be thought ©f, his general condition being such, that I 
had little hope of his surviving such a procedure. The plan of treatment that 
I decided upon, was to remove the tumor piecemeal, taking off small masses at SARCOMA OF THE NASO-PHARYNX. 
603 
a time, and in such a manner that all shock to the system should be as far as 
possible avoided. This was accomplished by means of the wire snare ecraseur, 
the instrument I used being the curved modification of Jarvis’ snare seen in 
Fig. 136. The snare being mounted with No. 5 piano wire, a small loop was 
arranged, and pressed upon a small portion of the border of the growth, and 
the screw being turned, the loop would bury itself in the soft tissue, and in 
this manner, a portion perhaps not larger than a split pea, would be taken off. 
In this manner, several small pieces were removed the first day I saw the 
patient. Immediately on cutting off a piece of the tumor, the parts were 
showered with a weak solution of borax and carbolic acid, until all pain and 
irritation were allayed. In this manner I operated every day, removing small 
portions successively, until my patient was too much wearied to proceed. 
A piece of the growth was sent to Dr. William Welch, who reported on 
June 30th: “The specimen consists of a number of fragments, the largest the 
size of a small bean. Their consistency is rather soft. After hardening with 
alcohol, sections were prepared and examined microscopically. The surface of 
the specimen is covered with laminated flat epithelium. Beneath this, the 
new growth begins at once. This new tissue is composed of lymphoid cells, 
chiefly, between which is a reticulum of anastomosing fibres. In addition, 
there are some fusiform and branching cells, and here and there giant cells, 
the nuclei of which are mostly in the centre of the cell. The structure is there- 
fore like that found in lymphatic glands, and called lymphatic or adenoid tissue. 
There is no alveolar arrangement to be observed. The growth is therefore a 
sarcoma. The main features are those of lympho-sarcoma, but the type is 
somewhat mixed, by the presence of the giant cells.” 
From June 26th to July 12th, I saw him daily, and operated as above, re- 
moving a number of pieces. His condition at this time became somewhat 
alarming. His strength was failing, and he was suffering much from neuralgia 
of the face. I therefore sent him to the sea-shore near the city, where I could 
continue my daily attendance. A few days at the sea-shore seemed to revive 
him greatly. 
By July 16th, I had removed a considerable extent of the lower portion of the 
growth, and now came upon a large necrotic mass, embedded in the growth, 
which I was enabled to remove. This was about the size of a walnut, and 
seemed to be a superficial slough, the result of pressure exerted on the surface 
of the tumor, the different lobes, as it were, growing from the sides of the 
pharynx, and crowding upon each other. With the removal of the slough, the 
neuralgic pain was relieved, the fetid discharge and offensive odor disappeared, 
and in every way his general health improved. He had evidently been suffer- 
ing all this time with a mild septicaemia, the result of absorption from this 
necrotic mass. 
July 23d.—The parts from which the growth had been extirpated were 
cauterized with the galvano-cautery, resulting in some inflammatory reaction, 
which compelled me to desist from operative measures for several days. 
July 30th.—The growth is so far cleared away, that its extent can be seen in- 
volving the whole of the upper pharynx, and its lateral walls, surrounding the 
Eustachian orifices of each side, and forming a fringe, as it were, about each 
posterior naris, but not extending into the nasal cavities. There was also 
found to be a long fusiform mass, extending along the upper surface of the 
soft palate, from the right side of the uvula to its junction with the hard pa- 
late. His general condition was now everything that could be desired, and 
rapid progress was made in removing the growth. I might add here, that the 604 
DISEASES OF THE NASO-PHARYNX. 
loop was placed in position in the pharyngeal vault by means of the rhinoscopic 
mirror, the patient holding the spatula in one hand, and drawing forward his 
palate by a palate-hook with the other. The galvano-cautery was again used 
over the surface operated upon, followed by inflammatory reaction, not very 
well marked, however. 
August 4th.—Galvano-cautery used. 
August 8th.—Returned to the city; doing well. 
August 15th.—Galvano-cautery ; considerable reaction. . 
August 27th.— Galvano-cautery used; reaction very marked, so much so 
that the operation had to be given up for several days. 
At this time I sent a specimen of the growth removed from the vault of the 
pharynx to Dr. Charles Heitzman for examination. His report was as follows : 
“Numerous medullary corpuscles, greatly varying in size and shape, some nu- 
cleated, others coarsely, others, again, finely granular, are closely pasted to- 
gether, and separated from each other by scanty cement-substance,'or fibrous 
basis-substance. The blood-vessels traversing the tissue are very scanty. 
Diagnosis; round-cell sarcoma, or globo-myeloma of a very malignant type. 
Tumors of this kind, after extirpation, almost invariably recur, and within a 
few months or years cause a fatal termination.” 
September gth.—Galvano-cautery used, and following this there was a very 
marked aggravation of all the symptoms; the growth on the soft palate as- 
sumed an angry and threatening aspect. 
September 12th.—The growth on the soft palate extended through the pa- 
late and down on the right tonsil and anterior pillar of the fauces. I now re- 
moved a number of pieces from the soft palate and tonsil. 
September 20th.—There appeared a new centre of development in the 
lower pharynx, and on September 25th, it had so far extended, that it now in- 
volved the right half of the oro-pharynx, down to the level of the epiglottis, 
the right tonsil, the right anterior pillar of the fauces and a portion of the soft 
palate, part of the palate having been removed. There was also a considerable 
portion of the growth remaining in the pharyngeal vault. The whole aspect 
of the case was most discouraging. 
Dr. Frank H. Hamilton and Dr. Beverley Robinson now saw the patient 
with me in consultation, and both expressed the opinion -which I entertained, 
that the case was hopeless. 
I felt convinced, however, by this time, that the galvano-cautery was re- 
sponsible in no small degree for the bad turn which the case had taken, and 
determined to follow out my origipal plan of procedure, but without the cau- 
tery. At each later application of the cautery, a notable inflammatory reaction 
had set in, and this had been more marked with each successive application, 
and finally there were grounds for thinking that the reaction and rapid exten- 
sion of the tumor were in no small degree due to its use. 
Following the plan, then, of removing the growth piecemeal, while at the 
same time every possible precaution and care was exercised in avoiding any 
unnecessary irritation of the parts, I dispensed entirely with all caustics or 
other application. As each piece was removed, the part was showered with 
the carbolized alkaline spray, till all pain was arrested, and after each opera- 
tion the cut surface was coated with vaseline. In this manner, I very soon 
commenced to make headway again, and from this time on, matters com- 
menced to improve, and with no single untoward symptom developing. I finally 
completely removed the last portion of the growth, and discharged my patient 
on November 4th, 1882. SARCOMA OF THE NASO-PHARYNX. 
605 
Since that time I have occasionally seen the patient, the last time within 
a few months, and now at the end of nearly seven years, I think that any pos- 
sibility of a recurrence can be entirely dismissed. 
This case has been reported very fully, and at considerable 
length, but it has seemed to me that this is fully justified in view 
of the fact that it is the only case of recovery yet reported from a 
sarcoma of the naso-pharynx, a result which I think without doubt 
was entirely owing to the method of treatment adopted for its 
eradication. 
In addition to the above, Thomas1 reports the case of a girl, 
aged fourteen, who presented with a history of nasal stenosis and 
deafness, due to a growth in the naso-pharynx, which on examina- 
tion was found to be of sufficient size as to block the orifice of the 
left Eustachian tube, together with the posterior nares of that side. 
The neoplasm was removed by means of Woakes’s post-nasal for- 
ceps, the patient being in Rose’s position. This case is reported as 
one of naso-pharyngeal sarcoma, yet there is no histological exami- 
nation of the growth given, and no further report of-the case. I 
am disposed to think, therefore, that this case scarcely warrants 
record as one of malignant disease. 
Duffield, in a letter to the American Lancet, April, 1887, p. 
125, also describes having seen Wahl, of Dorpat, perform Bruns’s 
operation on the nose, after which a sarcomatous tumor of the 
naso-pharynx was extirpated, by means of a curette. This case, 
however, as far as I know, has never been fully reported. 
ETIOLOGY.—Sarcoma is usually regarded as belonging rather to 
the earlier period of life. This is true as compared with carcinoma, 
and yet in the nineteen cases, above reported, there occurred: 
Between 1 and 10 years of age .... 2 
“ 10 and 20 “ “ .... 5 
“ 20 and 30 “ “ .... 3 
“ 30 and 40 “ “ .... 2 
“ 40 and 50 “ “ .... 7 
Sex seem to exercise a notable influence, in that 14 of the cases 
occurred in males, while but 5 were in females. This excess is 
easily accounted for when we consider that sarcomatous tumors be- 
long to the connective-tissue series, and bear a certain relation, 
therefore, to fibrous tumors, which as we know, occur almost exclu- 
sively in males. 
Symptomatology.—In the early stages of the development of 
these growths, they give rise to no symptoms which differ in any 
notable degree from those caused by the existence of any form of 
1 Australasian Medical Gazette, 1885-87, p. 164. 606 
DISEASES OF THE NASO-PHAR YNX. 
tumor in this region which has attained sufficient size to impede 
normal nasal respiration, unless possibly the character of the secre- 
tion may possess symptomatic indication, as in most cases of sar- 
coma this is somewhat peculiar, in that it is of a sero-mucous, 
ichorous character, and usually quite offensive. This symptom 
manifests itself quite early in the history of the case, and is present 
in the majority of instances. Epistaxis also is liable to occur some- 
what early, although it is not a prominent symptom, occurring in 
perhaps from one-third to one-half of the cases. The attacks, how- 
ever, are rarely severe, or frequently repeated, and never become 
a grave symptom, as occurs in cases of fibroma. The general 
health seems to suffer also somewhat early in the history of the 
case, not that there is any special sarcomatous cachexia, nor does 
it appear to be due to any mechanical interference with respiration 
or deglutition, for in many instances it is observed before the tumor 
has attained such dimensions as to give rise to these symptoms. I 
take it that this impairment of the general health is due in no 
small degree to the offensive character of the discharge, which un- 
doubtedly acts in a certain measure to impair digestion, and to 
vitiate the inspired air. The patient, in fact, lives in an atmosphere 
poisoned constantly by the offensive ill-smelling discharges from 
the tumor. Moreover, when we consider that so many of these 
cases occur during youth, I think we must recognize the interfer- 
ence with respiration, and its consequent impairment of the proper 
oxygenization of the blood, as forming an important factor in pro- 
ducing impairment of the general health, as is observed so fre- 
quently in connection with the benign growths in this region. As 
the growth develops in size, the additional symptoms of difficult deg- 
lutition, with recurrent attacks of dyspnoea, set in. The encroach- 
ment of the tumor upon the orifice of the Eustachian tube, natu- 
rally leads to the early development of impaired hearing, or the 
complete loss of this function. In Massei’s case, there was suppu- 
rative otitis in both ears, although this occurred after an operation, 
and was possibly its direct result. 
Pathology.—The origin of these growths is usually from the 
basilar process of the occipital bone, starting in the deeper layers 
of the mucous membrane lining the part, developing in the form of 
rounded, somewhat lobulated growths, which extend downward, 
forming a veil, as it were, over the posterior nares, and which more 
or less rapidly increase in bulk, while at the same time the attach- 
ment slowly extends over a larger area. As they develop, they send 
prolongations into one or both nasal cavities, but the activity of the 
growth usually seems to be downward, gradually encroaching upon 
the lower pharynx, and crowding forward the soft palate. They SARCOMA OF THE NASO-PHARYNX. 
607 
are usually of soft consistency, and do not seem to possess the 
power of displacing the hard parts, or causing their destruction, 
although in Veillon’s first case, the basilar process was perforated, 
and the brain invaded. This, however, was probably not the result 
of erosion by pressure, but more likely due to the fact, that the 
disease invaded the bony structures. In Marjolin’s and Eppinger’s 
cases also, the basilar process was destroyed in the same manner. 
In both Veillon’s cases, and also in Verneuil’s, the orbital cavity 
was invaded by prolongations of 
the tumor through the sphenoidal 
fissure, while in Neureuter’s and 
Marjolin’s cases, prolongations 
extended through the spheno- 
maxillary fissure, and invaded the 
tissues of the neck. In most of 
the instances above recorded, the 
tumor preserved its individuality, 
or distinct outline, during its 
whole history, with the exception 
of Case I., cited by Brevet, and 
Case XIX., reported by myself, in 
which at the end of three months 
it changed its character, in that it 
became diffused, and extended 
by a somewhat rapid progress, 
infiltrating the mucous membrane 
of the fauces. From the histo- 
logical point of view, these 
growths differ in no essential de- 
gree from a sarcoma of the nasal 
cavity; the microscopic charac- 
teristics of the tissue need not be repeated here. Fig. 139 illus- 
trates the appearance found in the author’s case (Case XIX). 
DIAGNOSIS.—In appearance, these growths present an irregular, 
rounded, somewhat lobulated aspect, with a grayish-yellow, muddy- 
looking color, with perhaps a pinkish tinge, according to the rich- 
ness of their vascular supply. They have the appearance to the 
eye, of a soft, pultaceous mass, which is verified by palpation with 
the finger. Their general aspect is apparently midway between 
the somewhat translucent appearance of a myxomatous tumor, and 
the pinkish-white, dense, opaque look of a fibroma. Their recog- 
nition, however, by mere ocular inspection, either by direct vision or 
the rhinoscopic mirror, can rarely be depended upon, and our only 
means of certain diagnosis, lies in a removal of a piece of the 
Fig. 139.—Round-Cell Sarcoma of the Naso- 
pharynx (Case XIX.). E, Remnants of epithe- 
lium; C, dense fibrous connective tissue carrying 
capillaries; Z, large round-cell sarcoma; S, small 
round-cell sarcoma; V, V, sinuous veins. 608 
DISEASES OF THE NASO-PH AT VAX. 
growth for microscopic examination. This procedure is easily ac- 
complished by a sharp cutting forceps, or the cold wire snare. 
Suspicion should be excited always, by the peculiar character of 
the discharge, which, as before stated, is of an ichorous and some- 
what offensive character, but usually thin and watery, in contra- 
distinction to the more purulent character of the discharge from a 
carcinomatous tumor. Furthermore, the hard, dense feeling of a 
carcinoma to the touch, is notably different from the softer con- 
sistency of the less malignant tumor. 
The character of the tumor having been recognized, it becomes 
a matter of some importance to determine whether it arises in the 
nasal cavity, or in the naso-pharynx. This problem presents diffi- 
culties not always easy of solution. The points of difference already 
made in this connection in the discussion of naso-pharyngeal fibroma, 
apply with equal force to sarcoma. In addition to this, it is a 
somewhat notable clinical fact, that a nasal tumor is attended very 
rarely with secondary infiltration of the cervical glands, and when 
this does occur, it occurs late in the history of the disease, whereas 
in a pharyngeal growth, this symptom, if it occur at all, is liable to 
occur quite early. Secondary glandular enlargement is not usu- 
ally characteristic of a sarcomatous tumor, and yet this is present 
in a certain proportion of cases, perhaps a third of those above re- 
ported. As regards sarcoma of the nasal cavities, I think it may 
be stated as a rule, that it shows a marked hesitancy in making its 
way into the pharynx, and that the mere presence of a tumor, 
which is ascertained to be of a sarcomatous character, more or less 
completely filling the pharynx, is a pretty clear evidence, that it 
had its origin in that region. 
Course and Prognosis.—A sarcoma, especially in early life, 
runs a somewhat rapid course, although this rapidity of growth is 
dependent in no small degree upon the special character of the 
tumor. In a general way we may state, that a tumor composed of 
small round cells, runs an exceedingly rapid course, while the spin- 
dle-cell tumor develops more slowly, and in those cases in which 
there is a large admixture of fibrous tissue, the development of the 
neoplasm is very greatly retarded. Thus, in Lincoln’s and Massei's 
cases, the tumor was reported as fibro-sarcoma, and its develop- 
ment extended respectively over periods of three and two years. 
On general grounds we must regard the prognosis in these cases as 
exceedingly unfavorable. In all of the above cases, death occurred 
either as the result of the disease, or from the operation, with the 
exception of Brevet’s, Depr£s’, Lincoln’s, Massei’s, Annandale’s, 
Bryant’s and my own. With the exception of my own, the complete 
history of the case after the operation is not given, leaving, therefore, SARCOMA OF THE NASO-PHARYNX. 
609 
but a single instance in which we have the report of a successful ex- 
tirpation of one of these growths, and yet I think if one carefully ana- 
lyses these cases, the conclusion is justified, that certainly in a very 
large proportion of them, the attempts at relief were not only post- 
poned too long, but in many cases were not such as to warrant the 
expectation of a successful issue. In other words, these cases seem to 
prove, that the successful removal of a naso-pharyngeal sarcoma is 
not to be accomplished by resection of the upper jaw, or by any similar 
capital operation; but it remains yet to be proven, that the nicer 
manipulation, which is acquired by those devoting themselves to a 
special practice, may not yet be fully equal to dealing with these 
cases, especially when, from the onset, the patients are saved from 
the terrible hazard of a capital operation, especially in an individual 
already in a condition of impaired general health, as the result of the 
disease. Certainly in a case seen sufficiently early in its history, I 
think that there may be instances in which we can give a more fa- 
vorable prognosis than the reports above given would seem to in- 
dicate.' In this connection, it should be stated that sarcoma, es- 
pecially in the very young, shows a tendency to generalization, as 
occurred in Neureuter’s and Veillon’s first case, this complication, 
of course, being evidenced by symptoms referable to the.special 
organs affected. 
TREATMENT.—After what has already been said, it is scarcely 
necessary to state, that the failure in all cases to even relieve symp- 
toms by extirpating these tumors by means of a radical operation, 
and the fact that so many die upon the table, warrants us in con- 
demning utterly this procedure. If success is to be in any manner 
anticipated, the growth must be extirpated through the natural 
passages, and by simple measures. I know of no cases in which 
electrolysis has been used, but what has already been said in regard 
to this measure in sarcoma of the nose, bears with equal force in 
regard to similar tumors in the naso-pharynx. The same also cap 
be stated in regard to the use of caustics. The only question for 
discussion, therefore, in this connection, is as to the comparative 
merits of the use of the cold wire snare, or the galvano-cautery. 
Certainly no better result could possibly be accomplished, than that 
reported by Lincoln, as far as the immediate operation was con- 
cerned, nor could any operation be more successful, or more skil- 
fully done. The selection of the means, however, must always be 
decided by the individual preferences of the operator, and the greater 
skill which his own experience may have given him, in the man- 
agement of any special device. Certainly my own preferences are 
decidedly in favor of the cold wire snare, either in the form of Jar- 
vis’s instrument, or one of its various modifications. In removing 610 
DISEASES OF THE NASO-PHARYNX. 
a sarcoma by this means, the operation is to be done much in the 
same manner as that already described in connection with fibromata 
of this region, with the difference, however, that hemorrhage in 
connection with sarcoma is not to be anticipated, to anything like 
the extent with which an operation for fibroma is complicated. 
Hence in removing the whole mass, or a portion of it, the separa- 
tion of the part may be accomplished by a somewhat rapid move- 
ment. The advantage of the cold wire snare, as before stated, is 
the ease with which it may be manipulated, on account of its light- 
ness of construction, and the additional fact, that in the naso- 
pharynx it can be operated, either through the nose, or perhaps 
better still, through the oral cavity, where we can obtain a thor- 
oughly wide and open access to the part, by means of a simple 
palate retractor, or by tying up the palate, after the method already 
described on page 24. This access having been obtained, the wire 
loop is easily adjusted, either to the whole of the tumor, or to such 
portion of it as it is desired to remove, either under ocular inspec- 
tion, or by the aid of a rhinoscopic mirror. Of course, if the growth 
has attained such size as to render these simple manipulations im- 
practicable, wider access to the growth may be obtained by slitting 
the palate, a simple operation, which would scarcely complicate the 
case, or if demanded, Bruns’s operation, or some similar preliminary 
operation on the external nose must be done, but I am disposed to 
think, that in the majority of cases the simpler operations offer the 
best hope of successfully extirpating these growths, and at the 
same time of protecting the patient from a recurrence. This lat- 
ter, of course, is to be anticipated, as the clinical history of sarcoma 
teaches us. The question therefore arises, how we may best pre- 
vent this recurrence. Much stress has been laid, especially by Lin- 
coln, on the importance of cauterizing the base of the tumor, after 
an operation. I am disposed to think, that there is a certain dan- 
ger in this, especially in the naso-pharynx. Caustic agents cannot 
be used in this region with impunity, and it has by no means been 
determined that the use of a caustic may not, instead of destroying 
diseased tissue, stimulate the parts to a renewed malignant action. 
The suggestion occurs that we may with more safety depend on 
watching the parts carefully from time to time, and controlling any 
tendency to recurrence by the removal of the small masses as they 
develop. In other words, to discourage the growth by constantly 
taking away new tissue as it appears. This was successfully done 
in my own case, above reported, as also in my three cases of sar- 
coma of the nose. Mr. Butlin, in his recent work on sarcoma, 
teaches us that sarcoma rarely affects the lymphatic glands, and 
that it is therefore amenable to local measures of treatment. His SARCOMA OF THE NASO-PHARYNX. 
611 
explanation is, that sarcoma arises by the proliferation of the cel- 
lular elements of the solid structures of the connective tissue, which 
compresses the lymphatics. Is it not safer, therefore, to depend on 
the complete eradication of the local disease, by such means as are 
attended with the least injury to soft tissues, viz., by their removal 
with the snare, rather than to make use of a device, such as the gal- 
vano-cautery, or other caustic agent, which, while destroying a cer- 
tain amount of tissue, is liable to excite inflammatory reaction in 
the surrounding healthy structures? CHAPTER LXVII. 
CARCINOMA OF THE NASO-PHARYNX. 
The literature of carcinoma of the naso-pharynx is completed, 
as far as 1 have been able to learn, in the report of the following 
cases. 
Case I.—Reported by Durand-Fardel.1 A male, aged 75, had suffered with 
difficulty in deglutition and respiration for some time, together with marked 
impairment of the general health, and progressive emaciation. An examina- 
tion failed to reveal any difficulty with the thoracic or abdominal viscera. The 
voice was of the peculiar dead quality characteristic of stenosis of the naso- 
pharynx. An examination of the throat showed the palate pressed down- 
ward and forward by a tumor which seemed to have its origin in the upper 
pharynx. The mucous membrane was a purplish-red color. On earth side of 
the neck and the face, were two elongated tumors, extending from the zygo- 
matic arch to the lower part of the neck, consisting of enlarged parotid and 
cervical glands. 
The subjective symptoms continued to increase, until suffocation seemed 
imminent, the tumor finally filling almost the entire buccal cavity, rendering 
the swallowing of food impossible, and the patient finally died of exhaustion. 
The autopsy revealed a tumor, double the size of a hen’s egg, taking its 
origin from the soft palate, and extending backward to the posterior pharyn- 
geal wall, upward to about the level of the orifices of the choanae, which it 
closed completely, and downward almost to the epiglottis. The tumor is re- 
ported as one of scirrhus, although no microscopic examination was made. 
Case II.—Reported by Maisonneuve.2 This is the report of a case of can- 
cer of this region, occurring in a man, aged 50, upon whom two operations had 
previously been done, respectively three, and one year before, the last opera- 
tion consisting in extirpation of the superior maxilla. At the time the patient 
came under Maisonneuve’s observation, the neoplasm completely filled the 
space formerly occupied by the jaw, and sent prolongations into the pharynx. 
Access to the tumor was obtained by an incision through the cheek, ex- 
tending from the oral commissure to the ear, after which a snare was applied, 
and the growth extirpated. It was found attached to the base of the occipital 
bone, and to the body of the sphenoid. The base was cauterized, as also some 
suspicious tissue on the right pterygoid. No further record of this case is 
given. The diagnosis of carcinoma was made. 
Case III.—Reported by Lotzbeck.s The case of a woman, 37 years of age, 
who suffered from primary carcinoma of the thyroid, and a secondary deposit 
in the inferior maxilla, the latter giving rise to fatal hemorrhage. On autopsy, 
1 Bull, de la Soc. Anat., 1837, p. 73. 
3 Deut. Klin., 1859, No. 12, p. 122. 
2 Gaz. des Hopitaux, 1859, P- 3r3* CARCINOMA OF THE NASO-PHARYNX. 
613 
a third deposit was found, which had destroyed the basilar process of the 
occipital bone, and the body of the sphenoid, and entering the cranial cavity, 
had filled up the greater part of the middle fossa on the right side, and to a 
certain extent, on the left also. This portion had invaded the nasal cavity; 
the right antrum and orbit, and to a slight degree, the left orbit also. 
The patient had suffered from amblyopia and then amaurosis of the right 
eye, headache, exophthalmos, and sudden amaurosis of the left eye, coming on 
in six hours. 
Case IV.—Reported by Flour.1 A rather curious case occurring in a 
woman, aged 39, who for five or six years had noticed a small tumor on the 
right side of the neck. The growth had been quiescent for a considerable 
period, but within the past few months had increased quite rapidly in size, and 
its feeling upon palpation gave evidence that it involved the deep glands 
which surrounded the carotid artery, as well as the superficial cervical and the 
glands. 
Upon closely questioning the patient it was found that she had been sub- 
ject to attacks of epistaxis, colds in the head, nasal stenosis, and difficulty in 
hearing, these symptoms being more marked on the right side. The voice 
was of peculiar harshness. An inspection of the anterior nares revealed noth- 
ing of note. On examining the throat a tumor was discovered in the upper part 
of the pharynx, of a reddish-blue color, the origin of which could only be sat- 
isfactorily explored by passing the finger behind the palate. This manipula- 
tion revealed that the tumor sprang from the basilar apophysis of the occipital 
bone, and obstructed the posterior orifice of the right nasal fossa. It was hard, 
firm, and somewhat nodulated to the touch. 
The growth had apparently existed for a long time, and had given rise to 
comparatively insignificant symptoms. An examination of the larynx revealed 
complete paralysis of the right vocal cord, showing that the pneumogastric 
was involved in the glandular enlargement of the neck, and a contraction 
of the pupil seemed to point to a similar involvement of the sympathetic nerve. 
Flour regarded this case as one of a primary carcinoma of the vault of the 
pharynx, with a secondary deposit in the cervical glands of the right side. No 
microscopic examination was made of the growth, and no operation was per- 
formed. 
Case V.—Report by Schmid.2 A case of carcinoma of the naso-pharynx 
as occurring in a male, 65 years old. Nine months before presenting himself 
for treatment he noticed that he had frequent colds in his head with mucous 
and muco-purulent discharge from the nose, occasionally tinged with blood. 
There had also been constantly increasing nasal stenosis, and of late, swallowing 
had been difficult, as though there was a foreign body in the throat. 
Examination revealed an elastic tumor filling the naso-pharyngeal cavity 
and blocking the choanae. 
The tumor was removed by Gussenbauer’s operation. Two months after 
there was a recurrence which necessitated the removal of the greater part of 
both superior maxillae. At the end of two weeks recurrence again took place, 
and operative interference being deemed hopeless, the patient died a few 
weeks later. The growth was a small-celled medullary carcinoma. 
The following case occured in my own practice. 
Case VI.—Miss L , a maiden lady, aged 59, consulted me on November 
1 These de Paris, 1873 (cited by Veillon, These de Paris, 1874, p. 463). 
2 Prag, Med. Wochenschr., 1881, vol. vi., p. 262. 614 
DISEASES OF THE NASO-PHARYNX. 
9th, 1886, with the following history : For two years she had had a catarrhal 
trouble attended with nasal stenosis and a somewhat unpleasant discharge, the 
symptoms being more marked on the right side. The secretion, although not 
abundant, was muco-purulent, containing occasionally dark blood clots. Eight 
months previously there appeared on the neck a large mass of swollen glands, 
hard, somewhat nodular, and irregular in shape, but not painful. These con- 
ditions had changed but little when she came under observation. At this 
time a rhinoscopic examination revealed the existence of an irregularly 
rounded, grumous-looking mass in the pharyngeal vault, attached apparently 
to the basilar process of the occipital bone, and hanging down over and oc- 
cluding the right posterior nares, while an examination through the nasal cav- 
ity simply revealed a certain amount of stenosis of that side due to a deflected 
septum, but no tumor was observed in this manner. The pharyngeal tumor 
was extracted in a number of pieces by means of a cold wire snare manipulated 
through the mouth. The amount removed was perhaps the size of a small 
f'lG. 140.—Carcinoma of the Naso-pharynx (Case VI). E, E, Columnar epithelium in proliferation; 
Z, lymph or adenoid tissue with blood-vessels; M, multi-nuclear bodies or giant cells; C, cancer epithelium. 
walnut. The operation gave entire relief to the nasal stenosis. A portion of 
the growth was submitted to Dr. Chas. Heitzmann for examination, who re- 
ported as follows: 
“ The shreds removed from the pharyngeal vault of a lady, 59 years of age, 
after having been hardened in a chromic acid solution, under the microscope 
presented the following features: The tissue is composed mainly of lymph or 
adenoid corpuscles in different stages of development, imbedded in a delicate 
myxomatous reticulum. Scanty bundles of fibrous connective tissue traverse 
the lymph-tissue, mostly broken up into inflammatory corpuscles. In the 
lymph tissues there are imbedded numerous small nests of concentrically ar- 
ranged epithelia, all of small size. In one of the sections a lymph-vessel was 
seen crowded with lymph-corpuscles and single epithelia of a moderate size; 
besides coagulated fibrin. 
“Diagnosis: Medullary cancer invading lymph-tissue.” (See Fig. 140.) 
The patient was seen several times during the following month, and small 
pieces of the growth removed from time to time by the snare. The patient 
expressed great relief at the operations and seemed to think that the glandular 
enlargement in the neck had subsided “ fully one-fourth,” as she expressed it. CARCINOMA OF THE NASO-PHARYNX. 
615 
The mass in the neck originally covered an area as large perhaps as the palm 
of the hand, and was situated immediately below the angle of the right jaw, a 
hard and dense, irregularly rounded mass with the characteristic feeling of 
malignant infiltration. This patient continued under observation until the 
following June. During this period the glandular mass became somewhat 
larger, and during the early spring ulceration set in upon its surface, which con- 
tinued for perhaps six weeks, discharging a sero-sanguinolent fluid, and finally 
healed up. Her health during this time became notably impaired, the typical 
cancerous cachexia setting in. In June, she went to the mountains, where 
little change took place other than progressive and gradual failure of the vital 
powers until early in September, when brain symptoms manifested themselves, 
as evidenced by somnolence and occasional lapses into a semi-unconscibus 
state from which she could not be aroused. This condition lasted until the 
middle of October when death occurred from exhaustion. No autopsy was 
made on the case. While under my observation during the summer, the 
pharyngeal growth seemed to be in abeyence, as there was very little recur- 
rence of the malignant disease in this region, its powers apparently expending 
themselves in the cervical infiltration, which increased largely during the sum- 
mer, and ultimately by an invasion of the cranial cavity. During the whole 
history of this case there was comparatively little pain referable to the site of 
the growth or neighboring parts, and especially was this characteristic of her 
latter days, which consisted mainly of a state of stupor or semi-unconscious- 
ness. 
We find, thus, that in its primary development and in the sub- 
jective symptoms to which it gives rise, carcinoma of the naso- 
pharynx differs in no notable degree from that of sarcoma, caus- 
ing as it does simple obstruction to nasal respiration together with 
a certain amount of unpleasant discharge, mixed perhaps with 
blood, and the deformity and impairment of function of the fauces 
according to the size of the tumor. It is noticeable, however, in 
all those cases of which we have complete clinical records, that 
secondary enlargement of the tissues of the neck occurred com- 
paratively early in the history of the disease, and furthermore that 
this infiltration proceeded without much change, and with little 
tendency to rapid development, for a considerable period of time. 
The diagnosis, of course, would be in most instances rendered 
fairly complete by the existence of this one symptom, although its 
thorough determination must always depend upon the removal of 
a piece of the neoplasm for microscopic examination. 
As regards both prognosis and treatment, there is little to be 
said. The disease is necessarily fatal and runs its course in from 
one to three years, for although the histories in Maisonneuve’s and 
Flour’s cases are not complete, there can be no question whatever 
as to the ultimate result of .the disease. 
The plan of treatment is necessarily one which must be decided 
by the surgeon in each individual Case, or even the question as to 616 
DISEASES OE THE NASO-PHAR YNX". 
whether any treatment at all should be resorted to. In my own 
case the successful removal of the growth was accomplished with 
but a trivial amount of pain or even discomfort to the patient, and 
the relief to symptoms was not only very great for a time, but fur- 
thermore, the patient was made happy for weeks and even months 
with the idea that her disease was being brought under subjection. 
There may possibly be something of suggestion in this. 
A witty French writer has told us, that the only treatment for 
consumption is by opium and lying, an assertion in which there is 
less of cynicism than would at first appear, and which might equally 
well be made in regard to cancer. 
As regards the advisability of a radical operation, such as a re- 
section of the superior maxilla, and procedures of this kind, there 
would seerri to be very little justification for subjecting a patient to 
this great hazard, from our clinical experience of the disease as at 
present recorded. Section III. 
External Surgery of the Nose. EXTERNAL SURGERY OF THE NOSE. 
CHAPTER XLVIII. 
EXTERNAL SURGERY OF THE NOSE. 
UNDER this heading is embraced a description of those opera- 
tions, by which a larger access to the nasal passages is obtained for 
the removal of tumors, either of the nasal cavity itself, or of the 
naso-pharynx and which involve, 
(ist) incisions through the hard or soft palate, or both. 
(2d) incisions through the external integument alone, and 
(3d) incisions through the external integument, together with 
section of bone. 
Under the first group are included the following operations : 
Manne’s operation, consisting in a division of the soft palate. 
Maisonneuve’s operation, of median incision of the soft palate, 
with preservation of its free border. 
Nelaton’s operation of division of the soft palate, with a resec- 
tion of a portion of the hard palate. 
Botrel’s operation, of incision of the soft palate, with the preser- 
vation of its free border, and a resection of a part of the hard pal- 
ate. 
Richard’s operation of trephining the hard palate. 
Sedillot’s operation of osteo-plastic resection of the hard palate. 
Dezeanneau’s operation of a temporary resection of a portion 
of the hard palate. 
Under the second group is described: 
Dieffenbach’s minor operation, which consists of a slitting up one 
or both alae of the nose, or a section of the columna. 
Lariche’s operation for separation of the columna. 
Under the same group may be included: 
Rouge’s operation, which consists of an incision through the 
mucous membrane at the ginglivo-labial fold, which is carried up- 
ward, in such a manner as to permit of the upper lip and soft 
structures of the nose being turned upward so as to expose the 620 
EXTERNAL SURGERY OF THE NOSE. 
bony orifice of the nasal cavities; as also the operation of Palasciano 
and Rampolla, of puncturing the superior meatus through the os 
unguis, for the manipulation of a ligature. 
Under the last group are embraced: 
Boeckel’s operation of turning the nose bodily to one side, by 
incisions through the integument, nasal bones, nasal process of the 
superior maxilla on one side, and the septum. 
Ollier’s operation, which consists of depressing the nose bodily, 
after incision through the integument, nasal process of the superior 
maxilla and nasal bones on both sides, and the septum. 
Lawrence’s operation of turning the nose bodily upward on the 
forehead, by incisions through the columna, alae, septum, nasal 
bones, and nasal process of the superior maxilla on both sides. 
Langenbeck’s operation, which consists of a temporary resec- 
tion of one nasal bone, together with the nasal process of the su- 
perior maxilla of the same side. 
Linhart’s operation, which consists of a separation of a nasal 
bone from the septum, and the corresponding bone of the opposite 
side, in the median line. 
Bruns’s operation, which consists of tilting the nose bodily to one 
side, somewhat after the manner of Boeckel, but differing in that a 
wider opening is obtained, by extending the bony section beyond the 
nasal bones, into the superior maxilla, the nostril being left intact. 
Fournaux-Jordan’s operation, which consists of exposing and 
enlarging the bony orifice of the anterior naris. 
Huguier’s operation, which consists of a temporary depression 
of the lower portion of the superior maxilla. 
Cheever’s operation, which accomplishes the same purpose by a 
somewhat simpler means. 
Cheever’s double operation, which consists of a temporary de- 
pression of the lower half of the superior maxillary bones of both 
sides. 
Waterman’s operation, in which the depressed superior maxilla 
of one side remains attached only posteriorly, the hard palate being 
divided close to the septum. 
Roux’s operation, which consists of a temporary resection of 
the entire superior maxilla. 
Annandale’s operation of separating the superior maxillae by 
division through the hard palate. 
Langenbeck’s operation of temporary resection of the upper 
portion of the superior maxilla. 
Billroth’s operation for accomplishing the same purpose, differ- 
ing somewhat from Langenbeck’s, in that the mass is turned out- 
ward instead of upward. FIG.I I. MAISONNEUVES OPERATION FOR THE PERMANENT RESECTION 
OF THE LOWER PORTION OF THE SUPERIOR MAXILLA. 
PLATE I. 
FIG.I. ROUGE'S OPERATION. EXTERNAL SURGERY OF THE NOSE. 
621 
Demarquay’s operation of permanent resection of the anterior 
wall of the antrum and the nasal process of the superior maxilla. 
Syme’s operation, of permanent resection of the entire superior 
maxilla of one side. 
Maisonneuve’s operation of permanent resection of the lower 
half of the superior maxilla of one side. 
Pean’s operation of permanent resection of the posterior and 
lower portion of the superior maxilla of one side. 
Mott, Huguier, Vallet, and Berard’s operations, of permanent 
resection of a portion of the superior maxilla. 
Manne’s Operation. 
This simple operation was first performed by Manne,1 in order 
to gain wider access to the naso-pharynx, for the removal of a 
fibro-myxomatous growth, the size of an egg, which completely 
filled that cavity, the incision being made through the soft palate, 
from below upward, by means of a bistoury, in the median line, ex- 
tending from the tip of the uvula to the junction of the hard 
palate. Subsequently Levret,2 in a somewhat similar case, slit the 
palate at the side of the uvula, thus accomplishing an equally good 
purpose, with a shorter line of incision, a proceeding regarded by 
Jobert3 as preferable. This operation is, of course, quite simple 
in its performance, and involves no complications. The parts are 
subsequently restored by the insertion of one or more sutures, 
although the tissues would become re-united probably in the ma- 
jority of cases even without such interference. 
Maisonneuve’s Operation.4 
This device consists of making an incision in the median line 
from the junction of the hard palate down into the body of the uvula 
as far as may be necessary, thus securing a somewhat wide open- 
ing through the soft palate, while at the same time its free border 
is preserved. 
The advantage of this procedure becomes quite apparent with- 
out further comment. It was originally done by Maisonneuve for 
the removal of a fibro-vascular tumor, which was successfully ex- 
tracted by means of a snare, after which the parts were reunited by 
a single suture. 
1 “ Dissertation curieuse, au sujet d’un polype extraordinaire,” etc., Avignon, 1717. 
2 “ Obser. sur la cur radicale de plusieurs polypes,” Paris, 1749. 
3 Gaz. des Hopitaux, July 22d, 1858, p. 337. 
4 Comp. Rendu de l’Academie des sciences, July to Dec., 1859, vol. xlix., p. 292. 622 
EXTERNAL SURGERY OF THE NOSE. 
Nelaton’s Operation.1 
Following out the method of Manne, the distinguished French 
surgeon Nelaton devised an operation for the extirpation of growths 
arising from the basilar apophysis, which he performed as follows: 
The uvula being seized with a pair of forceps, it, together with 
the curtain of the palate, was divided exactly in the median line as 
far as the hard palate, then with a stout double-bladed knife, this 
median incision was continued along the hard palate to a point 
about seven-eighths of an inch from the incisor teeth. From the 
extremity of this incision the membrane covering the hard palate 
was incised on either side, directly outward, that is, in a line per- 
pendicular to the first, over a dis- 
tance of from three-quarters of an 
inch to an inch. The wound in the 
hard palate thus assumed somewhat 
the form of the letter T. A perios- 
teum knife was now introduced, and 
the mucous membrane covering the 
hard palate was separated along the 
line of incision, as far back as the 
velum. The knife was now passed 
through the junction of the mucous 
membrane of the nasal cavity with 
that of the palate. Next, at the outer 
extremity of each horizontal inci- 
sion, a perforation was made through 
the hard palate, through which one 
blade of a stout pair of scissors was inserted, and all this portion 
of the bony palate was removed, together with a portion of the 
vomer (see Fig. 141), taking care to preserve as much as possible 
of the mucous membrane covering the upper surface of the frag- 
ment, that is. of the floor of the nose. A large opening was thus 
formed, which gave easy access to the base of the skull. Moreover, 
this wound could be kept open for any length of time, and any evi- 
dences of recurrence promptly treated and dissipated. After a 
cure had been effected the margins of the palatine wound could 
be approximated, and in many cases a certain amount of bone was 
reproduced, and the contour of the hard palate restored. 
Fig. 141.—Lines of Bony Section in 
Nelaton's Operation. 
Botrel’s Operation.2 
In order to gain a wider access to the naso-pharynx, and still 
preserving the free border of the soft palate, Botrel combined 
1 Gaz. des Plop., 1849, 3 S., vol. i., p. 128. 
2 Rev. Med. Chir. de Par., 1850, vol. viii., pp. 90-102. EXTERNAL SURGERY OF THE NOSE. 
623 
Maisonneuve’s incision of the soft palate, with Nelaton’s operation 
just described, of resecting a portion of the hard palate; the steps 
of the operation need not be entered into, as they differ in no re- 
spect from those already described. 
Richard’s Operation.1 
This device accomplishes much the same purpose as that of 
Nelaton, while at the same time the integrity of the soft palate is 
preserved. The procedure is as follows: An incision is made in 
the median line, from the posterior border of the hard palate, 
forward to the alveolus, extending well down to the bone, after 
which the periosteum is dissected up on either side, over the whole 
area of the bone, which it is designed to remove, when the bony 
palate, to such an extent as may be necessary, is removed by 
means of a chisel, and free access gained to either one or both 
nasal cavities, according as may be desired. After the indications 
for which the operation is done have been fulfilled, Richard ap- 
parently leaves the mucous membrane and periosteum in situ, with- 
out further procedure, although Gus- 
senbauer2 performed a similar opera- 
tion subsequently, and inserted su- 
tures for reuniting the flaps of mu- 
cous membrane and periosteum. 
Sedillot’s Operation.3 
Sedillot makes a linear incision 
in the median line through the soft 
palate, by means of a bistoury, ex- 
tending the incision through the mu- 
cous membrane of the hard palate 
as far forward as the palato-max- 
illary suture, cutting down to the 
bone, after which, by means of a 
periosteum elevator, the oral faces 
of the palatal process are denuded, and subsequently, bypassing up 
behind the border of the soft palate, its nasal surface is subjected to 
the same manipulation. After this, the horizontal plate of the pala- 
tal bone is exsected (see Fig. 142), by means of a stout scissors or 
forceps. By this means, fairly wide access is obtained to the naso- 
pharyngeal cavity, for such subsequent procedure as may be indi- 
cated. The edges of the wound are to be reunited by sutures, with 
Fig. 142.—Sedillot’s Operation; Lines of 
Bony Section 
1 As cited by Beuf, These de Paris, 1857. No. 69, p. 32. 
2 Arch, fur Klin. Chir., 1879, V°P xxiv., p. 265. 
3 Memoires de la Societe de Med. de Strasbourg, 1864, vol. i., p. 160. 624 
EXTERNAL SURGERY OF THE NOSE. 
the prospect of complete restoration of the bony parts which have 
been removed. Sedillot detailed the steps of this operation, as one 
which he'intended to pursue, in a case presented to the society, 
although we have no record of the 
operation having been done. 
Dezeanneau’s Operation. 
This operation was performed by 
Dolbeau,1 who assigns to Dezean- 
neau the credit of having devised it. 
It was done for the removal of a 
fibroid tumor in the nasal cavity, 
and consists in making a complete 
section through the hard palate, in- 
cluding the soft parts covering it, 
commencing at its junction with the 
soft palate, in the median line, and 
carrying the incision forward to, or 
beyond, the palato-maxillary suture, 
when it is carried across at right angles, until it approaches the 
alveolar process, and is again turned and carried back to the junc- 
tion of the hard and soft palate, 
at its alveolar extremity (see 
Fig. 143). In this manner, a 
quadrilateral flap, as it were, is 
formed in the hard palate, 
which can be depressed in such 
a manner as to admit of free ac- 
cess to the nasal cavity above, 
the flap turning on the junction 
of the hard and soft palates as 
a hinge. 
Fig. 143.—Dezeanneau’s Operation; Lines of 
Section of Hard Palate. 
Dieffenbach’s Operation, 
This operation is designed 
to obtain a wider access to the 
anterior nares, for the removal 
of such growths in this region 
as do not admit of extraction 
through the natural passages, 
and although perhaps previ- 
ously suggested by Dupuytren,2itwas first performed by Dieffenbach.3 
Fig. 144.—Dieffenbach’s Operation; Line of Cutaneous 
Incision. 
1 Gaz. des Hopitaux, 1862, p. 530. 2 Jour, de la Clin., vol. ii., 1830. 
3 J. compl. du Diet. d. Sc. Med., Par., 1831, vol. xl., pp. 41-45. EXTERNAL SURGERY OF THE NOSE. 
625 
It consists in making an incision which, commencing at the lower 
and outer angle of the nostril, is carried along the base of the nose, 
in the naso-labial fold (see Fig. 144), until the ala of that side can 
be easily turned upward and inward, thus exposing the whole of 
the anterior chamber and lower meatus, with a portion of the mid- 
dle meatus. If it is necessary to expose both cavities, the same 
operation can be done on the opposite side, the opening being no- 
tably enlarged, by separating the columna, by an incision through 
the integument at the labio-columnar fold. 
The proceeding is attended with no special danger or complica- 
tion, the hemorrhage being slight. The parts reunite readily, 
although Dieffenbach advises the insertion of sutures. I have done 
this operation in but a single case, and that for the extraction of 
a dead osteoma, whose size did not admit of its removal through 
the nostril. I am disposed to 
think, however, it will be but 
rarely indicated at the present 
day, in that the additional 
space gained, would not great- 
ly facilitate our methods of 
manipulation through the an- 
terior nares. 
Lariche’s Operation.1 
A somewhat similar device 
was that of Lariche, who in 
order to remove a tumor in- 
volving the lower portion of 
the cartilaginous septum, 
made a V-shaped incision hav- 
ing its ends in the lower border 
of either nostril, while the 
apex was in the median line 
perhaps a quarter of an inch below the columna. In this manner 
the columna was separated from the upper lip and the lower 
border of the septum (see Fig. 145). This being turned upward, 
the lower portion of the septum, together with the growth, was re- 
moved with a scissors, and the columna subsequently restored to 
its position, and held in place by sutures. 
I'ig. 145.—I.ariche s Operation; Lines of Cutaneous 
Incision. 
1 Gaz. des Hopitaux, Paris, 1874, p. 579. 626 
EXTERNAL SURGERY OE THE NOSE. 
Rouge’s Operation. 
(See Colored Plate I., Fig. I.) 
This operation was first devised by Rouge,1 in order to gain 
freer access to the nasal cavities, in a case of syphilitic ulceration 
and necrosis, and is performed as follows: The patient being turned 
on his side, to facilitate the escape of blood, the upper lip is seized 
firmly by a assistant, and drawn up over the nose in such a way as 
to thoroughly expose the ginglivo-labial fold, when an incision is 
made through the mucous membrane, extending from the first 
molar tooth on one side, to the same point on the opposite side, 
after which the lip and face are dissected from the bones, until the 
lower border of the anterior nares is exposed, and the septum 
reached, which is now divided by means of a stout pair of scissors, 
in sufficient extent to allow of the nose being turned up over the 
face, in such a manner as to more or less completely expose the 
bony openings of the nasal passages. If necessary, the cartilagi- 
nous septum may be completely divided, in order to facilitate the 
rolling backward, as it were, of the lower part of the face. The 
facility of access thus gained to the nasal cavities, is practically 
limited only by the size of their bony openings anteriorly. For 
convenience of manipulation, and ease of illumination therefore, 
the gain is no small one/especially when we consider the compara- 
tive simplicity of the operation, which, according to Rouge, is ac- 
complished without any dangers, and with no great risk of com- 
plications. The hemorrhage is comparatively slight, the reaction 
not notable, and furthermore, after restoration of the parts, union 
is complete in one or two days, the patient suffering but trivial dis- 
comfort as the result of the operation. The operation, however, 
is interesting, more from an historical point of view, and from its 
novelty, than as one which would be frequently resorted to at the 
present day, and yet undoubtedly, many cases may occur, in which 
indications will best be carried out by its performance. The field 
of operation might undoubtedly be further enlarged, without com- 
plicating the procedure, by temporarily resecting one or both nasal 
bones, and perhaps removing a portion of the septum. 
This operation is interesting, only as illustrating one of the 
curious devices which occasionally originate in the minds of sur- 
geons. It consists of making an incision through the integument over 
the lachrymal sac (see Fig. 146), which is partially dissected out, 
Palasciano’s Operation. 
1 Bull. Soc. Med. de la Suisse Rom., Lausanne, 1868, vol. ii., pp. 265-268. EXTERNAL SURGERY OE THE NOSE. 
627 
when a puncture is made through the os unguis, and access gained 
to the superior meatus 
through the opening, when 
a canula is inserted, carrying 
a ligature, which, in some 
manner, is arranged around 
the pedicle of a polyp, which 
being separated in this man- 
ner, is extracted through the 
natural passages. Four cases 
are reported by Palasciano1 
and Rampolla2 as having been 
operated upon in this man- 
ner. Their success, however, 
was by no means flattering, 
recurrence having taken place 
in two cases, death in the 
third, while in the remaining 
case, abscess of the orbit fol- 
lowed the operation. 
Fig. 146.—Line of External Incision in Palasciano’s 
Operation. 
Boeckel’s Operation.3 
This operation is designed to 
obtain a wider access to either 
the nasal cavity, or to the naso- 
pharynx, and consists of a tem- 
porary resection of the whole 
body of the external nose, in 
the following manner: An in- 
cision is made across the bridge 
of the nose, from one lachrymal 
sac to the other, the cut being 
carried well down to the bone. 
A second incision is then made, 
commencing at one extremity 
of the primary incision, and 
carried along the nasal furrow, 
down to the margin of the nos- 
tril, which it opens. A third 
incision separates the columna 
Fig. 147.—Line of Cutaneous Incision in Boeckel’s 
Operation. 
1 Bull, de la Soc. de Chir. de Paris (i860), 1861, 2 S., vol. i.. pp. 372-376. 
2Ibid.,pp. 140-144. 
3 “ Addition a la traduction du Traite des Resections d’Heyfelder,” par M. Boechel, 
1863, P- 294. 628 
EXTERNAL SURGERY OE THE NOSE. 
from the upper lip (see Fig. 147). The bones in the line of the 
first incision are now divided by means of a chain saw, which is en- 
tered through a puncture made directly through from the one side 
to the other. The bones in the line of the second incision are then 
divided by means of a saw (see Fig. 148), after which the septum 
opposite the line of the primary incision, or as far back as it can 
conveniently be done, is separated by means of stout scissors or 
cutting forceps. The whole body of the nose is now turned over 
upon the cheek of the opposite side by means of a stout pair of 
forceps, thus fracturing the nasal process of the superior maxillary 
bone on that side. If, however, there 
is too much resistance, this part can 
be weakened or severed on the inner 
side, by means of a chisel. In this 
manner, free access to the nasal pas- 
sages is obtained, but if it is desired 
to gain a larger access to the naso- 
pharynx, the additional step may be 
taken, of complete resection of the 
vomer, and the turbinated bones also 
if necessary. 
After the removal of the growth, 
for which the operation was done, 
the nose is placed in position, and 
held by sutures through the integu- 
ment, in the line of the original in- 
cisions. The parts reunite readily, without deformity, the cicatrix 
being scarcely noticeable. The procedure is a comparatively sim- 
ple one, and involves no great danger or complications, but few 
vessels requiring ligature. 
This operation, in all its essential features, had already been 
done previous to Boeckel’s time by Chassaignac 1 in a case of malig- 
nant disease of the nose (see Case IV., Sarcoma of the Nose), and 
has been the subject of some discussion as to priority. Boeckel, 
however, undoubtedly first suggested it as a complete temporary 
resection, in that in Chassaignac’s case there is no report of his 
having restored the bony parts to their normal position, although, as 
a matter of fact, this could not have been done, in that they were 
much disorganized as the result of the malignant disease. 
Fig. 148.—Line of Bony Section in Boeckel's 
Operation. 
1 Moniteur des Hopitaux, 1854, vol. ii., pp. 266-268 FIG.II.CHEEVER'S OPERATION FOR THE TEMPORARY DEPRESSION 
PLATE II. 
FIG.l.OLLIERS OPERATION FOR DEPRESSING THE EXTERNAL NOSE EXTERNAL SURGERY OF THE NOSE. 
629 
Ollier’s Operation.1 
(See Colored Plate II., Fig. I.) 
This operation was first performed by the surgeon whose name 
it bears, in 1864, upon a patient suffering form a naso-pharyngeal 
fibroma, which completely blocking the naso-pharynx, rendered 
nasal respiration impossible, and by pressure had partly destroyed 
the vomer. The patient having been etherized, an incision was 
made, beginning just above the ala of the nose, extending upward 
to its root, thence across this, and downward to a corresponding 
point on the opposite side of the nose (see Fig. 149). The in- 
Fig. 149.—Line of Cutaneous Incision in Ollier’s 
Operation. 
Fig. 150.—Line of Bony Section in Ollier's 
Operation. 
cision divided all the parts down to the bone. A thin-bladed saw 
was then made to divide the nasal bones and the septum, in the line of 
the cutaneous incision (see Fig. 150). The nose, thus freed from its at- 
tachment, was tilted downward upon the face, thus giving free access 
to the nasal cavity, and through this, to the vault of the pharynx. 
The tumor was removed in a number of pieces, by means of for- 
ceps, the nasal cavities being thoroughly explored with the finger, 
for any traces of the growth remaining in them. The nose was then 
replaced, and held in position by metallic sutures, the periosteum 
1 Mem. et Compte Rendu de la Societe de Science Medicale de Lyon; 1864-65; vol. 
iv., 2d part, p. 46. 630 
EXTERNAL SURGERY OF THE NOSE. 
not being included in the sutures. The nasal fossae were filled with 
sponges, to prevent hemorrhage. Primary union took place through 
almost the entire wound, and the patient was discharged cured, in 
about six weeks. 
Lawrence’s Operation.1 
This operation is designed to accomplish the same purpose as 
those of Ollier and Boeckel, differing from them only in this feature, 
that the body of the nose is tilted upward upon the forehead. It is 
done in the following manner: An incision through the integu- 
ment is made with a scalpel, extending from the lachrymal sac of 
Fig. 151.—Line of Cutaneous Incision in Lawrence s 
Operation. 
Fig. 152.—Line of Bony Section in Lawrence’s 
Operation. 
one side, along the nasal furrow, to the margin of the nostril, 
which is opened. A second incision is made upon the opposite side, 
and in the same line, and lastly, the columna of the nose is divided 
at its junction with the upper lip (see Fig. 151). Subsequently, 
by means of a stout pair of scissors, or bone forceps, the bone in 
the line of each lateral incision is divided, from below upward, 
while the septum is divided in the same way (see Fig. 152). The 
nose is now seized with a stout pair of forceps, or the fingers, and 
turned bodily up upon the forehead, thus breaking up the suture 
between the nasal bones and the internal angle of the frontal; which 
thus acts as a hinge, as it were, upon which the whole mass turns. 
1 Med. Times and Gaz., London, 1862, vol. ii., p. 491. FIG.ll. PEAN'S OPERATION FOR THE PERMANENT RESECTION OFTHE 
LOWER POSTERIOR PORTION OF THE SUPERIOR MAXILLA 
PLATE III 
FIG. I. LANGENBECKS OPERATION FOR THE TEMPORARY RESECTION 
OFTHE NASAL BONE. EXTERNAL SURGERY OF THE NOSE. 
631 
After the removal of the tumor, the nose is placed in position, and 
held by sutures, union taking place readily, without deformity. 
It should be stated, however, in regard to this operation, that while 
accomplishing the same purpose as those of Boeckel and Ollier, it 
involves a somewhat greater risk, in that the pedicle being so small, 
there is a possible danger of perfect circulation not being restored 
to the parts after the operation, and hence sloughing of the flap 
might occur. 
Langenbeck’s Operation for Resection of the Nasal Bone.1 
This was done in order to again access to the anterior nasal pass- 
ages, by temporary resection of the bony lateral wall of the nose, and 
is done as follows: A primary incision, by means of a bistoury, is made, 
commencing in the median line, just above the root of the nose. 
Fig. 153.—Line of Cutaneous Incision in Langenbeck’s 
Operation. 
Fig. 154.—Lines of Bony Incision in Langen- 
beck’s Operation. 
This is carried across the bridge of the nose, and down one side, 
and extended along the middle of the nasal bone, till it reaches the 
ala (see Fig. 153), after which the cutaneous flap is dissected up by 
means of an elevator, until the nasal bone, covered with its perios- 
teum, is laid bare in its whole extent. The ala is then separated 
from the nasal bone, and a forceps inserted through the opening, 
and the nasal bone separated from its fellow along the median line. 
1 Deut. Klin., 1859, No. 48, p. 471. 632 
EXTERNAL SURGERY OF THE NOSE. 
The forceps is now inserted at the outer angle of the lower incision, 
and a section made directly up through the nasal process of the 
superior maxilla, extending toward the inner canthus, until the 
orbit is reached (see Fig. 154), thus making a small opening into the 
antrum of Highmore. The piece thus separated, is now seized with 
forceps and turned directly up over the eye. In this manner, a 
comparatively wide opening 
is made into the nasal cavi- 
ties, and if necessary, access 
obtained to the naso-pha- 
rynx. When the design of 
the operation has been ac- 
complished, the parts are 
restored to place, and held 
by sutures through the in- 
tegument. This operation is 
attended with no special 
danger or complications. 
This procedure was sub- 
sequently modified by Lan- 
genbeck1 (see Colored Plate 
III., Fig. I.), in that instead 
of the single incision through 
the integument, two incisions 
were made; one along the 
anterior and another along 
the posterior border of the nasal bone, coming down to the ala, at 
which point they were united by an antero-posterior incision, sep- 
arating the ala from the lower border of the nasal bone (see Fig. 
155). The bone was then divided along the line of the cutaneous 
incision, and the osteo-cutaneous flap was turned upward, securing 
the same opening as in the first operation. 
Fig. 155 —Lines of Cutaneous Incision in Langenbeck’s 
Later Operation. 
Linhart’s Operation.2 
This operation is designed to gain access to the anterior nares, 
and is performed, by making a linear incision from the root of the 
nose to its tip, which is then extended into the nostril of one side, 
after which the nasal bone is seized by forceps, and turned forcibly 
to one side, after separating its attachment to its fellow. 
A somewhat similar operation was performed for the removal 
of a vascular tumor of the septum by Verneuil3 who made a linear 
1 Archiv fur Klin. Chir., 1867, vol. viii., p. 423. 
2 “ Operations-Lehre,” 3 Aufl., as cited by Bruns, Berliner Klin. Woch., 1872, No. 13. 
3 Annal. des Mai. de l’Oreille, 1875. vol. i., p. 169. EXTERNAL SURGERY OF THE NOSE. 
633 
incision from the root of the nose in the median line to the junc- 
tion of the nasal bones with the alae, and then alone the lower bor- 
der of each nasal bone, to 
the malo-nasal furrow, thus 
making a Y-shaped incision, 
after which the nasal bones 
were separated, opening each 
nasal cavity and exposing 
the tumor on the septum. 
Bruns’s Operation.1 * 
(See Colored Plate IV., Fig. II.) 
This operation resembles, 
to a certain extent, that of 
Boeckel, in that the whole 
body of the nose is tempo- 
rarily resected, and turned 
over to one side. The inci- 
sions, however, involve a 
larger area than those of 
Boeckel, thus gaining a wider 
access to the cavity. The 
operation is done as follows: The first incision commences just 
below the outer margin of the nostril of the healthy side, and is 
carried directly across in a horizontal line, to from half to three- 
quarters of an inch beyond the margin of the opposite nostril. The 
incision is carried fully down to the 
bone, care being exercised not to 
puncture the mucous membrane of 
the ginglivo-labial fold. A second 
incision is made directly across the 
narrowest part of the bridge of the 
nose, the terminus being just above 
each inner canthus. A third incision 
joins the outer extremities of those 
two, thus extending into the cheek, 
somewhat beyond the nasal furrow 
(see Fig. 156). A saw is now in- 
serted at the point of origin of the 
first incision, its tip being carried 
into the nasal cavity. A section is 
now made through the anterior nasal spine and the septum, and 
the saw carried throughout the whole extent of the original line of 
-‘ife--- 
Fig. 156.—Lines of Cutaneous Incision in Bruns’s 
Operation. 
Fig. 157.—Lines of Bony Section in Bruns’s 
Operation. 
1 Berliner Klin. Woch., 1872, No. 12 and 13, pp. 137 and 149. 634 
EXTERNAL SURGERY OF THE .NOSE. 
incision, the section being confined entirely to the superior maxilla, 
cutting through also the septum, and the anterior portion of the 
lower turbinated bone (see Fig. 157). What Bruns accomplishes 
here, is an enlargement of the original bony opening of the anterior 
nares, sawing out a strip of bone, as it were, from a quarter to 
three-eighths of an inch wide, surrounding this opening. In order 
to accomplish this, as we see, the free end of the saw plays in the 
nasal cavity, the instrument being tilted, as it were, in this direction, 
thus making a bevelled cut. After the primary section is made with 
the saw, the bony septum is cut by means of a stout forceps or 
scissors from belowr upward, and the whole nose seized with the 
fingers or forceps, and turned bodily over on the cheek. This opera- 
tion of Bruns is very simple, and yet a very ingenious device, as by 
this means he obtains a wide access to the nasal passages, and if 
necessary, to the naso-pharyngeal cavity, for the removal of neo- 
plasms, or the carrying out of other indications. No vessels of any 
size are encountered during the steps of the procedure, and the 
operation may be finished without notable complication. After the 
indications have been accomplished, the parts are restored to posi- 
tion and held in place by sutures through the integument. 
It might be noticed in this 
connection, that in one of 
Bruns's operations, the 
wound was left open for a 
period covering three vreeks, 
for the purpose of treating 
the stump of the growth, at 
the end of which time, the 
edges being somewhat fresh- 
ened, they were easily and 
successfully reunited by su- 
tures. 
Fournaux-Jordan’s Op- 
eration. 
An operation which ac- 
complished much the same 
purpose as that of Bruns, and 
in a much more simple man- 
ner, is that devised by Four- 
naux-Jordan1 and which is done as follows. A sharp-pointed bis 
toury being inserted into the ginglivo-labial fold, just below the 
posterior margin of the nostril, is carried forward into the nasal 
Fig. 158.—Line of Cutaneous Incision in Fournaux- 
Jordan’s Operation, 
1 British Med. Journal, 1885, vol. i., p. 888. FIG.I I. BRUNS OPERATION FOR THE LATERAL OSTEOPLASTIC RESECTIQF 
PLATE IV 
FIGI • LAN_G EN BECKS_ 0 PER ATI ON FORJHE TEMPORART RESECTION EXTERNAL SURGERY OF THE NOSE. 
635 
cavity, after which the whole of the upper lip, including the margin 
of the nostril, is severed by cutting upward. The ala of the nose is 
now cut through, in a similar manner, in a line continuous with that 
of the first incision, and the cut extended along the lateral face of 
the nose, to a point just below the inner angle of the eye (see Fig. 
158). The flaps being now drawn to one side and the other, reveal 
freely the bony orifice of the anterior nares, which can be enlarged 
by means of the rongeur, or other suitable instrument, to such size 
as may be demanded for the special manipulation for which the 
operation is done. 
Huguier’s Operation.1 
This procedure is designed to gain access to the naso-phar- 
yngeal cavity, and consists of a temporary resection or depression 
of the lower portion of the superior maxillary bone. The mouth 
being opened, a transverse slit is made through the soft palate on 
the affected side, at its junction with the hard palate, after which, 
by means of a Bellocq’s sound, 
a strong ligature is passed 
through the inferior meatus, 
thence through this slit in the 
soft palate, and finally drawn 
out through the mouth. The 
two ends of the thread are 
then tied together. An in- 
cision is then made from the 
commissure of the lips on the 
affected side, through the 
whole thickness of the cheek, 
outward to the anterior bor- 
der of the masseter muscle. A 
second incision is made from 
the upper border of the ala of 
the nose on the affected side, 
along the nasal furrow, sepa- 
rating the ala from the nostril, 
and is prolonged in the median 
line, through the whole thickness of the upper lip, through its free 
border (see Fig. 159). The large triangular flap thus formed, is 
then dissected up, exposing the entire anterior surface of the lower 
half of the superior maxillary bone. The first incisor tooth on the 
affected side is then drawn, and by means of a bone forceps, one 
Fig. 159.—Lines of Cutaneous Incision in Huguier’s 
Operation. 
1 Gaz. des Hopitaux, 1861, vol. xxxiv., p. 337. 636 
EXTERNAL SURGERY OF THE NOSE. 
blade of which is introduced into the nostril, the alveolus is cut 
through. A flat-bladed saw is then passed into the nostril, and the 
entire hard palate is sawed through, taking care not to injure the 
oral periosteum. The finger is inserted at the posterior extremity 
of the first incision, and the tuberosity of the superior maxilla is 
felt. Directly behind this is felt the projecting pterygoid process 
of the sphenoid bone, which is cut off by means of bone forceps. 
A narrow-bladed saw is then introduced behind the tuberosity of 
the superior maxilla, and the body of this bone is sawed through 
from behind forward, the section being made into the inferior 
meatus of the nose (see Fig. 160). Traction downward is then 
made by means of the ligature previously passed through the 
nostril and through the opening in 
the palate, and the entire lower half 
of the superior - maxillary bone is 
depressed into the mouth, hinging 
upon the undivided oral periosteum 
of the hard palate. Free access is 
thus gained to the pharyngeal cav- 
ity, as well as to the antrum. The 
cutaneous incisions necessitate the 
application of ligatures to the facial 
artery at two points. Aside from 
this, no vessels of any considerable 
size are divided. The bony and soft 
parts can be replaced, and the dis- 
placed bone may or may not be 
held in position by means of me- 
tallic sutures, according to the choice of the operator. The wounds 
in the soft parts are closed by means of sutures, and union readily 
takes place. It is ordinarily necessary for the patient to wear an 
obturator in the mouth for some time to prevent displacement of 
the bony fragment. 
The above description is taken from Huguier’s original report, 
and is that of an operation which was done for the removal of a 
fibroid tumor of the naso-pharynx. In this case, however, con- 
siderable bony necrosis resulted, which marred the success of the 
operation, bony reunion not having taken place at the end of three 
years, and all the teeth of that side having become carious. This 
result was undoubtedly due largely to the fact that the pedicle con- 
sisted simply of the periosteum of the oral face of the hard palate, 
and that this had been subjected to the risk of injury, by sawing 
through the bone from above, with a straight saw. 
Fig. 160.—Lines of Bony Section in Huguier’s 
Operation. EXTERNAL SURGERY OF THE NOSE. 
637 
This device accomplishes the same purpose as that of Huguier, 
in a much simpler, and certainly in a much safer manner. The ex 
ternal incision is confined 
to one simple cut, extending 
from just below the inner 
canthus of the eye on the 
affected side, to the outer 
angle of the mouth (see Fig. 
161), after which the anterior 
face of the lower portion of 
the superior maxilla is ex- 
posed, by dissecting up the 
flaps, and drawing them to 
one side. The next step con- 
sists in the extraction of the 
first incisor tooth on the af- 
fected side, after which the 
alveolus is cut through by 
means of a bone forceps. 
The finger is now passed be- 
hind the body of the upper 
jaw, and the tuberosity being 
located, a straight saw is passed behind this, and worked up along 
the pterygo-maxillary junction, and brought forward, thus severing 
the body of the bone (see Fig. 162). 
The mass is now seized with the 
forceps and depressed, thus fractur- 
ing the hard palate. In this manner 
the whole mass drops into the oral 
cavity, thus opening a wide access to 
the naso-pharynx. 
Cheever’s original operation was 
done in a case of fibroma, and seems 
to have been a complete success. 
The parts were restored to position, 
and the bony fragments held in place 
by means of a wire suture around 
the teeth, the soft parts being united 
in the usual manner. Bony union is 
reported as having been complete at 
the end of a few weeks, no serious complications having occurred. 
Cheever’s Operation.1 
Fig. 161.—Line of Cutaneous Incision in Cheever’s 
Operation. 
Fig. 162.—Line of Bony Section in Cheever’s 
Operation. 
1 Boston Med. and Surgical Jour., 1867-8, vol. Ixxvii., pp. 161-164. 638 
EXTERNAL SURGERY OF THE NOSE. 
The advantages of this procedure over that of Huguier consist in 
the fact that a more complete circulation is maintained through the 
hard and soft palate, and 
also through the posterior 
palatine vessels, which pass 
through the pterygo-maxil- 
lary fissure. 
Cheever’s Double Opera- 
tion.1 
(See Colored Plate II., Fig. II.) 
This consists in the de- 
pression or temporary re- 
section of the lower halves 
of both superior maxillary 
bones at the same time, and 
is performed as follows: 
An incision, commencing 
just below the inner canthus 
of the eye, is carried down- 
ward along the nasal furrow, 
to the base of the nose, when 
it is carried around the margin of the nostril, which it opens, to 
the median line, and extended down through the upper lip. A 
similar incision is made on the opposite side, until it meets that al- 
ready completed (see Fig. 163). The 
triangular flap is dissected from the 
anterior face of each superior maxil- 
lary bone, until the lower portion is 
completely exposed. The superior 
maxillae are next cut through from 
behind forward, the saw being carried 
so that it emerges in the middle 
meatus of the nasal cavity (see Fig. 
164). The septum is now completely 
divided from before backward, by 
means of scissors, when the mass is 
depressed into the mouth, hinging 
on the pterygoid processes behind. 
This operation was originally done 
by Cheever in a case of naso-pharyn- 
geal fibroma, with fatal results. This, however, was not neces- 
sarily attributable to the operation, as the patient was in an ex- 
Fig. 163.—Lines of Cutaneous Incision in Cheever’s 
Double Operation. 
Fig. 164.—Lines of Hony Section in Cheever’s 
Double Operation. 
1 Med. and Surg. Reports of the Boston City Hosp., 1870, p. 164. EXTERNAL SURGERY OF THE NOSE. 
639 
ceedingly enfeebled condition. In a case subsequently operated 
on by Tiffany1 by this method, the results were very successful. 
Waterman’s Operation.2 
Waterman, for the purpose of removing a nasal growth, resorted 
to a procedure, very similar to that of Cheever, of depressing the 
lower portion of the jaw, only that after having exposed the face of 
the bone, and having made an incision in the median line, through 
the hard palate, and also a lateral bony incision above the alveolus, 
the fragment was depressed in such a manner as that it hinged 
upon the hard palate posteriorly, in much the same manner as in 
Cheever’s double operation. The steps of the operation do not 
differ in any essential manner from those of Cheever’s. 
Roux’s Operation.3 
This rather curious operation consists of a temporary resection 
of the superior maxilla, in which the external incisions are confined 
to those points at which the bony sections are made for severing 
the bone from its attach- 
ments. Perhaps a better ap- 
preciation of the operation 
will be arrived at, by describ- 
ing somewhat in detail its 
various steps. 
First Step.—Division of 
the fronto-malar attachment. 
For this purpose, a hori- 
zontal incision over this artic- 
ulation, about half an inch in 
length, is made with a scal- 
pel, and carried well down 
upon the bone. Then, by 
means of a chisel or chain- 
saw, the frontal process of 
the malar bone is cut 
through, to the spheno-max- 
illary fissure. 
Second Step.—A vertical 
incision of the same length is made over the zygoma, which is cut 
through in a similar manner. 
Third Step.—An incision is made from the inner canthus of 
Fig. 165.—Lines of Cutaneous Incision in Roux’s 
Operation. 
1 Trans. M. and Chir. Fac. Maryland, Balto., 1878, pp. 180-187. 
2 Boston Med. and Surgical Journal, vol. lxxx., pp. 165. 
3 Gaz. des Hopitaux, 1861, vol. xxxiv., p. 354. 640 
EXTERNAL SURGERY OF THE NOSE. 
the eye, along the nasal furrow, around the base of the nose, 
stopping at the columna, or, the incision may be extended through 
the median line, completely dividing the upper lip (see Fig. 165), 
after which, by means of a chain- 
saw or scissors, the whole wall which 
separates the nasal cavity from the 
orbit is cut through (see Fig. 166), 
the section extending into the 
spheno-maxillary fissure. 
Fourth Step.—This consists of 
separating the pterygo-maxillary ar- 
ticulation, by means of a stout pair 
of scissors, carried up behind the 
tuberosity of the superior maxilla, 
this procedure being facilitated, of 
course, by sliding back somewhat 
the flap of the integument, and op- 
erating through the oral cavity. 
Fifth Step.—The hard and soft 
palate are now separated on the same side, by a transverse incision, 
after which the first incisor tooth is drawn and the hard palate, 
together with the alveolus, completely divided by means of the 
saw (see Fig. 167). 
The superior maxilla is thus completely separated from all its 
bony attachments, and is simply 
held in place by the soft palate and 
external integument. The further 
procedure consists of inserting a 
pair of stout flat-bladed forceps, 
into the line of incision through the 
hard palate, when by forcibly open- 
ing its blades, the whole body of the 
upper jaw is forced laterally and up- 
ward into the temporal fossa, thus se- 
curing a fairly wide opening through 
the hard palate into the nasal cavity 
and naso-pharynx, for the removal 
of growths in this region, or for such 
other indications as may be de- 
manded, after which the parts are 
easily restored to position, and secured by means of sutures in both 
the hard and soft parts. 
This operation was only suggested by Roux, who described it in 
full detail, and demonstrated it on the cadaver. According to his 
Fig. 166.—Lines of Itony Section in Roux s 
Operation. 
Fig. 167.—Line of I'.ony Section of the Palate 
in Roux's Operation. EXTERNAL SURGERY OE THE NOSE. 
641 
statement, a space half an inch in width is secured by this means, 
for operating in the cavities above. He further adds, however, that 
this may be somewhat increased, by cutting off the pterygoid pro- 
cess at its base, and also removing a portion of the vomer. If 
necessary, the same temporary resection may be performed simul- 
taneously on the opposite side. 
This operation is an exceedingly ingenious one, although it 
would scarcely seem to afford as free an access to the nasal and 
naso-pharyngeal cavities as can be obtained by Cheever’s, or even 
some of the simpler operations. Furthermore, although no large 
vessels are encountered during the operation, hemorrhage from the 
smaller vessels might occur, and be of such a nature as to render 
its arrest by no means an easy matter. As far as I know, this 
operation has been performed in but a single instance on the living 
subject. The result in this case, however, seems to have been 
entirely successful, the procedure having been adopted by Fontan1 
in a case of naso-pharyngeal fibroma. 
Annandale’s Operation.2 
In order to gain access to the naso-pharynx, for the removal of 
neoplasms, Annandale exposes the anterior nares, as in Rouge’s 
operation. The septum is then divided throughout its entire 
extent, where it unites with the superior maxillae. Next the soft 
parts covering the hard palate are divided in the median line, the 
soft palate may or may not require division, according to the extent 
of the growth. The hard palate and alveolus are then cut through 
in the median line, and the two jaws separated, by prying them 
apart. The amount of separation obtainable, varies from one-half 
to one inch. The growth is then removed by forceps or the snare, 
the parts are replaced, and held in position by sutures through the 
alveolus and palate. 
Langenbe.ck’s Operation for the Temporary Resection 
of the Upper Portion of the Superior Maxilla.3 
(See Colored Plate IV., Fig. I.) 
This operation is really designed to obtain access to tumors in- 
vading the spheno-maxillary fossa, and yet is very properly re- 
corded in this connection, as one of the means by which access is 
gained to the naso-pharyngeal cavity. It consists of a temporary 
resection of the upper portion of the superior maxillary bone, 
1 Revue Mensuelle de Laryng., 1888, No. 4, p. 198. 
2 Lancet, Jan. 26th, 1889, p. 162. 
3 Deut. Klin., 1861, p. 281. 642 
EXTERNAL SURGERY OF THE NOSE. 
and is performed in the following manner: By means of the 
scalpel, a curved incision is made through the integument, commenc- 
ing at the lower border of 
the nasal bone, and carried 
outward with a downward 
curve, beneath the promi- 
nence of the malar bone un- 
til it reaches the middle of 
the zygoma. A second in- 
cision, commencing just be- 
low the inner canthus of the 
eye, is carried along, imme- 
diately below the border of 
the orbit, horizontally and 
outward, until it meets the 
first incision (see Fig. 168). 
These incisions are carried 
well down to the bone. At 
the point at which the inci- 
sions meet, the finger is in- 
serted directly into the sphe- 
no-maxillary fossa, the sphe- 
no-palatine foramen being usually dilated by the growth, in many 
cases allowing the finger to pass directly into the pharynx. A 
straight saw is then inserted through this opening, its movement 
being guided by the finger in the mouth, when the body of the 
superior maxillary bone is cut di- 
rectly through, first, in the line of 
one incision, and subsequently in the 
line of the other, the section being 
carried completely into the nasal cav- 
ity (see Fig. 169). An elevator is 
now introduced behind the mass, 
which is pried out of its position, and 
turned directly inward over the eye 
of the opposite side, thus hinging 
upon the nasal process of the supe- 
rior maxillary bone and the external 
flap, which, it will be noticed, i's not 
dissected from the bone. 
If the lower of the two primary 
incisions is made to commence at 
the ala of the nose, instead of the upper border of the ala, the 
operation may be to an extent facilitated, in that in this case the 
Fig. 168.—Lines of Cutaneous Incision in Langenbeck’s 
Operation. 
Fig. 169.— Lines of Bony Section in Langen- 
beck’s Operation. EXTERNAL SURGERY OF THE NOSE. 
643 
section of bone can be made from within outward and from before 
backward, the saw being inserted into the nasal cavity. 
In making the primary incisions, it should be borne in mind 
that the facial artery is severed by the low"er cut, which, therefore, 
should be made first, and the hemorrhage properly arrested. This 
complication is to an extent avoided by an incision which com- 
mences at the lower border of the nasal bone. Aside from this, the 
operation is not attended with any notable hemorrhage, unless it 
be dependent on the neoplasm itself, for the removal of which the 
operation is done. The fragment is easily replaced, and need only 
be secured by sutures through the soft parts. 
Billroth’s Operation for the Temporary Resection of 
the Superior Maxilla.1 
This operation is designed to accomplish the same purpose as 
that of Langenbeck, but differs from it somewhat in the details. It 
is performed as follows: 
An incision is made with a bistoury through the integument, 
commencing at the root of the nose, and extending in the median 
line to its tip, when it is carried 
into the nostril, upon the side 
on which the operation is to be 
performed. A second incision 
is made, commencing at this 
nostril, and extends horizon- 
tally across the cheek, for about 
an inch and a half, to near the 
anterior border of the masseter 
muscle. A third incision, com- 
mencing at the root of the nose, 
is carried outward, just below 
the margin of the orbit, parallel 
with the lower incision, and to 
the same length (see Fig. 170). 
The nose is now severed by 
means of a chisel or other in- 
strument in the line of the me-,, 
dian incision, after which, by 
means of a straight saw, the 
body of the superior maxilla is completely divided from within out- 
ward, in the line of each horizontal incision (see Fig. 171). The 
whole mass is now pried out of its position by means of a leverage, 
Fig. 170.—Lines of Cutaneous Incision in Billroth’s 
Operation. 
1 Arch, fur Klin. Chir., 1869, vol. x., p. 106. 644 
EXTERNAL SURGERY OF THE NOSE. 
acting in the nasal cavity, and turned outward upon the cheek, 
hinging upon the pterygoid process. The line of incisions through 
the bone, in this operation, are much the same as those in Lan- 
genbeck’s operation; hence, the source of hemorrhage is largely 
in the facial artery, which requires 
ligation. The course of the upper 
incision lies very near the infra-orbi- 
tal foramen. This, however, is 
avoided with a little care; otherwise, 
troublesome hemorrhage might arise 
from the artery, which emerges at 
this point. The restoration and se- 
curing of the fragment in position, 
after the completion of the opera- 
tion, is, of course, a simple matter. 
Boeckel’s Operation. 
Bocckel,1 in operating upon a case 
of naso-pharyngeal fibroma, adopted 
essentially Billroth’s method, with 
some minor changes, although reporting it as a new operation. 
It may be noted, that instead of carrying his saw completely 
outward in the upper section of the bone, he stops at the infra- 
orbital foramen, and then, in order to avoid the danger of wounding 
the artery, inserts the needle of the chain saw through the spheno- 
maxillary fissure, carrying it subcutaneously until it passes through 
the sphcno-maxillary fissure and emerges at his lower incision, when 
he divides the union between the malar and superior maxillary 
bones subcutaneously, after which the remaining portion of the 
floor of the orbit is divided by scissors. 
Fig. 171,—Lines of Bony Section in Billroth’s 
Operation. 
Demarquay’s Operation." 
This distinguished surgeon performed the operation which bears 
his name, for the first time, upon a patient aged forty-nine, a female, 
suffering from a naso-pharyngeal tumor which had invaded the 
antrum and the left nasal fossa. The operator was deterred from 
making an incision on the dorsum of the nose, on account of the 
age and the poor condition of the patient. An incision was made 
from the internal angle of the left eye, following the nasal fur- 
row, to the free margin of the nostril. From this point, a horizon- 
tal incision was carried outward to the anterior border of the 
1 Gaz. Med. de Strasbourg, 1872, No. 2, p. 18. 
2 Bull, de Therapeutique, Paris, 1862, vol. lxiii., p. 276. EXTERNAL SURGERY OF THE NOSE. 
645 
masseter muscle (see Fig. 172). Two flaps were thus formed, a 
nasal and a malar. 
These two being dissected up, together with the underlying 
periosteum, Liston’s forceps were applied, and a portion of the 
nasal process of the superior maxilla, and the entire anterior wall 
Fig. 172.—Lines of Cutaneous Incision in Demarquay’s 
Operation. 
Fig. 173.—Lines of Bony Section in Demar- 
quay’s Operation. 
of the antrum were removed, enough of the nasal process being 
left to retain the shape of the nose (see Fig. 173). The tumor 
was then extirpated by means of forceps, and the margins of the 
wound brought together with metallic sutures. The patient was 
cured with scarcely any disfigurement, and the anterior wall of the 
antrum was reproduced. 
Maisonneuve’s Operation. 
(See Colored Plate I., Fig. II.) 
Permanent resection of. the whole of the superior maxilla was 
done as early as the latter part of the last century, although Syme,1 
of Edinburgh, was the first to resort to this procedure for the re- 
moval of a nasal fibroid, while soon afterward, and apparently with- 
out knowledge of Syme’s operation, the same procedure was adopted 
by Eve,2 for the removal of a similar neoplasm, and Mott ;3 although 
1 Edinburgh Medical and Surgical Journal, 1832, vol. xxxviii., pp. 322-324. 
2 Southern Medical and Surgical Journal, Augusta, 1836-37, vol. i., pp. 78-80. 
3 American Journal of Medical Sciences, 1843, N. S., vol. v., pp. 87-91. 646 
EXTERNAL SURGERY OF THE NOSE. 
in the latter case, the whole of the jaw was not exsected. This 
seems a somewhat formidable operation for the removal of a sim- 
ple nasal or naso-pharyngeal tumor, and certainly at the present 
day no one would resort to so radical a measure, in that a partial 
resection fulfils for this purpose 
every indication that the complete 
resection affords, a truth very early 
recognized by Maisonneuve,1 whose 
operation, first proposed in i860, 
has never been specially improved 
upon. This operation is done with- 
out making any external incisions 
whatever through the integument, 
although, if necessary, the upper 
lip may be divided from the margin 
of the nostril to the free border on 
the affected side. The lip being 
drawn well up over the nose, the 
anterior surface of the lower por- 
tion of the bone is exposed, by 
sweeping the scalpel along the ginglivo-labial fold, until the bony 
opening of the anterior nares is exposed. The soft palate is separ- 
ated, by a transverse incision, from the hard palate, and then a first 
incisor tooth having been drawn, the whole of the hard palate, 
together with the alveolar process, 
is divided by means of bone forceps, 
introduced through the nostril (see 
Fig. 174). Then, with the one blade 
of the cutting forceps introduced 
into the nostril, and the other ap- 
plied externally along the anterior 
face of the bone, the whole mass is 
severed, the section being carried 
back as far as the tuberosity, at its 
junction with the pterygoid process 
(see Fig. 175). The fragment is now 
seized by forceps, and wrenched from 
its position. This procedure is at- 
tended with no notable hemorrhage, 
aside from that which is dependent 
upon the character of the tumor, or other complications. It gives 
ample access to the nasal and naso-pharyngeal cavities, for the re- 
moval of such tumors- as may exist there, and a large freedom of 
Fig. 174.—Line of Bony Section in Maisonneuve's 
Operation. 
Fig. 175.—Lines of Bony Section in Maison- 
neuve’s Operation. 
1 Union Medicale, i860, Second Series, vol. vii., pp. 393-96. EXTERNAL SURGERY OF THE NOSE. 
647 
movement for subsequent manipulations. After the tumor has 
been removed, the subsequent treatment consists of such simple 
measures as are suggested by the rules of ordinary surgical prac- 
tice. At the expiration of a few weeks, an artificial palate is -worn 
with comfort, and subsequently, a set of false teeth adapted to that 
side. The deformity resulting from this operation is very slight 
ordinarily, and the only objection that lies against the operation, is 
the loss of the teeth on that side, an objection easily obviated. The 
very great advantage of the operation over temporary resection, 
lies in the fact, that permanent access is gained to the nasal or naso- 
pharyngeal cavity, for the treatment of the stump, for the obser- 
vation of any tendencies to recurrence, and the prompt application 
of such remedies as may be indicated. In other words, if recur- 
rence occurs, a second operation is rarely necessary, as would be 
demanded probably in the majority of cases, where a temporary 
resection only had been performed. Hence, when we remember 
that this operation is done in the large majority of instances for 
fibroma of the naso-pharynx, and that these are met with in young 
children, where there is a marked tendency to recurrence, it would 
seem in every way, that indications are best carried out, where a 
radical operation becomes necessary, by the performance of a per- 
manent, rather than a temporary resection. As regards sarcoma, 
in which a recurrence is to be expected almost with certainty, the 
successful eradication of the growth certainly can be far better 
hoped for by the permanent removal of a portion of the jaw. in 
that after removal of a growth of this kind, the most constant and 
observant watchfulness is required, if we expect to successfully 
control its subsequent development. 
While this operation of Maisonneuve, therefore, is undoubteldy 
the best which has yet been devised for accomplishing its special 
indications, there are several others involving permanent resection 
of a portion of the superior maxillary bone, which may be indicated 
in special cases, prominent among which are Pean’s, Berard’s, 
H’uguier’s, and Vallet’s. 
Pean’s Operation.1 
This consists of a permanent resection of the posterior portion 
of the lower half of the superior maxilla, and is performed as fol- 
lows : 
A linear incision, commencing at the root of the nose, is made 
in the median line, by means of a bistoury, and carried down to 
(See Plate III., Fig. II.) 
1 “ Lemons deClin. Chir.,” 1879, vol. ii., p. 128. 648 
EXTERNAL SURGERY OF THE NOSE. 
the tip of the organ, and into the nostril, and subsequently extended 
from the lower border of the nostril, through the median line of 
the upper lip, which is com- 
pletely divided (see Fig. 176). 
The flap is now dissected up, 
until the bony opening of 
the • anterior nares and the 
anterior surface of the su- 
perior maxilla is completely 
exposed. The next step con- 
sists in separating the peri- 
osteum from that portion of 
the hard palate which the 
operator designs to remove. 
The second bicuspid tooth 
is now drawn, and with a 
stout pair of cutting forceps, 
the alveolus at this point is 
cut through into the cavity 
of the antrum, when the for- 
ceps are still further inserted, 
one blade in the antrum, and 
the other in the oral cavity. The section is extended back until 
it reaches the median line at the posterior border of the hard 
palate (see Fig. ■77)- The external wall of the antrum is now 
Fig 176.—Line of Cutaneous Incision in Pean’s Operation. 
Fig, 177.—Line of Bony Section in Pean’s 
Operation 
Fig. 178.—Lines of Kony Section in Fean's 
Operation. 
divided in a line extending up to a point immediately below the 
infra-orbital foramen, when from this point, by means of forceps, 
a section is made, extending backward in a horizontal direction, EXTERNAL SURGERY OF THE NOSE. 
649 
to the pterygo-maxillary junction (see Fig. 178), after which the 
mass is seized with a strong forceps, and wrenched from its posi- 
tion. In this manner access is gained to the posterior portion of 
the nasal cavity, and the naso-pharynx. The operation is com- 
paratively simple, and involves no serious complications, and while 
affording a somewhat restricted opening, possesses the advantage 
of leaving in position the incisor teeth, the patient being deprived 
simply of the last three molars, and one bicuspid. 
Pean evidently had some idea of the restoration of the hard 
palate, in directing the preservation of the periosteum, although 
just how this is to be accomplished, he does not make clear. 
Berard’s Operation.1 
This operation is devised to obtain access to the cavities of the 
nose and naso-pharynx, by means of a permanent resection of the 
central portion of the superior maxilla, without disturbing the alve- 
olar process, and is made as follows: 
The anterior face of the bone is exposed by making an incision 
Fig. 179.—Line of Cutaneous Incision in Berard’s 
Operation. 
Fig. 180.—Lines of Bony Section in Berard’s 
Operation. 
through the integument either along the median line of the nose, 
or the side of the nose, extending down through the upper lip (see 
Fig. 179). After the bony orifice of the anterior nares, together 
with the anterior wall of the superior maxilla, is exposed, a section 
1 Diet, en 30 vols., t. xxviii., p. 367. 650 
EXTERNAL SURGERY OF THE NOSE. 
is made of the nasal process, by means of a cutting forceps, one 
blade of which is introduced into the anterior nares, and the other 
into the orbit, the direction of the incision being obliquely outward. 
A second incision is made in a similar manner through the malar 
bone, at its junction with the superior maxillary bone, after which 
a section is made from the lower border of the bony orifice of the 
anterior nares, through the body of the bone, to the pterygo-maxil- 
lary junction (see Fig. 180). The detached fragment is then 
wrenched from position, thus removing the outer wall of the nasal 
cavity, together with the anterior wall of the antrum, giving access 
to the nose through an opening, which really is commensurate with 
the size of the antral cavity. 
Huguier’s Operation.1 
This operation differs in no marked degree from that of Berard 
except that he removes a smaller fragment. The outer bony 
section, instead of being extended 
through the malar bone, is made 
through the body of the superior 
maxilla, almost entirely within the 
malo-maxillary junction (see Fig. 
181). Both Berard and Huguier 
report having made successful ope- 
rations in the manner above de- 
scribed, although it is not easy to 
understand, why a prominent source 
of difficulty would not be, in the 
lack of a firm support to the alve- 
olar process, after the removal of 
so much of its bony attachment, 
for, as we see, after the removal of 
the fragment, this process is held in 
position for a time certainly, by the surviving portion of the ptery- 
go-maxillary junction, together with the intermaxillary junction. 
Fig. 18 i.—Lines of Bony Section in Huguier’s 
Operation. 
Yallet’s Operation.2 
This procedure consists of a permanent resection of a still 
smaller portion of the body of the superior maxillary bone, and is 
done as follows: An incision, commencing just below the internal 
angle of the eye, is carried along the nasal furrow, and around 
the root of the nose, to the nostril, and then extended from 
the inner border of the nostril, down the median line, completely 
2 Gaz. des Hopitaux, March 31st, 1859. 
1 Bull, de la Soc. de Chir., 1850, p. 574. EXTERNAL SURGERY OF THE NOSE. 
651 
dividing the upper lip. The flap being dissected off, exposes the 
bony opening of the anterior nares of that side, together with the 
anterior wall of the superior maxillary bone. A section of bone is 
now made with a chisel, commenc- 
ing at the lower border of the bony 
opening of the nares, and extending 
outward and parallel with the alve- 
olus, as far as the first bicuspid. A 
similar section is made, commencing 
in the nares, and parallel with this, 
extending outward, just below the 
infra-orbital foramen. The outer 
ends of these two incisions are united 
by a third section (see Fig. 182), 
when, by means of stout scissors or 
forceps, the outer wall of the nasal 
cavity is cut, first below, and then 
above, in the lines of the original 
parallel sections through the anterior 
wall of the superior maxilla. The fragment is now wrenched from 
its position. As will be seen, Vallet in this operation simply re- 
moves the anterior and inner wall of the maxillary sinus, which is 
thus opened into the nasal cavity, giving a free access to this pas- 
sage, although a somewhat limited one to the pharyngeal vault. 
Fig. 182.—Lines of Bony Section in Vallet’s 
Operation. BIBLIOGRAPHICAL INDEX. 
Abeille, 176 
Acoluthus, 579 
Adams, 300 
Adelon, 89 
Agnew, 456 
Albucasis, 579 
Allen, 176, 202, 207, 282 
Althaus, 260, 274, 276 
Alvarez, 381 
Ammannus, 258 
Anderson, 253 
Andrew, 255 
Anglade, 106 
Annandale, 601, 620, 641 
Antoni, 317 
Arnold, 40, 418 
Aschenbrandt, 94 
Ashhurst, 435 
Astier, 476 
Auphan, 34 
Auspitz, 424 
Avery, 3 
Axinann, 328, 329 
Aysaguer, 423 
Baber, 296, 327, 328, 330, 563 
Babington, 3 
Baratoux, 176, 351, 467, 490 
Barth, 397 
Barthelemy, 579 
Bartolini, 326 
Bassereau, 336, 338 
Baumgarten, 293, 312 
Baumler, 360, 364 
Baxter, 265 
Beach, 327 
Beard, 201, 209, 216, 221, 237 
Beau, 233 
Behrends, 331 
Bell, 401 
Bennati, 3 
Bennett, 232 
Berard, 276, 621, 649 
Berger, 481, 484, 486, 488 
Bergson, 35 
Bernard, 273 
Berrueco, 408 
Berthold, 371 
Bertin, 255 
Beschorner, 200 
Bettman, 190, 194, 227, 330 
Beuf, 574 
Beyer, 400 
Biermer, 234 
Bigelow, 82, 138, 327, 328 
Billroth, 379, 381, 388, 389, 392, 399, 4x0, 
412, 463, 620, 643 
Binningerus, 200 
Binz, 201, 227 
Birdsall, 253 
Birkett, 577 
Blachey, 490 
Blackley, 201, 204, 212, 213, 224, 227, 231 
Blake, 549 
Blandin, 273, 298 
Bloch, 97 
Bocker, 239 
Boeckel, 597, 620, 627, 644 
Bolton, 299 
Bonet, 278 
Bordenave, 476 
Bornhaupt, 418 
Bostock, 199, 200, 203 
Bosworth, 91, 122, 143, 162, 189, 202, 220, 
228, 237, 261, 262, 303, 306, 327, 445, 
446, 459, 501, 539, 541, 565, 602, 613 
Botallus, 200 
Botrel, 619, 622 
Bouchard, 197 
Boucheron, 467 
Bovill, 327, 329 
Bowditch, 255 654 
BIBLIOGRAPHICAL INDEX. 
Boyle, 347 
Bozzini, 3 
Brand, 114 
Bree, 233 
Bresgen, 83, 181, 184, 185, 290, 293, 376, 
Brevet, 574, 596 
Briggs, 567 
Brodie, 326 
Broich, 516, 526, 527, 536 
Bronner, 491 
Brooks, 230 
Brown, 327 
Browne, 6, 121, 167, 176, 190, 393, 394, 
467, 487, 513, 516, 519, 554, 563 
Brown-Sequard, 187 
Bruns, 581, 620, 633 
Bryant, 401, 535, 601 
Bryk, 410, 596 
Buchanan, 410 
Buck, 117 
Budd, 233 
Burckhardt, 431, 442 
Burnett, 171, 600 
Burns, 466 
Burow, 29 
Butlin, 388, 400, 423, 442, 458, 610 
Calmettes, 444 
Campbell, 457 
Cartaz, 371 
Casabianca, 456 
Casey, 255 
Caspari, 254 
Casselberry, 410 
Cazenave, 201, 225, 226, 231 
Celsus, 579 
Chassaignac, 287, 297, 299, 438, 628 
Chatellier, 84, 94, 168, 410, 444, 465, 539, 
550, 562, 588 
Cheatham, 190, 230, 231 
Cheever, 620, 637, 638 
Chiari, 312, 319, 410 
Chibrac, 252 
Christie, 251 
Ciniselli, 582 
Clark, 327 
Clarke, 203, 227, 330 
Clauder, 326 
Clay, 327 
Clerq, 336 
Cloquet, 287, 331 
Clutton, 376 
Cochran, 334 
Cohen, in, 154, 176, 180, 315, 328, 504, 
516, 561 
Collis, 376 
Constant de Rebecque, 200 
Cooke, 327 
Copeland, 233 
Coquerel, 332, 333 
Cornil, 381, 383, 453 
Coupard, 322 
Courtin, 255 
Courty, 255 
Coyne, 588 
Cozzolino, 376, 410, 423 
Cruveilhier, 82, 398, 430 
Cullen, 186 
Curtis, 301, 561 
Cutter, 588 
Czermak, 4, 88, 522, 539 
Dalby, 563 
Dalrymple. 446 
Daly, 202, 204, 236, 237, 405 
Dauvergne, 587 
Dauzats, 334 
David, 551 
Davies, 259 
Davis, 381 
Dawson, 255 
Deane, 255 
De Blois, 142 
Debousquet-Laborderie, 176 
De Budberg, 208, 227 
Dechambre, 201, 222 
Delavan, 177, 431 
Delstanche, 458, 563 
Demarquay, 298, 326, 328, 498, 621, 644 
Demme, 370 
Depres, 273, 599 
Desgranges, 24 
Dessar, 33 
Devalz, 435 
Devasse, 338 
Deville, 338 
Dezeanneau, 619, 624 
Dickson, 409 
Diday, 361 
Dieffenbach, 297, 619, 624 
Dietrich, 382, 383 
Dobell, 515 
Dolbeau, 410, 414, 418, 570, 575, 624 BIBLIOGRAPHICAL INDEX. 
655 
Donaldson, 401 
D'Ornellas, 574 
Doutrelepont, 381, 384 
Dubreuil, 273, 277 
Duffield, 605 
Duka, 417 
Dumenil, 431, 588 
Duncan, 254 
Dunglison, 89 
Duplay, 441 
Dupuytren, 551, 624 
Durand-Fardel, 6x2 
Duret, 290 
Durham, 324, 435 
Duverney, 82 
Earle, 454 
Eccheverria, 315 
Eder, 456 
Elliotson, 201, 226, 259 
Elsberg, 189 
English, 251 
Eppinger, 599 
Erichsen, 327, 388, 393, 401, 402, 435, 439 
Fabricius, 579 
Fayrer, 439 
Fenger, 418 
Ferre, 327 
Ficano, 445 
Figuiere, 409 
Fincke, 189, 193 
Finne, 192 
Fischer, 261, 409, 582 
Fisher, 409 
Fletcher, 274 
Fleury, 455 
P'lint, 90, 187 
Flour, 613 
Fontan, 641 
Forster, 258 
Fournaux-Jordan, 620, 634 
Fournier, 170, 336 
Fowler, 443 
187 
Frank, 317 
Frankel, 128, 154, 162, 166, 170, 180, 311, 
320, 332, 333, 467, 472, 479, 539, 550, 
552, 553. 562, 564, 568 
Frantzius, 332 
Frazer, 255 
Fricker, 311 
Frisch, 381, 383 
Fritsche, 114 
Frontis, 471, 473 
Gahrlieb, 331 
Galen, 28 
Gallozzi, 441 
Gamperz, 423 
Ganghofner, 386, 505 
Gangolphe, 588 
Garcia, 3 
Garel, 467 
Garretson, 467, 474 
Gaubert, 418 
Gay, 410 
Geber, 381 
Gelle, 168, 319, 467 
Gensoul, 579 
Gerdy, 392, 409 
Gibbons, 256 
Giraldes, 477 
Gluck, 181 
Gomez, 409 
Gordon, 201, 223 
Gosselin, 427, 439, 455, 570, 576, 582, 588 
Gottstein, 166, 175, 290 
Gourewitscha, 187 
Graefe, 326, 328 
Graham; 86 
Graucher, 555 
Graves, 274 
Grehant, 90 
Gruening, 190 
Grynfeltt, 440, 453, 577 
Gussenbauer, 623 
Guttman, 255 
Guye, 189, 563 
Guyon, 431 
Habermaas, 418 
Habermann, 164 
Hack, 188, 202, 212, 396 
Hajek, 371 
Hall, 186, 187 
Hamilton, 273 
Harrison, 251 
Hartmann, 180, 184, 185, 475, 480, 567 
Harvey, 320 
Hawkins, 363 
Heberden, 200 
Hebra, 381 
Flecker, 454 656 
BIBLIOGRAPHICAL INDEX. 
Helmholtz, 4, 88, 226 
Hempel, S9 
Henderson, 142 
Hendley, 327 
Hering, 327 
Herlinus, 200 
Hertzog, 202 
Heurtaux, 457, 458, 595 
Heylen, 297, 328, 329 
Heymann, 282, 290, 298, 391, 394 
Higgins, 443 
Hildebrandt, 308 
Hinkle, 230 
Hippocrates, 437, 579 
Hitchcock, 410 
Hodgen, 410 
Holmes, 88 
Hooper, 539, 550, 554 
Hopkins, 255 
Hopmann, 290, 392, 422, 442 
Horn, 326 
Horner, 488 
Hortoles, 579 
Huguier, 431, 620, 621, 635, 650 
Huguenin, 273, 279 
Hulke, 399 
Hunerswolf, 200 
Hunt, 380 
Hunter, 478, 504, 539 
Huss, 255 
Hyrtl, 308 
Ingals, 283, 298, 318, 410, 483, 582 
Ischwald, 82 
Jackson, 274 
Jacobi, 193 
Jacquemart. 410 
Jarvis, 100, 150, 152, 287, 301, 403, 410, 
43L 434 
Jedkins, 230 
Jimenez, 410 
Joal, 193, 311 
Job-a-Meckren, 579 
Johnson, 429 
Joiion, 463 
Jourdain, 479 
Juffinger, 371 
Julius, 252 
Jurasz, 300 
Kaposi, 377 
Kassowitz, 360 
Kayser, 95 
Keetley, 315 
Keimer, 516 
Kempf, 410 
Kergaradec, 347 
Kern, 326 
Keyes, 357 
Kikuzi, 372, 376 
Kinnear, 212, 223, 254 
Kirtikar, 410 
Knapp, 418, 483, 494 
Kohlrausch, 82 
Kolaczek, 440, 448 
Kolliker, 82, 328 
Kostonecki, 503 
Kotlin, 327 
Kough, 376 
Krakauer, 394 
Kratschemer, 187 
Krause, r66, 465 
Kuhn, 446 
Kussmaul, 311 
Labbe, 588 
La Font, 576 
Laforgue, 201, 222 
Lahory, 332 
Lamadrid, 253 
La Morier, 479 
Lancereau, 347 
Lange, 562 
Langenbeck, 287, 469, 620, 631, 641 
Lariche, 619, 625 
Lastra, 322 
Laveran, 369 
Lavrand, 316 
Lawrence, 454, 620, 630 
Leber, 264 
Ledelius, 200 
Lees, 112 
Lefferts, 429 
Leflaive, 210, 215 
Lefort 336 
Le Galois, 186 
Legg, 273 
Legouest, 418 
Lehmann, 536 
Lermoyez, 210 
Lessdorf, 253 
Levi, 253 
Leyden, 234 BIBLIOGRAPHICAL INDEX. 
657 
Lichtenberg, 410 
Liebl, 455 
Liegeois, 85 
Lincoln, 442, 577, 582, 586, 600 
Lingard, 266 
Linhart, 298, 620, 632 
Linon, 588, 593 
Lloyd, 490 
Lockemann, 276 
Loder, 273 
Loewy, 291, 293 
Lotzbeck, 612 
Louis, 467 
Lowndes, 321 
Lowenberg, 164, 282, 283, 539, 541, 544, 
549,,562, 563 
Luc, 372, 496, 516, 526, 527 
Luchsinger, 187 
Luschka, 503, 504 
MacCarthy, 336 
MacCullough, 200, 221 
Mackenzie, John, 81, 188, 191, 202, 207. 
2x2, 226, 297, 431 
Mackenzie, M., hi, 121, 154, 167, 170, 
176, 202, 207, 222, 224, 227, 229, 236, 
239, 271, 280, 282, 295, 312, 314, 315, 
319. 33L 334, 345, 382, 391, 393, 395, 
404, 409, 423, 435, 450, 503, 512, 515 
Magendie, 89, 276 
Maier, 470 
Maisonneuve, 410, 462, 612, 619, 621, 645 
Major, 445, 562 
Mankewitz, 332 
Manne, 619, 621 
Manz, 37 
Marchal, 334 
Marjolin, 598 
Marsh, 202 
Martineau, 336 
Mason, 439 
Massei, 601 
Mathias de Gardi, 326 
Mathiesen, 266 
Mathieu, 35 
Mauriac, 345 
Maxwell, 402 
McBride, 189, 197 
McGregor, 331 
Menocal, 581 
Meyer, 87 
Meyer, J. O., 504 
Meyer, Wilhelm, 539, 540, 541, . 554, 560, 
561, 569 
Michael, 563 , 
Michaux, 438 
Michea, 255 
Michel, 164, 193, 418, 553, 567, 568, 5S2 
Michon, 417 
Mickulicz, 381, 478 
Middledorpf, 145, 225, 403 
Miliard, 370 
Miot, 289, 298 
Mo, 441 
Moinel, 376 
Moldenhauer, 79, 180, 183, 185, 190, 197 
3x4, 321, 322, 324, 328, 334, 391, 467, 
471, 473, 475, 568 
Molliere, 273, 274 
Moorhead, 224 
Morel, 332 
Morelli, 327 
Morgagni, 281 
Morgan, 417 
Morton, 234 
Mott, 409, 418, 579, 621 
Moquin-Tandon, 332 
Mougins, 409 
Moure, 191, 312, 314, 318, 319, 322, 336 
390, 398, 444, 518, 522, 531 
Muller, 595 
Mueller, 186, 187 
Muron, 573 
Neisser, 377, 378, 379 
Nelaton, 401, 431, 570, 576, 581, 599, 619, 
622 
Nettleship, 264 
Neudorfer, 454 
Neureuter, 597 
Nolte, 327, 329 
Noquet, 164, 176, 322, 433, 467 
North, 189 
Notta, 273, 277, 280 
Nourse, 327 
Noyes, 227 
Obermeier, 311 
Ogle, 86, 273, 274, 275, 277 
Oliver, 253 
Ollier, 620, 629 
Ollivier, 418 
Onodi, 290 
Oppert, 273, 278 658 
BIBLIOGRAPHICAL INDEX. 
Osio, 440 
Packard, 334 
Paget, 259 
Palasciano, 620, 626 
Pamard, 418 
Panas, 431, 488, 588, 592 
Paquet, 582 
Pare, 437 
Patrick, 315 
Pean, 456, 621, 647 
Pelleta, 437 
Peltier, 588 
Pepinster, 409 
Pepper, 457 
Petrequin, 332, 391 
Pettesohn, 495 
Pfuhl, 234 
Phoebus, 201, 203 
Plater, 326 
Pluyette, 570 
Post, 488 
l’otain, 541 
Potter, 181 
Prevbst, 273 
Prince, 332 
Procheska, 186 
Pserhofer, 29 
Puech, 311 
Pugliese, 427 
Quelmalz, 281, 287, 297 
Rabitsch, 439 
Rabow, 116 
Rafin, 376, 380 
Rampolla, 620, 627 
Ramsay, 86 
Ranvier, 453 
Rastelli 324 
Raynaud, 277 
Reed, 376 
Rees, 258 
Remy, 91 
Rendu, 418 
Reute, 4 
Ricchi, 381 
Richard, 619, 623 
Richardson, 193 
Richet, 188, 298, 418, 431, 435, 441 
Ricord, 336 
Riedel, 369 
Riedlin, 200 
Riedlinus, 326 
Riehl, 370 
Rigal, 376 
Rindfleisch, 327, 328 
Roberts, 201, 305 
Robertson, 149, 289 
Robin, 389, 427 
Robinson, 100, 112, 142, 143, 171, 175, 
190, 203, 212, 228, 229, 298, 312, 318, 
319,393, 397, 401, 408,467, 515,518, 
519, 531 
Roe, 202, 220, 305, 327, 431, 539, 544, 553 
Roger, 360 
Rolfinc, 81 
Rollet, 336 
Romberg, 274, 364 
Roosa, 33. 502 
Rose, 317 
Rosenthal, 91 
Roser, 299 
Rostan, 233 
Rotch, 273 
Rouge, 487, 619, 626 
Routier, 444 
Roux, 620, 639 
Rouyer, 327 
Ruault, 187, 190, 191 
Ruppert, 82 
Ruprecht, 299 
Ruysch, 326 
Ryerson, 181 
Sajous, 6, 8, 1x2, 167, 171, 210, 225, 226, 
3i3, 3i4, 328, 391, 399- 408, 512, 567 
Sales-Girons, 34 
Sallinger, 189, 193 
Salter, 233, 237, 239, 476 
Sanger, 340 
San Juan, 273 
Sargent, 441 
Saviales, 326 
Savory, 481 
Schaus, 286, 287 
Schaffer, 189, 193, 371, 373, 443, 458, 480, 
491 
Schech, 117, 167, 240, 310, 317, 323,324, 
329, 348, 391, 469, 485, 486, 491, 493, 
496, 516, 561 
Schiffers, 465, 479 
Schmid, 599, 613 
Schmidt, 473 BIBLIOGRAPHICAL INDEX. 
659 
Schmitt, 332 
Schmiegelow, 308, 376, 400, 422, 443, 458, 
496 
Schneider, 81 
Schoetz, 327 
Scholz, 490 
Schuller, 379 
Schulthess, 381, 385 
Schuster, 340, 349, 351, 355 
Schutz, 562 
Schwabach, 505, 516, 517 
Sedillot, 619, 623 
See, 254, 255 
Seeliger, 453 
Seifert, 176, 180, 192, 327, 328 
Seiler, 167, 178, 188, 293, 296, 298, 301, 
302, 303, 354, 402, 408, 410, 431, 516 
Seiss, 496 
Semeleder, 281 
Semon, 313, 381, 555 
Shakespeare, 457 
Shrady, 576 
Shuller, 180 
Shurley, 177, 376 
Siegle, 43 
Silitch, 327 
Simon, 361 
Smith, 410 
Smith, Priestley, 265 
Sommer, 311 
Sonnenberg, 484 
Speirs, 264 
Spicer, 552 
Spillmann, 345, 369 
Spottiswood, 255 
Sprengle, 418 
Squibb, 144 
St. Ange, 317 
Starke, 376 
Steele, 299 
Steinbriigge, 431 
Steiner, 410 
Stewart, 315 
Stepanow, 383 
St. Germain, 588 
Stoker, 226 
Stork, 475, 522, 564 
Stukowenco, 381 
Swinburne, 547, 564 
Syme, 409, 579, 621 
Tanturri, 381 
Temain, 324 
Tennison, 372 
Terrier, 442 
Testelin, 423 
Theile, 281 
Theulot, 446 
Thiedemann, 334 
Thomas, 605 
Thost, 164 
Thouret, 326 
Thudicum, 32 
Tiffany, 639 
Tillaux, 259 
Tillmanns, 418 
Tobold, 10 
Todd, 233 
Todd-Bowman, 78 
Tornwaldt, 370, 516, 522, 526, 536 
Trelat, 442, 588 
Trendelenburg, 287 
Troeltsch, 522 
Tiirck, 3, 4 
Tyrman, 481, 484, 486 
Tyndall, 86 
Upson, 579 
Urbanek, 332 
Urbantschitsch, 547 
Ure, 435 
Vallet, 621, 650 
Van Buren, 438 
Vanderpoel, 431 
Van Domelin, 343. 409 
Van Harlingen, 364 
Van Helmont, 200 
Van Rosen, 360 
Van Santvoord, 376 
Veillon, 598, 599 
Verdos, 396 
Verhaeghe, 409 
Verneuil, 327, 417, 423, 426, 431, 435, 
441, 461, 469, 497, 632 
Vernujne, 483 
Viennois, 439 
Vierordt, 89 
Vieusse, 266 
Villar, 410 
Vimont, 577 
Virchow, 328 
Volkmann, 290 
Voltolini, 91, 188, 236, 386, 391, 404, 567 660 
BIBLIOGRAPHICAL INDEX. 
Vossius, 482 
Wagner, 142, 155, 391, 431, 463 
Waldeyer, 455 
Wales, 24 
Walshe, 233 
Walston, 404 
Ward, 423, 426 
Waterman, 620, 639 
Watson, 336, 347, 429, 455, 456, 468, 469, 
473 
Weber, 32, 235, 332, 351, 362, 435,440, 450 
Weichselbaum, 369, 370, 481, 487 
Weinlechner, 382, 440, 457 
Weir, 306, 444, 600 
Welcker, 287, 292 
Welge, 496 
Wendt, 515 
Wepfer, 326 
West, 327 
White, 25 
Whytt, 186 
Williams, 253 
Willigk, 369 
Willis, 253 
Winch, 255 
Wintrich, 233 
Woakes, 33, 117, 143, 172, 176, 397, 481, 
516, 544, 547, 548, 561 
Wohl, 605 
Wohlfahrt, 331 
Wolfram, 475 
Wood, 255 
Wright, 405 
Wyeth, 468 
Wyman, 201, 208, 210 
Wyss, 169 
Yeo, 234 
Zahn, 522 
Zaufal, 168 
Ziem, 189, 291, 470, 471, 475, 487, 489 
Zuccarini 486 
Zuckerkandl, 71, 72, 73, 75, 78, 82, 168, 
282, 289, 291, 296, 308, 387, 389, 390, 
423, 465, 466, 468, 471, 479, 486, 487, 
49T, 492, 493 GENERAL INDEX. 
Accessory cavities, differential diagnosis 
between diseases of the, 496 
sinuses of the nose, the, 74 
sinuses of the nose, diseases of the, 465 
Acute naso-pharyngitis, 508 (see Naso- 
pharyngitis) 
rhinitis, 105 (see Rhinitis) 
Adenoid growths, 539 (see Pharyngeal ton- 
sil, hypertrophy of the) 
Adenoma of the nasal passages, 427 
Age, etiological factor of, in carcinoma of 
the nose, 460 
in sarcoma of the nose, 447 
Agger nasi, 73 
Air pumps, 40 
Anatomy of mucous membranes, the, 48 
of the external nose, the, 69 
of the nasal fossae, the, 70 
of the naso-pharynx, the, 501 
of the nose, the, 69 
Angioma of the nasal passages, 431 
Course and prognosis, 434 
Diagnosis, 433 
Etiology, 432 
Pathology, 432 
Symptomatology, 432 
Treatment, 434 
Anosmia, 272 
Diagnosis, 278 
Etiology, 272 
Atrophic rhinitis, 275 
Congenital, 273 
Deficiency of pigment, 275 
Intra-cranial disease, as occurring 
in tabes, 274 
Lesion of terminal filaments of 
nerve, 274 
Morbid conditions of the nerve, 
Anosmia, etiology: 
Obstructive lesions in the nose, 272 
Pathology, 278 
Prognosis, 276 
Symptomatology, 275 
Relation between smell and taste, 
276 
Treatment, 279 
Anterior rhinoscopy, 15 
Antrum, disease of, 465 
Diagnosis, 471 
Exploratory puncture, 473 
Position of patient, 472 
Etiology, 465 
Carious teeth, 466 
Catarrhal inflammation in the 
nose, 466 
Nasal polypi, 468 
Traumatism, 469 
Pathology, 469 
Prognosis, 474 
Symptomatology, 470 
Treatment, 474 
Exploration of cavity, 477 
Opening antrum into the nasal 
cavity, 478 
Opening the antrum through the 
alveolus, 475 
Use of drainage tube, 476 
Apparatus, the fixed, 10 
Asthma, 232 
Differential diagnosis, 249 
Etiology and history, 232 
Dependent upon three conditions, 
237 
Report of author’s cases, 240 
Physical signs, 248 
Prognosis, 249 
Symptomatology, 247 662 
GENERAL INDEX. 
Asthma, treatment, 250 
of local morbid condition, 250 
of paroxysm, 250 
Arsenic, 252 
Bromides and chloral, 254 
Carbonic acid gas, 252 
Cocaine, 251 
Cold to spine, 254 
Counter-irritation to spine, 
254 
Morphine, 253 
Nitrite of amyl, 254 
Saltpetre, 251 
Stramonium, 251 
General treatment, 254 
Change of climate, 256 
Astringents in acute rhinitis, 112 
Atomization, history of, 34 
Atomizers, 34 
Atrophic rhinitis, 162 (see Rhinitis) 
Aural symptoms in acute naso-pharj’ngitis, 
5ii 
symptoms in acute rhinitis, 131 
symptoms in adenoid disease of naso- 
pharynx, 546 
Symptoms in atrophic rhinitis, 171 
symptoms in hypertrophic rhinitis, 131 
symptoms in naso-pharyngeal catarrh, 
526 
Auto-laryngoscopy, 3 
Blindness, sudden, as a symptom of 
sphenoidal disease, 497 
Blood-vessels of nasal mucous membrane, 
81 
Bulla ethmoidalis, the, 73 
Bursa pharyngea, the, 504, 516 
pharyngea, formation of the, 5x7 
Canal, the lachrymal, 72 
Carcinoma of the nasal passages, 453 
Diagnosis, 462 
Etiology, 460 
Histories of cases, 453-460 
Pathology, 460 
Prognosis, 462 
Symptomatology, 461 
Treatment, 463 
Carcinoma of the naso-pharynx, 6x2 
Enlargement of cervical glands in, 615 
Radical operation in, 616 
Report of cases, 612-615 
Cartilages, the nasal, 69 
Catarrh, derivation of, ioi 
Catarrhal disease, excessive secretion as a 
symptom of, ioi 
disease, general considerations con- 
cerning, 98 
inflammation of mucous membranes, 52 
Chondroma of the nasal passages, 435 
of the naso-pharynx, 595 
Climate, etiological relation to hypertrophic 
rhinitis, 120 
Cold, prevention of, 62 
taking, 57 
treatment of, 67 
Columnar cartilage, dislocation of the, 306 
Concha santoriniana, 71 
Coryza, syphilitic, 337 
syphilitic, treatment of, 352 
Croupous inflammation of mucous mem- 
branes, 55 
rhinitis, 180 (see Rhinitis) 
Crust formation in atrophic rhinitis, 169 
formation in hypertrophic rhinitis, 127 
formation in lupus, 377 
Cystic degeneration of myxoma, 389 
Cystoma of the nasal passages, 429 
Deformities of the nasal septum, 281 (see 
Nasal septum) 
Deformity of the septum as a cause of 
hypertrophic rhinitis, 124 
Depressing the tongue, method of, 20 
Development of the laryngoscope, 4 
Dilator tubas muscle, the, 502 
Diphtheritic inflammation of mucous mem- 
branes, 56 
Disease of the accessory sinuses of the nose, 
465 
of the antrum, 465 (see Antrum) 
of the ethmoidal sinuses, 479 (see Eth- 
moidal Sinuses) 
of the frontal sinuses, 492 (see Frontal 
Sinuses) 
of the sphenoidal sinuses, 486 (see 
Sphenoidal Sinuses) 
Douches, 31 
Dust, effects of, in the hypertrophic rhinitis, 
123 
Epileptiform convulsions in syphilis, 362 
Epistaxis, 310 
Diagnosis, 313 
Etiology, 310 
Diathetic, 310 GENERAL INDEX. 
663 
Epistaxis, etiology: 
Local lesions, 311 
Traumatic, 310 
Vicarious, 311 
Pathology, 312 
Symptomatology, 313 
Treatment, 314 
Applications to bleeding point, 319 
Ice, 314 
Infusion, 320 
Local applications, 315 
Plugging through anterior nares, 
317 
the posterior nares, 318 
Position, 314 
Pressure, 314 
Erectile tissue, history of the discovery of 
the nasal, 81 
Ethmoidal bulla, the, 73 
Ethmoidal sinuses, disease of the, 479 
Diagnosis, 483 
Etiology, 480 
Pathology, 482 
Prognosis, 484 
Symptomatology, 482 
Treatment, 484 
Eustachian tube, the, 502 
Examination, the, 13 
Examining the upper air passages, methods 
of, 3 
Exophthalmos as symptom of ethmoidal 
disease, 483 
as a symptom of disease of the an- 
trum, 470 
Experiments upon the function of nose in 
respiration, 90, 94, 95, 97 
External nose, anatomy of the, 69 
muscles of the nose, 70 
Eyeball, displacement of, in disease of the 
antrum, 470 
displacement of, in disease of the eth- 
moidal sinuses, 483 
displacement of, in disease of the 
frontal sinuses, 349 
displacement of, in disease of the 
sphenoidal sinuses, 490 
Fibroma of the nasal passages, 409 
Diagnosis, 413 
Etiology, 410 
Pathology, 412 
Prognosis, 414 
Fibroma of the nasal passages : 
Symptomatology, 411 
Treatment, 415 
Fibroma of the naso-pharynx, 570 
Diagnosis, 574 
Etiology, 570 
Pathology, 573 
Prognosis, 575 
Dependence upon method of treat- 
ment, 577 
Invasion of cranial cavity, 576 
Spontaneous disappearance, 576 
Symptomatology, 571 
Treatment, 578 
Cauterization of base, 586 
Curette, 581 
Ecrasement, 583 
Electrolysis, 581 
Evulsion, 580 
Excision, 581 
Injection, 579 
• Ligation, 581 
Field of vision, narrowing of, in disease 
of the antrum, 470 
of vision, narrowing of, in disease of 
the sphenoidal sinuses, 488 
Fixed apparatus, the, 10 
Foreign bodies in the nasal passages, 321 
Diagnosis, 323 
Etiology, 321 
Symptomatology, 322 
Treatment, 324 
Fossa of Rosenmiiller, the, 502 
Frontal sinuses, disease of the, 492 
Diagnosis, 493 
Etiology, 492 
Pathology, 492 
Prognosis, 494 
Symptomatology, 493 
Treatment, 495 
Intranasal treatment, 496 
Opening the sinus, 495 
Function of the nose in phonation, 87 
of the nose in respiration, 89 
of the nose in respiration, experiments 
upon the, 90, 94, 95, 97 
General considerations concerning catar- 
rhal disease, 98 
Glands of the pharyngeal vault, 504 
Glandular enlargement in carcinoma of the 
nasal passages, 461 664 
GENERAL INDEX. 
Gummy tumor, the, 341 
tumor the, treatment of, 353 
Image, the rhinoscopic, 25 
Inflammation of mucous membranes, 51 
of mucous membranes, catarrhal, 52 
of mucous membranes, croupous, 55 
of mucous membranes, diphtheritic, 56 
Inhalations, 43 
Innervation of the nasal mucous membrane, 
79 
Inspired air, changes effected in passing 
through the nose, 91 
Instruments, methods of treating the upper 
air passages by means of, 28 
Insufflations, 28 
Hay Fever, 199 
Course and duration, 215 
Definition, 199 
Diagnosis, 219 
Etiology, 203 
Age, 208 
Blackley’s experiments, 204 
Diathetic conditions, 210 
Heredity, 210 
Morbid condition of the nasal mu- 
cous membrane, 207 
Neurotic habit, 206 
Presence of pollen in the atmos- 
phere, 204 
Sex, 209 
Geographical distribution, 218 
History, 199 
Pathology, 210 
Prognosis, 219 
Symptomatology, 212 
Asthma, 213 
Formication in the nose and throat, 
212 
Nasal stenosis, 213 
Watery discharge from the nose, 
213 
Treatment, 221 
Constitutional treatment, 221 
Treatment of diseased condition 
of the upper air passages, 225 
Treatment of the exacerbation, 226 
Bougies, 229 
Snuffs, 230 
Sprays, 228 
Headache in acute rhinitis, 107 
Headache in adenoid disease, 550 
in hypertrophic rhinitis, 132 
in naso-pharyngeal catarrh, 526 
Hiatus semilunaris, the, 73 
History of atomization, 34. 
of laryngoscopy, 3 
of the discovery of the nasal erectile 
tissue, 81 
Hydrorrhoea, nasal, 258 
Etiology, 267 
Ablation of function of fifth nerve, 
267 
Irritation of sympathetic nerve, 
268 
Neurotic habit, 268 
Prognosis, 270 
Report of cases, 258-266 
Symptomatology, 269 
Treatment, 270 
Hypertrophic rhinitis, 119 (see Rhinitis) 
Lachrymal canal, the, 72 
Laryngoscope, the, 5 
the fixed, 10 
history of the, 4 
Laryngoscopy, history of, 3 
Levator palati, the, 502 
Light, forms of, 6 
Lupus of the nasal passages, 376 
Course, 379 
Diagnosis, 379 
Etiology, 376 
Pathology, 378 
Prognosis, 37g 
Symptomatology, 377 
'Treatment, 380 
Maxillary ostium, the, 73 
Membrane, the mucous, of the nasal fossae, 
78 
Membranes, mucous, 47 
Methods of examining the upper air pas- 
sages, 3 
of retracting the palate, 24 
of treating the upper air passages by 
means of instruments, 28 
Mirror, the reflecting, 8 
the throat, 5 
Mucous membrane of the nasal fossae, 78 
membranes, 47 
membranes, anatomy of, 48 
membranes, inflammation of, 51 
membranes, physiology of, 50 GENERAL INDEX. 
665 
Mucous patch, the, 338 
patch, the treatment of the, 352 
Muscles, the external, of the nose, 70 
Myxoma, malignant degeneration of, 399 
Myxo-fibroma of the naso-pharynx, 588 
Diagnosis, 591 
Etiology, 589 
Pathology, 590 
Prognosis, 591 
Symptomatology, 589 
Treatment, 593 
Myxoma, 387 
Classification, 387 
Diagnosis, 397 
Etiology, 391 
Age, 393 
Development of, in nasal hydror- 
rhoea, 392 
Heredity, 394 
Sex, 393 
Pathology, 388 
Attachment, 390 
Cystic degeneration, 389 
Prognosis, 399 
Symptomatology, 394 
Anosmia, 395 
Aural symptoms, 397 
Disease of the antrum, 396 
Reflex disturbances, 396 
Sneezing and stenosis, 394 
Treatment, 401 
Destruction in situ, 401 
Method of operating, 405 
Removal by forceps, 402 
by snare, 403 
Nasal cartilages, the, 69 
cavities, parasites in the, 331 (see Para- 
sites) 
fossae, anatomy of the, 70 
fossae, mucous membrane of the, 
78 
hydrorrhcea, 266 (see Hydrorrhoea) 
hydrorrhoea, development of polypi in, 
267, 392 
mucous membrane, blood supply of 
the, 81 
mucous membrane, effect upon in- 
spired air, 91 
mucous membrane, innervation of, 79 
passages, adenoma of the, 427 (see 
Adenoma) 
Nasal passages, angioma of the, 431 (see 
Angioma) 
passages, carcinoma of the, 453 (see 
Carcinoma) 
passages, chondroma of the, 435 (see 
Chondroma) 
passages, cystoma of the, 429 (see Cys- 
toma) 
Nasal passages, foreign bodies in the, 
321 
Diagnosis, 323 
Etiology, 321 
Symptomatology, 322 
Treatment, 324 
Nasal passages, lupus of the, 376 (see Lu- 
pus) 
passages, myxoma of the, 387 (see 
Myxoma) 
passages, osteoma of the, 417 (see 
Osteoma) 
passages, papilloma of the, 422 (see 
Papilloma) 
passages, syphilis of the, 336 (see 
Syphilis) 
passages, tuberculosis of the, 369 (see 
Tuberculosis) 
reflexes, 186 (see reflexes) 
Nasal septum, deformities of the, 281 
Classification, 283 
Diagnosis, 295 
Tubercle of septum, 296 
Etiology, 287 
Abnormalities of facial develop- 
ment, 287 
Abnormality of palate, 287 
Congenital, 291 
Excessive development of vomer, 
287 
Rachitis, 291 
Syphilis, 291 
Traumatism, 288 
Prognosis, 296 
Symptomalogy, 292 
Aural symptoms, 295 
Deformity, 292 
Epistaxis, 293 
Laryngeal symptoms, 294 
Stenosis, 292 
Treatment, 297 
Earlier operations, 297 
Operation by means of the punch, 
298 666 
GENERAL INDEX. 
Nasal septum, deformitiesof the, treatment: 
Refracturing the septum, 300 
Removal of deformity by the 
chisel, 302 
Removal of deformity by the saw, 
303 
Removal of deformity by the 
snare, forceps, or dental en- 
gine, 301 
Roberts’s operation, 305 
Nasal specula, 15 
Naso-pharyngeal catarrh, 515 
Diagnosis, 528 
Etiology, 518 
Alcohol, 519 
Cold, 519 
Contagion, 519 
Diathetic conditions, 518 
Disease of the nasal mucous mem- 
brane, 5x9 
Method of development, 520 
Result of adenoid disease in early 
life, 518 
Tobacco, 519 
History, 515 
Pathology, 521 
Microscopic appearances in the 
diffuse form, 522 
Presence of bursa pharyngea, 516 
Prognosis, 530 
Symptomatology, 524 
Accumulation of mucus in fauces, 
524 
Aural symptoms, 526 
Frequent attacks of acute inflam- 
mation, 525 
Nasal symptoms, 527 
Pharyngeal and laryngeal symp- 
toms, 525 
Reflex disturbances, 526 
Treatment, 530 
Abstinence from alcohol and to- 
bacco, 531 
Cleansing lotions, 532 
Galvano-cautery, 535 
Internal medication and hygienic 
measures, 530 
Local applications, 534 
Natural waters, 532 
Silver nitrate, 536 
Naso-pharyngitis, acute, 508 • 
Diagnosis, 511 
Naso-pharyngitis, acute : 
Etiology, 508 
Pathology, 511 
Prognosis, 512 
Symptomatology, 509 
Aural symptoms, 511 
Laryngeal symptoms, 510 
Neuralgia, 510 
Treatment, 513 
Constitutional treatment, 513 
Local treatment, 514 
Naso-pharynx, anatomy of the, 501 
boundaries of the, 501 
carcinoma of the, 612 (see Carcinoma) 
chondroma of the, 595 (see Chondroma) 
fibroma of the, 570 (see Fibroma) 
measurements of the, 503 
myxo-fibroma of the, 588 (see Myxo- 
fibroma) 
nerve supply of the, 506 
physiology of the, 506 
sarcoma of the, 596 (see Sarcoma) 
vascular supply of the, 506 
Necrosis, syphilitic, 344 
Nerve supply of the nasal mucous mem- 
brane, 79 
supply of the naso-pharynx, 506 
Neuralgia, in acute naso-pharyngitis, 510 
in disease of the antrum, 470 
reflex, 192 
Nose, the anatomy of the, 69 
the external muscles of the, 70 
the physiology of the, 85 
Osteoma of the nasal passages, 417 
Diagnosis, 420 
Etiology, 418 
Pathology, 419 
Prognosis, 420 
Symptomatology, 418 
Treatment, 421 
Ostium maxillare, 73 
maxillare accessorius, 73 
Palate, levator of the, 502 
methods of retracting the, 24 
tensor of the, 502 
Palato-pharyngeus, the, 503 
Papilloma of the nasal passages, 422 
Diagnosis, 424 
Etiology, 423 
Frequency of, 422 
Pathology, 423 GENERAL INDEX. 
667 
Papilloma of the nasal passages: 
Prognosis, 425 
Symptomatology, 423 
Treatment, 426 
Parasites in the nasal cavities, 331 
Diagnosis, 333 
Symptomatology, 333 
Treatment, 334 
Perforation of the septum, 307 
Pharyngeal bursa, the, 516 
bursa, formation of the, 517 
Pharyngeal tonsil, hypertrophy of the, 539 
Diagnosis, 553 » 
Digital exploration, 554 
Impermeability of nasal passages, 
555 
Posterior rhinoscopy, 553 
Etiology, 539 
Age, 539 
Heredity, 541 
Sex, 541 
Pathology, 542 
Prognosis, 556 
Sequelae, 569 
Symptomatology, 544 
Altered facies, 551 
Asthma, 550 
Aural symptoms, 546 
Cough, 550 
Deformity of the chest, 551 
Effect upon the voice, 545 
Epistaxis, 550 
Pleadache, 550 
Hypersecretion, 544 
Nightmare, 550 
Night sweats, 550 
Treatment, 556 
Completion of operation in one 
sitting, 564 
Curette, 562 
Destructive agents, 559 
Extirpation, Meyer’s method, 560 
Forceps, 561 
Internal medication, 556 
Snare, 565 
Sprays, 557 
Use of an anaesthetic, 568 
Pharyngeal tonsil, the secretion of the, 506 
vault, the glands of the, 504 
Phonation, the function of the nose in, 87 
Phosphorus as a cause of ethmoidal disease, 
481 
Physiology of mucous membranes, the, 50 
of the naso-pharynx, the, 506 
of the nose, the, 85 
Plica salpingo-palatina, 502 
salpingo-pharyngea, 502 
Polypi, cauterization of the base after re- 
moval of, 407 
Posterior rhinoscopy, 19 
Prevention of a cold, 62 
Processus unciformis, 73 
Pumps, air, 40 
Purulent rhinitis, 154 (see Rhinitis) 
Recessus pharyngeus medius, the, 505 
Reflecting mirror, the. 8 
Reflexes, nasal, 186 
Aphonia, 189, 193 
Aprosexia, 189 
Asthma, 192 
Chorea, 189, 193 
Eneuresis, 189 
Epilepsy, 189, 193 
Headache, 194 
Ocular symptoms, 190, 194 
Salivation, 189 
Spasm of the Eustachian tube, 193 
of the glottis, 192 
Vertigo, 193 
Causation, 
Hack’s theory, 190 
Mackenzie’s sensitive areas, 191 
Moure’s theory, 191 
Occurrence in atrophic rhinitis, 192 
Diagnosis, 194 
Cocaine test, 196 
Deformity of septum, 196 
Polypi, 196 
Relaxed turbinated tissues, 195 
Treatment. 197 
Respiration, function of the nose in, 89 
Retracting the palate, methods of, 24 
Rhinitis, acute, 105 
Diagnosis, 108 
Etiology, 105 
Prophylaxis, 109 
Symptomatology, 106 
Treatment, no 
Rhinitis, atrophic. 162 
Diagnosis, 172 
Etiology, 166 
Congenital deficiency of facial 
bones, 168 668 
GENERAL INDEX. 
Rhinitis, atrophic, etiology: 
Development from hypertrophic 
rhinitis, 167 
from purulent rhinitis, 168 
Osteitis, 168 
Tubercular diathesis, 168 
Method of development, 162 
Pathology, 164 
Prognosis, 174 
Symptomatology, 169 
Aural symptoms, 171 
Crust formation, 169 
Dryness of pharynx, 170 
Epistaxis, 170 
Hoarseness, 171 
Laryngitis sicca, 171 
Odor, 169 
Treatment, 174 
Douche, 178 
Galvanism, 177 
Galvano-cautery, 176 
Grafting, 176 
Iodol, 176 
Noquet’s method, 176 
Snuffs, 178 
Sprays, 174 
Tampons, 175 
Rhinitis, croupous, 180 
Diagnosis, 183 
Etiology, 181 
Pathology, 182 
Prognosis, 184 
Symptomatology, 182 
Treatment, 184 
General treatment, 184 
Local treatment, 185 
Rhinitis, hypertrophic, 119 
Diagnosis, 134 
Anterior rhinoscopy, 135 
Posterior rhinoscopy, 136 
Use of cocaine, 138 
Etiology, 119 
Deformity of the septum, 124 
Diathesis, 123 
Effect of dust, 121 
Influence of climate, 120 
Tobacco, 122 
Pathology, 132 
Symptomatology, 126 
Aural symptoms, 131 
Cough, 130 
Crusts, 127 
Rhinitis, hypertrophic, symptomatology: 
Discharge, 127 
Elongated uvula, 130 
Headache, 132 
Mouth breathing, 128 
Naso-pharyngeal catarrh, 128 
Treatment, 139 
Abscission, 142 
Bougies, 142 
Caustics, 143 
Galvano-cautery, 145 
Injections, 142 
Powders, 141 
Snare, 149 
Sprays, 140 
Rhinitis, purulent, of children, 154 
Diagnosis, 158 
Etiology, 157 
Prognosis, 159 
Symptomatology, 157 
Treatment, 159 
Powders, 161 
Sprays, 159 
Rhinoliths, 326 
Causation, 327 
Diagnosis, 330 
Symptomatology, 329 
Treatment, 330 
Rhinoscleroma, 381 
Diagnosis, 383 
Etiology, 382 
Pathology, 383 
Prognosis, 384 
Symptomatology, 382 
Treatment, 386 
Rhinoscopic image, the, 25 
Rhinoscopy, 15 
anterior, 15 
Rhinoscopy, posterior, 19 
Rosenmiiller, fossa of, 502 
Sarcoma of the nasal passages, 437 
Diagnosis, 450 
Etiology, 446 
Pathology, 447 
Prognosis, 450 
Report of cases, 437-446 
Symptomatology, 449 
Treatment, 451 
Cauterizing the base of the growth, 
452 
Sarcoma of the naso-pharynx, 596 GENERAL INDEX. 
669 
Sarcoma of the naso-pharynx: 
Diagnosis, 607 
Etiology, 605 
Pathology, 606 
Prognosis, 608 
Advisability of radical operation, 
609 
Report of cases, 596-605 
Symptomatology, 605 
Treatment, 609 
Cauterization of the base, 610 
Secretion of the pharyngeal tonsil, the, 506 
Sense of smell, the, 85 
Septum, deformities of the, 281 (see Nasal 
Septum) 
deformity of the, as a cause of hyper- 
trophic rhinitis. 124 
dislocation of the columnar cartilage of 
the, 306 
perforation of the, 307 
Sex, etiological factor of, in sarcoma of the 
nose, 447 
Sinuses, the accessory, 74 
the accessory, differential diagnosis be- 
tween diseases of, 449 
the ethmoidal, 76 
the frontal, 75 
the maxillary, 74 
the sphenoidal, 76 
Smell, the sense of, 85 
Specula, nasal, 15 
Sphenoidal sinuses, disease of the, 486 
Diagnosis, 489 
Etiology, 486, 
Pathology, 487 
Prognosis, 490 
Symptomatology, 487 
Treatment, 490 
Opening the sphenoidal sinuses, 
490 
Surgery, external, of the nose, 619 
Synopsis of operations, 619, 621 
Annandale’s operation, 620, 641 
Berard’s operation, 621, 649 
Billroth’s operation, 620, 643 
Boeckel’s operation, 620, 627 
Botrel’s operation, 619, 622 
Bruns’s operation, 620, 633 
Cheever’s double operation, 620, 638 
Cheever’s operation, 620, 637 
Demarquay’s operation, 621, 644 
Dezeanneau’s operation, 619, 623 
Surgery, external, of the nose: 
Dieffenbach’s operation, 619, 624 
Fournaux-Jordan’s operation, 620, 634 
Huguier’s operations, 620, 621, 635, 
650 
Langenbeck’s temporary resection of 
a nasal bone, 620, 631 
Langenbeck’s temporary resection of 
the superior maxilla, 620, 641 
Lariche’s operation, 619, 625 
Lawrence’s operation, 620, 630 
Linhart’s operation, 620, 632 
Maisonneuve’s operations, 619, 621, 
649 
Manne's operation, 619, 621 
Nelaton’s operation, 619, 622 
Ollier’s operation, 620, 629 
Operation of Palasciano and Rampolla, 
620, 626 
Pean’s operation, 621, 647 
Richard’s operation, 619, 623 
Rouge’s operation, 619, 626 
Roux's operation, 620, 639 
Sedillot’s operation, 619, 623 
Vallet’s operation, 621, 650 
Waterman’s operation, 620, 639 
Syphilis, congenital, of the nasal passages, 
360 
Diagnosis of, 363 
Early manifestations of, 361 
Prognosis, 365 
Symptomatology, 362 
Treatment, 366 
General, 368 
Local, 367 
Syphilis of the nasal passages, 336 
The deep ulcer and bony necrosis, 344 
Course and duration of, 349 
Diagnosis of, 348 
Most frequent site of, 345 
Symptomatology of, 346 
The gummy tumor, 341 
Course and duration of, 344 
Diagnosis of, 342 
Pathology of, 343 . 
Symptomatology of, 341 
The mucous patch, 338 
The primary lesion, 336 
Diagnosis of the primary lesion, 
337 
The superficial ulcer, 339 
The syphilitic coryza, 337 670 
GENERAL INDEX. 
Syphilis of the nasal passages: 
Treatment, 352 
general, 357 
of the coryza, 352 
of the deep ulcer, 355 
of the gummy tumor, 353 
of the mucous patch, 352 
of the primary lesion, 352 
of the superficial ulcer, 352 
Syringes, 31 
Taking cold, 57 
cold, etiology of, 59 
cold, theories of, 57 
Tamponing the nose in epistaxis, 319 
Tensor palati, the, 502 
Theories of taking cold, 57 
Throat mirror, the, 5 
Tobacco as a cause of hypertrophic rhi- 
nitis, 122 
Tongue, method of depressing the, 20 
Tube, the Eustachian, 502 
Tuberculosis of the nasal passages, 369 
Diagnosis, 374 
Etiology, 373 
Pathology, 373 
Tuberculosis of the nasal passages: 
Prognosis, 374 
Symptomatology, 373 
Treatment, 375 
Turbinated bodies, the, 81 
bone, the fourth, 71 
bone, the inferior, 71 
bone, the middle, 71, 72 
bone, the superior, 71 , 
Ulcer, the deep, of syphilis, 344 
the deep, of syphilis, treatment of, 355 
the superficial, of syphilis, 339 
the superficial, of syphilis, treatment 
of, 352 
Unciform process, the, 73 
Upper air passages, the, methods of examin- 
ing, 3 
air passages, the, methods of treating 
by means of instruments, 28 
Vapors in acute rhinitis, 113 
Vascular supply of the nasal fossae, 81 
supply of the naso-pharynx, 505 
Watery discharge from the nose, 266 (see 
,^Iiydrorrhoea)