DISEASES 
OF THE 
THROAT AND NOSE. COMPLETE IN TWO HANDSOME OCTAVO VOLUMES, WITH OVER 
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DISEASES OF THE THROAT AND NOSE. 
BY 
MORELL MACKENZIE, M.D., London, 
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ON DISEASES OF THE THROAT AT LONDON HOSPITAL MEDICAL COLLEGE. 
ON THE THROAT AND NOSE. Including the Pharynx, Larynx, Trachea, 
Oesophagus, Nasal Cavities and Neck, with Appendices and Formulae. 
Vol. I. Including the Pharynx, Larynx, Trachea, etc. 112 Illustrations. Cloth, 
$4.00; Leather, $5.00. 
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THE 2 VOLS. CLOTH, $6.00; LEATHER, $7.50. 
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“ It is both practical and learned ; abundantly and well illustrated; its descriptions of disease are 
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else have we seen so elaborate a statement of the subject. We can predict for this work a high 
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BY THE SAME AUTHOR. 
THE PIIARMACOPCEIA OF THE HOSPITAL FOR DISEASES OF THE 
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OF THE 
Throat and Nose 
INCLUDING THE 
PHARYNX, LARYNX, TRACHEA, OESOPHAGUS, NOSE, 
AND NASO-PHARYNX. 
BY 
MORELL MACKENZIE, M.D., London, 
id ’ ’ 1 
CONSULTING PHYSICIAN TO THE HOSPITAL FOE DISEASES OF THE THROAT, LECTURER ON DISEASES 
OF THE THROAT AT THE LONDON HOSPITAL MEDICAL COLLEGE, AND CORRESPONDING 
MEMBER OF THE IMPERIAL ROYAL SOCIETY OF PHYSICIANS OF VIENNA. 
VOLUME II. 
DISEASES OF THE (ESOPHAGUS, NOSE, AND NASO-PHARYNX, 
WITH INDEX OF AUTHORS AND FORMULAE FOR 
TOPICAL REMEDIES. 
ILLUSTRATED. 
PHILADELPHIA: 
P. BLAKISTON, SON & CO., 
1012 WALNUT STREET. 
1 8 84. PREFACE. 
It is now nearly twelve years since this work was commenced, and 
during that period there is scarcely a page that has not been written 
and re-written many times. This slow rate of progress has been due 
partly to the inevitable delay caused by the many other demands on 
my time, and in part also to the rapid development of a new specialty 
involving frequent modification of views, and bringing constant 
additions to the literature of the subject. 
No one can be more keenly aware than myself how great a gulf is 
fixed between the conception and the actual execution of my design, 
and in a book of such extent numerous errors must, in spite of the 
utmost vigilance, have escaped my notice. I confess that had I fore- 
seen how much time and trouble the work, imperfect as it is, would 
have cost me, I should never have had the courage to undertake it. 
Even now I am unable to issue the volume in its integrity as originally 
planned, the section of Diseases of the Nose and Naso-Pharynx having 
grown under my hands to such dimensions that it has been found 
impossible to include Diseases of the Neck. I hope, however, that 
this division, the greater part of which is already in print, will shortly 
appear in a separate form as one of my series of “ Essays on Throat 
Diseases.” 
I have once more to express my thanks to several friends and 
assistants who have aided me in clinical investigations and literary 
researches, and in particular I must acknowledge my deep obligations 
to Mr. C. L. Taylor for his invaluable help during the last four years. 
Mr. Mark Hovell has again been good enough to prepare an index 
to the book, and the careful way in which he has performed this most 
useful task cannot fail to be gratefully appreciated by those who have 
occasion to refer to these pages. VI 
PREFACE. 
Dr. Felix Semon’s translation will be published simultaneously 
with the original, and it is, naturally, a source of much gratification 
to me that my labors should be made known to my fellow-workers 
in Germany by so thoroughly able an exponent. 
M. M. 
19 Harley Street, Cavendish Square, 
April 1, 1884. 
The appearance of the book has been delayed for several months in consequence 
of the entire edition having been destroyed, on the very eve of publication, by a 
disastrous fire which consumed the premises of the printers. The reprinting has 
been carried out with all possible rapidity from proof-sheets in my possession. 
I think it necessary to make this statement in order to explain how it is that several 
valuable writings, published within the last few months, are unnoticed in the present 
volume. CONTENTS. 
PAGE 
Anatomy of the Gullet; Examination of the Gullet; (Esophageal Instruments; 
Diseases of the Gullet; Acute GEsophagitis; GEsophagitis in Infants; 
Phlegmonous Oesophagitis; Ulcer of the Gullet; Traumatic GEsophagitis; 
Chronic GEsophagitis; Varicose Veins of the Gullet; Peri-CEsophageal 
Abscess; Thrush of the Gullet; Diphtheria of the Gullet; Malignant 
Tumors of the Gullet; Cancer of the Gullet; Sarcomata; Non-Malignant 
Tumors of the Gullet; Syphilis of the Gullet; Tubercular Disease of the 
Gullet; Dilatations of the Gullet; Simple Dilatations; Sacciform Dilatations; 
Traction-Diverticula; Cicatricial Stricture of the Gullet; Simple Stenosis of 
the Gullet; Compression of the Gullet; Rupture of the Gullet; Wounds of 
the Gullet; Foreign Bodies in the Gullet; External (Esophagotomy; 
Neuroses of the Gullet; Paralysis of the Gullet; Spasm of the (Esophagus; 
Malformations of the Gullet; Post-mortem Softening of the Gullet, . . 17 
SECTION IV.—THE GULLET. 
SECTION V.—THE NOSE. 
Anatomy of the Nasal Fossae; Rhinoscopy; Anterior Rhinoscopy; Median 
Rhinoscopy; Posterior Rhinoscopy; Posterior Rhinoscopy by Double Reflec- 
tion; Nasal Instruments; Acute Nasal Catarrh; Acute Coryza in Infants; 
Purulent Nasal Catarrh; Traumatic Rhinitis; Hay Fever; Chronic Nasal 
Catarrh; Hypertrophy of the Mucous Membrane of the Nose; Dry Catarrh 
often leading to Ozsena ; Chronic Blennorrhcea of the Nose and Air-Passages; 
Bleeding from the Nose; Non-Malignant Tumors of the Nose; Polypus of 
the Nose ; Fibrous Polypi of the Nose; Papillomata of the Nose; Erectile 
Tumor of the Pituitary Membrane; Enchondromata of the Nose; 
Osteomata of the Nose; Exostoses of the Nose; Malignant Tumors of 
the Nose; Syphilitic Affections of the Nose; Hereditary Syphilis of the 
Nose; Tubercular Disease of the Pituitary Membrane; Lupus of the 
Pituitary Membrane ; Rhinoscleroma ; Glanders; Affections of the Nose in 
Eruptive Fevers and other Acute Diseases ; Fractures of the Nose; Disloca- 
tion of the Nasal Bones; Deviation of the Nasal Septum; Blood-Tumors 
of the Nasal Septum ; Abscess of the Nasal Septum; Foreign Bodies in the 
Nose; Rhinoliths; Maggots in the Nose; Entomozoaria in the Nose; 
Anosmia; Parosmia; Disease of the Fifth Nerve, or its Nasal Branches; 
Congenital Deformities of the Nose; Synechise of the Nasal Fossae, . . 235 VIII 
CONTENTS. 
SECTION VI.—DISEASES OF THE NASO-PHARYNX. 
PAGE 
Chronic Catarrh of the Naso-Pharynx; Dry Catarrh of the Naso-Pharynx; 
Adenoid Vegetations of the Naso-Pharynx; Fibrous Polypi of the Naso- 
Pharynx ; Fibro Mucous Polypi of tho Naso-Pharynx; Enchondroma of the 
Naso-Pharynx; Malignant Tumors of the Naso-Pharynx; Throat Deaf- 
ness, 472 
APPENDIX. 
Special Formula for Topical Remedies; Buginaria; Collunaria—Nasal Douches; 
Lotiones—Nasal Washes; Nebulae—Nasal Sprays; Gossypia Medicata— 
Medicated Cotton Wools; Olfactoria—Olfactories; Pastils; Insufflationes ; 
Snuffs, 531 A MANUAL 
OF 
DISEASES OF THE THROAT AND NOSE. 
SECTION IV.—THE GULLET. 
ANATOMY OF THE GULLET. 
The gullet or oesophagus is that portion of the alimentary canal which 
connects the pharynx and the stomach. It commences at the lower border* 
of the cricoid cartilage on a level with the inferior margin of the body of the 
fifth cervical vertebra, and passing downwards behind the trachea in an almost 
vertical direction, traverses the lower part of the cervical region and the whole 
of the thorax, and after piercing the diaphragm opposite the ninth dorsal ver- 
tebra terminates in the stomach opposite the tenth (ninth dorsal spine).f 
* The distinction between the pharynx and the gullet is, of course, purely arbi- 
trary. Most anatomists consider that the oesophagus commences on a level with the 
lower border of the cricoid cartilage, but Quain (“ Elements of Anatomy,” vol. ii., p. 
821) makes the cricoid cartilage generally, without specifying any border, the limit 
of the upper extremity of the oesophagus. Mouton (“ Du Calibre de l’CEsophage,” 
Paris, 1874) in his laborious measurements of the gullet, does not clearly define its 
upper limit, but he appears to take an imaginary transverse line running across the 
middle of the posterior plate of the cricoid cartilage as the point of origin of the 
oesophagus. It would, however, be much more convenient to make the upper border 
of the cricoid cartilage the boundary line between the two sections of the food-tract. 
The sudden diminution in the calibre of the canal at this point makes, as it were, a 
natural division. At present, however, the lower border of the cricoid cartilage is so 
much more commonly accepted as the level at which the gullet commences, that I 
have thought it better to adhere to it. From the fact, however, that the cricoid car- 
tilage moves up or down, according to the position of the head, some anatomists object 
to taking any portion of it as the upper limit of the oesophagus. Middeldorpf (“De 
polypis oesophagi,” Yratislavise, 1857, p. 2), indeed, goes so far as to say that the extent 
of movement amounts to four centimetres when the head is thrown far back. This 
circumstance has led some writers to make one of the vertebrae the limit marking the 
upper extremity of the gullet, but the difficulty of recognizing the exact position of 
the cervical vertebrae during life more than neutralizes any advantage gained by this 
means. 
f It may be useful to note that as the spinous processes in the dorsal region are 
directed downwards, the spine of one vertebra corresponds with the body of that im- 18 
DISEASES OF THE THROAT AND NOSE. 
The oesophagus is often described as following the antero-posterior curves 
of the spinal column in its descent. This is true in the cervical region, but 
the backward curve which is usually described as occurring in the dorsal re- 
gion does not exist in the erect position of the body. In the upper part of its 
course the gullet is in the median line, but as it descends it curves slightly to 
the left until it reaches the root of the neck; at this point it inclines again 
towards the middle of the spinal column, which position it reaches opposite 
the fourth or fifth dorsal vertebra. Immediately before traversing the dia- 
phragm it makes a short curve forwards and slightly to the left. Owing to 
the very loose attachments of the oesophagus, the relations of the tube are apt 
to vary to some extent, its position being dependent on slight variations of the 
adjacent organs, scarcely amounting to abnormalities. 
The length of the oesophagus varies according to the stature of the indi- 
vidual, but in an adult male it generally measures from about twenty-four to 
twenty-six centimetres. The diameter of the tube varies at different levels, 
and, according to Sappey, it diminishes insensibly “ from its upper extremity 
to the fourth dorsal vertebra, and increases again from that point in an almost 
insensible manner to its termination. It is therefore composed of two trun- 
cated cones united at the apex.”* 
Braune’s sections! support this description in the main, but the measure- 
ments of the diameter of the gullet made by MoutonJ from plaster of Paris 
casts, give quite different results : 
Superior orifice of the oesophagus, .... 
. 14 millimetres. 
At 1 centimetre below superior orifice, 
. 19 
U 
At “ “ ... 
. 15 
cc 
At 4 « “ ... 
. 15 
u 
At rather less than 7 centimetres from superior orifice, 
. 14 
u 
At 11 centimetres from superior orifice, . 
. 20 
u 
At 14 “ “ ... 
. 17 
u 
At 15 “ “ ... 
. 21 
u 
At 17 “ “ ... 
. 20 
u 
At 21 “ ... 
. 12 
a 
At 22 “ “ ... 
12 
u 
At 25 “ “ ... 
12 
u 
At 25* “ “ ... 
14 
u 
With the view of determining still more accurately the calibre of the gullet 
in its whole extent, I performed some experiments suggested by that of 
mediately below. There is often some difficulty in counting the spinous processes, 
especially in the early stages of disease when there is but little emaciation, and it 
may, therefore, be well to remember that the oesophagus commences about an inch 
above the vertebra prominens, and terminates a little below the level of the inferior 
angle of the scapula. 
* Traits d’Anatomie Descriptive, ti iv., p. 150. 3me edition, Paris, 1879. 
f Atlas of Topographical Anatomy, translated by E. Bellamy. London, 1877. 
See plates vii., viii., ix., x., and xi. 
| Du Calibre de l’CEsophage. Paris, 1874, p. 17. ANATOMY OF THE GULLET. 
19 
Mouton, but more elaborate and on more than one subject. The following 
were the methods adopted. In the first case the body was securely fixed, 
with the head downwards, upon a hoard placed perpendicularly on the ground. 
The mouth and pharynx were then tightly stuffed with tow so as to close the 
upper outlet of the food-tract, the stomach laid open, a ligature passed loosely 
round the cardiac opening, and the ends held outside the wound so that they 
could be tightened at once when required. The nozzle of a large anatomical 
syringe, previously charged with a mixture of plaster and water of about the 
consistence of cream, was next introduced into the lower orifice of the gullet, 
and the contents were injected with as little force as possible into the canal. 
When a sufficient quantity of the material had been used, the ligature was 
tightened round the cardiac aperture of the stomach, and the body was left 
undisturbed for nearly eighteen hours so as to allow full time for the plaster 
to set firmly. On the next day the whole length of the gullet thus injected 
was removed from the body by a dissection conducted with the utmost care 
so as to avoid the least injury to the cast. The oesophageal wall was then 
carefully divided by a vertical incision carried along its whole length, when 
an accurate cast of the gullet was found to have been obtained. 
Subject I. 
A large-framed, muscular man, 6 feet in height. The injection was made 
at the London Hospital in the early part of January, 1881. The length of 
the oesophagus was 27 centimetres. The other measurements were as follows : 
Transverse 
Antero-posterior 
Point of Measurement. 
Diameter. 
Diameter. 
Lower edge of cricoid, 
25 millim. 
14 
millim. 
1 centim. below, 
25 
<< 
14 
It 
2 
ll 
23 
U 
18 
It 
3 
ll 
23 
(( 
19 
ll 
4 
ll 
24 
(( 
17 
ll 
5 
ll 
24 
u 
18 
ll 
6 
u 
21 
u 
19 
ll 
7 
ll 
22 
u 
18 
ll 
8 
a 
22 
u 
18 
ll 
9 
u 
23 
it 
19 
ll 
10 
a 
24 
ll 
18 
ll 
11 
it 
24 
« 
18 
ll 
12 
ll 
24 
u 
20 
ll 
13 
it 
26 
u 
21 
It 
14 
It 
27 
u 
23 
ll 
15 
It 
26 
ll 
23 
a 
16 
a 
27 
ll 
22 
it 
17 
(l 
25 
(l 
21 
it 
18 
u 
24 
ll 
20 
n 
19 
u 
23 
ll 
20 
it 
20 
“ 
25 
ll 
20 
a 
21 
ci 
24 
ll 
21 
u 
22 
u 
24 
It 
23 
it 20 
DISEASES OF THE THROAT AND NOSE. 
Point of Measurement. 
Transverse 
Diameter. 
Antero-posterior 
Diameter. 
23 centim. below, 
24 millim. 
23 millim. 
24 “ 
27 “ 
22 “ 
25 “ 
29 “ 
21 “ 
26 
31 “ 
22 “ 
27 “ 
31 “ 
25 “ 
Although the subject experimented on was a large man, the dimensions of 
the (esophagus at different levels were so much greater than those given by 
Mouton that I thought it possible some artificial distension had been effected 
by a too forcible injection with the syringe. In the second case, therefore, 
the liquid plaster was poured down the gullet from the stomach with the aid 
of a filler. 
Subject II. 
A man, 5 feet 4 inches in height. The oesophagus was injected with plaster 
of Paris, on January 21st, 1881, in the mortuary of the London Hospital. 
Death had taken place three days before, but the weather was very cold, and 
rigor mortis had not quite passed away. The length of the oesophagus was 
25j- centimetres. The following were the other measurements : 
Point of Measurement. 
Transverse 
Diameter. 
Antero-posterior 
Diameter. 
Lower edge of cricoid, 
21 millim. 
10 millim. 
1 centim. below, 
19 
U 
15 
it 
2 
tt 
22 
U 
15 
it 
3 
a 
22 
u 
14 
U 
4 
a 
19 
u 
13 
it 
5 
a 
18 
a 
15 
it 
6 
a 
18 
u 
15 
it 
7 
a 
19 
u 
13 
it 
8 
u 
18 
u 
12 
ft 
9 
it 
19 
(t 
14 
it 
10 
it 
21 
u 
10 
a 
11 
u 
23 
u 
11 
tt 
12 
u 
22 
u 
13 
a 
13 
u 
23 
u 
17 
tt 
14 
a 
23 
u 
17 
it 
15 
25 
it 
17 
tt 
16 
a 
25 
a 
15 
tt 
17 
a 
24 
u 
18 
it 
18 
u 
22 
a 
15 
a 
19 
u 
21 
u 
14 
<•' 
20 
u 
19 
it 
13 
it 
21 
u 
16 
u 
11 
a 
22 
u 
16 
a 
12 
a 
23 
u 
17 
u 
12 
u 
In the second experiment the measurements are jnuch smaller than the first, 
hut the body was not nearly so large. Even in this instance, however, the ANATOMY OF THE GULLET. 
21 
standard of size is throughout very much greater than in Mouton’s subject. 
The practical outcome of my experiments* is to show that the transverse 
diameter of the gullet is very considerably greater than the antero-posterior 
measurement. 
When not distended in the act of swallowing, the mucosa, which is only 
very loosely connected with the submucous areolar tissue, is thrown into 
longitudinal folds, which project into the lumen of the canal, and at certain 
points till it up altogether. It is only near its origin, however, and at about 
7 centimetres lower down, that this juxtaposition of the internal walls of the 
oesophagus closes the canal; at other levels it is probably always partially 
patent. As is shown by my experiments, the oesophagus is symmetrically 
flattened between the trachea and bodies of the vertebrae in the antero-poste- 
rior direction in the neck ; and lower down, though its canal occasionally ap- 
proximates to a circular form, it generally retains a kidney-shaped lumen. 
In its cervical and thoracic portions the gullet comes into relation with 
important adjacent structures, which must be borne in mind in the diagnosis 
and treatment of its diseases. In its brief abdominal course its relations are 
of minor practical interest. 
In the cervical region the gullet is in relation, anteriorly, with the membra- 
nous portion of the trachea, to which it is bound by loose areolar tissue. 
Posteriorly, it is separated from the vertebral column by the longi colli mus- 
cles. Laterally, it is in relation with the thyroid gland, especially its left 
lobe, with the common carotid arteries, and, more externally, with the pneu- 
mogastric nerves and internal jugular veins. In the angle between the trachea 
and oesophagus lie the two recurrent laryngeal nerves. Owing to its curve to 
the left, the oesophagus comes into more intimate relations with the left carotid 
artery than with the right, and for the same reason the left recurrent nerve 
is, at the root of the neck, almost in front of the tube. 
In the thorax, the oesophagus is contained in the posterior mediastinum ; 
it is in relation, anteriorly, from above downwards with the following parts, 
viz. : the trachea, the left carotid and subclavian arteries (near their origin 
from the left side of the transverse portion of the arch of the aorta', the bi- 
furcation of the trachea (opposite the third dorsal vertebra', the left bronchus 
(which crosses it obliquely', the bronchial glands; below this the posterior 
surface of the commencement of the arch of the aorta, and the posterior sur- 
face of the left auricle, or rather the corresponding par- of the pericardium, 
are in near relation to the gullet. Posteriorly, the oesophagus is at first in 
close contact with the spine and longi colli muscles, but in its descent it be- 
comes separated from these by loose connective tissue, by the right intercostal 
arteries, the vena azygos, and the thoracic duct as it passes obliquely upwards 
from right to left. Just before the gullet leaves the thorax, and on a level 
with the eighth dorsal vertebra, it comes into relation, posteriorly, with the 
descending aorta, the opening for which in the diaphragm is almost immedi- 
ately behind that for the oesophagus. Laterally, the thoracic portion of the 
oesophagus is in contact with the pleurae, with the vena azygos major on the 
* It would be highly desirable that these experiments should be repeated on an 
extens:ve scale. 22 
DISEASES OF THE THROAT AND NOSE. 
right side, and on the left with the descending aorta. The pneumogastric 
nerves lie at first one on either side of the tube, but in their descent they pass, 
the left in front of it, and the right behind it. 
The abdominal portion of the oesophagus is of very minor importance ; it 
is covered by the peritoneum both anteriorly and posteriorly. 
Like the rest of the alimentary tube, the oesophagus consists of three coats, 
mucous, submucous, and muscular. The mucous layer is of moderate 
thickness, and is mainly composed of loose connective tissue, which contains 
a large proportion of loose elastic fibres. Its surface is closely studded with 
delicate papillce, which, together with the intervening depressions, are covered 
by a laminated pavement-epithelium. Between the mucous and submucous 
coats is a layer of plain muscular fibres, the muscularis mucosae, which is im- 
perfect in the upper part of the tube, but attains a considerable development 
interiorly, where it forms a continuous investment, arranged in longitudinal 
folds. The submucous connective tissue is considerably thicker than the 
mucous coat, and so loosely attached to it as to allow very free movement of 
the latter, and to admit of its being arranged in longitudinal folds, when the 
tube is in its natural state of contraction. The constituent bundles of the 
submucous, like those of the mucous coat, include a considerable number of 
elastic fibres, and form a stratum supporting the vessels and nerves. The 
muscular coat is composed of two layers of fibres, a circular or internal, and 
a longitudinal or external. The latter is the thicker, especially at the com- 
mencement of the tube, but it diminishes in thickness as it descends. It con- 
sists of three divisions,—an anterior and two lateral. The former, which is 
by far the strongest of the three, is attached above to the ridge on the poste- 
rior surface of the cricoid cartilage by means of a triangular elastic ligament, 
while the lateral portions take origin from the elastic expansion of the palato- 
pharyngei muscles. In its course downwards the longitudinal layer often 
derives a small muscular slip from the left bronchus,—the broncho-cesophageus 
muscle, while similar additions to the circular layer are described as being 
occasionally obtained from the left lateral wall of the posterior mediastinum. 
The muscular coat of the oesophagus consists, in its upper fourth, mainly of 
striated fibres ; in its second fourth, of about equal proportions of voluntary 
and involuntary muscle ; while in the remainder of its course it is constituted 
almost entirely of unstriped fibres. The muscular coat is attached to the 
adjacent structures by a loose areolar investment, which contains a large pro- 
portion of elastic fibres. 
The oesophagus contains a considerable number of mucous glands of the 
acinous, racemose, and compound tubular varieties. 
These glands are lined with cylindrical epithelium, and are for the most 
part imbedded in the submucous connective tissue. They are less abundant 
in the human gullet than in that of many of the lower animals, and occur in 
greater numbers at the lower than the upper part of the tube. The vascular 
supply of the oesophagus is derived mainly from the thoracic aorta, inferior 
thyroid artery, and coronary branch of the coeliac axis ; the vessels have 
mostly a longitudinal direction, and anastomose freely with one another. At 
the lower part of the oesophagus the veins communicate pretty freely with 23 
EXAMINATION OF THE GULLET. 
the coronary veins of the stomach, and are thus brought into relation with 
the portal system. 
The lymphatics differ in their arrangement from those in other parts of the 
alimentary canal by forming only one layer, which is placed internal to the 
muscular coat. They communicate with neighboring glands, and near the 
root of the lungs terminate in the thoracic duct after having anastomosed 
with the pulmonary lymphatics. 
The nerves are derived from the pneumogastric, recurrent laryngeal, and 
sympathetic, offshoots from which join each other in a complicated network 
(plexus guise), which encircles the tesophagus, lying for the most part between 
the longitudinal and circular layers of its muscular coat. 
EXAMINATION OF THE GULLET. 
The gullet can be examined during life by auscultation, by sounding, 
and by direct inspection with the cesophagoscope. Palpation also 
should not be neglected, for although the oesophagus itself cannot be 
felt, useful information may sometimes be obtained as to the condition 
of the neighboring parts. Thus deepseated abscess of the neck, en- 
largement of the glands, fibroid thickening of the thyroid body, or the 
pulsation of an aneurism may be detected, whilst the negative evidence 
afforded by the absence of swelling or tenderness in the cervical region 
may in certain cases be important. 
Auscultation of the Oesophagus.—This consists in listening either 
through the stethoscope or directly with the ear over the course of the 
gullet, whilst the patient swallows some fluid. The proposal of this 
method of examination is entirely due to Hamburger, and the short 
articles since published by myself,* Elsberg,f and Clifford Allbutt,J 
are little more than epitomes of Hamburger’s§ essay. (Esophageal 
auscultation is easily carried out, but it requires considerable practice 
and much patience; practice, because it is requisite to get the ear well 
accustomed to the normal oesophageal sounds; patience, because in each 
case it is necessary to apply the stethoscope successively down the whole 
length of the oesophagus, and to listen attentively at each spot. Before 
* Lancet, May 30th, 1874. 
f Auscultation of the (Esophagus. Philadelphia, 1875. 
J British Med. Journ. 1875, vol.. ii., p. 420. 
£ Klinik der (Esophaguskrankheiten, Erlangen, 1871. Hamburger’s views, how- 
ever, had been developed previously in a series of papers in the (Esterreich. Med. 
Jahrb., 1867, 1868, 1869. 24 
DISEASES OF THE THROAT AND NOSE. 
attempting to apply the method in disease it is essential to become 
acquainted with the normal sounds produced in deglutition; and for 
this purpose repeated examinations should be made on healthy persons. 
The following is the best way of practicing the art. The individual 
to be examined should be directed to take a mouthful of drink—water 
does very well for the purpose, but a thickened fluid, such as gruel 
or arrowroot, answers better. The stethoscope is then applied over 
some portion of the food-tract, the person is directed to swallow, and 
the sound produced in the act of deglutition carefully listened to. As 
the small portion of fluid, or, as it has been somewhat arbitrarily called, 
“ the morsel/’ passes down the throat it produces various sounds, and 
conveys certain impressions to the mind of the listener. The proper 
interpretation of these sounds constitutes the art of oesophageal auscul- 
tation. If the stethoscope be applied to the side of the neck, on a 
level with the hyoid bone, and the person be directed to swallow a 
morsel, a loud, gurgling noise is heard, which may be called the u pha- 
ryngeal sound.” The word “ glouglou ” has been said to represent the 
pharyngeal sound; but in order to get an idea of it, “glouglou” should 
be pronounced in a loud whisper; and it must be admitted that in 
many healthy persons the sound does not bear much resemblance to 
this word. If instead of listening in the neck the stethoscope be applied 
to the left side of one of the dorsal vertebrae, the true “ oesophageal 
sound ” becomes audible. The pharyngeal sound, which is due to the 
sudden passage of air and liquid into the pharyngeal cavity, is some- 
times so loud, and so distinctly conveyed down the oesophagus, that it 
obscures the true oesophageal sound. In these cases it is better to let 
the patient take a continuous draught of water, as by this means the 
intermingling of air and water is greatly diminished, and the true 
oesophageal sound may often be detected. The sound which is heard 
conveys the idea of the rapid passing downwards of a “small spindle- 
shaped body of fluid consistence.” The sound is sharp and sudden, 
and ceases abruptly. Hamburger describes it as being suggestive of an 
egg-shaped body, about an inch in length, and half an inch in breadth, 
the small end of the egg being above and the large end below. He is 
also of opinion that the shape of the morsel affords a strong indication 
as to the condition of the muscular walls of the oesophagus, the lower 
end of the morsel or egg-shaped body being blunted or truncated in 
proportion to the feebleness of the muscular action. These, however, 
are refinements which it is difficult to arrive it. 
The principal points which have to be considered are: first, the EXAMINATION OF THE GULLET. 
25 
character of the oesophageal sound ; and, secondly, the quickness of the 
act of deglutition. In some cases the sound is very feeble, and occa- 
sionally altogether absent; sometimes, and this is often the case in 
organic strictures, a confused and continuous bubbling noise is heard, 
Diagram showing the Situation and Curves of the (Esophagus and its Relation to the 
Spinous Processes, Scapulae, and Bifurcation of the Trachea. 
a, inferior curved line of occipital bone about five-eigliths of an inch below the 
occipital protuberance, indicating the commencement of the pharynx ; b, fifth cervical 
vertebra, at which spot the oesophagus commences (this spinous process can be easily 
recognized from its relative position to the vertebra prominens, usually the seventh); 
c, second dorsal vertebra; d, sixth dorsal spine; e, ninth dorsal spine. The upper 
third of the gullet therefore corresponds to the distance between b and c, the middle 
third to the distance between c and d, and the lower third to the distance between d 
and e. The position of the bifurcation of the bronchi from the trachea is seen to be 
in the middle third. 
which lasts for several seconds; sometimes a grating sound maybe 
perceived at the same time. The quickness of the act of deglutition 
is also of some importance, and can be determined by placing the hand 
on the hyoid bone whilst the stethoscope is applied over the oesophagus 
posteriorly; as the patient commences to swallow, the operator feels 26 
DISEASES OF THE THROAT AND NOSE. 
the hyoid bone rise, and can thus estimate the length of time which 
elapses before the morsel reaches that portion of the oesophagus which 
is being auscultated. The rapidity of the act varies in different people 
in a state of health, and it can always be made to take place quite 
slowly. This will be at once apparent on directing a healthy man to 
continue for a few minutes swallowing some rather difficult substance, 
such as a mealy potato. Under ordinary circumstances the lapse of 
time between the entrance of the morsel into the gullet and its arrival 
opposite the stethoscope placed at the side of the eighth dorsal vertebra 
is so short that it cannot be determined ; but after swallowing several 
mouthfuls of potato without drink, two or three seconds elapse before 
the morsel arrives at the lower part of the oesophagus. 
Regurgitation can also be perceived when from any cause the food 
cannot descend into the stomach. The mode in which this takes place 
sometimes enables us to distinguish between a spasmodic and an organic 
stricture; for whilst in the latter case an appreciable time elapses before 
the food is forced upwards, in spasmodic stricture the regurgitation is 
instantaneous. According to Hamburger, when the oesophagus is 
pressed upon by a tumor in the posterior mediastinum, the sound may 
be heard more distinctly on the right side of the vertebrae than on the 
left. 
Sounding.—This method of exploration is carried out with the aid 
of bougies, and is employed for the purpose of determining the calibre 
of the gullet. It should be borne in mind, however, that much harm 
is often done by the introduction of these instruments. They should, 
therefore, never be used unless other means of investigation fail to give 
the desired information. Two kinds of bougies are employed under 
different circumstances, viz., those made of gum-elastic, and those in 
which there is a slender whalebone stem, terminating in an olive-shaped 
ivory knob. Ordinary gum-elastic bougies are cylindrical* in form 
throughout the greater part of their length, but the distal end is more 
or less conical. From the experiments, however, already detailed 
(pages 19 and 20), as well as from the appearance in frozen sections,f it 
is clear that the sectional outline of the gullet is oval or kidney-shaped, 
* In some cases, however, tapering and the so-called “ radish-shaped ” instruments 
may be useful. The tapering bougie is small at the distal end, and gradually increases 
in size for about three or four inches till the maximum diameter is attained, and the 
radish-shaped instrument is slender at its further extremity, then becomes somewhat 
suddenly greatly enlarged, again returning to the smaller dimensions, 
f Braune: Op. cit., pi. vii., viii., ix., x., and xi. 27 
EXAMINATION OF THE GULLET. 
the diameter from side to side being greater than from before back- 
wards. I have, therefore, arrived at the conclusion that bougies some- 
what flattened antero-posteriorly, would most easily adapt themselves 
to the lumen of the tube through which they are 
meant to be passed, and this view has been con- 
firmed by experience. Thirteen sizes are made, 
the measure of each one being based on the num- 
ber of millimetres in the transverse, i. e., their 
long diameter. The sizes are reckoned from No. 
3 to No. 15. Thus, No. 3 measures three mil- 
limetres from side to side, No. 4 four millimetres, 
and so on throughout the scale. Nos. 1 and 2 
are not made, as they are too small to be of any 
use. 
The ivory-knobbed bougies are sometimes use- 
ful when the obstruction is of a spasmodic char- 
acter, the spasm occasionally yielding to a knob 
whilst resisting a cylindrical body. The knob at 
the end of the whalebone stem resembles an olive 
in shape, the small end being directed downwards. 
The same whalebone rod can be used for several 
knobs of various sizes, as they are made to un- 
screw. These instruments have not hitherto been 
made according to any scale, and I very seldom 
use them on account of the risk there always is 
of the ivory knob becoming separated from the 
stem. Although in the ordinary course the little 
point would pass into the stomach and do no 
harm, there is some danger of its being vomited 
or hawked upwards, and finding its way into the 
air-passages. It is obvious that the danger is 
much increased where there is a stricture of the 
gullet, as under such circumstances the knob can- 
not pass downwards, and it will most likely be 
thrown violently upwards by sudden spasm of 
the muscular walls of the oesophagus. 
When a gum-elastic bougie has to be passed it 
should be warmed and then dipped into water or glycerine (not oil, as 
that is often very disagreeable to the patient), and then slightly bent at 
about an inch from its extremity, so that when introduced into the 
Fig. 2. 
The Author’s Scale for 
JEsophageal Bougies. 28 
DISEASES OF THE THROAT AND NOSE. 
throat the point of the bougie presses slightly by its own elasticity 
against the posterior wall of the pharynx, and is thus unlikely to enter 
the larynx. The patient should sit with his neck stretched out and 
his head thrown slightly back, whilst the operator standing in front 
depresses the tongue with the forefinger of his left hand, and directs 
the point of the instrument downwards in a slanting direction against 
the middle of the posterior wall of the pharynx at its lowest part. In 
introducing the bougie about four inches of its length should extend 
beyond the hand, and it should be pushed slowly and gently down the 
throat. When the instrument is judged to have entered the oesophagus, 
it'is a good plan to tell the patient to bend his head a little forwards, 
and to perform the act of swallowing. Should any obstruction to its 
course be encountered, the instrument should be withdrawn and again 
carefully passed into the gullet. 
If it be again arrested at the same point and the employment of very 
gentle pressure and manipulation fail to pass it beyond the obstacle it 
should be altogether withdrawn, and a bougie several sizes smaller in- 
troduced. Proceeding in the same manner and with like precaution, 
the operator should, if the attempt does not cause any great discomfort 
or irritation, try a third or fourth instrument, as the case may be, until 
he either penetrates the stricture or concludes that it is impermeable. 
Should the bougie be found to pass beyond the point at which the first 
instrument was arrested, it should be pushed steadily downwards until 
it reaches the stomach, whilst the character of the surface over which 
it glides—the direction in which it goes, the distance traversed, and the 
contractile power of the oesophagus at different levels—should be care- 
fully noted. It is necessary to take the precaution of passing the in- 
strument quite down to the stomach, as there sometimes exists a second 
stricture below the first. On withdrawing the bougie the distance from 
the patient’s teeth to its extremity should always be measured. It 
should be remembered, however, that the distance from the incisor teeth 
to the orifice of the oesophagus varies from 15| to 17 centimetres, and 
in estimating the situation of an obstruction this length must be always 
deducted from the length of the bougie passed into the body. If a 
good-sized bougie can be passed without encountering any obstacle, a 
larger one may be employed at the next visit if any symptoms of ob- 
struction continue. If, however, a No. 15 (see scale, p. 27) can be 
passed through the whole length of the canal it may be concluded that 
there is no mechanical obstruction—i. e., no organic stricture. An in- EXAMINATION OF THE GULLET. 
29 
strument has been invented by Dr. Gaston Sainte-Marie,* by means of 
which it is proposed to measure the calibre of the gullet throughout its 
entire extent, or at any given point. It consists of a hollow sound, at 
the lower end of which is a small olive-shaped bag made of india- 
rubber, so that its capacity is diminished by very slight pressure. Into 
the upper extremity of the sound is fitted a graduated glass tube, about 
ten centimetres long, provided at its upper part with a stopcock and a 
metallic funnel. By this means water, or some colored liquid, can be 
poured into the instrument, thus distending the bag at the other end to 
the fullest extent. It is obvious that any pressure on the walls of the 
bag will cause the fluid to rise above its original level in the glass tube, 
and the greater the pressure the higher will the contained fluid be 
forced. I am not aware that this instrument has ever been tried in 
actual practice, and it is evident that it would be difficult to use in such 
a way as to obtain any trustworthy results. 
GUsophagoscopy.—This method consists in the visual examination of 
the interior of the gullet, by means of suitable instruments. These 
must necessarily be in the form of tubes, and their use is always likely 
to be attended with considerable difficulty ; for, unlike the larynx and 
trachea, which are nearly always open to inspection, the orifice of the 
gullet is closed, and lower down the walls of the canal are usually in 
more or less close apposition. Further difficulty arises from the spas- 
modic contraction, so easily set up, of the muscular tunic of the oesoph- 
agus, and also from the pharyngeal irritation which almost unavoidably 
occurs in introducing instruments. 
The older surgeons do not appear to have endeavored to overcome 
these difficulties, and the first attempt to examine the gullet during life 
would seem to have been made by Semeleder and Stoerk in 1866.f 
This experiment, however, yielded only negative results. The instru- 
ment employed appears to have consisted of a forceps with spoon-shaped 
blades. The idea of the instrument originated with Semeleder, who 
offered himself to Stoerk for experiment. After the introduction of 
the instrument the laryngeal mirror was placed in the ordinary posi- 
tion, but it was at once found that the view was obstructed by a kind 
of figure-of-eight projection of the mucous membrane between each 
blade of the forceps.;}; 
* Des diffferents modes d’exploration de l’CEsophage. Paris, 1875, p. 21. 
f Private letter from Professor Stoerk, November 13th, 1880. Dr. Stoerk has since 
published an account of this experiment in the article in which his more recent in- 
vention is described (Wien. klin. Wochenschrift, No. 8, February, 1881). 
| In 18G8, Bevan (Lancet, vol. i., April, 1868) published a description of various 30 
DISEASES OF THE THROAT AND NOSE. 
Two years afterwards the late Dr. Waldenburg* invented an oesoph- 
agoscope. This instrument was a gum-elastic tube, eight centimetres 
in length. It was slightly conical in shape, the diameter above being 
one centimetre and a half, and below, one centimetre. It was connected 
to the extremity of a two-pronged fork, fourteen centimetres in length, 
in such a way that considerable movement was permitted between the 
fork and the tube. After the introduction of the instrument it was 
held with the left hand, and the tongue being slightly pressed down, 
the laryngeal mirror was put into the mouth. In the case in which 
Dr. Waldenburg used the instrument there was a pouch at the upper 
part of the gullet on the left side, and he was able to keep the instru- 
ment in situ for ten or fifteen seconds, and to see that the mucous mem- 
brane of the oesophagus was not ulcerated or in any way diseased. On 
introducing the speculum into the diverticulum itself, that cavity was 
seen to contain a small quantity of food. Afterwards Waldenburg had 
an instrument constructed of metal instead of gum-elastic, consisting 
of two tubes arranged telescopically, each tube being six centimetres in 
length, one playing on the other by means of a slot. Waldenburg’s 
instrument was exhibited and used on a patient by Professor Stoerk, 
before the Society of Physicians of Vienna.f 
Subsequently Stoerk employed an instrument resembling Walden- 
burg’s, but consisting of three tubes. In February, 1881, Professor 
Stoerk| described a new oesophagoscope, which consists of a lobster- 
jointed tube, covered with india-rubber, with a small mirror attached 
instruments for examining the pharynx, larynx, and posterior nares, fitted to a lamp, 
on the principle of the endoscope. In this paper there is no detailed description of 
the oesophagoscope, but merely a few lines describing the figure which illustrates it. 
As far as I can make out from this drawing, the oesophagoscope appears to be a straight 
tube, four inches long by three-quarters of an inch in diameter, which has attached to 
its upper extremity, by means of a wire on each side, a ring slightly larger in diameter 
and about one inch in length. This ring is placed at an angle of about forty-five de- 
grees to the tube, and to it the pharyngoscopic tube of the endoscope was, to use the 
words of the inventor, “ very easily applied.” It is not stated that any mirror was 
used, but as a reflector is seen in the drawing of the pharyngoscope it was probably 
employed for inspecting the gullet. A perusal of Bevan’s paper will convince any 
reader that the experiments were the results of work in the library rather than in the 
wards of a hospital; and, in fact, that the instrument is of no practical value. 
* Berlin, klin. Woehenschrift, No. 48, November 28th, 1870. 
f Letter before quoted. The professor does not recollect the exact date of the exhi- 
bition of the patient, but, no doubt, an account of it would be found in the Transac- 
tions of the Imperial Koyal Society of Physicians of Vienna in or about the year 
1871. 
J Loc. cit. EXAMINATION OF THE GULLET. 
31 
to its upper extremity, and with a handle, consisting of a two-pronged 
fork like that of Waldenburg. This tube is provided with a pilot, or 
director, consisting of a piece of elastic tubing, terminating in a small 
bag which projects beyond the end of the oesophagoscope, the diameter 
of the bag being a little larger than that of the tube. The ball being 
inflated, the instrument is passed into the gullet, when the air is allowed 
to escape, and the pilot withdrawn. 
My own attempts to examine the gullet with an oesophagoscope were 
first made in February, 1880. From the following description it will 
Fig. 3. 
The Author’s (Esophagoscope. 
The instrument is seen in a ready for introduction, the handle being almost in the 
same line as the stem. When the instrument has been passed down the gullet, as seen 
in B, the handle is depressed, and the moving rod a being thus drawn back, the lever 
b elevates the small ring with which it is connected, and raises the mirror to its proper 
place whilst it expands the skeleton tube, and thus dilates the oesophagus. 
be seen that the instrument which I have introduced* is altogether 
different from those hitherto employed. It consists of two parts,—a 
stem and a skeleton tube. The stem is made up of a handle and a 
shank, between which there is a hinge. The skeleton tube is only 
* This, as well as most of my other instruments described in this work, were made 
for me by Messrs. Mayer & Meltzer, Great Portland Street. 32 
DISEASES OF THE THROAT AND NOSE. 
formed when the instrument has been introduced into the gullet; before 
that, it consists of two flattened wires placed anteriorly and posteriorly, 
connected above and below, and at certain intervals between the ex- 
tremities by rings. When the rings lie in the vertical position the 
wires are separated from each other only by the thickness of the rings, 
but when the latter are thrown into the horizontal position the two wires 
become separated, and, with the rings, constitute a kind of skeleton spec- 
ulum.* At the top of the back wire there is a slot, into which the 
stem of a laryngeal mirror is fitted. In the upper figure (a) of the 
annexed cut it will be seen that the handle aud shank are almost in a 
line—a position which greatly facilitates the introduction of the instru- 
ment. When the vertical portion has been passed down the oesoph- 
agus, the operator, holding the handle in his hand, but leaving the 
index-finger free, presses with the latter on the upper part of the shank 
near the handle. The result of this is to turn the rings from the ver- 
tical to the horizontal position, and thus to open the speculum and ex- 
pand the gullet. With the view of causing as little irritation as possible, 
the operator should, before withdrawing the instrument, close the spec- 
ulum by pressing the under part of the shank (near the handle) with 
his thumb, and at the same time raising the handle. 
In November, 1880, I had attempted to use the instrument on fifty 
patients, and I had succeeded thirty-seven times. Subsequently I have 
employed it from time to time, whenever a suitable case has presented 
itself. 
Endeavors have recently been made to examine the interior of the 
gullet with the help of the electric light, and Mikuliczf claims to have 
made some very important clinical observations by this method. 
* In the earlier instrument which I employed there was a great number of rings, 
and the speculum was opened and closed by means of a movable slide on the upper 
part of the shank, the handle remaining fixed. 
f Wien. Med. Presse, 1881, Nos. 45-52. Mikulicz, who has lately been working 
with the assistance of Leiter, of Vienna, appears to have improved the apparatus of 
that instrument maker (see vol. i., p. 483, note 2.) When, however, Leiter’s earlier 
specula were exhibited in Paris, Dr. Kanse (Gazette M&iicale, No. 25, p. 331, 1880) 
maintained that the invention was little more than a reproduction of Trouvd’s “ poly- 
scope,” without some of the advantages of that instrument. OESOPHAGEAL INSTRUMENTS. 
33 
(ESOPHAGEAL INSTRUMENTS. 
Brushes.—These are of little use for applying remedies to the inte- 
rior of the oesophagus, as the medicament is to a great extent lost before 
it reaches the affected part; but they are sometimes of service when the 
disease is situated quite at the upper part. The kind of brush which 
should be employed for this purpose is one similar to those used for the 
larynx, but about two inches longer than No. 1 brush. 
Injectors.—For applying solutions to the interior of the gullet the 
“ oesophageal injector” is the most useful instrument. It consists of a 
long leaden tube, from sixty to seventy-five centimetres in length, and 
two to three millimetres in diameter, to which is welded a bulbous ter- 
minal portion, made of silver. The silver extremity is 
perforated by a number of fine holes, and the fluid is 
injected by means of a minute pear-shaped india-rubber 
ball. The tube is passed down to the desired spot; the 
nozzle of the elastic ball is then introduced into the 
upper end of the pipe, which is slightly funnel-shaped, 
and the fluid injected by pressing the ball. 
The Oesophageal Electrode.—This instrument is sim- 
ilar to the laryngeal electrode (vol. i., p. 256), but should 
be about twenty-six centimetres in length below the 
handle, and pliant in the stem, so that it may more 
readily adapt itself to the natural curves of the gullet. 
The CEsophageal Resonator.—For the discovery of 
small foreign bodies, such as pins or other metallic sub- 
stances, pieces of bone, etc., an ingenious instrument has 
been devised by M. Duplay.* It consists of a stem of 
very flexible steel, about eighteen inches long, covered 
throughout with india-rubber; to the lower end of this 
is screwed a hollow olive-shaped ball of ivory, which 
may be of various sizes, whilst to the upper end of this 
is attached a “ drum ” of copper, about six inches long, 
to serve as a sounding-box. To the proximal end of the drum is fixed 
an india-rubber tube, provided with an ivory ear-piece. The instru- 
ment is passed into the gullet in the ordinary way, and the ear-piece 
placed in the ear. Very slight scratching sounds, such as would be 
produced by the olive-shaped ivory ball coming in contact with a for- 
eign body, can then be readily distinguished. If the stem of the instru- 
Fig. 4. 
(Esophageal 
Injector. 
* Bull, de la Soc. de Chir. de Paris, October 7th, 1874. 34 
DISEASES OF THE THROAT AND NOSE. 
Fig. 5. 
Fig. 6. 
Fig. 7. 
Fig. 5.—Duplay’s (Esophageal Resonator.—a, india-rubber tube; 6, sounding-box 
of copper; c, metallic stem covered with india-rubber; x, olive-shaped ivory ball; y, 
junction of stem to sounding-box ; z, ivory ear-piece. 
Fig. 6.—The (Esophageal Forceps. 
Fig. 7.—The Parasol Probang.—A, the instrument ready for use with the catgut 
parasol closed; b, the instrument after it has been passed down the throat with the 
parasol open. CESOPHAGEAL INSTRUMENTS. 
35 
ment be properly graduated the situation of the foreign substance can 
also be ascertained with tolerable accuracy. 
It should be added that the instrument can be used as a common 
sound by detaching the sounding-box and ear-tube from its upper ex- 
tremity and screwing on a metallic ring, to serve as a handle. 
(Esophageal Forceps.—For the removal of foreign bodies from the 
gullet, a pair of long forceps may suffice, or specially-devised instru- 
ments, such as the parasol bougie, or the so-called “coin-catcher” may 
be required. The forceps should be about thirteen inches long, the two 
blades crossing each other at a point equidistant from the extremities. 
The curve should be very slight (Fig. 6). Forceps with a flexible stem 
may also be useful in extracting foreign bodies from the gullet, or 
Burge’s forceps, of the same shape as that used for the nose, may be 
employed. The mode in which this instrument acts will be understood 
by referring to the wood-cut representing the Axial Nasal Forceps (see 
Nasal Instruments). 
The Parasol Proha,ng.—This instrument consists of a whalebone rod, 
terminating in a twist of stiff horsehair, which is capped at the ex- 
tremity by a small metal knob or sponge. The whalebone rod is 
inclosed in an outer gum-elastic tube. The instrument should be passed 
in the same manner as the ordinary bougie, if possible, beyond the sup- 
posed position of the foreign body. Holding the gum-elastic tube in 
the left hand, the surgeon should then slightly draw up the whalebone 
rod with the right hand, the horsehair portion being thus made to ex- 
pand like a parasol. In withdrawing the instrument with both hands, 
the whole interior of the oesophagus is thus swept out, and any small 
foreign body is almost certain to be entangled in the meshes of the 
expanded web of horsehair. If the resistance is so great as to cause 
risk of injury to the soft structures, the whalebone rod controlling the 
parasol should be released and the instrument withdrawn with its ex- 
pansile portion closed. In the probang, as commonly made, the knob 
is about the size of a bullet, but it should not be larger than a good- 
sized pea—the object of the instrument not being to push the foreign 
body down, but to pull it up. 
Coin-Catchers.—There are two kinds of coin-catchers. One (Fig. 
8 a) consists of a small whalebone rod, about fifteen inches long, with 
a flexible metal plate one inch and a half in length securely fixed to 
its lower part. The distal extremity of the metallic plate is attached 
by means of a cross rivet to the interior of a small hollow metal cone 
about its middle. Free play is thus allowed to the cone on either side 36 
DISEASES OF THE THROAT AND NOSE. 
Fig. 8. 
Fig. 9. 
Fig. 10. 
Fig. 8.—A, Griife’s coin-catcher, holding a coin ; b, ring coin-catcher. 
Fig. 9.—The CEsophagotome with the Knife concealed.—a, the protruded knife; a', 
the concealed knife; b', the button which acts on spring; b, the button pressed down; 
c, sliding tube containing the spring. 
Fig. 10.—Permanent (Esophageal Tube.—a, gum-elastic catheter; b, whalebone 
pilot rod; c, strings; d, side opening in tube. (ESOPHAGEAL INSTRUMENTS. 
37 
of the stem, so that a little cradle is formed, the concavity of which looks 
upwards. The surfaces of the cone which correspond to the metallic 
part of the stem are fenestrated, whilst the rim of the cradle is slightly 
notched at each side. Another form of coin-catcher (Fig. 8 b), which 
is perhaps more commonly employed, consists, like the above, of a 
whalebone rod, to which a short plate of flexible metal is attached. 
This plate, however, ends in a small metal ring, to the lower part of 
the circumference of which another ring of similar size is securely 
welded so as to form an angle of about 45° with its fellow. 
Both these instruments easily slip down at the side of a small foreign 
body, but on being withdrawn, a piece of money or any other object 
lying loose in the canal, such as a fruit stone, or a set of artificial teeth, 
is very likely to be caught. Even when such a body has passed into 
the stomach it may sometimes be fished up ! A remarkable case of the 
kind has been recorded* in which Mr. L. S. Little, formerly of the 
London Hospital, succeeded in removing a set of false teeth with a gold 
plate from the stomach of a woman who had swallowed them during 
an epileptic fit. 
The Sponge-Probang.—This instrument is merely a gum-elastic bou- 
gie, tipped at its distal end with a piece of sponge securely tied on. It 
is used for pushing down into the stomach any substance of the nature 
of food which has stuck in the gullet, or a foreign body of any kind 
which cannot be extracted. 
The G&ophagotome.—For the internal division of strictures of the 
gullet, various instruments have been invented, particularly by French 
surgeons. I have devised a very simple instrument (Fig. 9) which has 
been successfully used, both by myselff and by Dr. Eoe,J of Rochester 
(U. S.). It consists of a gum-elastic bougie about fifteen inches long, 
terminating in a small metal cap about one inch in length and of 
slightly larger calibre than the rest of the instrument. Through the 
interior of the bougie passes a wire, the lower end of which is attached 
to a small cutting blade, whilst its upper extremity is connected with a 
spiral spring. By pressing a metallic button at the top of the bougie, 
the knife is projected through a slit in one side of the metal cap. A 
little notch in the edge of the button corresponding to the slit, guides 
the operator as to the position of the knife. Instruments with two 
* Royal Med. and Chir. Soc. Proc., February 8th, 1870. Lancet, February 19th, 
1870, p. 268. 
f For details of my ease see “Cicatricial Stricture of the Gullet.” 
1 Ibid. 38 
DISEASES OF THE THROAT AND NOSE. 
blades catting sideways have been used by Trelat* and Dolbeauf for 
the division of oesophageal strictures, but a single blade seems to me 
preferable, and the close proximity of the internal and common carotid 
arteries at the upper part of the gullet on both sides and of the aorta 
lower down on the left side, makes it desirable that the knife should 
cut only in a backward direction. 
The Permanent Oesophageal Tube.—This instrument (Fig. 10), which 
I have used for several years with considerable success, consists of two 
parts; the lower portion being a fine gum-elastic catheter, of No. 6 
size (English), about six inches in length. To the upper end of this 
tube are attached two strings, about one foot long, and loaded at their 
free extremity with small shot. The upper part of the instrument is a 
solid stem, made of vulcanite or whalebone, the lower extremity of 
which is pointed so as to fit loosely for about an inch into the upper 
orifice of the catheter. The instrument should be passed down the 
gullet in the manner recommended in describing the use of solid bou- 
gies, the strings being held close to the upper part of the whalebone 
guide, so as to keep its point inside the catheter. When the latter has 
been passed through the strictured portion of the canal, the solid stem 
or handle should be withdrawn, care being taken to release the strings 
so that the catheter may not be pulled out at the same time. The 
strings should then be fastened round the patient’s ears or the back of 
his head. The catheter is thus left in the narrowed part of the gullet, 
and liquids can be swallowed with comparative ease. The great ad- 
vantage of the instrument is, that it causes no pharyngeal irritation. 
It can generally be allowed to remain in situ for five or six days, when 
it should be removed by means of the strings, as the gum-elastic is 
likely to be decomposed, or the tube itself clogged up. Another instru- 
ment may then be substituted for it in the same manner. It is to be 
remarked that I only employ this instrument where absolute aphagia 
exists, and that generally the catheter has to be pushed through the 
stricture with force. 
Dr. Krishaber,J of Paris, has lately recommended that in cases of 
advanced stricture of the gullet a common gum-elastic catheter of suit- 
able size should be passed into the patient’s stomach through one of his 
nostrils,§ and left permanently in situ. The instrument is fixed in 
* Bull. Th4rap., Mars 30, 1870, t. lxxviii., p. 252. 
f Soc. de Cliir. de Paris, Mars 16, 1870. 
J Trans. Intern. Med. Congress, London, 1881, vol. ii., p. 392, et seq. 
\ In insane persons, or others who perversely refuse food, this method of adminis- 
tering sustenance is most efficacious, as any difficulty in opening the patient’s mouth is CESOPHAGEAL INSTRUMENTS. 
39 
position by means of a strong needle transfixing the catheter near its 
mouth, and having attached to its ends two strings, which are fastened 
to the brow with strips of plaster. A plug should be left in the upper 
end of the tube, except when the patient is being 
fed. By means of this instrument Dr. Krishaber 
has been successful in prolonging for several 
months the lives of patients who must otherwise 
inevitably have died of starvation. In one case, 
indeed, life was maintained in this manner for 
the greater part of a year (305 days). Mr. 
Durham* has successfully tried the same plan, 
but prefers passing the catheter through the 
mouth as being less disagreeable to the patient. 
Fig. 11. 
Fig. 12. 
(Esophageal Feeding 
Tube. 
The Rectal Feeding 
Bottle. 
The Oesophageal Feeding Tube.—This instrument is very useful when 
there is a fistulous communication between the gullet and the air-passage, 
which allows the ingesta to find their way into the larynx or trachea. 
thereby avoided, and he is unable to apply his teeth to the instrument, or to the fingers 
of the operator. 
* Proc. Clin. Soc. Lond., November 11th, 1881, reported in Lancet, November 19th, 
1881, vol. ii., p. 873. 40 
DISEASES OF THE THROAT AND NOSE. 
The instrument consists of three portions: first, a gum-elastic tube of 
the size of a No. 8 English catheter, terminating at one end in a slightly 
bulbous extremity perforated laterally by two rather large holes, and 
at the other in a metal ring and bayonet joint; secondly, a pear-shaped 
india-rubber bottle; thirdly, a connecting portion of metal tubing 
provided with a screw and a tap. The mode of using this instru- 
ment is as follows : The connecting portion is first unscrewed and the 
nutritive fluid poured into the bottle, when the metal tubing is again 
screwed on, and the tap closed. The practitioner now introduces the 
gum-elastic tube into the oesophagus, and an assistant at once hands 
him the feeding bottle, which he quickly adjusts to the bayonet joint, 
and turning the tap, injects the fluids. As there is generally great irri- 
tability of the throat in such cases, the success of the operation largely 
depends on the quickness with which it can be performed. In cases of 
emergency, where this instrument is not at hand, a common catheter 
and an ordinary enema-bottle can be used, but the tap and bayonet 
joint greatly facilitate the operation of feeding. 
The Rectal Feeding Bottle.—It so often happens that in diseases of 
the throat feeding per rectum becomes necessary, that this seems to be 
the appropriate place for describing the instrument which will be found 
most serviceable for the purpose. The ordinary liquid injections, such 
as beef-tea, eggs, milk and brandy, have proved so unsatisfactory in 
my hands that I have for a long time employed the panada first recom- 
mended by Leube (see Appendix, vol. i., p. 556). As this panada, 
however, will not pass through an ordinary enema pipe, it is necessary 
that the elastic bottle should be furnished with a short vulcanite tube, 
having a bore of not less than half an inch. The difficulty of drawing 
up the nutritive fluid through the tube by the common vacuum process, 
makes it requisite that the vulcanite nozzle should be capable of being 
easily unscrewed, in order that the bottle may be filled with a spoon or 
funnel. ACUTE CESOPHAGITIS. 
41 
DISEASES OF THE GULLET. 
ACUTE CESOPHAGITIS. 
Latin Eq.—QEsophagitis acuta. 
French Eq.— aigiie. 
German Eq.—Acute Entzundung der Speiserohre, 
Italian Eq.—Esofagite acuta. 
Definition.—Acute idiopathic inflammation of the mucous mem- 
brane of th$ oesophagus, giving rise to extreme odynphagia, and often to 
aphagia. The disease is attended icith some danger, but generally ends 
in resolution, and only in extremely rare cases terminates in ulcer, abscess, 
or gangrene. 
History.—Amongst the ancient physicians Galen* alone appears-to have recognized 
this disease. After referring to difficulty of swallowing caused by tumors and paralysis, 
he observes that when the oesophagus is affected by inflammation the condition of the 
part itself acts as a hindrance to the passage of food; deglutition, moreover, being ac- 
companied by excruciating pain. In 1722 Boehmf called attention to the complaint, 
especially dwelling on the pain and heat which “ reach even down to the stomach, ac- 
companied by hiccough and a constant flow of serum from the mouth.” In 1745 Van 
SwietenJ gave a short account of the affection, obviously based more upon literary re- 
search than experience. Honkoop! published a thesis on inflammation of the gullet in 
1774, and in 1785 Bleuland|| described the disease in his short treatise on the oesophagus. 
Bleuland’s remarks are entitled to special weight, inasmuch as he had himself suffered 
from a violent attack of the disorder, whereas the previous accounts of this rare affection 
appear to be entirely founded on Galen’s description, which is admirably accurate so 
far as it goes, but necessarily incomplete. Besides his own attack Bleuland states that 
he was acquainted with the details of four other cases of the complaint which had 
occurred in the practice of his master Van Doeveren. A good description of the dis- 
ease wTas given in 1792 by John Peter Frank,f who first proposed to designate it by 
the name “ oesophagitis.” Some years later the pathology of inflammation of the gullet 
as it is met with in new-born children was studied with great zeal and ability by Billard,** 
* De locorum affect, notitia, lib. v., cap. iv. 
f Dissertatio de morbis oesophagi. Halse, 1722. This was a thesis presented by 
Boehm for the doctor’s degree, under the academical presidency of the celebrated 
Hofmann, to whom the work has generally been ascribed by subsequent writers. 
X Comment, in H. Boerhaave aphorismos. Lugduni Batavorum, 1745, t. ii., p. 662, 
g 804. 
| Diss. de morbo oesophagi inflammatorio. Lugduni Batavorum, 1774. 
|| Obs. anat. med. de sana et morbosa oesophagi structure. Leidse, 1785. 
De curandis hominum morbis, lib. ii., pp. 104, 105. Mannhemii, Tubingse, Yiennse, 
1792-1821. 
** Maladies des Enfants nouveau-nds. Paris, 1828. See also 3d edition, 1837. 42 
DISEASES OF THE THROAT AND NOSE. 
who in 1828 published a number of very interesting cases of the affection, together with 
some important observations as to its etiology. In 1829 Mondiere,* who, like Bleu- 
land, had had an opportunity of observing the disorder in his own person, chose it as 
the subject of his inaugural thesis, and described the symptoms and course of the affec- 
tion very accurately. He founded his pathology, however, entirely on Billard’s de- 
scription of the appearances in fatal cases occurring in new-born infants—cases which 
differ widely as to their etiology, nature, and course, and cannot be accepted as afford- 
ing a satisfactory basis for the pathology of idiopathic oesophagitis in adults. In 1831 
Mondieref returned to the subject, treating it with fuller learning, but with no further 
novelty. In 1835 made some remarks on oesophagitis in commenting on a 
case of the disease which he had been called upon to treat. The subject has received 
additional illustration from Hamburger,§ Padova,|| and Laboulbene.^f 
Etiology.—This affection is certainly very rare, but not so rare as the 
exceedingly brief description, and frequent complete omission of the 
subject from the ordinary text-books of surgery and medicine would 
lead the student to imagine. It is highly probable that the very insuf- 
ficient way in which the subject has been handled is the cause of the 
complaint often not being recognized, and I venture to hope that in 
future the true nature of some cases will be appreciated which might 
otherwise have been overlooked. 
There are not sufficient examples on record to enable us to arrive 
with any degree of certainty at the cause of this affection in adults. 
Occasionally it appears to originate in the pharynx and to spread down- 
* Sur l’lnflammation de (Esophage. These de Paris, 1829. Mondiere afterwards 
studied diseases of the gullet in general with much assiduity, aud collected a large 
amount of material scattered through various waitings. Although his laborious com- 
pilation shows more industry than discrimination, his essays are of very considerable 
value even at the present day, for, in spite of his somewhat unwieldly erudition, he was 
a shrewd observer. His writings have been the source from which much of the litera- 
ture of oesophageal disease has since been drawn. Thus in Velpeau’s article (“(Eso- 
phage”—“ Dictionnaire eu Trente Volumes”), in Follin’s essay (“Sur les R6tr4cisse- 
ments de l’CEsophage”), in Copland’s Dictionary, and lastly in the highly creditable 
work of Knott on the “Pathology of the (Esophagus,” Dublin, 1878 (published whilst 
the author was still in statu pupillari), we find the cases of Roche, Bourguet, Broussais, 
Paletta, and several others collected by Mondiere, constantly referred to, with very few 
original illustrations of the disease. On the other hand, but scanty justice has been 
done to Billard, whose work in this field was the fruit of careful independent investi- 
gation. 
f Arch. Gdn. de Med. 1831, t. xxv., p. 358. 
J Clinical Lectures. Dublin, 1848, vol. ii., p. 199. 2d edition. Previously re- 
ported in “ Lond. Med. and Surg. Journ.,” No. 172. 
\ Medicin. Jahrb. Bd. xviii. and xix., December 8 and 22, 1869. 
|| Annali Universali di Medicinae Chirurgia. Milano, Aprile, 1875, vol. ccxxxii., 
pp. 17-24. 
If Nouveaux Elements d’Anatomie Pathologique. Paris, 1879, p. 84. ACUTE (ESOPHAGITIS. 
43 
wards, and in some epidemics of “angina” this tendency has been very 
remarkable;* in one instance the disorder seems to have extended 
upwards in the course of a general inflammation of the intestinal tract, 
but the disease in this case was complicated by ague.f In an example 
related by Laboulbene,J the drinking of cold water was the only assign- 
able cause. Mondiere§ reports one case in which the disease followed 
an attack of inflammation of the stomach, but the actual occurrence of 
the oesophageal mischief was attributed to a dose of castor oil. Another 
instance is on record|| where the onset of the complaint was attributed 
to violent muscular exertion in a fit of passion, but the nature of the 
case was somewhat obscure, and by some physicians it was thought that 
there was partial rupture of the muscular fibres of the oesophagus. Out 
of five cases which I have myself met with, in one the disease was caused 
by direct application of cold to the lining membrane of the gullet 
through eating ices; in a second the supposed cause was the abuse of 
alcohol; in a third the attack followed accidental immersion in a river ; 
whilst in the remaining two the malady occurred in patients who were 
subject to rheumatism. 
Symptoms.—In adults the most marked symptom is odynphagia, the 
pain on attempting to swallow being often of a most excruciating burn- 
ing or tearing character, and sometimes reaching such a degree of in- 
tensity that the patient is obliged to desist altogether from taking food 
or even drink. Even when he is not swallowing there is often a dull 
aching sensation in the pharynx behind the jugular fossa or the ensi- 
form cartilage. Pressure made by the surgeon on the larynx or trachea 
from before backwards intensifies this uncomfortable feeling. The pa- 
tient generally complains of stiffness of the neck, and holds his head in 
one position, the least movement aggravating his suffering. 
He is usually unwilling to speak on account of the pain caused by 
any actioh of the laryngeal muscles. There is not unfrequently a sen- 
sation as of a foreign body in the throat. patient described 
a feeling like a knot in the throat, whilst in Graves’s** case the sensa- 
tion was that of a ring, beyond which the food could not pass. The 
patient almost always experiences great thirst, and being unable to get 
relief by drinking, he is much tormented by this distressing symptom. 
* Annales de Montpellier, t. iv., p. 87. 
f Padova: Annali Univ. di Med. Milano, Aprile, 1875. 
| Nouveaux Elements d’Anatomie Pathologique. Paris, 1879, p. 84. 
§ Arch. Gdn. de Med., t. xxiv. || Ibid, 
f Loc. cit. ** Loc. cit. 44 
DISEASES OF THE THROAT AND NOSE. 
The earlier writers lay great stress on hiccough as an unfailing accom- 
paniment of this malady, but it has not been present in any of the cases 
that have come under my notice. When the inflammation is slight, it 
may give rise to spasm of the oesophagus, a condition which will be 
hereafter considered. If the mischief extend to the ary-epiglottic folds, 
dyspnoea may supervene. In adults the constant expuition of frothy 
or glairy mucus is very characteristic. In all my five cases this symp- 
tom was present. 
The general symptoms are those of irritative fever, but not of a high 
degree; in no case that I have met with has the temperature been above 
102° F., and the pulse has not exceeded 130. Occasionally, however, 
there is some delirium. Bleuland* himself suffered from this compli- 
cation, and it was present in one of my cases. 
It is probable that, in some instances, the inflammation becomes 
really purulent in character, but this has not occurred in my own ex- 
perience, and I have not met with a single recorded example of idio- 
pathic origin in which it was observed. Should the inflammation, 
however, result in the formation of an abscess, rigors oocur, and the 
local symptoms generally become intensified for the time. When the 
abscess bursts, blood and pus are expectorated, and a rapid recovery 
usually takes place. When the disease is confined to a particular por- 
tion of the gullet, its situation can be ascertained by auscultation, the 
oesophageal sound abruptly terminating immediately below the point 
of inflammation. 
When once a favorable change has set in, convalescence is generally 
pretty rapid, although Mondifire asserts that he was obliged to take his 
food cold for many months after recovery from the acute symptoms. 
If, as is usually the case, the inflammation gradually subsides, the diffi- 
culty of swallowing and other symptoms pass off; but, if ulceration 
should take place, the symptoms persist in full force, the pain becoming 
more severe and more constant. If the expectoration is frequently 
tinged with blood, ulceration may be suspected. 
jPathology.—It is probable that in acute oesophagitis the usual phe- 
nomena of catarrhal inflammation of mucous membrane are present; 
that is to say, there is great redness of the membrane, together with 
succulence of the epithelium and increased secretion of watery fluid 
containing imperfectly developed epithelial cells. The abundant secre- 
tion which occurs during life comes not only from the oesophagus, but 
from the pharynx and the salivary glands, which appear to be sympa- 
* Loc. cit. ACUTE CESOPHAGITI8. 
45 
thetically stimulated. Zenker and Ziemssen,* following Klebs, assert 
that inflammation of the gullet is altogether different from inflamma- 
tion as it affects other mucous membranes, but this view is not borne 
out by the only case of idiopathic oesophagitis in which the post-mor- 
tem appearances have been recorded. In this instance the following 
changes were observed chiefly at the upper and lower ends of the tube : 
“ The mucous membrane was red, but not ulcerated, extremely congested 
and thickened ; the glands were more prominent than usual, the mucous 
membrane was covered in several places with a glutinous, gray, or 
grayish-yellow coating, which could be washed off. On section the 
submucous tissue appeared to be thickened and infiltrated with liquid. 
Strong pressure between the fingers made it thinner. There was no 
pus to be seen. Microscopically, the viscous coating was found to con- 
sist of mucus with abundant epithelium cells and pus-corpuscles.”f 
Although as a rule the acute inflammation rapidly subsides, yet oc- 
casionally it leads to ulceration. This appears to have occurred in the 
case recorded by Paletta,J in which a young woman, who died from 
extensive inflammation of the throat, involving the pharynx, larynx, 
and oesophagus, was found to have a large ulcer on the anterior wall of 
the gullet. Mondiere§ also mentions the case of a woman who suc- 
cumbed to an attack of oesophagitis, terminating after four months’ 
illness in ulceration of the oesophagus, for which there appeared to 
have been no other cause than simple inflammation. 
It rarely happens that the inflammation leads to the formation of a 
distinct abscess, though this sequel is common enough in cases of trau- 
matic origin. Three instances, however, are on record in which oeso- 
phagitis terminated in abscess; in one|| of these the sac was accidentally 
opened by the pressure of a bougie, whilst in the others spontaneous 
rupture occurred, and pus was continuously expectorated, in one 
for three or four days, and in the other** for a fortnight. 
More rarely still the disease ends in gangrene. I know of only two 
instances in which this termination is recorded. In oneff of these the 
patient was a man, aged thirty-eight, who was suffering from purpura 
and general inflammation of the gastro-intestinal canal, and the mucous 
membrane of the oesophagus was found thickened and of an inky-black 
* Op. cit., vol. viii., p. 135. f Laboulb5ne : Op. cit, p. 84. 
X Exercit. Pathol., 1820, p. 228. \ Arch. Gfen. de M5d., t. xxiv. 
|| Bourget: Gazette de Sante, 1823, p. 221. Padova: Loc. cit. 
** Barras : Arch. G4n. de Med., 1825. 
-j-f Habershon: Diseases of the Abdomen.” 1878, 3d ed., p. 53. 46 
DISEASES OF THE THROAT AND NOSE. 
color. The other* occurred in a man, aged sixty, in whom the gullet 
was found to be gangrenous from its upper extremity to within an inch 
of the cardiac orifice of the stomach. The whole thickness of its wall 
was sphacelated, the lining surface, however, being most involved. 
It is possible that there may sometimes be a myalgic condition of the 
oesophageal walls rather than actual inflammation, but such a disorder 
would of itself give rise to no appreciable pathological change. 
Diagnosis.—The extreme odynphagia and the absence of all inflam- 
mation of the pharynx, or of the framework of the larynx, as ascertained 
with the help of the laryngoscope, strongly point to acute disease of the 
oesophagus. The pain which is experienced on pressure of the larynx 
and trachea backwards, is more marked than when the air-passages are 
themselves inflamed. Mondi&re attaches much importance to the sen- 
sation of heat which is felt at the lower part of the neck, when, at the 
same time, there is entire absence of any redness in the throat. The 
same author also refers to the intense anxiety often manifested by the 
patient, a symptom which is usually aggravated by attempts to swallow 
even fluids. This has sometimes led to the disease being mistaken for 
hydrophobia. In that complaint, however, solids can often be swal- 
lowed when the very sight or even the sound of fluid will bring on a 
severe spasm. Moreover, the general hyperaesthesia, asphyxial parox- 
ysms, and psychical phenomena of hydrophobia are .all so characteristic 
that, when once seen, little confusion is likely to arise between that dis- 
ease and oesophagitis. Pericarditis with abundant effusion sometimes 
causes pressure on the oesophageal canal, and occasionally gives rise to 
dysphagia, but seldom to any considerable amount of odynphagia. In 
pericardial affections, moreover, the pain is generally limited to the 
epigastric region ; in these cases the physical exploration of the chest 
at once determines the nature of the affection. It need scarcely be said 
that in acute inflammation of the gullet neither the oesophagoscope nor 
the bougie can be used. 
Prognosis.—This is generally favorable, but in at least two cases, 
viz., in that of Padova and in one of my own, the patient was in a very 
critical condition. In Laboulbene’s case, the patient died suddenly 
from cerebral haemorrhage. 
Treatment.—The most important element in successful treatment con- 
sists in maintaining the oesophagus in a state of absolute rest. It does 
not require any persuasion on the part of the physician to secure this 
condition, for if the symptoms are at all severe the patient is quite un- 
* Arch. G6n. de Med., t. xxiv. ACUTE (ESOPHAGITIS. 
47 
able to swallow. Nutrient enemata should be administered, unless the 
inflammation rapidly subsides, and morphia must be given hypodermi- 
cally. Poultices should be applied along the upper part of the spine; 
or if there be much pain, anodyne embrocations, such as the oleate of 
morphia (gr. ad 5j.) and belladonna liniment may be rubbed into 
the back. Mondiere insists on the importance of venesection, cupping, 
leeching (from twelve to thirty leeches being applied to the side of the 
neck), counter-irritation (mustard poultices and moxas), and derivatives. 
General bleeding, however, or even the local abstraction of blood to the 
extent recommended by Mondiere, is not likely to be carried out in the 
present day, and I have not found any benefit from counter-irritation. 
Derivatives, on the other hand, especially very hot pediluvia, are often 
of signal service. Bleuland used blisters “loco dolenti” between the 
shoulders with success. 
Pagenstecher* has reported two cases in which he attributed consid- 
erable importance to the internal use of hydrochlorate of ammonia. Tt 
may be remarked, however, that fifty years ago this drug was highly 
lauded by physicians (especially the Germans and Dutch) as a remedy 
for almost every kind of disease. 
The passage of bougies can only do harm, and should never be 
attempted, in spite of a case related by Mondiere,f in which an abscess 
was accidentally ruptured in this way, and the patient thereby cured. 
When convalescence commences the change from a liquid to a solid 
diet should be very gradual, and should pain in deglutition recur, the 
patient must be again immediately restricted to fluids. 
CASES ILLUSTRATING ACUTE (ESOPHAGITIS. 
Case 1.—Mr. A. W., aged twenty-six, applied to me in July, 1868, on account of 
great pain and difficulty in swallowing. He stated that he first noticed this two days 
previously, and that it came on the morning after he had been at a ball, where he had 
eaten several ices. He acknowledged that he had become very hot in dancing, and 
had gone out of the ball-room into the open air, though the evening was fresh ; but 
lie attributed the throat affection to eating ices, because he had once before bad a 
similar attack produced in that way, whilst he had often exposed himself to cold after 
dancing without any ill effects. He said that he had scarcely been able to swallow 
any food for the last two days, having been quite unable to take solids, and fluids 
causing great pain. He had slept very badly the last two nights, owing to the quan- 
tity of saliva, which repeatedly woke him by giving rise to attacks of coughing. When 
first seen by me his condition was as follows: He swallowed some water, which caused 
great pain opposite the seventh dorsal vertebra, and which he said darted upwards to 
the back of his throat. His power of deglutition was then tested with solids, and it was 
* Journal von Hufeland. 1827, p. 51. 
f See antea, case of Bourguet. 48 
DISEASES OF THE THROAT AND NOSE. 
proposed that he should try bread, meat, and potato. He succeeded in getting down a 
small piece of stale bread, but was obliged, at the same time, to drink water; the effort, 
however, caused him very great pain, and he was unable afterwards to swallow either 
the meat or the potato. On examination with the laryngoscope, the pharynx and 
larynx were seen to be quite normal. This patient was treated with hypodermic in- 
jections of morphia, but they were used only five times. For two days nutritive 
enemata were employed, but afterwards the patient sucked ice, and swallowed iced 
milk and cold beef-tea. Nine days after the first occurrence of the inflammation he was 
able to take semi-solids, and a few days later he could swallow any cold or tepid food. 
At the end of a month he was still obliged to be careful in his diet. 
Case 2.—Charles E., aged forty-one, night watchman in a warehouse, came under 
my care at the London Hospital in February, 1873, on account of chronic rheumatism 
affecting the right knee and left ankle. The patient had suffered from two attacks of 
acute rheumatism, for both of which he had been treated in the hospital. He was 
placed on iodide of potassium and bicarbonate of potash. After being under treat- 
ment for a month with slight benefit he was suddenly attacked by seveye odynphagia, 
together with a constant flow of glairy saliva. He experienced, just above the level 
of the upper border of the sternum, a burning pain, which was greatly increased by 
pressure on the front of the trachea. For three days the patient was unable to take 
any food or drink, and he was scarcely able to sleep at all, owing to the mucous secre- 
tion passing down into the larynx, whenever he began to lose consciousness, and giving 
rise to paroxysms of coughing. He was obliged constantly to sit up and support his 
head between his hands. The pharynx and upper part of the larynx were seen to be 
healthy. Nutrient enemata were administered on two occasions, but the patient ob- 
jected to them so much that they had to be discontinued. Subcutaneous injections of 
morphia relieved the constant burning pain, but did not produce sufficient anaesthesia 
of the oesophagus to allow deglutition. On the fourth day from the establishment of 
the severe symptoms the patient was able to swallow a little milk, and at the end of a 
fortnight could eat almost anything when cold, though hot food still caused pain. 
Case 3.—Henry E., aged twenty-three, consulted me on June 24th, 1875, on account 
of difficulty of swallowing. He stated that two days previously he had been upset 
from a boat on the Thames, and that it was some time before he was rescued. After 
being brought to the shore he became insensible, and remained in this condition for 
more than half an hour. Next day he was very feverish, and in the afternoon felt 
difficulty in swallowing. In the evening, whilst trying to take some soup, it was vio- 
lently thrown back through the nose. The same night he was slightly delirious; he 
was scarcely able to sleep, being obliged to sit upright and expectorate saliva. The 
next day, when I saw him, he was feverish, the pulse being 120 and the temperature 
101.5° F. He was spitting up large quantities of ropy mucus. The lower part of the 
pharynx and the epiglottis were seen to be slightly inflamed, but the interior of the 
larynx and trachea was normal in appearance. The patient swallowed a little water 
in my presence, but declined to take a second spoonful on account of the great pain it 
caused. The following day the difficulty of swallowing still continued; the patient 
complained of severe thirst, but was unable to swallow little lumps of ice, or even 
iced water. On the morning of the fourth day he was able to get down a small quan- 
tity of cold soup, and a few hours later he took a large drink of milk. From this date 
he rapidly improved, and at the end of a week from the commencement of the attack 
he was perfectly well. The only treatment in this case consisted in subcutaneous injec- 
t ions of morphia. 
Case 4.—Mr.W., aged forty-seven, who had a short time before been suffering from sub- (ESOPHAGITIS IN INFANTS. 
49 
acute rheumatism, sent for me on May 27th, 1879, on account of difficulty of swallowing 
which had come on the previous eveniug. Examination with the laryngoscope showed 
that the larynx was healthy, and the pharynx also appeared quite normal. Mr. W. said 
that he could swallow, but that it caused him great pain at a point which he indicated 
midway between the cricoid cartilage and the upper edge of the sternum. There was 
no expectoration. I ordered the patient to suck ice. In the evening, feeling much 
worse, Mr. W. sent for me again. He informed me that he was unable to take the ice, 
as it caused him so much pain. He had begun to expectorate frothy mucus. I admin- 
istered morphia subcutaneously. The next day he felt better, but could not yet swallow 
at all. The subcutaneous injection was repeated, and a nutrient enema was adminis- 
tered. (See vol. i., p. 556.) The patient was fed by enemata for five days; after this 
he began to swallow, but for three weeks he experienced difficulty at times. Indeed, 
one month after the date of the attack, whilst swallowing a piece of potato, he felt so 
much pain and difficulty that he thought his old symptoms were returning. This, how- 
ever, did not prove to be the case. 
Case 5.—There was nothing remarkable about this case. The patient was a lady, 
aged twenty-seven, who had recently suffered from rheumatism and pleurisy. The 
attack of oesophagitis occurred in November, 1880, and was not so severe as those above 
described. Belladonna plasters, applied to the back between the shoulders, gave much 
relief, and no hypodermic injections were used. 
(ESOPHAGITIS IN INFANTS. 
As already remarked, Billard * was the first to call attention to this 
affection, and soon afterwards Ryan f described it in almost identical 
terms. Though his lectures contain no reference to Billard, there can 
be little doubt as to the source of his information. Subsequent Eng- 
lish writers have altogether passed over the disease.;}: 
The predisposing cause of the affection in infants appears to be the 
physiological hypersemia of the gastro-intestinal mucous membrane 
which exists at birth. Out of 200 bodies of newly-born children, free 
from any sign of disease, Billard § found the mucous membrane of the 
oesophagus, as well as that of the isthmus of the fauces, more or less 
congested, 190 times; no ramifying vessels could be seen, but the mu- 
* Op. cit., p. 278. 
f Lectures on Diseases of Infants, London Medical Journal, July 18, 1835. 
J This is probably to be accounted for by the fact that even in children’s hospitals 
patients under two years of age are not admitted. Within the last two years, how- 
ever, a hospital has been established in Boston (XL S.) by Dr. Havens, which is exclu- 
sively devoted to infants under this age. Much valuable information concerning the 
maladies of early infancy is likely to be obtained at this institution, whilst the problem 
of artificial feeding will be worked out in a scientific manner hitherto impossible. 
I Op. cit., p. 274. 50 
DISEASES OF THE THROAT AND NOSE. 
cous membrane presented a uniform redness, which did not extend 
deeper than the epithelial layer. Billard considers that in these cases 
there was passive congestion due to the imperfect establishment of the 
relation between respiration and circulation. Indeed, autopsies made 
on newly-born infants show conclusively that when the circulation 
through the lungs, heart, or liver is obstructed, hyperaemia of the oeso- 
phagus is almost always present. In older children the same condition 
is brought about by morbid conditions of the blood, as in fevers and 
diphtheria. Even when the first months of infantile life have been 
safely passed through, the oesophageal veins become readily gorged in va- 
rious affections of the more important organs, as well as in cases of severe 
general disease. Thus Steffen * reports 10 cases of hyperaemia and 6 of 
ulceration of the mucous membrane of the oesophagus, out of 44 cases 
of fatal disease in infants and young children. In most of these there 
was circumscribed pneumonia, whilst in 2 there was enteritis, and in 2 
cholera infantum. In some of Billard’s cases, however, it would appear 
that the morbid changes had actually commenced before birth. The 
exciting cause of the complaint seems to be sore nipples or a defective 
quality of milk on the part of the mother or nurse, or improper food. 
The principal symptom of oesophageal inflammation in children is an 
unwillingness to suck. When the child, however, can be induced to 
take the breast it leaves off sucking after a second or two and com- 
mences crying. Most of the milk is immediately returned, quite un- 
changed, a very small quantity probably reaching the stomach. Gentle 
pressure on the lower part of the trachea will, as Billard f has pointed 
out, often make the child cry. 
The diagnosis of this affection is very difficult. If occurring at 
the time of birth it may be confounded with a congenital malforma- 
tion of the oesophagus. In the latter case, however, all the milk is 
rejected, and paroxysms of suffocation are brought on by attempts to 
swallow. On the other hand, in the affection now under consideration, 
although the child cries after trying to suck, a small quantity of nutri- 
ment is retained. 
The pathological changes vary in different cases. Sometimes the 
whole lining membrane is inflamed, whilst occasionally the hyperaemia 
affects only a limited surface. Ecchymotic patches are often present. 
Sometimes the inflammation goes on to ulceration. The ulcers vary in 
form and size. Thus, in one of Billard’s| cases the upper part of the 
t Op. cit., p. 290. 
* Jahrb. fur Kinderheilkunde, N. F., 1869, Bd. ii. 
t Ibid., p. 276. PHLEGMONOUS OESOPHAGITIS. 
51 
oesophagus was highly injected, and there were two sharply-cut ulcers 
of oblong shape, each measuring about four lines in its longest diam- 
eter. In another of Bil lard’s.* cases the whole of the upper third of the 
gullet showed erosions of the epithelium, whilst in a third instance por- 
tions of the epithelial were expectorated as broad yellowish 
shreds; on post-mortem examination the mucous membrane exhibited 
large patches of a bright red color, which appeared to correspond with 
the membranous material expectorated during life. Ulcers, when 
present, generally affect only a limited portion of the oesophagus—the 
upper or lower part—and, according to Steffen,f their number is in in- 
verse proportion to their size. It not unfrequently happens that the 
inflammatory process is confined to the follicles, the orifices of which 
are often slightly ulcerated, and are surrounded by red rings, which are 
much brighter than the general purple hue of the rest of the mucous 
membrane. Occasionally the disease goes on to gangrene, one case 
having been reported by Dillard,! in which the lining membrane of the 
oesophagus presented large, loose, irregular eschars, the intervening sur- 
face being highly inflamed and traversed by deep excoriations. 
The prognosis is generally unfavorable in these cases, not only on 
account of the very tender age of the patient and the extreme difficulty 
of carrying out suitable treatment, but because the oesophageal inflam- 
mation is so often associated with pneumonia and gastro-intestinal irri- 
tation. 
In the treatment of this affection it is most important to pay attention 
to the quality of the milk and the condition of the mother’s nipples; 
or, if artificial nutriment is used, the cooking utensils and feeding-bot- 
tles should be carefully looked to. As regards medicine, the remedies 
found useful in thru.-h, such as chlorate of potash dissolved in milk, 
and borax mixed with honey, may be employed. Dr. Ryan§ strongly 
recommended antiphlogistic remedies, such as leeching, but it must be 
remembered that this advice was given nearly fifty years ago, and that 
the views then in vogue have completely passed away. There is less 
objection to this author’s other suggestion, viz., the application of warm 
fomentations to the neck. 
Phlegmonous (Esophagitis. 
It is exceedingly doubtful whether acute inflammation of the sub- 
mucous areolar tissue ever occurs as an independent affection. It was 
* Ibid., p. 279. 
f Loc. cit. 
£ Op. cit., p. 288. 
\ Loc. cit. 52 
DISEASES OF THE THROAT AND NOSE. 
first described by Belfrage and Iledenius,* as occurring in a case in 
which a fish-bone had become impacted in the throat, and it has since 
been observed in a case of poisoning by sulphuric acid, but as a rule 
the injury proceeds from without. Zenker and Ziemssenf have reported 
a number of cases, in most of which the morbid condition resulted from 
the penetration of abscesses (generally of scrofulous glands) through 
the external coats of the gullet. The condition is not likely to be 
recognized during life, and at present must be regarded as a pathological 
curiosity, the result of the burrowing of pus between the constituent 
parts of the oesophageal walls. As such it will be referred to in con- 
nection with those diseases (traumatic oesophagitis, peri-oesophageal 
abscess) in which it is occasionally observed after death. 
Ulcer of the Gullet. 
Although ulceration is present in almost every case of prolonged 
obstruction of the gullet, there is no conclusive evidence that it ever 
occurs as an independent disease. None of the cases hitherto recorded 
present any analogy to the “simple perforating ulcer of the stomach.” 
When a limited surface of the latter viscus is deprived of its supply of 
blood by embolism, or through any other morbid condition, the solvent 
action of the gastric juice comes into operation, and an ulcer can quickly 
form. It need scarcely be pointed out that a lesion of this nature could 
occur in the gullet only under very exceptional circumstances, if at all, 
during life, and that the oesophageal mucous membrane can, as a rule, 
be acted on by the gastric juice only after death (see “Post-mortem 
Softening of the Gullet”). The cases of “simple ulcer of the oesoph- 
agus,” which have been reported by the older writers, are too incom- 
plete to be relied upon, whilst many modern cases, nearly all of which 
have been carefully collected by Knott,J are open to the objection that 
the disease may have been of malignant nature, the ulcerated surface 
not having been submitted to the test of microscopic examination. This 
observation applies to a case of my own,§ and to another of Dr. Ben- 
son. || Again, in other cases of so-called “ simple ulceration,” there is 
not the slightest evidence that the morbid process commenced in the 
gullet. In some of the supposed examples the disease probably origi- 
nated in the trachea. Thus, in a case occurring in the practice of Dr. 
* Schmidt’s Jalirh., bd. clx., p. 33. 
f Cyclopaedia of Medicine, vol. viii., p. 151, et seg., English Trans., 1878. 
$ Pathology of the (Esophagus, Dublin, 1878. 
§ Trans. Path. Soe., vol. xix., p. 213. || Knott: Op. cit., p. 73. TRAUMATIC (ESOPHAGITIS. 
53 
Gordon,* the patient had suffered from repeated attacks of dyspnoea a 
considerable time before dysphagia supervened. In other cases,f in 
which the early history is obscure, it is quite possible that the original 
lesion may have been due to the temporary impaction of a foreign body, 
to a peri-oesophageal abscess, or even to the penetration of a scrofulous 
gland. In any of these instances, by the time the autopsy is made, 
there is often nothing which can reveal the original cause of the malady, 
and there is at present no ground for considering that ulceration of the 
oesophagus can take place as an independent process. Ulcers of the 
gullet may follow oesophagitis,£ and they are certainly found in cancer, 
syphilis, and phthisis, as well as in thrush, diphtheria, variola, typhoid 
fever, and in cases of traumatic lesion. 
TRAUMATIC (ESOPHAGITIS. 
Latin Eq.—(Esophagitis traumatica. 
French Eq.—(Esophagite traumatique. 
German Eq.—Traumatische Entziindung der Speiserohre. 
Italian Eq.—Esofagite traumatica. 
Definition.—Acute inflammation of the oesophagus caused by caustics 
or irritants,§ giving rise, when very severe, to complete destruction of the 
walls of the gullet, in slighter cases to limited desquamation, and when 
mild to active hypercemia. 
History.—Inflammation of the gullet from the action of caustics has been more or 
less known to physicians since the earliest dawn of scientific medicine, but it is only 
in modern times that the special effects of the various irritant and corrosive poisons 
on the mucous membrane of the alimentary canal have been attentively studied. Less 
attention has, however, been given to the action of such substances on the gullet, 
probably because its resisting lining membrane, its freedom from recesses, and its per- 
pendicular direction combine to make it much less vulnerable than the mouth or 
stomach. A mere reference to the various ancient writers who have mentioned cases 
of oesophageal injury from this cause would possess but little interest. Those, however, 
* Knott: Op. cit., p. 68. t p 75. £ See page 45. 
g (Esophagitis set up by the impaction of foreign bodies is purposely omitted here, 
the condition of the gullet under those circumstances being so dependent on the nature, 
position, and ultimate course of the foreign body that it can be best considered in con- 
nection with the accidents which give rise to it. 54 
DISEASES OF THE THROAT AND NOSE. 
who care to look more closely into this matter may consult a list of cases of oesophageal 
strictures given by Bdhier,* many of which are the result of traumatic oesophagitis, 
and several typical instances may be seen in Luton’sf article on the oesophagus. Both 
CasperJ and contain much valuable information on this subject. 
Etiology.—The disease is nearly always caused by accidental or sui- 
cidal swallowing of corrosive poisons, or highly irritant solutions, but 
occasionally these fluids have been administered to young children with 
murderous intention.|| Sulphuric acid, from its common employment 
for domestic purposes, is often used by poor and ignorant persons for 
suicide, better educated people generally seeking a less painful poison. 
Nitric acid is not very easily obtained, and is therefore not so frequently 
used. Accidents often occur through swallowing soap-lees, a mixture 
generally consisting of about three parts of caustic soda to eight of 
water. These strong alkaline solutions appear to be very carelessly 
used in some parts of Austria, for in five years treated no less 
than forty-six such cases amongst children in the Mariahilf Hospital at 
Vienna. 
Symptoms.—The specific action of many of the poisons has already 
been described under “Traumatic Pharyngitis” (vol. i., p. 113, etseq.), 
but a few additional remarks must be made here. In the first hours 
after the accident the special lesion of the oesophagus does not attract 
particular notice, the mouth, pharynx, and stomach being generally 
simultaneously involved, and all claiming attention. If a strong irri- 
tant has been swallowed, the mouth is excoriated; the surface of the 
tongue, when the agent is sulphuric acid, being white, and when nitric 
acid, yellow. In both cases the tongue is swollen, the uvula oedema- 
tous, and the pharynx greatly inflamed and presenting numerous bleed- 
ing excoriations. If a laryngoscopic examination can be made, the 
epiglottis and arytenoid cartilages are seen to be red, and enormously 
oedematous, or not much swollen, but covered with loose, dark-colored 
shreds and bloodstained mucus. At a later stage of the case, however, 
morbid changes result, which give rise to very marked oesophageal 
* Clinique M6dicale, Paris, 1804, p. 113. 
f Nouveau Diet, de Mhd. et de Chir., Paris, 1877, t. xxiv., p. 416. 
X Handbook of Forensic Medicine, New Syd. Soc. Trans., 1862, vol. ii., p. 55 et seq. 
§ Principles and Practice of Medical Jurisprudence, London, 1873, vol. i., p. 211 et 
seq., second edition. 
|| Casper (Handbook of the Practice of Forensic Medicine, New Sydenham Soc. 
Trans., 1862, vol. ii., pp. 75, 78, and 84) reports three cases (Nos. 188, 191, 198) in 
which mothers killed their infants by administering sulphuric acid 
(Ester. Zeit. fiir prakt. Heilkunde, Nos. 45-47, 1862. TRAUMATIC (ESOPHAGITIS. 
55 
symptoms. This remark especially applies to the weak alkaline solu- 
tions, which often produce cicatricial changes in the oesophagus, whilst 
the pharynx, probably owing to its greater lumen, may escape injury 
altogether. 
A peculiar form of oesophageal inflammation is occasionally produced 
by the action of antimony, which in some cases appears to have a special 
action on the mucous membrane of the oesophagus even when admin- 
istered in medicinal doses. There is a specimen in University College 
Museum (No. 1052) which is a good illustration of this. Antimony, 
in ordinary doses, had been given to a patient exhausted by pneumonia, 
and after death the mucous membrane of the epiglottis and pharynx 
was seen to be destroyed, and the epithelium stripped off at the upper 
part of the oesophagus, while at the lower extremity the mucous mem- 
brane was completely ulcerated through, the circular muscular fibres 
being laid bare. There were likewise some smaller patches of ulcera- 
tion above this point. Vogel* has reported a case of poisoning by 
antimony in which ulcers were found in the oesophagus. Sometimes, 
however, the effects of the poison are shown in the production of pus- 
tules. A remarkable instance of this kind is described and figured by 
Laboulbene,f in which the pustules were found scattered throughout 
the gullet. The action of antimony on the oesophagus is, however, by 
no means uniform. Thus, in three cases of poisoning by that agent 
reported by Taylor,J in which large quantities were taken, the oesoph- 
agus is described as being uninjured in every instance, although in one 
of them a “ burning sensation down the gullet” was complained of 
during life. In this instance the patient was a girl, aged sixteen, and 
from forty to sixty grains of antimony had been taken, whilst in the 
other cases, occurring in young children, ten grains of the poison had 
been swallowed. 
In briefly describing the effects of poisoning by phosphorus in the 
article “ Traumatic Pharyngitis” (vol. i., p. 313), I omitted to mention 
two very characteristic symptoms, viz., the belching forth of bluish- 
white fumes luminous in the dark, and the evacuation of primrose- 
colored stools.§ 
In cases of injury by irritants the symptoms depend on the strength 
* Lehrbuch der Kinderkrankheiten, p. 99. f Op. cit., p. 87. 
J Op. cit., vol. i., pp. 309, 310. 
§ I am indebted to the editor of the Birmingham Medical Review (October, 1880) 
for calling my attention to these omissions, and also for a very kind and critical review 
containing other valuable suggestions. 56 
DISEASES OF THE THROAT AND NOSE. 
of the poison. When the mineral acids, chloride of zinc, ammonia, 
or some other solutions in a concentrated state, are swallowed, they 
corrode the mucous membrane, and give rise to the most serious and 
painful symptoms, whilst the dilute acids and weak alkaline solutions 
set up acute, or, in some cases, only subacute inflammation. 
Immediately after swallowing a powerful corrosive poison, or strong 
caustic, the patient experiences a burning sensation in the fauces and 
stomach, or he may complain of an agonizing pain at the root of the 
neck or between the shoulders. In some of the most severe cases, 
however, in which both the stomach and oesophagus are deeply cor- 
roded, the sensibility seems to be blunted, and but little pain is com- 
plained of. This problably results from extreme shock to the system. 
The patient expectorates and vomits either dark-colored fluid ora frothy 
secretion containing blood and shreds of membrane. The vomiting 
may continue for two or three days, but occasionally, in the most severe 
cases, it ceases altogether after three or four hours, and notwithstanding 
this apparently favorable turn the patient may succumb within a short 
time. • If the larynx is implicated, there is extreme difficulty of breath- 
ing, together with troublesome cough. There is usually very great 
prostration, the pulse being quick and small, and the skin bathed in 
perspiration. Sometimes, however, there is active vascular excitement, 
the skin is hot and dry, the pulse hard and quick, and as the result of 
cerebral irritation, or possibly of some form of intoxication produced 
by the poison, the patient is very restless, or even delirious. Most 
patients suffer from distressing thirst, and if they survive there is nearly 
always obstinate constipation. 
In less severe cases, when the mineral poisons have been taken in a 
diluted form, the symptoms are comparatively slight, and resemble 
those described under “Acute (Esophagitis” (pp. 43, 44)—that is to 
say, there are inability to swallow and constant expectoration of glairy 
fluid. The characteristic anxious expression is also present in the coun- 
tenance. The patient complains of a burning acid, or of an acrid alka- 
line taste, according to the chemical nature of the poison. In these 
apparently mild cases, however, the dangerous symptom of progressive 
dysphagia may show itself at a later stage. 
Pathology.—The morbid changes, of course, depend on the nature 
and degree of concentration of the poison. In severe cases the gullet 
as a whole may be gangrenous, its walls here and there being even 
completely perforated by deep ulcers. In these instances the tongue, 
pharynx, and larynx are almost always extensively implicated in the TRAUMATIC OESOPHAGITIS. 
57 
destructive process. According to Casper,* in cases of poisoning by 
corrosive or irritant substances, “ the oesophagus is only in the rarest 
instances carbonized like the stomach; generally it is only hard to cut 
as if tanned, and of a gray color, and the vascular injection of its 
mucous membrane may still be recognized.” The tissues of the gullet 
are in fact quite firm, the mucous membrane is gray, and has an acid 
reaction. In poisoning by corrosive sublimate, the mucous membrane 
of the mouth, pharynx, and oesophagus, generally has a violet tint, but 
sometimes it is whitish. 
When the corrosive action has been less violent, the lining membrane 
of the oesophagus is of a brownish or ashen color, whilst its longitudinal 
ridges are partially corroded, and more or less detached. 
In the milder cases the mucous membrane is extremely hypersemic 
and highly succulent, whilst there is abundant cell-proliferation ; but 
it is only in cases where the injury kills through the severity of the 
gastric affection whilst the oesophagus remains comparatively unscathed, 
that these slight pathological changes can be studied. 
It is worthy of note that in some instances the stomach may be seri- 
ously injured, whilst the oesophagus altogether escapes the corrosive 
action of the poison.f 
Diagnosis.—It is very seldom that any difficulty in diagnosis can 
arise, the immediate occurrence of the symptoms on swallowing the 
poison leaving no doubt as to the nature of the affection. Casper,£ 
however, points out that in infants it is very important to distinguish 
between the state of the tongue in poisoning by sulphuric acid and that 
occurring in thrush. 
It is necessary to ascertain, if possible, the nature of the poison that 
has been taken. If the patient is insensible when the surgeon arrives, 
and the character of the poison is unknown, the bottles, vials, and 
vessels in the room should be examined, with the view of discovering 
some remains of the acrid fluid. If this does not supply the desired 
information the vomited matters should be tested. Should it happen, 
however, that the patient has not been sick, emetics should be admin- 
istered. The use of the stomach-pump, though constantly recommended 
by surgical writers, is in these cases attended with great risk, as the 
point of the instrument is extremely likely to be pushed through the 
walls of the oesophagus. 
It is only in dealing with the sequelce of the accident that there can 
* Op. cit., vol. ii., p. 57. 
J Op. cit., vol. ii., p. 57. 
f Lancet, November 6th, 1880. 58 
DISEASES OF THE THROAT AND NOSE. 
be any doubt as to the nature of the original lesion. Thus, a patient 
suffering from a stricture brought about by a corrosive poison taken 
with suicidal intent, is sometimes ashamed to confess the origin of the 
condition; and in these cases the question of diagnosis between cicatri- 
cial stricture and malignant disease may arise. This subject will be fully 
considered in the article on “Cicatricial Stricture of the (Esophagus.” 
Prognosis.—The prognosis must depend on the amount and degree 
of concentration of the corrosive poison that has been swallowed, and 
also on the extent to which adjacent parts are implicated. In severe 
cases the absence of pain must be looked upon as a very unfavorable 
sign. Vomiting of dark-brown fluid and of membranous shreds and 
extreme prostration are generally indications of an early death; but 
even in less severe cases it must not be forgotten that stricture is exceed- 
ingly likely to supervene. It may be added that though this may be 
cured for the time, it is almost certain to recur, and that patients who 
have once suffered from traumatic stricture are afflicted with an infir- 
mity which will probably exist all the rest of their life. 
Treatment.—Acids should always be neutralized by the administra- 
tion of alkalies largely diluted in water, barley-water, or milk. Car- 
bonate of soda, potash, and magnesia, are the best remedies, but any 
alkali that can be obtained, such as chalk, whiting, or even the scrap- 
ings from a whitewashed ceiling, should be at once administered. Sal 
volatile is generally at hand and can be given freely diluted. 
In the case of poisoning by phosphorus, carbonate of magnesia should 
be given in drachm doses every fifteen minutes till the breath ceases to 
be phosphorescent. 
If the poison has been an alkali, acids should not be used, as they 
increase the inflammation, but oil or melted butter should be given. 
Hot poultices should be applied over the lower part of the neck and to 
the back along the course of the gullet. The thirst must be assuaged 
by iced drinks. Very little food, and that only of the blandest char- 
acter, should be allowed to be taken by the mouth, but the patient 
should be fed from the very outset by nutritive enemata, and anodynes 
should be given subcutaneously. Should the patient recover from the 
immediate effects of the injury, prompt and persevering measures must 
be adopted to prevent the obliteration of the canal by cicatricial con 
traction. 
, As cases of corrosive poisoning are so common, and nearly every 
pathological museum in London contains specimens of the accident, I 
do not think it necessary to append any examples. CHRONIC OESOPHAGITIS. 
59 
It may not be out of place to mention that traumatic oesophagitis 
occasionally arises from the stings of insects accidentally swallowed. 
In these cases the inflammation develops suddenly; there is extreme 
odynphagia, as well as a burning pain at the seat of the sting. The 
patient is generally very prostrate and alarmed. If able to swallow at 
all he should be induced to take a weak alkaline solution, which gener- 
ally gives immediate relief. Should the pain be severe, morphia must 
be administered hypodermically. In a case related by Ranse* the sting 
was quickly followed by a swelling in the neck corresponding to the 
supposed site of the sting in the gullet, just below the thyroid gland on 
the right side, and by an urticaria-like eruption which affected the body 
generally, but was most marked on the side of the neck near the same 
point. The following case occurred in my own practice: 
In August, 1877, a gentleman, aged fifty-four, whilst drinking some beer, suddenly 
felt a very sharp pain in the gullet at a point corresponding to the episternal notch. 
This was followed by repeated severe paroxysms of coughing, and at length by vomit- 
ing. It was not till the contents of the stomach were brought up and a wasp seen that 
the nature of the injury was guessed. I saw the patient about three hours after he was 
stung, and he was then very anxious and rather faint, and complained of something 
lodging in the throat just above the level of the sternum. The pharynx and orifice of 
the larynx were seen to be free from congestion. I endeavored to administer a weak 
solution of ammonia, but the patient could not swallow it. I then gave morphia hypo- 
dermically. In the evening the patient felt pretty well, but still could not swallow. 
The next day he could take liquids but not solids, and deglutition was not fully re- 
established till nine days after the sting. 
CHRONIC (ESOPHAGITIS. 
Latin Eq.—(Esophagitis chronica. 
French Eq.—CEsophagite chronique. 
German Eq.—Chronische Entziindung der Speiserdhre. 
Italian Eq.—Esofagite cronica. 
Definition.—Chronic inflammation of the lining membrane of the 
oesophagus, giving rise to dysphagia and occasionally leading to ulcera- 
tion. 
Etiology.—The observations with regard to the comparative rarity 
of acute inflammation of the oesophagus (see page 42), apply also to 
* Gaz. Mbd. de Paris, September, 1875. 60 
DISEASES OF THE THROAT AND NOSE. 
the chronic form of the disease. Many cases of chronic oesophagitis 
are probably often regarded as examples of gastric irritation, and treated 
as dyspepsia, which, as will be hereafter shown, occasionally causes, and 
frequently follows, slight oesophageal inflammation. It is extremely 
probable, and the point has been insisted on by several writers, that the 
long-continued abuse of ardent spirits is a frequent source of chronic 
oesophageal inflammation. Daily experience proves that excessive in- 
dulgence in the stronger forms of alcohol irritates and inflames both 
the pharynx and the stomach; and though the oesophagus possesses 
greater powers of resistance than either of these parts, it is not likely 
that it enjoys absolute immunity. The complaint has been attributed 
to chewing tobacco, but there is no positive evidence on the subject. 
Habitual vomiting may sometimes produce the affection, and accord- 
ing to Cornil and Ranvier,* it is occasionally brought about by pyrosis. 
The disease probably sometimes commences in a slight accidental injury 
such as may be caused by swallowing a hard or pointed substance, or 
it may arise from taking food either too hot, or of too pungent a char- 
acter. 
It is generally asserted that the disease often follows the acute form 
of inflammation of the oesophagus, and from the analogy of most dis- 
orders of inflammatory nature such a sequence might reasonably be 
looked for. There is not, however, a single case on record which sup- 
ports this view, and my own experience, which, though very limited as 
regards this complaint, is large in relation to the number of published 
cases, is altogether opposed to the theory that the chronic affection often 
originates in an acute attack. I have met with one instance in which 
the disease followed an attack of pleurisy, the pleural inflammation 
being very localized and affecting the base of the left lung near the 
posterior mediastinum. In this case, as the pleura got well the oesoph- 
agus became affected, a slight degree of inflammation being set up 
which lasted for nearly three months. Though acute oesophagitis is 
comparatively common in infants, the chronic form of the disease ap- 
pears to be confined to adults. I have never met with it under twenty- 
five years of age, and most of my patients have been over forty. 
As a secondary phenomenon the condition is occasionally seen in 
phthisis, and when syphilitic ulceration of the gullet occurs, there is 
no doubt always some associated inflammatory action. In stricture of 
the oesophagus likewise, whether arising from cancer, syphilis, or injury, 
chronic inflammation is always present. This is brought about by 
* Majiuel d’Histologie Pathologique, Paris, 1869, p. 769. CHRONIC (ESOPHAGITIS. 
61 
the irritation of food (often undergoing fermentative changes), which 
lodges above the stricture, and sometimes probably by the passage of 
bougies. 
Symptoms.—The symptoms of the affection are obscure when the 
disease is slight, and it is only in rather severe and protracted cases 
that it can be distinctly recognized. The most marked symptom is dis- 
comfort or even pain in swallowing. Solids sometimes cannot be taken 
at all, whilst liquids cause considerable inconvenience. The act of 
swallowing is always performed very slowly. In most of the cases 
that have come under my notice the inflammation appeared to be at the 
upper part of the gullet, but I have met with one in which it was in 
the lower third. There is generally a good deal of expectoration of 
viscid mucus, but sometimes the sputa are frothy and closely resemble 
ordinary saliva. There is never such an abundant flow as is met with 
in acute oesophagitis. 
Pyrosis and hiccough are described by most writers as being present, 
but I have not observed them in any of the uncomplicated cases which 
have come under my notice. Occasionally chronic oesophagitis follows 
chronic gastric catarrh, and the two diseases may coexist for a long 
time. Again, as the existence of chronic oesophagitis compels patients 
to subsist for a long time almost entirely on liquids, dyspepsia not in- 
frequently follows. Whether the irritation of the stomach be primary 
or secondary, when once it is established, pyrosis is nearly sure to en- 
sue, and in my opinion must be looked upon as a gastric symptom. 
In these cases, in addition to the purely oesophageal troubles, gastric 
pain, flatulent distension of the abdomen and costiveness are present, 
whilst headache and depression of spirits are also complained of. 
On auscultating the oesophagus, the descent of the alimentary bolus 
can generally be perceived to be delayed, whilst, if the surface of the 
mucous membrane be roughened, a loud harsh noise may be heard ac- 
companying each act of deglutition. When there is much obstruction, 
air-bubbles, and sometimes perhaps the “ morsel” itself, can be heard to 
ascend. Exploration with the bougie should on no account be attempted, 
as this is likely to aggravate the mischief. 
The disease undergoes a good deal of variation, getting better and 
worse without any assignable cause; but a marked tendency to recur- 
rence after any degree of improvement is one of its most characteristic 
features. 
Pathology.—The morbid changes that take place have not hitherto 
been investigated, for the disease of itself, though causing much incon- 62 
DISEASES OF THE THROAT AND NOSE. 
venience, never terminates fatally. It is only in cases of cancerous 
obstruction and stricture that the pathological changes of chronic in- 
flammation of the oesophagus can be studied. In these cases, at a con- 
siderable distance from the morbid growth, the vessels are seen to be 
enlarged and tortuous, whilst the mucous membrane is irregularly thick- 
ened, and often presents numerous ulcers, which vary greatly both in 
size and depth. They are very frequently of a narrow oval form, and 
as the oesophageal glandulse are arranged in short longitudinal rows, 
it is probable that many of these ulcers are of follicular origin. There 
is often considerable proliferation of the areolar tissue beneath and 
around the ulcerated surface. 
Diagnosis.—The disease with which this complaint is most likely to 
be confounded is spasm of the oesophagus, in which affection there is, 
probably, always considerable hyperaemia of the mucous membrane. 
In chronic inflammation, however, the difficulty of swallowing is con- 
stant, whilst in spasm it varies to some extent from day to day, and even 
from meal to meal. The most important point of distinction between 
these two affections is that, whilst in spasm solids or semi-solids can 
often be swallowed with comparative ease, in simple chronic inflamma- 
tion liquids pass down much more readily. 
Chronic oesophagitis may be confounded with laryngeal disease in 
which implication of the epiglottis or arytenoid cartilages has given 
rise to dysphagia. In these cases the laryngoscope furnishes a means of 
diagnosis, but it must always be remembered that the two affections 
may coexist, the oesophageal malady being generally secondary. 
The symptoms of incipient cancer are very like those of inflamma- 
tion, but the former affection is mostly a disease incidental to the de- 
cline of life; in persons of middle age the progress of the case can 
alone enable the surgeon to distinguish between the two conditions. 
Prognosis.—There does not appear to be any danger to life from this 
disease, but it is extremely apt to recur, and any attack may be of long 
duration. 
Treatment.—The most important feature in treatment is the avoid- 
ance of anything that can irritate the mucous membrane. The diet 
must be confined to soft or liquid food. A bismuth pastil (Throat 
Hosp. Phar.), taken every half hour or hour, often seems to soothe the 
mucous membrane; and, when the disease is beginning to pass away, 
lozenges of rhatany, kino, or tannin, are now and then of use. Swal- 
lowing small particles of ice sometimes gives relief, but occasionally 
warm mucilaginous drinks are more soothing. There are cases, how- CHRONIC (ESOPHAGITIS. 
63 
ever, in which all remedies appear to act prejudicially, the most im- 
portant indication seeming to be the maintenance of the oesophagus as 
far as possible in a state of rest. If anodynes are required, they should, 
as a rule, be administered hypodermically. In some cases I have found 
counter-irritation, by means of mustard poultices, blisters, or croton oil, 
of considerable use. Hot foot-baths, as recommended in acute oeso- 
phagitis, sometimes act beneficially. 
CASES ILLUSTRATING CHRONIC (ESOPHAGITIS. 
Case 1.—C. S., a butcher, aged forty-seven, applied at the Throat Hospital on Janu- 
ary 14th, 1874, complaining of difficulty of swallowing, and pain over the episternal 
notch. He stated that up to that time he had enjoyed good health, although he had 
been accustomed to drink rather freely. He had latterly noticed a slightly increased 
flow of saliva. The laryngoscope showed the upper part of the throat to he healthy ; 
on auscultation, great slowness in the act of deglutition was perceived, hut there was 
no special roughness nor apparent obstruction at any one spot. A bougie could not 
be passed beyond the upper third of the oesophagus. The patient complained very 
much of the use of the instrument, and spat up about a teaspoonful of blood imme- 
diately after it was withdrawn. The next day difficulty in swallowing had slightly in- 
creased. He was put upon iodide of potassium, and no food hut milk and beef-tea was 
allowed. A week later he had slightly improved, hut alleged that the iodide of potas- 
sium caused such a constant disagreeable taste in his mouth that he was unable to take 
food. The medicine was accordingly discontinued. In a few days the patient ap- 
peared a little better, the pain in the neck being less, and he stated that he had eaten 
some bread and milk. The probable inflammatory nature of the disease was now first 
recognized, and the patient was persuaded to become a “ teetotaller.” He was given 
bismuth mixture, and ordered to discontinue crying out the price of food, inviting cus- 
tomers, etc., after the manner of butchers in the poorer quarters of London. At the 
end of March the man was quite cured, and was able to eat and drink anything with- 
out difficulty. In February, 1876, this patient had a second attack, which, however, 
was of milder character, and entirely passed off in three weeks. 
Case 2.—Mr. T. S., a farmer, aged twenty-nine, consulted me on November 11th, 
1876, on account of difficulty of swallowing. He stated that until recently he had been 
a strong, healthy man, and had always been temperate. In addition to the dysphagia 
there was slight odynphagia, besides an increased flow of saliva and pain between the 
shoulders. The affection had come on gradually about three months previously ; the 
patient had neither pyrosis, sickness, nor any other symptom of indigestion. Exami- 
nation with the laryngoscope showed the larynx and pharynx to be healthy. On aus- 
cultation of the gullet, slowness in swallowing and decided obstruction opposite the 
fifth dorsal vertebra were plainly perceived. An attempt to pass a bougie failed, the 
point of arrest appearing to be at the orifice of the oesophagus, much higher than aus- 
cultation had indicated. [The difficulty was probably caused by spasm, but the patient 
refused to permit an examination under an anaesthetic.] On November 12th, the day 
following the attempt to pass the bougie, the patient was unable to swallow at all, and 
he became very much alarmed. A hypodermic injection of morphia was given at 8 
p.m., and after a good night he was able to swallow nearly as well as on the 11th. In 
the course of a few weeks he quite recovered. 64 
DISEASES OF THE THROAT AND NOSE. 
VARICOSE VEINS OF THE GULLET. 
Latin Eq.—Varices oesophagi. 
French Eq.—Varices oesophagiennes. 
German Eq.—Varicositaten der Speiserohre. 
Italian Eq.—Vene varicose del esofago. 
Definition.—Enlarged veins at the lower part and occasionally at 
the middle third of the oesophagus, generally resulting from some obstruc- 
tion of the portal circulation, occasionally rupturing and giving rise to 
haematemesis. 
History.—Haemorrhage from the gullet was recognized by Galen,* but after his time 
there is no allusion to the subject till the early years of the present century, when a 
varicose condition of the oesophageal veins was mentioned by Portalf as sometimes 
giving rise to haemoptysis. It was not till 1820, however, that Peter Frank J pointed 
out the connection existing between gastric haemorrhage and obstruction of the portal 
circulation, and thus paved the way for the elucidation of oesophageal bleeding. In 
1840 Rokitansky $ published an instance of fatal haemorrhage from enlarged oesopha- 
geal veins. In 1853, Gubler,|| in comparing the loss of blood from enlarged haemor- 
rhoidal vessels with some forms of haematemesis, called attention to the analogy in the 
distribution of the veins at each end of the digestive tract, and described the peculiar 
arrangement of the veins at the lower part of the gullet. In 1858 Fauvel’slf case 
(which had been observed in 1837 and referred to by Gubler in the work just cited) 
was published together with one by Lediberder. In the following year Bristowe** 
related a case, and in 1874 an example was published by Ebstein.ft Since then Audi- 
bertJJ and I)usaussay£§ have treated the subject in short monographs, and Duret|||| has 
given a clear account of the anatomical conditions leading to the development of the 
affection. has devoted to it a few pages of his valuable article on the oeso- 
phagus, and quite recently Eberth*** and Hadden fff have described instances of the 
complaint. 
* De locis affectis, lib. v., cap. iv. 
f Cours d’Anat. M6d., Paris, an xii. (1803), t. iv., p. 539. 
J Traite de Med. Prat., t. iii., p. 245. 
§ Med. Jalirb. d. CEsterr. Staates, 1840, Bd. xxi., p. 230. 
|| De la Cirrhose, Paris, 1853, p. 62. 
Kecueil des Travaux de la Soc. M6d. d’Observ., 1858, fasc. iii., p. 257, 
** Trans. Path. Soc., London, 1859. 
ff Schmidt’s Jalirb., 1874, clxiv., p. 160. 
IX Des Varices CEsophagiennes, These de Paris, 1874. 
Etude sur les Varices de l’CEsophage, Th&se de Paris, 1877. 
1111 Progres Medical, t. v., 1877, p. 306. 
Ziemssen’s Cyclopaedia, vol. viii., p. 130, et seq. 
*** Deutsches Archiv. fiir Klin. Med., 1880, vol. xxvii., p. 566. 
Iff Trans. Path. Soc., London, 1882, vol. xxxiii., p. 190. VARICOSE VEINS OF THE GULLET. 
65 
Etiology.—-According to Galen,* haemorrhage may take place from 
the oesophagus, “ ob solam sanguinis plenitudinem,” but this theory is 
not likely to meet with acceptance in the present day. Cirrhosis of the 
liver has generally been considered to be the cause of this affection, but 
any hepatic disease which obstructs the portal circulation is apt to pro- 
duce it, and it would appear from Zenker’sf statistics that the affection 
occurs with relatively greater frequency in senile atrophy than in cir- 
rhosis. Thus, in 178 cases in which there was advanced chronic 
(especially senile) atrophy of the liver, oesophageal varices were found 
forty-three times, or in 24 per cent., whilst the varicose condition was 
present only once, i. e., 5J per cent, in 18 cases of cirrhosis. In Bris- 
towe’s case there was considerable enlargement of the spleen, but the 
liver was normal. The condition of the portal vein, however, is not 
described. It must not be forgotten, as Zenker very properly points 
out, that senile atrophy of the liver is a disease of old age, a period of 
life at which varices are most apt to occur, and hence that the dilated 
state of the oesophageal veins must not be regarded as necessarily due 
to hepatic obstruction. Zenker unfortunately does not mention to what 
extent varices were present in other parts of the body in his 178 cases. 
Klebs| has met with instances in which the affection was due to syphi- 
litic disease of the liver, and Konig§ states that he has also seen a case 
in which “ fatal haemorrhage took place from a varix in the neighbor- 
hood of the cardia in a patient suffering from syphilitic hepatitis.” As 
Gubler and Monneret|| have indicated, there is a tendency to loss of 
blood from various parts when the liver is diseased. Indeed, even as 
far back as the time of Hippocrates epistaxis in adults has been consid- 
ered to be a frequent concomitant of chronic hepatic disease. This 
no doubt depends on some morbid alteration in the condition of the 
blood. In the gullet, however, the peculiar relation of the veins 
at its lower part to the general circulation on the one hand, and to 
the portal system on the other, favors the development of the affec- 
tion. For, as Gubler remarks, there is towards the cardiac orifice of 
the stomach a neutral territory, in which two sets of veins meet each- 
other—one set being radicles of the vena azygos, and thus communi- 
cating with the general circulation, whilst the others end in the portal 
vein through the coronary branch of the stomach. This arrangement 
* De locis affectis, lib. v., cap. iv., sub. fin. f Op. cit., vol. viii., p. 132. 
t Handb. der pathol. Anat., 1868, Bd. i., p. 162. 
\ Deutsche Chirurgie v. Billroth u. Luecke.—Krankheiten des Pharynx und (Eso- 
phagus, p. 30. 
|| Gubler: Op. cit. p. 69. 66 
DISEASES OF THE THROAT AND NOSE. 
probably tends to cause obstruction to the circulation where the two 
currents meet; and Gubler* points out that at the lower part of the 
rectum, where there is an analogous communication between the sys- 
temic and portal veins, haemorrhoids are very common as the result of 
obstruction. 
An additional factor in the causation of these varices is, according to 
Duret,f the relative large capacity of the oesophageal plexuses as com- 
pared with the size of the thoracic veins with which they communicate. 
Hence, if anything prevents the former from emptying themselves into 
the coronary veins of the stomach, the blood is necessarily driven back, 
and the outflow into the bronchial, azygos, and phrenic vessels not 
being sufficiently free, retardation of the current is produced, the 
oesophageal plexuses become distended, and, if the cause continues, 
varix results. Paul BertJ has shown that each act of inspiration tends 
to increase the quantity of blood in the thoracic veins; it can, therefore, 
easily be understood that when, owing to the conditions which have 
just been described, these vessels are already over full, bodily effort or 
any other influence causing increased frequency of breathing favors the 
production of varix, or even rupture. 
It is possible, also, that, owing to the vertical position of the gullet, 
gravitation may play some part in the production of varicose veins, in 
the same way as it does in the legs. 
Symptoms.—Occasional hsematemesis occurring in elderly people in 
whom there is reason to suspect disease of the liver, kidney, or spleen, 
is suggestive of the existence of varicose veins of the gullet. It is sel- 
dom, however, that the disease can be recognized with certainty during 
life except by the aid of the oesophagoscope, and even with this instru- 
ment it is often impossible to detect the enlarged veins, which may be 
altogether at the lower part of the gullet. In one of the two cases I 
have met with, however, I succeeded in seeing the dilated veins during 
life. In both cases the patients complained of an uneasy sensation in 
the throat, and in one of them constant hiccough was a marked feature; 
but as the patient was a confirmed drunkard, this symptom has no 
special significance as regards the complaint now under consideration. 
In some of the recorded instances pain has been complained of in the . 
region of the stomach. The evacuations are sometimes distinctly bloody, 
but more often tarry in appearance. More rarely the stools are of nat- 
ural appearance. 
* Op. cit., p. 62. 
J Quoted by Duret: Loc. cit. 
f Progres Mfedical, 1877, t. v., p. 306. VARICOSE VEINS OF THE GULLET. 
67 
Diagnosis.—It is extremely difficult to determine with certainty dur- 
ing life that the disease exists, except in the rare cases in which the 
desired information can be got by cesophagoscopy. Even in these cases 
it is not unlikely that the veins of the stomach may also be affected in 
a similar manner, and that the source of the bleeding may be there. 
Haemorrhage caused by the rupture of varicose veins has likewise to 
be distinguished from that arising from other local conditions. Although 
none of these has any absolutely characteristic feature by which it can 
be identified, some special points may be indicated by which the cause 
of the bleeding may sometimes be recognized. Thus the li£emorrhage 
from perforation by an aneurism is excessively profuse, whilst in bleed- 
ing due to the pressure of a solid tumor or to ulceration, whether malig- 
nant or specific, there is a history of pre-existent severe dysphagia. In 
the case of foreign bodies, the occurrence of the accident is usually 
known. 
Pathology.—The general pathology of the disease has .already been 
described in dealing with the etiology, and it only remains to make 
some remarks on the local condition. It is probable that the cesopha- 
geal veins are more frequently dilated than is generally supposed, for 
out of eighteen gullets taken altogether at random, in seven I found 
more or less dilatation of the submucous veins, whilst there was distinct, 
although slight, varix in two cases. In four instances the enlargement 
was above the middle of the tube, in three it was at the lower end, and 
in one both the upper and lower portions of the gullet were affected, 
the intervening surface, to the extent of four inches, being normal in 
appearance. In all the cases the enlargement was most conspicuous on 
the front wall of the gullet, and varied in degree from well-marked 
arborescence of engorged venules to black, bead-like prominences, con- 
nected with vessels of about the size of the angular vein of the face. 
Although they were not examined microscopically, it seems certain that 
these neevoid points were true vascular expansions and not ecchymotic 
patches, for they could neither be washed nor scraped off. It may be 
remarked that the mucous membrane itself was perfectly free from red- 
ness, although until it was stripped off it appeared colored by the en- 
larged underlying vessels. It may be added that, so far as was known, 
none of the subjects from whom the specimens were taken had shown 
any sign of oesophageal trouble during life. 
In Eberth’s* case there was chronic catarrh of the intestinal mucous 
membrane, and he thought that this condition had led to general phle- 
* Loc. cit. 68 
DISEASES OF THE THROAT AND NOSE. 
bectasis of the chylopoietic viscera. Not only was the rectum the seat 
of large haemorrhoids, but the vessels of the liver were in many parts 
much dilated, and at one spot formed a true erectile tumor. The coats 
of the collapsed oesophageal vein, from which the bleeding had taken 
place, were extremely attenuated, and the vessel itself was so superfi- 
cial in situation, that to the naked eye it appeared to be lying quite bare 
of any mucous covering. 
Treatment.—There is but little to be done in the way of cure, though 
the haemorrhage can generally be arrested by making the patient swallow 
a strong styptic. Among remedies of this kind the mixture of tannic 
and gallic acids contained in the Throat Hospital Pharmacopoeia, under 
the name of Gargarisma Acidi Tannici fort., is probably the most effec- 
tual. Treatment is of little avail as regards the varicose condition of 
the vessels, and it is seldom that the hepatic disease upon which it 
depends can be relieved. 
CASES ILLUSTRATING VARICOSE VEINS OF THE GULLET. 
Case 1.—Mr. H. B., aged fifty-nine, consulted me in January, 1875, on account of a 
constant uneasy sensation in the throat, and occasional attacks of spitting of blood. 
The patient was an exceedingly stout man, of dull-gray complexion, and of a gener- 
ally unhealthy appearance. Though seldom drinking to intoxication he had freely 
partaken of spirits for the last forty years. He stated that he had been quite well till 
two years before, when he had had slight jaundice. Since then he had attacks at in- 
tervals, but they had generally not lasted more than a few days. Since the commence- 
ment of his illness he had occasionally had rather severe feverish colds, accompanied 
by pain over the liver. Six months after he first became ill he had severe bleeding 
from the nose, which broke out at intervals during a week, and was at last arrested 
only with the greatest difficulty. On physical examination, owing to the extreme 
obesity of the patient, it was very difficult to make out the limits of the liver. The 
heart-sounds seemed very feeble, but no murmur or other evidence of disease could be 
detected. Examination of the throat showed that the pharynx was much relaxed, the 
uvula elongated, and the mucous membrane of the larynx slightly congested. On 
February 7th I was summoned to see Mr. B. on account of what was called “spitting 
of blood,” but on arriving I found that the haemorrhage occurred in a gush with slight 
retching, and was clearly of the nature of haematemesis. There had been three gushes 
of blood, amounting in the aggregate to eleven and a half ounces. I directed the 
patient to swallow a small quantity of the Garg. Acid. Tannic, fort, of the Throat 
Hospital Pharmacopoeia, and no more haemorrhage occurred on that occasion. The 
patient, however, was greatly weakened by the loss of blood, and a few days later had 
a severe attack of diarrhoea. Two subsequent bleedings from the throat took place in 
March and April, and at the beginning of May the patient was attacked with bron- 
chitis and died in a few days. The following are the notes of the autopsy which was 
made by Mr. Poyntz Wright thirty-six hours after death. Rigor mortis not percepti- 
ble; subcutaneous tissue loaded with fat; lungs very oedematous in the lower third, 
especially at posterior part; mucous membrane of bronchial tubes bright red and cov- 
ered with frothy mucus; left lobe of liver much reduced in size, right lobe slightly PERI-OESOPHAGEAL ABSCESS. 
69 
smaller than normal; surface hob-nailed ; substance hard and dry on section. Numer- 
ous ecchymotic spots were seen beneath the lining membrane of the stomach, one 
being as large as a penny, but most of them much smaller. On opening the oesophagus 
the veins at its lower part were seen to be enormously enlarged. Six large veins with 
free anastomoses ascended for about two inches, whilst two of these reached consider- 
ably above the middle third of the tube. Three small hard whitish vertical cicatrices 
were seen three-quarters of an inch above the cardia, and one larger and redder cica- 
trix three inches from that point. 
Case 2.—Mr. M., a hotel keeper, aged fifty-one, was sent to me in October, 1880, by 
Dr. Robert Cross, of Craven Street. The patient, who had been a free liver, com- 
plained of a disagreeable sensation in the throat, with a constant feeling of sickness 
and frequent hiccough. Examination of the throat showed great relaxation of the 
mucous membrane of the pharynx and larynx, and elongation of the uvula. A portion 
of it was subsequently removed, with considerable relief to the symptoms. After about 
two months, however, the patient began to experience slight difficulty in swallowing. 
On examination with the cesophagoscope a dark round tumor, about the size of a pea, 
with a streak passing into it both above and below, was seen, rather below the 
middle third of the oesophagus, and I had little doubt but that this object was an en- 
larged vein. As the examination was exceedingly disagreeable, the patient would not 
submit to a second exploration. Nevertheless, I felt justified in writing to Dr. Cross, 
expressing my opinion that the patient had varicose veins of the gullet, and that 
haemorrhage was likely to occur. Up to this time it must be observed there had not 
been the slightest sign of haemorrhage. A month later my prediction was verified, for 
a sudden attack of haematemesis came on. This was repeated on several occasions, but 
though a large quantity of blood was brought up, the stools had only once a tarry 
character. This fact makes it almost certain that the bleeding came from the gullet 
and not from the stomach. In August, 1881, after a severe outburst of haemorrhage, a 
fatal attack of delirium tremens supervened. No post-mortem examination was allowed. 
PERI-GESOPHAGEAL ABSCESS.* 
>YNONYMS: POST-CESOPHAGEAL ABSCESS. ReTRO-CESOPHAGEAL 
Abscess.) 
Latin Eq.—Abscessus peri-cesophageus. 
French Eq.—Abces pdri-cesophagien. 
German Eq.—Pericesophagealabscess. 
Italian Eq.—Ascesso peri-esofageo. 
Definition.—An inflammatory swelling containing pus, generally orig- 
inating in the lymphatic glands adjoining the oesophagus, but sometimes 
* Although the term “ post-pharyngeal abscess ” is an appropriate one, as abscesses 
frequently form behind the back wall of the pharynx, the expression “post-oesophageal 
abscess" is less accurate, inasmuch as purulent collections in proximity to the oesoph- 
agus are quite as often at the side of the tube, or even in front of it, as behind it. It 70 
DISEASES OF THE THROAT AND NOSE. 
commencing in the areolar tissue, and more rarely induced by caries of 
the vertebrae. In adults the abscess occasionally penetrates the muscular 
coat, and gives rise to diffuse suppurative inflammation of the submucous 
areolar tissue, and, as a still rarer sequel, a cicatricial diverticulum of the 
oesophagus may result. 
History.—It has been already pointed out that it is useless to attempt to separate into 
two classes abscesses which are formed in the neighborhood of the pharynx, and those 
developed in immediate proximity to the gullet. The older writers made no such 
distinction, and accordingly in an historical retrospect it will be convenient to treat 
the whole subject together. The first notice of abscess in the pharyngo-oesophageal 
region dates as far back as in the second century of the Christian era, when Galen* 
related a case which had occurred in his own experience, and which terminated in 
spontaneous rupture. From his manner of alluding to the case it would appear that 
he had seen several examples of the same kind, most of which had ended fatally. No 
mention of the complaint was made by any other writer, so far as I am aware, till the 
middle of the eighteenth century, when we meet with Morgagni’sf careful description 
of a case in which an abscess pressing on the oesophagus and trachea caused the 
patient’s death by opening into the latter tube. In 1785 BleulandJ mentioned that 
his master, Van Doeveren, had seen a fatal instance of the disease at Groningen. In 
1819 reported three cases of retro-pharyngeal abscess which he had met 
with in young children, and he seems to have been the first physician who recognized 
the idiopathic character of the affection. He was under the impression that the dis- 
ease had never before been described, and he mistook his first case for croup. Sir 
Astley Cooper|| refers to two examples which he had seen in adults, the dissection of 
the first leading him to the diagnosis and successful treatment of the second. In 1839 
Petruntif published a case which he cured by making an incision into the oesophagus. 
In 1840 Fleming** described the affection with considerable detail as it occurs in the 
upper part of the neck, reporting three cases which had come under his own notice, 
and giving a drawing of an instrument devised by himself for the safe opening of such' 
abscesses. In 1841 Ballotff described a case of abscess in close relation to the gullet. 
MondiereJI followed in 1842 with a collection of cases gathered from many sources, and 
is true that for practical purposes there is no difference between an abscess behind the 
lower part of the pharynx and one behind the upper part of the oesophagus ; but there is a 
very wide difference between an abscess on a level with the hyoid bone, and another 
occurring some inches below the level of the cricoid cartilage. In point of fact, the 
pharynx is so broad, and extends laterally so far into the neck, that an abscess situ- 
ated at one side of it practically becomes a cervical abscess, and is generally very prop- 
erly treated as such. 
* De locis affect, lib. v., cap. iv. 
f De sedibus et causis morb., tom. ii., lib. xv., art. xv. 
X Observ. anat. med. de sana et morbosa oesophagi struct., Lugd. Batav., 1785. 
? Edin. Med. and Surg. Journal, vol. xv., p. 259 et seq. 
|| Princ. and Pract. of Surgery. Ed. by A. Lee 1836, vol. i., p. 79. 
T[ Gazette Mddicale, 2e s6rie, t. vii., p. 122. 
** Dublin Journ. of Med. Science, vol. xvii., p. 41 et seq. 
ff Arch. Gen. de Mfed., 3e sferie, t. xii., p. 257 et seq. 
L’Experience, January and February, 1842. FERI-CESOPHAGEAL ABSCESS. 
71 
a year later Duparcque* made some interesting observations on the subject. More 
recently Caulet,f Gillette,! and Gautier,\ have contributed to the literature of the 
disease. 
Etiology.—Peri-oesophageal abscess, regarded as a distinct disease, 
probably nearly always commences in the glands in the neighborhood 
of the gullet, though, in some instances, it may possibly originate in 
the areolar tissue. In some rare cases it appears to have its starting- 
point in a distinct tubercular deposit.|| As an occasional feature ac- 
companying caries of the vertebrae, it is also sometimes met with, but 
this form of abscess need only be referred to in connection with diag- 
nosis, its treatment coming within the province of the orthopaedist or 
general surgeon. The glandular inflammation may be either primary 
or secondary—that is to say, it may occur in a child previously appa- 
rently healthy, or it may be developed in the course of an eruptive 
fever. The special predisposition to glandular inflammation in young 
subjects is too well known to require comment. It has been suggested 
that the irritation of the glands in these cases takes its rise from diffi- 
cult dentition,and I have no doubt that it is sometimes also connected 
with post-nasal disease, e. g., chronic catarrh, or adenoid vegetations. 
According to Barthez and Rilliet,** abscesses in connection with the 
upper part of the food-tract are most frequently met with in the four 
earliest years of life, especially in the first. The cause of the disease is, 
however, often obscure, and in one of Petrunti’sff cases the origin was 
attributed to “ catching cold.” Though the affection is often met with 
in infants, early life as compared with adult age does not exhibit that 
preponderating frequency which is seen in the case of the similar ab- 
scesses involving the pharynx. Occasionally the malady is distinctly 
pysemic in character. Thus there is a case in Guy’s Hospital Museum 
in which purulent inflammation following amputation of the arm ex- 
tended through the axilla to the root of the neck, and gave rise to a 
peri-oesophageal abscess which ultimately involved all the tissues of the 
gullet. A case described by ZiesnerJJ appears to have had a similar 
* Gaz. des H6pitaux, 1843, p. 105. 
f De la Pdri-oesophagite, Paris, 1864. 
J Des Abces pharyngiens, Paris, 1867. 
§ Des Abces r4tro-pharyngiens, Geneve et Bale, 1869. 
|| : Anat. Pathol., Paris, 1879, p. 89. 
f Fleming : Loc. cit., p. 41. 
** Maladies des Enfants, Paris, 1853, 2d ed., t. i., p. 243. ft Loc. cit. 
Earns oesophagi morbus. See Disputat Hallerii, Lausannae, 1760, 'vol. vii., p. 
629. 72 
DISEASES OF THE THROAT AND NOSE. 
origin. The patient had suffered from puerperal fever and from ab- 
scesses in the ovary and kidney; a collection of pus was formed between 
the vertebral column and the gullet, finally bursting into the latter. 
Symptoms.—These depend on the size, seat, and stage of development 
of the abscess. Its size varies, as a rule, from a hazel-nut to a hen’s 
egg, but in some cases the sac attains enormous dimensions. The space 
corresponding to the interval between the fourth and seventh cervical 
vertebrae is a common seat of the affection; but a purulent collection 
may form in connection with any part of the oesophagus. Follin and 
Duplay* state that an abscess at the upper part of the food-tract is 
more often situated laterally than in a central position. Whatever may 
be its original site, however, the abscess, especially if chronic, as it in- 
creases frequently gives rise to a swelling on the side of the neck.f 
Hocken J has reported a case in which a fluctuating tumor of this nature 
reached as high as the mastoid process. Even if the abscess itself is at 
a considerable depth from the surface it may cause extensive oedema of 
the cervical region. In two cases related by Petrunti,§ the thyroid car- 
tilage was pushed forwards; lateral displacement may also occur, 
though this is probably very rare. In the early stage of the complaint 
the local symptoms are vague, there being usually nothing more than a 
feeling of dryness and swelling within the throat, accompanied, per- 
haps, by some slight tenderness in the neck if it be the upper part of 
the food-channel that is affected. Pain in swallowing is generally 
present from the outset; it is at first localized in some particular part 
of the canal, but soon begins to radiate—usually in an upward direc- 
tion—and may be referred to the entire length of the gullet. Any 
movement of the neck is also extremely painful, but even when the 
parts are at rest there is a constant throbbing pain, if the disease is 
acute. As the abscess develops dysphagia begins to be felt, deglutition 
gradually becoming all but impossible, not only from actual obstruction 
to the passage of food, but also from the inability of the patient to make 
the required muscular effort. As a rule, however, a bougie can be 
passed, and in two instances mentioned by Caulet,|| this circumstance 
led to the erroneous inference that there was no compression of the 
oesophageal canal. If the abscess presses on the windpipe there is, of 
* Traits E16m. de Pathol, externe, Paris, 1877, t. v., p. 252. 
f Mondi&re: 1842. 
J Journ. des Connaiss., MM.-Chir., Juillet, 1843. 
$ Gazette M6dicale, 1839, 2e t. vii., p. 122. 
|| De la Peri-oesophagite, Paris, 1864, p. 32. PERI-CESOPHAGEAL, ABSCESS. 
73 
course, some dyspnoea—which is generally more marked during the 
act of swallowing, the food in its passage down the gullet narrowing 
still further the tracheal lumen. The voice is generally altered, and 
occasionally, according to Duparcque,* it has a very peculiar character, 
resembling the “ quack of a duck.” Cough is not a constant symptom, 
and when present is too slight to be troublesome. The head is in most 
cases kept rigidly upright; occasionally, however, when the abscess is 
situated high up, the neck is thrown backwards almost as in opistho- 
tonos, whilst, if the disease is at a lower point, the patient’s chin may 
be draw down towards his sternum. 
The malady usually runs an acute course, and it is probably only 
when it originates in vertebral caries that it has a chronic character. It 
may end in spontaneous rupture of the sac, the contents being dis- 
charged into the gullet, from which they are at once expectorated. If 
the abscess, however, is large, its sudden evacuation in this manner is 
attended with considerable danger, for the matter may find its way into 
the larynx, and cause suffocation: On the other hand, the pus may 
penetrate the muscular coat, and burrow rapidly in the submucous 
tissue, giving rise to true phlegmonous oesophagitis or suppurative 
inflammation of the gullet. This complication, however (see “ Pathol- 
ogy ”), is most uncommon, and when it does occur, there is little change 
in the symptoms. In some cases the- inflammation becomes gangre- 
nous, when death quickly ensues, with the usual typhoid symptoms. 
Gautierf has collected six instances in which this sequel was observed, 
the abscess in all of them being connected with the upper part of the 
food-tract. 
The symptoms differ to some extent in children and in adults. In 
the former the abscess is, in the majority of cases, at the upper part of 
the neck, and, according to Barthez and Rilliet,| one of the earliest 
signs of the disease is a peculiar form of dry coryza, which shows itself 
within the first few days of the invasion. In children, moreover, the 
constitutional disturbance is generally very great; there is a consider- 
able degree of fever at the onset of the malady, and rigors ensue as sup- 
puration becomes established. Brain symptoms, such as convulsions 
and coma, are not unfrequent; they are more likely to occur when the 
abscess, being situated laterally, impedes the circulation through the 
large vessels, or presses on the vagus or spinal accessory nerve. In a 
* Annales d’Obst&rique, t. ii., p. 21. 
f Des AbcSs r&ropharyngiens, GenSve et Bale, 1869. 
1 Op. cit., p. 420. 74 
DISEASES OF THE THROAT AND NOSE. 
case reported by Fleming,* the child, which was comatose when lying 
on its back, recovered consciousness when placed in a sitting posture. 
In adults the onset of the complaint is not, as a rule, so sudden as it 
is in children, nor are the constitutional symptoms so severe. Nausea 
and vomiting may occur, and fever sets in with frequent rigors as the 
disease develops. The patient often exhibits an extraordinary anxiety 
of countenance, even at an early period of the complaint. 
The above description must be understood to refer to simple abscess 
produced by inflammation of the peri-oesophageal areolar tissue, or of 
the lymphatic glands contained in it. Where the disease owes its 
origin to caries of the vertebrae, the development of the abscess is slow 
and unattended with febrile disorder, and it consequently acquires con- 
siderable bulk before attention is drawn to it. In such cases, moreover, 
previous symptoms of spinal mischief are sure to have shown them- 
selves. Even if there be no curvature, tenderness over the affected 
part and diminished mobility of the vertebral column can be detected 
on careful examination. 
Diagnosis.—The disease may be mistaken for croup, such careful 
observers as Abercrombief and CarmichaelJ having fallen into this 
error. The dysphagia and stiffness of the neck which are present in 
peri-oesophageal abscess are, however, essential points of distinction. In 
true croup, moreover, the pharynx generally presents some traces of 
false membrane, whilst shreds can almost always be found in the sputa. 
The continued severity of the symptoms in peri-oesophageal abscess also 
serves to distinguish the disease from croup, which either terminates 
fatally or ends in recovery in a few days. Where the laryngoscope can 
be used it furnishes a ready means of differentiation. 
The disease can scarcely be confused with oesophagitis, in which a 
constant flow of saliva and extreme odynphagia are always present. 
Pericarditis with great effusion may simulate the affection, but physical 
exploration of the prsecordial region will at once reveal the real nature 
of the case. Peri-oesophageal abscess may occasionally present a like- 
ness to hydrophobia, in that liquids cannot be swallowed, but the char- 
acteristic terror is absent, and, moreover, the difficulty is still greater 
as regards solid food. 
Pathology.—When the abscess is formed at the upper part of the 
throat it is almost always situated behind the food-tract. In thirty- 
* Dublin Journ. of Med. Science, 1840, vol. xvii., p. 43. 
f Loc. cit. 
J Trans, of King and Queen’s Coll, of Phys. in Ireland, vol. iii. PERI-(ESOPHAGEAL ABSCESS. 
75 
eight autopsies Gautier* found it in this position in every case. The 
abscess occasionally pierces the muscular coat of the oesophagus, and 
whilst remaining beneath the mucous membrane rapidly sets up suppu- 
rative inflammation of the whole circumference of the pharyngo-oeso- 
phageal canal. The inflammation may be limited to a small section of 
the canal, or may involve its entire length, the extension being favored 
by the arrangement of the lymphatics in a single layer. (See “Anatomy,” 
p. 17.) According to Zenker,f who has greatly elucidated this rare 
affection, the submucosa under these circumstances soon becomes con- 
verted into a cavity filled with pus, amongst which bundles of areolar 
tissue may still be found. In favorable cases the pus bursts through 
the mucous membrane at several points, and produces cribriform ulcers, 
which may ultimately heal, leaving small saccular depressions lined with 
epithelium, as permanent evidences of the disease. Occasionally these 
minute cavities, wherein papillae may sometimes be found, are bridged 
across by little bands, which further reduce their orifices. In less favor- 
able cases the muscularis becomes involved, the pus disorganizes the 
fibrillae, and fatty degeneration of the structure occurs. When the 
abscess is circumscribed, and has emptied itself into the oesophageal 
canal, the sac may gradually contract, and in course of healing may 
draw a small portion of the mucous membrane outwards, giving rise 
to “traction-diverticula” (see “ Dilatations of the Gullet”). In another 
class of cases the abscess approaches the integument at the root of the 
neck, and comes within easy reach of the surgeon’s knife. 
Prognosis.—This is always grave, though many patients recover. 
The least favorable cases are those dependent on vertebral caries. Peri- 
oesophageal abscesses are less fatal than similar abscesses in immediate 
relation to the pharynx. 
Treatment.—According to Barthez and RillietJ neither antiphlogistic 
nor mercurial treatment can arrest the disease, even at its commence- 
ment. When once the case has been diagnosed, the neck should be 
constantly fomented; and if there be any distinct fulness, poultices 
should be applied over the part. It is generally desirable to feed with 
the oesophageal tube, but if the tender age of the patient renders this 
method impossible, recourse must be had to nutritive enemata. A fear 
of establishing an oesophageal fistula or even a diverticulum has some- 
times prevented surgeons from making a prompt incision into the 
abscess; but this danger is comparatively slight, penetration of food into 
* Op. cit., p. 20. 
t Op. cit., p. 243. 
f Ziemssen’s Cyclopaedia, vol. viii., p. 147. 76 
DISEASES OF THE THROAT AND NOSE. 
the tissues being only likely to occur in cases of a decidedly gangrenous 
character. Where practicable the abscess should be opened; but other- 
wise, when there is reason to believe that suppuration has taken place, 
emetics may be given, in the hope that during vomiting the sac may burst. 
Sometimes the surgeon can cut down through the neck, and reach the 
abscess. A remarkable illustration of this procedure has been pub- 
lished by Petrunti,* who made an incision along the anterior border of 
the sterno-mastoid one inch and a half in length, and dissected carefully 
down till the oesophagus was exposed, and the situation of the abscess 
could be clearly made out. On opening the sac, twelve ounces of pus 
escaped, to the immediate relief of the patient. Drainage was kept up 
by means of a strip of lint, and the cure was complete in a month. 
After incision or accidental bursting of the sac, the case must be watched, 
as the opening is very likely to heal up prematurely. When the abscess 
has been opened, or has burst, deglutition greatly assists in emptying 
the sac, by causing pressure on its walls. 
Tracheotomy is sometimes called for, but as might be expected, does 
not always relieve the symptoms. This was shown in a case reported 
by Ballot,f in which, however, the disease was mistaken for oedema of 
the glottis. 
THRUSH OF THE GULLET.! 
(Synonym: Aphtha.§) 
Latin Eq.—Aphthae oesophagi. 
French Eq.—Muguet de l’oesophage. 
German Eq.—Soor der Speiserohre. 
Italian Eq.—Mughetto del esofago. 
Definition.—Inflammation of the oesophagus occurring in infants, 
generally accompanying a similar disease of the buccal mucous membrane, 
* Loc. citi f Loc. cit., p. 258. 
% The fact that aphthse attack the oesophagus more frequently than the pharynx has 
led me to treat the subject in greater detail in this section than in the first volume. 
§ The Greek writers used the word a<p6a (derived from 2nroi, “I set on fire”) for 
ulcerated spots in the mouth. The English word thrush is supposed to be allied to 
thrust, signifying a “ breaking out,” its earliest occurrence, so far as I am aware, being 
in Arbuthnot’s Practical Rules of Diet, London, 1732 (chap, iii., p. 355), where he 
defines thrush as “ small round superficial ulcerations which appear first in the mouth.” THRUSH OF THE GULLET. 
77 
characterized by an exudation, creamy in color and consistence, which 
usually contains large quantities. of the parasitic fungus known as oidium 
albicans. 
History.—In dealing with the history of this disorder, it may be remarked that the 
buccal affection has been recognized from the earliest periods, whilst the oesophageal 
form has only been described in modern times. Hippocrates* mentions the fact of 
newly-born children being liable to aphthae. Celsusf also treats of the subject in some 
detail, but from his expressions I am inclined to believe that he is speaking of some 
more serious disease than thrush. Indeed, all the earlier writers seem to have included 
under the general name of aphthae every form of ulceration affecting the mouth. An 
approach to a more correct knowledge of thrush was made by Boerhaave,]; who de- 
scribed it as a papular or vesicular eruption on the mucous membrane of the mouth. 
Particular attention was attracted to the affection by a very severe epidemic which oc- 
curred at the Children’s Hospital in Paris, in 1766, and some years later a prize of 
1200 livres, offered by the Acad6mie de Medecine for the discovery of the cause of the 
disease, was divided among four competitors, who all agreed in regarding “muguet” 
as consisting essentially in a creamy exudation from the inflamed mucous membrane. 
In 1785 Bleuland| related a most remarkable case, in which the oesophagus of 
an old woman who died from inanition was found filled with “ aphthae albse,” a condi- 
tion which, in his opinion, gave rise to the fatal aphagia. Baillie|| gives some draw- 
ings of the disease, in one of which the vegetation is seen to occupy the entire length 
of the gullet. After the publication of Bretonneau’s researches of diphtheria in 1821, 
At present, English writers apply the word thrush to any aphthous affection occurring 
in the mouths of infants; in the words of our great medical classic, “ Children in arms 
who exhibit aphthse are said to have the thrush.” (Sir T. Watson: Lectures on the 
Principles and Practice of Physic, 1857, 4th ed., vol. i., p. 119.) The French, on the 
other hand, make a great distinction between aphthe and muguet, the latter being a name 
derived from the resemblance of the vegetation to the white blossom of the May-flower. 
Thus the term muguet is strictly limited to the parasitic affection in which the o'idium 
albicans is found,'whilst aphthe is employed to describe a non-parasitic pseudo-mem- 
branous exudation. [The above was in type before the French translation of the first 
volume of this work appeared. My distinguished friends, Drs. Moure and Bertier, 
have added a long note in order to “ establish a line of demarcation between aphtha and 
muguetf confounded together by the author” (myself). Whilst there is much to be 
said in favor of the French view, the presence or absence of the minute fungus has not 
hitherto been accepted by English writers as a sufficient ground of distinction. The 
difficulty of the subject is not diminished by the admission of Drs. Moure and Bertier 
that muguet rather frequently complicates aphthe (see also Diet. Encyclop. des Sciences 
Medicales, t. v., p. 668)]. The German writers (see Niemeyer: Lehrbuch d. Speciellen 
Pathologie und Therapie, 7th Auflage, Berlin, 1868, Bd. i., p. 472 and p.483) use the 
words Soor and Schwammchen, as the French employ muguet for the parasitic affection, 
whilst they apply the term aphthen to simple exudative inflammation of the mucous 
membrane of the mouth. 
* Epidem., lib. iii. f De medicine, lib. vi., cap. xi. 
J Van Swieten: Comment, in H. Boerhaave aphorismos, t. iii., p. 197. 
\ De sana et morb. oesoph. structura, Leidse, p. 71. 
|| Engravings of Morbid Anatomy, London, 1813, tab. ii., fasc. iii. 78 
DISEASES OF THE THROAT AND NOSE. 
thrush was classed among false membranes, and treated of from that point of view by 
Lfelut,* V6ron,f and Blache.J The latter writer also pointed out the occurrence of the 
vegetation in adults suffering from wasting diseases, such as cancer and phthisis, and 
insisted on it as a sure sign of impending death under these circumstances. Billard§ 
gives some remarkable examples of the oesophageal form of the disease, which is also 
noticed by Andral.|| Valleixf studied the malady with much attention, and was 
familiar with the fact of its occurrence in the gullet. Cruveilhier** in his great work 
gives three plates portraying thrush in the oesophagus. Finally, in 1842, Berg,ff of 
Stockholm, was able by microscopic examination to establish that the disease is gen- 
erally of parasitic nature, and owes its existence to a cryptogamic fungus, to which he 
gave the name oidium albicans. The life-history of this parasite was very completely 
worked out by RobinJJ in 1853. Two years later Seux£§ published the results of an ex- 
tensive clinical experience, and whilst accepting the view as to the parasitic origin of 
thrush, he endeavors to show that it is essentially a constitutional disorder, the exuda- 
tion on the mucous membrane being of the nature of an exanthem. Quite recently, 
M. Parrot|||| has described the minute character of the disease with the greatest accu- 
racy, concluding that it is a local expression of general malnutrition. 
Etiology.—The origin of the disease is not clear, the exact bearing of 
the fungus which is commonly present being as yet undetermined. It 
is also often impossible to tell what relation the local affection bears to 
the extensive visceral disease which frequently accompanies it. Thrush 
is usually supposed to be more commonly met with in the cold northern 
countries than in the south, but this view is not absolutely correct. It 
appears to be much more frequently seen in Paris than in London, 
and according to Seux*** it is more common in Marseilles than in Paris. 
This physician, however, observed that in the capital the disease is 
more severe than in the southern city, a circumstance which he attrib- 
uted to causes connected with the nutrition of the little patients. Thus 
* De la fausse Membrane dans le Muguet, Arch. G4n. de M4d., lxiii. 
f Observ. sur les Maladies des Enfants, Paris, 1825. 
J Art. Mnguet, Diet, en xxx. vol. 
§ Maladies des Enfants nouveau-nds, Paris, 1828, p. 283, et seq. See, also, the 
Atlas d’Anat. Pathol., which accompanies that work, pi. i. and ii. 
|| Precis d’Anat. Pathol., Paris, 1829, p. 161. 
f Clinique des Maladies des Enfants nouveau-n6s, Paris, 1838, p. 237, et seq. 
** Anatomie Pathologique, Paris, 1835-42, livr. xv., pi. v. 
ft Quoted by J. Muller, Arch. f. Anat. u. Physiol., 1842, p. 291. 
JJ Hist. Naturelle des Vegfetaux Parasites, etc., Paris, 1853. 
Recherches sur les Maladies des Enfants nouveau-n6s, Paris, 1855. 
1111 Clinique des nouveau-nfes, Paris, 1877, p. 213, et seq. 
Iff In comparing the diseases of infancy in London and Paris, it must not be forgotten 
that, whilst in Paris infantile affections are carefully studied from birth at the Hospice 
des Enfants-Trouvfes by thoroughly trained internes, in London children are not ad- 
mitted into the Children’s Hospitals under the age of two years. 
*** Op. cit. p. 197. 79 
THRUSH OF THE GULLET. 
he found that in Paris, on the appearance of the slightest symptom of 
the affectiom the nurses, fearing that the disease might be commu- 
nicated to their nipples, at once weaned the children, whereas at Mar- 
seilles the infants were suckled during the whole course of the malady. 
Thrush often invades the oesophagus after it has attacked the mouth 
and pharynx, but it not unfrequently passes by the pharynx altogether 
and involves the gullet. Indeed, thrush of the bucco-oesophageal 
mucous membranes is more common than the coexistence of the affec- 
tion in the pharynx and mouth. It is, however, extremely rare for the 
disease to be limited to the oesophagus. Steffen* did not meet with a 
single example of this circumscribed form of the malady in forty-four 
autopsies on infants who had died from oesophageal disease. Indeed, 
as far as I am aware, there are but three cases on recordf in which thrush 
was found to be confined to the gullet. Unlike the pharyngeal form 
of this affection, which frequently attacks adults in the last stages of 
chronic disease, oesophageal thrush is scarcely ever met with except in 
infants. 
Symptoms.—If a child is suffering from aphtha of the mouth, and 
suddenly shows signs of difficulty in swallowiug, it may be suspected 
that the disease has passed down to the gullet; but if spots can actually 
be seen in the pharynx, the oesophageal affection will generally soon 
come on, for when the disease reaches the pharyngeal mucous mem- 
brane it almost always extends downwards. Whilst the affection is 
confined to the pharynx it seldom gives rise to any dysphagia, but this 
symptom immediately occurs when the oesophagus is involved. The 
local phenomena are generally complicated by serious disease of the 
internal organs. In the three uncomplicated cases above referred to, 
the most prominent symptoms were inability to swallow and obstinate 
vomiting; death took place from marasmus. Wherever situated, 
thrush is often associated with erythema of the buttocks and enteritis; 
indeed, Valleix! asserts that, in new-born children, intestinal inflam- 
mation hardly ever occurs without thrush. 
* Jahrb. fur Kinderheilk., 1869, Bd. ii., p. 142. It is worthy of note, however, 
that among these forty-four cases, Steffen has recorded not less than fifteen instances 
of oesophageal diphtheria (!), a disease, which, according to the experience of all other 
physicians, is extremely rare. It is highly probable that some of Steffen’s cases 
(notably Nos. 12, 13, 15, 19, 26, and 31) of supposed diphtheria, were, in fact, examples 
of thrush. 
f Valleix, op. cit., p. 89 (for a full account of this case, see p. 239, et seq., of the same 
work); Andral, op. cit., p. 161; Bleuland, op. cit., p. 71. 
X Op. cit., p. 481. 80 
DISEASES OF THE THROAT AND NOSE. 
Pathology.—The disease is found in the oesophagus in three forms: 
First, as minute adherent, slightly elevated, grayish-white specks, vary- 
ing from a pin’s head to a lentil in size, resembling little drops of tal- 
low, or morsels of curd ; secondly, in patches mostly elliptical in shape, 
the long axis of which corresponds with that of the oesophagus; thirdly, 
in zones of varying width, covering from one-third to two-thirds of the 
circumference of the gullet. These zones, according to Parrot,* are 
not generally uniform in elevation, but are alternately raised and de- 
pressed; they vary in hue from pale-white to grayish-yellow, the white 
zones being usually wider than the others. 
According to Seux,f the oesophagus ranks next to the mouth as re- 
gards frequency of invasion by thrush, the lower portion of the tube 
being the part most prone to the disease, which, however, very seldom 
extends farther down than to within a centimeter of the cardia. In 
some rare instances, however, the thrush extends beyond the oesophagus, 
having reported two cases in which not only the whole of the 
oesophagus, but the stomach and small intestines were implicated in the 
morbid process. Taking twenty-six of Seux’s cases, and twenty-two of 
Valleix’s—together forty-eight examples—the pharynx was involved 
in twenty-three, and the oesophagus in thirty-two. In two of the latter 
the gullet alone was affected, but in no case was the pharynx the sole 
seat of disease. As a rule, however, thrush does not involve the gul- 
let except when the mouth is very severely affected. 
Although the color of the vegetation, when first formed, is probably 
always yellowish-white, it is often found after death to be gray, green, 
or even black, the hue probably depending on the nature of the food 
and medicine taken, or the matters vomited, and in some cases on de- 
generative changes of the materies morbi itself. The mucous membrane 
underneath may show only slight injection, or there may be extensive 
ulceration, or even, as in one of Seux’s cases, the walls of the oesophagus 
may be totally destroyed by gangrene. 
The consistency of the exudation varies from that of cream to stout 
blotting-paper which has been wetted, and it generally adheres to the 
underlying epithelium with sufficient tenacity to resist slight attempts 
to tear or scrape it off. 
Even the softer kind, which can be washed off, leaves behind a sort 
of thin foundation layer which requires some degree of force to separate 
it from the surface of the mucous membrane. The granular specks are 
usually much more intimately attached than the patches. On digesting 
* Op. cit., p. 214. 
f Op. cit., p. 113. 
t Loc. cit. THRUSH OF THE GULLET. 
81 
the morbid material in liquor potassa, and submitting it to microscopi- 
cal examination, it is generally seen to consist of the spores and filaments 
of the oidium albicans, with fat globules, epithelial cells, and granular 
d&bris. Zenker has also found pus-cells in the epithelium. The fungus 
itself consists of cylindrical, highly-refracting filaments, composed of 
long cells connected together, which contain granules, and terminate in 
spores and spore-cells; the latter are round or oval, generally adherent 
to each other, and, like the filaments, often contain granules. 
The oesophageal fungus, according to Wagner,* is at first situated on 
the level surface of the epithelium; this, however, soon becomes de- 
pressed by the penetration of the filaments, which sometimes strike so 
deeply as to drive in the walls of the bloodvessels of the submucosa. 
Parrotf states that in some instances the fungus nearly reaches the 
muscular coat. The rough pathological distinction between the false 
membrane of diphtheria and thrush consists in the fact that the former 
frequently attains a dense cohesion, thick wash-leather-like tissue being 
produced, whilst the thrush-exudation, though sometimes thick enough 
to narrow materially the lumen of the cesophagus, is merely a pulpy 
mass of aggregated particles. The microscopic characters of diphtheria 
have already been described (vol. i., p. 162, et seq.). 
Diagnosis.—It is impossible to diagnose the disease with certainty 
during life, but where there is evident difficulty in swallowing, and the 
vomited matters contain oidium albicans, there can be little doubt that 
thrush is present in the oesophagus. 
Prognosis.—If it can be ascertained that the gullet is extensively 
involved, the prospects of the patient must be regarded as extremely 
unfavorable. In doubtful cases, if the thrush in the mouth becomes of 
a dark color, if the food be regurgitated, if there be much vomiting or 
diarrhoea, and if there be marked general wasting, an unfavorable opinion 
must be given. The presence or absence of enteritis is, however, prob- 
ably the most important factor in prognosis. Few cases of thrush re- 
cover if there be inflammation of the bowels, whilst on the other hand, 
in the absence of this complication, thrush is seldom a serious disorder. 
Treatment.—The rules already laid down under pharyngeal thrush 
(vol. i., p. 130) should be carried out with even more assiduity. 
* Manual of General Pathology. Trans, by Van Duyn and Seguin. London, 1876, 
p. 99. 
f Op. cit. 82 
DISEASES OF THE THROAT AND NOSE. 
DIPHTHERIA OF THE GULLET. 
Diphtheria of the gullet is extremely rare, and when present has no 
special clinical significance. After death, however, the false mem- 
brane is sometimes found to have involved the oesophagus. Amongst 
the few writers who have published cases are—Bretonneau,* Ferrand,f 
Espagne,J West,§ Seitz,|| Steffen,Ziemssen,** Trendelenburg,ff and 
Laboulbene.|| Greenhow§§ appears to have heard of cases occurring in 
the practice of others, but to have met with no examples himself. 
Squire|||| mentions the occurrence of the oesophageal affection in two 
instances out of a tabulated of seventy-four cases of general diph- 
theria, but this probably represents an unusually large proportion. In 
their more important works neither Trousseau nor Oertel gives any 
example of oesophageal diphtheria, whilst Ernpis points out that its 
non-occurrence in the oesophagus is one of the essential points of dis- 
tinction between diphtheria and thrush, which so often attacks the 
gullet. In two of Bretonneau’s cases the disease extended to the gullet. 
In the first, which occurred in a weakly boy, aged fifteen, it reached in 
the form of long bands to the cardiac extremity of the tube, leaving the 
intervening portions of the mucous membrane healthy; whilst in the 
second, in which the patient was an infant eight months old, the exuda- 
tion formed a continuous loosely-adherent coating. Ferrand has re- 
ported two cases in which the disease was secondary to scarlatina. The 
false membrane extended deeply into the air-passages, and the upper 
part of the oesophagus was invaded. Laboulbene states that he has 
met with three cases. In one of them the membrane, which appeared 
to have extended from the pharynx, was of slight consistence, and did 
not lie on an ulcerated surface. Seitz has reported one instance in 
which a thin membranous exudation, covered with pus, extended four 
* Memoirs on Diphtheria. Syd. Soc. Transl. 1859, pp. 17, 18, 77, etc. 
f De l’Angine Membraneuse. Paris, 1827, pp. 17, 20. 
| De la Diphth6rite. Montpellier, 1860, p. 107. 
§ Diseases of Infancy and Childhood. London, 1874, 6th ed., p. 426. 
|| Diphtherie und Croup, von Dr. F. Seitz. Berlin, 1877, p. 349. 
Jahrb. fur Kinderheilk. 1869, Bd. ii., p. 143. 
** Cyclopaedia, vol. viii., p. 145. 
ff First published in Petit’s Traitd de la Gastrostoinie. Paris, 1879, p. 261, et seq. 
Jt Nouveaux Elfem. d’Anat. Pathol. Paris, 1879, p. 85. 
\\ Diphtheria. London, 1860, p. 184. 
1111 Reynolds’s System of Medicine. 1866, vol. i., p. 399. 
flf This list is given in the Brit. Med. Journ. 1859, p. 305, et seq. CANCER OF THE GULLET. 
83 
centimetres down the oesophagus. Steffen* has reported no less than 
fifteen examples, nearly all of which were complicated with one or more 
of the following conditions, viz., pneumonia, tubercle, chronic peritonitis, 
intestinal catarrh, follicular enteritis, caseation of the bronchial glands. 
In one instance there was a splenic abscess. Of the four cases in which 
the diphtheritic membrane was confined to the oesophagus, in one there 
were also extensive noma and chronic miliary tubercle of the lungs; 
in another there were chronic peritonitis, circumscribed pneumonia, 
and splenic abscess; in a third there were oedema of the lungs and 
intestinal catarrh ; and in a fourth there were pneumonia, catarrhal 
inflammation of the epiglottis, and an ulcer at the lower part of the 
gullet. 
I have myself seen two cases of diphtheria of the gullet, one in a 
child aged three, in which the upper third of the oesophagus was cov- 
ered with a thick adherent membrane, a similar deposit being present 
in the pharynx. My other case was that of a boy aged six, whose 
pharynx, posterior nares, larynx, and trachea were covered with false 
membrane, whilst the whole of the oesophagus to within an inch of the 
cardia was similarly coated. 
The nature and treatment of diphtheria have already (vol. i. pp. 131 
to 193) been so fully discussed that they need not be again referred to 
here. 
MALIGNANT TUMORS OF THE GULLET. 
Under this head are included (1) Carcinomata and (2) Sarcomata, 
CANCER OF THE GULLET. 
Latin Eq.—Carcinoma oesophagi. 
French Eq.—Cancer de l’oesophage. 
German Eq.—Krebs der Speiserohre. 
Italian Eq.—Cancro del esofago. 
Definition.— Cancerous growth in the walls of the gullet, generally 
undergoing ulceration, but giving rise at the same time to great narrowing 
of the canal, often to perforation of the trachea or bronchi, and in rare 
instances to penetration of one of the large bloodvessels. In nearly all 
cases extreme dysphagia and marasmus are present. 
* Loc. cit. See first foot-note on page 79, respecting these cases. 84 
DISEASES OF THE THROAT AND NOSE. 
History.—From the fact that the earlier writers did not attempt to separate malig- 
nant from non-malignant growths, there is considerable difficulty in giving an accurate 
historical sketch of cancer of the oesophagus. Inasmuch, however, as benign growths 
are exceedingly rare in this situation, in doubtful cases it has been assumed that the 
writers have referred to malignant tumors. 
In the second century Galen* speaks of fleshy growths completely or partially ob- 
structing the oesophagus. In the tenth century Avicenna,! in describing the various 
conditions giving rise to dysphagia, mentions tumors as a frequent cause. Fernel,! 
who flourished in the sixteenth century, relates the case of a woman who dipd in con- 
sequence of her gullet being blocked up close to its cardiac extremity by a large hard 
mass, which prevented any food passing into her stomach for two months before her 
death. Coiter,$ who lived somewhat later, mentions an interesting case o? a woman 
who died after having suffered from dysphagia for eight years. After death a “ scir- 
rhous tumor of the size of a man’s fist was found obstructing the lower end of the 
gullet.” In Bonnet’s|| large collection of post-mortem records there are several cases of 
growths connected with the oesophagus, which had destroyed the patient by rendering 
swallowing impossible. An excellent account of various forms of oesophageal obstruc- 
tion was given by Beutel.f Boerhaave and his pupil and commentator, Van Swieten,** 
were familiar with cancer of the gullet, and to the latter is due a remarkably vivid de- 
scription of the sufferings endured by the victims of this disease. The subject did not 
escape the attention of Morgagni,ff who, besides commenting on the cases of Bonnet 
and others, mentions one or two occurring in his own experience. LietaudJ! gives 
several examples, chiefly collected from the writings of other observers. Sir Everard 
IlomeR relates many cases of oesophageal stricture, some of them undoubtedly malig- 
nant. Baillieim referred to the subject in his work on pathology, giving also some 
excellent of oesophageal tumors, and soon afterwards Monro tertius*** 
published some additional cases. Subsequently Bell,!!! Howship,!JJ and Mondiere§$$ 
recorded examples of the disease, and described its features in some detail. Since then 
numerous cases have been published in the medical journals, and in the transactions of 
* De symptomatum causis, lib. iii., c. ii. 
f Canon, lib. iii., feu 13, tract, i., cap. iv. et v. 
t De morbis univers., et particular. Libri quatuor posteriores pathologise. Lib. 
vi., cap. i., p. 125. Traiecti ad Rhenuin. 1656. 
§ Observ. Anatom. Chir., p. 121. 
|| Sepulchretum. Genevse, 1700, lib. iii., sect, iv., obs. ii. 
][ De strumfi. oesophagi. Tubingen, 1742. 
** Comment, in H. Boerliaave aphorismos. Lugdun. Batavorum, 1745, t. ii., \ 
797, p. 644, et seq. 
ff Epist. anat. med. de sedibus et causis morborum. Lugdun. Batavorum, 1767, 
ep. xxviii., sect. 14, 15, 16, t. iii., p. 12, et seq. 
Jt Hist. Anat. Med. Parisiis, 1767, t. ii., p. 305, et seqv 
R Practical Observations on the Treatment of Strictures in the Urethra and the 
(Esophagus. 1805, 3d ed., vol. i., p. 537, et seq. 
1111 Pathological Anatomy. London, 1802. 
Engravings to illustrate Morbid Anatomy. London, 1812, tab. ii., fasc, iii. 
*** Morbid Anatomy of the Human Gullet, etc. Edinburgh, 1811. 
Iff Surgical Observations. London, 1817, vol. i., p. 76, et seq. 
Jtt Practical Remarks upon Indigestion, etc. London, 1825, p. 161, et seq. 
R$ Arch. G4n. de M6d. 1833, 2e sferie, t. iii. CANCER OF THE GULLET. 
85 
the various medical societies, whilst the subject has been more or less fully treated 
by Walshe,* Lebert,f Follin,.j Bthier,§ Zenker and Ziemssen,|| Luton,f Konig,** and 
Butlin.ff 
Etiology.—Though cancer of the gullet may be regarded as the typ- 
ical disease of that organ—the affection with which most practitioners 
are best acquainted—it is not relatively common. According to Zenker 
and Ziemssen,JJ in 5079 autopsies, primary cancer of the gullet was 
present only thirteen times. Concerning the relative liability to cancer 
of the oesophagus as compared with other organs, there is less positive 
evidence. Dr. Walshe§§ states that 13 out of 8289 deaths from malig- 
nant disease in Paris were ascribed to cancer of the oesophagus. In a 
table of 471 cases, the accuracy of which is vouched for by Lebert,|||| 
the gullet was the seat of the disease in eight instances. The differ- 
ence in the last two series is so great that at present the question must 
remain undecided. The same causes which predispose to or excite can- 
cer in other parts of the body lead to its development in the oesophagus. 
Amongst the former are heredity, age, and sex ; amongst the latter, 
continued local irritation, accidental injury, and chronic inflammation 
may probably be reckoned. Heredity appears to have considerable 
influence, for among sixty cases which I have examined with reference 
to this circumstance, some member of the patient’s family had died 
from malignant disease in eleven instances, whilst among ten cases ob- 
served by Richardson,there was in no instance wanting a history of 
some malignant affection amongst the relatives. Age greatly influences 
the outbreak of the disease, which is extremely rare under forty. The 
greatest number of cases are met with between fifty and sixty, although 
the decennia immediately before and after that period furnish almost as 
many cases. In my 100 fatal cases the incidence of the disease in rela- 
tion to age was as follows :*** 
* On the Nature of Cancer. London, 1846. 
f Traits des Maladies Cancfereuses. Paris, 1851, p. 442, et seq. 
J Sur les Retrecissements de l’CEsophage. Paris, 1853, p. 49, et seq. 
\ Conferences de Clinique Medicale. Paris, 1864, p. 57, et seq. 
|| Cyclopaedia of Pract. Medicine. London, 1877, vol. viii., p. 172, et seq. 
1F Nouveau Diet, de Mdd. et de Chir. Paris, 1877, t. xxiv., p. 384, et seq. 
** Deutsche Chirurgie, von Billroth und Liicke. Krankheiten des Pharynx und 
(Esophagus. Stuttgart, 1880, p. 68, et seq. 
ft Sarcoma and Carcinoma. London, 1882, p. 159, et seq. 
Cyclopaedia, vol. viii., p. 173. \\ Op. cit., p. 270. |||| Op. cit., p. 441. 
TfT[ Trans. St. Andrew’s Med. Grad. Assoc., 1872-73, vol. vi., p. 184. 
*** of these 100 cases, 60 of the patients were under my own care, 23 having been 
treated by me in private practice, 28 at the Throat Hospital, and 9 at the London Hos- 86 
DISEASES OF THE THROAT AND NOSE. 
Age. 
No. of cases. 
From 30 to 40, 
8 
u 
40 to 50, 
28 
u 
50 to 60, 
34 
u 
60 to 70, 
24 
u 
70 to 80, 
6 
Total, 
100 
Table I.—Author’s Cases. 
The following table is an analysis of thirty cases occurring in the 
Transactions of the Pathological Society.* It will be seen that the 
results closely correspond with my own cases : 
Table II.—Cases from Trans. Path. Soc. 
Age. 
No. of cases. 
Percentage. 
From 30 to 40, . 
. 2 
6.66 
U 
40 to 50, . 
. 6 
20. 
u 
50 to 60, . 
. 11 
36.66 
a 
60 to 70, . 
. 8 
26.66 
u 
70 to 80, . 
. 2 
6.66 
Over 80, . 
. 1 
3.33 
Total, . 
. 30 
The following is an analysis of forty-three eases observed by Behier,f 
but it is right to remark that in three of the cases occurring between 
twenty and forty the diagnosis was doubtful: 
pital; 25 were treated by my colleagues at the Throat Hospital, and 15 by my col- 
leagues at the London Hospital. These cases all occurred before the year 1875, when 
1 published some lectures on the subject in the Medical Times and Gazette. My 
clinical experience is based on a far larger number of cases, but patients suffering from 
cancer of the gullet seek a great variety of medical advice, and cases which have been 
treated up to within a few weeks of their death are often finally lost sight of. My 
published statistics being based on 100 cases, I have not thought it worth while to in- 
troduce fresh figures by adding those I have met with since 1875. 
* There are in all forty nominal cases reported in the Transactions up to the end of 
the session, 1874-75, but some of them do not appear to have been true cases of cancer, 
others are incomplete, and a few having been reported by myself or my colleagues are 
included in my own series. 
f Conferences de Clinique Medicale. Paris, 1864, p. 119 et seq. CANCER OF THE GULLET. 
87 
Table III.—Beiiier’s Cases. 
Age. 
No. of eases. 
From 20 to 30, 
“ 30 to 40, 
4 
“ 40 to 50, 
10 
“ 50 to 60 
11 
“ 60 to 70, 
10 
“ 70 to 80, 
3 
At 82 
1 
At 86, 
1 
Total, .... 
43 
The following table gives the result of fifty-eight cases collected by 
Mr. Butlin :* 
Table IV.—Butlin’s Cases. 
Age. 
No. of cases. 
From 30 to 40, 
8 
“ 40 to 50, 
13 
“ 50 to 60, 
24 
“ 60 to 70, . f . 
11 
“ 70 to 80, 
1 
Over 80, 
Total, .... 
58 
It may be remarked, however, that if the various tables were cor- 
rected in accordance with the number of people living at each decennial 
period, they would show a constantly increasing mortality from the 
disease as age advances. 
Men are much more liable to the disease than women, a fact which 
is very distinctly borne out by my own series of 100 cases, of which 
71 were of the male, and only 29 of the female sex. Habershonf 
gives a table of “ 85 cases collected from Guy’s Hospital Post-mortem 
Records, the Pathological Society’s Transactions, and other sources,” of 
which 59 were men and 26 women. In Petri’s| cases examined at the 
Pathological Institute at Berlin, the liability of the male sex to the 
disease is even more remarkable, for out of 44 cases, in only 3 were 
women the subjects of the disease. Ziemssen§ reports 18 cases, among 
* Mr. Butlin gives a list comprising fifty-nine cases, but in one of these the age of 
the patient is not stated. 
f On Diseases of the Abdomen, 1878, 3d ed., p. 84. 
J Ueber 44 im Pathologischen Institut in Berlin in der Zeitvon 1859 bis zum Marz 
1868 vorgekommene Falle von Krebs der Speiserohre. Berlin, 1868. 
I Ziemssen’s Cyclopaedia, vol. viii., p. 193. 88 
DISEASES OF THE THROAT AND NOSE. 
which there was but 1 female, but the diagnosis was not verified in 
every instance. Zenker* met with 15 cases of the disease, of which 11 
were men and 4 women. Whilst, however, men are more frequently 
attacked than women, the latter suffer at an earlier age. Thus, in 
Table I., all the patients under forty years of age were women, three 
of them having been thirty-four, and the rest older. The average age 
of the men in my series was 52.43, and that of the women 44.5, whilst 
in Habershon’s cases the average age of the men was 55£, and that of the 
women 44J, the latter average tallying exactly with mine. The greater 
predisposition of the male sex to cancer of the oesophagus is remark- 
able when it is recollected that more than twice as many women as men 
die of malignant disease, and that cancer of the contiguous viscus— 
the stomach—which in its liability to irritation is exposed to the same 
conditions as the gullet, is equally common in both sexes.f 
The tubercular diathesis, which is ordinarily regarded as antagonistic 
to cancer in general, has been thought, on the contrary, by Lebert,| 
Hamburger,§ and Fritsche,|| to predispose to that disease in the gullet. 
Lebert observed the coexistence of pulmonary tubercle with cancer of 
the oesophagus in seven out of nine cases, whilst insists on the 
frequent coincidence of the two affections. The general experience of 
the profession points to an opposite conclusion, and considering the 
frequency of tubercle, the two diseases cannot be said to coexist fre- 
quently. Petri** found only 4 examples in his 44 cases, whilst out of 
100 examples I only met with 3, in all of which the pulmonary disease 
showed signs of retrograde change. 
Amongst local causes, the abuse of spirits has, since the time of 
Gyser,ff been looked upon as an important factor in the production of 
oesophageal cancer, and the greater prevalence of the disease among 
men as compared with women has been attributed to this cause. Out 
of my own 60 cases only 5 acknowledge to have been free drinkers, and 
6 others were publicans by occupation. It is quite possible that the 
abuse of spirits may predispose in several ways to the development of 
* Ziemssen’s Cyclopaedia, vol. viii., p. 186. 
f Excluding cancer of the sexual organs, which is disproportionately frequent in 
woman, malignant disease affects both sexes in an almost equal ratio. This makes the 
greatly more common occurrence of cancer of the gullet in men all the more remark- 
able. 
J Op. cit., p. 445. 
\ Klinik d. CEsophaguskrankheiten. Erlangen, 1871. 
|| Ueber d. Krebs d. Speiserohre. Berlin, 1872. 
Op. cit. ** Loc. cit. 
ft De fame lethali ex callosa oesophagi angustia. Argentorati, 1770, sect. vi. CANCER OF THE GULLET. 
89 
cancer in the gullet. Thus, by lowering the tone of the nervous system 
and causing degeneration of tissue, it may render all the organs less 
capable of resisting the constitutional taint. There does not, however, 
exist any decisive evidence on this point. Again, alcohol may directly 
irritate the mucous membrane or indirectly produce a similar result by 
causing eructations and vomiting. Further, when people are half in- 
toxicated, they are apt to be careless as to what and how they eat, and 
under these circumstances pieces of meat or foreign bodies accidentally 
introduced into the food are more likely to be swallowed, and thus to 
set up irritation. My own impression, on the whole, is that the effect 
of excessive indulgence in alcohol has been overrated in considering the 
etiology of oesophageal cancer. 
The accidents which arise from taking too large or too hot morsels 
of food deserve a passing notice. Nearly a century and a half ago Van 
Swieten* was disposed to attribute the origin of the disease to swallow- 
ing very hot fluids, especially coffee, which at that time was coming into 
general use. This view, however, was no doubt erroneous, and was 
strongly opposed by Morgagni.f It is only when an excessively hot 
morsel has been swallowed that it can give rise to active symptoms. It 
is possible, also, that hot liquids may in some cases have caused an ulcer 
which has subsequently contracted in healing, and that the disease 
afterwards met with, though mistaken for cancer, was not really of a 
malignant ' • 
Sometimes the supposed cause, such as a foreign body sticking in 
the throat, is only the first symptom of the malady, but there appear 
to be other cases, such as those of Henoch§ and Fritsche,|| in which the 
swallowing of a very hot morsel of food seems to have determined the 
site of the growth. 
In addition to other causes of oesophageal cancer the irritation set up 
by indigestion, with its attendant troubles, eructations, and vomiting, 
must be mentioned. These have been already referred to as resulting 
from the abuse of alcohol, but of course they may arise from other 
causes. 
* Op. cit., t. ii., pp. 647-8. 
f Op. cit., § 797, ep. xxviii., art. 15, t. iii., p. 15. 
| As in a case reported by Leroux, Cours sur les generality de la Medecine Pra- 
tique. Paris, 1825, t. i., p. 315. 
§ Casper’s Wochenschr. f. d. gesammte Heilk. 1847, No. 39. 
|| Op. cit., p. 74. These cases are quoted by Zenker and Ziemssen, who also refer 
to another case by Deininger, which, however, does not appear to me to be so conclu- 
sive. 90 
DISEASES OF THE THROAT AND NOSE. 
In three cases that have come under my notice the patients suffered 
from vomiting for many years before any dysphagia was observed, and 
it is quite possible that in these instances the retching excited the de- 
velopment of cancer in the gullet. It is worthy of note that none of 
these patients were addicted to the use of alcohol. 
Cancer may supervene on simple stenosis, as in a case reported by Dr. 
Hilton Fagge;* and I have met with several instances in which slight 
chronic inflammation having existed for many years, cancer ultimately 
showed itself. The following is a good illustration, but others equally 
remarkable have come under my observation. A poor woman, aged 
forty-five, consulted me in 1863, on account of dysphagia. A bougie 
could be passed with ease, and, as the patient was of very nervous tem- 
perament, I treated her with valerianate of zinc and similar remedies. 
She frequently consulted me, and for some years I regarded her case as 
“ functionaljudged of, however, by the light of others which I have 
since met with, I feel sure that the symptoms were due to chronic in- 
flammation of the oesophagus. In the early part of 1874 a cancerous 
growth was seen with the mirror protruding from the orifice of the 
oesophagus, and by the end of the year the patient died from extensive 
epithelioma of the gullet. It appears more probable that the cancer 
originated at a spot chronically inflamed than that malignant disease 
existed all the time, but was completely masked, and progressed so 
slowly that.it did not terminate fatally for ten years. 
The frequency with which cancerous growths originate in cicatrices 
in other parts of the body makes it probable that they sometimes have 
a similar starting-point in the oesophagus. Neumannf has recorded 
what appears to be an example of this mode of origin, and Ziemssen| 
has met with another which might bear a like interpretation. From the 
analogy of the tongue, where it is a matter of common observation that 
syphilitic ulceration is prone to take on a carcinomatous character, it 
may justly be inferred that scars left by old venereal mischief in the 
gullet may become the site of malignant disease. 
Symptoms.—The most constant, striking, and important phenomenon 
is difficulty in swallowing. It is this which usually first attracts and 
then rivets the sufferer’s attention. The train of symptoms is generally 
somewhat as follows: The patient first experiences an occasional ob- 
struction to the descent of food if he takes a large mouthful, or if the 
* Guy’s Hospital Reports, series 3, vol. xvii. 
f Virchow’s Archiv, Bd. xx., p. 142. 
% Cyclopaedia of Medicine, vol. viii., p. 188. CANCER OF THE GULLET. 
91 
food is of a dry nature. In a short time this difficulty becomes 
habitual, and the patient complains that food lodges somewhere— 
usually at the same point—when he tries to swallow. He now often 
begins to be troubled with cough, especially when deglutition is at- 
tempted, and as the disease progresses he is obliged to wash down every 
mouthful with a draught of liquid, and he soon finds that he cannot 
take solids at all, except after prolonged mastication and with the aid 
of fluids. Then he is no longer able to swallow solid food in any form, 
his diet is restricted to liquids, and he loses flesh rapidly. As time 
goes on in some cases the stricture becomes so narrow that even liquids 
cannot be got down, or a fistulous opening being formed between the 
oesophagus and trachea, the swallowed liquids pass into the windpipe, 
and are immediately ejected by a violent and painful attack of cough- 
ing. As soon as the gullet becomes much contracted the patient begins 
to spit up a frothy fluid, which is at first clear, and closely resembles 
saliva, but which soon becomes viscid or muco-purulent, and is not un- 
frequently streaked with blood. Sometimes small particles are voided, 
which, on microscopic examination, are found to be of cancerous na- 
ture. Emaciation rapidly advances, and the patient soon becomes 
greatly wasted, and so weak that he is unable to take any exercise, or 
indeed to perform any act requiring muscular effort. The cancerous 
cachexia is often absent, the patient dying of starvation before the con- 
stitution becomes markedly perverted. 
On analyzing the symptoms it will be found that there is not one 
which may not be occasionally absent, and that the mode of their oc- 
currence varies in particular cases. Dysphagia is the most constant 
symptom, but there is at least one case on record* where it was not 
present. The patient generally states that the food is arrested at the 
upper part of the gullet, even in those cases where subsequent post- 
mortem evidence shows that the stricture was situated quite low down, 
a circumstance, probably to be explained by the occurrence of reflex 
spasm. Though the dysphagia generally comes on gradually, it some- 
times arises quite suddenly. I do not refer here to those cases in which 
the patient having swallowed too large or too hot a mouthful, the symp- 
toms have developed from that date, but to those rare instances of which 
the following, recently under my notice, may be taken as an illustra- 
tion : 
E. Y:, aged fifty-six, was in perfect health, as far as he was aware, until a certain day 
when at dinner. After eating a few mouthfuls, a piece of meat stuck in his throat, 
* Trans. Path. Soc., vol. vii., p. 188. 92 
DISEASES OF THE THROAT AND NOSE. 
and he had to leave the table, and eject it. He returned to his dinner, but could not 
swallow any food, though he was able to drink beer. In the evening he tried some 
supper, but found he could not swallow solids, and from that day till his death, seven 
months afterwards, he was never able to take a morsel of solid food. 
As has been already shown, dysphagia begins with a difficulty in 
swallowing solids, and the patient is soon obliged to depend entirely on 
liquids. In swallowing these, he makes a loud, gurgling noise, which 
is audible to himself, and even to those standing near. At first, he 
drinks easily, but after a little time he finds that the fluids will only 
pass very slowly down the gullet, and, if he is not very careful, the 
drink will be suddenly and violently ejected through the mouth and 
nose. Occasionally, a portion of the drink or semi-solid substance may 
be retained for a few minutes and then vomited, but the alkaline char- 
acter of the ejecta shows that they come from the oesophagus, and not 
from the stomach. 
Patients in extremis, previously almost unable to swallow liquids, 
may suddenly regain their power of taking semi-solid food for a short 
time before death, but such improvements are illusory, and may proba- 
bly be explained by the sloughing away of a portion of the growth, or 
by diminution of spasm from increasing muscular debility. The act 
of deglutition is very seldom painful, but there is sometimes a dull 
aching sensation,which, if present, is generally aggravated on swallowing. 
The pain is occasionally referred to a definite spot, which corresponds 
with the point where the food seems to lodge. At other times it is felt 
between the shoulders, behind the sternum, at the epigastrium, or more 
rarely in one of the ears. The pain is often slight, amounting to little 
more than uneasiness, and it is only in rare cases that it is described as 
sharp, cutting, or burning. The suffering is, as a rule, more keenly 
felt at night, and sometimes it is sufficiently severe to keep the patient 
from sleeping. 
Here it may be mentioned, as a curious circumstance, that a darting 
pain between the shoulders—occurring independently of deglutition, and 
not increased by that act—is occasionally the first symptom of cancer of 
the gullet. I have met with two instances, in which this symptom 
preceded dysphagia by more than three months.* 
The digestion becomes greatly impaired. Milk or eggs sometimes 
remain in the stomach for four or five hours, without undergoing any 
appreciable change. Positive evidence of this can often be obtained on 
* Odynphagia preceded dysphagia in a case of malignant disease of the oesophagus 
reported by Cooper Forster (Guy’s Hosp. Reports, 1858, 3d series, vol. iv\, p. 1, et seq.), 
and in another by Sidney Jones (Trans. Path. Soc., 1860, vol. ix., p. 101). CANCER OF THE GULLET. 
93 
examination of the vomit of patients after the passage of bougies for the 
purpose of dilatation. In order to lessen the chance of inducing sick- 
ness I always direct the patient to abstain from food for some hours 
before the instrument is to be used, but, in spite of this precaution, the 
contents of the stomach are occasionally brought up, and I have not un- 
frequently remarked that they have scarcely been acted on by the gastric 
juice. Independently of the use of instruments, however, real gastric 
vomiting occasionally takes place, and, when the disease is advanced, 
this is a very distressing symptom, for the stricture appears to become 
tightened at the moment of vomiting, and entirely prevents the ejection 
of matters from the stomach, whilst repeated fruitless contractions of 
the latter viscus often give rise to a feeling of weight and sometimes to 
a dull heavy pain in the epigastrium. The patient is also further tor- 
mented in some instances by the impossibility of ridding himself by 
eructation of the gas which is formed in large quantities. As might be 
expected, the excretions become much diminished in quantity. The 
bowels frequently do not act for a week or ten days together, and the 
fseces are very hard; as a rule, very little urine is passed. 
Hunger is sometimes complained of when the patient begins to be 
unable to swallow solids, but this soon passes off, and, in an advanced 
stage of the disease, the very thought of food is generally loathsome. 
When the canal is nearly closed up, the patient’s sufferings are aggra- 
vated by dryness of the throat and intense thirst, which generally per- 
sist till within a few hours of death. Should there be much ulceration 
(and especially when the disease affects the upper part of the throat) the 
breath has often a faint or foetid odor, whilst, if gangrene comes on, the 
smell is horribly offensive. 
Cough is often of frequent occurrence, and is generally due to slight 
chronic laryngitis, which commonly accompanies stricture of the oesoph- 
agus. The affection of the windpipe may occur as an extension of the 
cancer, or it may be caused by the passage of food, or the overflow of 
saliva into the larynx. If a fistulous communication has been estab- 
lished between the oesophagus and the trachea or bronchi, the coughing 
is of a very violent kind, and is called forth whenever swallowing is 
attempted. Dysphonia is not unfrequent. It may be caused by slight 
inflammation of the larynx, or by paralysis of a vocal cord from impli- 
cation of one of the recurrent nerves in the disease. For obvious ana- 
tomical reasons (see vol. i., Fig. 90), the left nerve is much more fre- 
quently affected than the right. When the latter is paralyzed, it usually 
indicates that the cancer is situated in the upper part of the throat. 94 
DISEASES OF THE THROAT AND NOSE. 
There may even be some dyspnoea or stridor, when, as generally hap- 
pens in the early stage of nerve-pressure, it is the abductor muscle 
which is mainly affected. The laryngeal symptoms are, of course, 
greatly intensified when both abductors are involved (see vol. i., p. 443, 
Case 3). 
In an advanced stage of the malady, the growth may press directly 
on the windpipe posteriorly, and thus give rise to severe dyspnoea. There 
are seldom any external signs of the disease ; but, when the upper third 
of the gullet is affected, careful examination will sometimes detect a 
slight thickening in the neck, some distance below the surface, and in 
rare cases the deep cervical glands can be perceived to be enlarged. 
Still less frequently the superficial glands are enlarged and tender. On 
introducing the cesophagoscope, the situation and character of the dis- 
ease can sometimes be made out, but its extent cannot be ascertained. 
On auscultating the gullet, the site of the disease can generally be 
determined. At the commencement of the affection, the “ bolus ” may 
be merely delayed, or irregularly forced down, but temporary arrest in 
its descent can generally be observed at a very early period. As the dis- 
order gains ground, the acoustic signs become more marked. Instead 
of the sound of a small fluid body rapidly passing beneath the stetho- 
scope, a prolonged and confused gurgling noise is heard over the diseased 
spot, and a little above it. Below this point deglutition is scarcely 
audible. 
The bougie, as a rule, furnishes very precise information, if it be 
carefully used while the patient is fully under the influence of an anaes- 
thetic. On the other hand, the knowledge obtained by means of this 
instrument, whilst the patient retains consciousness, is generally incom- 
plete and often misleading. Chloroform is the best agent for the pur- 
pose, ether having an irritating effect in these cases, and nitrous oxide 
being too transient in its action. On attempting to pass a bougie, it 
will be found that the progress of the instrument is completely arrested 
at a certain spot,' or that it can only be passed with difficulty through a 
constricted opening. Sometimes, after the bougie has penetrated one 
stricture, it encounters a second, the two obstructions generally cor- 
responding to the upper and lower edges of a single ulcer, but in rare 
cases being caused by two separate growths.* However gently the in- 
* See the cases of S&lillot (Gaz. M6d. de Strasbourg, 1853, p. 69); Poinsot (reported 
by Bidau, De l’CEsophagotomie, Bordeaux, 1881, p. 79); Golding Bird (Trans. Clin. 
Soc., 1882, vol. xv., p. 36); and Annandale (Liverpool Med.-Chir. Journ., July, 1881, 
p. 14). CANCER OF THE GULLET. 
95 
strument may be used, its point will sometimes be found to be smeared 
with blood, and the patient may spit up a few drops, or even a drachm 
or two, of blood directly after the operation. 
The local phenomena and physical signs of the disease having been 
discussed in some detail, it is necessary to make a few further remarks 
on the general symptoms exhibited by the patient. These are progres- 
sive emaciation, extreme muscular debility, and intense faintness. 
The weight of the patient gradually but steadily diminishes. Thus, 
one of my patients was reduced from twelve to five and a half stone in 
less than three months, and in another case five stone were lost in seven 
weeks. 
But whilst emaciation almost invariably accompanies the malady, 
patients occasionally die from asthenia, while the nutrition is still almost 
unimpaired. As an example I may mention that in one of my patients on 
whom Mr. Heath performed gastrostomy after nine days’ total privation 
of food, the fat in the abdominal walls was an inch in thickness, whilst 
the omentum was a mass of adipose tissue. In another case, on which 
I recently made a post-mortem examination, though the disease had 
run an unusually long course, there was not a trace of wasting in any 
part of the body. All patients, however, experience a dreadful sense 
of faintness. Whilst revising these pages I have received a letter from 
a patient in a very advanced stage of the complaint, in which the fol- 
lowing passage occurs: “I do not think anything has passed down 
during the last forty-eight hours! My weakness rapidly increases, and 
I suffer from a terrible faintness. My flesh decreases daily, and my 
body has gone hollow.” Except in very warm weather there is often 
a feeling of cold, not only in the extremities but in the body generally. 
Although the sufferings are very severe until within a day or two of 
the fatal termination, the last hours are generally quite placid, the pa- 
tient retaining his faculties till very near the end, and passing away in 
a state of gradually deepening coma. 
Death usually takes place from exhaustion, unless some complication 
should arise from the extension of the disease to neighboring organs. 
The most common form of this is perforation into the air-passages. In 
my 100 cases, death resulted from exhaustion in 78, from pneumonia 
in 17, from acute pleurisy in 3, and from gangrene of the lungs in 2 
instances. 
The modifications in the symptoms, which are caused by the spread 
of the cancer in different directions, require a brief notice. As just re- 
marked, the most common extension is into the air-passages, between 96 
DISEASES OF THE THROAT AND NOSE. 
which and the oesophagus a communication or perforation* is often es- 
tablished, but in rare cases a large vessel may be laid open by the ulcera- 
tive process. As the result of the invasion of neighboring parts by 
the growth, inflammation of many adjacent organs and tissues may 
occur, pericarditis, pleurisy, pneumonia, or even peritonitis being occa- 
sionally met with, whilst two cases are on recordf in which paralysis of 
the lower extremities ensued from the disease at last reaching the spinal 
cord. 
The signs of perforation cf the gullet depend on the nature of the 
communication which is set up with the food tract. Thus, simple per- 
foration into the peri-oesophageal connective tissue leads to abscess, slough- 
ing, and gangrene, but the symptoms are often so slight that they are 
not recognized during life. On the other hand, perforation into the air- 
passages produces such a characteristic train of symptoms that it is 
generally easily discovered. This is the most common form of perfora- 
tion, and is especially to be feared in those cases in which there is fre- 
quent but not severe spitting of blood. Violent coughing and con- 
siderable dyspnoea when the patient attempts to swallow, are the symp- 
toms which show that the air-passage has been penetrated.£ 
Perforation of a large vessel is a rare termination of the disease, and 
did not occur once in my 100 cases. Although there are numerous 
instances recorded in medical literature, it must not be forgotten that 
these cases are generally published on account of their comparative 
rarity, and that they exemplify the exception rather than the rule. If 
a large vessel be ruptured, violent haemorrhage comes on, to which the 
patient may succumb in a few seconds, or the bleeding may stop for 
some hours—but only to break out anew with a fatal result. The 
* By some authors ■perforations of the gullet, from whatever cause arising, and what- 
ever the nature of the communication established, are classified together and treated 
in a separate article, though the utility of such an arrangement is not obvious. The 
perforations produced by a malignant growth, an aneurism, or a foreign body, are to- 
tally different in their mode of development, in the symptoms they cause, and in their 
ultimate termination. Again, the widest difference exists, according as the perforation 
takes place into the air-passages, into a large vessel, or into the peri-oesophageal tissue. 
It is difficult, therefore, to discover what advantage can be derived from bringing to- 
gether a set of accidents disagreeing in almost every particular. 
f Mondiere, Arch. G6n. de M4d., t. xxx., p. 515, and Zenker, Ziemssen’s Cyclopae- 
dia, vol. viii., p. 180. 
J According to Lebert (op. cit., p. 445), perforation of the air-passages does not 
always give rise to these symptoms, and it sometimes happens that the lesion is not 
suspected until the autopsy is made. This observation can only apply to very small 
perforations, or to those which have taken place only a short time before death. CANCER OF THE GULLET. 
97 
subject of perforation will be again referred to in dealing with the 
pathology. 
Pathology.—There has been a growing tendency for some years past 
to consider that a very large proportion of cancers of the oesophagus are 
of epitheliomatous nature, and Zenker and Ziemssen* go so far as to 
state that this is the only form which is met with in this situation. 
This statement, however, is too absolute, for in the elaborate collection 
of cases of malignant disease made by Mr. Butlin/f* three were undoubt- 
edly scirrhous in character, whilst one certainly belonged to the medul- 
lary, and another to the colloid variety of carcinomata. The three in- 
stances of hard growth showed a well-marked alveolar structure, and 
their course was much more chronic than that of the epitheliomatous 
cases. The nature of the medullary tumor was determined by so high 
an authority as Dr. Joseph Coats,| of Glasgow, whilst the case of col- 
loid cancer was reported on by the committee of the Pathological Soci- 
and may therefore be accepted as undoubtedly genuine. It pre- 
sented a honey-combed structure, and contained a viscid material. The 
opinion, however, seems to be now pretty generally entertained by patho- 
logists that the appearances which sometimes resemble scirrhous or ence- 
phaloid cancer depend on the varying degrees of density in the struc- 
ture of the stroma, or on degenerative changes which may have taken 
place in the morbid tissues themselves. The disease is usually sup- 
posed to commence in the deeper layers of the mucosa, but in some 
cases it appears to be developed from the epithelial lining of the follicles. 
If the oesophagus could be exposed to view at a very early date, 
the disease would probably present itself in the form of one or 
more small isolated patches; but by the time death takes place, it 
has generally involved the whole circumference of the gullet, and 
extended for three or four inches in the vertical direction. Some- 
times, however, even when the patient has died from dysphagia, 
it is found after death that the growth occupies only one side of 
the oesophageal canal. The surface of the tumor is more or 
less irregular, and is generally extensively and deeply ulcerated. 
Among Butlin’s fifty-three cases ulceration had taken place in forty- 
nine. The ulcer has, as a rule, a foul sanious base and a raised tliick- 
* Cyclopaedia of Medicine, vol. viii. p. 173. 
f Sarcoma and Carcinoma. London, 1882, pp. 177, 178. See also Tables, pp. 185— 
187. 
f Glasgow Med. Journ. 1872, 2d series, vol. iv., p. 402. 
\ Trans. Path. Soc. 1868, vol. xix., p. 228. 98 
DISEASES OF THE THROAT AND NOSE. 
ened everted edge. It can generally be perceived that the stricture 
which has existed during life has been caused by masses of growth 
projecting into the canal, or by general thickening of the walls, or by 
the out-turned edges of the ulcer diminishing the oesophageal lumen. 
This last cause is principally in operation at the upper and lower bor- 
ders of an ulcerated surface, and hence observers have sometimes been 
led to imagine that there were two growths, each causing a stricture in 
Fig. 13. 
Malignant Disease of the Gullet. 
At the narrowest part only the fine glass rod shown in the cut could be passed through 
the stricture. 
(From a Specimen in the Museum of the Throat Hospital.) 
the canal, when, in point of fact, there was only one tumor.* When 
the mass is cut into, the section is of a grayish-white or occasionally of 
a brownish-red color, and when squeezed, yields a milky juice. On 
microscopic examination this fluid is found to consist of aggregated and 
distinct epithelial cells, and the growth is seen to be made up of a 
stroma of fibrillated tissue, arranged so as to form alveoli of various 
* See a case reported by Motta, Gazette Medicale, 1873. CANCER OF THE GULLET. 
99 
shapes and sizes, within which flat epithelial cells are found. Some of 
these bodies are grouped together so as to produce concentric globes, 
which, on being cut through, present the well-known form of nested 
cells. The epithelial elements may be seen making their way into the 
tissues around the ulcer, and beyond these again will be found an in- 
filtration of small round corpuscles (indifferent cells). 
There is considerable difference of opinion as regards the part of the 
gullet most frequently attacked. Sir Everard Home* says : “There 
is this one spot immediately behind the cricoid cartilage where the 
fauces may be said to terminate and the oesophagus to begin, in which 
such a contraction is so often met with, that I must consider it as more 
liable to become diseased than the rest of the canal.” Rokitanskyf 
affirms that the upper half of the gullet is most often the seat of the 
disease, and Ilabershon’s experience and my own point to the same 
conclusion. Klebsj and Rindfleisch§ find the middle portion most fre- 
quently affected, whilst Petri,|( and Zenker and Ziemssen,T[ have ob- 
served that the lower third furnishes the greatest number of cases. The 
following tables show these various results : 
Mackenzie. 
Upper third, . 44 
Middle third, 28 
Lower third, 22 
Lower half, 6 
100 
Petri. 
Upper third, 2 
Middle third 13 
Lower third, 18 
Upper and middle thirds, 1 
Middle and lower thirds, 8 
Whole canal, 1 
43 
Habershon. 
Upper part, ........ . . . 33 
Middle part, 30 
Lower part, 10 
73 
* Op. cit., vol. ii., p. 395. 
f (Esterr. medicin. Jalirb., 1840, Bd. xxi., p. 225. 
J Handbuch d. pathol. Anatomie, 1868. 
$ Pathol. Histology, Syd. Soc. Transl., 1872, p. 457. 
Op. cit., p. 176. 
|| Loc. cit. 100 
DISEASES OF THE THROAT AND NOSE. 
Zenker. 
Upper third, 2 
Middle third, ........... 1 
Lower third, 6 
Upper and middle thirds, 2 
Lower and middle thirds, 3 
Whole canal, 1 
15 
Mr. Butlin* states that in his series of fifty-nine cases, “ in by far 
the larger number of instances, the disease occurred in the upper than 
in the middle or lower thirds,” but “ the point of junction of the middle 
and lower thirds was three times more often attacked than that between 
the two upper thirds; so that if the canal be divided into halves in- 
stead of thirds, the number of cases affecting each half is very nearly 
equal.” 
As the result of clinical examination, Ziemssenf has found the dis- 
ease situated in the lower third of the gullet in thirteen cases out of 
eighteen. The great discrepancy between the different tables may, 
perhaps, be explained by the fact of some pathologists having excluded 
cases of cancer of the upper part of the oesophagus in which the pharynx 
was also implicated. As has already been pointed out (vol. ii., p. 17), 
the line of demarcation between the pharynx and the gullet is arbitrary, 
some anatomists fixing the lower border of the cricoid cartilage as the 
point of separation, whilst others take the cricoid generally as the 
boundary line. As cancer of the food-tract behind the cricoid is rela- 
tively very common, it makes a great difference whether this situation 
be included in the pharynx and excluded from the oesophagus in statis- 
tical tables. Further, as Mr. Butlin| observes, when the disease is 
widespread, the difficulty of determining its primary point of invasion 
impairs the accuracy of all calculation as regards the part of the oesoph- 
agus most frequently affected. 
As Konig§ has remarked, the situation of cancer of the oesophagus 
is a matter of some practical importance, for if the growth is at the 
lower part, gastrostomy is the only palliative operation that is jutifiable. 
Cancer of the oesophagus is sometimes confined to that tube, but ob- 
servation shows that it spreads both by continuous extension and by 
* Sarcoma and Carcinoma, London, 1882, p. 162. f Op. cit., p. 193. 
t Op. cit., p. 163. 
\ Deutsche Chirurgie yon Billroth und Luecke. Krankheiten des Pharynx und 
(Esophagus, von Professor Konig, Stuttgart, 1880, p. 69. CANCER OF THE GULLET. 
101 
secondary deposit. In ray 100 cases the deep cervical glands were 
alone attacked in fourteen cases (in conjunction with other glands in 
three other cases, and in conjunction with other organs in four cases); 
in two cases one lung was involved, in one case the liver, and in one 
the liver and one lung were implicated, whilst the left kidney, stomach, 
and tongue were each once affected. Out of forty-four cases of cancer 
in the upper third, in twelve the disease at the same time involved the 
pharynx above the level of the arytenoid cartilages, and in one case the 
thyroid gland, whilst of thirty cases at the lower part of the oesophagus, 
in only one the disease reached the stomach. In thirty-six cases in 
which there was a broncho-oesophageal fistula, the tissues surrounding 
the opening were thickened in every instance, whilst in thirteen there 
was distinct disease within the trachea. In seven other cases in which 
perforation had not taken place, there were nodular elevations of the 
lining membrane of the tracheo-bronchial canal. In the whole series 
of 100 cases perforation of the air-passages took place thirty-six times, 
the trachea being perforated twenty times, the right bronchus seven and 
the left bronchus four times, the base of the lungs in two instances, and 
the pleural cavity in one, whilst twice the perforation took place into 
the peri-oesophageal tissues. In my 100 autopsies the left recurrent 
nerve was found to be involved nine times, the right recurrent once, and 
in one instance both nerves were affected. It should, however, be re- 
marked that all these eleven observations occurred among my own 
sixty patients (see last foot-note on page 85), and it may be presumed 
that if this matter had been carefully looked into in the other forty 
cases, nerve-lesion would have been frequently met with. 
Perforation of bloodvessels, according to Lebert,* is rare, whilst 
Rokitansky,f in expressing a somewhat similar opinion, asserts that the 
aorta and right pulmonary artery are the vessels which most frequently 
yield. In addition to these vessels, the carotid,J subclavian,§ vertebral,|| 
oesophageal,and superior intercostal** arteries may be mentioned as 
having been thus perforated. 
I have met with two cases (Specimens 101 and 200, Throat Hospital 
Museum) in which abscess was developed in connection with the dis- 
* Op. cit., p. 444. 
f Pathological Anatomy, Syd. Soc. Transl., London, 1854, vol. ii., p. 11. 
- | Lancet, February 14th, 1860. 
I Trans. Path. Soc., vol. xxii., p. 134. 
|| Ibid., vol. ix., p. 194; vol. xii., p. 108. 
Ibid., vol. xiv., p. 167. ** Ibid., vol. viii., p. 210. 102 
DISEASES OF THE THROAT AND NOSE. 
eased mass in the gullet, and a further example of a similar complica- 
tion has lately been reported by Dr. Semon.* 
Diagnosis.—Although under ordinary circumstances the recognition 
of cancer of the oesophagus is easy, cases of doubtful nature occasion- 
ally present themselves. It is important, therefore, to determine at 
once whether the dysphagia be due to an extrinsic or an intrinsic cause. 
Laryngoscopic examination enables the observer to discard disease either 
of the pharynx or larynx as a possible factor, whilst the absence of 
swelling or tenderness in the neck will serve to eliminate most of the 
morbid conditions in that region which could give rise to compression 
of the gullet. When this is produced by deeply-seated tumors or ab- 
scesses, a bougie can be passed in most cases, but the pressure on the 
canal resulting from great enlargement, whether cancerous or fibroid, 
of the thyroid body, or from malignant deposit in the mediastinum, is 
sometimes sufficient to prevent the introduction of the finest instrument. 
In such instances, however, the external evidences and physical signs 
of the radical disease are generally obvious. 
In aneurism of the aorta and in other affections of the circulatory 
system, there is seldom any difficulty in passing the oesophageal bougie, 
though force should on no account be used ; the physical signs of aneu- 
rism are also generally discernible by auscultation and percussion. 
When it has been established that the disease is intrinsic, it must next 
be decided whether the dysphagia be organic or functional. 
Spasmodic stricture is far more common in women than in men, and 
usually occurs under the age of forty. The symptoms are suddenly, 
not progressively, developed as in cancer. There is no pain or regur- 
gitation of frothy fluid, though the mouthful of solid or liquid food 
may be immediately and forcibly ejected. A bougie can always be 
passed, though sometimes this can only be effected under the influence 
of an anaesthetic. There is seldom any considerable wasting, but on 
the contrary, the patient, though weak, is often plump. Collateral 
evidence, such as a markedly emotional disposition, may assist in the 
diagnosis. 
Paralysis of the oesophagus generally occurs in the old and feeble— 
that is, in people whose muscular system is weak, or in cases of chronic 
wasting disease. The dysphagia is seldom extreme, and the easy pas- 
sage of a bougie at once shows the absence of true stricture. 
Passing to organic lesions, in syphilitic disease there may be a clear 
history of infection or the acknowledgment of former symptoms, such 
* Archives of Laryngology, 1882, vol. iii., p. 125. 103 
CANCER OF THE GULLET. 
as a skin eruption, falling of the hair, nocturnal pains in the shin-bones, 
or the scars of former ulceration either on the skin or mucous mem- 
brane; or coexistent disease of an undoubtedly syphilitic character may 
remove all doubt as to whether the system has been infected. Of course, 
cancer may occur in syphilitic individuals; but the curative effects of 
iodide of potassium in truly syphilitic cases, and the fact of its being 
virtually inoperative when cancer has been engrafted on syphilitic 
ulceration, will eliminate this source of difficulty. Narrowing of the 
canal, caused by tubercular deposit, being extraordinarily rare, and 
always secondary, requires ouly to be mentioned. 
In traumatic stricture the history of the case explains its origin, but 
it may be added as a negative sign that in this class of cases the recur- 
rent nerves are very seldom involved. In chronic cesojihagitis the 
dysphagia is also much less marked than it is in carcinoma, and the 
inflammatory affection is not progressive. The food can, indeed, gener- 
ally be swallowed, though with uneasiness, or even pain. On the other 
hand, the odynphagia is much more marked in chronic inflammation, 
and a bougie usually causes so much pain that it can only be passed 
under the influence of an anaesthetic. 
In simple dilatation frequent regurgitation of unaltered food after a 
meal is a prominent symptom, and although there may be difficulty in 
passing a bougie, this can generally be overcome with perseverance. 
Cancer of the pyloric orifice of the stomach is occasionally mistaken 
by the inexperienced for malignant disease of the oesophagus; but in 
the former complaint the food is generally retained for an hour or two, 
and, when brought up, has a decidedly acid reaction. Lastly, the diag- 
nosis may be assisted by a careful consideration of the symptoms, which, 
taken together, are characteristic of cancer of the oesophagus; these are 
progressive dysphagia, expuition of a fluid, at first frothy, but after- 
wards thick, muco-purulent and sometimes tinged with blood, obstruc- 
tion to the passage of a bougie, frequent paralysis of one, and occasional 
paralysis of both abductors of the vocal cords, with progressive emacia- 
tion and debility occurring in a person over forty years of age. 
Prognosis.—The course of the disease tends steadily towards a fatal 
issue, the opinion of Rokitansky,* based on the frequent appearance of 
certain cicatrices in the oesophagus, that cancer in this situation is often 
cured, being opposed to all other experience. In my 100 cases, the 
average duration of life after undoubted symptoms were developed was 
only eight months—the maximum being sixteen months, and the mini- 
* Lehrbuch d. path. Anatom., 1855, Bd. i., p. 278. 104 
DISEASES OF THE THROAT AND NOSE. 
mum five weeks. Each case, however, must of course be judged on its 
own merits. We must take into consideration the age of the patient, 
his previous health, and especially his temperament—persons of nervous 
organization generally resisting the slow starvation much longer than 
the phlegmatic. The duration of life is, however, dependent on such 
purely accidental conditions that it is never safe to give an opinion as to 
how long it may be extended. The gullet, which has remained par- 
tially pervious for months, may be suddenly completely blocked, or a 
perforation may occur without any warning. 
When a perforation into the air-passages takes place, the patient sel- 
dom survives more than three or four weeks—unless he can be fed with 
a tube, when life may still occasionally be prolonged for a few months. 
If a considerable haemorrhage occurs and is arrested, its speedy recur- 
rence must be looked for. 
Apparent improvements are only of the most temporary character, 
and the recovery of the power of swallowing at a late period of the dis- 
ease must not be regarded as a favorable symptom, but rather the 
reverse, indicating, as it usually does, sloughing of the growth or the 
mere giving way of spasm from increasing weakness. 
Treatment.—In dealing with cancer of the oesophagus, we have no 
satisfactory task, but something may be done to prolong life and more 
to assuage suffering. Local treatment is rarely of any use, but when 
the disease is situated at the orifice of the gullet, the growth may some- 
times be in part destroyed by electric cautery, or removed with cutting 
forceps. I have also seen benefit from insufflations of a powder com- 
posed of one part of persulphate of iron to three parts of starch. This 
astringent application causes some shrinking of the growth, and thereby 
widens the canal. This effect, however, is, of course, only mechanical 
and temporary. Directly there is a suspicion of malignant disease the 
food should be most carefully selected. Milk, on account of its highly 
nutritive and unirritating character, should be regarded as the staple 
article of diet, but beef-tea, mutton-broth (free, of course, from pepper 
or salt), eggs, arrowroot, or thin, soft, farinaceous food may be given; 
stimulants should, if possible, be avoided, as they irritate the diseased 
surface. It is important to determine the circumstances which justify 
the use of bougies, and also to appreciate the conditions under which 
the feeding-tube may be employed with advantage. In the first place, 
it must be distinctly stated that, as long as the patients can swallow 
liquids easily, bougies should not be passed. When, however, fluid 
nourishment can only be got down with difficulty, and when that dif- CANCER OF THE GULLET, 
105 
ficulty is steadily increasing, the time for instrumental interference has 
arrived, and the question arises whether an attempt shall be made 
merely to keep the oesophagus open, or whether the surgeon shall 
endeavor to enlarge the narrowing canal. At this period it will gen- 
erally be found that only a No. 3, or at most a No. 4 (author’s scale, 
vol. ii., Fig. 2, p. 27) cau be passed, but sometimes a No. 5 or No. 6 
can be got through. As a rule, the mere passage of a bougie from time 
to time is of little use, for it is found that progressively smaller sizes 
have to be employed, and that, at the end of a few weeks, no instru- 
ment will pass. Hence it is almost always desirable to attempt some 
dilatation. This should be done twice a week, and the surgeon must 
be satisfied if he can dilate to the extent of No. 8. If the passage of 
a bougie causes bleeding, instrumental treatment should be discontinued 
for a time. In any case, however, when dilatation has been practiced 
for a few weeks, it is almost certain on one occasion or another to give 
rise to some inflammatory action within the gullet, and the patient may 
find that, after the use of the instrument, he is unable to swallow for 
many hours. After a few days’ rest, however, liquids again pass and 
mechanical treatment can be resumed. 
In certain cases, it may be possible to remove projecting portions of 
the growth, and so open a way for an oesophageal tube. By means of 
the cesophagoscope I was able, on one occasion, to carry out the line of 
treatment here suggested. The following are the details of the case : 
Mrs. B., aged sixty-two, was sent to me by Mr. Yate, of Godaiming, on June 28th, 
1880, on account of difficulty of swallowing, which had commenced two years pre- 
viously. She was able to take liquids easily, but could not swallow solids. The 
dysphagia gradually increased, and, at the beginning of August, Mrs. B. could take 
liquids only with the greatest difficulty. At last, even liquids could not be 
swallowed. With the cesophagoscope a ragged, projecting mass was seen about three 
inches below the lower border of the cricoid cartilage. On August 18th, in the pres- 
ence of Mr. Yate, Mr. Hovell, and Mr. Bailey (who administered chloroform), I suc- 
ceeded in removing with the oesophageal forceps a piece of growth about the size of a 
cherry. The effect of the operation was most satisfactory. The patient felt some pain 
for two or three days, but a week after the operation she was able to swallow semi- 
solids with ease. Microscopic examination showed that the tumor was an epithelioma. 
Mrs. B. lived rather more than half a year after the operation, which may fairly be 
considered to have prolonged life for four or five months. 
The oesophageal feeding-tube (vol. ii., Fig. 11, p. 39) may be used 
under two conditions: first, when the disease is complicated by spasm, 
and, secondly, when there is a broncho-oesophageal fistula. In cases of 
spasm it is only when the muscular contraction is of a very enduring 
character—that is, when it lasts for the greater part of the day—that 106 
DISEASES OF THE THROAT AND NOSE. 
the feeding-tube is required. Under these circumstances the patient 
should be placed fully under the influence of chloroform, and a pint of 
strong nutriment administered at least once in the twenty-four hours. 
When this process has been repeated for a few days, the spasm often 
passes off, and the artificial feeding can then be discontinued. 
It is, however, when a tracheo-oesophageal fistula has been established 
that the feeding-tube is of special service. The train of symptoms, by 
which the existence of the fistula can be recognized, has already been 
described (p. 96). If the opening between the two tubes is small, al- 
though liquids when swallowed will pass through the aperture, and give 
rise to violent coughing and choking, the point of the instrument will 
often glide over the orifice of the fistula, and thus allow the patient to 
be fed. When, however, the opening of the fistula is large, there is a 
risk of the feeding-tube passing through it into the windpipe. Hence, 
it is very important not to use force in introducing the tube, and the 
operator should be quite certain that the feeding-tube has not found its 
way into a false passage before he injects any food. If the instrument 
has penetrated the windpipe, some spasm is nearly sure to be set up, 
and the patient on coughing will force air through the tube, and thus 
demonstrate its position. In most cases of fistula, the feeding-tube 
should be used as long as the patient survives, but sometimes the tracheo- 
oesophageal opening increases in size after a few weeks, and the tube 
can no longer be passed with safety. When the patient is quite unable 
to swallow, either from complete closure of the gullet, or from the es- 
tablishment of a large fistula, the time for using nutritive enemata com- 
mences. It is a mistake to begin this method of feeding as long as the 
patient can get down any considerable quantity of liquid food, as it may 
irritate the bowtel prematurely, and thus prevent rectal alimentation, 
when it might remain as a last resource. The patient should be fed 
with Leube's pancreatized meat (the formula for which I have slightly 
modified)* twice in the twenty-four hours. Should there be a difficulty 
in retaining the enemata (though the solid kind just mentioned causes 
far less irritation than the liquid injections, such as beef-tea or eggs 
beaten up in milk, which are commonly used), or should the food be re- 
turned, without having undergone any digestive change, the permanent 
oesophageal tube(vol. ii., Fig. 10, p. 36) may be introduced. It should 
be explained to the patient or his friends that the use of this instru- 
ment is attended with some danger, but that it may be the means of pro- 
longing life for a few days—occasionally for a week or two, or even longer. 
* See vol. i., p. 556. CANCER OF THE GULLET. 
107 
If thirst be greatly complained of in the last days, tepid footbaths 
of milk often comfort and refresh the patient, and possibly afford some 
slight nourishment. 
The question of a cutting operation has been deferred to this late 
stage of the subject for the sake of clearness, but in actual practice it 
must be entertained directly the diagnosis of the disease is accurately 
established. Surgical measures, which at an early period may be at- 
tended with the happiest results, if postponed till the patient is worn 
out with disease, can only end in failure, and add to his sufferings. 
The point, which has first to be considered, is whether excision of the 
growth is practicable, the alternative operations being oesopliagostomy 
and gastrostomy. 
The idea of excising a portion of the gullet appears to have originated 
with Billroth,* who, in 1872, published a short account of two experi- 
ments made on dogs. In each case a part of the oesophagus was cut out; 
one dog died five days afterwards from the result of an accident, but the 
other recovered completely, and lived for several months, when he was 
killed, in order that the parts might be examined. The first surgeon, 
however, so far as I am aware, who attempted to carry out this pro- 
ceeding in the human subject, was Kappeler,f who, in 1875, endeavored 
to excise a portion of the gullet in a man, aged forty-two, who had 
suffered from dysphagia for about eight months. The operator, how- 
ever, was baffled by the extent and connections of the diseased mass, 
which also prevented him from opening the tube below the stricture. 
He had, therefore, to content himself with introducing a catheter into 
the oesophagus above the seat of disease, and trying to force a passage 
downwards. The patient died on the following morning. Resection 
of the oesophagus was again attempted by Kappeler| in 1876, but with 
no better result. The patient was a man, aged sixty-five, who had felt 
difficulty in swallowing for three years and a half. The main features 
of this case were almost identical with the one just related, as far as 
the operative procedures are concerned, and the result was equally un- 
satisfactory, as the patient died on the second day. A year or two later 
Professor Czerny§ was more fortunate. The patient in this instance 
was a woman, aged fifty-one, who had suffered from dysphagia for 
some months. Czerny made an incision from the level of the hyoid 
bone down to the sternum along the anterior edge of the sterno-mastoid 
* Langenbeck’s Archiv. fur klin. Chir., 1872, Bd. xiii., p. 66. 
f Deutsche Zeitschr. fiir Chirurgie, 1877, Bd. vii., p. 370. 
§ Beitrage z. operat. Chir., Stuttgart, 1878, p. 41. 
t Ibid. 108 
DISEASES OF THE THROAT AND NOSE. 
on the left side; the omo-hyoid muscle was divided, the thyroid body 
was pushed upwards and inwards, and the oesophageal tumor, which 
could then be felt with the finger, was carefully dissected out. A seg- 
ment of the gullet, involving the upper six centimetres of the canal, 
was removed, and the upper orifice of the lower section of the divided 
tube was stitched to the edges of the skin-wound. A catheter, through 
which the patient could be fed, was then passed into the oesophagus 
through the wound, and the lips of the superficial incision were brought 
together. By the fourth day all the sutures were removed, and the 
catheter was replaced by a large, hollow bougie, which at first was left 
permanently in situ, but in a short time was taken out, and only intro- 
duced when nourishment had to be given. The patient learnt to feed 
herself in this manner, and five months after the date of the operation 
she was still in perfect health, without any trace of recurrence. She 
continued to use the sound for the purpose of taking food. On exami- 
nation a partition, about half a centimetre in thickness, was found 
closing the lower aperture of the pharynx, thus cutting off all commu- 
nication between the upper and lower parts of the pharyngo-oesophageal 
canal. In this instance the disease was epitheliomatous in character, 
and the mass encircled the gullet, but no perforation of the tube or ex- 
tension of the growth beyond its walls had taken place, and there were 
no enlarged glands. Whilst, therefore, Professor Czerny must be con- 
gratulated on the highly successful issue of his bold procedure,* the 
case itself was an exceptionally favorable one for the operation. 
The fact, however, that malignant disease of the gullet spreads to 
contiguous organs at an early period is likely to prevent the operation 
of resection being frequently applicable. 
The surgeon has in the next place to take into consideration the 
chances offered to his patient by oesophagostomy or gastrostomy. The 
advantages and disadvantages of these procedures will be fully consid- 
ered under the head of “Cicatricial Stricture of the Gullet,” a condi- 
tion which is much more favorable for such operations than where the 
narrowing is due to malignant disease. 
* Whilst these sheets are passing through the press I learn from Professor Czerny 
that the woman died rather more than a year after the operation described in the text. 
Recurrence of the disease took place to an extent which rendered tracheotomy neces- 
sary, and the patient succumbed some weeks afterwards. (Private letter, dated July 
22d, 1882.) SARCOMATA. 
109 
SARCOMATA. 
Sarcomata are occasionally met with in the oesophagus. Rosenbach* 
has reported a case in which a growth about the size of a common fowl’s 
egg was attached to the right side of the gullet, just below its junction 
with the pharynx. The tumor was soft, slightly lobulated, and almost 
transparent, closely resembling an ordinary nasal polypus. On micro- 
scopic examination, however, it was found to be a round-celled sarcoma. 
Tracheotomy having been first performed, the growth was removed by 
subhyoid pharyngotomy. In another case, reported by Chapman,! 
several tumors, partially connected, varying from one and a half to 
two inches in diameter, were found occupying the upper orifice of the 
oesophagus. 
Cases of calcification, cartilaginous stricture, and even ossification of 
the oesophagus, are referred to by some of the older authors, such as 
Sampson,| Morgagni,§ Gyser,|| and It is not improbable 
that calcification sometimes occurs in this situation,** but I know of no 
authentic instance of such a transformation recorded in modern litera- 
ture. 
* Berlin, klin. Wochenschrift, September 20th and 27th, 1875. 
f Amer. Jour. Med. Sci., October, 1877, vol. cxlviii., p. 433. 
J Miscell. Curios., 1613, p. 170. 
§ De sedibus et causis morb. Ep. xxviii., art. 15, ed. sec. Patavii, 1765, t. ii., p. 10. 
|| De fame lethali ex callosa oesoph. angustia. Argentorati, 1770, p. 16. 
T[ Journ. de Corvisart, 1801, t. iv., p. 203. 
** Both enchondromata and osteomata have been found in the mucous membrane of 
the trachea, and though the normal presence of cartilage in the windpipe renders it 
a more likely locality for the development of these growths, it is quite possible that 
they may also occur in the gullet. 110 
DISEASES OF THE THROAT AND NOSE. 
NON-MALIGNANT TUMORS OF THE GULLET. 
(Synonyms: Benign Growths of the Gullet. Polypi of 
the Gullet.) 
Latin Eq.—Tuniores non maligni oesophagi. 
French Eq.—Tumeurs non malignes de l’oesopbage. 
German Eq.—Gutartige Geschwiilste der Speiserohre. 
Italian Eq.—Tumori non maligni del oesofago. 
Definition.— Growths of benign character, generally mucous or 
fibro-mucous in structure, giving rise to nausea, sometimes to pain, occa- 
sionally to dyspnoea, and frequently to extreme dysphagia. 
History.—In 1717 Schmieder* published an example of polypus of the oesophagus, 
but I know no particulars of the case beyond those contained in the title-page of his 
essay.f In 1750 VaterJ reported the case of a man who had suffered from dys- 
phagia for some time. This improved after he had vomited a “ fleshy mass about the 
size and thickness of a finger;” subsequently, however, the difficulty of swallowing 
recurred, and the patient sank from inanition. After death the walls of the oesophagus 
above the cardiac orifice were found thickened, the lumen of the tube being much nar- 
rowed. There was the appearance of a cicatrix on the oesophageal wall at this part. 
This seems to have been an example of simple polypus, which, as in Coats’s case (see 
below) gave rise to chronic inflammation, and probably ulceration of the mucous mem- 
brane. The inflammatory changes were presumably too far advanced to permit the 
recovery of the patient after the spontaneous separation of the growth. In 1763 Dal- 
las£ met with a remarkable instance, in which the polypus had so long a stalk that on 
making the patient retch it was projected into the mouth as far as the front teeth. In 
1764 De Graef|| reported the case of a patient who died from inanition, in whose ceso- 
* Dissert, de polypo oesophagi vermiformi rarissimo e pulveris sternutatori Hispani 
abusu progenito. Italse, 1717. 
f In a list of examples of oesophageal polypi given by Middeldorpf at the end of his 
essay (De polypis oesophagi, Vratislavise, 1857, pp. 22, 23) cases are cited from Pringle, 
Gilbert, Waugh, and Lesueur. These, however, have not been included in the above 
history, as they were not true benign polypi. Pringle’s case (Med. Essays and Ob- 
servations by a Society in Edinburgh. Edinburgh, 1737, 2d ed., vol. ii., pp. 324, 325) 
was probably malignant; Waugh’s (Ibid., vol. i., p. 274) was clearly an example of 
oesophageal abscess terminating in complete recovery after spontaneous rupture of the 
sac; whilst the growth in Lesueur’s case (Revue Med.-Chir. de Paris, 1850, t. viii., p. 
360) is distinctly stated by the reporter to have been encephaloid cancer. 
J Dissert, inauguralis de deglutitione difficili et impedita. Vitembergse. 
\ Edin. Literary and Phys. Essays, vol. iii., p. 525. This ease is associated with the 
name of Monro, who saw the patient in consultation with Dallas, and suggested the 
ligature. It is related at length in Monro’s Morbid Anatomy of the Gullet, etc., 1830, 
3d ed., p. 426. 
|| Diss. illustrans hist, de callos. excrescent, oesopli. obstruente. Altorfii, 1764. NON-MALIGNANT TUMORS OF THE GULLET. 
111 
phagus was found a small cone-shaped growth, with its apex towards the cardiac open- 
ing. In 1776 Macquart* published an account of a tumor in the gullet, which does 
not seem to have been malignant. In 1784 Schneiderf gave a description of a case 
in which three polypi were found in the gullet after death. Baillie,J in 1802, stated 
that he had seen a fibrous growth springing from the inner coat of the gullet. In 1806 
Vimont£ placed on record two examples of oesophageal polypi, both occurring in 
women who had long suffered from goitre. Dubois,|| in 1818, related an instance in 
which an oesophageal polypus had been ligatured, and the patient was suffocated from 
the tumor coming away in his sleep and finding its way into the air-passage. Roki- 
related a case in which a very large polypus in the gullet caused little or no 
dysphagia. In 1847 Arrowsmith** described a pedunculated and freely movable pol- 
ypus growing at the upper part of the gullet, and admitting of easy removal if the 
affection had been recognized. In 1857 Middeldorpf,ff having met with a remarkable 
example of the disease, and having collected a few previously published cases, wrote a 
monograph of considerable value on the subject. Since then examples of myomatous 
polypi in the oesophagus have been published by Eberth,JJ Coats,£$ Fagge,|||| and 
TonoliAf whilst Wyss,*** Ziemssen,fff and Sappey,Jhave recorded the occurrence 
of small cystic tumors in the same situation. I have myself met with two examples of 
non-malignant growth in the gullet. 
Etiology.—These growths are very rare, and probably originate in 
most instances in chronic inflammation. As far as the recorded cases 
go, it would appear that oesophageal polypi are more common amongst 
men than amongst women. In De Graef’s case the patient had been a 
free drinker, and had frequently suffered from inflammation of the 
throat and tonsils, but none of the others show a similar history. As 
regards myomata, it was to be expected, a priori, that they would be 
occasionally met with in a muscular canal like the oesophagus. 
Symptoms.—The most frequent symptom is slowly increasing dys- 
phagia. The disease, however, may exist for many years, as in Roki- 
* Obs. sur une Tumeur dans l’QSsophage. Hist, et Mem. de la Soc. R. de M4d., 
1776, Hist., p. 280. 
f Chirurg. Geschichte. Chemnitz, 1784, Bd. x. 
J Pathological Anatomy, p. 102. 
\ Annales de la Soc. de M4d. Prat, de Montpellier, t. viii., p. 60. 
|| Propos. sur 1’Art de Guferir. Th&e de Paris, 1818, No. 104. 
CEsterr. medicin. Jahrb. 1840, Bd. xxi. 
** Med.-Cliir. Trans. 1847, vol. xxx., p. 229. 
ff De polypis oesophagi. Vratislavise, 1857. 
XX Virchow’s Archiv. 1868, Bd. xliii., p. 137. 
\\ Glasgow Med. Journ. February, 1872. 
|||| Trans. Path. Soc. London, 1875, vol. xxvi., p. 94. 
Gazetta Medica Ital. Lombard. 1880, serie viii., t. ii., No. 49, p. 479. 
*** Virchow’s Archiv. 1870, Bd. li., p. 144. 
ftf Cyclopaedia of Pract. Med., vol. viii., p. 161. 
ftt Traite d’Anatomie Descriptive. Paris, 1879, 3me ed., t. iv., p, 155. 112 
DISEASES OF THE THROAT AND NOSE. 
tansky’s case, even when the growth is very large, without interfering 
with deglutition, until an advanced period of its development. Some- 
times no symptom whatever has been observed, and the tumor has only 
been discovered after death.* In other cases the dysphygia has been 
attributed to cancer, f These growths are often pedunculated, and the 
stalk may be so long that, as in Dallas’s patient, the polypus, in retch- 
ing, may be projected into the mouth. Sometimes it may be seen 
with the laryngoscope, at the lower part of the pharynx; and in 
one instance, hereafter reported, I was able, by means of the oesophago- 
scope, to obtain a view of a growth situated about one inch below the 
cricoid cartilage. A bougie can occasionally be passed and withdrawn 
without difficulty, although the operation may cause severe pain, as in 
Coats’s case. On the other hand, in some instances, an obstruction may 
be perceived in using the instrument, or it may be impossible to pass it 
at all. In Tonoli’s case a movable tumor could be distinctly felt with 
the bougie. Sometimes the tumor has been known to give rise to 
dyspnoea and indistinctness of utterance,| and in one instance great 
pain was experienced; but in this case (Coats’s) the pressure of the 
growth had induced extensive ulceration of the oesophageal walls, and 
the pain was probably due to this condition. Middeldorpf’s patient 
complained of severe pain in the fauces and in the back. 
In one case (Vater’s) the growth separated spontaneously, and was 
ejected by the mouth ; but even in this instance, as already remarked, 
the patient died from inanition, apparently owing to the chronic inflam- 
mation which had been set up by the growth. 
Pathology.—The most common kinds of non-malignant growths met 
with in the oesophagus are those of a simple, warty, or papillary struct- 
ure. “ They are sometimes single, at other times in large numbers, 
scattered over the whole length of the tube.Ӥ Small cysts, contain- 
ing a clear, colorless viscid fluid, are occasionally found :|| they proba- 
bly originate from obstructive distension of the mucous follicles. 
has described a case in which a cyst was situated on the posterior wall 
of the oesophagus one and a half centimetres from the cardia. It was 
of the size of an apple, and was filled with liquid, which was found, on 
microscopic examination, to contain globules of free mucus and ciliated 
epithelium. Sappey** states that he has on several occasions seen cysts 
* Schmieder; Fagge. f Coats. } Dallas. 
| Ziemssen’s Cyclopaedia, vol. viii., p. 168. 
|| Ibid. Also, Fagge: Loc. cit. 
f Loc. cit. ** Op. cit., t. iv., p. 155. Foot-note. NOX-MALIGNANT TUMORS OF THE GULLET. 
113 
in the gullet, and he describes one case, in which there were about twenty- 
small cysts, varying from ten to twelve millimetres in length. Fibromata 
are also met with, and often attain a much larger size than the growths 
already described. They are usually single, but occasionally multiple. 
In Schneider’s case, as already remarked, three polypi were found after 
death. These tumors vary in size from a currant to a hazelnut, but 
sometimes attain much larger proportions. In Rokitansky’s case, the 
polypus measured seven and a half inches in length, and its broadest 
part was two and a half inches in thickness. The mucous mem- 
brane covering the growth is generally smooth, but sometimes it 
is rough, and covered with papillae. In Bail lie’s case the surface of the 
growth was considerably ulcerated. In the well-known instance, re- 
ported by Middeldorpf, the exact origin of the growth was not ascer- 
tained. It may have grown from one of the ary-epiglottic folds or 
from the posterior part of the cricoid cartilage, or from the upper part 
of the oesophagus. On making the patient vomit, a large purple 
body, which at first appeared to be the tongue, was thrown forwards 
against the teeth. The tumor, which was ligatured, and then removed, 
was three inches long, and half an inch wide; it was smooth and glis- 
tening, somewhat uneven and warty at the lower part, and superficially 
ulcerated. It had a covering of pavement epithelium, beneath which 
were conical papillae, and under these again was embryonic connective 
tissue. In Tonoli’s case, the growth was oblong in shape, and was at- 
tached by a short stalk to the left side of the gullet at the lower part 
of its middle third. 
Weigert* has reported a case of adenoma polyposum about the size of 
a hazelnut, which grew from the anterior wall of the lower third of the 
oesophagus. It contained numerous hollow spaces, lined with cylin- 
drical epithelium, and surrounded by a stroma of connective tissue. 
Zenker and Ziemssen,f in commenting on this case, remark that it 
probably originated in the mucous follicles. 
Lipomata are stated by Laboulbene| to be occasionally found in the 
oesophagus, but he does not refer to any actual cases. 
As already stated, examples of myomata have been recorded by 
Eberth, Arrowsmith, Coats, and Hilton Fagge. In the last-mentioned 
case, the patient, who was under the care of Mr. Bryant, died from the 
effects of an injury to the knee-joint, and there was no mention of dys- 
phagia in the clinical history. The tumor grew from the anterior wall 
* Virchow’s Archiv, 1876, Bd. Ixvii., pp. 516, 517. 
f Cyclopaedia, vol. viii., p. 169. 
J Nouv. Eldm. d’Anat. Pathol., Paris, 1879, p. 91. 114 
DISEASES OF THE THROAT AND NOSE. 
of the oesophagus just below the level of the bifurcation of the trachea. 
It was about two inches in length, one and a quarter in width, and one 
inch in thickness. In Coats’s case, the patient was a man, aged sixty- 
one, and the growth was elongated, and irregularly oval in shape. It 
was attached to the posterior wall of the oesophagus, six inches and 
three-quarters below the level of the glottis, by a thin fibrous pedicle, 
one inch and three-quarters long, which was inserted into the body of 
the tumor, two inches below its upper end. The polypus measured 
four inches and three-quarters from above down, two from side to 
side, one to one and a quarter from before backwards. The surface 
was irregularly lobulated, generally grayish in color, but of dark brown 
tint at the upper part. The body of the tumor was horizontally con- 
stricted, the upper part being larger than the lower. Portions of the 
surface had an appearance of sloughing. On section the growth was 
tough, but not very dense. The oesophagus was dilated near the seat 
of implantation of the polypus, and its surface was of a slaty color, and 
ulcerated in several parts, two of the ulcers having eaten through the 
mucous coat, and one through the entire thickness of the gullet-wall. 
Diagnosis.—There is considerable difficulty in diagnosing these tu- 
mors, for, as has been observed, they sometimes give rise to no symp- 
toms at all, whilst in other instances they produce almost the same 
symptoms as malignant growths. As compared, however, with cancer, 
the dysphagia, as a rule, progresses much more slowly, and it may be 
years before it gives rise to serious inanition. When the growth has a 
long pedicle it may be occasionally protruded into the mouth, and in 
other cases it may be seen with the laryngeal mirror or with the oesoph- 
agoscope. Careful examination of the neck and chest will eliminate 
cervical and mediastinal tumors. 
Prognosis.—The prospects of the patient must depend on the situa- 
tion of the growth, on its size, and on the rapidity of its increase. 
Small warty growths need give rise to no anxiety, but if the polypus 
be large it must be looked upon as a serious disease, which at any mo- 
ment may so much interfere with deglutition as to briug the patient’s 
life into immediate danger. 
Treatment.—When the tumor is projected into the mouth it may be 
ligatured and cut off. This course, as already mentioned, was pursued 
by Middeldorpf, whilst in the earlier case of Dallas a ligature was 
applied, the polypus was again swallowed, and allowed to come away 
per anum. In this instance, owing to the dyspnoea that was produced 
when the polypus was vomited into the mouth, it was necessary to per- 115 
NON-MALIGNANT TUMORS OF THE GULLET. 
form tracheotomy as a preliminary measure. When a ligature has 
been applied it is highly desirable that the patient should remain under 
close observation, as in one case in which separation occurred during 
sleep, the growth became impacted in the pharynx and caused fatal 
apnoea.* In two cases that came under my own care some years ago, 
in which I had not diagnosed the growth, polypi were removed with 
the parasol-probang, which was used because the patients were under 
the impression that they had foreign bodies in their throats. In a more 
recent instance I was fortunately able, by means of the oesophagoscope, 
to diagnose a small polypus, situated about one inch below the upper 
orifice of the oesophagus, and to remove it with forceps. 
Should a growth, which cannot be removed per vias naturales, occupy 
the upper part of the gullet, recourse should be had to oesophagotomy, 
whilst if the tumor be in the lower part of the tube, gastrostomy offers 
a prospect of permanent relief. 
CASES OF NON-MALIGNANT GROWTH IN THE GULLET. 
Case 1.—Mrs. M., aged thirty-seven, was sent to me by Mr. Symonds, of Oxford, in 
March, 1874. She had felt some difficulty in swallowing for eleven months; but dur- 
ing the eight weeks previous to her coming under my observation, the.dysphagia had 
become intensified to such a degree that she could take only liquid nourishment. The 
patient stated that she had lost flesh, and she was afflicted with a troublesome cough. 
Laryngoscopic examination showed that her larynx was healthy, and no sign of disease 
could be found in the lungs. From the fact that she had first noticed a difficulty in 
swallowing whilst eating hashed pheasant, Mrs. M. was under the impression that a 
bone had stuck in her throat. A bougie (No. 10 English measure) was passed with 
some trouble, a hitch having been felt in the upper third of the gullet. Two days 
later I introduced a parasol-probang, and on withdrawing it with a little difficulty, a 
round smooth growth of about the size of a marble, with a pedicle half an inch in 
length, was brought up with the instrument. The patient spat up two or three drachms 
of blood, and next day was unable to swallow even liquids. On the second day, how- 
ever, the dysphagia had abated, and by the end of a week it had quite passed off’. J 
saw this lady again in 1875, and she had experienced no further difficulty in degluti- 
tion. On microscopic examination the growth proved to be of true fibrous structure, 
the fibrillse being arranged concentrically round a white nuclear portion, and the whole 
being covered with squamous epithelium. 
Case 2.—The Eev. P. E., aged forty-seven, consulted me in June, 1875, on account 
of difficulty of swallowing. This symptom was first noticed two years and a half pre- 
viously, after eating some fish, and the patient attributed the trouble to the lodgment 
of a bone. The difficulty in swallowing had increased by slow but not regular degrees. 
At first it was slight, and only came on occasionally, whilst at other times the food 
went down perfectly well. During the first six months of 1874 the dysphagia passed 
off, but in the beginning of July of that year it suddenly returned, and since then there 
had always been some trouble. The patient stated that he had consulted several prac- 
* Dubois: Loc. cit. 116 
DISEASES OF THE THROAT AND NOSE. 
titioners, and on two occasions attempts had been made to pass a bougie, but he was 
under the impression that the instrument had been stopped in the upper part of the 
throat. These measures had not given him any relief. At the patient’s urgent solici- 
tation, rather than with the idea of meeting with any foreign body, I passed a parasol- 
bougie. Though it went down easily, I had some difficulty in pulling it up, and was 
about to release the web of the bougie, when the obstruction suddenly yielded, and on 
withdrawing the instrument a small pedunculated tumor, about the size of a bantam’s 
egg, fell from the patient’s mouth. He subsequently brought up about a teacupful of 
blood. I forbade the patient taking any solid food, but this injunction was scarcely 
necessary, as for several days he experienced considerable pain even in swallowing 
liquids. There was no return of the bleeding. The patient ultimately made a good 
recovery, and I heard in January, 1878, that he was perfectly well. The tumor was 
of somewhat oval shape, though one side was very much flattened, and the surface 
ulcerated. On microscopical examination made by Dr. Stephen Mackenzie, it was 
found to be of fibrous structure, but covered, except at the ulcerated point, by pave- 
ment epithelium. 
Case 3.—Miss P., aged twenty-seven, consulted me in August, 1880, on account of 
difficulty of swallowing, which had existed more or less for six or seven years. Ex- 
amination with the oesopliagoscope revealed an oval, semi-transparent polypus, situated 
on the right of the gullet, one inch below the cricoid cartilage. On August 28th, in 
the presence of Mr. C. L. Taylor, I removed a growth about the size of a white currant. 
The patient felt some slight pain for twenty-four hours after the operation ; but at the 
end of a week she was able to swallow perfectly, and has not since had any recurrence 
of the symptoms. The following is the report of Dr. Stephen Mackenzie on the speci- 
men : “ The surface of the growth is covered with squamous epithelium, beneath which 
is a very lax oedematous and highly vascular mass with numerous lymphoid cells 
(leucocytes) infiltrated into the tissue. It appears, in fact, to be a polypus arising from 
chronic inflammation of the oesophageal mucous membrane.” 
SYPHILIS OF THE GULLET. 
Latin Eq.—Syphilis oesophagi. 
French Eq.—Syphilis de l’oesophage. 
German Eq.—Syphilis der Speiserohre. 
Italian Eq.—Sifilide del esofago. 
Definition.—Constitutional syphilis manifesting itself within the gul- 
let by the usual secondary or tertiary lesions, or more rarely occurring in 
the congenital form, causing dysphagia and occasionally leading to death 
by marasmus. 
History.—Severinus,* who lived in the latter part of the sixteenth and the first half 
of the seventeenth centuries, appears to have been the first writer who called attention 
* Quoted by Lieutaud : Hist. Anat. Med., Parisiis, 1767, t. ii., lib. iv\, obs. 105. SYPHILIS OF THE GULLET. 
117 
to this disease, and his contemporary, Rhodius,* recorded the case of a patient suffer- 
ing from syphilis, in whom a growth was found originating from cicatricial thickening 
at the lower end of the oesophagus. Ruysch,f who flourished somewhat later, gave an 
account of a case treated by himself and Boerhaave, in which very severe dysphagia, 
due apparently to some obstruction at the level of the fifth or sixth dorsal vertebra, 
yielded to a short course of mercurial baths.J In 1820 Palletta§ described an example 
of dysphagia occurring in a patient who had previously suffered from syphilis; the 
difficulty of swallowing came on on two occasions, and each time readily yielded to 
mercurial treatment. The first mention of congenital syphilis in the oesophagus was 
made by Billard,|| who found ulcers which he considered to be of specific character, 
in the gullet of a girl six days old. In recent years a few additional examples of 
oesophageal syphilis have been observed. In 1860, of Birmingham, published 
two cases which settled the question as to the occurrence of syphilis in the oesophagus. 
He also quoted three other supposed examples of the same disease, two from Car- 
michael, and one from Turner. From a careful perusal of the notes, however, it ap- 
pears that in all these instances the disease was situated in the pharynx West** soon 
afterwards related a third example occurring within his own experience, in which a 
woman, suffering from rupia and ulceration on the face and legs, died from marasmus, 
consequent on inability to swallow. Follinf f refers to two cases which had come under 
his notice. In one there was palmar psoriasis and dysphagia; the latter symptom 
disappeared without instrumental treatment. In the other the lesion was probably 
more severe, and only a partial cure was effected. YirchowJJ states that he has in 
his possession two specimens illustrating the disease. In one of them he describes a 
softened gumma closely connected with a contracting cicatrix in the oesophagus. In 
the other case the preparation shows a flat ulcer with a “fatty indurated base.” Wilks 
and Moxon§§ affirm that they have seen in a syphilitic subject two yellowish gumma- 
tous patches in the oesophagus, and in another instance they describe the gullet as 
having been penetrated by a large soft syphilitic deposit originally outside it. The 
same authors also allude to a specimen showing a contracted cicatrix in the oesophagus, 
which they consider to be probably due to syphilitic lesion. Knott|||| has added two 
cases. One of them—a specimen of ulceration of the oesophagus—was brought before 
the Pathological Society of Dublin in 1839 by Cusack. In another case that had 
come under Knott’s own notice, severe oesophageal dysphagia occurred in a patient 
* Obs. Anat. Med., Patavii, 1657, Cent, ii., obs. 46. 
f Advers. Anat. Med.-Chir., Arastelodami, 1717. Decad i., obs. x., p. 24 et seq. 
J Haller has been quoted (Follin, Retr4cissements de l’CEsopliage, Paris, 1853, p. 
30), as describing a case of syphilitic stricture of the gullet which was cured by the 
use of mercurial pills. On reference to the original report, however (Opuscula Patho- 
logica, obs. lxxviii., in Haller’s Opuscula Minora, Lausannse, 1768, t. iii., pp. 380, 381), 
I can find no evidence whatever, either that the disease was venereal or that Haller 
considered it to be so. 
\ Exercit. Pathol., Mediolani, 1820, p. 226 et seq. 
|| Traits des Maladies des Enfants nouveau-nfes, Paris, 1833, p. 307. 
Dublin Quarterly Journ. of Med. Science, February, 1860, No. 57, p. 86 et seq. 
** Ibid., August, 1860, vol. xxx., p. 29 et seq. 
ff Trait6 E16m. de Pathologie externe, Paris, 1861, t. i., p. 696. 
Die Krankhaften Geschwiilste, Berlin, 1864-65, Bd. ii., p. 415. 
\\ Pathological Anatomy, London, 1875, 2d ed., pp. 365, 366. 
1111 Pathology of the (Esophagus, Dublin, 1878, p. 161. 118 
DISEASES OF THE THROAT AND NOSE. 
suffering from tertiary syphilis who quickly recovered the power of swallowing under 
the use of iodide of potassium. In 1868 Steffen* recorded two cases of ulcers of the 
oesophagus found in children suffering from congenital syphilis. In 1870 a case was 
published by Maury,f of Philadelphia, in which syphilitic stenosis of the gullet ren- 
dered gastrostomy necessary. In 1873 Podrazkij described a case in which a man, 
who had suffered from severe tertiary syphilis, experienced difficulty in swallowing 
during more than two years ; gradual dilatation was tried without success, but great 
benefit was afforded by mercurial inunction. After death a cancerous stricture was 
found, but from the long duration of the symptoms, and the temporary good effect of 
the anti-syphilitic remedy, it is probable that the affection was venereal at least in the 
earlier part of its course. In 1874$ I recorded a case of probable syphilitic ulcera- 
tion of the oesophagus which had caused dysphagia on previous occasions, and which 
was relieved by iodide of potassium. In the following year an example of oesopha- 
geal syphilis was related by Godou.|| The patient, a man aged twenty-four, recovered 
rapidly under the use of iodide of potassium and ice. In 1876 Reimerf published a 
case of congenital syphilis occurring in a boy of tw'elve; besides many other lesions, 
there was a sinus opening on the surface of the neck and leading into the oesophagus. 
The tissues of the gullet for some wray round the ulcer were diseased. In 1877 
Bryant** related an instance of oesophageal stenosis occurring in a tubercular subject, 
which he considers to have been due to syphilitic ulceration. The dysphagia was so 
severe that gastrostomy wras judged necessary. In the same year Lutonff gave a brief 
account of a case in which a man aged forty, suffering from syphilitic disease of the 
gullet which had resisted treatment by mechanical dilatation, wras speedily and per- 
manently cured bv iodide of potassium. A case has been reported by BillrothR in 
which serious difficulty of swallowing was caused by syphilitic deposit behind the 
cricoid cartilage. The patient, a man aged fifty-five, had condylomata in the mouth 
and on the tongue. The dysphagia yielded promptly and permanently to anti-venereal 
remedies combined with mechanical dilatation. 
Etiology.—When the system has become infected with the venereal 
poison, local manifestations may take place in any part of the body. 
The oesophagus, however, shows comparatively little proclivity to syph- 
ilitic affections, and is probably attacked only when previous disease or 
injury has produced a locus minoris resistentice at some point in the 
canal. Hereditary syphilis probably shows itself but seldom in the 
gullet; indeed, I know of no cases but those of Billard, Steffen, and 
Reimer, above referred to, in which this form of the affection has been 
actually observed.§§ 
* Jahrb. fur Kinderheilk., vol. ii., p. 144. 
f Amer. Journ. Med. Sci., April, 1870, p. 356. 
t Wien. Med. Wochenschr., 1873, Nos. 33, 35, 36. 
\ Lancet, May 30th, 1874. 
|| Archives of Dermatology, 1875, vol. i., p. 276. 
][ Jahrb. f. Kinderheilk., vol. x., p. 98. ** Lancet, 1877, vol. ii., p. 9. 
ff Nouv. Diet, de Mfid., Paris, 1877, t. xxiv., pp. 403, 404. 
Clinical Surgery, Syd. Soc. Transl., London, 1881, p. 128. 
§§ It was formerly believed that congenital syphilis of the larynx was extremely 
rare, but the recent researches of Dr. John Mackenzie, of Baltimore (Amer. Journ. SYPHILIS OF THE GULLET. 
119 
Symptoms.—The chief of these is dysphagia, which, in its mode of 
development, greatly resembles that due to swallowing an irritant or 
mild corrosive poison. Thus, difficulty of deglutition occurs at the 
time the ulcer forms, disappears as it heals, and recurs when the cica- 
tricial tissue begins to shrink. 
Fig. 14. 
Syphilitic Cicatrices in the (Esophagus. 
(Seen from behind.) 
o and a', anterior wall of gullet; b, sides of the gullet thrown outwards; c, situation 
of transverse ridges of cicatricial tissue (above and below them vertical ridges are 
seen); d, posterior surface of cricoid cartilage (between d and a a portion of the pos- 
terior wall of the trachea is visible); e, left, and/, right bronchus; g, edge of trachea. 
Pathology.—The morbid changes closely resemble those met with in 
the pharynx and larynx—that is to say, simple ulceration of the mucous 
membrane may take place; or gummata may be formed in the sub- 
Med. Sci., October, 1880), have proved this condition to be of more frequent occur- 
rence than was previously supposed, and if the gullet could be thoroughly examined 
during life in patients suffering from congenital syphilis, this canal also would prob- 
ably be found to be affected much more often than is generally suspected. 120 
DISEASES OF THE THROAT AND NOSE. 
raucous tissue, which slowly break down, ulcerate, and give rise to rigid 
contracting cicatrices.* In my first case there was a single raised cica- 
tricial band just below the cricoid cartilage. It was nearly half an inch 
in width, and ran. round the tube for three-fourths of its circumference, 
reducing the canal to the size of a No. 3 oesophageal bougie (old Eng- 
lish scale). In my second case (Fig. 14) slightly raised transverse 
ridges occupied the anterior wall of the gullet one inch and a half below 
the cricoid cartilage, the upper and lower bands giving off short vertical 
spurs. There was very little thickening of the walls of the gullet 
except immediately beneath the cicatricial bands. In one of West’s 
cases the oesophagus was constricted four inches below its upper orifice 
for about two inches and a half, and the narrowed portion, owing to 
thickening of the mucous membrane, and fibrous deposits in the form 
of bands and ridges, presented very much the appearance of an old 
stricture of the urethra. In another case reported by West the oeso- 
phagus presented reddish livid erosions for about two inches above the 
cardiac orifice, and there was a considerable amount of fibrous deposit 
in the submucous tissue. Laboulbenef found in the gullet of a man, 
aged thirty, who had died of acute oedema of the larynx caused by an 
ulcerated growth in that situation, scars of old ulcers and interstitial 
deposits of a hard, whitish, fibroid material, which infiltrated the mu- 
cous membrane. All who saw it agreed that it was of gummatous 
nature. 
Diagnosis.—The diagnosis of syphilitic disease of the gullet is ex- 
tremely difficult, and under the most favorable conditions can never 
amount to anything more than conjecture. The affection presents no 
pathognomonic feature, and the surgeon can only come to a probable 
conclusion by a consideration of all the circumstances of the case. The 
history of the patient must always be carefully investigated. Inqui- 
ries should be made as to the previous occurrence of skin eruptions, 
loss of hair, miscarriages, nocturnal pains in the shin-bones, and the 
various other symptoms indicative of constitutional syphilis. The skin, 
tongue, pharynx, and larynx should be carefully examined to see if 
there are any old scars or patches of induration ; nodes should be sought 
for on the front of the tibia, and the condition of the sub-occipital 
* Berkeley Hill: Syphilis and Local Contagious Disorders, 1868, p. 127. 
f Nouv. E16m. d’Anat. Pathol., Paris, 1879, p. 96. The same writer also states that 
he had met with an example of stricture of the gullet in which a woman suffering 
from tertiary syphilis was cured by iodide of potassium, and refers to two similar cases 
related to him by Fournier. SYPHILIS OF THE GULLET. 
121 
glands should be ascertained. The duration of dysphagia for some 
time, its apparent complete cure by anti-venereal remedies, and its sub- 
sequent recurrence, are the salient features of the malady. 
It is not to be wondered at, however, that, in a matter so beset with 
difficulties, observers are often led astray. It is likely that in many 
instances syphilis of the gullet has been mistaken for cancer, and, on 
the other hand, erroneous conclusions may be arrived at even when the 
history and course of the complaint seem most clearly to indicate a 
specific origin. Thus, in a case of dysphagia which came under my 
own notice, I supposed the symptom to be one of syphilitic lesion at 
the upper part of the oesophagus. This was rendered more probable 
by the fact that the patient was suffering from a well-marked venereal 
affection of the pharynx. After death, however, absolutely no trace of 
disease could be seen in the gullet, and the difficulty of swallowing was 
found to have been due to great enlargement of the posterior part of 
the cricoid cartilage. 
Prognosis.—This is very unfavorable, for though when the lesion 
only amounts to superficial ulceration the patient can generally be re- 
lieved by treatment, there is a great probability of permanent stricture 
resulting from subsequent cicatricial contraction. Although this may 
be sometimes combated for a time by the use of bougies, it very often 
happens that as soon as the patient feels a slight improvement in his 
condition he will discontinue his attendance, and when he again pre- 
sents himself it may be impossible to pass an instrument. When a large 
gumma forms, or when the walls of the gullet become much thickened, 
the prospects of the patient are still more gloomy. 
Treatment.— The constitutional remedies which are suitable in other 
forms of tertiary syphilis may be employed here. When the presence 
of gummata or specific ulcers is suspected, iodide of potassium, in doses 
of ten grains three times a day, will probably quickly relieve all the 
symptoms. Ammonia, which is so useful in combination with this 
drug, should not be given in these cases, as it is apt to irritate the gul- 
let. Should frequent relapses take place, bichloride of mercury (one- 
sixteenth of a grain) twice or three times a day, or the cyanide of mer- 
cury (one-eighth of a grain) may be found beneficial. 
The proper treatment of the actual constriction of the oesophagus will 
be considered under “ Cicatricial Stricture of the Gullet.” 
The first two of the following cases were undoubtedly examples of 
syphilitic disease of the oesophagus, and the last one probably belongs 
to the same category: 122 
DISEASES OF THE TIIKOAT AND NOSE. 
Case 1.—Sarah H., a married woman, aged forty-one, applied at the Throat Hospital 
in June, 1874, on account of difficulty in swallowing. She stated that she had had three 
miscarriages. There was a large rubial eruption over the right shin-bone. Careful 
examination of the pharynx and larynx gave negative results ; but, on attempting to 
explore the gullet, it was found impossible to pass the bougie beyond the upper orifice 
of the canal, even when the patient was under chloroform. Iodide of potassium was 
given, liquid diet of highly nutritious quality was obtained for her, and she was directed 
to wean an infant which she was suckling. In a few weeks Sarah II. had so far recov- 
ered as to be able to swallow semi-solid food. She thereupon discontinued her attend- 
ance. In February, 1875, however, word was brought to the hospital that she was 
dying. Mr. Poyntz Wright saw her several times, but, in spite of every effort to over- 
come the obstruction, her oesophagus was found impermeable, and she soon died from 
exhaustion. After death the canal, about an inch below the cricoid cartilage, was 
found so much narrowed that a No. 3 bougie (old English scale) could with difficulty 
be passed into it. The contracted portion extended downwards for less than half an 
inch in a vertical direction, and consisted of a raised ridge, occupying three-fourths 
of the circumference of the tube. Two whitish nodules, presenting all the appearance 
of syphilitic gummata, one about the size of a filbert, and the other somewhat smaller, 
were found in the liver. 
Case 2.—John W., aged sixty-five, came to me at the Throat Hospital in July, 1376, 
on account of dysphagia. He had suffered from primary syphilis seven years pre- 
viously, and his palate had been perforated by an ulcer in 1874. The patient was 
much emaciated, and very feeble; he had also paresis of the left arm. Examination 
of the pharynx showed no signs of disease, and the larynx was healthy, with the ex- 
ception of slightly impaired mobility of the left vocal cord. The patient could not 
swallow solids at all; but liquids went down pretty easily. On auscultation of the 
gullet prolonged gurgling noises were heard over the sixth and seventh vertebrae, 
whilst below that point the oesophageal sounds were scarcely audible. An attempt to 
pass a No. 6 bougie (old English scale) altogether failed, owing to obstruction just be- 
low the cricoid. Stricture was diagnosed, and it was thought that the disease might be 
syphilitic. No improvement, however, was produced by iodide of potassium; the dys- 
phagia gradually got worse, and the patient died in January, 1877. Post-mortem exam- 
ination showed fine, slightly raised, almost transverse ridges on the anterior wall of 
the gullet (Fig. 14). The uppermost ridge was about an inch and a half below the 
lower border of the cricoid cartilage, and from it two spurs passed upwards. The lowest 
transverse ridge also sent a prolongation downwards. These ridges were darker in 
color than the rest of the mucous membrane, and presented an uneven surface. The 
walls of the gullet were very little thickened, except just beneath the ridges. 
Case 3.—A man, aged sixty-one, came under my care in June, 1873. He had suf- 
fered since the foregoing February from dysphagia, which had gradually become worse, 
till, when I saw him, he could only swallow fluids. He had had venereal disease 
eighteen years before, and had on two different occasions since then suffered from diffi- 
culty of swallowing. One of these attacks had occurred eleven and the other four years 
previously. There was neither cough nor expectoration, and the pharynx appeared 
healthy, with the exception of a slight cicatricial puckering on the right anterior pillar 
of the fauces. The larynx was normal. On auscultation of the gullet, however, the 
“ morsel ” was found to be arrested at a point opposite the sixth dorsal vertebra, and 
on exploration with the bougie a tight stricture was recognized about the junction of 
the lower with the two upper thirds of the gullet. Iodide of potassium was given, and 
in ten days the patient had recovered his power of swallowing. TUBERCULAR DISEASE OF THE GULLET. 
123 
Although the evidence in this case amounts to no more than probability, I think it 
may be accepted as a genuine example of syphilitic stenosis. The previous history of 
the patient, and especially his rapid recovery under iodide of potassium, point clearly 
to such a conclusion. 
TUBERCULAR DISEASE OF THE GULLET. 
This affection is characterized by the secondary deposit, in the mucous 
membrane of the oesophagus, of tubercles, which break down in the 
ordinary way and end in ulceration. It is only in comparatively recent 
times that this disease has been recognized. The first mention of it 
appears to have been made by Andral,* who speaks of finding tuber- 
cles beneath the oesophageal mucous membrane. Some years later a 
case was reported,f in which tubercles were found at the upper part 
of the gullet. In 1851 OppolzerJ referred to tubercle of the oeso- 
phagus as a pathological curiosity. An instance of the affection was 
recorded by Willigk,§ in 1854, and ten years later Maisonneuve|| related 
an example of stricture of the upper part of the gullet, caused by tuber- 
cular infiltration. In 1868 a conclusive case was published by Chvo- 
and a doubtful one by Paulicki.** Zenker and Ziemssenff briefly 
allude to two cases which 11 they believe could be called tubercular.” One 
of these, however, appears to have been merely an example of caseous 
peri-oesophageal glands perforating the gullet. The account of the 
other case is so meagre that it is impossible to arrive at any independent 
opinion as to its nature. In both instances the microscopic examina- 
tion gave only negative results. Knotty quotes a case which was re- 
ported to the Pathological Society of Dublin by Professor R. W. Smith. 
Laboulbene§§ states that he has met with two instances of the disease, of 
which he had unfortunately neglected to keep notes. The etiology of 
the disease is obscure, the well-known tendency of tubercle to become 
* Prteis d’Anat. Pathol., Paris, 1829, t. ii., p 274. 
f Wiirtemberg Med. Corresp. Blatt., 1844, Bd. xxiii. 
J Wien. Med. Wochenschrift, 1851, Nos. 2, 5, and 12. 
§ Prag. Vierteijahrschr., 1854, lx., 4. 
|| Clinique Chirurgicale, Paris, 1864, t. ii., p. 410. 
(Esterr. Zeitschr. fur prakt. Heilk., 1868, xiv., 17 and 18. 
** Virchow’s Arcliiv, 1868, Bd. xliv., pp. 373-375. 
ff Cyclopaedia of Pract. Med., vol. viii., p. 191. 
Pathology of the (Esophagus, Dublin, 1878, p. 215. 
$$ Nouv. Elbm. d’Anat. Pathol., Paris, 1879, p. 95. 124 
DISEASES OF THE THROAT AND NOSE. 
developed in various organs after its primary deposit in the lungs being 
manifested only to a very slight extent in the oesophagus. No satisfac- 
tory evidence of the primary occurrence of tubercle in this situation has 
yet been produced, though in the case quoted by Knott the dysphagia 
was present some months before there was any evidence of pulmonary 
mischief. I have myself never seen an example of the disease. It is 
probable, however, that it is more common than the small number of 
recorded cases would lead us to suppose, and I have little doubt that 
examples of it will be more frequently met with as the pathology of 
the gullet comes to be more closely studied. 
From the few cases on record this affection would appear generally 
to occur in middle life or old age, and it has not hitherto been met with 
in children. The only symptoms are dysphagia and odynphagia, the 
former being generally the more marked. In Chvostek’s case the 
patient, a man aged forty-three, was attacked by acute pulmonary 
tuberculosis in April, 1865; pain and difficulty in swallowing came on 
in January, 1866, and the patient died a week or two later. Paulicki’s 
patient began to suffer from dysphagia two months after the first signs 
of lung disease showed themselves, and death was very gradual. 
The pathological changes vary greatly in different cases. In that of 
Chvostek, pleurisy, pulmonary tubercle, and enlargement of the liver 
were found, but there was no intestinal ulceration. The mucous mem- 
brane of the gullet was smooth and unbroken at the upper part, but 
downwards from the level of the third dorsal vertebra there were 
numerous ulcers of various shapes with sharp-cut edges. In some in- 
stances the ulcers had a smooth, in others a villous, base of dark-gray 
color. Over their surface were scattered whitish-yellow nodules, from 
some of which a thick yellowish purulent fluid could be squeezed out. 
The character of the ulcers in this instance was established microscopi- 
cally by Professor Engel, whilst in Paulicki’s case the tubercular origin 
of the oesophageal lesions was rendered probable by the history of the 
disease, although microscopic examination failed to prove it. Here, 
together with signs of old pleurisy, a suppurating cavity was found in 
the left, and some caseous deposits in the right apex. In the gullet, at 
the level of the cricoid cartilage, there was a stricture; and on the pos- 
terior wall were two ulcers, one of them being half an inch in length 
and reaching through the entire depth of the mucous membrane, which 
was congested for some distance round. 
The diagnosis of this affection from cancer of the oesophagus must 
rest chiefly on the fact that the dysphagia is not regularly progressive; DILATATIONS OF THE GULLET. 
125 
there is probably, too, in most cases abundant evidence of tubercular 
deposit in the lungs. The fact that malignant disease of the gullet 
occasionally coexists with tubercle of the lungs must not, however, be 
forgotten, and hence, even when there is undoubted evidence of pul- 
monary phthisis, it cannot be absolutely determined that the oesophageal 
disorder is of similar nature. 
As the disease has not hitherto been detected during life, nothing can 
be said as regards prognosis. The affection can only be treated symp- 
tomatically; if there be much pain in swallowing, hypodermic injec- 
tions of morphia should be given. 
DILATATIONS OF THE GULLET. 
(Synonyms : Diverticula. Pouches.) 
Latin Eq.—Dilatationes oesophagi. 
French Eq.—Dilatations de l’oesophage. 
German Eq.—Ervvei ter ungen der Speiserohre. 
Italian Eq.—Dilatazioni del esofago. 
Definition.—Sacculated protrusions from the oesophageal canal, or 
uniform expansion of its walls, giving rise to dysphagia and regurgitation 
of the ingesta. 
History.—Bias ins* described, under the name of “ double stomach,” what, from his 
own report, and the rough drawing which accompanies it, was undoubtedly an instance 
of dilatation of the lower part of the gullet. A case of oesophageal pouch was referred 
to by Morgagnif in 1765 as having been described by Grashuis long before, and two 
years later LudlowJ reported his remarkable case. Isolated examples of the affection 
have, since then, been placed on record by Gianella,§ Bell,|| Worthington,** 
* Obs. med. anat. rarior., pars, iv., obs. ix. Lugdun. Batav., 1711, p. 53, and Tab. 
vi., Fig. 5, ibid., p. 113. 
f De sed. et caus. morb., epist. xxviii., art. 18, ed. secund., Patavii, 1765, t. ii., p. 11. 
t Med. Observ. and Inquiries, by a Society of Physicians in London, London, 1767, 
vol. iii., p. 85 et seq. Ludlow’s letter describing the case is dated September 9th, 1764. 
\ Borsieri: Istituz. di Med. Prat., cap. xxxix., \ mccxix., Firenze, 1837, t. ii., p. 
998, foot-note 4. The case was observed in 1782. 
|| Surgical Observations, London, 1817, vol. i., p. 64 et seq. 
f London Med. and Phys. Journ., 1821, xlvi., p. 541. 
** Med.-Chir. Trans., London, 1847, vol. xxx., p. 199 e< seq. 126 
DISEASES OF THE THROAT AND NOSE. 
Mayo,* and others. In 1840, Rokitansky! described an instance in which part of the 
oesophageal wall had been drawn outwards in the course of cicatrization of a diseased 
lymphatic gland—a class of cases to which Zenker and Ziemssen subsequently gave 
the name of “ traction-diverticula.” In 1861 Rokitansky! described systematically 
the various kinds of dilatations which are found in the pharyngo-oesophageal canal. 
In 1867 an inaugural dissertation on the subject of oesophageal pouches was published 
by Fridberg-3 In recent years, Zenker|| has collected a large amount of pathological 
material bearing especially on the question of traction-diverticula, and the whole sub- 
ject has been treated with remarkable completeness by Zenker and Ziemssen. 
*** Dilatations differ so wddely as regards their mode of origin, 
situation, symptoms, course, and termination, that in dealing with them 
it will be found more convenient to depart from the regular plan adopted 
in this work, and to describe separately each form of the disease. 
Simple Dilatations. 
These dilatations may be either primary or secondary—the former 
occurring without any obvious cause, and the latter being the result of 
a stricture of the oesophageal canal at a lower level. 
Primary Dilatations. 
These are cylindrical or fusiform in shape, generally affecting the 
whole length and circumference of the oesophagus, and usually attain- 
ing their maximum girth in the thoracic region about the middle of the 
gullet. The fact of the widest expansion occurring in this situation is 
probably to be explained by the greater freedom of the tube at this 
point from immediate pressure by the neighboring parts. In the case, 
however, described and figured by Blasius,** the dilatation was just 
above the diaphragm, and affected only the lower three inches of the 
gullet. Judging from the drawing, the dilatation must have been 
spheroidal in shape, measuring about four and a half inches from side 
to side. 
This form of dilatation is rare, and the cause of it is probably general 
weakness, congenital or acquired, of the oesophageal wall in its whole cir- 
cumference. In most of the recorded examples the symptoms appear 
* Outlines of Pathology, London, 1835, p. 285. 
f CEsterr. Jahrb., 1840, Bd. xxi., p. 219. 
$ Lehrbuch d. pathol. Anat., vol. iii., p. 127. 
\ Diss. de oesophagi diverticulis, Giessen. 
|| Cyclopaedia of Pract. Med., vol. viii., p. 68. y Ibid. 
** Op. cit. See also von Ammon, Die angeborenen chirurg. Krankheiten des Men- 
schen, Berlin, 1842, p. 37, and Taf. viii., Fig. 15. DILATATIONS OF THE GULLET. 
127 
to have commenced between the ages of fifteen and twenty, but it is 
probable that in many of these cases the predisposing local weakness 
had existed since birth. One example of feeble development has been 
observed by Zenker* in which simple dilatation of the gullet occurred 
in a seven months’ child which died on the seventh day after birth. 
Klebsf has reported a case of dilatation which he supposed to be due 
to atony of the walls of the tube. Spengler| has recorded an example 
in which the first symptoms came on after swallowing a very hot dump- 
ling, which was temporarily arrested in the gullet. Purton§ has re- 
ported a case in which the affection developed after a blow on the chest, 
and a similar instance is related by Hannay.|| An example of the 
disease is mentioned by in which the patient had taken 
large quantities of warm water to relieve gout. Although it is not at 
all impossible that in this case mechanical dilatation may have been 
effected in the manner described, it is much more likely, as Knott** 
suggests, that a gouty condition of the muscles of the oesophagus dimin- 
ished their power of resistance, and thereby favored dilatation. 
The most prominent symptom exhibited by patients laboring under 
this affection is the regurgitation of food some hours after it has been 
swallowed. The matters thus returned are alkaline or neutral in reac- 
tion, and if starchy food has been taken, they have a sweetish taste. 
They present no digestive alteration, however long they may have been 
retained; thus, in a case reported by Delle Chiaje,ft coffee was thrown 
up four or five days after it had been swallowed without having under- 
gone any change whatever. There is generally a greatly increased 
secretion of saliva, which the patient has continually to spit out. In 
Worthington’s case a pint and a half of fluid was frequently voided 
from the mouth in the course of twenty-four hours. There is usually 
also some dysphagia. 
The patient’s breath is in most cases fetid owing to the decomposition 
of the food which remains in the gullet. Sometimes there is an ago- 
nizing feeling of distension, from which relief can only be obtained by 
vomiting. Occasionally there is a sensation of heat or burning through- 
* Op. cit., p. 51. 
f Quoted by Zenker: Ziemssen’s Cyclopaedia of Pract. Med., English transl., vol. 
viii., p. 47. 
% Wien. Med. Wochenschr., 1853, No. 25. 
\ London Med. and Phys. Journ., 1821, xlvi. 
|| Edin. Med. and Surg. Journ., July, 1833. 
f Wien. Med. Wochenschr., 1851, Nos. 2, 5, 12. 
** Op. cit., p. 21. ff II Progresso, Napoli, 1840. 128 
DISEASES OF THE THROAT AND NOSE. 
out the gullet. When the dilatation affects the thoracic portion of the 
tube, the distended oesophagus may, by pressure on the heart, give rise 
Fig. 15. 
Luschka’s Case of Dilated (Esophagus (after Cohen). 
A, the thyroid cartilage; B, the thyroid body ; c, the trachea; d, the oesophagus ; 
E, the stomach. 
to fainting and to symptoms similar to those of angina pectoris. In 
Davy’s* case there was a pulsation resembling that of an aneurism, 
* Med. Press and Circular, May 5th, 1875. 129 
DILATATIONS OF THE GULLET. 
together with considerable pain and tenderness on pressure. There was 
also marked dulness on percussion. This patient was only able to 
swallow in a semi-recumbent position, with his right arm over the back 
of a chair; in any other posture deglutition was impossible, and the 
attempt was accompanied by a sense of suffocation which gave rise to 
violent attacks of coughing. 
A bougie can be passed only in certain cases, the possibility of doing 
so probably depending on whether the oesophagus remains of normal 
length, or whether, becoming stretched, it is doubled upon itself. 
The progress of the disease is generally slow, lasting from five to ten 
years or even more. Indeed, in some cases, sufficient food always 
reaches the stomach, and there is no wasting. A very remarkable case, 
however, has been recorded by Dr. Ogle* in which great emaciation 
resulted, not only from the difficulty of swallowing, but more especially 
from the pressure of the dilated portion of the gullet on the thoracic 
duct. 
In the cases now under consideration, after death the calibre of the 
oesophagus is found to be greatly enlarged, the dilatation being generally 
somewhat spindle-shaped. In LuschkaVf case (Fig. 15) the oesophagus 
was forty-six centimetres in length and thirty centimetres in circumfer- 
ence at the widest part. From the extreme length of the organ in this 
instance, it is clear that during life it must have been doubled upon 
itself. In these cases the muscular fibres over the affected part are 
greatly hypertrophied, the submucous tissue and. the mucous membrane 
being thickened, whilst the latter is almost invariably congested, and 
frequently presents patches of ulceration. Occasionally, haemorrhagic 
spots are seen, and the papillae are often much enlarged. 
The diagnosis of this condition may be assisted by the exclusion of 
the various other causes of dysphagia, but can only be arrived at with 
certainty when, whilst unaltered food is regurgitated some hours after 
it has been swallowed, a large bougie can be easily passed down the 
gullet. 
The prognosis as regards cure is exceedingly unfavorable,'but by 
selection of suitable food the patient’s life may be prolonged for many 
years. 
The treatment must consist in the use of bland liquid food, taken at 
frequent intervals and in small quantities. If alcohol should be indi- 
* Trans. Path. Soc., London, 1866, vol. xvii., p. 142. 
f Virchow’s Archiv., 1868, Bd. xliii., p. 473 et seq. 130 
DISEASES OF THE THROAT AND NOSE. 
cated by the weak condition of the patient, it should be given in a very 
dilute form. 
Secondary Dilatations. 
These are always the result of obstruction. 
Although writers on stricture of the gullet frequently describe dilata- 
tion as existing above the narrowed part, this condition is, in fact, ex- 
tremely rare. Among the very large number of cases of cancer of the 
gullet which I have examined, I have not met with a single example of 
secondary dilatation. Wilks and Moxon* state that they have not seen 
much of the condition, and suggest as reasons for the rarity of its occur- 
rence that in such cases little or no food is taken, and that if the disease 
is malignant, its course is usually too rapid for a dilatation to have time 
to form. A few well-marked instances of secondary dilatation have, 
however, been recorded. Monrof speaks of having found it in cases 
where the gullet had been for a long time obstructed by an impacted for- 
eign body, or “ by any other cause.” has given a drawing of 
a case in which the gullet was narrowed at its lower part and dilated 
above. Lindau§ has described an example which he met with in a man 
aged thirty, who was suddenly seized with difficulty in swallowing; 
after a time the food began to be regurgitated, and the patient died of 
exhaustion rather more than a year after the onset of the complaint. 
The gullet was found dilated in its whole length, but chiefly at its mid- 
dle part, where it measured eleven centimetres across. Around the 
cardiac orifice was a rigid band, the exact structure of which is not de- 
scribed; this ring narrowed the opening, but had not prevented the pas- 
sage into the stomach of a sponge-probang during life. In the dilated 
portion was found one'killogramine (two and one-fifth pounds) of pul- 
taceous fluid, acid in reaction, and horribly foetid, composed of mucus, 
coagulated albumen, and altered blood. The mucous membrane was 
almost completely stripped off. The muscular coats were greatly 
stretched over the expanded portion, the longitudinal and circular 
fibres being separated so as to give them the appearance of forming a 
wide-meshed network. Watson|| refers to a preparation showing dilatation 
of the gullet above a cancerous stricture of the cardiac orifice of the gullet. 
* Morbid Anatomy of the Human Gullet, etc., Edinburgh, 1811, p. 12. 
f Lectures on Pathological Anatomy, London, 1875, 2d ed., p. 364. 
J Anatomie Pathologique, Paris, 1835-42, livraison 38, pi. 6. 
I Casper’s Wochenschr fiir die gesammte Heilkunde, 1840, p. 356. 
|| Principles and Practice of Physic, London, 1857, 4th ed., vol. ii., p. 372. 131 
DILATATIONS OF THE GULLET. 
Gradenwitz* has related a remarkable instance in which the oesophagus 
of a man who had suffered from difficulty in swallowing for forty-three 
years "was found thickened and contracted at the lower part and dilated 
above. He had been in the habit of making the food which accumu- 
lated above the narrowed part pass into the stomach by stretching him- 
self, when it could be heard to go down with a loud gurgling noise. 
In a case of syphilitic stricture, described by We.st.f the constricted 
portion occupied two inches and a half of the oesophagus about its 
middle, and was so narrow as barely to allow a No. 4 catheter to go 
through; above this point the gullet was much dilated. In 1877 a 
case was reported by in which the patient, a girl aged 
four, had swallowed lye two years before she came under notice. 
(Esophagostomy was done with a fatal result, and after death the gullet 
was found narrowed for about eight centimetres at its middle. Above 
the point of stricture the tube was irregularly dilated for two and a half 
centimetres, the bulging being greatest towards the front and the left 
side. In 1878 Gouguenheim§ described a case of oesophageal stricture, 
probably malignant in character, in which the gullet was dilated above 
the seat of disease, the walls of the expanded portion being greatly 
thinned. Soon afterwards a good example of secondary dilatation was 
published by Brazier.|| The patient was a woman, aged ninety-six, who 
died of cancer of the stomach. The gullet was found greatly constricted 
for six or seven centimetres at its lower end; above this narrowed por- 
tion was a dilatation extending some way upwards, and measuring 
“some centimetres” across. The mucous membrane lining this pouch 
was sodden and pulpy, owing probably to the prolonged sojourn of food 
at this part. The oesophageal wall at the point of stricture was found to 
consist entirely of bundles of muscular fibres, so rigid as almost to sug- 
gest the idea of contraction. A case has recently been recorded by Mar- 
in which the gullet was expanded above the situation of an epi- 
theliomatous growth ; this being the only instance among thirty autop- 
sies collected by that writer in which such a condition was found. 
A case of a different kind has been reported by Wilks,** in which 
* Schmidt’s Jahrb., 1859, vol. ci., p. 298. 
f Dublin Quarterly Journal of Medical Science, No. 57, February, 1860, p. 86 
et seq. 
X Wien. Med. Wochenschr., 1877, No. 25. 
| Gazette des Hopitaux, 1878, p. 446. 
|| Contribution a l’Etude de l’GSsophagisme. These de Paris, 1879, pp. 89, 90. 
de l’CEsophage. These de Paris, 1880, p. 50. 
** Guy’s Hospital Reports, 1871-2, vol. xvii. 132 
DISEASES OF THE THROAT AND NOSE. 
there was a supposed congenital stricture of the cardiac end of the gul- 
let with great dilatation of the entire organ above the point of constric- 
tion (Fig. 16), but whether the dilatation 
was congenital or secondary to the stricture 
cannot be determined. In cases of strict- 
ure of the gullet, uncomplicated by dilata- 
tion, the food, on reaching the narrow part 
of the canal, is usually at once returned; 
but should there be a dilatation above the 
contracted portion of the tube, the food 
would probably be retained for a time and 
afterwards thrown up unchanged. 
This form of dilatation may be distin- 
tinguished from that last described bv the 
fact that in the case of simple pouches, as 
already explained, there may be a diffi- 
culty in passing a bougie at one time 
and not at another, whilst if a stricture be 
present, the obstruction will be persistent; 
the prognosis depends on the original cause 
of the affection, and the treatment must be 
directed to the stricture. (See “ Cicatricial 
Stricture.”) 
Fig. 10. 
Wilks’s Case of Supposed Con- 
genital Stricture and Dilata- 
tion of the (Esophagus (after 
Knott). 
Sacciform Dilatations. 
These depend on weakness of a small 
portion, generally of the muscular structure, 
of the wall of the gullet. They have been called “ pressure-diverticula ” 
(“ Pulsions-Divertikel ”) by Ziemssen, owing to the fact that they are 
formed by pressure of the oesophageal wall outwards. 
They vary in size from a slight bulging to a sac five inches or even more 
in length. They are rare, and are, in the majority of instances, situated 
in the posterior wall of the oesophagus, at its junction with the pha- 
rynx, and pass down between the food-tract and the vertebral column. 
They are, in fact, pharyngeal rather than oesophageal pouches. Most 
writers believe that these pouches originate in congenital weakness of a 
limited portion of the oesophageal wall. Although the protrusion is 
very slight, and perhaps inappreciable in early life, it is probable that 
the oesophagus gives way under some trifling pressure at a later 
period. Hitherto, no example of this condition has been observed in a DILATATIONS OF THE GULLET. 
133 
newborn infant, or even in a child, but a case has recently been pub- 
lished by Fere,* which furnishes a possible explanation of the mode of 
formation of some oesophageal pouches. Although in this instance 
the deficiency of tissue was not in the situation where a pouch is usually 
formed, but at a spot precisely in the middle of the anterior wall of the 
gullet, the case has a direct bearing on the point under consideration. 
The muscular coat was found to be wanting over a space one milli- 
metre square, and about one centimetre below the upper end of the 
oesophagus. Even with the microscope no trace of muscular covering 
could be seen in this place. The borders of the space were thickened, 
and the interval was filled up by areolor tissue, mingled with some 
elastic fibres. The congenital absence of the muscular covering at any 
point would, it need scarcely be remarked, greatly favor the develop- 
ment of a pouch. Billroth,f however, who has recorded an instance 
in which a pouch on the left side of the gullet was covered, not 
only by the mucous membrane, but by the proper muscular investment 
of the tube, suggests that such diverticula have their origin in a branchial 
fissure, the internal orifice of which remains patent, whilst the external 
outlet has become obliterated in the normal way. Cases are more often 
met with in men than in women. In twenty-nine cases collected by 
Zenker and ZiemssenJ in which the sex is stated, there were but two 
women, and in both of them the origin of the affection was appar- 
ently traumatic. According to the same authors,§ the disease most 
commonly begins after the fortieth year, and they explain the special 
predisposition of males and the age at which the disease occurs by the 
ossification of the cricoid cartilage, which, it is well known, is much more 
frequent and comes on at an earlier age in men than in women. 
Zenker and Ziemssen|| point out that the muscular investment of the 
pharynx is weaker near its junction with the gullet than at any other 
part of the pharyngo-oesophageal canal, for where the lower fibres of 
the inferior constrictor muscle become continuous with the upper circu- 
lar fibres of the oesophagus there is a triangular space left covered only 
by the transverse fibres of the constrictor. Owing to the narrowness 
of the tube just below this, and the comparatively unyielding wall 
formed in front by the back of the cricoid cartilage, a hard morsel of 
food or a foreign body is likely to be driven against the posterior wall. 
* Progres Mfedical, 1879, vii., p. 227. 
f Clinical Surgery, Syd. Soc. Transl., London, 1881, p. 130. 
t Ziemssen’s Cyclopaedia of Pract. Med., English transl., vol. viii., p. 64. 
\ Op. cit., p. 65. || Ibid., p. 59. 134 
DISEASES OF THE THROAT AND NOSE. 
A depression thus made is liable to be constantly enlarged by the 
pressure of descending food; and the pouch, which mainly consists of 
mucous membrane protruded between the muscular fibres, has no power 
of emptying itself by contraction on its contents. As it becomes 
larger it pushes the corresponding part of the oesophagus slightly for- 
wards; and subsequently the food, in descending, tends to pass into 
the diverticulum, instead of going down the normal canal. Further, 
Fig. 17. 
Ogle’s Case of Sacciform Dilatation of the (Esophagus (after Knott) 
as the pouch becomes full, resistance to its distension in a backward 
direction is offered by the vertebral column, and consequently the sac 
presses anteriorly on the oesophagus, and sometimes closes it completely. 
A good illustration of this form of compression is shown in the annexed 
drawing of a case (Fig. 17) reported by Dr. Ogle.* For many years 
the patient had suffered from extreme dysphagia, which was supposed 
to be due to stricture of the tube. Cases originating in the manner 
* Trans. Path. Soc., London, 1866, vol. xvii., p. 141. DILATATIONS OF THE GULLET. 
135 
above described have been published by Ludlow;* Dendy,f and Kuhne.| 
Gassner§ records an instance of the affection in which an officer re- 
ceived a severe injury to his neck in a fall from horseback, which 
gradually resulted in the formation of an oesophageal pouch, which 
ultimately caused his death. In a case reported by Waldenburg|| the 
patient ascribed the origin of the condition to his having been throt- 
tled, whilst in another described by the supposed cause was the 
impaction of a fishbone. Bucking** has related an example (which, 
however, was not verified by post-mortem examination), in which the 
affection was ascribed to wearing too tight a necktie. I have recently 
met with a case (see “Cicatricial Stricture”) in which a small pouch, 
two and a half centimetres in length and four millimetres in diameter, 
resulted from the swallowing; of a strong; alkaline solution. The sac 
was situated about seven centimetres above the cardia. Half of it was 
really a fistulous passage between the muscular coats, but the lower por- 
tion, which projected obliquely downwards and was covered with 
muscle, was a true pouch. The sac communicated with the oesophagus 
by means of three small openings (see Fig. 20, d). It probably became 
developed in the following manner: The caustic solution caused an 
ulcer in which particles of food lodged; further swallowing drove the 
first particles—possibly some gritty substance—more deeply into the 
wall of the gullet, which finally was itself pushed out. 
The symptoms are at first so slight as not to attract much notice. 
They consist chiefly in the temporary retention of small fragments of 
food. It is only when the diverticulum enlarges and begins to press 
on the gullet that medical advice is sought. Owing to the situation of 
the pouch, when it attains any size, it is always visible in the neck at 
the side of the larynx. The swelling may be unilateral or bilateral. 
It is often impossible to pass a bougie, but it sometimes happens that 
it can be pushed down one day and not the next, the possibility of in- 
troducing the instrument depending on the fulness or emptiness of the 
sac. As a rule, when this is full, the oesophageal canal is pressed upon, 
and the bougie cannot be passed, but sometimes when the sac is of 
moderate dimensions, its temporary distension by food prevents the 
sound entering the abnormal cavity, and permits it to traverse the nor- 
* Loc. cit. f Lancet, June, 1848. 
f Froriep: Chirurgische Kupfertafeln, Weimar, 1820-1847, Taf. 392. 
\ Fridberg: Diss. de oesophagi diverticulis, Giessen, 1867. 
|| Berlin Med. Wochenschr., 1870, No. 48, p. 578. 
f Giinsburg’s Zeitschr. fur klin. Med., 1850, Bd. i., p. 344. 
** Baldinger’s Neues Magazin fur Aerzte, 1781, Bd. iii., p. 242. 136 
DISEASES OF THE THROAT AND NOSE. 
mal canal. In an instance reported by Belz* a loud splashing sound 
could be heard on pressing over the episternal notch. As the sac in- 
creases in size a considerable quantity of food lodges in it, and this is 
from time to time regurgitated in a manner somewhat resembling rumi- 
nation. After a time the patient may gradually waste, and actually 
perish from inanition. In many cases, however, death has not taken 
place till an advanced age. 
The pathology of these cases is very simple. The pouch, as already 
remarked, almost invariably forms at the junction of the pharynx with 
the oesophagus, and as it increases in size it usually becomes pyriform 
in shape. The lining membrane of the sac generally shows signs of 
chronic inflammation. The mucous membrane and the submucosa are 
very much thickened, the surface of the former being sometimes cov- 
ered with papillary growths. Zenker and Ziemssenf maintain that the 
sac has no muscular covering except at its neck, but in Worthington’s 
case it is stated that “nearly the upper two-thirds were covered with 
muscular fasciculi derived from the pharyngeal constrictors, the fibres 
of which were unusually developed,” and in Billroth’s case, as already 
pointed out, the sac had a complete muscular covering. The disease does 
not seriously shorten life, for out of nineteen cases collected by Zenker 
and Ziemssen,! in which the age is given, death took place as follows: 
Deaths. 
Between the ages of 40 and 50, 2 
“ “ 50 and 60, ........ 3 
“ “ 60 and 70 8 
“ “ 70 and 80, 5 
At the age of 80, 1 
19 
These authors further point out that the progress of the disease is 
generally very slow, and that in many cases it is reported to have lasted 
from twenty to thirty years, and in one instance for forty-nine years. 
The brief remarks made under “Simple Dilatation ” as to diet and 
treatment apply here. 
Traction-Diverticula. 
The peculiarity of these diverticula is that the cause of them is alto- 
gether external to the oesophageal wall. 
This form of dilatation is relatively common, and is generally found 
on the anterior wall of the oesophagus, most frequently at a point either 
opposite or very near to the bifurcation of the trachea. These diver- 
ticula are generally, but not invariably, conical in shape, the broad base 
* Schmidt’s Jahrb., 1873, Bd. clx., p. 183. 
f Op. cit., p. 57. 
+ Op. cit., p. 64. DILATATIONS OF THE GULLET. 
137 
corresponding to the oesophageal wall, and the apex directed horizon- 
tally forwards or even upwards. The disease probably begins in child- 
hood, and it seems to affect both sexes in nearly equal proportion. Out 
of fifty-four cases collected by Zenker and Ziemssen,* twenty-nine 
occurred in men, and twenty-five in women. The sacs vary in size 
from two to eight millimetres, but occasionally they measure as much 
as twelve millimetres from the base to the apex; indeed, in the case 
reported by Fridberg,f the pouch was one and a half inches long. 
Traction diverticula appear to originate most commonly in scrofulous 
disease of the lymphatic glands, which are so abundant about the bifur- 
cation of the windpipe. The inflammation spreads from the gland to 
the peri-oesophageal areolar tissue, and sometimes reaches even the 
muscular coat; subsequently, fibroid or calcareous degeneration of the 
gland takes place, followed by cicatricial contraction, and it is by the 
latter process that the wall of the gullet is drawn out and a sac formed. 
In some instances the suppuration of a scrofulous gland appears to 
have produced direct ulceration of the oesophageal wall, and in such 
cases the altered gland-structure forms the outer covering of the diver- 
ticulum. It is probable that these are the cases in which the conical 
form is not preserved. Vertebral caries has sometimes led to the for- 
mation of pouches.J The disease occasionally seems to originate in the 
trachea from the inhalation of gritty particles, which, by setting up 
disease in the respiratory passages, may ultimately lead to peri-oesoph- 
ageal contraction. 
As far as I am aware, this form of diverticulum never gives rise to 
any symptoms during life. It is just possible that in some cases the 
orifice of the sac might be seen on the anterior wall with the oesopha- 
goscope. The opening is generally exceedingly black, and the mucous 
membrane around it puckered, and if it came within the range of the 
mirror it could not be mistaken. 
The form and size of traction-diverticula have already been described, 
and it now only remains to be observed, that in those cases in which 
the fundus of the diverticulum has ulcerated, disease of adjacent organs 
is often noticed after death. In such instances a dark-colored fluid and 
occasionally portions of food are found within the sac; and Rokitansky§ 
has reported a case in which a small flat piece of bone was met with, 
which was supposed to have given rise to a perforation at the distal end 
of the diverticulum. In such cases a fistulous tract may even extend 
to the pericardium, the pleural cavity, or the apex of one of the lungs, 
* Op. cit. f Op. cit. f Zenker and Ziemssen: Op. cit., p. 75, foot-note 1. 
§ Lehrb. d. pathol. Anat., Wien, 1861, p. 38. 138 
DISEASES OF THE THROAT AND NOSE. 
where it is sometimes in communication with a previously existing 
vomica. The most frequent course of the fistula, however, is into one 
of the bronchi. The passage of small particles of food or portions of 
ichorous matter into the bronchial tubes may give rise to bronchitis, 
pneumonia, or even gangrene. The fistula may cause instant death by 
perforation of the aorta, as in a case observed by G. Merkel,* but this 
is a very rare phenomenon. 
As the disease has not hitherto been recognized during life, the ques- 
tion of prognosis does not come within the domain of practical medi- 
cine. No treatment is likely to be of any avail, and should the com- 
plaint be suspected, all that the physician can do is to recommend a 
soft and non-irritating diet. 
The following is a good illustration of traction-diverticulum which 
recently came under my notice: 
In the gullet of a man, aged fifty-three, a pouch was found, of which the annexed 
woodcuts give a good representation (Figs. 18 and 19). It was situated at the junction 
Fig. 18. 
Fig. 19. 
Fig. 18.—The gullet laid open, showing the pouch as seen from the inside. 
Fig. 19.—Portions of the oesophagus and trachea about three and a half inches 
below the level of the cricoid cartilage, showing adhesion between the wall of the gul- 
let and the windpipe at one point. 
of the anterior and left walls, the opening being vertical in direction, and irregular 
from puckering of the mucous membrane. The aperture was from four to five milli- 
* Ziemssen’s Cyclopaedia, vol. viii., p. 81. CICATRICIAL STRICTURE OF THE GULLET. 
139 
metres wide and nineteen in length, its upper end being rather more than nine centi- 
metres below the lower rim of the cricoid cartilage. The diverticulum was large 
enough to admit the tip of the little finger, and extended inwards for eleven milli- 
metres at the deepest part. The lining membrane was perfectly healthy but much 
puckered. The direction of the pouch was horizontally forwards to the trachea, into 
which the fibres were inserted by a quasi-aponeurotic band of thickened areolar tissue. 
The attachment was about a quarter of an inch in breadth, and joined the posterior 
wall of the trachea to the left of the middle line—that is to say, altogether on the car- 
tilaginous part of the air-tube ; the insertion of the pouch was more or less vertical in 
direction, corresponding to the intra-oesophageal opening, but with a distinct inclina- 
tion downwards and inwards. External to the pouch were some enlarged glands, and 
it was surrounded, especially near the tracheal extremity, by a good deal of thickened 
tissue. No symptoms traceable to this condition had been noticed during life. The 
patient died from cancer of the gullet, but the malignant disease was at the upper part 
of the tube, and did not approach nearer than from two to three centimetres to the 
pouch. No connection could be discovered between the two affections, and, as far as 
could be judged from the appearance of the surrounding tissues, the diverticulum was 
long antecedent to the carcinomatous growth. 
CICATRICIAL STRICTURE OF THE GULLET. 
Latin Eq.—Coarctatio oesophagi a cicatrice. 
French Eq.—Retrecissement cicatriciel de Foesophage. 
German Eq.—Narbige Strictur der Speiserdhre. 
Italian Eq.—Strettura cicatriciale del esofago. 
Definition.—Diminution of the lumen of the oesophagus caused by 
contraction of the cicatrix of a previously existing ulcer or wound, giving 
rise to severe dysphagia, and often to death by starvation. 
History.—The ancient physicians had probably no acquaintance with traumatic 
stricture of the gullet, for in those days the strong acids and the weak alkaline solu- 
tions, now so largely used in the arts and for household purposes, were confined to the 
alchemist’s laboratory. (Esophageal stricture, however, arising from the healing of 
syphilitic or variolous ulcers* did not escape the notice of the earlier writers. (See 
“Syphilis of the Gullet.”) Cicatricial contraction was distinctly recognized by Beutelf 
* Two cases have been related (Brechfeld : Ephera. Natur. Curios, 1671, p. 182. 
Lanzoni: Ibid , Ann. 3i., obs. ix., t. xlv., p. 80) in which obstruction appears to have 
been due to the agglutination of the opposite sides of the gullet from ulceration con- 
sequent on variolous pustules. The affection, however, is so extremely rare, that it has 
not been thought necessary to treat of it in a separate article, 
f De struma oesophagi, Tubingen, 1742. 140 
DISEASES OF THE THROAT AND NOSE. 
as a possible cause of narrowing of the oesophageal canal, and it was also mentioned 
by Morgagni.* At a later period cases of injury to the oesophagus from corrosive solu- 
tions, followed by stricture of its channels, were related by Charles Bell,f Cumin,! 
Dewar,\ Syme,|| Gendron,f Bayle and Cayol,** Wolff,ff and B4hier.!! In 1862 Kel- 
ler$$ reported a number of cases occurring in young children, whilst quite recently 
Wolzendorf mi has published ninety-one examples of the affection collected from va- 
rious sources. 
Etiology.—Cicatricial stricture of the gullet may result from any 
disease or injury in which ulceration is followed by healing. The most 
common cause of these contractions is probably to be found in the 
swallowing of weak alkaline solutions, especially soap-lees, but occa- 
sionally they are due to the action of concentrated poisons (see “ Trau- 
matic (Esophagitis ”). Most of the patients in this country are adults, 
but abroad the accident appears to be not unfrequent among children 
and even infants, Keller having reported no fewer than forty-five cases 
met with in children between twelve and fifteen months old. Contrac- 
tion also sometimes arises from the temporary impaction of a foreign 
body producing an ulcer, which ultimately cicatrizes. men- 
tions a case in which the narrowing followed the swallowing of very 
hot liquid containing a piece of leek. A most interesting case has 
lately been related by Dr. Kendal Franks,*** in which gradually increas- 
ing dysphagia had followed the impaction of a hard piece of bread- 
crust. When the patient, a girl, aged twenty, was first seen by Dr. 
Franks, the affection had existed for four years and a half, and she was 
much emaciated. There was no evidence of hysteria, and I think there 
can be no doubt that the stricture was due to cicatricial thickening at 
the place where the gullet had been injured by the rugged edge of the 
crust at the time of the accident. 
Symptoms.—The characteristic symptom of cicatricial stricture of the 
* De sed. et causis morb., ed. secunda, Patavii, 1765, ep. xxviii. 
f Surgical Observations, 1817, vol. i„ p. 80. 
| Trans. Edin. Med.-Chir. Soc., 1827, vol. iii., p. 600, etc. 
§ Edin. Med. and Snrg. Journ., vol. xxx., p. 310, etc. 
|| Edin. Med. and Surg. Journ., October, 1836. 
f Journ. des Connaissances Med.-Chir., 1837. 
** Diet, en 60 volumes, t. iii., p. 615. 
ff Archiv. Gen., 1853, t. ii., p. 490. 
Jf Conferences de Clinique Medicale, Paris, 1864, pp. 113-117. 
§§ CEsterr. Zeitung fur prakt. Heilk., 1862, Nos. 45-47. Keller’s cases have already 
been referred to under Traumatic (Esophagitis. 
1111 Deutsche Militararztl. Zeitsclir., 1880, p. 477. 
Cours surles G6n4ralit6s de la M4decine pratique, Paris, 1825, t. i., p. 315. 
*** Med. Press and Circular, April 19th, 1882, p. 335. CICATRICIAL STRICTURE OF THE GULLET. 
141 
oesophagus is dysphagia, which, in general terms, may be said to vary 
in degree according to the amount of narrowing of the canal. Some- 
times, however, though the actual organic obstruction may be slight, 
deglutition is rendered difficult by superinduced spasm. Where the 
contraction results from the swallowing of a weak caustic or irritant solu- 
tion, there is generally, at the commencement, an inflammatory period, 
during which there is great dysphagia and often odynphagia; these 
symptoms persist as long as the ulceration continues, but when the 
ulceration heals the patient can generally swallow with ease, and for 
some time may consider himself cured. At the end of a few months, 
however, owing to the contraction of the tissue forming the cicatrix, 
difficulty in swallowing is again experienced. From this period the 
dysphagia generally grows steadily worse, and if not relieved is ex- 
tremely likely to prove fatal. In cases where the poison has been a 
strong caustic, the dysphagia does not pass off at all, or only subsides 
for a few days, and soon again becomes urgent. Thus in a case re- 
ported by Fugier,* after the expulsion of a large mass of membrane, 
liquids passed easily, tut this improvement only lasted for twelve days, 
when it became impossible for the patient to swallow nourishment of 
any kind. The course of cicatricial stricture resulting from disease is 
very similar to that arising from accidental injury, for the dysphagia 
from which the patient suffers whilst the ulcer is open passes off as the 
surface heals, and again causes trouble after cicatrization. 
The position of the stricture may be ascertained by auscultation, or 
by the passage of a bougie. On listening over the*course of the oeso- 
phagus posteriorly it will be noticed that fluids pass at the ordinary 
rate and give rise to tiie normal sound till they reach the upper part of 
the stricture, when the fluid is partially arrested, and a gurgling or 
trickling noise is perceived below the point of obstruction. The latter 
phenomenon may be observed to continue for three, four, or even five 
minutes after a mouthful of fluid has been swallowed. On using the 
bougie, the instrument is either arrested at the point of obstruction or 
is passed beyond it with difficulty. Sometimes a second stricture may 
be foundf lower down, whilst occasionally even three strictures are 
present.^ 
Diagnosis.—As a rule, in the traumatic cases, the diagnosis presents 
no difficulty, the history of an irritant poison having been swallowed 
* Des Rdtrecissements de PCEsophage. These de Paris, 1877, p. 20. 
f Bull, de la Soc. Anat., 1841, p. 170. 
J Basham : Med.-Chir. Trans., vols. xxxiii. and xlv. 142 
DISEASES OF THE THROAT AND NOSE. 
at once removing all doubt. It is only in very rare instances—where, 
for example, the temporary lodgment of a foreign body or the fact of 
an irritant having been swallowed in early life has been forgotten, or 
where a caustic poison having been taken suicidally the patient is un- 
willing to confess the circumstance, or where an insane person is the 
subject of the stricture—that any question can arise. Under such ex- 
ceptional circumstances it will be necessary, first, to determine whether 
the difficulty of swallowing be due to stricture or to compression of the 
oesophagus; and, secondly, in the event of the affection being intra- 
oesophageal, to eliminate the various other diseases of the gullet. In 
cases of compression, the difficulty of swallowing, though considerable, 
is seldom so marked as in cicatricial stricture, except in certain rare 
instances of fibrous or cancerous enlargement of the thyroid gland, or 
of tumor in the posterior mediastinum. In aneurism of the arch of the 
aorta, and enlargement of the cervical or bronchial glands, as well as 
in peri-oesophageal abscess, the difficulty in swallowing is seldom so 
extreme or so constant. The morbid conditions, moreover, which cause 
dysphagia by compression are in most cases sufficiently obvious to be 
at once recognized. They will be again referred to in the article on 
“ Compression of the Gullet.” 
The only diseases of the oesophagus itself which require to be differ- 
entiated from cicatricial contraction are cancer and simple stenosis. 
Malignant disease may be recognized by its usual occurrence in persons 
over forty years of age, and by its progressive character, the dysphagia 
generally attaining its full intensity in the course of a few months. The 
special, though not invariable, characteristic of true cicatricial stricture, 
on the other hand, is the peculiar character of the dysphagia; that is 
to say, the primary occurrence, its disappearance, and its subsequent 
return in a more severe and intractable form. In cases of simple 
stenosis there is a history of difficulty in swallowing from an early 
period of life, and the symptom is not progressive. Where cicatricial 
stricture results from the healing of an ulcer caused by disease, a clear 
history of the previous existence of the constitutional complaint can 
alone establish the diagnosis. 
Pathology.—The stricture in traumatic cases nearly always occu- 
pies two or three inches of the gullet, and may occasionally involve its 
entire length. In a case reported by Czerny,* cicatricial tissue replaced 
the normal structures throughout the lower third of the tube. In one 
of my cases (Sarah C.), hereafter reported, the stricture extended from 
* Beitrage zur Operativen Chirurgie, 1878, p. 70. CICATRICIAL STRICTURE OF THE GULLET. 
143 
within half an inch of the cricoid cartilage to within an inch of the 
cardia. In nearly every instance the walls of the oesophagus are con- 
siderably thickened. The lumen of the canal is generally very much 
narrowed, and sometimes, as in a case related by Horsey,* absolutely 
obliterated, the gullet being represented by a dense fibrous cord. The 
lining membrane presents considerable variety of appearance, for some- 
times long vertical folds are met with, which, during life, no doubt, 
meet in the centre of the canal, or even interlock in such a way as 
completely to occlude the passage. Sometimes there are transverse 
bands, and not unfrequently a rough reticular stricture is found formed 
by short fibrous ridges running in every direction, whilst occasionally 
a quasi-cribriform appearance is produced by the presence of a great 
number of small, deep excavations. In nearly all cases there are some 
smooth indurated patches where the mucous membrane has been re- 
placed by cicatricial tissue. Although dilatation of the oesophagus 
above the seat of stricture is not generally observed in cases of cicatri- 
cial contraction, still it has been occasionally met with.f 
Prognosis.—The prospects of the patient depend a good deal on the 
strength of the irritant solution which has been swallowed. For this 
reason, in suicidal cases where strong mineral acids are usually taken, 
extensive and intractable cicatrices are much more likely to be present 
than where patients have accidentally swallowed solutions of soap-lees. 
It may, however, be laid down as a general rule that cicatricial stricture 
is always attended with considerable danger, for not only is it often 
exceedingly difficult to effect dilatation, but even in cases where some 
degree of expansion has been produced, subsequent contraction is likely 
to take place unless the use of bougies is regularly persevered with. 
Many instances of cure, however, have been reported. The most suc- 
cessful series is that of Iveller’sJ thirty-five cases, of which twenty- 
three were cured, three benefited, five died (one of them from gangrene 
of the lungs), and four remained under treatment at the time of the 
report.§ When it is remembered that in all these instances the patients 
were infants under two years of age, the success of the treatment is all 
the more remarkable, and must indeed be regarded as quite exceptional. 
It is probable that in many of these cases the obstruction was due rather 
* Amer. Journ. Med. Sei., 1876, New Series, lxxii., p. 114. 
f See Dilatations of the Gullet. f Loe. cit. 
\ Keller reports forty-six cases of traumatic oesophagitis, caused by swallowing soap- 
lees, but eight of these were slight cases in which no stricture resulted, and three died 
soon after the accident. 144 
DISEASES OF THE THROAT AND NOSE. 
to inflammatory thickening and induration than to actual cicatrization. 
Out of seventy-five cases of which details are given by Wolzendorf,* 
twenty-three proved fatal. 
Treatment.—Medical treatment is of little use, but, as is shown by 
the above figures, surgery claims many cures. More often, however, all 
that can be done is to prolong life. The following are the various 
methods of combating the local condition : 1, gentle dilatation ; 2, for- 
cible dilatation ; 3, internal oesophagotomy; 4, cesophagostomy; and 5, 
gastrostomy. 
Gentle dilatation is the method by which the largest number of cases 
have been cured, but it is obvious that its success is likely to be greatest 
where the disease is slight and recent, and more especially in those cases 
which, though originating in the same way as true cicatricial stricture, 
and scarcely to be distinguished therefrom in their clinical history, 
strictly belong to the class of indurations. Dilatation is best etfected 
by passing bougies of gradually increasing diameter. The mode of 
using these instruments has already been described (pp. 27 and 28). 
Where there is obvious difficulty in swallowing, a No. 6 (Author’s scale) 
should first be tried, and if this will not pass, a smaller instrument 
must be employed. As the passage of the bougie often provokes cough- 
ing and a considerable flow of saliva and mucus, the patient should be 
made to bend forwards in order that the secretion may fall easily into 
a hand-basin. The bougie should, if possible, be left in position on 
the first occasion for five minutes, and as the patient gets accustomed 
to its use, he may be able to tolerate it for ten or twenty minutes or 
even for half an hour at a time. The operation may be repeated twice 
a week, and in some cases on alternate days. Very few patients can 
bear the daily passage of the instrument. The same size of bougie 
should be passed on at least two occasions, and generally it is better to 
use it three or four times before a larger one is employed. Some 
surgeons after withdrawing a bougie, immediately try to pass a larger 
one, under the impression that an instrument of greater size can by this 
means be more easily made to traverse the stricture. I have not found 
this to be the case, but on the contrary it has appeared to me that the 
passage of one bougie generally gives rise to a slight amount of conges- 
tion, which renders it difficult to introduce a second one at the same 
sitting. In adults it is unnecessary to dilate the cesophagus beyond the 
size of No. 15 (Author’s scale), whilst for children under twelve, bougies 
* Loc. cit. CICATRICIAL STRICTURE OF THE GULLET. 
145 
larger than No. 8 should not be used, and for those between twelve and 
sixteen years of age, the maximum size should be No. 12. 
I formerly attempted to dilate cicatricial strictures by means of 
oversliding catheters—that is to say, by first passing a whalebone 
bougie, and then running over it a catheter finely tipped with metal, 
but though I tried a great variety of instruments, I found that, owing 
to the relaxed condition of the walls of the oesophagus, the catheter 
was so often caught in folds of the mucous membrane that I was obliged 
to give up this method. 
Forcible Dilatation.—My experience of forcible dilatation has not been 
satisfactory. In 1862 and the following year I had several instru- 
ments made,* and I had an opportunity of using them in four cases of 
cicatricial stricture, but though I did not meet with any accident, I found 
it extremely difficult to apply the dilating force at exactly the right 
spot, and also to regulate the degree of expansion. Some of these cases, 
which appeared to be curedf at the time, relapsed after a few months, 
and I ultimately abandoned the method altogether. Quite recently, 
however, Dr. Kendal has been more fortunate, and in the case 
already alluded to under “Etiology,” he succeeded in effecting the cure 
of a fibrous stricture by rapid stretching with Otis’s dilating urethro- 
tome followed by the irregular passage of bougies. 
Of the remaining operations, internal oesophagotomy, oesophagostomy, 
and gastrostomy, the two latter have been performed much more fre- 
quently for cancerous than for cicatricial stricture, not because the results 
in the former condition promised to be more favorable, but because 
cancer of the gullet gives rise to obstruction much more often than any 
other affection. It has therefore been thought desirable to consider 
these two operations irrespectively of the special lesion for which they 
have been undertaken. 
Internal (Esophagotomy.—Strictures may sometimes be cut through 
by means of an instrument introduced through the narrowed portion of 
the gullet. 
History of the Operation.—To Maisonneuve§ belongs the credit of first attempting to 
relieve cicatricial stricture of the gullet by internal incision. He operated on three 
cases, of which two died and one recovered. In the two fatal cases the patients were 
* By Krohne and Sesemann. 
f See a report of one of these cases in the Transactions of the Clinical Society, 
1870, vol. iii., pp. 181, 182, where also a description of the instrument which I used 
may be found. 
J Loc. cit., p. 335. g Clinique Chirurgicale, Paris, 1864, t. ii., p. 409.. 146 
DISEASES OF THE THROAT AND NOSE. 
women, and succumbed to peritonitis, which Maisonneuve believed to have been 
set up by the operation in consequence of a special sympathy which he assumed to exist 
between the gullet and the peritoneum. In a fourth case in which the same surgeon 
attempted internal cesophagotomy, the patient’s death was due to a false passage which 
was made into the posterior mediastinum. Lanelongue* soon afterwards operated 
successfully. Dolbeauf performed the operation on two patients, both of whom ap- 
peared to be cured as long as they continued under observation. had a 
good result from the procedure in spite of severe primary and secondary haemor- 
rhage. Tillaux,$ Studsgaard,|| and have each reported a successful case. 
The last-named surgeon was less fortunate in a second instance, in which the pa- 
tient died from profuse haemorrhage.** Czernyff performed theoperation on a child who 
died from peri-oesophageal cellulitis complicated by diphtheria. Recently cases have 
been treated after this method by myself and by Dr. Roe,JJ of Rochester, U. S., the par- 
ticulars of which will be found below. Dr. Elsberg,$§ of New York, has also operated 
successfully in two cases. 
The stricture has sometimes been divided from above downwards,|||| 
but this method is extremely dangerous, and should never be at- 
tempted. The incisions should always be made from below up- 
wards. The use of the oesophagotome (Fig. 9, p. 36) is perfectly 
simple. It is introduced with the blade concealed, and when the 
portion of the instrument containing the knife is felt to be be- 
low the stricture, the blade is to be made to project, and by a rapid 
upward movement of the instrument the obstructing band should be 
cut through. If necessary, two or three incisions may be made. A 
week after the operation a medium-sized bougie should be passed to 
counteract the tendency of the divided tissues to shrink in healing, 
and instruments of gradually increasing size should be used from time 
to time. 
From an examination of the results of the published cases (see “ His- 
tory ”) internal cesophagotomy does not appear to be a very satisfactory 
operation. Of the seventeen cases in which it has been practiced four 
died, i.e., 23.5 per cent. This estimate includes only cases which 
proved fatal within fifteen days of the operation ; the mortality would, 
* M6m. de la Soc. de Chir. de Paris, 1865, t. vi., p. 547. 
f Gazette des Hopitaux, 1870. 
J Bull. Gen. de Thdrap., 1870, t. lxxviii., p. 252. 
§ Bull, de 1872, t. lxxxiv., p. 14. 
|| Canstatt’s Jaliresb., 1873, Bd. ii., p. 487 ; and 1875, Bd. ii., Abtheil ii., p. 297. 
f Correspondenz-Blatt. d. arztl. Yereins in Rheinland, April, 1877, No. 19, p. 19. 
** Ibid. tf Beitriige zur Operat. Chirurg., 1878, p. 70. 
New York Med. Record, November 11, 1882. 
§£ Arch, of Laryngol., January, 1883, vol. iv., No. 1, p. 56 et seq. 
[HI By Maisonneuve, Lanelongue, and Studsgaard. CICATRICIAL STRICTURE OF THE GULLET. 
147 
doubtless, appear much higher if all the cases were counted in which 
death, though directly traceable to the operation, did not occur within 
the above-mentioned period. Thus, in my own case, the patient died 
three months after the oesophageal stricture was divided; but the pul- 
monary inflammation, to which he ultimately succumbed, came on so 
soon after the operation that it is most probable there was a causal 
relation between the two events. 
On analyzing the statistics more closely it will be found that the 
operation has been done eleven times for the relief of cicatricial stric- 
ture, twice for oesophageal stenosis of an indefinite nature, once for 
malignant and once for tubercular disease. Of the remaining two cases 
I have no details beyond the fact recorded by the operator that they 
were successful. Of the cicatricial cases three, i. e. 27.28 per cent., 
died. This average, however, would be considerably reduced if each 
individual act of oesophagotomy were to be counted as a separate case, 
for the operation was performed six times on one of the patients, three 
times on another, and twice on a third. This would raise the total 
number of operations to nineteen, with a mortality of only 15.7 per 
cent. In the case of malignant disease intra-oesophageal section was 
practiced five times, on each occasion with definite, though transient, 
benefit, and the patient finally died of phthisis. The patient with 
tubercular stricture died of peritonitis four days after the operation. 
The advantages of internal oesophagotomy are: 
1st. That it is attended with an inconsiderable amount of shock. 
2dly. That, if the stricture can be thoroughly divided, gradual dila- 
tation can be carried out, and a cure thereby be effected. 
3dly. That the procedure involves no external wound requiring con- 
stant attention and giving rise to disfigurement. 
The disadvantages of internal oesophagotomy are: 
1st. That it can only be safely performed in cases where it is still 
possible to get a bougie through the stricture.* 
2dly. That, owing to the formation of these strictures, which often 
extend far down the gullet, it is difficult to get beyond all the points of 
obstruction. (It may be added that, in many cases of cicatricial nar- 
rowing, the obstructing ridges are vertical in direction, and therefore 
cannot be divided by any instrument [see Fig. 20, <x]). 
3dly. That in many cases the walls of the oesophagus are so much 
thickened that limited longitudinal incision cannot relieve the obstruc- 
tion. 
4thly. That the actual danger attending the performance of the ope- 148 
DISEASES OF THE THROAT AND NOSE. 
ration is far from inconsiderable. (Indeed, the thinness of the oeso- 
phageal walls, the close proximity of many vital organs, and the fact 
that in disease the gullet is often intimately adherent to the surround- 
ing parts, constitute dangers which cannot be ignored. In one of the 
fatal cases death was due to haemorrhage, and in one of the successful 
operations bleeding occurred to an alarming extent.) 
The following case illustrates cicatricial stricture: 
Henry A. drank a solution of potash on September 17th, 1880, and, in spite of im- 
mediate treatment at the London Hospital, his gullet became so much narrowed that 
thirteen weeks elapsed before he was able to swallow fish. The stricture was treated 
by gradual dilatation until February, 1881, when, owing to an attack of small-pox, the 
patient discontinued his attendance for four weeks. When seen again he could swallow 
nothing but jelly. He was admitted into the Hospital for Diseases of the Throat, under 
my care, on April 7th, 1881, being by that time in an extremely weak condition. The 
stricture was found to begin just below tbe level of the cricoid cartilage, the canal of 
the oesophagus at the affected part being very tortuous and deviating to the left side. 
Gradual dilatation rendered it possible to pass a No. 8 bougie by June 2d ; but more 
than a month later an advance of only one size had been made. On July 12th I per- 
formed internal cesophagotomy, dividing the stricture in the middle line behind from 
below upwards. A No. 14 bougie could then be passed without difficulty. The pain 
of the operation was slight, but in a few hours the patient began to feel some discom- 
fort over the base of the right lung, and unmistakable signs of pneumonia soon after- 
wards showed themselves. Dilatation with bougies was resumed after a few days, and 
in August No. 15 could be passed easily. The patient was shown to the members of 
the International Congress on August 4tli; and at that time, whilst still suffering from 
some pulmonary trouble, his general condition was fairly satisfactory. He passed from 
my care a day or two afterwards, as the Throat Hospital had to be closed for the pur- 
pose of being rebuilt. He soon afterwards re-entered the London Hospital, and died in 
that institution about the middle of October, 1881. At the autopsy both lungs showed 
patches of pneumonia, and there was some purulent effusion in the right pleura. The 
gullet was found thickened to such an extent as to narrow considerably the calibre of 
the tube for three inches downwards from the level of the cricoid cartilage. The stric- 
tured portion was found to have been divided posteriorly for about an inch at the 
lower part. 
Dr. Roe, of Rochester,.U. S., has lately reported two cases* in which 
lie has successfully used my oesophagotome. One was that of a lady, 
aged twenty-four, on whom he twice operated for stricture of the gullet, 
making on the first occasion one posterior incision, and on the second 
two lateral cuts, after which dilatation with bougies could be satisfac- 
torily carried out. 
The patient in the other case was a boy, aged eight years, whose 
oesophagus was narrowed at its lower part through the action of a caustic 
fluid, to such a degree that even milk could scarcely be swallowed. Dr. 
* New York Med. Record, November 11th, 1882, pp. 536, 538. CICATRICIAL STRICTURE OF THE GULLET. 
149 
Roe divided the stricture in six different places at intervals of a few 
days, and then practiced dilatation with success. 
Qlsophagostomy.—The gullet may sometimes be opened either at the 
seat of stricture, or below it. This is an operation which, in a few 
cases, has proved highly successful. 
History of the Operation.—The establishment of a fistulous opening in the neck for 
the relief of stricture of the oesophagus appears to have been first suggested by Stoffel.* 
The first recorded instance, however, in which the operation was performed is one 
briefly alluded to by Tarengetf in 1786. The operator’s name has not been preserved, 
but the case was more successful than any of those which have been done since. The 
patient was a woman suffering from what would seem to have been cancer of the gullet, 
and in spite of the fact that the cervical and submaxillary glands were already en- 
larged at the time of the operation, she is stated to have survived for a period #f six- 
teen months, during which she was fed entirely through the fistula. More than half 
a century later, WatsonJ published a case of what he calls tubercular stricture, in which 
he opened the gullet. The disease, however, was possibly malignant, as there were no 
signs of tubercle in the lungs. The patient—a young man, aged twenty-four—lived 
two months after the operation, and died of oedema of the glottis, and for which trache- 
otomy had to be done. The thyroid body was greatly enlarged, but does not appear 
to have pressed upon the gullet. Soon afterwards Lavacherie£ operated on a man, aged 
sixty-eight, suffering from what was probably a cancerous stricture of the oesophagus. 
This case is of somewhat doubtful character, as the cutting operation appears to have 
been undertaken mainly, if not solely, for the extraction of an ivory tube which had 
been passed into the stricture and could not be withdrawn. The gullet was opened, 
and the patient was fed through a tube, but it is not clear whether this was introduced 
through the wound or through the mouth. Death took place on the fifteenth day. 
CEsophagostomy was successfully performed by Monod|| on a woman suffering from 
cancerous stricture of the upper part of the food-channel. She survived the operation 
three months, and died from the inevitable progress of the disease. In 1853 Foiling 
published a monograph on stricture of the gullet, wherein he advocated cesophagos- 
tomy in suitable cases. Bichet** states that he performed the operation for imperme- 
able narrowing of the gullet opposite the second dorsal vertebra; the canal was 
opened, and a sound passed through the stricture and left in situ. Unfortunately, no 
further details are given, either as to the result of the case or the nature of the disease. 
In 1859 Brunsff reported the case of a man, aged thirty-eight, suffering from dysphagia, 
on whom he operated. The patient lived ten days, and, after death, the cause of the 
complaint was found to be compression of the oesophagus by an enlarged thyroid. A 
somewhat similar case was related by the same surgeonJJ a few years later. The patient 
was a man, aged thirty-seven, who had been afflicted with difficulty of swallowing for 
* Quoted by Bonet: Sepulchretum, Lugduni, 1700, lib. iii., sect, iv., obs. xx., p. 35. 
f Journ. de Med.-Chir. et Phar., 1786, t. lxviii., p. 250. 
X Dublin Journ. of the Med. Sciences, 1845, vol. xxvii., p. 260. 
| Bull, de l’Acad. de Mfed. Eoyale de Belgique, 1845, t. iv., p. 758. 
|| Quoted by Follin: Rfetrfecissements de l’CEsophage, Paris, 1853, p. 116. 
f Ibid. 
** Traitfe Prat. d’Anat. Mfed.-Chir., 1860, 2e 4d., p. 508. 
ft Deutsche Klinik, 1859. %% Ibid., 1865, p.^37. 150 
DISEASES OF THE THROAT AND NOSE. 
a year ; cesophagostomy was done, and the man died in five weeks. In this case, as in 
Watson’s above related, death was due to pulmonary disease and to oedema of the 
larynx, which made tracheotomy necessary. The thyroid was found to be somewhat 
enlarged, and a vast abscess with gangrenous walls was seen encircling the upper part 
of the gullet. Three years afterwards, Willett* performed the operation on a woman, 
aged forty-seven, suffering from oesophageal carcinoma; the patient had begun to re- 
gain her strength when she refused to be fed, and died of exhaustion eighteen days 
after the establishment of the fistula. In 1868 Cheeverf, in an interesting report of 
two cases of external oesophagotomy for foreign bodies, took occasion to make some 
remarks on the same proceeding when practiced for stricture of the gullet, and two 
years later the whole subject was fully discussed by Terrierf in an elaborate and valu- 
able monograph. In 1870 the operation was performed by Menzel§ on a man, aged 
forty-four, a patient of Billroth’s, who was suffering from cancerous stricture; death 
took place on the following day. Three years subsequently, Podrazki|| performed 
cesophagostomy on a man, aged forty, who had suffered from well-marked syphilis; 
the patient died two days afterwards, and his disease, which, during life, had been 
supposed to be of venereal origin, was found to be purely carcinomatous. In 1875, 
Poinsotjf operated on a woman, aged fifty-five, whose oesophagus was obstructed by 
malignant growths; the patient expired twenty hours after the operation. In 1876** 
1 recoreded a case in which cesophagostomy had been performed by Evans, nine years 
previously, on a woman, aged forty-three. The disease was malignant, and the patient 
died of collapse fifty hours after the operation. In the same year a case was related 
by Horsey,ff in which he operated on a boy, aged five, who had swallowed some caustic 
fluid; the gullet was unintentionally opened above the stricture, which was found to 
be quite impervious. The wound was therefore closed, and the little patient died of 
shock wdthin twenty-two hours. In 1877 Kappelerff related two cases of oesophageal 
cancer, in which he made an opening into the gullet through the neck. In each in- 
stance the operation had been undertaken with a view to actual removal of the disease 
by excision, and it was only when this was found impracticable, owing to the extent 
and situation of the morbid mass, that, as a desperate measure, cesophagostomy was 
tried. The first patient, a man, aged forty-two, died five days after the operation ; 
whilst the other, a man of sixty-five, survived only forty-four hours. In the same 
year, Bryk$| published a case in which he had performed cesophagostomy for the relief 
of cicatricial stricture; the patient was alive seven weeks after the operation, but the 
ultimate result is not stated. Nicoladoni|||| also recorded a case in which he had re- 
course to cesophagostomy. The patient was a girl, aged four, who was suffering from 
cicatricial stricture of two years’ standing; the gullet was incised above the point of 
narrowing, when it was found that the tube was expanded into a pouch at its upper 
* St. Barth. Hosp. Rep., 1868, vol. iv., p. 204. 
f Two Cases of CEsophagotomy, Boston, 1868, p. 61. 
J De 1’CEsop]iagotomie Externe, These de Paris, 1870. 
I Wien. Med. Wochenschr., 1870, No. 56, p. 1350 etseq. 
|| Ibid., 1873, Nos. 33, 35, 36. 
If Reported by Bidau : De l’CEsophagotomie, Bordeaux, 1881, p. 19. 
** Med. Times and Gaz., 1876, vol. ii., p. 137. 
ff Amer. Journ. of Med. Sci., New Series, 1876, vol. lxxii., p. 114. 
Deutsche Zeitschr. f. Chir, 1877, vol. vii., p. 381 et seq. 
\\ Wien. Med. Wochenschr., 1877, Nos. 41 and 45. 
[||| Wien. Med. Wochenschr., 1877, No. 25. CICATRICIAL STRICTURE OF THE GULLET. 
151 
part. The little patient died in six days. An instance is related by Zenker,* where 
the operation was done on a boy, aged three years and a half, for cicatricial stricture. 
Death occurred within twenty-four hours. Simon is referred to by Konigf as having 
opened the oesophagus in a case of cancer, but no detail is given beyond the fact that 
the patient survived only thirty-four hours. HadlichJ operated in 1880 on a man, 
aged sixty, who was unable to swallow from some cause, the nature of which was 
not clearly made out. The patient died thirteen months after the operation, but no 
autopsy was permitted. In the same year performed oesophagostomy on 
a woman, fifty-two years of age, suffering from cancerous stricture ; she improved con- 
siderably after the operation, and died five months later from the natural progress of 
the disease. The same surgeon|| operated quite recently on a girl, aged nine, who 
had swallowed nitric acid. Death took place eight days afterwards, owing to “ hannor- 
rhage from the internal jugular vein caused by septic ulceration.” In 1880 oesopha- 
gostomy was also performed by IIolrner,’[ of Copenhagen, on a man, aged fifty-seven, 
for cancer of the right tonsil and pharynx; the patient lived two months. In 1881 
Annandale** related three cases in which he had performed the operation for cancerous 
stricture. In the first the patient, a woman, aged forty-two, survived three months, 
and finally died of septicaemia; in another the patient, also a woman, aged fifty-three, 
died in ten days. Unfortunately, no details are given of the third case, which is the 
more to be regretted, as it was one of exceptional interest, a second stricture having 
been encountered when the gullet had been opened below the first, and gastrostomy 
having, therefore, been found necessary. The operation has lately been practiced by 
Timothy Holmes.ff The patient was a man, about fifty years of age, who suffered 
from malignant stricture of the oesophagus; he died about three days after the opera- 
tion. ReevesJJ has also recently performed oesophagostomy on a man, aged sixty- 
three, who died on the eighth day. To these cases should be added one in which 
Butlin£$ states that he witnessed an attempt at oesophagostomy which had to be aban- 
doned owing to the wide extent of the disease, and another reported by Maydl,|||| in 
which it was found impossible to open the gullet in a case of cicatricial contraction, 
because of the extreme hardness of the walls.^^f 
The mode of performing oesophagostomy is as follows : The patient 
should be placed on his back with his shoulders somewhat raised, and 
* Zieinssen’s Cyclopaedia, vol. viii., p. 28. 
f Krankheiten des Pharynx und (Esophagus, Stuttgart, 1880, p. 122. 
J Deutsche Zeitschr. f. Chir., 1882, Bd. xvii., p. 138 et seq. 
| Hospitals Tidende, 2 R. vii., No. 43, Copenhagen, October 27th, 1880. 
|| Private letter from Dr. Studsgaard to the Author, dated December 21st, 1882.. 
Hospitals Tidende, Copenhagen, 1882, No. 1. 
** Liverpool Med.-Chir. Journ., No. 1, July, 1881, p, 14 et seq. 
ft Med. Times and Gaz., July 29th, 1882, p. 117. 
XX Private letter from Mr. Reeves to the Author, dated July 20th, 1882.. 
|| Sarcoma and Carcinoma, London, 1882, p. 184. 
IHI Wien. Med. Blatter, 1882, No. 17, p. 523. 
Gross (System of Surgery, 6th ed., 1882, vol. ii., p. 495) refers to cases in which 
cesophagostomy has been practiced by Packard and Cohen. As I am unable to find 
any published details of either of these cases, they have not been included in the above 
summary. 152 
DISEASES OF THE THROAT AND NOSE. 
his head turned towards the right side. An anaesthetic having been 
given, the surgeon, standing behind the patient’s head, should make an 
incision through the skin on the left side from just above the sterno- 
clavicular articulation to about the level of the hyoid bone. The 
platysma should be cut through, and if a vein of any size, such as the 
external or anterior jugular, is met with, it should be divided between 
two ligatures and turned aside. The superficial fascia should next be 
slit up on a grooved director along the line of the original incision, and 
the anterior edge of the sterno-mastoid laid bare. The patient’s head 
should then be slightly raised so as to relax the tissues of the neck, and 
an assistant should draw aside the sterno-mastoid w7ith a retractor. 
The omohyoid (which can be recognized by its direction inwards and 
upwards) having thus been brought into view, should be divided as 
near to its hyoid insertion as possible. The carotid sheath is now to 
be held aside together with the sterno-mastoid, whilst the trachea is 
drawn inwards by a second assistant. The connective tissue having 
been torn through with the handle of the knife, the left lobe of the 
thyroid body should be raised and pushed towards the middle line, 
when the trachea will be fully exposed, together with the oesophagus 
behind it. It may sometimes be difficult to identify the latter tube, 
and it may therefore be necessary to pursue the dissection down to the 
prevertebral muscles. At this stage a sound* should, if possible, be 
passed from the mouth through or into the stricture. By this the ope- 
rator will be guided to the situation of the gullet, which should be 
opened by a vertical incision 2J to 5 centimetres long, through its 
lateral wall. In cases of cancerous stricture the opening should be 
made as far below the seat of disease as possible, whilst in cicatricial 
stenosis the knife may be carried through the contracted tissues. When 
the tube has been opened a silk ligature should be passed through each 
edge of the oesophageal wound, and again through the corresponding 
lip of the cutaneous incision, and the gullet should be gently drawn 
towards the surface and loosely attached to the outer wound. A curved 
tube, measuring about, three inches in length below and one inch above 
the bend, with a suitable shield at its upper extremity, should be in- 
troduced into the oesophagus through the wound, and fixed in position 
* A special instrument was devised for this purpose by Yacca Berlinghieri (Della 
Esofagotomia, Pisa, 1820), consisting of a curved hollow sound, containing a stylet, 
which projects two inches beyond the distal extremity of the tube. The sound ends 
at its lower part in a staff grooved at one side. On pushing down the stylet its point 
is protruded and thrusts the wall of the gullet outwards. An ordinary flexible bougie 
tipped with a metal knob will, however, be found to answer just as well. 153 
CICATRICIAL STRICTURE OF THE GULLET. 
by means of tapes round the neck. Sutures may be used to bring the 
edges of the skin-wound together above and below the feeding tube, 
should this appear desirable. 
The food should, of course, be liquid, and in order to prevent it 
from soaking into the tissues of the neck, when the patient is to be fed, 
it is better to pass a second long inner tube some way down the gullet, 
through the shorter tube, which is constantly worn. The nutritive fluid 
may either be injected with a syringe or poured in through a glass 
funnel. 
(Esophagostomy should never be performed unless there be good 
reason to believe that it will be possible to introduce a tube into the 
gullet below the seat of stricture. 
On analyzing the recorded cases of cesophagostoiny, it will be found 
that out of twenty-six cases in which the operation was performed, six- 
teen, i. e., 61.5 per cent., died within a fortnight, whilst death from 
shock occurred within forty-eight hours in seven, or 26.9 per cent. 
(Esophagostomy has been performed seventeen times for the relief of 
cancerous stricture, four times for cicatricial contraction, three times for 
dysphagia caused by compression of the gullet from without, and twice 
for stenosis of somewhat doubtful character.* The longest duration 
of life after the operation in any of these cases was sixteen months, the 
shortest eighteen hours. 
In the malignant cases the average duration of life after the opera- 
tion was rather more than fifty-two days. If, however, Tarenget’s case, 
in which the patient lived sixteen months, be omitted from considera- 
tion as too vaguely reported and of too ancient date to be quite trust- 
worthy, the average term of survival in the remaining fifteen instances 
was twenty-four days. In seven cases of oesophagostomy for cancer, 
in which sufficiently full details are given for an estimate to be made, 
the average duration of the symptoms before the operation was six 
months, the longest being eleven months, and the shortest three months. 
In the four cases in which oesophagostomy was done for cicatricial 
contraction, the average duration of life after the operation was nearly 
seven weeks. In three of the four, however, the patients were children, 
and in them the average was little more than two days and a half. This 
high mortality of the operation in the case of children utterly nega- 
tives the opinion that the shock caused by oesophagostomy is inconsid- 
erable. 
In the three instances of dysphagia from compression the average 
* Richet’s case is too lacking in detail to be taken into account. 154 
DISEASES OF THE THROAT AND NOSE. 
period of survival was five months, whilst in the two cases of doubtful 
nature it was nearly two months. 
Death from the immediate shock of the operation took place in four 
of the cases of malignant obstruction, and in two of the cases of cica- 
tricial contraction. The statistics of this operation do not show the 
steadily progressive improvement which is seen in the case of gastrostomy. 
The great advantages that are claimed* for oesophagostomy are: 
1st. That it is attended with comparatively little systemic shock. 
2dly. That it facilitates subsequent dilatation of the stricture; in 
other words, it is so far curative that it may enable the patient’s exist- 
ence to be indefinitely prolonged. 
The supposed absence of shock, however, is not borne out by the 
actual facts, seeing that in five casesf death occurred within twenty- 
four hours after the operation, whilst in a sixth,J the attempt to open 
the gullet had to be given up, owing to the collapsed condition of the 
patient. As regards the second alleged advantage, it does not appear 
that there is any case on record in which an oesophageal stricture has 
been successfully dilated through an opening in the neck. 
The disadvantages of the operation are : 
1st. That owing to the depth from the surface at which the gullet is 
situated, and the fact that when diseased it is often fixed to the sur- 
rounding parts, the operation is a very difficult one. (To this should 
be added, in cases of cicatricial stenosis, that the walls of the organ 
may be so tough as to make it difficult, or even impossible,§ to cut 
through them.) 
2dly. That great danger inevitably attends a cutting operation 
carried out in immediate proximity to such important structures as the 
large bloodvessels and nerves of the neck, and the thyroid gland, which 
is not unfrequently enlarged in cases of oesophageal stenosis. 
3dly. That there is great uncertainty in any given case whether the 
opening in the oesophagus can be made below the stricture. (Even 
when its upper limit can be made out with tolerable accuracy, the ex- 
tent of the disease cannot even be guessed at, and if in an exception- 
* Whilst Follin (R6tr6eissements de l’CEsopliage, Paris, 1853, pp. 125-6), Terrier 
(De 1’QEsophagotomie Externe, Paris, 1870, p. 62 et seq.), Annandale (Liverpool Med. 
Chir. Jonrn., No. 1, July, 1881, p. 13), Bidau (De l’CEsophagotomie, Bordeaux, 1881, p. 
38 et seq.), and T. Holmes (Med. Times and Gaz., July 29,1882, p. 118) give a moderate 
support to the operation, Mr. Reeves (Trans. Clin. Soc., vol. xv., 1882, p. 26 et seq.) has 
come forward as an uncompromising champion of it. 
f Menzel, Poinsot, Kappeler, Horsey, Zenker. J Maydl: loc. cit. 
\ Maydl: ibid. CICATRICIAL STRICTURE OF THE GULLET. 
155 
ally favorable case the lower margin could be approximately ascer- 
tained, a second stricture may exist lower down.) 
4thly. That a discharging fistula in the neck is a conspicuous disfig- 
urement. 
Gastrostomy.—This has been the most frequently practiced, and will 
probably be proved to be the most valuable of all the operations for 
the relief of oesophageal stricture. 
History of the Operation.— Gastrotomy, for the extraction of foreign bodies, has been 
practiced since the sixteenth century, but gastro-stomy, or the establ ishment of a “ mouth ’* 
in the stomach, for the purpose of feeding a patient who is unable to swallow, was first 
proposed, and fully described by Egeberg,* a Norwegian surgeon, in 1837. It was, 
however, actually carried out for the first time in France by Sedillot,f in 1849. After 
him it was performed by Fenger, Cooper, Forster, Sydney Jones, Curling, Bryant, 
Van Thaden, myself, Troup, Durham, Fox, Maury, Low, MacCormac, Jouon, Smith, 
Clark, Mason, Jackson, Rose, M oiler, Jacobi, Hjort, Kiister, Tay, Heath, Verneuil, 
Callender, Schonborn, Lanelongue, Courvoisier, Trendelenburg, Le Dentu, Riesel, 
Messenger Bradley, Studsgaard, Langenbuch, and Langton. The details of all the 
operations performed by these surgeons may be found in an elaborate treatise published 
by H. PetiQ in 1879. Since the appearance of that work cases have been reported by 
Littlewood,! Milner Moore,|| Escher,** Lucke,ff Elias,ft Pye-Smith,$$ 
Buchanan,|||| Morris,McGill,*** Gritti.fft Kronlein,JJJ Bryant,\\\ Langton,|||||| 
Reeves,**** Kappeler,ff+t Anders,Fowler,\\\\ Bugantz,|||||||| 
Maydl,and Hume.***** Several cases have been operated on by Howse and 
Davies-Colley, but the details have not been published. 
* Memoir read before the Med. Society of Christiania, May 8th, 1837. 
f Gazette Medicale de Strasbourg, 1849, p. 366. 
£ Traits de la Gastro-stomie, Paris, 1879. § Lancet, 1879, vol. i., p. 475. 
|| Ibid., 1879, vol. ii., p. 425. f Ibid., 1879, vol. ii., p. 466. 
** Centralblatt f. Chirurgie, Leipzig, 1880, vii., p. 625. 
ft Med. Times and Gazette, 1880, vol. ii., p. 187. 
Deutsche Med. Wochenschr., Berlin, 1880, vi., pp. 329-333. 
\\ Trans. Intern. Med. Cong., 1881, vol. ii., p. 456 et seq. 
dll Lancet, 1881, vol. i., p. 7. Ibid., 1881, vol. ii., p. 873. 
*** Ibid., 1881, vol. ii., p. 942. 
fff Gazzetta Med. Ital. Lombardia, 1881, serie viii., t. iii., p. 3. 
+++ Centralblatt f. Chirurgie, 1881, p. 16. Lancet, 1881, vol. i., p. 572. 
Illlll Brit. Med. Journ., July 15th, 1882. 
If 1[1[ Trans. Clin. Soc., 1882, vol. xv., p. 33 et seq. 
**** Ibid., p. 26. 
ttft Deutsche Zeitschrift f. Chirurgie, 1882, Bd. xvii., Ileft 1 and 2. 
++++ St. Petersburg Med. Wochenschr., 1882, xvii., p. 185 et seq. 
§$$$ Ann. Anat. and Surg., Brooklyn, New York, 1882, vi., p. 27 et seq. 
IH'IIII Quoted by Maydl: Wien. Med. Blatter, 1882, No. 22, p. 682. 
Ultff Wien. Med. Blatter, 1882, Nos. 15, 16, 17, 18, 19, 21, 22, 23, and 24. Twelve 
cases are here reported by Maydl, but the actual operator in six of them was Albert. 
***** Lancet, December 23d, 1882, p. 1074. 156 
DISEASES OF THE THROAT AND NOSE. 
The following is the best mode of operative procedure: The patient 
having been placed on his back, and an anaesthetic having been admin- 
istered, the surgeon should first try to map out by careful percussion 
the situation of the stomach. The area of stomach-resonance varies 
somewhat in different individuals, and also in the same person accord- 
ing to the condition of the viscus itself. In those who have been suffer- 
ing for some time from partial starvation, the organ is apt to be re- 
tracted so as to be altogether covered by the inferior margin of the 
thorax. To obviate any difficulty from this source the stomach has 
sometimes been successfully inflated with air before the operation, or 
ether has been pumped into the viscus from the mouth, or gas has been 
generated within the organ itself by the administration, first of hydro- 
chloric or tartaric acid, and shortly afterwards of bicarbonate of soda.* 
When the stricture is not impermeable, any of these plans may be of 
service, but none of them is necessary. 
Gastrostomy should always be done with the strictest antiseptic pre- 
cautions. There are three stages in the operation: 1, to open the ab- 
dominal parietes; 2, to transfix the stomach and secure it to the edges 
of the wound in the abdomen, and to the integument; and, 3, to open 
the stomach. Between the second and third stages it is most important 
that some days should elapse. 
l&f Stage.—An incision should be made through the skin for a dis- 
tance of two or three inches in a direction parallel to the left costal 
* Schonborn (von Langenbeck’s Archiv., vol. xxii., p, 500) fitted an india-rubber 
ball to the end of a fine hollow sound, which he passed down the gullet. When the 
ball was in the stomach it was inflated by blowing down the tube. F61izet (Lancet, 
October 7th, 1882), in a case in which he had lately to open the stomach for the re- 
moval of a foreign body, passed a small india-rubber tube through one of the patient’s 
nostrils into the stomach. The proximal extremity of the tube was bifurcated, a funnel 
being connected with one branch, and the other communicating, by means of a piece 
of tubing, with a recipient containing ether. The stomach was first washed out with 
a solution of sodium bicarbonate poured in through the funnel, and made to flow out 
again by depressing the tube below the level of the viscus, so as to make the former 
act as a syphon. When the patient was fully under chloroform the ether-holder was 
plunged into a vessel of Water, at a temperature of 60° Centigrade, when the stomach 
at once became distended by the vapor. It is obvious that neither this nor Schonborn’s 
plan could be pursued if the gullet was much narrowed. Jacobi (New York Med. 
Journ., 1874, vol. xx., p. 142) passed a fine catheter into the stomach, and injected a 
solution of bicarbonate of soda, and shortly afterwards a solution of tartaric acid. 
Fowler (Annals of Anat. and Surgery, Brooklyn, 1882, vol. vi., p. 27) injected thirty 
drops of dilute hydrochloric acid, mixed with an ounce of water, followed, after an 
interval of from two to three minutes, by an ounce of a saturated solution of bicar- 
bonate of soda. CICATRICIAL STRICTURE OF THE GULLET. 
157 
margins, and about one finger’s breadth to their inner side; the centre 
of the incision being made to fall about three-quarters of an inch in- 
ternal to the outer edge of the rectus abdominis muscle.* The lips of 
the skin-wound should then be held asunder, and the fibres of the 
rectus should be divided in a vertical direction for about an inch, all 
haemorrhage being at once checked by torsion of the vessels, or ligature 
with fine earbolized catgut. When the parietal peritoneum is reached 
it should be gently picked up with forceps, and a minute opening should 
be made in it with the knife. Through this aperture a grooved di- 
rector should be introduced, on which the membrane is to be slit up in 
the axis of the incision through the rectus. The peritoneal sac being 
thus laid open, the stomach will in most cases be at once visible, but 
sometimes instead of it the omentum, or even the colon, comes into 
view. The former is not likely to mislead the operator, but as it has 
actually happened that the colon has been opened instead of the stom- 
ach, it is well to be on guard against such an accident. The longitu- 
dinal bands, together with the appendices epiploicce, and the thinness of 
the walls will serve to identify the colon, which should be gently pushed 
downwards out of the way. Should the omentum present itself in the 
wound, gentle traction should be made on it until the stomach is brought 
down so as to bulge out of the wound somewhat like a hernia. 
2d Stage.—To keep the stomach in a proper position and prevent 
its falling back into the abdominal cavity during the remaining steps 
of the operation, the base of the projecting portion should be trans- 
fixed in a direction parallel to the surface of the belly by two 
long needles, the extremities of which should reach considerably be- 
yond the edges of the wound on either side.f The stomach is thus 
held fast between two transverse supports resting on the surface of the 
body. The viscus should now be stitched to the abdominal wall either 
by a single or a double series of sutures. Verneuil uses one set of 
stitches, the sutures, which are of silver wire, being passed first through 
the skin close to the edge of the wound, next through the parietal 
* Some surgeons prefer to make a vertical incision along the outer margin of the 
left linea semilunaris, commencing immediately below the edge of the thorax, and con- 
tinued downwards for three or four inches. The incision through the rectus, as recom- 
mended above, was first practiced by Mr. Ilowse, to whom the greater success of gas- 
trostomy in this country in recent years is largely due. The straight fibres of the rectus 
form a sphincter round the gastric wound, and the dribbling of the contents of the 
stomach so prone to occur during coughing is thereby prevented. 
f This plan was first recommended by Verneuil (Bull, de 1’Acad. de M6d , 1876, p. 
1025). 158 
DISEASES OF THE THROAT AND NOSE. 
peritoneum, lastly through the peritoneal and muscular coats of the 
stomach, and out again ; the ends are then threaded through a perfo- 
rated plate, and afterwards through shot drilled for the purpose, when 
they are fixed by crushing the leaden ball over them with pincers. 
Howse, on the other hand, prefers a double circle of stitches; the outer, 
which consists of carbolized silk sutures, passes through the serous and 
muscular tunics of the stomach, and afterwards through the skin about 
three-quarters of an inch beyond the lip of the wound, and is here tied 
over pieces of quill; the inner circle is made with ordinary sutures of 
fine wire or carbolized silk, and unites the serous coat of the viscus to 
the skin close to the edge of the incision. The object of the two circles 
of stitches is to provide a greater area for adhesion, the whole of the 
zone between the two rings being likely to unite with the abdominal 
parietes. 
3d Stage.—As already remarked, it is most important to delay this 
till adhesions have been produced between the corresponding peritoneal 
surfaces round the wound, and the stomach thereby securely fixed to 
the abdominal wall. Mr. Howse’s method is to defer the third step of 
the operation till the fifth or sixth day, and by some surgeons* an in- 
terval of a week or even a fortnight is allowed to elapse between the 
preliminary part and the completion of gastrostomy. The stomach 
may be opened by puncturing the centre of the exposed portion with a 
fine-pointed bistoury. As considerable haemorrhage has followed this 
apparently simple proceeding on more than one occasion, the surgeon 
should be prepared for such a contingency, the occurrence of which is 
probably favored by the congested condition of the islet of stomach-wall 
included within the ring of sutures. Pressure will probably suffice to 
stop the bleeding, or the risk may perhaps be altogether obviated by 
opening the stomach with a thermo-cautery point, after the manner of 
Albert. An india-rubber tube, provided with a plug, may be left in 
the wound, and kept in situ by means of a silver suture, passing through 
it and the skin on each side, or, as is Mr. Howse’s practice, the fistu- 
lous opening, which is at first made only large enough to take a No. 6 
catheter, may be gradually dilated to the size of a No. 32 instrument 
(French scale). In either case the wound should be dressed with a pad 
of lint steeped in carbolized oil (1 in 60), over which may be put an 
additional pad of boracic lint, the whole being kept in place by means 
of a body-bandage. The sutures should not be removed for about ten 
days. 
* Maydl (loc. cit., No. 15) gives two cases where the interval was fourteen days. CICATRICIAL STRICTURE OF THE GULLET. 
159 
In the interval between the second and third stages of gastrostomy 
the patient’s strength should, if possible, be maintained by rectal ali- 
mentation. If, however, aphagia has existed for more than two or three 
days it may be necessary to do the entire operation in one act. 
A few words must be added regarding the manner of feeding the 
patient after the completion of as the success of the opera- 
tion greatly depends on this. Nourishment should be administered in 
small quantities and at very frequent intervals, and during the first few 
hours it should be given cold or even iced, in order to check vomiting. 
The act of feeding should, as far as possible, be an imitation of the 
natural mode of taking food,—that is to say, nourishment should be 
given in small spoonfuls, about half a minute being allowed to inter- 
vene between the helpings. The cause of failure after gastrostomy has 
undoubtedly sometimes been the unphysiological mode in which the 
food has been administered. At first the diet should be confined to 
milk, beef-tea, and a little stimulant; later on, when the stomach has 
become more accustomed to the novel conditions under which it has to 
work, light puddings of tapioca or arrowroot, hot milk sweetened with 
sugar, eggs boiled very soft, beef-tea, and chicken broth may be allowed. 
Pounded meat or panada may be given when the power of digestion 
has become established. Trendelenburg* advises that the patient should, 
if possible, masticate the food, and should then blow it through an 
elastic tube passing from his mouth to the permanent tube in the gastric 
fistula. The patient has thus the enjoyment of eating, and the digestive 
process has the advantage of the salivary function. 
Many operators have noticed that after gastrostomy the oesophageal 
stricture yields a little; this is probably due to relaxation of the mus- 
cular spasm, and subsidence of the inflammation which almost invari- 
ably affects the mucous membrane near the seat of disease. Hence a 
day or two after the establishment of the gastric fistula, a little liquid 
food can often be swallowed. In this way the feeding through the 
stomach may be minimized at first, and that organ gradually habituated 
to the abnormal method of receiving nutriment. 
Gastrostomy has been done sixty-seven times for cancer of the gullet, 
twelve times for cicatricial stricture, and twice for syphilitic stenosis. 
On examining the records of seventy-six examples of the operation 
concerning which I have been able to obtain sufficient details, it appears 
that the total number of deaths occurring within a fortnight was fifty- 
five, i. e., 72.4 per cent. 
* Von Langenbeck’s Archiv, 1878, vol. xxii., p. 227. 160 
DISEASES OF THE THROAT AND NOSE. 
In the cases of malignant disease the average duration of life after 
the stomach was opened was rather more than twenty days, the longest 
period of survival having been six months, and the shortest twelve hours. 
On looking more closely into the matter, however, it is plain that the 
results of this operation are progressively growing more favorable. 
Thus, in thirty-five cases collected by Petit, and extending over a period 
of thirty years, the average survival of the patient after gastrostomy 
for oesophageal cancer was slightly more than fourteen days and a half, 
whilst in thirty-two cases in which the operation has been done for the 
relief of the same disease within the last three years the average sub- 
sequent duration of life has been more than thirty days. This estimate 
does not include Howse’s cases, which have been alluded to by several 
surgeons as amongst the most successful operations of the kind that 
have yet been performed. It should be added that, in fifty-seven cases 
of which a sufficiently detailed account is given, the average duration 
of the symptoms at the time of the operation was about six months 
and a half, the longest being three years, and the shortest six weeks. 
In twelve cases in which gastrostomy has been done for cicatricial 
stricture the average of after-life has been more than five months and 
a half, not including a case of Bryant’s, where the result is simply in- 
dicated as “cure,” without further details. In these cases the average 
duration of symptoms at the time of the operation had been rather 
more than five months, the longest period having been one year, and 
the shortest four weeks. 
Lastly, in two cases in which this operation has been done for syph- 
ilitic stenosis, the average survival has-been slightly over three days, 
whilst the average duration of the symptoms had been seven months 
and a half. 
In a total number of eighty-one gastrostomies death from shock oc- 
curred within forty-eight hours in twenty, i. e., in 24.6 per cent. 
The advantages of gastrostomy are : 
1st. That it can be carried out with comparative ease. 
2dly. That there is very little risk in the steps of the operation itself, 
especially if done in two acts separated by a proper interval of time. 
3dly. That there is almost entire certainty* of being able to effect 
the object aimed at, which is the establishment of an alimentary fistula 
altogether beyond the seat of stricture. 
* See, however, two cases reported by Maydl (loc. cit.), in one of which the opera- 
tor was foiled by finding a larger growth in the stomach itself, whilst in another there 
was a cancerous condition of the fundus and anterior wall of that organ in addition to 
the oesophageal disease. CICATRICIAL STRICTURE OF THE GULLET. 
161 
4thly. That the fistula is hidden from sight. 
The only disadvantage, on the other hand, is, that gastrostomy, with 
every aid of antiseptic precautions in the actual performance of it, and 
the improved after-treatment which is now adopted, still yields a high 
percentage of deaths. 
Comparing gastrostomy and oesophagostomy together, it may be 
affirmed : 1st, that gastrostomy is both easier and safer to perform, the 
risk of haemorrhage and other surgical complications being much less; 
and 2dly, that gastrostomy always meets the difficulty to be overcome; 
that is to say, the obstruction to the passage of food into the stomach, 
except in those comparatively rare cases in which the stomach itself is 
also diseased. The effect of either procedure in relieving the patient’s 
immediate sufferings, notably from thirst, and occasionally, in a less 
degree, from hunger, is often very marked, and it may be expected that 
the malady will make less rapid progress when the gullet is no longer 
exposed to irritation by persistent endeavors to swallow. It can hardly 
be denied, however, that the benefit of these operations has often been 
shown more in the euthanasia which they have brought about, than in 
any appreciable prolongation of the patient’s life. In fact, judging 
from statistics alone, operative interference would seem to be attended 
with less satisfactory results than the milder palliative measures gen- 
erally adopted. Thus, whilst the average duration of life in my series 
of 100 cases* of malignant stricture of the gullet in which no operation 
was attempted was eight months, the average extent of life after the 
first manifestation of distinct symptoms till death in fifty-three cases in 
which gastrostomy was performed was seven months.f The records of 
oesophagostomy for cancer seem at first sight more favorable than either 
of the above estimates, for in eight cases of which sufficient details are 
given to form the basis of such a calculation, the average period from 
the first appearance of dysphagia till death was ten months. This result 
is largely due to Podrazki’s case being included. It may be pointed 
* See page 86. 
f It is right to state, however, that the recent records of this operation, taken alone, 
show much better results. Thus, in twenty cases reported since 1879, the average duration 
of life from the first onset of the disease was seven and a half months, notwithstanding 
that in one case the period of survival is only reckoned as four months, and in an- 
other as ten days, though the patients in each instance were still alive, and likely to 
live for some time at the date of report. If the Albert-Maydl cases alone are consid- 
ered, a still more favorable result will be found. The total average in seven cases was 
eleven and a half months, notwithstanding that one of the patients still living at the 
date of report is only counted as surviving the operation six weeks. 162 
DISEASES OF THE THROAT AND NOSE. 
out, however, that the long duration of antecedent dysphagia in this 
case furnishes no very certain measure of the length of time during 
which the cancer had existed, the patient having suffered severely from 
syphilis, and the difficulty of swallowing having at first yielded to 
anti-venereal treatment. Moreover, as the patient survived the opera- 
tion only two days, it is obvious that the weight which the case ap- 
parently throws into the scale in favor of oesophagostomy is altogether 
illusory. Podrazki’s case may therefore be disregarded as being merely 
a disturbing element in the present calculation. The remaining seven 
cases of oesophagostomy for malignant disease show an average dura- 
tion of life of only seven months after the first appearance of symptoms. 
On reviewing the whole subject, gastrostomy may be said to have 
now taken its place among the procedures of everyday surgery, and a 
hope may legitimately be cherished that as the increasing resources of 
science render earlier recognition of oesophageal disease possible, the 
results of the operation will be still more satisfactory in the future. 
The fatality of gastrostomy has been in a great measure due to the fact 
that it has often been performed only at the eleventh hour, when the 
patient was almost moribund— “a species of refined cruelty reflecting 
no credit on surgery,” to use the words of Professor Gross.* CEsopha- 
gostomy has a much narrower range of usefulness; it is always more 
or less a “leap in the dark,” and though its effect may occasionally be 
brilliant, it is, after all, an operation more likely to find favor with the 
adventurous surgeon than with the careful practitioner. In cases of 
syphilitic origin, however, where the stricture is at the upper part of 
the gullet, oesophagostomy offers a very good prospect of success, as the 
disease is much more likely to be limited in extent than either cancer 
or the lesion produced by corrosive fluid. As regards internal oesopha- 
gotomv, increased experience will probably show that, though its im- 
mediate results are not so frequently fatal, its ultimate effects even when 
successful are less beneficial to the patient than those of either gastros- 
tomy or oesophagostomy. 
The following is an interesting example of cicatricial stenosis of the 
gullet in which gastrostomy was performed : 
Sarah C., aged twenty-six, swallowed hydrochloric acid on February 16th, 1879. 
She was taken to Guy’s Hospital, where the immediate symptoms were treated, but 
the dysphagia increased so much that on April 24th gastrostomy was performed by 
Mr. Howse. The patient was fed entirely through the artificial opening for nearly a 
year, when dilatation of the oesophagus with bougies, which had been found iinprac- 
* System of Surgery, 1882, 6th ed. vol. ii., p 495. CICATRICIAL STRICTURE OF THE GULLET, 
163 
Fig. 20. 
Traumatic Stricture of the Gullet, extending from within half an inch of the Cricoid 
Cartilage to within an inch of the Cardia. Over the whole extent of the stricture the 
walls of the oesophagus can be seen to be enormously thickened. 
a, upper portion of gullet, showing vertical ridges terminating in a raised annular 
band; 6, middle portion of oesophagus, showing a network of fibrous trabeculae with deep 
holes interspersed ; one of these was a perforating ulcer communicating with the wind- 
pipe; outside b, can be seen some enlarged glands and thickened tissue with the bron- 
chi projecting at either side; c, smoother surface, but depressed cicatrices and raised 
bands still to be seen here and there; d, three openings communicating with a small 
pouch ; e, two depressions near the cardia; /, the stomach. 164 
DISEASES OF THE THROAT AND NOSE. 
ticable at an earlier period, owing to the tightness of the stricture, was again attempted. 
By this means the patient recovered the power of swallowing to such a degree that 
Mr. Howse allowed the fistulous opening to close, warning her at the same time that 
it would be necessary to pass a bougie occasionally. She left Guy’s Hospital in August, 
1880, by her own desire. On September 6th, in the same year, she came under my 
care at the Throat Hospital. A No. 2 bougie was passed, and the stricture was grad- 
ually dilated till it was large enough to admit a No. 9, and the patient’s condition im- 
proved considerably. In February, 1S81, however, the dysphagia had again become 
so severe that she had to be taken into the Throat Hospital, where, for three months, 
she was confined to bed, suffering from constant pain between the shoulders, which was 
increased when she tried to swallow. During all this time her temperature was always 
above the normal point, being often as high as 102° Fahr. in the evening. No cause, 
however, could be discovered for the pyrexia. After this illness the patient steadily 
improved for some time, notwithstanding occasional relapses. In the autumn of 1882 
her gullet again became almost blocked up, in spite of constant attempts at dilatation, 
and she gradually lost strength till the early part of November, when she died. 
The following are the notes of the post-mortem examination. The body showed 
little sign of wasting, there being fully an inch of fat on the abdominal walls. Both 
lungs were adherent to the chest-wall. The oesophagus was bound to the prevertebral 
muscles by bands of dense fibrous tissue, rendering its separation from the surrounding 
parts very difficult. Barely half an inch below the cricoid cartilage the stricture com- 
menced, and extended downwards to within two centimetres and a half of the cardia. 
The walls of the gullet throughout the whole of the strictured portion were enormously 
thickened, the cut edge in some places being an eighth of an inch in width, and very 
tough. The narrowest part of the stricture corresponded to the upper inch and a half 
of the gullet (Fig. 15, a), and consisted of four longitudinal ridges, mainly situated on 
the anterior wall, but partly on the sides of the gullet. These ridges almost blocked 
up the lumen of the oesophagus, which was still further narrowed below by a transverse 
cicatricial band connecting,the longitudinal folds together. Lower down the stricture 
was made up of a mesh-work of bands, most of which had a transverse direction. 
Throughout the strictured portion of the gullet its walls were hard and thickened. 
Seven centimetres above the cardia there were three openings, admitting a large probe, 
surrounded by some cicatricial bands. These openings communicated with a canal, 
which ran for two centimetres and a half downwards, and slightly to the right between 
the muscular fibres, and terminated in a pouch covered with muscular fibres, half an 
inch long, external to the gullet. Higher up, at a point rather below the middle of 
the oesophagus, there was a minute perforation, leading into the trachea through its 
posterior wall. The stomach was 64- inches in its smaller curvature, and l‘2k in its 
larger curvature. Its anterior surface measured 3J inches in its widest part, and 2 
inches in its narrowest part. 
There was a cicatrix 2j inches long in the abdominal wall, and on opening the 
stomach a depressed cicatrix, with radiating ridges, was seen about an inch and a half 
from the greater curvature, and rather nearer the pylorus than the cardia. The stom- 
ach was united to the anterior wall of the abdomen by a dense fibrous tissue. SIMPLE STENOSIS OF THE GULLET. 
165 
SIMPLE STENOSIS OF THE GULLET. 
Latin Eq.—Strictura oesophagi. 
French Eq.—Retrecissement de l’oesophage. 
German Eq.—Verengung der Speiserohre. 
Italian Eq.—Stenosi del esofago. 
Definition.—Abnormal narrowness of a limited portion of the oesoph- 
agus without any morbid change in any of its component tissues at the 
seat of stricture. 
History.—The earliest recorded example of this affection is that of Blasius.* More 
than a century later, Sir E. Homef related some instances in which the oesophagus 
presented a uniform circular contraction behind the cricoid cartilage. CassanJ de- 
scribed a case in which the gullet was contracted for a length of eight millimetres. 
There was not the least change in the mucous membrane at the seat of narrowing, but 
the pharynx above was increased to double its usual width. Cruveilhierf has placed 
on record a case of simple narrowness of the oesophageal channel at its lower part, 
while there was a dilated portion above, the inner surface of which was covered with 
large polypoid vegetations. Wilks,|| in 1866, and Hilton Fagge,1[ in 1872, have each 
recorded an example of stenosis at the lower part of the tube, whilst Zenker** has lately 
described a case in which the oesophagus was greatly contracted at its upper part, the 
mucous membrane in that situation being pale, thin, and loosely attached to the sub- 
mucosa, but presenting no anatomical change. At the lower part the tube was of nor- 
mal calibre, but the mucous membrane was unnaturally pale. 
Etiology.—The origin of this condition is exceedingly obscure. In 
most of the cases it is stated that the patient had a “small swallow” 
since childhood, but every practitioner must be aware that this phrase 
is used in a very vague way, and by numberless people who have no 
real narrowing of the oesophagus. Although it is highly probable that 
the condition is a congenital abnormality, I am not aware that there is 
any instance on record in which its existence in early life has been 
proved by post-mortem examination. It is possible that the smallness 
of a portion of the gullet may be simply due to an arrest of growth in 
* Observ. Anat., 1674, p. 170. 
f Pract. Obs. on the Treatment of Strictures in the Urethra and (Esophagus, Lon- 
don, 1803, vol. ii., p. 414. 
X Arch. G6n., 1826, t. x., p. 79. 
§ Anatomie Pathologique, Paris, 1835-1842, livr. 38, pi. 6. 
|| Trans. Path. Soc., 1S66. Guy’s Hospital Reports, 1872, p. 413. 
** Ziemssen’s Cyclopaedia of Pract. Med., English trans., vol. viii., p. 19. 166 
DISEASES OF THE THROAT AND NOSE. 
infancy or early childhood, or it may result from partial paralysis of a 
portion of the longitudinal fibres of the oesophagus in infant-life, the 
frequency of other paralytic affections at that period being an estab- 
lished fact. In cases where the narrowing is at the lower part, there is 
occasionally some degree of dilatation above, and it may be, under these 
circumstances, that the original formative material constituting the 
oesophageal walls has been unequally distributed. Dr. Wilks was 
strongly of opinion that the dilatation in his case, as well as the stric- 
ture, was congenital, but it is scarcely necessary to point out that a con- 
genital stricture is extremely likely to give rise to dilatation higher up. 
Symptoms.—In all the cases that have been recorded, although there 
has been more or less difficulty of swallowing from an early period of 
life, the dysphagia has remained stationary till not long before death, 
when, in some instances, disease has developed above the seat of stric- 
ture. In Fagge’s case, during twenty years the patient had at intervals 
suffered from complete occlusion of the oesophagus, which on one occa- 
sion lasted for a period of eight days. 
Regurgitation appears to occur chiefly in those cases in which there 
is a pouch above the stricture. The patients can generally swallow 
liquids with ease, but solids have to be washed down with drink. Evi- 
dence as to the nature of the affection can be obtained by the bougie 
and by auscultation, for an instrument of medium size is arrested at the 
seat of stricture, whilst on listening over the oesophagus, the food can be 
perceived to reach the point of constriction at the ordinary rate, whilst 
below this only a trickling or dropping sound can be heard. 
Pathology.—In nearly all the cases that have been observed, it is 
stated that the tissues had undergone no pathological change; but it 
does not appear that the muscles and nerves of the oesophagus have ever 
been submitted to microscopical examination in these cases. Disease is 
likely to be found in the part of the gullet above the stricture. Thus, 
in Cassan’s case there were signs of general inflammation, whilst Crn- 
veilhier’s, as already remarked, presented polypoid vegetations on the 
mucous membrane of the dilated sac, and in Fagge’s, cancer had become 
developed in the wall of the pouch. 
Diagnosis.—The absence of any traumatic cause of stricture, the con- 
tinuous existence from early childhood of dysphagia, and the non- 
progressive character of this symptom, serve to distinguish this class of 
cases. 
Prognosis.—In two instances the patients lived to the age of seventy- 
four years, and the prognosis is not very unfavorable if great care be taken COMPRESSION OF THE GULLET. 
167 
in the selection of diet. The predisposition to secondary disease above 
the stenosis, however, must not be forgotten. 
Treatment.—It is extremely important in these cases that the patient 
should take only liquid or semi-liquid food of a non-irritating character, 
whilst stimulants must, as a rule, be avoided. The patient should be 
enjoined to eat with care and deliberation. Dilatation should not be 
attempted, as it could only give rise to rupture of one or more of the 
oesophageal tunics. There remains, therefore, only oesophagostomy or 
gastrostomy. Considering, however, the non-progressive character of 
the stricture, these operations are not likely to be called for unless some 
complication should arise. 
COMPRESSION OF THE GULLET. 
Compression of the gullet may be effected by any of the organs ill 
its immediate neighborhood. It is seldom, however, that severe com- 
pression is produced, except in the case of constricting or cancerous 
bronchocele, enlargement of the deep lymphatic glands near the tube, 
or tumors of malignant character in the neck or in the posterior 
mediastinum. Neither aneurism nor dilated heart, as a rule, gives 
rise to extreme dysphagia. The condition most frequently causing 
compression is constricting goitre. Twice I have known this to cause 
death by inanition; one of these will be recorded and illustrated under 
the head of “ Goitre.” I have seen several examples of cancer of the 
thyroid gland pressing so much on the gullet as to hurry on the fatal 
termination. In several patients suffering from lymphoma, whom I 
have been called on to treat, dysphagia has been a troublesome symp- 
tom. Cases have been recorded in which compression was produced by 
thickening of the posterior plate of the cricoid cartilage,* and one in- 
stance (Specimen No. 132, Throat Hospital Museum) has come under 
my own notice in which this part measured one centimetre in thickness, 
and caused death by starvation. In other instances dysphagia has been 
attributed to abnormal length of the styloid process,f to ossification of 
the stylo-hyoid ligaments,]! and to lordosis of the spinal column.§ Sir 
* Travers: Med.-Chir. Trans., vol. vii.; Gibb: Diseases of the Throat, 1864, 2d 
ed., p.378; Wernher: Chirurg. Centraiblatt, 1875, No. 30; Hadlich: Deutsche Zeit- 
schrift f. Chirurgie, 1882, Bd. xvii., p. 138 el seq. 
f Wien. Med. Wochensclir., No. 5, 1882. 
J Emminghaus : Deutsches Archiv. f. klin. Med , Bd. xi., p. 304. 
g Sommerbrodt: Berlin, klin, Wochensclir., 1875, p. 334; Hevmann: Ibid., 1877 
p.763; Lennox Browne: The Throat and its Diseases, London, 1878, p. 119. 168 
DISEASES OF THE THROAT AND NOSE. 
Astley Cooper* related a case in which great difficulty of swallowing 
was caused by the sternal end of a dislocated clavicle pressing on the 
gullet. The dysphagia was at once relieved on the inner end of the 
bone being sawn off. Morgagnif refers to a case in which a soldier, 
suffering from opisthotonos, was unable to swallow, which he attributes 
to the over-extension of the gullet caused by the arching backwards of 
the neck. It is obviously possible, however, that the oesophageal mus- 
cles may have been in a state of tetanic contraction. Some illustrations 
of compression caused by aneurism have been collected by Knott.J In 
general, however, as already stated, aneurisms of the aorta, even when 
they impinge on the gullet, do not seriously obstruct the passage of 
food. Out of fourteen marked cases of aortic aneurism pressing on the 
oesophagus, brought together by Moni6re,§ in twelve there had been no 
dysphagia. Perforation, however, not unfrequently takes place in such 
cases; and among one hundred and twenty examples of perforation of 
the gullet, rupture of the aorta occurred in eighteen, whilst the pulmo- 
nary, carotid, subclavian, inferior thyroid, and superior intercostal 
arteries each furnished one instance. Hypertrophy of the heart, and 
especially fluid effused into the pericardium,|| sometimes occasions con- 
siderable difficulty in swallowing, but the pressure of an enlarged heart 
sometimes has a totally different effect, and may give rise to hypertro- 
phy of the oesophageal walls. Thus Wilks and have found 
“ the muscle of the oesophagus thrice its normal thickness,” from this 
cause. 
The means of distinguishing between compression of the oesophagus 
and cancerous stricture, have been pointed out in dealing with the lat- 
ter subject (p. 102), and as regards the treatment, it is obvious that all 
remedial measures must be directed against the essential disease. A 
feeding tube can be introduced in some cases when the normal descent 
is interfered with, and by this means life may occasionally be prolonged ; 
but it must not be forgotten, that when an aneurism is the cause of the 
compression, there is some danger in using such an instrument. (Esopli- 
agostomy, or gastrostomy, remains as a last resource, and the relative 
* Lectures on Surgery, London, 1827, vol. iii., pp. 296, 297. 
f De sedibus et causis morb. Epist. xxviii.* art. 14. Lugd. Batav. 1767, t. iii., 
p. 13. 
J Pathology of the (Esophagus, Dublin, 1878, p. 217 et seq. 
\ Arch. G6n., 1833, 2e s6rie, t. iii., p. 51. 
|| Several interesting cases of dysphagia due to this cause may be found in a short 
treatise by Bourceret, De la Dysphagie dans la Pericardite, Paris, 1877. 
Pathology, London, 2d ed. 1875, p. 364. RUPTURE OF THE GULLET, 
169 
merits of the two methods should be considered, not only qua operation 
(see “Cicatricial Stricture of the Gullet”), but more especially in rela- 
tion to the nature and situation of the compression. 
RUPTURE OF THE GULLET. 
Latin Eq.—Diruptio guise. 
French Eq.■—Rupture de l’oesophage. 
German Eq.—Ruptur der Speiserohre. 
Italian Eq.—Rottura del esofago. 
Definition.—Sadden bursting of the gullet daring prolonged and 
violent vomiting, giving rise to acute pain in the course of the tube, to ex- 
treme dyspnoea, and sometimes even to orthopncea, to subcutaneous em- 
physema, and to collapse generally quickly ending in death. 
History*—The earliest case on record is that related by Boerhaave,f in 1724, as an 
injury of which there was no previous example in medical literature. An abstract of 
this interesting case will be found at the end of this article. In 1788 a case was re- 
ported by Dryden,j; a military surgeon serving in Jamaica, in which, as in Boerhaave’s 
patient, the gullet had given way under the strain of vomiting. In 1811 Monrof 
stated that he had in his possession the gullet of a child in whom this lesion had 
taken place, adding that an example of a similar occurrence had been related to him 
by Carmichael Smyth.|| Both these cases, however, must be regarded with suspicion 
for the reason hereafter stated in the short article on “Post-mortem Solution of-the 
Gullet;” a remark which also applies to the following case, but in a less degree, owing 
to the symptoms observed during life. In 1812 an account was published by 
of a rupture of the oesophagus which took place in a little girl, aged seven, during an 
* Several cases of so-called rupture have been omitted in this place as being too doubt- 
ful in themselves or too incompletely described to be of much value. Such cases are 
those of Kade (De morbis ventric., Halae, 1798, p. 17 et seq.); Thilow (Baldinger’s 
Magazin f. Aerzte, 1790, vol. xii., p. 114); Bouillaud (Arch. G6n. de Med., 1823, t. i., 
p. 531), and Le Bay (Roumegoux, Essai sur les Plaieset les Ruptures de l’CEsophage, 
These de Paris, 1878, No. 369, pp. 34, 35). Two interesting but doubtful cases recently 
reported by Mr. Stanley Boyd (Trans. Path. Soc., 1882, vol. xxxiii., p. 123 et seq.) do 
not seem quite to come within the terms of the above “definition.” 
f Atrocis nee descripti prius morbi historia, Lugduni Batavorum, 1724. 
X Medical Commentaries, Edinburgh, 1788, Dec. ii., vol. iii., p. 308. 
§ Morbid Anatomy of the Gullet, Stomach, and Intestines, Edinburgh, 1811, 1st ed., 
p. 311. 
|| Dr. Carmichael Smyth was a man of considerable distinction in his profession, and 
Physician to the King in Scotland towards the close of last century, 
f Bull, de la Fac. de M6d. de Paris, 1812, t. i., p. 73. 170 
DISEASES OF THE THROAT AND NOSE. 
attack of fever in which there had been much nausea and vomiting. In 1837 a case 
was related by Heyfelder,* in which a drunkard died in convulsions, and after death 
his gullet was found ruptured at its lowest part. This, however, seems to me a very 
doubtful example of the accident now under consideration. In 1843 Wilkinson Kingf 
described as an instance of post-mortem digestion of the gullet, a case in which there 
appears every reason to believe that the tube had been ruptured during life. In 1848 
C. J. B. Williams! published a case in which not only the oesophagus but the dia- 
phragm had given way under the strain of violent and prolonged vomiting. Examples 
of this rare injury have also been recorded by Oppolzer,§ Meyer,|| Grammatzki,!) 
Griffin,** Charles,ff Bailey,!! Fitz,$$ Adams,|||| and Taendler.lf![ (All the unequiv- 
ocal cases of rupture which have been published, amongst which several, though re- 
ferred to in the above short historical summary, cannot be included, are placed in a 
table at the end of this article.) 
Etiology.—The immediate cause appears always to be violent retch- 
ing, in most cases following a heavy meal. In some instances the 
vomiting was brought on voluntarily with the help of emetics, whilst 
in others it followed a drunken debauch, or came on in the course of a 
severe febrile complaint. In two cases, however, the accident seems to 
have originated in forcible efforts to dislodge a foreign body from the 
gullet. In one*** of these the action was reflex—that is to say, it con- 
sisted in vomiting; but in the otherff f there was violent voluntary strain- 
ing to expel the impacted substance. In both instances some bleed- 
ing took place at the time of the accident, and it is highly probable 
that a wound was made in the oesophageal wall. It is likely that 
vomiting only causes rupture when the contents of the stomach cannot 
be expelled through the gullet at the same rate that they leave the vis- 
cus. This want of relation between expulsion and transmission may 
be due to the abnormal quantity of fluid in the stomach, or to obstruc- 
* Sanitiitsbericht liber das Fuerstenthum Hohenzollern-Sigmaringen wahrend des 
Jalires 1837. 
f Guy’s Hospital Reports, 1843, 2d series, vol. i., p. 113. 
J Trans. Path. Soc., London, 1848, vol. i., p. 151. 
§ Wien. Med. Wochenschr., 1851, p. 65. 
|| Med. Vereinszeitung v. Preussun, 1858, Nos. 39, 40, 41. 
Ueber die Rupturen der Speiserohre, Konigsberg, 1867. 
** Lancet, 1869, vol. ii., p. 337. 
ff Dublin Journ. Med. Sci., 1870, vol. i., p. 311. 
New York Med. Journ., May, 1873. 
$$ Amer. Journ. Med. Sci., January, 1877, p. 17. The case is narrated by Dr. Fitz, 
who made the autopsy, but the patient had been under the professional care of Dr. 
Allen. 
1111 Trans. Path. Soc., London, 1878, vol. xxix., p. 113. 
Deutsche Zeitschr. f. prakt. Med., 1878, No. 52. 
*** Meyer. fff Fitz. 171 
RUPTURE OF THE GULLET, 
tion of the oesophageal canal. It is obvious also that any disease or 
injury causing softening or atony of the walls of the gullet, or any 
morbid condition of the tissues surrounding the tube which restrains its 
normal expansion at any part, would favor rupture. 
Analyzing these causes of rupture, it may be remarked that in nearly 
every case of which details on the subject have been published, the 
stomach was sufficiently full at the time of the accident to have its con- 
tents expelled with some force. But it is probable that some temporary 
obstruction near the upper end of the gullet, preventing the flow of 
fluid matters from the stomach, is the essential factor in the rupture. 
To determine the cause of this obstruction is not always possible. In 
two cases, as already remarked, a foreign body was impacted in the 
oesophagus, but these were exceptions. In all the others the obstruc- 
tion, if present, must have been due to something inherent in the tube 
itself. This is probably to be found in strong contraction of the cir- 
cular fibres of the gullet at the upper part of the oesophagus. In two 
cases—those of Fitz and Wilkinson King—there was tetanic spasm, 
affecting in the one the flexor muscles of the limbs, and in the other 
the abdominal muscles; and it need scarcely be pointed out that if such 
a condition existed at the same time in the muscular walls of the gullet, 
rupture would be likely to take place. In other cases it is probable 
that the spasm was limited to the oesophageal muscles. Absolute 
obstruction, however, is not necessary; if the contents of the stomach 
pass into the gullet more quickly than they can escape, a rupture may 
occur. It must be borne in mind that the upper two-thirds of the 
oesophageal canal are covered by striped muscular fibres, whilst the 
lower third has only unstriped fibres; and that whilst electrical shocks 
throw the former into violent contraction, the latter only take on gentle 
peristaltic action.* The lower portion of the tube would, therefore, be 
less capable of resisting pressure from within, and more likely to rup- 
ture. It is possible, however, that in some cases the obstruction is not 
caused by muscular contraction, but is due to the unyielding character 
of the pharyngeal orifice of the gullet, protected anteriorly by the cricoid 
cartilage, and behind by the vertebral column. 
Supposing, then, an obstruction to exist at the upper end of the tube, 
it becomes interesting to ascertain what strain its wall will withstand 
when the contents of the stomach are thrown violently into the canal. 
In order to determine the bursting-point of the gullet, I made the follow- 
ing experiments with the assistance of Mr. Charles L. Taylor: The 
* Todd and Bowman: Physiological Anatomy, London, 1859, vol. ii., p. 189. 172 
DISEASES OF THE THROAT AND NOSE. 
upper end of a healthy oesophagus, removed from the body shortly after 
death, having been tied, water was thrown in at the opposite orifice by 
means of a forcing-pump provided with a pressure-gauge. The aver- 
age pressure at which the tube gave way was rather over seven pounds, 
the highest being eleven and the lowest five and three-quarters. Among 
the subjects from whom the gullets were taken there were eight males 
and four females; their average age was between thirty-eight and thirty- 
nine years, the oldest sixty-six and the youngest seventeen. In three 
of the twelve cases the rupture occurred about an inch above the liga- 
ture, i. e., speaking roughly, about two inches above the cardia; in 
eight, the rent took place at a point one to two inches higher, whilst in 
one case the gullet burst just above the junction of the lower and middle 
thirds. In every instance the solution of continuity was vertical in 
direction, and varied from a third of an inch to nearly two inches in 
length. These experiments imitated, as far as possible, the expulsion 
of the contents of the stomach through the gullet in violent vomiting, 
and produced a condition exactly like rupture as it occurs during life 
—that is to say, a vertical rent with clean-cut edges at the lower part 
of the gullet. Thinking it possible that the occurrence of the rent in 
the lower portion of the gullet might have been due to the injection 
having been made near that part, the experiment was reversed, and the 
cardia having been tied, the injection was made from above. In five 
out of six trials* the rupture occurred within three inches of the cardia, 
and only once higher up. 
The conclusions to be drawn from these experiments are: 1st, that 
rupture by direct pressure applied within the gullet always takes place 
in a longitudinal direction ; 2dly, that the rent never occurs in the upper 
half of the tube, and in most cases is confined to the lower third ; 3dly, 
that the mucous membrane offers greater resistance to strain than the 
muscular covering. As regards the actual production of the rent, the 
following seemed to be the sequence of events : as the water was pumped 
in, the tube became distended, especially at the lower part, where the 
* In the six cases in which the injection was made from above, the average bursting- 
point was a trifle over six pounds, the maximum being eight, and the lowest just under 
five. The subjects were all of the male sex, and their ages averaged nearly forty-nine 
years, the oldest being fifty-nine, and the youngest twenty-six. The direction of the 
rent was vertical in every case, and its situation was from one to three inches above 
the point of ligature in five of the cases, whilst in the remaining one the oesophagus 
gave way exactly midway between the cricoid cartilage and the diaphragm. The rup- 
ture occurred four times in the posterior wall, once in the middle line in front, and 
once on the left side of the tube, (he length of the rent varying from three-quarters of 
an inch to an inch and a half. RUPTURE OF THE GULLET, 
173 
muscular coat became gradually blanched from stretching; next, in 
eleven of the eighteen cases, the muscle and the mucous membrane gave 
way together, the former presenting a somewhat irregular fissure with 
ragged edges, and often with nerve-fibres stretching unbroken across it, 
whilst the mucous membrane showed a clean straight slit, as if it had 
been cut with a knife. In the remaining seven cases the rupture took 
place gradually, the muscular bundles first separating at one place, and 
leaving an interval through which the mucous membrane bulged out in 
a hernia-like sac, which was stretched to an extreme degree of tenuity 
before giving way. In all the eighteen cases the laceration of the mu- 
cous membrane was from a quarter to half an inch shorter than the 
fissure in the muscular coat. 
There is no difficulty in showing that the walls of the tube have, in 
several of the published cases of oesophageal rupture, been in abnormal 
condition. In one* of them there was slight cicatricial stricture of the 
gullet near the cardia; whilst in anotherf it is stated that the patient 
had had occasional difficulty in deglutition since infancy ; and in a thirdj 
that the food could only be taken in small morsels and slowly for some 
years before the accident. In the two cases in which foreign bodies had 
been impacted, it is extremely probable that some injury was done to 
the wall of the gullet which lessened its power of resistance. Although 
in most of the other examples the mucous membrane is said to have 
been perfectly healthy, except as regards digestive solution, it may be 
pointed out that all the patients were men, and that most of them had 
been accustomed to the free use of ardent spirits, and had suffered from 
habitual vomiting—circumstances which would have been very likely 
to lead to slight, though perhaps not apparent, changes in the textural 
firmness of the lining tunic of the gullet. In one of the most recent 
examples! of this accident a small, white, stellate cicatrix was found 
beside the lower part of the rent, and further down there was another 
smaller scar, showing that ulceration had previously existed. It is 
highly probable, therefore, that the texture of the lining membrane of 
the gullet was somewhat weakened, and that the canal itself was slightly 
dilated. In certain instances there may likewise have been some change 
in the muscular coats of the oesophagus or some impairment of innerva- 
tion—conditions which would, doubtless, diminish the power of resist- 
ance to strain. From the previous habits of life of those who have 
suffered from rupture of the oesophagus, it is likely enough that some 
* Meyer. 
f Charles. 
% Fitz. 
\ Adams: loc. cit. 174 
DISEASES OF THE THROAT AND NOSE. 
of them were the victims of gout. As regards one patient* it is ex- 
pressly mentioned that this was the case. 
Although it is not stated in any of the accounts that the oesophagus 
was bound down externally at any point, yet it is quite possible that in 
some cases there may have been small unobserved cicatrices in the peri- 
oesophageal tissue, which would have deprived the tube of the natural 
mobility, which, no doubt, helps it to bear the strain occurring during 
vomiting. 
It remains now to consider the'various othdr views which have been 
put forward as to the etiology of rupture. 
Boerhaave, arguing from his unique observation, attributed the rup- 
ture to direct traction on the gullet in the act of vomiting, the lower 
end of the tube being drawn down by the weight of the overloaded 
stomach, aided by the rigid contraction of the diaphragm, whilst the 
superior extremity was forcibly stretched above by the straining efforts 
induced bv tickling the fauces. As in Boerhaave’s case there was a 
transverse rupture, it is highly probable that his explanation is correct. 
It does not, however, meet the other cases, in all of which the rent was 
vertical. 
Zenker and Ziemssenf consider that the accident results chiefly from 
“ intra-mortem oesophageal malacia,” or softening of the coats from 
peptic solution in the last hours of life. With a view of testing the 
traction-power of the gullet, Ziemssenf suspended an oesophagus, freshly 
removed from the body of a powerful man, aged fifty-five, and attached 
weights to the lower end. It was found that, although the muscular 
coat gave way under a weight equal to five kilogrammes, the mucous 
membrane remained uninjured under a weight of twelve and a half 
kilogrammes. Ziemssen argues from this, that no amount of strain 
that could be applied within the body would cause rupture of the gullet 
when its tissues are in a healthy condition, or, in other words, until soft- 
ening has been produced by the digestive action of the gastric juice. I 
have repeated this experiment in four cases with the following results : 
In the first the gullet (taken from a man aged sixty-four) began to 
stretch at a weight of six kilogrammes, and the muscular coat gave way 
close to the upper end on the addition of one kilogramme. At this 
time the tube had lengthened fully two inches; after a weight of eight 
kilogrammes had been attached to it the gullet continued to stretch for 
a few seconds, when it ruptured close to the upper end. In the second 
* Boerhaave. 
f Cyclopaedia of Medicine, vol. viii., p. 100. 
X Op. cit., vol. viii.j p. 96. RUPTURE OF THE GULLET. 
175 
case the oesophagus was taken from a woman aged sixty; the tube 
stretched a little, but without rupture, as weights were gradually added, 
up to nine kilogrammes, when both the muscular and the mucous coats 
gave way with a sudden snap close to the lower extremity. The third 
experiment was made on an oesophagus taken from the body of a woman 
aged thirty; the tube began to stretch under a weight of seven kilo- 
grammes, and finally gave way at the upper end under a total weight 
of eleven kilogrammes. The fourth experiment was made with the 
gullet of a woman aged*fifty-four, which was torn asunder suddenly 
close to its lower end when a weight of six kilogrammes had been 
attached to it. 
The average point of rupture under tension, therefore, in these four 
cases was eight and a half kilogrammes, i. e., about eighteen pounds, 
the greatest resistance being eleven, and the least being six kilogrammes. 
The average age of the subjects was fifty-two. Hence it is probable 
that in Ziemssen’s case the resistance was somewhat exceptional, and 
the varying results show, as was probable d priori, that there is a con- 
siderable difference in the strength of the human gullet. If, however, 
we accept the highest power of traction, viz., twelve and a half kilo- 
grammes, I do not think it at all impossible that it will be found to be 
exceeded by the combined expulsive power of the diaphragm and the 
strong abdominal muscles. Moreover, it must not be forgotten that in 
these experiments just described the force was gradual, and was applied 
in a totally different way to that which occurs during life, when fluid 
is dashed violently and suddenly against the inner walls of the oesoph- 
agus. 
The foregoing experiments, which merely show the traction-power of 
the gullet, though of value in relation to Boerhaave’s case, in which the 
solution of continuity was horizontal in direction, have no bearing on 
any of the other recorded cases, in all* of which the rent was vertical. 
Zenker and Ziemssenf further call attention to the occasional tearing 
of the pleura, which, they consider, “ forces them ” to accept the theory 
of oesophagomalacia. They think that the repeated efforts at vomiting 
cause the regurgitated food and gastric juice to remain in the gullet 
sufficiently long to give rise to digestive softening of its walls, and that 
the faint condition of the patient produces “spastic ischaemia,” a condi- 
tion commonly expressed by the blanched face of a person who is vom- 
iting. This explanation appears to me somewhat far-fetched, for vom- 
* In Wilkinson King’s case the direction of the rent is not stated, 
f Op. cit., p. 97. 176 
DISEASES OF THE THROAT AND NOSE. 
iting, with its accompaniment of so-called spastic ischaemia, is a very 
common occurrence, while rupture of the gullet is one of the rarest of 
accidents. It is further negatived by the fact that the lesion generally 
takes place when the stomach is loaded with food or drink, and there- 
fore when the gastric juice is extremely diluted. The suddenness of 
the event, and the fact that the lesion has usually been produced when 
the patient was in the upright position (in which case the gastric juice 
could not remain in the gullet), render it highly improbable that ante- 
mortev\ peptic softening can be the cause of tly; injury. Further, were 
the rupture caused by digestive solution, whether before or after death, 
it is probable that the opening would be more or less irregular, the 
edges of the wound being “ ragged and fringed with flocculent shreds 
of half-dissolved tissue” (see “Post-mortem Digestion”), and not a 
longitudinal rent with sharply-cut edges, such as almost invariably 
occurs when the accident results from vomiting. 
An attempt was made by Wilkinson King* to prove that no such 
lesion as rupture of the oesophagus during life ever occurs, the supposed 
symptoms of such an accident being, according to him, due to other 
conditions, and the rent found after death resulting from post-mortem 
softening. This theory was based mainly on the following case, to 
which I have alluded in the historical summary as an undoubted ex- 
ample of rupture during life: 
A cabinet-maker, aged twenty-four, who had been very intemperate for years, had 
complained for many months of severe epigastric pain and sickness, and had also been 
troubled by loss of appetite and flatulence. While at a public supper, at about 9 
o’clock in the evening, he felt sick, and soon afterwards left the table. He vomited 
slightly, and had to be assisted home. Castor oil was then administered. When first 
seen by a medical man (at 3 a.m.) the patient complained of great pain at the pit of 
the stomach, the abdominal muscles were rigidly contracted, he could only breathe 
when sitting up in bed and leaning forwards on his hands, whilst his countenance ex- 
pressed the greatest anxiety. Emetics (antimony and ipecacuanha) were given with- 
out effect. At 7.30 the pain was less severe, but the dyspnoea was much worse, and 
there was emphysema of the face, throat, and chest; another emetic was given, and 
an enema was administered, but without effect. The stomach-pump was used at 10 
o’clock without result; death took place at noon ; that is to say, fifteen hours after the 
patient had sat down to supper. 
Post-mortem.—“A large rent was found in the gullet as it passes through the dia- 
phragm, filled with ingesta from the stomach (sic). There was food in the posterior 
portion of the chest.”f The left end of the stomach was softened by digestion. The 
* Guy’s Hospital Reports, 1842, p. 139, and 1843, p. 113. 
f The ipsissima verba are given, as the passage is somewhat involved, but the author 
probably meant that a space, i.e., the pleural cavity, communicating with the rent (not 
the rent itself), was filled with ingesta. RUPTURE OF THE GULLET. 
177 
lungs on both sides seemed congested, the left being “ contracted there was some dark 
offensive fluid with castor oil floating on it in the left side of the chest. A small quan- 
tity of plastic lymph was found inside the pericardium, hut the heart was healthy. 
Wilkinson King himself admits the imperfection of the report of the 
case, observing that it was compiled from “ the hasty notes of Mr. Com- 
ley.” It is conceded that the patient died very suddenly, i. e., in four- 
teen hours after the first marked symptom, that he vomited, and that a 
rent was found in his gullet after death, yet King thinks it more rea- 
sonable to attribute the death to “sudden inflammatory tumefaction of 
the larynx,” of which there is not any evidence whatever in his pub- 
lished record of the autopsy. The extensive emphysema is in like 
manner ascribed to a “ rupture of the air-tube,” of which again there 
is no mention in the account of the post-mortem examination. No 
attempt is made to explain the other features in the case, such as the 
inability to vomit and the acute pain in the epigastrium. 
My own view is that the vomiting was much more severe than it is 
said to have been in the “ hasty notes ” of the case, or that the epigas- 
tric pain, from which the patient had suffered for some months, was 
due to ulceration of the oesophagus, and that therefore its walls gave 
way under much less strain than in the other instances. If this latter 
explanation be correct, the case would closely resemble that reported by 
Mr. Adams. 
The almost universal occurrence in these cases of subcutaneous emphy- 
sema closely following the patient’s own sense of some grave accident 
having befallen him, is a strong argument against the theory of post- 
mortem digestion. It is well known that even in ordinary respiration 
some air is drawn into the gullet, and when dyspnoea is present (as in 
most cases of oesophageal rupture) the quantity of air thus swallowed is 
probably considerable. Hence, should a rent occur in the tube, it is 
clear that subcutaneous emphysema would be almost sure to take place. 
In the cases in which the bowels were distended with flatus (as in those 
of Boerhaave, Meyer, Wilkinson King, and Charles) it is not improb- 
able that the gas was formed in the intestinal canal. Instead of ac- 
cepting these obvious sources, Wilkinson King remarks that the peri- 
carditis began before the dyspnoea, and says, “ I impute to the latter 
the production of emphysema, though by no means definitely. We 
know that violent efforts of respiration rupturing the air-tube do cause 
the extravasation of air into the cellular tissue as well as the fracture 
of the rib ” (sic). This passage is somewhat involved, but I gather 
from it that King attributes the emphysema to a rent in the trachea, 178 
DISEASES OF THE THROAT AND NOSE. 
although, as already remarked, there is not the slightest allusion to any 
such lesion in the account of the post-mortem examination. It will be 
seen that the views of King do not deserve serious consideration, and 
they have only been refuted because they have so often been referred to 
by medical writers, who have evidently not read the original article. 
It need scarcely be pointed out that the presence of the gastric con- 
tents in the mediastinum or pleural cavity, does not in any way militate 
against the theory of rupture from violent contraction, npr support that 
of post-mortem or intra-vitam digestion of the oesophageal walls, for if 
the vomiting continue after a rent has taken place, the gastric juice and 
the contents of the stomach will be forced through the aperture, and 
may be found after death in the mediastinum, or in one or both pleural 
cavities. 
Symptoms.—As already remarked, the accident usually occurs during 
vomiting after a full meal or a drunken carousal. The patient sud- 
denly feels as if something had given way, his face becomes blanched, 
and expresses extreme anxiety; cold sweat breaks out over the body, 
and there may even be syncope. Excruciating pain is often felt along 
the course of the oesophagus or in the epigastric region, or occasionally 
shooting through from the ensiform cartilage to the back. This last 
symptom, however, is not invariably present at the time of the accident; 
but, as in Fitz’s case, may be deferred for some hours, probably showing 
that the actual rupture did not take place at the first onset of the symp- 
toms. The patient, who has previously been retching, suddenly be- 
comes unable to empty his stomach, or can only with the greatest diffi- 
culty bring up a small quantity of the liquid that has been swallowed.* 
In three casesf it is mentioned that the patient could endure his suffer- 
ing only when supported in a half upright position, with the body bent 
slightly forwards. The least movement generally aggravates the pain. 
In nearly every instance subcutaneous emphysema has been observed, 
usually beginning at the root of the neck anteriorly, and extending 
more or less over the body. In Meyer’s case, however, this was first 
noticed on the right side of the face. Sometimes the patient complains 
of thirst, and he can generally swallow with ease, although the greater 
part of the fluid probably passes into the mediastinum. 
Pathology.—«The rent in the gullet has, in every recorded case, been 
at the lower end of the tube, and in all but one| it has been longitudi- 
nal in direction. The exception occurred in the memorable instance 
related by Boerhaave,§ an abstract of which is given further on. In 
* For exceptions see foot-note f, p. 180. 
J See foot-note *, p. 175. 
f Boerhaave, Meyer, Granunatzki. 
$ Loc. cit. 179 
RUPTURE OF THE GULLET. 
this case the two ends of the tube seem to have been drawn apart. In 
the other cases the rent varied from two to five centimetres in length. 
In most of them the gullet was torn only at one place, but in that ob- 
served by Grammatzki* a second longitudinal fissure was found on the 
opposite side of the tube, involving, however, only the mucous mem- 
brane. Externally to the opening there is usually a cavity in the me- 
diastinum, containing a discolored fluid, and in some instances frag- 
ments of food. Often this space, in its turn, communicates with one or 
both pleural cavities, which also frequently contain a large quantity of 
the fluid drunk during the last hours of life, but discolored with blood 
Fig. 21. 
Charles’s Case of Rupture of the (Esophagus (after Knott). 
A, the lower part of the oesophageal canal; B, the external wall of the gullet; C, 
stomach ; a, longitudinal fissure reaching through all the coats of the oesophagus; b, 
small aperture communicating with left pleura; c, large irregular aperture, probably 
accidental ; d, fundus of stomach, mucous membrane very soft and dark; e, pylorus, 
near which the mucous membrane is red; /, very prominent rugae. 
and softened tissue. In Boerhaave’s case no less than 104 ounces of 
this fluid were removed from the thoracic cavity. In the examples re- 
ported bv Wilkinson Kingf and Charles,| the greater curvature of the 
stomach was very much softened. 
Diagnosis.—Boerhaave§ remarks that from the description of his case 
any future accident of the kind could be recognized. This, however, 
has not proved to be the fact, for in no single instance, except that of 
Meyer, has the nature of the lesion been recognized during life. The 
* Loc. cit. 
f Loc. cit. 
t Loc. cit. 
$ Op. cit., p. 60. 180 
DISEASES OF THE THROAT AND NOSE. 
diagnosis has been laid down somewhat dogmatically by Oppolzer,* 
who states that rupture of the gullet may be conjectured to have taken 
place when previous signs of an affection of the oesophagus having been 
present, there suddenly occurs violent pain along the course of that 
organ, with expuition of blood, great shock, and inability to vomit, f 
The “ previous signs of an affection of the oesophagus ” have not, how- 
ever, in the recorded cases been sufficiently obvious to attract attention. 
suggests that auscultation may be of use, but it is ex- 
tremely doubtful whether any trustworthy information can be gained 
by this method in such cases. 
Prognosis.—All the reported cases have ended fatally, the patients 
generally dying within a few hours of the rupture, though in one case 
life was prolonged for some days. In one instance§ the patient died in 
four hours, in two|| in seven hours, in two in twelve hours; in 
other cases death took placein thirteen,** fourteen,'ff seventeen, eighteen 
and a half,§§ and twenty-four|||| hours respectively. In one case, how- 
ever, the patient did not succumb till fifty after the accident, 
and in another,*** in which the rent was probably very small at first, and 
afterwards extended, life was protracted for nearly eight days, during 
which the sufferer passed through a sharp attack of delirium tremens. 
Treatment.—Directly the rent occurs it might be worth while to in- 
troduce the permanent oesophageal tube (vol. ii., Fig. 10, p. 36). It 
must be admitted, however, that the instrument would be not unlikely 
to pass through the rent into the mediastinum; and that should this 
accident be avoided, the introduction of the tube would probably give 
rise to attempts at vomiting. But if the instrument can be tolerated, it 
is within the range of possibility that a small and extremely narrow 
rent might heal. If, however, the patient be unable to bear the tube, 
it will be necessary to feed him entirely by nutrient enemata. The fact 
that Allen’s patient lived for more than seven days shows that sometimes, 
at least, there is time for the employment of therapeutical measures, 
amongst which the administration of anodynes must be considered the 
most important. 
* Vorlesungen iiber specielle Pathologie u. Therapie. Erlangen, 1872, Bd. ii., 
Lieferung i., p. 151. 
f Baron de Wassenaer was slightly sick several times after the accident, and in the 
case of Bailey’s patient, efforts at vomiting continued till death. Allen’s patient also 
'vomited the contents of his stomach frequently after surgical emphysema had occurred. 
J Klinik der CEsophaguskrankheiten, Erlangen, 1871, p. 189. 
§ Taendler. 
** Williams. 
Boerhaave. 
II Charles and Adams, 
ft Wilkinson King. 
j||| Bailey. 
f Dry den and Grammatzki. 
JJ Griffin. 
Meyer. *** Fitz. RUPTURE OF THE GULLET. 
181 
ABSTRACT OF THE CASE OF RUPTURE OF THE (ESOPHAGUS 
OBSERVED BY BOERHAAVE. 
(The original occupies seventy closely-printed pages.) 
The subject of this accident was Baron de Wassenaer, a man over fifty years of age, 
and of powerful frame, whpse appearance betokened perfect health. In his youth he 
had frequently suffered from “ angina,” and for many years during the winter he had 
been subject to gout, attributed by himself to over-eating and want of exercise. After 
a full meal he always felt a sensation of great weight at the pit of the stomach, and to 
relieve this he was in the habit of taking ipecacuanha in a copious infusion of blessed- 
thistle,* though he sometimes used the latter beverage alone. 
At the time of the accident which caused his death, Baron de Wassenaer was atoning 
by low diet for an excess at table committed three days before, and a glance at his last 
meal—an early dinner—may give some idea of the character and amount of his food 
when he was not stinting his appetite. It has long been supposed that the baron was 
a gross feeder, but after a careful perusal of the case, so eminent an authority as Pro- 
fessor von Ziemssen does not think this opinion warranted by the facts. An examina- 
tion of the following list, which does not represent the bill of fare, but only that por- 
tion of it which was partaken of by the baron, will enable the reader to determine for 
himself a matter which has an important etiological bearing on the case: 
Dinner. 
Yeal Soup, with Herbs. 
Boiled Lamb and Cabbage. 
Fried Sweetbread and Spinach. 
Duck. 
Two Larks. 
Compote of Apples. 
Pears, Grapes, Sweetmeats. 
Dessert. 
Beer and Moselle. 
Injustice to Baron de Wassenaer it must be stated that he does not seem to have 
eaten largely of any of these viands, except, perhaps, of the duck, of which he took a 
leg and breast. In the afternoon he went out riding, and returned in his usual health. 
No supper was taken, but about half-past ten in the evening, he began to complain of 
the old disagreeable feeling about the stomach, and he swallowed three tumblerfuls of 
a hot infusion of thistle. As this did not act with its usual efficacy, he took four more 
glasses of the same infusion, but still without effect. Much surprised at this, the Baron 
ordered another dose to be prepared, and in the meantime strove to excite vomiting 
by tickling his fauces. Whilst straining violently he suddenly felt a horrible pain, 
and gave such a cry of anguish that his servants hastened to his assistance. He ex- 
claimed that something had burst or been violently displaced near the pit of his stom- 
ach, and that he was sure he must die immediately. He was put to bed in a state of 
* Carduus or Cnicus Benedictus. This herb was once much used as a febrifuge and 
tonic and as a mild diaphoretic. The infusion is said to induce vomiting, or rather to 
assist the action of emetics, but probably it has much the same effect as warm water. 182 
DISEASES OF THE THROAT AND NOSE. 
utter prostration, being pale, bathed in cold sweat, and pulseless. Half an hour after 
the seizure he swallowed four ounces of olive oil, and with the help of his finger suc- 
ceeded in vomiting some of the oil together with a certain quantity of the thistle- 
infusion. Two ounces more of olive oil, however, produced neither nausea nor vomit- 
ing, and the pain increased. Shortly afterwards the baron drank about six ounces of 
warm spruce-beer. 
On his arrival Boerhaave found the baron sitting in bed, with his body bent forwards 
almost double. Three servants supported him in this attitude, as every other posture, 
especially sitting or standing upright, caused excruciating agony. On examining his 
patient, Boerhaave found that there was nothing to be seen in the throat; there was 
no nausea, scarcely any eructation, the breath was not offensive, there was neither pain 
nor difficulty in swallowing, there was no thirst, and the feeling of weight about the 
stomach was no longer present. 
No swelling or hardness could be detected in the chest or abdomen. The urine was 
natural, and could be passed without difficulty. The patient’s body seemed to be of 
normal temperature, the pulse quick and full, but regular, the breathing and sound of 
the voice natural. There was frequent deep sighing, but no cough. The color of the 
baron’s face was natural, his mind was quite clear, and there was no paralysis. In 
short the only sign of disease was the agonizing pain felt by the patient, and an inde- 
finable sense of some change in the situation of parts within the chest. The pain was 
situated at first in the epigastric region, and was described by the patient himself as a 
feeling of some sensitive membrane having been torn; it never ceased, and hardly 
abated for an instant. Later on, the pain, without leaving its original seat, extended 
backwards, then along the sides, and finally over the whole inner wall of the chest. 
The patient stated that flatulence caused extreme suffering, the gas apparently not 
finding its way up; he could feel it leave the stomach, and then almost immediately 
experienced an excruciating pain in the chest. The physician in vain sought for a 
satisfactory explanation of the phenomena, the possibilities of “ internal inflammation,” 
thoracic tumor, displacement of parts, poison, and gout being successively considered 
and dismissed. 
Boerhaave was inclined to give a hopeful prognosis from the absence of any symp- 
tom of disease except pain, which, in spite of its atrocious severity, he did not think 
would be sufficient to cause death. With the view of diminishing his agony the patient 
was bled almost to syncope, but this measure failed to give the slightest relief. Poul- 
tices, applied near the stomach, made his sufferings worse. Anodyne draughts were 
administered, but the use of narcotics was avoided, as tending to lessen excretion. 
The bowels were emptied by enemata. The voiding of urine was diminished to a few 
drops, passed with great straining and a sensation of scalding. The urine was thick, 
red, and strong-smelling, these characters proving to Boerhaave’s mind that none of 
the abundant quantity of fluid which the baron had swallowed could have reached the 
kidneys. The heart now (sixteen and a half hours after the seizure) began to fail, the 
face grew pale, the extremities cold, the breathing became hurried, and though the 
patient’s mind continued clear, death seemed imminent from mere exhaustion. As a 
last resource, thinking that possibly the cardiac orifice of the stomach was obstructed 
by undigested food, Boerhaave ordered two ounces of sweet almond oil, to be followed 
by seven ounces of warm water, and directed that the action of the remedy should be 
assisted by tickling the fauces with a feather dipped in oil. As the result of this, a 
little dark liquid was thrown up, but none of the oil returned, and no relief was ob- 
tained. Here it may be mentioned that there had been no hiccough during the whole 
course of the affection. Boerhaave was still inclined to believe that the upper orifice RUPTURE OF THE GULLET. 
183 
of the stomach was blocked up on reckoning up the large quantity of drink taken by 
the patient, and the small amount vomited up or passed as urine, it seemed clear that 
the fluid could not have reached the stomach. A swelling was .now observed in the 
epigastrium, which seemed to confirm this view. Shortly after the administration of 
the last emetic, eighteen and a half hours from the beginning of his cruel suffering, 
the baron showed signs of collapse, and, rather to the surprise of his physician, sud- 
denly expired. 
Autopsy twenty-four Hours after Death.—A large livid stain was seen on each side of 
the thorax, with black patches here and there. There was emphysema all over the 
front and sides of the chest. The abdomen was inflated and extremely tense. On 
opening it, the peritoneum, intestines, and stomach were all found enormously distended 
with air, but to Boerhaave’s extreme amazement, the latter viscus contained only a few 
drops of reddish-brown fluid. The bladder was empty and contracted. On opening 
the chest-cavity Boerhaave, who, at the time, knew nothing of the nature of the 
patient’s last meal, remarked a strong smell of roast duck. The pleural sacs were 
found distended with gas, the lungs collapsed and almost bloodless. In each side of 
the chest there was a large quantity of fluid resembling that previously seen in the 
stomach, mixed with some of the thistle-infusion. Floating on this was the almond 
oil ordered by Boerhaave, but, on careful examination, not a drop of blood or pus 
could be seen. The fluid collected from both sides of the chest measured 104 ounces 
(Amsterdam measure). On the part of the pleura covering the left side of the oesoph- 
agus, at a distance of two inches from the diaphragm, there was a discolored patch 
about three inches in diameter, in the middle of which a fissure was perceived half an 
inch in length, and three lines in breadth. This fissure was found to communicate 
with a space in the mediastinum, from which the retracted ends of the ruptured oesoph- 
agus had been drawn asunder in opposite directions. The most minute inspection 
failed to show the least sign of ulcer or other disease in the oesophagus; Boerhaave 
emphatically states that, though he searched in the expectation of finding some pre- 
existing lesion of the gullet-walls to explain so unprecedented an accident, the more 
he looked at the edges of the rent and the surface of the oesophagus near them, the 
more perfectly healthy they seemed to be. The stomach was also quite free from 
disease. 
ABSTRACT OF DR. FITZ’S CASE OF RUPTURE OF THE GULLET. 
The patient was a man aged thirty-one, whose constitution was much impaired by 
the abuse of alcohol. For several years he had cut his food into small pieces and 
eaten it very slowly, but he had experienced neither pain nor difficulty in swallowing. 
About a year previous to the accident he had suffered from delirium tremens, followed 
by very obstinate gastritis, from which, however, he recovered, but a few weeks before 
his death he had another attack of inflammation of the stomach. On both occasions 
the vomiting was distressing, and was accompanied by hsematemesis. 
At supper one evening he was suddenly “ partially strangled ” by a piece of food 
which lodged in his throat. There was intense discomfort, but no cyanosis or dyspnoea. 
About an hour after the occurrence, by straining with his whole strength, he succeeded 
in dislodging the impacted substance, which was shot out with considerable noise, as 
if discharged from a popgun. It proved to be a piece of gristly meat one inch in 
length, and rather more than half an inch in diameter. The patient then fell back 
exhausted, and spat up some liquid and clotted blood. A swelling (emphysema) was 
soon afterwards observed at the angle of the jaw on the left side, and a little later a 
similar swelling appeared on the right side, the two soon extending and meeting across 
the front of the neck. The patient was thirsty, and could swallow fluids easily. He 184 
DISEASES OF THE THROAT AND NOSE. 
did not complain of pain, but his face had an expression of great anxiety. There was 
some tenderness on the left of the trachea just over the clavicle. There was slight 
nausea, and the patient had vomited about an hour after the accident, there being no 
blood in the matters brought up. He was drowsy, but could not sleep. During the 
night pain came on in the left side of the chest, and also in a less degree on the right 
side, and at the upper part of the back; the swelling of the neck extended down the 
arms to the fingers and over the front of the chest, the skin being tense, hard, and 
dark, and having the appearance of erysipelatous inflammation. There was tenderness 
on both sides of the trachea, and ropy mucus mingled with blood was constantly ex- 
pectorated. The contents of the stomach were frequently vomited, sometimes mixed with 
blood. 
The treatment consisted of hypodermic injections of morphia together with bismuth 
internally, and a mustard poultice over the stomach. Ice was given to assuage the 
burning thirst, cooling lotions were applied to the swollen skin, and the patient was 
fed with milk and beef-tea. During the next two days there was little change in his 
condition; the emphysema had spread over nearly all the subcutaneous tissue of the 
body. The bowels and kidneys acted regularly. The patient was very weak and 
restless, but Hoffmann’s anodyne seemed to give him relief. During the fourth, fifth, 
and sixth days he passed through an ordinary attack of delirium tremens,%falling into 
a deep stertorous sleep on the evening of the sixth day. He could retain the food and 
stimulants given to him. On the seventh day he passed three bloody stools, and bad 
three fits of “ cramp,” each lasting for half an hour. They began with trembling of 
the limbs, which was followed by rigid and painful contraction of the flexor muscles. 
There was excruciating pain over the heart and stomach, together with apparent dys- 
pnoea ; the countenance expressed great terror, but there was no loss of consciousness. 
After each fit there was profuse cold sweating. On the eighth day, after a quiet sleep, 
the patient woke up quite rational. He took some nourishment and a little stimulant, 
but became more and more prostrate, and died quietly just seven and a half days after 
the beginning of his illness. 
Autopsy by Dr. Fitz forty-eight Hours after Death.—The anterior mediastinum was em- 
physematous. The right lung was partly adherent to the chest-wall by recent fibrinous 
exudation. There was a cheesy nodule in the apex of the right lung, and a similar 
deposit in the upper lobe of the left lung. 
In front and to the right, from the level of the bifurcation of the trachea downwards, 
the oesophagus presented a longitudinal rent two inches in length, reaching completely 
through all its coats. The edges were clean-cut, and there was no evidence, even on 
microscopic examination, of pre-existing ulceration or degeneration. The wound 
opened into a cavity in the right side of the posterior mediastinum extending between 
the gullet and the trachea in all directions, and also partly behind the former. This 
space might have contained a small lemon, and was crossed by fibrous trabeculae, the 
intervals between them being filled with clotted blood. The walls of the cavity were 
of greenish hue, and the vagus nerve could be seen behind, thickened and red. The 
internal surface of the gullet, from the tracheal bifurcation down to the cardiac orifice 
of the stomach, was greenish in color, the epithelial layer was flocculent, and here and 
there somewhat thickened, but it was entirely wanting over a space about an inch in 
diameter below the rent. The oesophageal walls were of normal consistence. The 
stomach showed the usual appearance of chronic catarrhal gastritis; there was no trace 
of post-mortem softening. Some black grumous material,.probably altered blood, was 
found in the intestines, the spleen was enlarged and softened; there was “ cloudy 
swelling ” of both kidneys, and fatty infiltration of the liver. The heart presented 
signs of fatty degeneration. RUPTURE OF THE GULLET. 
185 
Author. 
Sex. 
Age. 
Drinker. 
Nature of rent. 
Surgical emphysema. 
Duration of life after 
accident. 
Remarks. 
1. Boerhaave. 
M. 
50 
? 
Transverse in direction, 
tearing gullet quite 
asunder 2 in. above the 
diaphragm — opening 
into left pleural cavity. 
Emphysema over front 
and sides of chest, and 
in the posterior medi- 
astinum. 
IS}4 hours. 
Patient was a great eater, and 
suffered much from gout. 
He had been addicted to 
the free use of emetics. 
2. Dry den. 
M. 
? 
Yes. 
Longitudinal rupture just 
above the diaphragm 
sufficient to admit fore 
and middle fingers— 
probably on the left 
side. 
Emphysema “all round 
neck and throat.” 
From “in the morn- 
ing after break- 
fast” till 10 p.m. 
Patient avoided emetics, as 
he always felt weak and 
sore after the strain of 
retching. He had taken 
warm water just before the 
rupture. 
3. Wilkinson King. 
M. 
24 
Yes. 
“ Large rent ” where the 
oesophagus passes 
through the dia- 
phragm. 
Emphysema of the face 
and "throat. 
14 hours. 
There was post-mortem solu- 
tion of the cardiac end of 
the stomach 
4. Williams. 
M. 
? 
? 
Longitudinal rent close 
above the lower end of 
the gullet on the left 
side, 1% inches in 
length, opening into 
left pleura. 
Not stated. 
13 hours. 
Diaphragm also ruptured. 
5. Meyer. 
M. 
38 
Yes. 
Longitudinal rent 1% in. 
long, 3 in. above the 
cardia. 
Emphysema of side of 
face,"neck, and front of 
chest. 
50 hours. 
Gullet was narrowed at lower 
part; patient had swallow- 
ed soap-lees. Large cavity 
separating the gullet from 
the surrounding parts for 
5£ in. upwards from cardia. 
6. Grammatzki. 
M. 
35 
Probably. 
Longitudinal rent, 5 cen- 
timetres long, running 
into the stomach. 
Emphy sem a of face, neck 
and chest, also of ante- 
rior and posterior me- 
diastinum. Double 
pneumothorax. 
From “morning” 
till 6.30 p.m. 
Cavity large enough to hold 
a walnut just above cardia. 
Rent in cardia itself reach- 
ing to “ submucosa.” 
TABLE OF CASES OF RUPTURE OF THE GULLET. 186 
DISEASES OF THE THROAT AND NOSE. 
Author. 
Sex. 
Age. 
Drinker. 
Nature of rent. 
Surgical emphysema. 
Duration of life after 
accident. 
Remarks. 
7. Griffin. 
M. 
49 
Innkeeper, 
but per- 
sonal habits 
not stated. 
Longitudinal rent 1 inch 
in length, running up- 
wards from just above 
the diaphragm—open- 
ing into left pleura. 
Emphysema above both 
clavicles. 
17 hours. 
Patient had had two solid 
meals at a rather brief in- 
terval. 
8. Charles. 
M. 
35 
Yes. 
Longitudinal rent, 1}/, in. 
long from below cardia, 
on left side, opening 
into left pleura. 
Not stated. 
7y2 hours. 
Cavity in posterior mediasti- 
num full of grumous mate- 
rial. Post-mortem digestion 
of stomach. 
9. Baily. 
M. 
22 
? 
Longitudinal rent, % in. 
long, from 1 in. above 
cardiac orifice. 
JSTot stated. 
24 hours. 
Patient was a negro and re- 
markably robust. 
10. Fitz. 
M. 
31 
Yes. 
Longitudinal rent, 2 in. 
long, in front and some- 
what to the right,down- 
wards from level of bi- 
furcation of trachea. 
Emphysema almost all 
over the body. 
180 hours (7y2 days). 
Cavity of size of small lemon 
on right side of posterior 
mediastinum, between gul- 
let and windpipe, also be- 
hind gullet. 
11. Adams. 
M. 
35 
7 
Longitudinal rent in 
posterior wall of gullet, 
in. long, upwards 
from diaphragm, open- 
ing into left pleura. 
Not stated. 
7 hours. 
Old cicatrices in oesophageal 
wall close to rupture. The 
same in stomach. Patient 
had long been dyspeptic. 
12. Hcyfelder. 
M. 
7 
Yes. 
Irregular rent, of size of 
threepenny-piece,close 
to cardia. 
Not stated. 
7 
13. Taendler. 
M. 
17 
No. 
Longitudinal rent, ]/2 
cent. long. 
Emphysema over left 
half of thorax. 
4 hours. 
Patient was suffering from 
pyaemia. 
TABLE OF CASES OF RUPTURE OF THE GULLET (Continued). WOUNDS OF THE GULLET. 
187 
WOUNDS OF THE GULLET.* 
Latin Eq.—Vulnera oesophagi. 
French Eq.—Plaies de l’oesophage. 
German Eq.—Wunden der Speiserohre. 
Italian Eq.—Ferite del esofago. 
Definition.— Wounds of the oesophagus of an incised, punctured, or 
contused, character, caused by sharp bodies penetrating the walls of the 
tube either from within or from without, always giving rise to dysphagia. 
History.—Wounds of the oesophagus have hitherto attracted comparatively little 
notice, owing to the fact that this organ is seldom injured alone. Jts deep situation, 
indeed, protects it to a very great extent from external wounds. When the gullet is 
wounded the windpipe and the large vessels of the neck are generally implicated in 
the injury, and from the urgency of the immediate symptoms they absorb the attention 
of the surgeon. 
Ambroise Par6f appears to have been familiar with wounds of the gullet, and he 
directs that they should be treated with sutures when possible to apply them. He 
placed on record j an extraordinary case in which the windpipe and gullet were both 
completely divided. Pare succeeded in uniting the divided trachea sufficiently to allow 
of the patient recovering the power of speech so far as to be able to name his assailant, 
but all his efforts to bring the retracted ends of the oesophagus together in the same 
way failed, and death took place on the fourth day. 
Isolated cases were reported by Larrey,$ Boyer, || and but the subject 
was first systematically treated by Horteloup.** More recently several additional cases 
have been brought together by Durhamff and Knott.JJ 
Etoliogy.—Wounds produced by the perforation of small sharp sub- 
stances that have been swallowed will be referred to under “ Foreign 
Bodies,” and it therefore only remains to consider wounds arising from 
the introduction of cutting weapons, such as swords and foils, and 
those caused by external injury. Accidents belonging to the former 
category are extremely rare, but a case is recorded by Levillain,§§ in 
* Extensive wounds in which the gullet is only one of several important structures 
involved will be considered in a separate article under the head of “ Cut-throat.” 
f See the chapter “ Des Plaies de l’CEsophague,” CEuvres (Malgaigne’s edition, 
Paris, 1840), vol. ii., p. 90. 
J (Euvres, liv. x., ch. 31. 
\ Clinique Chirurgicale, Paris, 1829, t. ii., p. 158. 
|| Traits des Maladies Chirurgicales, t. vii., p. 279. 
If Blessures par Armes de Guerre, t. ii., p. 334. 
** Plaies du Larynx, de la Trachde, etc.. Paris, 1869. 
ff Holmes’s System of Surgery, London, 1870, 2d ed., vol. ii., pp. 445 and 457. 
XX Pathology of the (Esophagus, Dublin, 1878, pp. 151-154. 
\\ Journ. Univ.de Mdd., 1820, p. 238. 188 
DISEASES OF THE THROAT AND NOSE. 
which an officer whilst fencing received a wound from a foil as he was 
stooping. The point of the foil entered his mouth, lacerating the soft 
palate, and ran through the posterior wall of the oesophagus at the level 
of the fourth or fifth dorsal vertebra. A remarkable accident was re- 
lated by Dr. Parkes* in which a sword-swallower pushed his weapon 
through the anterior wall of his gullet five and a half inches below the 
pharynx. The pericardium was pierced, most acute inflammation of 
the membrane ensued within an hour, and the patient died on the 
second day. No other injury was found after death. A peculiar fea- 
ture in this case is that whilst one of the immediate symptoms caused 
by the wound was violent vomiting, the matters thrown up consisted 
solely of the contents of the stomach without a drop of blood. An ex- 
traordinary case was reported by Guise,f of Charenton, in which a 
lunatic thrust the handle of a fire-shovel into his throat with such force 
that it tore through the gullet, and fractured the fourth rib at the costo- 
vertebral ligament. 
In illustration of injury from without there are several examples. 
Boyer! has described the case of a young man, who received a bayonet- 
thrust at the anterior and upper part of the chest, causing a wound four 
lines from the sternum between the third and fourth ribs, from which 
there was a violent escape of air. Three days later food and drink ap- 
peared through the wound, but the patient ultimately recovered. Lar- 
rey§ has reported an example of this accident which proved fatal. The 
patient, who had received a sword-thrust at the upper part of the chest, 
between the first and second ribs, at first improved under treatment, 
but was ultimately suffocated in trying to swallow some large pieces of 
bread. In another instance,|| the patient, having received a wound be- 
tween the fifth and sixth ribs, died at the end of thirty-six hours, all 
fluids that were drunk passing through the wound. There is also a 
case on in which a soldier was wounded by a bullet which tra- 
versed the oesophagus at its upper part. Drink passed through the 
wound, but the patient ultimately made a good recovery* In Dupuy- 
tren’s** case, the patient, a woman, was stabbed just above the clavicle 
* Trans. Path. Soc. London, 1848-9, p. 40. 
f Quoted by Horteloup: op. cit., p. 24. 
J Traits des Maladies Chirurgicales, t. vii., p. 279. 
g Clinique Chirurgicale, Paris, 1829, t. ii., p. 158. 
|| M. C. Etienne: Consid. gdn6r. sur les causes qui g6nent ou la deglu- 
tition, These de Paris, 1806, p. 8. 
I" Horteloup: op. cit., p. 61. ** Loc. cit. WOUNDS OF THE GULLET. 
189 
on the left side. She died on the seventh day, the fact that the gullet 
was wounded not having been recognized during life. 
Symptoms.—The characteristic symptom of wounds of the oesophagus 
is the escape of food from the opening. It must not be forgotten, how- 
ever, that when the trachea or larynx is injured from without, and 
especially if the pneumogastric or superior laryngeal nerve has been 
divided, the food may pass into the windpipe, and, as in wounds of the 
gullet, may come out through an opening in the neck. In most of the 
reported cases, violent hiccough and intense thirst have been present. 
There is often difficulty in breathing, but this appears to be due to 
complications arising from injury of the lungs or trachea. 
Diagnosis.—The history of the case, taken in connection with the 
objective signs, generally renders the diagnosis easy. It is only in rare 
instances, such as that of Dupuytren, where a wound was inflicted on 
the oesophagus through the neck, and fluids subsequently swallowed did 
not escape, that the nature of the accident is likely to be overlooked. 
Possibly some cases of this kind occur which are never suspected, for, 
as Horteloup* points out, stabs with a knife or dagger as a rule cause 
only minute punctured wounds. 
Prognosis.—For many years it was supposed that complete trans- 
verse division of this tube always proved fatal, and this was strongly 
supported by the experiments of Jobert.f This view, however, has 
been proved to be fallacious. When the wound is in the cervical por- 
tion of the gullet, and is limited to that organ, the case almost invaria- 
bly does well; but of course, if the air-passages are injured at the same 
time, the prognosis is much more serious. Wounds in the thoracic por- 
tion are extremely fatal. 
Treatment.—If the wound be large the edges should, if possible, be 
stitched together. The patient should be entirely fed by nutrient ene- 
mata (vol. i., p. 556). If, however, this mode of administering nutri- 
ment does not seem sufficient to sustain the patient, he should be fed by 
the oesophageal feeding-tube (vol. ii., Fig. 11, p. 39) passed an inch or 
two beyond the wound; and if there be any difficulty in carrying out 
this treatment, an anaesthetic should be administered each time that the 
patient is fed. In some cases, however, owing to the irritation caused 
by the passage of the instrument, or to the impossibility of striking the 
orifice of the lower segment of the oesophagus when it has been com- 
pletely cut across, it may be necessary to allow the patient to swallow 
* Op. cit., p. 19. 
f Boulin : Plaies de PGEsophage, These de Paris, 1828, p. 20. 190 
DISEASES OF THE THROAT AND NOSE. 
bland liquids. Although, under these circumstances, most of the food 
will escape by the wound, a small quantity will trickle down the gul- 
let. “ When the necessities of nature require nourishment to be taken 
by the mouth,” as Heister* remarks, “ the wound should constantly be 
diligently cleaned afterwards, lest any part of what was taken should 
stick by the way and putrefy, which would bring on very bad symp- 
toms.” It is only when there does not appear to be the slightest chance 
of the wound healing that the patient should be nourished by means of 
an instrument passed through the neck. 
As a rule, a very nutritious and stimulating diet is necessary, and, 
in most cases, anodynes are required. 
FOREIGN BODIES IN THE GULLET. 
Latin Eq.—Corpora adventitia in oesophago. 
French Eq.—Corps etrangers dans l’oesopbage. 
German Eq.—Fremde Korper in der Speiserohre. 
Italian Eq.—Corpi stranieri nel esofago. 
Definition.—Foreign bodies lodged in the gullet, most commonly 
gaining access to that canal by the mouth, but occasionally passing up 
from the stomach, and, more rarely still entering through the neck, giving 
rise to dysphagia, sometimes to dyspnoea, and often causing death. 
History.—The literature relating to the impaction of foreign bodies may be said to 
begin with the elaborate memoir on the subject presented by in the middle of 
last century to the French Academy of Surgery. In this essay the author collected 
nearly all the instances of this accident scattered throughout the medical records of 
former times, and discussed the best methods of dealing with such cases. His work 
remains to this day the most complete account of foreign substances lodged in the 
oesophagus, and subsequent writers have added little to it, except descriptions of more 
convenient instruments for exploration of the canal and the extraction of bodies im- 
pacted in it. Bordenavej; soon afterwards published a short memoir on “Foreign 
Bodies in the Gullet,” and a work by Eckhold$ on the same subject appeared in 1799, 
in which the instrument, now known as Griife’s coin-catcher, is described and fig- 
ured. This author, however, does not claim to have invented it, but says that he had 
first seen it used in London. In 1830 Mondiere|| devoted one of his papers on the 
* General System of Surgery, English trans., 1743, vol. i., p. 77. 
f Mdmoires de 1’Acaddmie R. de Chir., 1761, vol: i., p. 444 et seq. 
J Thesis de corporibus extraneis intra oesophagum latentibus, Parisiis, 1763. 
\ Ueber das ausziehen fremder Korper aus dem Speisekanal, Leipzig, 1799. 
|| Arch. G6n., 1830, Ire s6rie, t. xxiv., p. 388 et seq. FOREIGN BODIES IN THE GULLET. 
191 
cesophagus to foreign bodies in that canal. Several yearslater essays were written by 
Simon,* Haken,f Bournbria,! Pawlikowski,§ and Gebser,|| and in 1867 
published a collection of 314 cases of foreign bodies in the gullet and pharynx.** In 
1868 a thesis on “ Foreign Bodies in the Gullet” was written by Martin,ff and in 1876 
von LangenbeckJJ published the mature results of a very large experience of such 
accidents. In 1879 Nevot|| brought together several interesting cases in which foreign 
bodies had perforated the gullet and laid open neighboring bloodvessels. 
Etiology.—The most common cause of accidents of this kind is the 
lodgment in the gullet of substances such as fragments of bone, gristle, 
fruit-stones, or even pieces of wood swallowed with the food, or the 
impaction of large unmasticated morsels in hurried or gluttonous eat- 
ing.|||| Such foreign bodies as pins and knives,*** forks,fff 
spoons,buckles,§§§ rings,|||||| coins, singly or in rou- 
* Des corps Etrangers dans l’CEsophage, Strasbourg, 1858. 
f De corporibus alienis cesophago illatis, Dorpati Livonorum, 1859. 
J Des Accidents produits par les Corps Etrangers arretes dans l’CEsophage, 
Strasbourg, 1860. 
§ De corporibus alienis in cesophago, Vratislavise, 1860. 
|| Ueber fremde Korper im Oesophagus und Pliarynx, Leipzig, 1865. 
f Prager Yierteljahrschrift f. prakt. Heilkunde, vol. xcvi., p. 66 et seq. 
** This unfortunate mingling of cases diminishes the value of the paper. General 
conclusions drawn from such statistics are fallacious, inasmuch as the impaction of 
foreign bodies in the pharynx is ceteris paribus far less dangerous than when they are 
lodged in the gullet. 
ff Des Corps Etrangers de l’GSsophage, These de Paris, 1868, No. 117. 
it Berlin klin. Wochenschr., Dec. 17 and 24, 1876. 
§§ Perforation des Gros Vaisseaux par les Corps Etrangers de l’CEsophage, These 
de Paris, 1879, No. 81. 
HI See Par6, Le Dran, Fabricius Hildanus, Wierus, Khodius, Houillier, all in 
Hevin, loc. cit., pp. 446, 447, 448, and 455. 
See particularly Lond. Med. Gazette, February, 1844, where a case is related 
by Bell in which death resulted from perforation of the right common carotid, and 
Schmidt’s Jahrbuch, vol. xxxix., p. 334, where an instance is recorded in which death 
occurred from gastritis more than two years after the foreign bodies had been swal- 
lowed. 
*** H6vin : loc. cit., pp. 471, 515, and 595. 
fff Ibid., p. 518. H6nocque : Gazette Hebdom., 1874, p. 229. 
ttt Fournier: Diet, des Sciences Med., Art. Cas Rares. Baraffio : Progr&s Med- 
ical, 1876, p. 70. 
Harrison: Dublin Journ. of Med. Sci., vol. viii. Fournier: loc. cit. 
Illlll Hfevin: loc. cit., p. 449. 
H’TI’fl Edin. Med. and Surg. Journ., 1843, vol. lx., p. 195. The French poet Gilbert 
died in the Hotel-Dieu in 1780, having swallowed the key of his room five weeks be- 
fore, whilst delirious from the effect of an injury to his head. 192 
DISEASES OF THE THROAT AND NOSE. 
leaux,* seals,f beads,J nails,§ and stones|| have found their way into 
the oesophagus by accident, or have been deliberately swallowed by 
insane people, or out of mere bravado by persons considered sane. 
Sometimes jewels or money have also been swallowed for the pur- 
pose of concealment. An extraordinary instance is on of a 
blacksmith who was killed by a fragment of a red-hot key which he 
was in the act of forging. The key broke, and a bit of the metal flew 
down the man’s throat and lodged in his gullet. False teeth and 
palate-obturators have sometimes slipped down into the gullet, and this 
mischance is especially likely to happen during sleep or unconscious- 
ness, if such objects are not removed from the mouth. A curious case 
has been reported by von Langenbeck,** in which a woman who had 
suffered from syphilis was for some time in a critical condition from 
the greater part of the bony framework of her nose having become 
detached by necrosis, and fallen into her gullet while she was asleep. 
Many accidents have occurred from the well-known propensity of in- 
fants to put into their mouths anything which they can lay their hands 
on. Older children have sometimes swallowed playthings which they 
have had in their mouths on going to sleep. There are also cases on 
record in which children have introduced most dangerous foreign bodies 
into other people’s throats. In two instances of this nature, fish-hooks 
have been fixed in the oesophagus, apparently through a precocious 
love of sport. In one case,ft a little boy, finding his mother asleep 
with her mouth open, ingeniously introduced a fish-hook attached to a 
line. The mother, suddenly awaking, involuntarily swallowed the 
hook, which, after passing several inches down, penetrated the walls of 
the gullet. In another case,|| a boatman’s children, aged five and four 
years respectively, agreed to “play at fishing,” the elder persuading 
the younger to take the part of “ fish.” The hook wras baited with a 
tempting morsel, and the younger boy, having played round it for 
* Hdvin: loc. cit., p. 449, 452, 455, 459. Gay : Boston Med. and Surg. Journ., 
1879, p. 356. Mignot: Gazette Hebd., October 30, 1874. 
f Billroth : Arcliiv. f. klin. Cliir., 1872, vol. xiii. 
J Monti: Jahrb. f. Kinderlieilk., 1875, vol. ix. 
§ Harrison : Dublin Journ. of Med. Sci., vol. viii. Hevin: loc. cit., p. 471. 
. || Castresana: Espana Medica, August 18, 1859. Holmer: Med. Times and Gaz., 
January 13, 1883, p. 47. 
If Bierfreund: Med. Zeitung Bussl., 46, 1848. 
** Memorabilien Jahrg., Bd. xxii., Heft 1. 
ff Leroy : Revue Med.-Chir. de Paris, 1847, t. ii., p. 110. 
Xt Baud : Ibid., 1848, t. iii., p. 44. FOREIGN BODIES IN THE GULLET. 
193 
some time after the manner of fishes, seized it with his mouth and 
swallowed it. The youthful angler at once dexterously jerked the line, 
and hooked the “ fish ” near the lower end of the gullet. In both these 
remarkable cases, the hooks were removed by an ingenious device to 
be presently described. 
There are several instances in which ears of rye are stated* to have 
been taken into the oesophagus with serious and even fatal results, but 
a careful study of these cases shows that in nearly all of them the 
foreign body had really been drawn into the trachea, and not into the 
gullet. 
Frogs,f small live fish,! eeH§ and even snakes|| have, in various 
manners, found their way into the oesophagus, and there are a consid- 
erable number of cases in which severe symptoms have been caused by 
the presence of a leechf in the gullet. All the recorded examples of 
the latter accident have occurred in soldiers, which is accounted for by 
the fact that, during campaigns, brackish water has often to be hur- 
riedly drunk out of wayside pools. 
Undigested substances thrown up from the stomach have not un- 
frequently become impacted in the gullet.** Parasitic worms have 
been vomited through the mouth after having caused obstruction of the 
oesophagus, ff 
One of the most complicated cases of foreign body in the gullet is 
related by Adelmann,!| in which a man swallowed a piece of mutton 
with some of the bone. Attempts at extraction with forceps, and at 
propulsion with the sponge-probang, having failed, Grafe’s coin-catcher 
was tried. This instrument was passed below the foreign body, but 
became so tightly wedged in that it could not be withdrawn. The 
unfortunate patient remained with this additional foreign body in his 
gullet for more than two days. The coin-catcher was finally loosened 
by means of a gum-elastic catheter, which was threaded over it, and 
* Hevin : loc. cit., p. 553. Desgranges : Journ. de MMecine, t. xxxviii., No. 
1359. 
f Allgem. Kepert, 1838, ix., p. 109. 
X Union Mddicale, 1863, p. 568. Archiv. f. klin. Chir., 8, p. 481. Norman Che- 
vers: Manual of Med. Jurispr., Calcutta, 1870, p. 619. 
§ Allgem. Repert, 1838, xi., p. 90. || Ibid., 1838, xi., p. 89. 
Journ. Univ. des Sciences Mfedicales, January, 1828. Baizeau : Gazette Medicale 
de Baris, 1863. 
** H6vin : loc. cit, p. 455. Boulard : Archives G6n., t. xxiii., p. 528. 
ff Laprade : Compte rendu des Travaux de la Socidt£ de Medecine de Lyon, 1821, 
p. 62. M4plain : Journ. Complfem., t. xvii., p. 372. 
Loc. cit., p. 66 et seq. 194 
DISEASES OF THE THROAT AND NOSE. 
when the impacted instrument had been got out, the original foreign 
body was pushed into the stomach. The patient succumbed about a 
fortnight after the first accident, but it does not seem that the fatal 
result was in any way caused or accelerated by the surgical mishap. A 
similar accident occurred quite recently to Dr. Holmer, of Copenhagen, 
whilst attempting to pull out a stone impacted in the gullet of a lunatic 
who had swallowed it with suicidal purpose. External oesophagotomy 
was at once performed, and both the foreign bodies were removed, the 
patient making a good recovery. The stone was five centimetres long, 
and five broad at its widest part.* 
Symptoms.—Foreign bodies, which are at all large, are especially 
liable to be arrested either at the upper orifice of the oesophagus, or at 
the middle third, where the left bronchus crosses the gullet. Small 
sharp bodies, such as pins and fish-bones, may stick into the oesophageal 
wall at any level. The symptoms depend mainly on the consistence, 
dimensions, and form of the foreign body. Thus, bodies of soft struc- 
ture, such as pieces of food, even when large, though temporarily ob- 
structing the oesophagus, generally soon become sufficiently macerated 
to pass downwards. Large hard bodies give rise to the most urgent 
symptoms, such as extreme dysphagia, intense dyspnoea, acute pain, 
and profound oppression and anxiety. If, as is commonly the case, 
such a body becomes lodged in the cervical part of the gullet, it may 
give rise to a swelling in the neck. If the body be not large enough 
to cause immediate danger, the inflammation which is set up causes 
considerable fever, and the patient usually wastes rapidly. Small hard 
bodies, if rough or angular, generally give rise to slight dysphagia and 
a constant feeling of irritation. In some cases, however, there is rather 
severe spasm of the gullet, so that great difficulty in swallowing is ex- 
perienced. In other instances, the symptoms, though slight at the 
time, may ultimately become serious. The following is a casef of this 
kind : A girl, whilst eating some soup, accidentally swallowed a frag- 
ment of bone. The first symptoms soon passed off, but after a time her 
voice became reduced to a whisper. She became feverish, lost flesh, 
and had a troublesome cough, with thick blood-stained expectoration. 
At the end of fourteen years this patient was seen by Gauthier de 
Claubry, who at first believed her to be in the last stage of phthisis. 
On pressing her neck, however, he found marked tenderness above the 
left clavicle. This examination caused an inclination to vomit, and the 
* Med. Times and Gazette, January 13, 1883. 
f Journ. de la Soc, de M6d. de Paris, t. xxiv., p. 13. FOREIGN BODIES IN THE GULLET. 
195 
patient brought up the piece of bone, feeling at the same time a “ tear- 
ing” pain in the neck. Her health was subsequently completely 
restored. 
Sometimes, however, foreign bodies produce very little irritation, and 
I may remark that I know of an instance where a halfpenny was re- 
tained in the oesophagus for many years without giving rise to much 
inconvenience. From the symptoms it appeared that the coin was 
pressed laterally against the sides of the oesophagus, in which position 
it was probably retained by bands of fibrous tissue. A still more re- 
markable case has been reported by Larrey,* in which a five-franc 
piece became impacted in a man’s gullet. Propulsion was tried, and 
was thought, both by the surgeon and the patient, to have been success- 
ful. The patient, however, suffered afterwards from convulsions, and 
died two months later from meningitis. After death the coin was 
found fixed perpendicularly about an inch above the cardiac orifice, the 
rim pressing on the wall of the gullet on each side. The coats of the 
tube were much thickened at this part, and the pneumogastric nerves 
were stretched over the edges of the coin. There was spindle-shaped 
swelling, with great redness of both nervous cords, especially of the 
right one. It is remarkable, however, that the mucous membrane 
presented scarcely any trace of inflammation. 
Analyzing the symptoms in greater detail, the dysphagia, as already 
indicated, varies to a considerable extent, being sometimes so extreme 
that even the saliva cannot be swallowed, whilst in other instances 
solids can be taken without much pain. Dyspnoea likewise may be 
either present or absent, its occurrence being generally due to the large 
size or angular form of the foreign body. In the former case the in- 
terference with respiration may result from direct pressure on the back 
of the trachea, in the latter from reflex spasm of the glottis. If the 
dyspnoea be intermittent, it may be inferred that it is of reflex origin. 
The oppression and anxiety which are caused by the presence of a 
foreign body in the gullet are characteristic of nearly all acute affec- 
tions of the ceosophagus, and they are sometimes accompanied by cold 
sweats and syncope. The voice is often greatly modified, and some- 
times altogether extinguished. The pain is sometimes described as 
being of-a “bursting” character, and frequently gives rise to straining 
and unsuccessful efforts at vomiting. In some cases convulsions and 
even lockjawf have followed the impaction of a foreign body in the 
* Clinique Chirurgicale, Paris, 1829, t. ii., p. 165. 
f Godinet: Annales de Montpellier, t. iii., p. 230. 196 
DISEASES OF THE THROAT AND NOSE. 
gullet. These various symptoms often abate for a few hours, to come 
on again with additional violence. On the other hand, small smooth 
foreign bodies may be occasionally lodged in the oesophagus for a con- 
siderable time without giving rise to any active symptoms, and it is 
only when inflammation is set up that they attract attention. 
The exact position of a foreign body can often be ascertained by 
physical exploration. Sometimes it may be possible to use the oesoph- 
agoscope, and when this instrument is employed to detect an im- 
pacted body, it is better to administer an anaesthetic. In other cases 
useful information may be obtained by means of the bougie. The sen- 
sation caused by the contact of a foreign body with the instrument may 
be greatly intensified by using Duplay’s resonator (vol. ii., Fig. 5, p. 34). 
By auscultation of the oesophagus in the ordinary way during the act 
of deglutition, fluid may be heard to strike against the foreign body, 
whilst below this point there is either no distinct sound or only a slight 
trickling noise can be perceived. 
If the foreign body be allowed to remain and the patient survive, a 
variety of secondary symptoms may arise. In many cases inflamma- 
tion is set up, and the tissues imprisoning the foreign substance being 
destroyed by ulceration, it is set free and may be vomited up or may 
fall into the stomach. Whether the offending body be extruded or not, 
however, perforation of the oesophagus is a frequent consequence of the 
accident. Sometimes extensive ulceration takes place in the areolar 
tissue surrounding the gullet, and a large cavity is formed in the medi- 
astinum. Occasionally the ulceration may extend to the trachea, 
bronchi, or pericardium, giving rise to acute inflammation of any of 
these organs. In a case reported by Walshe,* the point of a knife had 
perforated the pericardium and set up pericarditis; and, in a somewhat 
similar instance,f the entrance of air and particles of food into the peri- 
cardial sac through the wound in the gullet, had caused the pericardial 
inflammation to be of a purulent character. Occasionally vessels are 
laid open, and death ensues from haemorrhage. A circumscribed abscess 
is sometimes formed, and this may point in the neck. Two cases! are 
on record in which the temporary impaction of a foreign body led to 
rupture of the oesophagus. In one instance! a fish-bone, perforating 
* 
* Diseases of the Heart and Great Vessels, 1873, 4th ed., pp. 42 and 273. 
f Ibid., p. 218. 
t Meyer: Canstatt’s Jahresb., 1858, vol. iii., p. 334. Allen: Amer. Journ. Med. 
Sci., January, 1877, p. 17. 
| Andrew: Lancet, 1860, p. 186. FOREIGN BODIES IN THE GULLET. 
197 
the gullet in the neighborhood of the heart, pierced the pericardium and 
fixed itself in the middle of the septum after wounding the right coro- 
nary vein. When the foreign body penetrates by ulceration into one 
of the pleural cavities, it generally soon gives rise to empyema, and the 
offending substance has sometimes been removed by paracentesis. In 
a case which I saw some years ago with Dr. Turtle, of Woodford, a 
very careful examination failed to discover a fish-bone which had acci- 
dentally found its way into an infant’s throat. The baby gradually 
wasted away, and when it died, at the end of some months, it was found 
that the fish-bone had passed through the intervertebral substance and 
wounded the cord. In some instances the foreign body reaches the 
stomach, or it may pass into the intestines, and cause fatal ulceration in 
any part of its course; or perforating into the areolar tissue of the groin 
or lumbar region, it may give rise to an artificial anus. If, however, 
the body be small and smooth, it will often pass through the whole 
intestinal tract, and be got rid of per rectum without doing any harm. 
Pathology.—Any of the various pathological conditions which have 
been referred to under the head of “Symptoms,” such as inflammation, 
abscess, gangrene, or perforation involving either the oesophagus alone, 
the surrounding areolar tissue, or any of the adjoining organs, may be 
present. Abscesses are especially likely to be formed even a consider- 
able length of time subsequent to the impaction of the foreign body. 
The interval in Adelmann’s* cases ranged from a week to fifteen months. 
In the same series,f perforation of the aorta occurred fourteen times, 
and of the common carotid six times, whilst the right subclavian and 
the pulmonary artery were each wounded once. 
Diagnosis.—In most cases this is easily arrived at from the history, 
and, as a rule, it is only when the patients are insane persons or chil- 
dren that any doubt can arise. Under such circumstances the sudden 
establishment of dysphagia will lead to an examination of the oesopha- 
gus, and one of the methods of exploration already described will, in 
most cases, clear up all doubts. The following example will show the 
advantange of oesophagoscopy in facilitating the detection and removal 
of foreign bodies that might otherwise baffle the practitioner’s efforts : 
Mrs. B., aged fifty-one, was sent to me by Dr. Spitta, of Clapham, in February, 1881. 
She complained of great difficulty of• swallowing and a feeling of something sticking 
in her throat. The symptoms had commenced suddenly whilst she was taking a meal, 
a fortnight previously. At the first examination with the oesophagoscope, the interior 
of the gullet was seen to be highly inflamed, but no foreign body could be perceived. 
* Loc. cit., p. 99. 
f Loc. cit., p. 103. 198 
DISEASES OF THE THROAT AND* NOSE. 
At a second sitting, however, a few days later, a flat lamella of bone, about four milli- 
metres square, was detected on the anterior wall of the oesophagus, about two inches 
below the cricoid cartilage. The bone, together with a small piece of decayed meat, 
which was adherent to it, was easily removed with forceps. Mrs. B. felt some slight 
inconvenience for three or four weeks after the foreign body had been taken out, but 
when last seen she was able to swallow without any difficulty. 
Prognosis.—This depends, in the first place, on whether the foreign 
body is removed or remains fixed in the oesophagus. In the latter ease, 
if the substance be of any considerable size, the prospects of the patient 
are extremely unfavorable. 
Even if the foreign body be quickly ejected, however, inflammation 
may have been set up which may subsequently give rise to very dan- 
gerous complications. Further, when the body has remained long 
enough in situ to cause sloughing, it must not be forgotten that, though 
relief may be obtained for a time by the expulsion of the offending sub- 
stance, the patient’s life may be brought into jeopardy in the progress 
of subsequent cicatrization. 
Treatment.—In all cases an attempt should be made, in the first in- 
stance, to withdraw the foreign body from above per vias naturales. 
This may be accomplished—either with the parasol-probang, with 
Grafe’s coin-catcher, or with forceps. The first-mentioned instrument 
is by far the most serviceable for small bodies; Grafe’s snare answers 
well when a coin is lodged in the gullet; whilst the use of forceps is 
indicated where the body is large and firmly imbedded. The reader is 
referred to the description of these instruments and the mode of using 
them already given (vol. ii., pp. 35, 36). Where instrumental treat- 
ment has to be adopted, it is often very desirable to administer an 
anaesthetic. This is especially the,case if the foreign body be large, if 
there be much spasm, or if the patient be nervous or of tender years. 
Exceptional bodies require exceptional instruments for their removal. 
In the cases where fish-hooks were swallowed,* they were both re- 
moved by a very similar procedure, which suggested itself quite inde- 
pendently to two different surgeons, Baud and Leroy, both practising 
in the Low Countries. Baud did not record his case, which appears to 
have occurred some time previously to that of Leroy, until the latter 
surgeon had published an almost identical example of the accident. 
The tnode in which the fish-hooks reached the gullet has already been 
described under the head of “ Etiology.” In both instances a leaden 
bullet pierced through the centre was threaded along the fishing line, 
* Leroy: loc. cit. Baud: loc. cit. FOREIGN BODIES IN THE GULLET. 
199 
and allowed to fall by its own weight down the oesophagus till it 
reached the hook. The further descent of the bullet dragged the hook 
downwards, and thus disengaged it, and its barb having come in con- 
tact with the lead, both were drawn up together. Baud employed a 
ball which had a diameter double that of the hook, whilst Leroy used 
a smaller bullet, with a hollow reed attached—an arrangement which 
he considers assisted in disengaging the hook from the flesh. On the 
whole, however, Baud’s method appears the more simple and effica- 
cious. In another case, reported quite recently by Laurent,* a fish- 
hook was removed from the gullet of a boy who had accidentally swal- 
lowed it, by the following plan : A full-sized hollow oesophageal bougie 
was threaded along the line attached to the hook till it reached the 
bend of the latter. Gentle pressure with the instrument set the hook 
free, when the line was tightened, and the bougie withdrawn together 
with the foreign body. 
Formerly emetics were often administered, with the view of effecting 
the expulsion of foreign bodies, and this measure has often proved suc- 
cessful. I do not recommend this treatment, but there are occasions 
when it may be desirable to try it. As the patient is unable to swallow, 
the best mode of producing vomiting is by the subcutaneous injection 
of hydrochlorate of apomorphia, to of a grain. One grain 
may be dissolved in 50 minims of distilled water, but as the solution is 
very unstable it should always be freshly prepared for hypodermic use. 
Enemata of tobacco have also been used for the same purpose, and, in 
some instances, with success. In a few cases, intravenous injection 
of tartar emetic has proved effectual, but this is a dangerous plan. 
Treatment by emetics has sometimes been attended with success, even 
in cases where the foreign body hafi remained in the gullet for a con- 
siderable period, but, as a general rule, it cannot be relied upon. Other 
plans have occasionally been tried. Thus, an instance*}* is on record in 
which a large soft substance w*as thought to have been digested in the 
gullet by the administration of pepsine sixty-eight hours after the acci- 
dent. Inversion, as already described in detail (vol. i., p. 547), may 
be useful when the body to be dislodged is smooth and heavy. The 
first recorded instance;}; of inversion for the extraction of a foreign body 
impacted in the gullet, which I have been able to find, is in the case of 
a patient who had swallowed a knife. At his own suggestion, he was 
* Lancet, 1882, vol. ii., p. 745. 
i Hfevin: loc. cit., p. 595. 
f Deutsche Klinik., 1861, p. 109. 200 
DISEASES OF THE THROAT AND NOSE. 
several times hung up by the heels in the hope that the knife might 
fall out by its own weight. His persevering efforts were, however, 
unavailing, and the knife was removed by gastrotomy. In a case in 
which the patient was threatened with asphyxia through the impaction 
of several large pieces of potato in the oesophagus, Dupuytren* man- 
aged to pinch the gullet with his fingers through the neck, so as to 
crush the potato and thereby enable it to be swallowed. Langenbeckf 
was on two occasions able, by the same method, to alter the shape of a 
tough piece of meat sufficiently to allow the impacted morsel in one 
instance to descend into the stomach, and in the other to be removed 
through the mouth with forceps. In a case reported by Atherton,| 
the patient herself, an old woman, had attempted, and partly succeeded, 
in forcing an impacted bone downwards by external manipulation. 
If it be found impossible to draw up the foreign body, it must either 
be left in situ, pushed into the stomach, or if situated in the cervical 
portion of the gullet, removed by oesophagotomy. If the patient is 
able to swallow liquids, it is better, when the foreign body cannot be 
removed, to leave it alone, in the hope that as soon as the spasm gives 
way, or the inflammation subsides, the substance may be vomited up. 
Sucking small particles of ice is sometimes of use in these cases. 
Large angular bodies, such as false teeth or pieces of bone, should be 
pushed into the stomach only as a last resource, and when they are im- 
pacted in the lower part of the oesophagus. Such bodies cannot re- 
main long in that situation without causing death, and it is therefore 
better, under the circumstances, to thrust them down, even if some de- 
gree of force has to be employed. Propulsion may be most readily 
effected by means of the ordinary spoilge-probang. Injection of water 
into the gullet and dilatation of the canal by means of an air-pessary 
passed down to the foreign body have also been used with success for 
the same purpose. In the former case the force is applied directly to 
the foreign body, whilst in the latter, where an india-rubber bag is 
inflated with air, the impacted body is probably set free by the forcible 
expansion of the oesophageal walls. If the body be inconsiderable in 
size, such as a fish-bone, or a small fragment of the bone of any animal, 
or even a coin, it is best, if a careful attempt at propulsion has failed, 
to leave the offending substance undisturbed, provided the patient can 
•swallow sufficient nutriment. 
CEsophagotomy is indicated in all cases where, the foreign body being 
* Quoted by Luton : Nouveau Diet, de M&l. etde Chir., Paris, 1877, t. xxiv., p. 356. 
f Loc. cit. £ Boston Med. and Surg. Journal, 1870. 201 
FOREIGN BODIES IN THE GULLET. 
situated in the cervical or the upper part of the dorsal region of the 
gullet, deglutition is impossible, or there is dangerous pressure on the 
trachea. 
EXTERNAL (ESOPIIAGOTOMY. 
History.—This operation appears to have been first suggested by Verduc* towards 
the end of the seventeenth century. About fifty years later Guattanif read a paper 
before the Academy of Surgery of Paris, in which he strongly maintained the practi- 
cability of the operation, and gave an account of some experiments on the dead body 
made with the view of determining the best method of carrying it out, and of some 
vivisections on dogs undertaken to test the result of such a procedure. External oeso- 
phagotomy, however, had at that time been already carried out in actual practice, 
although the cases had not been published. One operation of the kind had been done 
for the removal of a foreign body; whilst another is merely mentioned without any 
detail.;!; In 1871 a thesis was sustained on the subject by Sue,£ at Paris, in which he 
gave the results of some experiments on dogs which had been forced to swallow frag- 
ments of bone of such large size that they became impacted in the oesophagus. A few 
years later Eckholdt|| proposed to open the gullet between the heads of the sterno-mas- 
toid, a plan which would enable the surgeon to reach the tube quite at the lower part 
of tlie neck. This difficult operation has never, I believe, been tried on the living 
subject. In 1820 Vacca published an essay, in which he advocated cut- 
ting into the oesophagus on a sound previously passed through the mouth as a guide. 
In 1832 a valuable paper on external oesophagotomy was written by Begin,** who was 
the first to describe in detail all the steps necessary for opening the gullet with the 
least possible danger to the many important neighboring structures. Since that time 
the operation has become a recognized surgical procedure. A full history of external 
oesophagotomy, with a detailed account of most of the cases recorded in medical litera- 
ture, was published in 1S70 by Terrierff in his valuable monograph on the subject. 
It would appear from Terrier’s|| statistics that the success of the 
operation depends in great measure on its early performance, for out of 
six operations done before the sixth day only one death occurred, while 
of five cases where it was carried out from the eighth to the thirty- 
sixth day three proved fatal. The mode of performing the operation is 
as follows: 
* Traits des Operations de Chirurgie, Amsterdam, 1739, t. ii., pp. 381, 382. (The 
original edition was published in Paris in 1693.) 
f M<5m. de l’Acad. Koyale de Chir., 1747, t. iii., p. 351. 
J Both these cases are mentioned in the Mern.de l’Acad. de Chirurgie, 1757, t. iii., 
p. 14. 
§ Programma de (Esophagotomia, Paris, 1781. 
|| Ueber das Ausziehen fremder Korper aus dem Speisecanal, Leipzig, 1799. 
Della Esofagotomia, Pisa, 1820. The instrument has already been described in 
speaking of oesophagostomy (see foot-note, p. 152), for which operation it is more use- 
ful than for the removal of a foreign body. 
** Mem. de Med. de Chir. et de Pharm. Milit., 1832, t. xxxiii., p. 241. 
ft De l’CEsophagotomie Externe, Paris, 1870. tJ Op. cit., pp. 116, 117. 202 
DISEASES OF THE THROAT AND NOSE, 
External Q^sophagotomy.—The preliminary steps of the operation are 
similar to those already described under the head of “ (Esoplmgostomy ” 
(see p. 152). The incision need not, however, be so long as is there 
recommended, but should be made so that the middle part of it shall 
correspond to the supposed point of impaction of the foreign body. A 
special difficulty is likely, according to von Langenbeck,* to be 
encountered in cases where a large foreign body has been impacted 
behind the cricoid cartilage for several days. Under these circumstances 
the thyroid body is exceedingly apt to be so much swollen by venous 
congestion as almost entirely to cover the gullet. To expose that tube, 
therefore, the thyroid must be carefully raised from it, and for this 
purpose the capsule of the gland must be incised. When the gullet has 
been laid bare, the foreign body will, in most cases, be seen or felt 
projecting through the wall, which should be nicked with the knife, just 
sufficiently to permit the impacted substance to be drawn out with for- 
ceps. Should it, however, be too small to be felt, a bougie with a 
metallic or ivory knob should be passed into the gullet by the mouth, 
or Yacca Berlinghieri’s sound may be used. Upon the extremity of 
one of these instruments an incision should be made in the oesophagus 
for about half an inch in the direction of the long axis of the tube, care 
being taken to open it as far back from the trachea as possible, in order 
to avoid wounding the recurrent nerve. The fact that the gullet has 
been opened will be rendered apparent by the escape of a considerable 
quantity of mucus from the wound. If the impacted substance has 
not already been discovered, it should now be searched for and removed. 
The edges of the oesophageal wound should afterwards be brought 
together with catgut-sutures, the ends of which should cut off short. 
If possible the patient should receive nourishment only by enemata for 
the first week or ten days, but if this means of sustaining life prove in- 
adequate, a gum-elastic tube must be passed down the gullet beyond 
the seat of the wound and food administered through it. 
* Loc. cit. PARALYSIS OF THE GULLET. 
203 
[NEUROSES OF THE GULLET.] 
PARALYSIS OF THE GULLET. 
Latin Eq.—Imbecillitas guise. 
French Eq.—Paralysie de l’cesophage. 
German Eq.—Lahmung der Speiserohre. 
Italian Eq.—Paralisi del esofago. 
Definition.—Loss of power of the muscular fibres of the oesophagus, 
causing food to lodge in the canal, or to be sticaUowed with difficulty. 
History.—Galen* was acquainted with this disease, which he referred to as “ irabe- 
cellitas guise,” carefully distinguishing between difficulty of swallowing from this cause, 
and that due to narrowing of the canal itself, or to the pressure of a tumor on its walls. 
The affection was mentiened by iEtiusf in the sixth century, but the complaint was 
not generally recognized till after the middle of the seventeenth century, when our 
own celebrated physician, Willis,J published a remarkable case in which he had kept 
a patient alive for nearly twenty years by teaching him to push his food down with a 
sponge-probang. The subject was treated'of by Stalpaert van der Wiel,$ in 1682, 
and by Spies,|| in 1727, whilst Hoffmann,f in 1734, described the case of a patient 
who was obliged to wash down every mouthful of food with water. Some years later 
van Swieten** gave a clear account of the affection, and in 1757 Wepferff recorded sev- 
eral instances in which palsy of the gullet had followed an attack of apoplexy. The 
subject was discussed, with somewhat less than his usual thoroughness, by Morgagni, 
and in the early part of the present century Monro§§ published many interesting ex- 
amples of the complaint. Esquirol,|||| in 1829, described paralysis of the oesophagus as 
a condition somewhat frequently occurring in lunatics, and occasionally proving the 
direct cause of their death. In 1833 Mondieref f treated the subject with his usual 
erudition, and since then the disease has been more or less fully described in nearly 
every text-book of medicine. 
Etiology.—The affection is met with under three forms, viz., first, 
where it is due to central disease; secondly, where it results from nerve- 
* De locis affectis, lib. ii., cap. v. f Tetrabiblos, ii., Sermo ii., c. 33. 
J Pharm. Rat., part i., sect. 2, cap. i., Oxonii, 1674. 
$ Obs. med. rarior. centur. post, 1682, p. i., obs. xxvii. 
|| De deglutitione lsesa, Helmsted, 1727. 
f Consult, et respons. cent., t. i., p. 304. 
** Comment, in H. Boerhaave Aphorismos, Lugd. Batav., 1745, t. ii., p. 701. 
ff Historia Apoplect., Venetiis, 1757, p. 376. 
De sedibus et causis morb., ed. secunda, Patavii, 1765, epist. xxviii., art. 14. 
\\ Morbid Anatomy of the Human Gullet, etc., Edinburgh, 1811, p. 290 et seq. 
HU Annales d’Hygi&ne Publique, 1829, No. 1, p. 141. 
ff Archiv G£n., 1833, t. iii. 204 
DISEASES OF THE THROAT AND NOSE. 
pressure; and thirdly, where it arises from muscular weakness. It is 
obvious, however, that all these conditions, or any two of them, may 
coexist. As examples of central diseases giving rise to loss of power in 
the oesophagus may be- mentioned haemorrhage into the pons Varolii, 
or the medulla oblongata, or the development of a tumor in either of 
these situations, bulbar paralysis, multiple sclerosis, progressive locomo- 
tor ataxy, or cerebral atrophy as it occurs in general paralysis of the 
insane; in short, any condition affecting the “centre of deglutition” 
may be the cause of the paralytic phenomena. Wepfer* has recorded 
several cases in which the immediate cause of death in persons suffering 
from apoplexy was inability to swallow, and a very remarkable exam- 
ple of the central origin of cesophageal paralysis has been related by 
Flaudinf in which a patient suddenly lost the power of deglutition 
whilst at table, the seizure being followed within a few hours by facial 
paralysis. LarreyJ published an interesting case in which a lance thrust 
through the posterior lobe of the left hemisphere of the brain was sup- 
posed to have penetrated to the fourth ventricle. The wounded man 
recovered with the loss of most of his special senses, and with complete 
paralysis of the pharynx and oesophagus. Esquirol§ observes that palsy 
of the gullet is very common in the insane, and that in such patients 
asphyxia often results from food accumulated in the oesophagus pressing 
on the trachea. A case is related at the end of this article which well 
illustrates the effect of pressure by a small clot, probably in the vicinity 
of the fourth ventricle. Montaut|| mentions an instance in which 
oesophageal paralysis was caused by a hydatid cyst at the base of the 
brain. 
As regards peripheral lesions it is doubtful whether paralysis of one 
pneumogastric nerve would seriously interfere with the function of the 
gullet, and the conditions are very rare in which both nerves are dis- 
eased or pressed upon by diseased structures. As far as I am aware 
there are no illustrations in recent medical literature of oesophageal 
palsy resulting from nerve-pressure, but relates an instance of 
paralysis in which tubercular infiltration of the bronchial lymphatic 
glands compressed the pneumogastric nerves, and Wilson** met with a 
case in which the nerves were injured by a syphilitic enlargement of the 
* Op. cit., p. 376. 
t Recueil de M4m. de Chir., 1821. 
§ Annales d’Hygiene Publique, 1829, No. 1, p. 141. 
|| Quoted by Arch. G6n., 2e s6rie, t. iii, p. 43. 
Ibid., p. 42. ** Ibid., p. 46. 
f Journ. Hebdom., 1831, No. 4. PARALYSIS OF THE GULLET. 
205 
cervical vertebrae. The exostosis having disappeared under anti-venereal 
treatment, the power of swallowing was at once recovered. 
In these various examples of central and peripheral paralysis, it must 
be borne in mind that the imperfect action of the muscular fibres of the 
oesophagus may be due either to a direct derangement of the motor func- 
tion or to impairment of the sensibility of the mucous membrane, which 
accordingly fails to convey the necessary stimulus for reflex action. It 
is probable, however, that in most instances both the motor and sensory 
nuclei of the vagus are at fault. 
In approaching dissolution the function of the nerve-centre control- 
ling the act of deglutition is extinguished some time before circulation 
and respiration cease. 
In simple weakness the disease is probably in a great measure myo- 
pathic, but in some cases the muscles may become feeble from impaired 
innervation. This is the most common form of paralytic dysphagia, 
and it is met with in persons broken down by ill-health or old age; it 
is much more frequently found in men than in women. 
In addition to these special causes of paralysis of the oesophagus, 
there are certain general conditions of the system with which it is often 
associated, and in which it is hard to determine how far the affection is 
myopathic or neuropathic in origin. Thus in many of the acute fevers 
there is difficulty of swallowing, apparently from imperfect action of 
the pharynx and oesophagus, but whether this depends on loss of sensi- 
bility, derangement of the motor apparatus, or diminished excitability 
of the “centre of deglutition,” it is not easy to tell. It is not improb- 
able, indeed, that the dysphagia in these cases is sometimes mainly me- 
chanical,—that is to say, that it arises from mere dryness of the mucous 
membrane. In diphtheria the affection is generally a neurosis,* whilst 
syphilis may affect either the medulla, or the nerves in some part of 
their course. In palsy of the gullet arising from lead poisoning, of 
which I have met with two examples, the muscular structure is prob- 
ably most implicated. This variety of poisoning is also said to have 
occurred through the use of lead gargles.f 
many years ago described a form of oesophageal paralysis 
which on three occasions he had observed in nurslings. The onset of 
* See Diphtheria, its Nature and Treatment, by the Author, London, 1879, pp. 
56, 57. 
f Hufeland’s Journal, 1797, Bd. iii. p. 698. It should he observed that in this 
case the paralysis was preceded by sharp spasm. 
J Schmidt’s Jahrb., 1837, Bd. xvi., pp. 50-52. 206 
DISEASES OF THE THROAT AND NOSE. 
the affection was in each case preceded by aphthous eruptions about the 
corners of the mouth and round the anus. This was followed by rigors 
and high fever, with vomiting and profuse alvine discharge of a milky- 
looking fluid without any smell. The whole pharyngo-oesophageal 
canal next appeared to be stricken with paralysis, and death quickly 
ensued from collapse. The post-mortem appearances were not recorded, 
and it is highly probable that these cases were not really examples of 
paralysis, but of thrush of the gullet (see vol. ii., p. 76). 
Though hysteria so frequently gives rise to paralysis of other mus- 
cles, it very seldom affects the oesophagus in this way, generally, on the 
contrary, causing spasm of the tube. 
Symptoms.—In all cases of paralysis of the gullet the essential symp- 
tom is dysphagia, its sudden or gradual development, and the degree 
it attains being dependent on the fundamental cause of the malady. 
The difficulty of swallowing, though considerable, probably never 
reaches to the extent of complete aphagia, unless the pharynx is at the 
same time paralyzed. 
As bilateral paralysis of the nerves is extremely rare, and would pro- 
duce nearly the same oesophageal symptoms as cerebro-spinal disease, 
two divisions are sufficient for clinical purposes : these are central and 
local paralysis. 
In central disease the mode of development depends on the special 
nature of the medullary lesion; thus in haemorrhage, the symptom 
occurs suddenly, and at once attains its maximum intensity. In cases 
of cerebral tumor the dysphagia becomes gradually developed, whilst 
in bulbar paralysis, multiple sclerosis and locomotor ataxy, oesophageal 
palsy is a very rare symptom, and, if present, comes on, as a rule, only 
at an advanced stage of the disease. In general paralysis of the insane, 
dysphagia is more common and occurs at an earlier period. In almost 
all cases of central origin, signs of impaired innervation of the larynx, 
such as anaesthesia of the mucous membrane or paralysis of the abductor 
filaments of the recurrent nerve, accompany the oesophageal symptoms. 
The patient is almost always feeble and depressed, but emaciation is not 
usually a marked symptom. 
In local paralysis, the development of the dysphagia is very gradual. 
I have seen several instances in which the disease has lasted from ten 
to twenty years. It apparently leads, after a time, to some stenosis of 
the gullet, and in long-standing cases the isthmus faucium, and even 
the mouth, is often much contracted. In 1875 I had a patient under 
my care whose mouth had become so reduced in size that it only 207 
PARALYSIS OF THE GULLET. 
measured one inch and an eighth across, whilst the distance between 
the lips, when parted to the utmost extent, was no more than a quarter 
of an inch. This patient had suffered from dysphagia for sixteen years, 
and for the last five years had lived entirely on corn-flour and tea, with 
a little beef-tea once a week. In this form of oesophageal paralysis, 
owing to the longer duration of life, emaciation is a much more marked 
symptom than when the loss of power is due to central disease. 
In both varieties important information may be obtained by the em- 
ployment of the bougie and by auscultation. Certain features are com- 
mon to both kinds of nervous dysphagia. Thus a bougie can usually 
be passed easily, and the employment of the instrument does not give 
rise to so much nausea and retching as in health. Occasionally, how- 
ever, when the disease has existed for many years, the habitual use of 
liquids appears to lead to general narrowing of the canal, so that there 
may be considerable difficulty in passing an instrument. On ausculta- 
tion the normal oesophageal sound is found to be greatly altered or 
altogether lost, and the act of deglutition is observed to be markedly 
prolonged. Hamburger points out that the “ morsel” seems to lose its 
resemblance to the form of an inverted egg, and to assume the shape of 
a funnel, but I have never been able to verify this refinement of diag- 
nosis. In extreme cases there is no longer any sound like that of a 
defined body of fluid passing downwards, and all that is heard is a thin 
stream trickling down drop by drop. 
There is seldom any regurgitation in paralysis, but in slight cases, 
where semi-solids can be taken, patients often complain of the food 
lodging in the gullet. 
Pathology.—The various lesions of the nerve-centres which may be 
met with after death have already been referred to under the head of 
“Etiology.” My own experience in this affection is entirely clinical, 
and I have never had an opportunity of making an autopsy in a case of 
either central or local paralysis of the gullet. In most instances there is 
probably more or less degeneration of the muscular tunic of the oesoph- 
agus, and possibly some structural lesion of the nerves themselves. 
Diagnosis.—It is important to distinguish paralysis both from spasm 
and from malignant disease. 
In spasm the dysphagia is intermittent, the patient being sometimes 
able to swallow quite well, whilst at other times he cannot get down a 
morsel of food. On the other hand, in paralysis the dysphagia under- 
goes little, if any, variation. In spasm it is often quite impossible to 
pass a bougie, whilst, as already remarked, in paralysis there is seldom 208 
DISEASES OF THE THROAT AND NOSE. 
any difficulty in using that instrument. In the latter affection there is 
no regurgitation, but in spasm this is often very marked. The acoustic 
signs are also quite different; for whilst in paralysis only a confused 
gurgling noise is heard, in spasm a sharp click can be perceived, some- 
times in one part and sometimes in another. Again, whilst paralysis 
more frequently affects the old and feeble, spasm is more often met with 
in the young and hysterical. 
Cancer, like paralysis, is a disease which occurs in the decline of life, 
but the comparatively rapid progress of malignant disease soon sets the 
question of diagnosis at rest. Moreover, in cancer there is always ob- 
struction to the passage of a bougie. 
Although the diagnosis of oesophageal paralysis is generally very easy, 
there are some cases where the affection probably altogether escapes ob- 
servation, owing to the pharyngeal contraction forcing the food through 
the gullet. For the experiments of Chauveau* clearly show that even 
in complete paralysis of the oesophagus from section of its motor nerves 
vigorous contraction of the pharynx can impel the food into the stom- 
ach. Although Chauveau’s observations were made on the horse, it 
seems reasonable to infer that the almost vertical position of the canal 
in man would render the passage of food still easier. 
Prognosis.—This, of course, depends on whether the disease be local 
or central. In the simple local paralysis due to muscular weakness, 
the prognosis is always favorable. Long-standing cases can generally 
be benefited, and those of shorter duration can be cured. In cases of 
diphtheria and lead-poisoning the prognosis is very favorable, but when 
the oesophageal paralysis is due to the coarser forms of nerve-disease, 
the prospect must always be most grave. 
Treatment.—In the more severe forms of paralysis, little can be done 
in the way of treatment, but in the simple local cases a cure can often be 
effected. In all cases treatment must be directed to the fons et erigo 
mali. In the milder local form of paralysis attention must be paid to 
the general health, and tonics, such as strychnia, iron and ergotine, are 
often of advantage. The patient requires a nourishing and stimulating 
diet, and a glass of wine taken at the commencement of a meal acts 
beneficially both as a local and a general stimulant. Condiments should 
always be freely taken, and the patient should be encouraged as far as 
possible to eat solids. Pungent viands are more likely to stimulate the 
constrictors to reflex action than soft insipid food. In the way of local 
treatment topical stimulants, such as a benzoic acid lozenge of the 
* Journ. de Physiologie de Brown-S6quard, t. v., p. 327. PARALYSIS OF THE GULLET. 
209 
Throat Hospital Pharmacopoeia taken five minutes before eating will 
often prove serviceable. The value of electricity was recognized at an 
early date, Monro* having reported several cases in which the external 
use of it was followed by marked improvement, and in some by cure. 
The best method of applying electricity, however, is by internal fara- 
dism. The positive pole being placed, by means of the necklet, in con- 
tact with the spinous processes of the upper cervical vertebrae, the 
negative pole is applied to the interior of the gullet by means of the 
oesophageal electrode (vol. ii., p. 33). This instrument should be used 
at least daily, and if possible, several times in the day. The best time 
for it is before meals. On each occasion the electrode should be intro- 
duced three or four times, and retained in situ for a few seconds whilst 
a succession of shocks are passed. The treatment generally requires to 
be continued for several weeks, but after the first week or two the ap- 
plication need not be made so often. By this method I every year cure 
a large number of patients. 
Palliative measures must be adopted when those of a more radical 
character fail, and in connection with this point some hints may per- 
haps be obtained from oases like that of Willis,f already referred to 
(see “ History ”). BasterJ has also supplied a somewhat similar illus- 
tration where a girl, who for fourteen months had fed herself by push- 
ing her food down with a probang, ultimately recovered her power of 
swallowing. Desault§ claims to have cured a man by feeding him 
with a tube, and Sedillot|| mentions an instance of a young woman 
whose power of swallowing was completely restored by blisters to the 
neck, ammonia liniment, and gargling and swallowing mustard and 
water. 
The following is a remarkable illustration of oesophageal palsy de- 
pendent on a central cause: 
Master W. B. C., aged sixteen, of Utica, New York, U. S. A., was brought to mef 
on June 18th, 1880. Besides the usual ailments of childhood, he had suffered at vari- 
ous times from “ croupv ” attacks, but for the three or four years preceding the onset 
of the complaint for which my advice was sought, he had enjoyed uninterrupted good 
* Morbid Anatomy of Gullet, etc., Edin., 1830, 2d ed., p. 290. 
f Pharmaceutice Rationalis, part i., sect. 2, cap. 1. 
J Referred to by Stalpaert van der Wiel: Observ. Med. rarior, cent. 2, part i., obs. 
xxvii. 
I Oeuvres Chirurg., Paris, 1801, t. ii., p. 291. 
|| Recueil Periodique, t. xl., p. 81. 
The patient had previously been seen by Dr. Elsberg, to whom I am indebted for 
some information respecting the beginning of the malady. 210 
DISEASES OF TIIE THROAT AND NOSE. 
health. In May, 1879, whilst playing at base-ball, he noticed that whenever he threw 
the ball a sharp pain seemed to shoot through the region of the larynx. This pain 
was of only momentary duration, but for several days afterwards he had frequent 
tingling, shooting sensations down the left arm from the shoulder to the wrist. He 
continued, however, to play ball daily, and on one occasion, about a fortnight after 
the occurrence of the laryngeal pain mentioned above, he became conscious, whilst 
greatly excited in the middle of a game, that he had some difficulty in swallowing.* 
That evening it cost him some effort to eat his supper, and on the following day the 
dysphagia jiad become so great that he could only swallow liquids, which, however, 
were occasionally thrown back through the nose. About the same time Master C. was 
attacked with almost constant hiccough, and his voice acquired a nasal twang. Dr. 
Gray, of Utica, was called in, and found it necessary to feed him with the help of a 
stomach-tube during three weeks. The patient then somewhat recovered his power 
of swallowing. In July, 1879, he had a fit of dyspnoea, followed by several similar 
paroxysms during the autumn. The difficulty of breathing gradually grew more per- 
sistent, and in January, 1880, the number of respirations had fallen to six per minute. 
Tracheotomy was performed about this time by Dr. Hutchinson, of Utica, and Master 
C.’s breathing was relieved, but his dysphagia did not improve. He gained weight, 
however, and his general condition was fairly satisfactory, but his left arm remained 
weak and somewhat numb, and he became partly deaf in the left ear. 
When I saw Master C. I found him wearing a tracheotomy-tube, but he was able to 
breathe fairly well when its orifice was closed with a cork. His voice was rather 
feeble and slightly nasal (from imperfect action of the uvula). His left arm and left 
leg were weak, and his power of grasp with the left hand was decidedly less than 
normal. He walked in a somewhat unsteady way, and when his eyes were closed his 
movements resembled those of a patient suffering from locomotor ataxy. On the left 
side he could not hear a watch tick at a greater distance than nine inches from the 
ear. On the right side the hearing was perfect. 
On inspecting the pharynx, the uvula was found to possess diminished sensibility, 
but was not drawn to either side. On laryngoscopic examination the vocal cords 
appeared to act imperfectly as regards abduction, adduction, and tension. The abduc- 
tors, however, were chiefly affected, the utmost separation of the vocal cords in forced 
inspiration affording an opening only about one-third of the normal size. There was 
also diminished sensibility of the mucous membrane of the larynx. On directing the 
patient to swallow some water, the act of deglutition was seen to be very slowly arid 
imperfectly performed. 
Having treated several somewhat similar cases in conjunction with Dr. Hughlings 
Jackson, I requested him to see the patient with me, and the following is his report: 
“ Discs normal, retinal veins strikingly irregular, patellar-tendon reflex quite absent.” 
Dr. Hughlings Jackson thought that there was a small tumor pressing on the medulla. 
I venture to suggest that rupture of a small artery in the medulla took place during 
the violent exercise in which the boy was engaged, and that the subsequent develop- 
ment of the symptoms was due to sclerotic changes in the clot. 
It need scarcely be said that I was unable to recommend the removal of the trache- 
otomy tube in this case, but whilst pointing out that no very remarkable results could 
be anticipated from treatment, I suggested that local faradism and galvanism might be 
* A few days previously he had taken a large quantity of ice-water whilst heated, 
and had eaten some ice-cream, but this does not seem to have had any causal relation 
with his malady. SPASM OF THE (ESOPHAGUS. 
211 
tried on alternate days. This treatment wras carried out by Dr. Ford, of Utica, who 
forwarded the following report in October, 1880, after he had pursued the treatment 
for a short time: “ I have applied electricity as you suggested, and observe that the 
parts are vastly more sensitive to electricity, but there is as yet no appreciable increase 
of motion.” Dr. Hutchinson, of Utica, was good enough to send me, quite recently 
(December 5th, 1882) some notes which bring the case almost down to the present 
time. “I saw the patient yesterday,” he says, “and found him quite strong and in 
apparent good health. He still wrears the tube, although he can breathe for some some 
with it closed. As he inspires the nose contracts and becomes pinched, and he breathes 
with some effort. He has still difficulty in swallowing, and does not like to be seen at 
the table by strangers. He is still uncertain with his left arm and leg, and has fallen 
from his horse because he could not keep his left foot in the stirrup.” 
SPASM OF THE (ESOPHAGUS. 
(Synonym : (Esophagism.) 
Latin Eq.—Spasmus oesophagi. 
French Eq.—Spasme de Foesophage. 
German Eq.—Krampf der Speiserdhre. 
Italian Eq.—Spasmo del esofago. 
Definition.—Rigid approximation of the walls of a segment of the 
oesophagus through contraction of the circular fibres of its muscular coat, 
giving rise to dysphagia, varying in intensity and duration. 
History.—The affection was referred to by Hippocrates,* but only in a casual manner, 
and no other ancient writer seems to have been acquainted with it. In more modern 
times van Helmontf pointed out, that difficulty of swallowing sometimes occurs in 
hysterical women, but he was under the impression that the symptom was due to an 
actual rising of the womb to the throat, which he thought caused temporary oblitera- 
tion of the oesophageal canal. It was not till the early part of the eighteenth century 
that the disease was really made the subject of rational investigation by Hoffmann, J 
and little has been added since his time to the clinical knowledge of the affection. A 
short essay on “Spasmodic Disease of the Gullet” was published by Courant§ in 1778, 
and a few years later Bleuland|| briefly discussed the malady in the little treatise which 
* De Morbis, Littrfe’s edition, 1. iii., c. xii., vol. vii., p. 133. 
f Ignot. Act. Regim., £ 43. Joannis Baptist* van Helmont, Opera Omnia, Fran- 
cofurti, 1707, p. 322 ; also Asthma et Tussis, \ 31, Ibid., p. 292, where he relates a case 
in which a woman had hardly swallowed anything for three months. He adds, “ I 
came, recognized the disease, and immediately the Lord cured her,” but van Helmont 
unfortunately omits to state how. 
J De morbis oesophagi spasm odicis, in F. Hoffmanni, Op. Omn., Phys. Med., 
Genevse, 1740, t. iii., p. 132. 
£ De nonnullis morbis convulsivis oesophagi, Montpellier, 1778. 
|| De sana et morbosa oesoph. structure, Leidee, 1785, p. 56. 212 
DISEASES OF THE THROAT AND NOSE. 
has been already several times referred to, and in particular pointed out that spasm of 
the gullet is sometimes produced by the irritation of a neighboring inflamed part, e. g., 
by gastritis* Several interesting examples of the disease were related by Monro,f 
and the subject also was treated of MondiSre.J A very full account of spasm of the 
gullet was given by Foiling and more recently Hamburger|| published an accurate 
account of the affection. A paper containing some important hints as to the diagnosis 
of the affection was written by Rouxf in 1873, whilst soon afterwards some good ex- 
amples of the complaint were reported by Foot,** and an important clinical lecture 
on the subject was published by the late Maurice Raynaud.ff More recently the dis- 
ease has been discussed in some detail by ZenkerJJ and by Brazier,$§ whilst it has also 
been fully dealt with in recent volumes of the Nouveau Dictionnaire de Medecine et de 
Chiruryie, |||| and the Dictionnaire Encyclop&dique des Sciences Medicates^ 
Etiology.—Spasm of the oesophagus occurs more comm oh ly in the 
female than in the male sex. It is most frequent in young women 
between the ages of eighteen and thirty, but it is often met with later 
in life, and sometimes, though very rarely, it occurs in childhood. I 
have twice seen it in patients under ten years of age. The affection, 
or at any rate, the nervous constitution which predisposes to it, is 
occasionally hereditary. In May, 1875, I succeeded in curing a patient 
whose mother and grandmother had both suffered from the same com- 
plaint. A case has also been reported by Stevenson,*** in which he suc- 
cessfully treated a mother and her daughter for spasm of the gullet, 
the former having suffered from the complaint for twenty years, and 
the latter, aged twenty, all her life. When men are the subjects of 
cesophagism they are always of a highly emotional temperament, and 
are generally victims of hypochondriasis. 
Spasm of the oesophagus may be (1) a mere psychical or hysterical 
phenomenon, or (2) it may occur in the course of certain nervous dis- 
orders, such as chorea, epilepsy, and especially hydrophobia; or (3) it 
* Ibid., p. 62. 
f Morbid Anatomy of the Human Gullet, etc., Edinburgh, 1811, p.223; and 2d 
ed., 1830, p. 268 et seq. 
J (Esophagisme—Archiv. G6n., 1833, t. i., p. 465. 
\ R6tr6cissements de l’CEsophage, Paris,. 1853, p. 154 et seq. 
|| Klinik der CEsophaguskrankheiten, Erlangen, 1871, art. iv., p. 94 et seq. 
f Diagnostic des R6tr4cissements Spasmodiques de l’Gisophage, Tli&se de Paris, 
1873. 
** Dublin Journ. of Med. Sci., April, 1874. 
ff Annales des Maladies de l’Oreille et du Larynx, 1877. 
Ziemssen’s Cyclopaedia of Pract. Med., 1878, vol. viii., p. 204. 
Contribution a l’Etude de l’CEsophagisme, These de Paris, 1879. 
1111 Paris, 1877, t. xxiv., p. 359. 
Iff Paris, 1880, 2e partie, t. xiv., p. 529. 
*** Med. and Phys. Journ., vol. viii., p. 35. SPASM OF THE (ESOPHAGUS, 
213 
may be due to some reflex irritation, the cause of which may be either 
in the gullet itself, or at a distance from that part; or (4) it may result 
from the strain of violent retching. Of the psychical causation of this 
malady the most striking example is to be seen in the case of patients 
who imagine that they are suffering from hydrophobia. A remarkable 
instance* of this is the case of a man who, on returning to France after 
an absence of twenty years, was told that his brother had died from the 
effects of the bite of a dog by which he had himself been bitten. 
Shortly after hearing this news of his brother he was seized with oeso- 
phageal spasm, which quite prevented him swallowing and ultimately 
proved fatal. A case is also relatedf of a man who was bitten by a 
favorite dog, which soon afterwards ran away. The master showed all 
the signs of hydrophobia until the dog returned, perfectly well, nine 
days after, when the man instantly recovered. Another remarkable 
example is related by Dr. Dolan,J on the authority of Trousseau, in 
which a man showed the characteristic signs of hydrophobia after a 
rabid dog had tried to bite him. The symptoms had come on after a 
feast, and vanished on his being made to vomit. 
In the severe nervous diseases to which reference has been made, 
such as tetanus and epilepsy; the oesophagus sometimes participates in 
the spasm which affects so many of the other muscles of the body. In 
chorea spasm of the gullet is less frequent, but I have seen two ex- 
amples of this complication. In true hydrophobia the muscles of the 
pharynx and oesophagus are specially involved. 
Setting aside foreign bodies, the most frequent topical source of reflex 
irritation of the gullet is probably to be found in a gouty condition of 
the blood. Brinton,§ who first called attention to this source of irrita- 
tion, was of opinion that in lithsemia the acid condition of the blood 
causes spasm of the oesophagus, in the same manner that it produces 
cramp in the legs, or numbness and formication in various parts of the 
body. The immediate cause of the oesophageal spasm in these gouty 
cases often appears to be the eructation of acid matters. Amongst the 
reflex causes acting at a distance, diseases of the stomach and affections 
of the uterus may be mentioned. Of the former, Howship|| has re- 
* Bibliothdque M4d., t. xxxix., p. 234. 
f Diet. Encyclop. des Sci. M6d., t. xiv., p. 530. 
t Quoted, with many other illustrations, by Dr. Dolan, in his admirable Report on 
Rabies or Hydrophobia (pp. 82, 83), as Commissioner for the Medical Press and; 
Circular, 1878. 
§ Lancet, 1866, pp. 2 and 253. 
j| Practical Remarks on Indigestion, London, 1825. 214 
DISEASES OF THE THROAT AND NOSE. 
corded two remarkable examples. One of these was that of a man who 
had been treated with bougies for four months on account of stricture 
of the middle third of the oesophagus. After death no stricture was 
found, but the stomach was in a state of “ fungous ulceration for a 
hand’s breadth.” In another case a lady, aged sixty-nine, suffered from 
spasmodic stricture of the upper part of the gullet, which was relieved 
by the passage of bougies. The patient, however, still continued to 
vomit a glairy fluid, and ultimately sank from exhaustion. At the 
post-mortem the stomach was found to be a mass of scirrhus, whilst 
the (esophagus was perfectly healthy. A similar case has been re- 
ported by Munro.* Another instance was related by John Shaw,f in 
which he had treated a patient for organic stricture of the oesophagus. 
After death the dysphagia was found to have been caused by ulceration 
of the larynx. The affection has been known to be caused by metritis, 
and to disappear on the cure of that disease.;}; I have myself met with 
two patients who always suffered from oesophageal spasm when preg- 
nant, but were relieved immediately after parturition. As an analogous 
case I may mention that I formerly treated a lady in whom the spasm 
came on whilst she was suckling. This recurred to such an extent at 
the birth of each child that she was never able to nurse. The case 
reported by Bettali,§ in which the presence of a tapeworm in the in- 
testinal canal gave rise to spasm of the oesophagus, and that referred 
to by Bouteille,|| in which the affection was caused by the existence of 
worms in the ear, may be mentioned as other examples of reflex action. 
There are two cases on record in which the spasm is said to have re- 
sulted from vomiting. One is related by Sir Everard Horae,in which 
a lady, after severe sea-sickness, was quite unable to swallow, owing to 
spasmodic contraction of the gullet. From the description of the symp- 
toms, however, I am disposed to believe that this was really a case of 
acute inflammation. The other, which is mentioned by Carron,** is 
more to the purpose. Here intense spasm followed sickness induced 
by the use of emetics. An extraordinary case of an opposite character 
is mentioned by Home,ft of a young man in whom difficulty of swal- 
lowing, apparently spasmodic in character, which had existed since 
childhood, was relieved for weeks at a time after violent retchinsr. 
* Op. cit., p. 266. f Lond. Med. and Phys. Journ., vol. xlviii., p. 185. 
J Arcliiv. G6n., t. xxxi., p. 474. 
\ Quoted by MondiSre : Arch. G6n., 1833, vol. i. 
|| Ibid. 
** Recueil Pferiodique, t. xl., p. 58. 
T[ Op. cit., p. 549. 
ft Op. cit., p. 550. SPASM OF THE (ESOPHAGUS. 
215 
As regards the actual mechanism of spasm, Dr. Andrew Smith* 
has advanced the following ingenious hypothesis : “ In normal deglu- 
tition,” he observes, “ the contact of the bolus with mucous membrane 
of the gullet produces an impression which is reflected to the muscular 
coat at a point above the mass which is being swallowed, and thus the 
resulting wave of contraction follows immediately after the bolus and 
forces it downward. But in spasm of the oesophagus, it would seem 
that the excitation is reflected to a point below instead of above the bolus, 
so that the resulting contraction presents an effectual obstacle to the 
passage of the alimentary mass, or even forces it upward.” 
Symptoms.—Dysphagia is always complained of. It varies in 
intensity from a slight feeling of difficulty in performing the act of 
deglutition, which can be overcome by an effort of the will, to an almost 
total inability to swallow. In slight and recent cases, solids or semi- 
solids are swallowed more easily than liquids, but as the disease 
becomes more established fluids pass the more readily, and warm' drinks 
can be taken with less trouble than cold ones. The dysphagia is also, 
as a rule, more or less paroxysmal, occasionally coming on in the middle 
of a meal, but sometimes it lasts, with slight intermissions, for months, 
or even years. 
Seneyt relates a case in which the morsel of food was seized in the 
oesophagus and could neither be swallowed nor rejected, the most severe 
cramp being felt at the same time in the throat. This is a rare symp- 
tom, and, so far as I am aware, it has not been mentioned by any other 
writer. I have myself never met with an example of this kind of 
spasm. 
In cases of spasm the patient not only cannot swallow, but generally 
has very little inclination for food. Regurgitation is sometimes present, 
and when it does occur, it comes on instantaneously after swallowing, 
there being no appreciable interval as in organic stricture. The food, 
under these circumstances, is sometimes rejected with so much force 
that it is thrown quite out of the mouth. Slight odynphagia may be 
complained of, and an uneasy sensation, or even a little pain, may occa- 
sionally be felt between meals. Sometimes the sufferer experiences the 
well-known feeling of a “ball rising in the throat.” 
indeed believes that “ globus hystericus ” consists in a wave of spasm 
affecting successive segments of the gullet from below upwards. He 
* Virginia Med. Monthly, 1877, vol. iii., No. 34, p. 743. 
f CEsophagisme Chronique, Th&se de Paris, 1873. 
| Klinik der (Esophaguskrankheiten, Erlangen, 1871, 4 art., p. 94. 216 
DISEASES OF THE THROAT AND NOSE. 
observes that if a patient can be examined with the stethoscope at the 
moment she experiences the sensation of “ the ball ” rising, a sudden 
contraction of the oesophagus and the ascent of a bubble of air will be 
heard. On the other hand, Rosenthal* found in two eases that gal- 
vanization of the hypoglossal nerve immediately inhibited the spasm of 
the oesophagus; and he considers that the fact that the patient can swal- 
low whilst the “globus hystericus” is felt, proves that the phenomenon 
cannot be due to cramp of the oesophageal muscles. A case, however, 
has recently come under my notice which directly controverts the last 
statement. The patient, a lady, aged sixty-two, whom I saw in con- 
sultation with Mr. Buee, of Slough, had been suffering on and off for 
several months from spasm of the gullet. She often went several days 
without swallowing a particle of food or drinking a drop of liquid. I 
saw her make the attempt, but violent coughing at once came on from 
the drink passing into the windpipe. When the spasm relaxed, how- 
ever, the patient was able to swallow easily. She stated of her own 
accord that the sensation in the throat was like a ball—in fact, like 
“ hysteria,” as she had experienced it when a girl. The patient also 
assured me, proprio motu, that as long as this sensation lasted nothing 
would go down the throat. 
Emaciation is often altogether wanting, and never bears any propor- 
tion to the duration and apparent severity of the obstruction ; often, 
indeed, well-nourished women are met with who declare that they 
cannot swallow at all. Expuition only occurs when the spasm is very 
severe, both as regards intensity and duration. There is seldom any 
alteration of the voice or cough, except when the spasm of the gullet is 
reflected from the larynx. 
Auscultation of the oesophagus often affords valuable information. 
Thus, the point of obstruction may be heard to vary in situation. The 
first morsel may be arrested or retarded at the upper part of the oesoph- 
agus, whilst the second or third morsel is stopped two or three inches 
lower down; or whilst the act of deglutition is arrested or delayed one 
moment, it may be performed perfectly the next. This is an absolute 
proof of the spasmodic character of the affection. Again, the morsel 
may be heard to be arrested or forced upwards for a second and then 
to pass down the gullet. There is generally not nearly so much of the 
bubbling or gurgling sound as is met with in organic stricture or oesoph- 
ageal diverticula. On passing a bougie, an obstruction will generally be 
felt in the region prone to be contracted, which is usually near the upper 
* Handbuch der Diagnostik und Therapie der Nervenkrankheiten, p. 245. 217 
SPASM OF THE CESOPHAGUS. 
or lower orifice of the gullet, but much more frequently the former. 
The obstruction can often be overcome by moderate force, but some- 
times tjie spasm is so tight that it will not yield to anything short of 
violence. In such cases repeated attempts should be made on different 
occasions to pass the instrument. Sometimes a rapid attempt to intro- 
duce it will succeed when a slower one fails, but more often the spasm 
gives way before steady pressure. If the patient be placed fully under 
the influence of an anaesthetic, all difficulty in using the instrument will 
disappear. It may be remarked here that in some cases the passage of 
the bougie causes great pain, a phenomenon probably dependent on the 
existence of extreme congestion of the lining membrane. 
Diagnosis.—The age, sex, and nervous temperament of the patient 
are of help in arriving at an accurate diagnosis. The abrupt commence- 
ment and intermittent character of the dysphagia, the suddenness of 
regurgitation (when it occurs), the fact that in most cases the obstruc- 
tion can be overcome with the bougie, and the absence of emaciation 
are the salient features. In paralysis of the gullet, the dysphagia is 
constant, and in malignant disease it is nearly always progressive.* 
Pathology.—The affection consists essentially of a spastic contraction 
of the circular fibres of the muscular coat of the oesophagus. Its more 
frequent occurrence at the extremities of the tube is explained by the 
greater abundance and higher development of the circular fibres in those 
situations. 
A perverted or unstable condition of the nervous centres is doubtless 
necessary for the production of the affection, and hence the complaint 
occurs in connection with hysterical and other nervous disorders. 
Although it is highly probable that whenever muscles are repeatedly 
thrown into a state of spasmodic contraction, both myopathic and neuro- 
pathic changes ensue, yet such morbid alterations of structure have not 
hitherto been observed. Even in hydrophobia, there is seldom any 
appreciable change to be seen in the condition of the oesophageal canal. 
In tetanus, Larreyf found the oesophagus and pharynx tightly con- 
tracted after death. 
* It might be extremely difficult to distinguish true spasm from the condition known 
as dysphagia lusoria. This is generally said to arise from the compression to which the 
gullet is subjected by the right subclavian artery when, as an abnormality, it springs 
from the arch of the aorta. In its course from the left to the right side of the chest, 
the vessel must of necessity pass either in front of, or behind the gullet, which may 
thus be pressed on. More or less intermittent dysphagia will in this manner be pro- 
duced. The existence of this form of dysphagia is, however, altogether denied by 
some writers. 
f M6m. de Med. Chir. et Pharm. Milit., t. xiv., p. 175. 218 
DISEASES OF THE THROAT AND NOSE. 
Prognosis.—The prognosis is generally favorable in recent cases, but 
where the disease is of very long standing, like many other nervous 
affections it becomes intractable. It is apt to lead to narrowing of the 
oesophagus, and may sometimes predispose to cancer or determine the 
site of its development. Even when the disease is of only moderately 
long duration the cure is often protracted, and relapses are apt to occur. 
Cases have been reported which have resulted in death, though no 
disease could be found in the oesophagus. Mr. Power* has related a 
remarkable instance which was seen by several eminent members of the 
profession, in which the spasm was sufficiently severe to destroy the 
patient, a man aged forty-eight, by inanition, and yet after death no 
organic lesions whatever, in or around the gullet, could be found to 
account for the symptoms. A case has also been recorded by McKib- 
ben.f in which death occurred in five days, spasm of the gullet, with 
absolute aphagia, and profound prostration of the nervous system being 
the only marked symptoms. There was no obstruction, and a stomach- 
tube could be easily passed, but the utmost efforts of the patient to swal- 
low were quite unsuccessful. The case, however, is very incompletely 
reported, and no autopsy was made. It seems highly probable that 
paralysis rather than spasm was the cause of the dysphagia. 
Treatment.—When the affection depends on serious disease of the 
general nervous system, the attention of the practitioner must be di- 
rected to the fundamental lesion. Thus, in hysteria the patient must 
be braced up by moral, as well as by hygienic and medicinal agencies. 
His mind should, if possible, be kept employed by regular and inter- 
esting occupation, or by change of scene and travel. By passing a 
bougie, and assuring the patient that there is no obstruction, such per- 
sons may sometimes be made aware of the groundlessness of their sen- 
sations. If the disease is believed to be of reflex origin, the cause must 
be sought out and if possible removed. Where the affection results 
from a gouty condition, an alkaline draught containing bicarbonate of 
potash and aromatic spirits of ammonia, will often at once give relief. 
Other drugs are sometimes of great service. I have employed bromide 
of potassium with marked benefit in several cases, and it has also been 
found useful by Gubler| and Amory,§ but valerianate of zinc in com- 
bination with assafoetida has proved even more effectual. In many 
* Lancet, 1866, vol. i., p. 252. 
f Amer. Journ. Med. Sci., Oct., 1859. Quoted by Andrew Smith: loc. cit. 
X Bull. Gen. de Thferap., 1864, t. 67, pp. 10, 11. 
g Diet. Encyclop., vol. xiv., p. 538. SPASM OF THE OESOPHAGUS. 
219 
cases the passage of bougies lessens the irritability of the canal and 
speedily brings about a cure, and it may be remarked that, as a rule, 
the ivory-knobbed bougies answer better for the purpose than the ordi- 
nary gum-elastic instrument. The bougie, which must be warmed, 
should either be kept in situ for a minute or two, or it should be slowly 
moved up and down the gullet; but it should not be used when there 
is hypersesthesia of the mucous membrane. Under such circumstances 
it is better to treat the case at first with injections. Various mineral 
astringents, such as chloride of zinc or perchloride of iron, may be used, 
but a weak solution of nitrate of silver (gr. v. or gr. x. ad 5j.) answers 
best. The solution should be warmed, and about half a drachm in- 
jected into the gullet with the “oesophageal injector” (vol. ii. Fig. 4, 
p. 33) as nearly as possible at the seat of spasm. Three or four injec- 
tions made on alternate days will often effect a cure, or they will relieve 
the irritability so much that bougies can subsequently be employed. 
Broca* cured a patient by forcibly opening the stricture with a dilator, 
but I believe that his case would have yielded to bougies. If, how- 
ever, mechanical measures do not succeed, galvanism will almost, invari- 
ably conquer the disease. Indeed, this remedy is so certain, that, if 
ordinary medication fails, I at once have recourse to it. A ten or 
twelve-celled battery should be used. The oesophageal electrode should 
be introduced into the gullet at least once a day, and kept in position 
for a minute or two or longer if the patient can bear it. The applica- 
tion should be made at such a time that a considerable interval may 
elapse between the treatment and the next meal. After a week or ten 
days, the application should be made on alternate days for a fortnight, 
when the cure will generally be complete. 
The dietary in these cases is of the greatest importance. If the spasm 
is very severe, thickened liquids should be given, and it is well to bear 
in mind the fact which has been already pointed out, that warm drinks 
are much less apt to bring on spasm than cold ones. It is remarkable, 
too, that in nine cases out of ten if the drink be sweetened it is better 
borne. Gradually the food may be thickened, and panadaf may be 
allowed. If the case progresses favorably, the patient will be able to 
return by degrees to ordinary diet. Stimulants should not, as a rule, 
be given, and all pungent food should be prohibited. It is the greatest 
mistake to force these patients to take solid food before the cure is com- 
plete. They may sometimes be tricked out of their malady when it is 
slight and recent, but rough measures always fail. 
* Gazette des Hopitaux, Aug. 7, 1869. 
f See vol. i., p. 556. 220 
DISEASES OF THE THROAT AND NOSE. 
MALFORMATIONS OF THE GULLET. 
Latin Eq.—Deformitates ingenitse oesophagi. 
French Eq.—Vices de conformation de l’cesophage. 
German Eq.—Missbildungen der Speiserdhre. 
Italian Eq.—Vizi di conformazione del esofago. 
Definition.—Congenital irregularities in the formation of the oesoph- 
agus, resulting in an excess, a, deficiency, or an imperforate condition of 
that tube. The first-named anomaly is exceedingly rare, and is only met 
with in disomatous monsters. Deficiency of a part of the oesophagus, 
generally affecting the middle third, together with an abnormal communi- 
cation between the gullet and the trachea or one of the bronchi, is the most 
common deformity, and though met with in monsters and still-born 
children, is most frequent in infants who are born alive, but survive only 
a few days. The other deformities are too rare to require definition. 
History.—In all probability, malformations of the oesophagus are of rare occurrence. 
All the recorded cases which I have succeeded in collecting amount to no more than 
sixty-two, and I am able to add only one from my own observation. These facts are 
especially significant when we remember that the condition, in viable infants at least, 
is attended by such striking symptoms, that it is hardly possible for them to escape 
notice, whilst the inevitably fatal result always affords an opportunity of investigating 
their cause. At the same time, it must not be forgotten that Hirschsprung himself 
personally observed four examples of the condition in less than seven months in a 
town of only 180,000 inhabitants, and that within three weeks Ilott met with two cases 
in a country district near London. It is, indeed, possible that if still-born infants, and 
especially monsters, were more uniformly submitted to careful dissection, malforma- 
tions of the oesophagus would be found more frequently than the small number of 
published cases would lead us to suppose. The earliest recorded instance of oesopha- 
geal deformity appears to be that related by Durston in 1670.* Two cases were pub- 
lished by Blasiusf in 1674, in one of which the tube bifurcated and again united, 
whilst in the other there was saccular dilatation of the gullet at its lower end. In 
1791 an instance was recorded by Tenon,J in which there was membranous obstruction 
of the gullet in its upper part. In 1810 Brodie§ reported a case in which there was 
blind termination of the tube, and a few years later Lozach|| published an example of 
complete absence of the organ. In 1821 Martin1[ published an example of deficiency 
of a portion of the oesophagus, with intercommunication between the alimentary and 
respiratory tracts. It was not, however, till 1861 that the literature of the subject was 
* Collect. Academ., Partie 6trangere, 1670, t. ii., p. 288. 
f Observ. Med. Rarior, Leidfe, 1674, tab. vi., fig. 5. 
J Fourcroy : La Medecine 6clair6e par les Sciences, 1791, t. i., p. 301. 
§ For the scanty particulars of this case the reader is referred to the French Bib- 
liotli. M6d., 1810, t. xxx., p. 381, as I have been unable to find the original article. 
|| Journ. Univ., 1816, t. iii., p. 187. 
Expose des Trav. de la Soc. Roy. de Med. de Marseille, 1821, p. 44. MALFORMATIONS OF THE GULLET. 
221 
collected. In that year, Hirschsprung,* in a small work of considerable merit, brought 
together ten cases of the affection, and further elucidated it by four examples which 
had come under his own notice. Since then, several fresh cases have been placed on 
record, whilst many others have been discovered in the annals of medical literature, 
and the following synopsis, I think, represents with a fair degree of completeness the 
facts published up to the present date. 
Of complete deficiency there are five cases on record, viz., those of Lozachf Sonder- 
land,J Mellor,| Heath,|| and a specimen in the Museum of the Army Medical Depart- 
ment at Netley.^f 
Of blind termination there are nine examples, viz., those of Durston,** Brodie,ff 
Roederer,JJ Marrigues,§§ Lallemand,|||| Van Cruyck,f][ Pagenstecher,*** Warner,fff 
and Pinard.JJJ 
Of cases in which there was an intercommunication between the oesophagus and air- 
passages, with deficiency of a portion of the former, or as they have been called, 
“ inosculating” cases, there are 43, the communication being with the trachea in 40, and 
with one of the bronchi in 3. The former category includes the cases of Martin,\\\ 
Houston,|||||| Padieiijlffll’ Scholler,**** Davis,tfff Tilanus,tJJJ Levv,$§£§ Gernet,|||||||| 
Liischka.IfHH Cruveilhier,***** Ayres,tfttt Ogle.JttU Ward,$$*$$$ Willigk,|||||||||| 
Steenberg,f Hirschsprung,****** (three cases) Maschka,fftfft Bendz,JJ 
* Den Medfodte Tillukning af Spiseroret, Copenhagen, 1861. 
f Journ. Univ., 1816, t. iii., p. 187. 
J Hufeland’s Journal, August, 1820. 
§ Lond. Med. Gaz., June 26, 1840, vol. xxvi., p. 542. 
|| Ibid. (Mellor’s case is given in detail, but Heath’s is only briefly referred to.) 
Catalogue of the Museum Army Med. Dept., 1845, p. 385. 
** Collect. Academ., Part, fetrang., 1670, t. ii., p. 288. 
ft Bibl. Mfed., 1810, t. xxx., p. 381. 
Meckel: Handbuch d. pathol. Anatomie, Leipzig, 1812, Bd. i., p. 494. 
U Ibid. 
|| || Observations pathologiques propres a 5clairer plusieurs points de physiologie, 
Paris, 1816. 
Bull, de la Soc. M6d. d’Emulation de Paris, 1824, p. 251. 
*** V. Siebold’s Journal f. Geburtshiilfe, etc., 1830, Bd. ix., p. 112. 
tff Lancet, 1839, vol. ii. Bulletin de la Soc. Anat., 1873. 
$§§ Loc. cit. IIUII Dublin Hosp. Rep., 1830, vol. v., p. 311. 
Bulletin de la Soc. Anat., 1835, t. x., p. 95. 
**** Neue Zeitschrift f. Geburtskunde, Berlin, 1838, vol. vi., p. 2. 
ttff Lond. Med. Gaz., Jan. 13, 1843, vol. xxxi., p. 543. 
++++ Verh. van bet Genootschap d. Genees en Heelk. te Amsterdam, 1844. 
§$$§ Neue Zeitschrift f. Geburtskunde, Berlin, 1845, vol. xviii., p. 436. 
IIIHIII Oppenheim’s Zeitschrift, 1847, p'. 378. 
mH Virchow’s Archiv, 1848, vol. xlvii., p. 178. 
***** Traitfe d’Anat. Pathol, gfen&r., Paris, 1849, t. ii., p. 232. 
tfttt Trans. Path. Soc., 1852, vol. iii., p. 91. 
JIbid., 1856, vol. vii., p. 52. Ibid., 1857, vol. viii., p. 173. 
|| || ||||II Prager Vierteljahrschr., Aug. 13, 1856, p. 34. 
mTH Hirschsprung: op. cit., p. 37. ****** Xbid., pp. 39-50. 
tttttt Allg. Wiener Med. Ztg., 1862, No. 9, p. 78. 
Ugeskrift for Lager, 1867. 222 
DISEASES OF THE THROAT AND NOSE. 
Boucher,* Annandale.f Luschka,J Porro,§ Sundewall,|| Polaillon,** Uottff 
(2 cases), Lehmann,Westbrook,§$ and Mackenzie,|||| together with specimens in the 
Museums of the Boyal College of Surgeons of of the Boston Society of 
Medical Improvement*** (2 cases), of the Army Medical Department at Washing- 
ton,fff and of the Boyal College of Surgeons of EnglandJJJ (3 cases). 
The three cases in which there was a communication with one of the bronchi are 
those of Levy,$$£ Hirschsprung,|||||| and an example in the Dupnytren Museum at 
Paris.HIir 
Of intercommunication between the oesophagus and trachea (the oesophagus being 
otherwise normal) there are two cases, viz., those of Lamb**** and Pinard.ffff 
Of membranous obstruction there are two cases in which the oesophageal canal was 
completely blocked up, viz., those of BossiJUJ and Tenon \\\\\ and one in which 
a valve-like opening allowed food to pass with difficulty. In the case of Bossi the 
obstruction was just above the cardia, and the infant died on the third day; Tenon’s 
case was similar, but the obstruction was in the upper part of the oesophagus. In the 
remaining case it is highly probable, although not absolutely certain, that the malfor- 
mation was congenital. 
The following are the particulars :|||||||| An old woman had manifested great diffi- 
culty in swallowing from early infancy. Oesophageal vomiting came on when she 
attempted to take food otherwise than in very small morsels. After death a dilatation 
of the gullet was found. About six lingers’ breadths below the pharynx there was a 
completely circular valve, with an opening about one centimetre in diameter. This 
valve seemed formed by a folding inwards transversely of the mucous membrane, in- 
* Bulletin de la Soc. Anat., 1868. 
f Edin. Med. Journ., January, 1869, vol. xiv., p. 598. 
$ Virchow’s Archiv, 1869. 
\ Annali Universali di Medicina, Milan, 1871, t. ccxvii., p. 421. 
|| Upsala Lakarefor-mings Torhandlinger, 5te Bandel, 5te Hiiftet. 
If Union MAlicale, 1873, No. 145, p. 894. 
** Gaz. des Hdpitaux, 17th July, 1875. 
ff Trans. Path. Soc. Lond., vol. xxvii., p. 149. 
Schmidt’s Jahrb., Bd. cxlviii., p. 269. 
\\ Annals of the Anat. and Surg. Soc. of Brooklyn, 1879, vol. i., pp. 98, 99. 
1111 Published in detail at the end of this article. 
Catalogue Boy. Coll. Surg. Ireland, Anatomy, vol. i., p. 152, Dublin, 1834, 
Spec. Ga., 53. 
*** Catalogue Boston Soc. of Medical Improvement, Specs. Nos. 456 and 457, p. 
128. 
fff Catalogue Mus. Washington, D. C., 1867. 
t+t Catalogue Mus. Boy. Coll. Surg., Eng., Teratological series, London, 1872, 
Specs. 394, 395, 396. 
Loc. cit. HUH Op. cit. 
Hlfft Specimen, No. 51. 
**** Philadelphia Med. Times, 1873, p. 705. 
j-fff Bulletin de la Soc. Anat., 1873. 
Memoire dell’Academia delle Scienze di Torino, 1826, vol. xxx., serie la, p. 
155-170. 
Fourcroy : La Med. 6clair4e par les Sciences Phys., t. i., p. 301. 
|||| || || Bolletino delle Scienze Mediche, t. xix., p. 267, 1851. 223 
MALFORMATIONS OF THE GULLET. 
volving the whole circumference of the tube, the free edge of the valve being strength- 
ened by firm tendinous fibres running round it. 
Of congenital pouch there is perhaps one example, viz., that of Blasius,* but the 
case is not given in sufficient detail to show whether the malformation was congen- 
ital or acquired. 
Of longitudinal division of the oesophagus there also exists one example, related by 
the same author.f 
Etiology.—The essential cause of congenital malformation of the 
oesophagus is involved in the same obscurity that hangs over the whole 
subject of teratology. It is obvious, however, that the deformity must 
arise from some abnormal conditions, either in the spermatozoon, in the 
ovum before impregnation, or in the embryo. That the first cause is 
sufficient to produce malformation is proved by the fact, that the same 
male occasionally produces a similar deformity in the offspring of differ- 
ent women.| With reference to the second cause, it is well known 
that unimpregnated ova are not unfreqnently diseased, and it is pos- 
sible that such ova, if fertilized, would in some cases produce a mal- 
formed foetus. At the same time, so far as I am aware, no observations 
have been made in connection with the female element in reproduction 
analogous to that mentioned above in referring to the male elephant— 
that is to say, there is no instance on record in which the same female 
has by different males given birth to infants with a similar deformity. 
It is probable, however, that it is the third cause which is the most 
potent, and that by far the larger number of malformations of the 
oesophagus are due to disease of an embryo previously well formed, or 
to a displacement of formative material at a very early period of em- 
bryonic life; the main argument in support of this view being that 
even in cases where the gullet is partly absent, there are almost always 
traces of the obliterated portion. The most generally accepted view as 
to the immediate cause of oesophageal malformations is that they de- 
pend on “ arrested This view is probably correct so 
far as it goes, but it does not explain the muse of the arrested develop- 
ment. Scholler|| considers that if the deformity were entirely due to 
imperfect evolution it would be more frequently met with, and 
Luschkaft[ suggests that both influences, viz., disease and irregular de- 
* Loc. cit. Many cases of oesophageal pouch have been recorded, but as far as I 
am aware, in every instance the subject has been an adult, 
f Ibid., Fig. 2. 
J Meckel: Handbuch d. patliol. Anatomie, Leipzig, 1812, vol. i. 
\ Meckel: loc. cit. BischofF: Beitrage zur Lehre von den Eyhiillen des Mensch- 
lichen Fotus, Bonn, 1834. 
|| Loc. cit. ft Loc. cit. 224 
DISEASES OF THE THROAT AND NOSE. 
velopment, are at work, and that in those cases in which the oesophagus 
and trachea intercommunicate, the sequence of events is somewhat as 
follows: First, The canal of the oesophagus becomes obstructed, then 
hypertrophy of the portion of it above the point of obliteration takes 
place, and the formative matter, being exhausted by the excessive de- 
velopment of the pouch, is not sufficient to close up the opening between 
the two canals. Hirschsprung* considers that the entire absence of 
anything in the least degree resembling a cicatrix refutes the idea of 
destructive ulceration, but it is probable that the effects of inflamma- 
tion and ulceration occurring in the earliest period of foetal life would 
be entirely obliterated at the time of birth. The frequent coexistence 
of other deformities with malformation of the oesophagus, has been 
regarded as evidence that the latter depends on imperfect evolution, 
and not on disease. This is merely begging the question; the facts 
sustain equally well the theory, that in such cases the embryo is exten- 
sively diseased. 
If a glance be taken at the normal development of the oesophagus 
and trachea, as recently described by Kolliker,f it will facilitate the 
comprehension of the mode in which the malformation may arise 
through some slight morbid deflection of the normal process. 
The whole intestinal canal, from the mouth to the anus, is formed of three segments 
i. e., a middle portion and two extremities. The former is called “the primitive intes- 
tine,” the latter are the “cephalic” and the “pelvic” portions. 
The primitive intestine is formed in mammals by the separation of the hypoblast and 
a layer of the mesoblast from the germinal vesicle. At first it consists of a groove or 
“ semi-canal,” but soon becomes transformed into a complete tube. Like the whole 
intestinal canal, this primitive intestine is also divided into three portions, an anterior, 
middle, and posterior. It is from the anterior portion that the pharynx, oesophagus, 
larynx, trachea, and lungs are developed. The opening of the primitive lung into the 
anterior portion of the primitive intestine is situated in mammals at the junction of 
the pharynx and oesophagus. In rabbits, on the tenth day, the anterior portion be- 
comes differentiated into a ventral and a dorsal division. The ventral part is the germ 
for the lungs, larynx, and trachea, whilst the dorsal portion is the nucleus of the 
pharynx and oesophagus. The lower part of the ventral division becomes expanded 
to form the lung, which at that time consists of a semi-canal, terminating in two vertical 
grooves, and freely communicating on its dorsal side with the oesophagus by means of 
a linear fissure, somewhat wider at its lower end. A separation of the two organs 
takes place on the eleventh day, the anterior portion of the primitive intestine being 
thus differentiated into an anterior or tracheal segment, and a posterior or oesophageal 
segment. The separation proceeds from behind forwards up to the level of the laryn- 
geal orifice in the pharynx, and gradually becomes more and more complete. Above 
* Op. cit. 
f Entwickelungsgeschichte des Menscken, Leipzig, 1879, p. 810, etc. MALFORMATIONS OF THE GULLET. 
225 
the laryngeal aperture no demarcation takes place between the air-passages and the 
digestive canals. The process just described occurs in the human foetus in exactly the 
same manner. Kolliker saw an embryo of four weeks in which the two tubes wrere 
almost completely separated, only a thin membrane intervening between them. The 
sac-shaped lungs constituted at that time a prominence at the lower end of the oeso- 
phagus, covering it on each side like a saddle. Whether at that time a fissure-like 
communication still existed between the tracheal and oesophageal tubes is not clear 
from Kolliker’s description. In any case, however, it is probable that, by the begin- 
ning of the second month, the entire separation of the two tubes is an accomplished 
fact. 
The cephalic portion of the intestine originates from the epiblast. It grows back- 
wards to meet the pharyngeal extremity of the anterior part of the primitive intestine, 
until they are separated only by a thin membrane (the pharyngeal membrane of Re- 
mak).* The membrane then disappears, and its residue forms the arcus palati and 
uvula. 
Symptoms.—The phenomena of congenital malformation of the oeso- 
phagus are so characteristic, that when present they will at once be 
recognized. The infant may appear healthy whilst at rest, but the 
moment it attempts to swallow the most distressing attacks of suffocation 
supervene, and there is great danger of one of these proving fatal. In 
Porro’s case, actual suffocation appears to have taken place through a 
large quantity of milk passing into the air-passages, but as a rule the 
infant becomes gradually weaker, and expires at the end of a few days 
from exhaustion. When the malformation affects the upper portion of 
the tube, it can sometimes be felt on passing the finger down the 
pharynx of the infant. At other times, the use of a bougie will reveal 
the condition of the canal, the instrument being arrested at the end of 
the oesophageal pouch. Although in most cases no nutriment reaches 
the stomach, meconium is often passed. 
Pathology.—The appearances after death vary according to the na- 
ture of the deformity. Where the oesophagus is absent, the pharynx 
ends in a cul-de-sac, and the stomach is generally adherent to the dia- 
phragm. Of the five instances of this kind one was an anencephalous 
monster; in another the pharynx, larynx, and trachea were wanting; 
and in two the condition of the other organs is not stated. In cases of 
blind termination the gullet may terminate quite high up, as in Roederer’s 
* In the two cases of “ obliteration ” of the oesophagus referred to, and probably in 
some of the examples of “ blind termination,” the malformation was probably due to 
non-obliteration of this normal embryonic membrane, and it might have been expected 
that obstruction of the pharynx itself would sometimes result from the same arrest of 
development. I am not aware, however, of the existence of any cases supporting this 
view. It may be added, that, common as are pouches of the pharynx, there do not ap- 
pear to be any proved examples of congenital deformity on record. 226 
DISEASES OF THE THROAT AND NOSE. 
case, or may reach nearly to the stomach, as in that of Warner. In the 
records of this class of cases, the other organs—especially the in- 
testinal canal—generally show a wide departure from the normal 
form : thus, in one instance* the stomach was deficient, the intestinal 
canal consisting of two parts, one comprising the colon and rectum, the 
other the small intestine; the latter terminated at both ends in a blind 
sac, and the upper portion of the larger bowel was closed in a similar 
manner. In another case,f the intestinal canal was divided into four parts, 
each terminating at both ends in a blind extremity, whilst the anus was 
imperforate. In a third example,! the fundus of the stomach was want- 
ing, but in its place was a wide round opening, the edges of which were 
formed of muscular tissue. In a fourth instance,§ the brain was imper- 
fectly developed, and the upper part of the oesophagus communicated 
through the vertebral canal with the mouth. In a fifth case the sub- 
ject was an anencephalous monster. || In other examples of this variety 
of malformation the condition of the other viscera is not stated. The 
cases, however, in which there is deficiency of a greater or less amount 
of the middle third of the oesophagus, with inosculation between it and 
the air-passages, are the most common, and the most interesting to the 
pathologist. Here the upper part of the gullet usually terminates in 
a dilated pouch about half an inch above the bifurcation of the trachea, 
whilst the lower portion generally originates from the windpipe still 
closer to the bifurcation, and passing downwards enters the stomach in 
the ordinary way. The portion of the oesophagus immediately at its 
origin from the trachea is generally very narrow, but as it descends it 
acquires its normal size. The upper portion, or pouch, is always much 
dilated, and its walls considerably thickened. Sometimes the pouch- 
like expansion is limited to the gullet (as in my case), whilst in others 
(as in those of Ilott) the enlargement involves the pharynx also. The 
two separate portions are generally connected by a small band of mus- 
cular or tendinous fibres. In my own case (see p. 231, Fig. 22 B) the 
lower extremity of the pouch (d) actually overlapped the lower seg- 
ment of the oesophagus (b') where it proceeded from the trachea. On 
laying open the gullet, the lining membrane is almost invariably seen 
to be perfectly free from disease. In only out of all the recorded 
cases is there any mention of ulceration of the mucous membrane, and 
in that instance the lesion was superficial, and was no doubt caused by 
* Roederer: loc. cit. 
J Pagenstecher: loc. cit. 
|| Pinard’s second case: loc. cit. 
f Marrigues: loc. cit. 
§ Lalleraand : loc. cit. 
H Scholler : loc. cit. MALFORMATIONS OF THE GULLET. 
227 
the retching and straining which occurred on attempting deglutition. 
On dividing the trachea, the opening of the oesophagus may generally 
be seen as a small aperture situated in its posterior wall and directed 
downwards. Sometimes the opening is described as oval and sometimes 
as round in shape, but in my specimen (Fig. 22 C bff) the aperture is 
distinctly crescentic, the concavity being directed downwards. In this 
specimen (Fig. 22 C a") the hypertrophied pouch of the oesophagus 
forms a projection on the posterior wall of the trachea, which consider- 
ably diminishes its lumen. In one of Hirschsprung's cases* more or 
less complete cartilaginous rings were found at the lower end of the 
oesophagus. 
As regards the associated deformities, in one instancef there were 
spina bifida, absence of anus, and a single horse-shoe kidney placed 
over the spine. In two cases there was trifurcation of the trachea,J 
and in two others there was atelectasis pulmonum.§ In another case 
the stomach and intestines were contracted.|| The other deformities 
associated in different cases with oesophageal inosculation were: mal- 
formation of the uterus combination of the male and female genital 
organs;** imperforate anus with a communication between the intestine 
and bladder and deformity of the pelvis absence of right lung and 
atresia ani imperforate anus with intercommunication between blad- 
der and rectum, deficiency of the radius in each arm, and clubbed 
hands;§§ imperforate anus with intercommunication between rectum and 
urethra and right auriculo-ventricular opening almost blocked up by 
membranous diaphragm.|||| 
In only three instances is it expressly stated that there was no other 
deformity; whilst in nineteen cases there is either no mention of the 
condition of the other organs, or it is formally stated they were not 
examined. 
Diagnosis.—There is no disease for which this malformation can be 
mistaken. The absolute inability to swallow, which cannot fail to be 
observed from the first time the infant attempts to suck, is character- 
istic; whilst, if a measured quantity of milk be administered with a 
teaspoon, and the ejected fluid collected, it will be found that it is all 
returned. The diagnosis can be further verified by the passage of a 
* Op. cit., case 7, p. 35. 
X Hirschsprung: loc. cit. 
|| Padieu : loc. cit. 
** Levy : loc. cit. 
Maschka: loc. cit. 
1111 Pollaillon : loc. cit. 
t Davis: loc. cit. 
| Ibid. 
If Spec. 457, Boston Museum, 
ft Hirschsprung: op. cit. 
|| .Pinard’s first case: loc. cit. 228 
DISEASES OF THE THROAT AND NOSE. 
catheter. In new-born children the minimum diameter of the oeso- 
phagus is four millimetres, whilst the distance from the border of the 
gums anteriorly to the cardiac orifice of the stomach is seventeen cen- 
timetres.* If, therefore, a catheter of suitable size cannot be passed 
for this distance, it may be presumed that there is a congenital ob- 
struction. 
Prognosis.—As already stated, infants born with a malformation of 
the oesophagus generally succumb in a few days, the duration of life 
probably depending more upon the vigor of the child when born, than 
on the exact nature of the malformation. Thus, in five cases of com- 
plete deficiency of the oesophagus, one infant lived seven days, another 
eight days, a third “a few days,” whilst in the two others no informa- 
tion is given on this point, though, from the context, it is possible that 
the infants were both born dead. In eight cases of blind termination 
three infants lived to the third, fourth, and fifth day respectively, whilst 
in five cases the duration of life is not stated. In thirty-seven cases, 
in which there was inosculation between the oesophagus and air-pas- 
sages, the duration of life was as follows: 
Date of death. 
Cases. 
Two hours after birth, .... 
1 
Second dav, 
8 
Third day, ...... 
4 
Fourth dav, 
6 
Fifth day, 
4 
Sixth day, 
1 
Seventh dav, ...... 
1 
Ninth day, 
1 
Eleventh dav, 
2 
Twelfth day, 
1 
A few days, ...... 
1 
Not stated, ...... 
7 
In one of the cases in which the gullet and trachea intercommuni- 
cated, whilst the former was otherwise normal, the patient lived seven 
weeks. The cause of this comparatively long existence will be under- 
stood from the following description : 
“ In the median line, nearly half an inch below the lower border of 
the cricoid cartilage, was a fistulous communication between the two 
tubes, having a longitudinal diameter of three lines, and a transverse 
diameter of one line. The direction of the fistula was downwards and 
backwards, the opening in the oesophagus being at a lower level than 
* Mouton: Du Calibre de 1’OEsophage, Paris, 1874, p. 61. MALFORMATIONS OF THE GULLET. 
229 
in the trachea; the edges were smooth and rounded, and the mucous 
membrane normal. The danger of passage of the contents of the oeso- 
phagus into the trachea appears to have been guarded against to some 
extent by the close apposition of the walls of the fistula.”* * 
In one of the two cases of membranous obstruction of the oesophagus, 
the patient lived till the third day; in the other the duration of life is 
not stated. 
Treatment.—In none of the recorded instances was any attempt made 
to preserve the life of the infant by any surgical procedure, and it is 
obvious that but little hope can be entertained of relief by art, as the 
opening into the air-passages, which is so often present, would probably 
interfere with the maintenance of life even if the oesophageal canal were 
patent throughout. Mr. Holmesf thinks that where no tracheal com- 
munication can be made out an operation might be attempted. “ The 
object,” he observes, “ would be to cut down upon the point of a catheter 
passed down to the pharynx, and then to attempt to trace the oblite- 
rated oesophagus down the front of the spine, until its lower dilated 
portion is found. A gum catheter would then be passed through an 
opening made in the upper portion, and so into the stomach through 
the lower portion. If the two portions are near enough to be connected 
by silver sutures over the catheter, and if the latter can be retained 
until they have united permanently, success might possibly be main- 
tained.” Such an operation would evidently be extremely hazardous 
and difficult, if not impracticable. Gastrostomy has been recommended 
by Sedillot, who remarks : “ In all cases where the oesophagus is simply 
obliterated, atrophied, or interrupted, gastrostomy would give the hope 
of saving the infant, without any accident except that of the operation 
itself. If there exists a communication between the lower end of the 
oesophagus and the trachea, there is a risk that food received into the 
stomach would be regurgitated into the air-passages; but the narrow- 
ing of the abnormal opening, and its natural tendency to close, would 
afford some security against such an inconvenience.” Whilst quoting 
the views of this eminent surgeon, I cannot indorse them, as I consider 
that section of the stomach and the subsequent artificial alimentation of 
a newly-born infant could not be attended with satisfactory results. 
The following case illustrates the malformation : 
In September, 1879, I was consulted (on the advice of Dr. Walker, of Putney) by 
the father of a male infant, eight days old. The history of the case, as supplied to me 
by Dr. Walker, was as follows: 
* Lamb : loc. cit. 
f The Surgical Treatment of the Diseases of Infancy, London, 1869, 2d ed. 230 
DISEASES OF THE THROAT AND NOSE. 
Mrs. S., a primipara, gave birth to a male infant in September, 1879. At birth the 
child was feeble and badly nourished, and had difficulty both in breathing and cry- 
ing ; there was also a constant rattling noise in the throat, which continued in spite of 
all efforts to remove the mucus. On the following day milk-and-water was given, but 
it was at once rejected through the mouth and nostrils; later in the day the breathing 
became more troubled. Dr. Walker administered a measured quantity of milk-and- 
water, and having taken steps to receive all that was ejected from the mouth and nose, 
found that nearly all the ingesta were returned. Next day the child was able to keep 
down a very small quantity of milk, but he had become extremely emaciated, and ap- 
peared to be sinking. Enemata of milk and lime-water were given, and a small quan- 
tity of brandy and water was occasionally administered by the mouth. On the fourth 
day Dr. Fenn, of Richmond, saw the child with Dr. Walker, and on passing a gum- 
elastic catheter down the pharynx, they found its course completely arrested about two 
inches below the cricoid cartilage. During the next few days the child seemed to im- 
prove, the breathing became easier, and crying and coughing much stronger. Drs. 
Walker and Fenn having arrived at the conclusion that the case was one of obstruc- 
tion of the oesophagus, consulted me as to whether I was prepared to perform any ope- 
ration with a view of overcoming the difficulty. I did not, however, feel myself justi- 
fied in recommending any operative procedure, and the child died from exhaustion on 
the eleventh day after birth. 
The father of the infant stated that a former wife had given birth to a child which 
died after nineteen days, with exactly the same symptoms as those recorded in this in- 
stance. No other child of his had any malformation. 
A post-mortem examination, limited to the throat, was made by Dr. Walker and 
Mr. Ho veil, with the following results: The infant was of ordinary size and well 
formed, but much emaciated. There was no malformation of the lips or palate. The 
pharynx was of normal configuration, but slightly constricted at its junction with the 
cesophagus, which consisted of two portions—an upper part, which communicated with 
the pharynx, and a lower portion, which, originating from the stomach, passed upwards 
and terminated in the trachea. 
The upper portion of the oesophagus terminated in a blind extremity two centime- 
tres and a half below its origin. The whole of this portion of the gullet was hyper- 
trophied, so that it measured three centimetres in circumference.* 
Ascending from the stomach, the lower end of the oesophagus passed upwards in the 
usual manner, but three and a half centimetres above the diaphragm its muscular 
fibres suddenly became thinner and paler, and the tube becoming smaller, terminated 
in the trachea immediately beneath the lower end of the upper division of the gullet. 
The connection between the two parts of the oesophagus was maintained by a narrow 
muscular fasciculus, which passed from the upper extremity of the inferior portion to 
the under surface of the upper part, and by a thin membranous expansion which in- 
tervened between the two portions. On dividing the trachea vertically in front, the 
lower part of the upper portion of the oesophagus was seen to form a distinct projection 
on the posterior wall of the trachea, considerably diminishing the antero-posterior 
diameter of the latter tube. Situated transversely on the posterior wall of the trachea, 
at a point just below the level of the lower end of the upper section of the oesophagus, 
was a minute crescentic opening, directed downwards and backwards, which led into 
the lower portion of the oesophagus. The rectum was normal. 
* The ordinary circumference of the oesophagus at birth is from one and a half to 
two centimetres, but it seldom exceeds eighteen millimetres. MALFORMATIONS OF THE GULLET. 
231 
Fig. 22. 
Congenital Malformation of the (Esophagus.—A. The tongue, pharynx, trachea, 
imperfect oesophagus, and stomach, a, the upper portion of the oesophagus; b, the 
termination of the lower portion of the oesophagus in the trachea; c, the lower fourth 
of the oesophagus which is seen to be well developed ; d, a small remnant of the dia- 
phragm ; tr, the trachea ; x, the upper part of the pharynx, cut in the middle and 
turned down; y, the epiglottis. B. Fragmentary illustration showing the posterior 
surface of the trachea and the two terminations of the oesophagus, where the abnor- 
mality exists. The upper extremity of the lower portion of the oesophagus, b', is thrown 
on one side, in order to show that it has no connection with the trachea, except just at 
the point where inter-communication takes place; the relation of the lower extremity, 
a', of the upper portion of the oesophagus is also distinctly shown. C. The lower por- 
tion of the trachea divided in front by a vertical incision, with its two sides widely sep- 
arated. a is the oesophageal pouch; a// shows the indentation in the posterior wall 
of the trachea caused by the pouch; b" is the opening between the trachea and the 
upper extremity of the lower portion of the oesophagus; a piece of twine is seen pass- 
ing from the trachea into the oesophagus, which has been (diagrammatically) divided 
in order to show the passage of the twine. 232 
DISEASES OF THE THROAT AND NOSE. 
Congenital Dilatations and Stenoses.—As, in consequence of symp- 
toms not manifesting themselves till later in life, it is often impossible 
to determine whether certain dilatations or stenoses are congenital or 
acquired, it has been thought better to treat those conditions as diseases 
rather than malformations. The dilatations which probably depend 
on some congenital weakness have been considered at page 126, and 
stenoses of probably congenital origin at page 165. 
POST-MORTEM SOFTENING OF THE GULLET. 
Just as softening, and even perforation, of the stomach sometimes 
occurs as a result of the action of the gastric juice, so likewise a similar 
process occasionally takes place in the gullet after death. This is much 
more rare, however, in the oesophagus than in the stomach, as the former 
is but seldom exposed to the action of the solvent. It has long been a 
moot question whether the softening takes place during the last hours 
of life or only after death; and, in spite of the patient consideration 
which has been given to this point by Budd,* Canton,f Ziemssen,| and 
others, the problem is not yet absolutely decided. 
The chief factors in post-mortem solution of the gullet are, first, the 
presence within its channel for a considerable time of gastric juice which 
retains its normal acidity; secondly, a proper degree of temperature 
(90° to 100° Fahr.); thirdly, the absence of resistance in the tissues 
themselves to the digestive power of the fluid—a resistance attributed 
by Hunter to the influence of the “ vital principle,” and by modern 
authorities, with some probability, to the neutralization of the acid of 
the gastric juice by the presence in the living tissues of a large quantity 
of alkaline blood. In the majority of cases where softening of the gullet 
has been observed, the stomach has also been more or less destroyed. 
Post-mortem solution is much more common in the bodies of young 
children than in the case of adults, but I am not aware that any expla- 
nation of this fact has been offered. The degree of maceration of the 
tissues varies from mere erosion of the epithelial layer, either in small 
patches or in longitudinal strips corresponding to the folds of the lining 
* Croonian Lect., London Med. Gazette, 1847, vol. xxxix., p. 896 et seq. 
f Lancet, October, 1859. 
X Cyclopaedia of the Practice of Medicine, vol. viii., p. 89 et seq. POST-MORTEM SOFTENING OF THE GULLET. 
233 
membrane of the tube, to complete perforation of the entire thickness 
of the gullet wall over a greater or less area. Intermediate stages of 
the process have been noted where, in addition to the stripping otf of 
the epithelium, the denuded mucous membrane had a whitish sodden 
look, as if it had been steeped in spirit. All these degrees of digestive 
solution may sometimes be observed in the same specimen. When per- 
foration has taken place the oesophageal wall may present one or more 
irregular rents, or it may be fissured in a longitudinal direction ; the 
edges of the apertures in either case being ragged, and fringed with 
flocculent shreds of half-dissolved tissue. In some instances the oesoph- 
agus is destroyed throughout its whole circumference, but usually the 
digestive action is confined to the posterior wall. The reason of this is 
no doubt to be found in the fact that the body has been lying in the 
supine position. In no recorded case, so far as I am aware, has the 
action been seen to have extended above the lower half of the gullet. 
The wall of the oesophagus in the neighborhood of the softened parts is 
generally quite normal in appearance, but the vessels of the contiguous 
mucous membrane are sometimes congested, and even patches of ecchy- 
mosis have been observed. In two cases reported by Hoffmann* the 
mucous membrane of the gullet was saturated with extravasated blood. 
Where the wall of the gullet has been eaten through, the solvent ac- 
tion of the gastric juice is found to have extended to the neighboring 
parts. One or both pleural cavities are seen to have been laid open by 
the destruction of the portion of the parietal layer of the membrane 
lying nearest to the point of perforation in the oesophagus; and gastric 
juice with shreds of undigested food, mixed, in some instances, with 
blood-stained fluid from maceration of the adjacent lower lobe of the 
lung, may be found in the thorax. There is generally, moreover, some 
emphysematous distension of the areolar tissue in the posterior medias- 
tinum. It will not unfrequently be found that only one pleural cavity 
has been opened, and in such cases it is almost invariably the left that 
communicates with the hole in the gullet.f The cause of this will be 
apparent, when it is remembered that the lower end of the oesophagus 
lies to the left of the vertebral column, and therefore in closer proxim- 
ity to the left pleural sac than to its fellow. 
It is probable that similar changes may take place in the gullet when 
life is at its lowest ebb, especially when the approach of death is very 
* Virchow’s Archiv., Bd. xliv., p. 352. Jbid., Bd. xlvi., p. 124. 
f A case, however, lias lately been reported by Quincke (Deutsches Archiv fur klin. 
Med., 1879, vol. xxiv., p. 72), in which the right pleural sac alone was perforated. 234 
DISEASES OF THE THROAT AND NOSE. 
slow and gradual, as in persons enfeebled by long wasting maladies. 
In such cases the conditions already described as necessary for the pro- 
cess of what may be called “self-digestion,” come into play. Long 
continuance in the horizontal position and atony of the muscular walls 
of the gullet are likely to favor regurgitation of the acid contents of the 
stomach beyond the cardiac orifice, whilst the feeble circulation of im- 
poverished blood leaves the tissues exposed to the digestive power of 
the gastric juice. Although this theory is very plausible, no positive 
proof of its soundness can be given ; nor is this a matter of any practi- 
cal importance, for the recognition of digestive solution of the oeosoph- 
agus, when the patient is in articulo mortis, can lead to no result. 
From statistics given by Ziemssen,* there seems to be some connec- 
tion between softening of the gullet and certain diseases of the brain. 
He affirms that in 2587 autopsies made at the Pathological Institute 
at Erlangpn, from 1862 to 1876, softening and perforation of the gul- 
let were found in nine cases. In one of these the head was not ex- 
amined, but in each one of the other eight cases there was (in addition 
to pathological changes elsewhere) some lesion of the brain. In four 
of them there was inflammation of the membranes at the base of the 
brain, together with acute hydrocephalus; in one there was an enor- 
mous congenital hydrocephalus; in one there was a cicatrix in the 
striate body, with slight chronic hydrocephalus; in one great conges- 
tion of the brain, with slight hydrocephalus, and in one moderate con- 
gestion, together with some oedema of the brain. The ages of these 
patients ranged from three months to fifty-eight years. Whether 
wider observation would confirm these statistics it is of course im- 
possible to say, but the simultaneous presence of pressure on the cere- 
bral substance and digestive solution of the gullet in all the cases ex- 
amined, certainly seems to suggest a relation of cause and effect between 
the two conditions. 
* Op. cit., p. 104. 235 
ANATOMY OF THE NASAL FOSSAE. 
SECTION V.—THE NOSE. 
ANATOMY OE THE NASAL FOSSAE. 
These intricate cavities are bounded above by the under surface of the an- 
terior third of the base of the skull, below by the upper surface of the hard 
palate, externally by the wall of the orbit and by the superior maxillary bone, 
whilst internally the two nasal chambers are separated from each other by a 
perpendicular septum, in part bony and in part cartilaginous. In front the 
nasal fossa? open into the cavities of the nostrils or vestibula nasi (hereafter 
described, p. 246) by two oval apertures—the anterior nares—placed in the 
vertical plane, and inclined very nearly at right angles to the external orifices 
of the nostrils. Posteriorly they communicate with the upper part of the 
pharynx by the posterior nares or choance, two quadrilateral openings looking 
backwards and somewhat downwards. Each nasal cavity may be described 
as an irregular four-sided passage, of somewhat pyramidal form. Of this pass- 
age the upper wall or roof is horizontal in its middle third, but inclines ab- 
ruptly downwards both in front and behind ; the lower wall or floor is almost 
horizontal, having only a slight inclination downwards and backwards, whilst 
the external and internal walls are, roughly speaking, vertical and parallel to 
each other. 
The roof is formed, in its horizontal portion, by the cribriform plate of the 
ethmoid bone, and constitutes, for a limited space, the immediate floor of the 
brain. In its anterior portion it is made up of the nasal process of the frontal 
and the nasal bone proper, its downward inclination gradually increasing 
from behind forwards. The posterior third of the roof, which is inclined 
almost at right angles to the horizontal portion, is formed by the body of 
the sphenoid bone, being continuous behind with the basilar process of the 
occipital. 
The floor of each nasal cavity is composed anteriorly of the palatine process 
of the superior maxilla, and posteriorly of the horizontal plate of the palate 
bone. It is slightly hollowed out from side to side, and presents anteriorly 
the orifice of the nasal canal. 
The internal or median wall, constituting the septum narium, is roughly 
quadrilateral in outline, and after the seventh year is generally inclined to one 
side or the other, thus slightly enlarging one cavity at the expense of its 
neighbor. In many cases, however, this lateral deflection of the nasal parti- 
tion is sufficiently pronounced to cause serious obstruction in one of the nasal 
passages, a deformity which will be subsequently considered under the head 
of “ Deviations of the Septum.” 
The septum of the nose is formed behind by the vomer and perpendicular 
plate of the ethmoid, and in front by a vertical cartilaginous plate received 236 
DISEASES OF THE THROAT AND NOSE. 
into the angle of junction between these bones. The inner edge of the palatal 
process of the superior maxillary bone and of the palate bone itself rises on the 
upper aspect into a crest which forms a slight bony ridge along the middle 
line of the floor of the nose when the bones of both sides are in apposition. 
This ridge is the base of the nasal septum. 
The external wall of each cavity is placed almost vertically, but with a 
slight inclination downwards and outwards. In its upper part it is formed 
by the frontal process of the superior maxilla, the lachrymal bone, and the 
orbital plate of the ethmoid ; in its lower part by the inner surface of the 
body of the superior maxilla, the perpendicular plate of the palate bone, and 
the internal pterygoid plate of the sphenoid. The surface of the outer wall 
is, however, rendered uneven by the turbinated bones which form projections 
in the nasal cavity, leaving intervening spaces between them which are called 
meatuses. 
There are always three turbinated bones, and frequently a fourth. Each 
one is formed of a thin lamina, somewhat triangular in shape, perforated by 
numberless minute openings, and so curved upon itself as to present a con- 
vexity upwards, inwards, and slightly forwards. The three turbinated bones 
spring from the lateral walls of the nasal cavity, at about equal distances 
from each other, their margins of attachment being horizontal and nearly 
parallel, while their free incurved margins are convex, so that each bone is 
widest at its centre. The posterior extremities of their attachments are 
placed nearly in the same vertical line, and as each bone is longer than the 
one above it the anterior extremity of the inferior bone approaches nearer to 
the anterior nares than that of the middle bone, and this, again, is very con- 
siderably in advance of the anterior extremity of the upper bone. Examining 
the turbinated or spongy bones more in detail, it will be seen that the in- 
ferior one is the most developed and the most compact in structure, and that 
it is the only one which is an independent bone. It varies in length from 
twenty-five to fifty millimetres, and in breadth from five to fifteen. It articu- 
lates with the superior maxilla, its anterior pointed extremity coming into 
relation with the anterior portion of the nasal process of that bone, while its 
posterior rounded extremity extends to the internal pterygoid process. The 
middle and superior bones are merely processes of the ethmoid, and though 
separated behind they are united together in front. The middle spongy bone 
is more rolled round at its centre than at its extremities. Near its anterior 
free end a small projection—the agger nasi*—is directed inwards, and on the 
corresponding level of the septum there is a slight bulge. These two minute 
protuberances make a faint line of demarcation between the olfactory region 
above and the respiratory passage below. Above the middle spongy bone is 
the superior one, and this, again, by a horizontal slit in its posterior edge, is 
often divided, so that there is, in fact, a fourth turbinated bone, which is still 
shorter than the one below it. The existence of the fourth bone was first 
pointed out by Santorini,! and, according to Zuckerkandl,t it is present in 
more than one-third of all cases. 
* H. Meyer: Lehrb. d. phvs. Anat., Leipzig, 1856. 
f Observ. Anatom., Venetiis, 1724, cap. v. p. 89. 
% Anatomie der Nasenhohle, Wien, 1882, p. 31. ANATOMY OF THE NASAL FOSSiE. 
237 
By the projection of the turbinated bones each nasal cavity is broken up 
into three passages or meatuses, communicating internally with that remain- 
ing narrow portion of the fossa where nothing is interposed between the roof 
and the floor. The uppermost of these passages, the superior meatus, is 
limited by the upper and middle turbinated bones and by that portion of the 
external wall included between them ; it communicates by means of a foramen 
with the posterior ethmoidal cells, and through them with the sinuses in the 
body of the sphenoid. When there is a fourth spongy bone, there is also a 
fourth meatus. The middle meatus is situated between the middle and inferior 
turbinated bones. It communicates above with the anterior ethmoidal cells, 
and on its outer wall is a crescentic opening—the hiatus semilunaris, or eth- 
moidal fissure—about two centimetres in length, the convexity of the crescent 
being directed forwards and downwards. The curve of the unciform process 
of the ethmoid bone forms the lower boundary of the hiatus semilunaris, the 
upper edge being constituted by the lower surface of the ethmoidal cells. One 
of the ethmoidal cells bulges outwards opposite the middle of the unciform 
process, giving rise to a prominence which has been called by Zuckerkandl* 
the bulla ethmoidalis. The hiatus semilunaris leads to a funnel-shaped cavity 
—the infundibulum—which communicates at its upper and anterior part with 
the frontal cells, and at its lower and posterior part by the ostium maxillare 
with the antrum of Highmore. Immediately behind the hiatus semilunaris 
there is also often a small additional opening into the antrumf—the ostium 
maxillare accessorium. The inferior meatus runs between the lower turbin- 
ated bone and the floor of the nasal cavity. In the anterior part of the meatus, 
at the articulation of the turbinated bone with the nasal process of the superior 
maxilla, is situated the orifice of the lachrymal duct. 
Each nasal fossa is, as already remarked, continuous in front with the cavi- 
ties of the nostril, or vestibula nasi. Here, however, the bony framework gives 
place to cartilaginous plates. These, though subject to variation in form and 
number, consist, in their simplest development, of three distinct cartilages, 
one median and two lateral. The former, by means of its rhomboidal per- 
pendicular plate, helps to complete the septum narium, and supports the 
bridge of the nose below the nasal bones. The portion of its anterior border 
which serves the latter purpose is broad and grooved, while the part above it 
is applied to the suture between the nasal bones, and that below it is bent 
abruptly backwards to terminate at the anterior nasal spine. Attached at an 
acute angle to the broad and grooved portion are two lateral plates which, 
together with the lateral cartilages proper, serve to support the outer walls 
of the cavities of the nostrils. Each of these lateral plates is triangular in 
form, and is attached above to the sharp margin of the nasal bone, while its 
lower margin is free and somewhat incurved, so as to make a slight projection 
inside the nostril. The lateral cartilages proper support the outer and a small 
part of the inner walls of the nostrils. They consist of two segments united 
together at an acute angle. The larger portions, roughly triangular in shape, 
* Op. cit., p. 36. 
f According to Zuckerkandl (op. cit., p. 22) this accessory foramen was found in 
every ninth or tenth cranium which he examined. 238 
DISEASES OF THE THROAT AND NOSF. 
slightly overlap the lateral plates of the median cartilage and form the frame- 
work of the alee nasi. The smaller portions give support to the septum be- 
tween the nostrils, filling up the space left by the retreating border of the per- 
pendicular plate. 
The interior of the nasal cavities is lined throughout by mucous membrane, 
which is continuous in front with the skin of the face and posteriorly with the 
mucous lining of the pharynx. It vax-ies considerably in character in different 
parts, but in its general arrangement it follows pretty closely the ramifica- 
tions of the bony framework. It consists of two layers, a deep fibrous, and a 
superficial mucous stratum which is covered by epithelium. The deep layer 
forms the immediate covering of the skeleton of the nose, having the functions 
of periosteum over the bones, and of perichondrium over the cartilaginous 
parts. It is somewhat loosely attached to the cartilages, but in other parts 
is firmly adherent. This membrane has been shown by Panas* to be much 
thicker and more fibrous at the upper and posterior part of the septum and 
the immediately adjoining space on the base of the skull than at any other 
part. The superficial layer of the mucous membrane maybe roughly divided, 
according to its histological character and physiological functions, into two 
portions—a superior, or olfactory, and an inferior, or respiratory, tract. In 
the former the membrane is thin and closely adherent to its deep layer or 
periosteum ; it is not very vascular, but is of a palish brown color from the 
presence of pigment in the epithelium and the glands. The epithelium is of 
the columnar variety, but without cilia, and lying amongst the column® are 
the peculiar rod-shaped bodies known as the olfactorial cells of Schulze. The 
blood-supply of the olfactor}7 region comes principally from the anterior- 
ethmoidal and the nasal branches of the posterior ethmoidal arteries, whilst 
the nerves are the terminal twigs of the olfactory itself, which, after passing 
through the aperture in the cribriform plate of the ethmoid is distributed to 
the roof and to the inner and outer wall of the nasal cavity in the upper third. 
In the respiratory tract the deep is separated from the superficial layer of the 
mucous membrane by some connective tissue which gives support to the 
numerous vessels and capillaries supplied to this part. Anteriorly the latter 
approximates in character to the external skin, its epithelium being tesselated 
and disposed in layers, while just within the nostrils it is provided with hair- 
sacs and sebaceous follicles. The tesselated epithelium not only covers the 
whole of the mucous membrane which has a cartilaginous framework, but 
extends as far back as the anterior extremity of the lower turbinated bone. 
The remainder of the respiratory tract is furnished with columnar ciliated 
epithelium, the cilia of which vibrate towards the posterior nares. The 
nervous supply of this portion of the nasal passage is mainly derived from 
offshoots of Meckel’s ganglion. In the neighborhood of the foramina, by 
means of which the nasal cavities communicate with the adjacent sinuses, the 
mucous membrane does not exactly follow the contour of the bony framework, 
but presents folds, which deserve a brief mention. Thus, in front of the 
cliink-like opening by which the anterior ethmoidal cells open into the middle 
meatus, the mucous membrane is raised into a fold to form a groove, which 
* Bull, de la Soc. de Chir., July 9, 1873. 239 
ANATOMY OP THE NASAL FOSS2E. 
corresponds to the fissure in the bony skeleton, already described as the hiatus 
similunaris, and considerably increases the depth of that cavity. The mucous 
membrane of the antrum is also occasionally continuous with that of the 
middle meatus by means of a small circular accessory opening placed just 
above the attachment of the inferior turbinated bone, near the posterior ex- 
tremity of the hiatus semilunaris. In the inferior meatus the shape of the 
outlet of the lachrymal duct is considerably modified by the disposition of the 
mucous membrane around it. In the recent state this orifice is sometimes 
circular in form and sometimes elongated, either in a vertical or transverse 
direction, whilst the mucous membrane is occasionally arranged so as to 
make a groove below the opening. On the floor of the nasal cavities the 
mucous membrane dips down into the naso-palatine foramina, which are 
situated one on each side of the septum at about half an inch from the an- 
terior nares, being sometimes continuous through these openings with the 
mucous covering of the hard palate. 
The mucous membrane covering the turbinated bones is crowded with 
glands, the openings of which may be readily seen upon its surface, though 
the glands themselves are deeply imbedded in the sub-epithelial structures. 
On the other hand, the glands in the membrane covering the septum are 
small in size and few in number. 
The arterial supply of the nasal fossae is derived from two sources, viz., the 
posterior nasal branch of the internal maxillary, and the anterior ethmoidal 
branch of the ophthalmic. The former enters at the spheno-palatine foramen 
and divides into two branches; a lateral, passing off behind the turbinated 
bones and supplying the adjacent structures, and a median branch supplying 
the septum and forming an anastomosis with the septal branches of the an- 
terior ethmoidal. The latter artery, besides supplying the anterior portion 
of the septum, also sends branches to the lateral portions of the fossae. All 
the above arteries contribute to form a dense capillary network, which is 
most developed beneath the mucous lining of the respiratory tract. The 
veins of the nasal cavities, as a rule, accompany the arteries, but are larger 
and more numerous. They communicate chiefly with the facial and oph- 
thalmic veins, but also pass through the cribriform plate of the ethmoid, and 
in young subjects send branches through the foramen csecum, the superior 
longitudinal sinus, a few twigs not unfrequently, indeed, terminating in the 
coronary sinus. The veins over the turbinated bones, between the periosteum 
and the mucous membrane, were first shown by Ivohlrausch* to form a “cav- 
ernous network,” and soon afterwards a more detailed description of this 
structure, with highly artistic illustrations, was given by Bigelow,f who de- 
monstrated the truly erectile character of the structure. Yoltolinij; pointed 
out that each turbinated bone, in spite of its extremely delicate structure, can, 
after maceration, be seen to be perforated by countless minute holes. Through 
these openings small vessels pass, and they perforate the bone in such abun- 
dance that in a space of three square millimetres ten patent vessels have been 
* Muller’s Arcliiv, 1853, p. 149. 
f Boston Med. and Surg. Journ., April 29, 1875. 
£ Monatssclirift fiir Ohrenheilkunde, 1877, No. 44. 240 
DISEASES OF THE THROAT AND NOSE. 
counted. The soft parts are closely adherent to the elevations and depres- 
sions of the periosteum, covering the bone, as Voltolini says, just as a sponge 
does the hard coral beneath it. The cavernous network, with its bony support 
and investing mucous membrane, constitutes the “turbinated bodies.” 
The lymphatics form a very superficial network, and terminate in two 
trunks which pass close to the openings of the Eustachian tubes to join glands 
in the lateral wall of the pharynx. 
The nerves are of two kinds—those of general and those of special sensa- 
tion. The former consists of the spheno-palatine branch of the second 
division of the fifth, and of the vidian nerve which supplies the upper and 
back part of the septum; of the nasal branch of the ophthalmic which rami- 
fies on the upper and anterior part of the septum and the upper portion of the 
external wall; of the naso-palatine nerve which supplies the middle part of 
the septum; and of the anterior palatine nerve which is distributed to the 
middle and inferior turbinated bodies. The nerve of special sense is the olfac- 
tory, the filaments of which, after passing through the foramina in the cribri- 
form plate of the ethmoid, are distributed to the upper third of the septum, 
and to the superior and middle turbinated bodies. Some filaments of the 
sympathetic can also be traced in the nasal mucous membrane. 
RHINOSCOPY. 
The nose can be examined by three methods. Thus, 1st, a speculum 
may be passed into the nares, and a large portion of the anterior part 
of the nasal cavity thereby brought into view; 2dly, the upper and 
central parts of the nose can be sometimes inspected by means of a 
small mirror introduced along the floor, with its reflecting surface di- 
rected obliquely upwards; and 3dly, the hinder portion of the nose 
and the posterior nares themselves can be seen by placing a mirror at a 
suitable angle behind the uvula. Hence anterior rhinoscopy, median 
rhinoscopy, and posterior rhinoscopy may be practised. 
Anterior Rhinoscopy. 
History.—From a very early period in the history of medicine attempts were no 
doubt made to inspect the interior of the nasal fossse by throwing back the patient’s 
head, and tilting the tip of the nose upwards with the finger. A nasal speculum was 
described and figured by Dionis* at the beginning of last century; it was simply a 
dilating instrument, and was recommended by the inventor chiefly as part of the appa- 
ratus required for the removal of polypi. In modern times Markusovzsky seems to 
have been the first to attempt a regular examination of the nasal cavity by means of a 
speculum, and in 1859, whilst on a visit to Pesth, I had an opportunity of seeing his 
* Cours de Chirurgie, Paris, 1714, 2e 6d., p. 483, and Fig. 37 E. 241 
RHINOSCOPY. 
instrument, which appeared to be a modification of Kramer’s ear speculum. In 1860 
Czermak* expressed his appreciation of it. Soon afterwards Yoltolinif stated that he 
was able to see the Eustachian cushion by passing an ear speculum into the nose. 
Subsequently he showedf that by dilating the nasal passages in a good light the 
pharyngeal wall could be easily seen, and that this was particularly the case in ozsena, 
when there was atrophy of the turbinated bodies. In 1868 Thudichum$ described a 
speculum for examining the anterior nares, whilst in the same year Duplayj| devised 
an excellent instrument for the inspection from the front of the deeper parts of the 
nose; to this method he gave the name of anterior' rhinoscopy. In 1872 Friinkelf pub- 
lished an account of his admirable speculum, hereafter described. In 1873 Michel** 
stated that he was often able, by means of Duplay’s speculum, to see the posterior half 
of the Eustachian orifice, and the whole of its cushion, and that he could perceive the 
movements of the tube in phonation and swallowing. 
A new departure was given to rhinoscopy, carried out from the front, by Zaufal,ff 
who, in 1875, first recommended the use of a funnel:shaped speculum, long enough to 
pass completely through the nasal cavity. Notwithstanding that the merit of this 
method has been contested by Weber-Liel, Gruber, Schrotter, and Voltoliui, it is un- 
doubtedly of value, and Habermann,JJ a pupil of Zaufal’s, has recorded a very 
large number of cases in which the funnel-speculum has been employed with much 
advantage. 
Nasal Specula.—For ordinary examination of the front part of the 
cavities Friinkel’s speculum will be found most serviceable. This in- 
strument consists, as may be seen in the annexed woodcut (Fig. 23), of 
two fenestrated blades, made of German-silver wire, two and a half 
Fig. 23. 
Dr. Frankel’s Nasal Speculum. 
centimetres in length, and somewhat resembling miniature obstetric for- 
ceps, but with shanks about five centimetres in length. The proximal 
extremities of the shanks are connected by a horizontal bar, through 
* Wien. med. Wochenschrift, 1860, No. 17. 
f Die Rhinoscopie und Pharvngoscopie, Festschrift zur 50 jiihrigen Jubelfeier der 
Universitat Breslau ziim 3 August, 1861. 
J Monatsschr. fur Ohrenheilkunde, No. 3, 1868. 
§ Lancet, 1868, vol. ii. pp. 243-4. 
|| Bull, de la Soc. de Cliir., 1868, 2e S£rie, t. ix., p. 446. 
If Berlin, klin. Wochenschrift, 1872, No. 6. ** Ibid., 1873, No. 34. 
ff Aerztliches Correspondenz-Blatt aus Bolimen, 1875. See also Archiv fur Ohren- 
heilkunde, Band xii., Yiertes Heft, 1877. 
ft Wien. med. Presse, 1881, Nos. 23, 24, and 25. 242 
DISEASES OF THE THROAT AND NOSE. 
which there is a central screw acting on both blades. Frankel recom- 
mends that one blade of the instrument should be introduced into each 
nostril, but mentions that both blades may be passed into a single nos- 
tril, and I prefer this plan. By turning the Screw the blades are grad- 
ually separated, and a good view of the interior of the nose is obtained. 
When the blades are sufficiently opened to press slightly on the nasal 
alse, the instrument becomes self-retaining, and the lower part of the 
speculum falling in front of the lip causes no obstruction to the sight. 
The great advantage of this-instrument consists in its affording an ex- 
cellent view, whilst causing no pain, and scarcely any inconvenience to 
the patient. 
Von Trbltsch* has taken the screw arrangement of Frankel’s in- 
strument, and replaced the wires by two solid blades, each three centi- 
metres in length, but I have not found this speculum so convenient as 
Frankel’s. 
Another speculum, the blades of which somewhat resemble those of 
Frankel’s, has been recently invented by Goodwillie,f of New York. 
The instrument is kept open by the elasticity of the wire which con- 
nects the two blades. With it, however, it is impossible to regulate 
the separation of the blades so accurately as with Frankel’s, and hence 
no fewer than five specula are needed to suit the varying sizes of the 
nasal orifices. Creswell Baber,| of Brighton, uses a speculum (Fig. 
24), which consists of two little curved wires, kept in position by a 
Fig. 24. 
Dr. Creswell Baber’s Nasal Speculum. 
band passing round the head. Spencer Watson § employs a modifica- 
tion of Noyes’s eye speculum attached to a frontal band worn by the 
* Lehrbuch der Ohrenheilkunde, Leipzig, 1877, p. 317. 
f Bosworth: Diseases of the Throat and Nose, New York, 1881, p. 23. 
J Brit. Med. Jonrn., 1881, vol. i., p. 55. The instrument is made by Messrs. Wright, 
of 108 New Bond Street. 
\ London Specialist, 1880, vol. i., No. 1. 243 
RHINOSCOPY. 
patient. I do not think, however, that either of these instruments is 
so convenient as Frankel’s. Thudichum’s speculum (Fig. 25) consists 
Fig. 25. 
Dr. Thudichum’s Nasal Speculum. 
of two flat blades united together, and at the same time kept apart by 
means of a piece of elastic wire. The objections already mentioned, in 
speaking of Goodwillie’s instrument, apply to that of Thudichum ; be- 
sides which it so often hurts the patient that I have now quite given 
up its use. 
Fig. 26. 
Nasal Specula. 
A. Duplay’s speculum: a and b, the two blades; c, male screw: e, handle of run- 
ning screw. The dotted lines show the position of the instrument when fully open. 
B. Schuster’s speculum: a and b, the two blades; e, handle of male screw; c, male 
screw. C. Yoltolini’s speculum : a and b, the two blades ; x, rack ; c, small spring for 
keeping x in position. When y and z are held together the instrument is kept closed, 
and by pressing on z it is opened. 
For examining the deeper parts of the nose Duplay’s speculum, 
which is a hollow cone-shaped bivalve instrument (Fig. 26 a), is of the 
greatest service. The two blades of the instrument are slightly flat- 
tened, so that the distal end is somewhat beak-shaped, but the inner 244 
DISEASES OF THE THROAT AND NOSE. 
blade (intended to be applied against the septem) is more flattened than 
its fellow. The outer blade is movable in the distal four-fifths of its 
length, and when pulled open is fixed in position by means of a running 
screw (Fig. 26 A, and e and e'). Its full size is shown in Fig. 26 A, 
and no larger instrument is ever required, and can seldom be tolerated. 
It will be seen that the blades open very widely. 
Schuster, of Aix-la-Chapelle, has modified Duplay’s speculum by 
employing a fixed instead of a running screw (Fig. 26 b). The instru- 
ment is rather too large, and yet does not open so widely as Duplay’s; 
but the blades can be opened more gradually, and are thus less likely 
to hurt the patient. Voltolini (Fig. 26 c) has also modified Duplay’s 
arrangement for opening the speculum, by adapting a rack movement 
to it, but I have not found this at all convenient, and the instrument is 
apt to cause a good deal of pain. Massei* again has varied Duplay’s 
speculum, by fenestrating one of the blades, and under some circum- 
stances this instrument is very useful. 
Elsberg has invented a trivalve speculum (Fig. 27), by means of 
which the interior of the nose can be thoroughly inspected. The three 
Fig. 27. 
Dr. Elsberg’s Trivalve Nasal Speculum. 
A, the instrument closed ready for introduction, b, the instrument expanded 
blades are separated by closing the handles, or may be more gradually 
separated by means of a screw in the shank of the instrument. This 
speculum, however, has the disadvantage of not being self-retaining, 
* Malattie del tratto respiratorio, Napoli, 1882, p. 178. The instrument was de- 
scribed and figured in a paper read before the Royal Med.-Chir. Society of Naples on 
the 30th May, 1875. RHINOSCOPY. 
245 
and though I occasionally use it, I much more frequently employ one 
of those previously described. Schnitzler* recommends Roth’s modi- 
fication of Kramer’s aural instrument further 
altered by the fenestration of each blade. 
For examining the posterior wall of the phar- 
ynx and the neighborhood of the Eustachian tube 
Zaufal’s funnel (Fig. 28) is very useful. The 
instrument is well-described by its name, as it is 
nothing more than a perfectly cylindrical metallic 
tube, widening at its proximal end into a funnel- 
shaped mouth. The length of the cylindrical 
portion of the speculum is from six to eight cen- 
timetres, that of the funnel is three centimetres, 
the total length of the instrument being, there- 
fore, from nine to eleven centimetres. The diam- 
eter of the proximal end is about two centimetres. 
The instrument is made in five different sizes, the 
smallest one (called No. 3) having a diameter of 
three millimetres at its distal extremity, the next 
(No. 4) a diameter of four millimetres, and the 
others having diameters of five, six, and seven 
millimetres respectively. There is no canula with 
a diameter of either one or two millimetres, as the 
lumen of such instruments would be too small to 
permit of satisfactory observation. The range is, 
therefore, from No. 3 to No. 7, both numbers in- 
clusive, and of these Zaufal himself most fre- 
quently employs Nos. 6, 5, and 4. The interior 
of the funnel-shaped mouth is blackened, whilst 
the cylindrical portion of the instrument has a 
polished inner surface. Zaufal at first used a pilot 
sound for passing the speculum through the nose, 
but has now discarded this. It may be added 
that he employs the instrument not only for diag- 
nostic, but also for operative, purposes. In the 
latter case he chooses, if possible, the largest tube, which serves, in fact, 
as a canula through which he introduces tube-forceps or snares. I have 
used Zaufal’s funnels in a good many instances, but more for the pur- 
pose of experiment than with a clinical object. I have, however, fully 
Fig. 28. 
Zaufal’s Funnel. 
b shows the size most 
frequently used ; a and c 
are sections of tubes of 
smaller and larger bore. 
* Laryngoscopie und Rhinoscopie, Wien, 1879, p. 59. 246 
DISEASES OF THE THROAT AND NOSE. 
convinced myself of the possibility of making observations in a con- 
siderable proportion of cases. Voltolini,* though strongly objecting 
to Zaufal’s instruments, has latterly made use of short funnels varying 
in length from four to seven and a half centimetres with a lumen of 
from five to eight millimetres. In connection with these he employs 
Brunton’s otoscope, f 
Illumination.—For anterior rhinoscopy a good light is required. 
Sunlight may be employed if it is available, but as this is unfortunately 
rarely the case in this country, it is better to have some artificial means 
of illumination. Any of the arrangements for this purpose, which have 
been already described (see vol. i., pp. 225-229), may be used. 
The Application of Anterior Rhinoscopy. 
The operator should wear a perforated concave reflector supported by 
a spectacle frame or frontal band (vol. i., p. 224), whilst the patient 
should sit upright opposite him. A good lamp being fixed near the 
patient’s head on the same side as that on which the surgeon wears the 
reflector, and the nose being tilted up, the vestibule comes into view. 
This is an irregularly oblong cavity, the outer wall of which (corre- 
sponding to the lower two-thirds of the lateral cartilage) extends 
farther back than the inner, which is formed by the inner returning 
portion of the lateral cartilage. This space is lined with common integ- 
ument, and on it grow numerous short coarse hairs, which protect the 
entrance of the nose. At the upper end of the vestibule is the opening 
of the anterior nares, the inner, upper, and outer borders of which are 
sharply defined. On introducing a speculum and separating its blades, 
the interior of the nostrils comes into view, together with the anterior 
extremity of the inferior turbinated body and a part of the cartilaginous 
portion of the septum. If the patient’s head be very slightly bent for- 
wards, the observer can trace the inferior turbinated body backwards, 
its outer convex surface and lower border being often visible through- 
out. Between the free edge of this body and the floor of the nose is 
the inferior meatus, the height of which is rather less than the distance 
between the upper and lower borders of the inferior turbinated body. 
A ray of light can generally be projected into the anterior half of the 
* Rhinoscopie und Pharyngoscopie, Erste Halfte, p. 81. 
f This instrument consists of a metallic tube provided with an eye-piece. Into this 
tube a funnel opens at right angles, through which the light is made to fall on a per- 
forated reflector, which throws the rays through the distal part of the cylinder into an 
ordinary ear speculum. RHINOSCOPY. 
247 
inferior meatus, but seldom beyond this point; and not unfrequently, 
owing to a slight twist inwards of the front part of the turbinated body, 
especially at the point where its anterior and inferior borders meet, only 
the anterior fourth of the lower meatus is visible. On inclining the 
patient’s head backwards, the lower border and the inferior portion of 
the inner convex surface of the middle turbinated body come into 
view, whilst a small portion of its outer concave part can sometimes be 
seen. The superior turbinated body can occasionally be observed quite 
at the back and near the vault of the nose, but this is the exception. I 
have never been able to distinguish the superior meatus from the front. 
If the patient throws his head very much forwards, the floor of the 
nose can often be followed to the posterior extremity. It is almost 
always uneven, and frequently presents small irregularly-rounded emi- 
nences. 
The septum can generally be seen, except its upper sixth and pos- 
terior eighth. The partition, as already stated (see Anatomy) is seldom 
quite symmetrical, being often slightly convex on one side, and corre- 
spondingly concave on the other. Even when the septum is straight, 
Fig. 29. 
A, the orifice at rest, b, the orifice as seen in deglutition and in certain acts of artic- 
ulation. eo, Eustachian orifice, ec, Eustachian cushion, bf, Rosenmiiller’s fossa. 
The Eustachian Orifice as seen from the Front (after Zaufal). 
irregular projections are often seen, especially at the lower and back 
part of the vomer. Small exostoses can also often be perceived at the 
angle where the perpendicular plate of the ethmoid, the vomer, and the 
cartilage of the septum meet one another. 
The color of the lining membrane of the nose varies in different situ- 
ations. The anterior border of the inferior turbinated body is, as a rule, 
bright red, and its inferior convex border is mostly of the same hue. 
The lower border of the middle turbinated body is generally quite pale, 
and is indeed less vascular than any other portion of the lining mem- 
brane of the nose. The floor of the nasal fossa is of a dull red color, 
whilst the surface of the mucous membrane covering the septum is pale 
red. 248 
DISEASES OF THE THROAT AND NOSE. 
On looking directly through the nose whilst the patient’s head is 
inclined slightly forwards, the posterior wall of the pharynx can some- 
times be seen ; and on directing him to swallow, the cushion of the 
Eustachian orifice may be observed to move upwards. A better view, 
however, of the posterior wall and Eustachian orifice can be obtained 
with Zaufal’s funnel. 
Median Rhinoscopy. 
Wertheim* first suggested the idea of passing into the nose a small 
tube provided with a steel mirror directed upwards, and a correspond- 
ing fenestra at its end, like Avery’s laryngoscope, and to this instru- 
ment he gave the name of “ conchoscope.” In order to prevent the 
mirror from becoming soiled by mucus on its introduction into the nose, 
Voltolini provided the fenestra with a small shield which could be 
drawn back by means of a thread when the instrument was in position. 
Voltolini also substituted glass for steel in the mirrors. 
The illumination recommended for anterior rhinoscopy is equally 
applicable to the median method, but the mode of examination itself is 
seldom of any practical advantage. I may mention, however, that by 
this plan I once succeeded in obtaining a view of a small polypus situ- 
ated just above the anterior extremity of the middle turbinated body, 
which could not be brought into view by any dilating speculum. 
Posterior Rhinoscopy. 
History.—The idea of examining the posterior nares by placing a mirror at the back 
of the mouth, with its reflecting surface directed obliquely upwards, appears to have 
occurred to Bozzini,f Baumes.J and others; but the practical application of the method 
is undoubtedly due to CzermakJ and the art of rhinoscopy dates from a paper published 
by him in August, 1859. In the following year Semeleder|[ made some remarks on 
the subject, and later he brought out a small work which contained many useful 
directions for rhinoscopy, a number of very interesting cases, and some beautiful col- 
ored illustrations. Soon after the appearance of Semeleder’s first paper, articles were 
* Ueber ein Verfahren zum Zwecke der Besichtigung des vorderen und mittleren 
Drittheiles der Nasenhohle, Wien. med. Wochenschrift, 1869, Nrs. 18, 19, 20. 
f Der Lichtleiter, oder Beschreibung einer einfachen Vorrichtung, und ihrer An- 
wendung zur Erleuchtung innerer Hohlen, und Zwischenriiume des lebenden animal- 
ischen Korpers, Weimar, 1807. 
J Compte-rendu des Travaux de la Soc. de M6d. de Lyon, 1836-38, p. 62. 
\ Wien. med. Wochenschrift, Aug. 6, 1859. 
|| Ueber die Untersuchungen des Nasenrachenraumes, Zeitschr. d. Gesellsch. d. 
Aerzte zu Wien, 1860. 
If Die Rhinoscopie und ihr Werth fur die arztliche Praxis, Leipzig, 1862. RHINOSCOPY. 
249 
published by Stoerk,* Tiirck,f and Voltolini.j: To the last-named writer, however, 
is due the credit of systematically working at the subject for many years, and of hav- 
ing produced the most valuable treatise? on rhinoscopy that has yet appeared. 
The Rhinal Mirror.—A small laryngeal mirror answers the purpose 
very well. Its reflecting surface should not be more than 1| centimetre 
(-§ inch) in diameter. An excellent rhinoscopic mirror has been in- 
vented by W. C. Jarvis, of New York (Fig. 30), which combines a mirror 
Fip. 30. 
a, the shank of the mirror; b, screw by which the shank is fixed to handle; c, de- 
scending arm of shank ; d, spring-joint at which the mirror can be fixed at any angle 
desired. The handle of the instrument can either be continued in the same line as 
the shank by fixing at a, or it can be secured at an angle by screwing it to c, as in 
the woodcut. The expanded portion of the shank acts as a tongue-depressor. 
and tongue-spatula in the most simple and convenient manner. Friinkel 
has devised an instrument in which the mirror is hinged on to the 
shank, and this again is fixed at nearly a right angle to a wooden 
handle (Fig. 31). By pushing forward a little bar acting on the hinge 
the angle of the mirror can be changed after its introduction. Michel|| 
has also invented a rotating mirror, in which the movement of the glass 
is rapidly effected by a spring in the handle of the instrument. The 
Dr. Jarvis’s Combined Tongue Depressor and Post-Nasal Mirror. 
* Rhinoscopie, Zeitschr. d. Gesellsch. d. Aerzte zu Wien, 1860, Nr. 26. 
t Beitriige zur Laryngoscopie und Rhinoscopie, Zeitschr. d. Gesellsch. d. Aerzte zu 
Wien, 1860. Nr. 21. 
J Die Besichtigung der Tuba Eustachii und der iibrigen Theile des Cavum pharyn- 
gonasale mittelst des Schlundkopfspiegels, Deutsche Klinik, 1860, Nr. 21. 
? Rhinoscopie und Pharyngoscopie, Breslau, 1879. 
|| Die Krankheiten der Nasenhohle, Berlin, 1876, p. 9. 250 
DISEASES OF THE THROAT AND NOSE. 
disadvantage of this arrangement is that the mirror has to be kept in 
the desired position by the constant pressure of the thumb on the spring. 
Frankel’s Post-Rinal Mirror. 
a, the hinge; b, the running bar. 
I may repeat, moreover, in connection with these various rhinoscopes, 
that I find the ordinary small-sized laryngeal mirror answer every 
purpose. 
Fig. 32. 
A, Voltolini’s palate-liook ; b, Frankel’s palate-hook; c, Czermak’s palate-hook. 
Palate-Hooks. 
Falate-Hooks.—The uvula often causes an impediment to posterior 
rhinoscopy, and various devices have been suggested for the temporary RHINOSCOPY, 
251 
removal of this obstruction. The first instrument invented for this 
purpose was the palate-hook of Czermak. This instrument* (Fig. 32 c) 
consisted of a metal rod about four inches in length, one end of which 
was fixed into a wooden handle, whilst the other was widened towards 
the distal extremity and terminated in a short blunt right-angled hook 
a quarter of an inch in length. Czermak remarks that the size and 
curve of the hook must vary according to the proportion of the parts. 
The value of an instrument of this kind is strongly insisted on by 
Voltolini,f who uses a much larger hook provided with two small 
wings attached to the distal extremity of the shank, just before the 
bend (Fig. 32 a). The object of these wings appears to be to form a 
kind of spoon-shaped cavity which supports the uvula in the middle 
line, thus keeping it from obstructing the view. An instrument of in- 
termediate size and fenestrated at the upturned part of the blade is used 
by Frankel (Fig. 32 b), who also occasionally employs an instrument 
combining a gag, a tongue-depressor, and a groove to hold his palate- 
hook. But it is very seldom that such instruments, however ingenious, 
can be successfully employed, and I may remark that I rarely use even 
a simple hook. 
Voltolini,;}; who, as already remarked, is a strong advocate of the 
palate-hook, attaches great importance to his mode of using it, which he 
describes in the following terms: “With the index finger of .the left 
hand the patient’s tongue should be strongly depressed, and then, with- 
out any ceremony or preparation, the hook, having been boldly and 
quickly passed high up behind the uvula, even to the posterior nares, 
should be drawn forcibly forward.Ӥ Voltolini states that he has never 
met with a patient who could not bear the application of the hook in 
this way, and he affirms that the uvula yields better to a “forcible 
grasp than to tender or timid handling.” He then proceeds to quote 
Lowenberg, Monro, Michel, and myself, to show that we all teach that 
the hook should be used gently, and that we consequently fail to appre- 
ciate its value. Voltolini maintains that most practitioners have over- 
looked the physiological law that a slight irritation causes more reflex 
action than strong pressure; and he also urges that when his hook is 
used the soft palate has less power of resistance, the muscles, as it were, 
losing their point of leverage. 
* Der Kehlkopfspiegel und seine Verwerthung fur Physiologie und Medizin, Leip- 
zig, 1860. 
f Rhinoscopie und Pharyngoscopie, 1879, p. 17. 
J Op. cit., pp. 17, 18. \ Op. cit, p. 17. 252 
DISEASES OF THE THROAT AND NOSE. 
Other Instruments for Drawing the Uvula Forwards.—Instead of 
using a hook, Tiirck* suggested that the uvula should be held with 
miniature calculus-forceps. He also devised for the same purpose a 
running noose, consisting of a piece of string passed through a tube. 
Voltolinif modified this somewhat by fixing one end of the string inside 
the tube (Fig. 33). I have always, however, found it exceedingly diffi- 
cult to apply this apparatus, but have occasionally employed a “ twitch ” 
(Fig. 34), consisting of a small piece of string threaded through the end 
of a rod four or five inches in length. With this the uvula can be 
readily caught, and a few twists of the shank will enable the operator 
Fig. 33. 
Fig. 34. 
Yoltolini’s Uvula-Noose. 
The Author’s Uvula-Twitch. 
to hold the part in any position that he may desire, without crush- 
ing or pulling it with undue violence. Dr. Lori, of Bnda-Pesth, 
has invented an instrument, resembling a paper-clip, which has been 
further improved by Voltolini.J It is rather more than three centi- 
metres in length, and to its handles threads are attached, the ends of 
which pass through the patient’s mouth, and can be fastened round one 
* Prakt. Anleitung zu Larvngoscopie, Wien, 1860, p. 65. 
f Op. cit., p. 10. 
J Op. cit., p. 12. RHINOSCOPY. 
253 
of the ears. Stoerk* proposed to pull the uvula forwards by means of 
a silk ribbon passed through the nose, and brought out through the 
mouth. The nasal and buccal ends are then tied together, and given to 
the patient, who, by gently pulling, endeavors to draw the velum forwards 
and upwards. This plan is open to the obvious objection that the soft 
palate, instead of being drawn directly forwards, is tilted sideways. 
Surgeon-General Wales,f of the American Navy, improved this method 
by suggesting the use of an elastic tractor, consisting of an india-rubber 
cord, about two millimeters in diameter. This should be not less than 
eighteen inches in length, and one end should be carried through 
each nostril into the pharynx with the help of Bellocq’s sound or a 
gum-elastic catheter. Each end, as it appears below the soft palate, 
should be seized with the finger or with forceps, and drawn out 
through the mouth. The middle part of the cord is thus fixed by the 
lower part of the septum in front, and by pulling gently on the free 
ends which pass through the mouth it will be found that the velum 
can be drawn forwards to any extent that may be desired. The ends 
may be held by an assistant, or may be tied round the patient’s head. 
I have tried this method of enlarging the naso-pharyngeal space for 
the purpose of rhinoscopy with some success, but the passage of the 
cords through the nose into the pharynx is highly disagreeable to the 
patient, and their contact with the mucous membrane often increases 
the natural irritability of the parts. Indeed, in addition to the “gag- 
ging” which is thus caused, a flow of secretion is sometimes excited, 
which seriously interferes with the examination. Jarvis, of New York, 
uses two elastic cords, which are passed through the nose and drawn 
out by the mouth in the manner just described, but they are fixed over 
the upper lip by means of clips provided with a small upright plate 
grooved on the upper edge so as to serve as a support for the stem of 
a snare or other instrument which it is desired to use within the 
nose. 
In order to set free one of the operator’s hands, the mirror and palate- 
* Op. cit., p. 95. It may be mentioned that Desgranges (Gaz. Hebdom., 1854, p. 
647) proposed a similar method of enlarging the lower opening of the naso pharynx, 
and Palasciano actually put it into practice a few years later (Bericht der Naturfor- 
scherversammlung in Carlsruhe ira Jahre 1858), but in each of these cases the object 
was to open a wider way for digital examination of naso-pharyngeal growths. Stoerk 
was, so far as I know, the first who had recourse to such a means of controlling the 
velum for rhinoscopic puposes. 
f New Method of Rhinoscopic Exploration, Washington, 1877, p. 7. 254 
DISEASES OF THE THROAT AND NOSE. 
hook have been combined together by Stoerk,* Baxt,f and Duplay4 
I cannot say, however, that I have found any advantage from this com- 
bination. 
Tongue Spatulas.—I seldom employ any instrument for depressing 
the tongue, but occasionally a spatula may be required. Under these 
circumstances the instruments of Turck or Frankel, in which the ordi- 
nary tongue-spatula is fitted to a long vertical handle, to be held by the 
patient well out of the way of the operator, will be found the most 
convenient. 
The Application of Posterior Rhinoscopy. 
The examination should be conducted as follows: 
The operator should place himself opposite the patient, who must be 
seated in an upright attitude, with his head erect or bent slightly for- 
wards, the lamp being in the same position as in laryngoscopy. The 
patient should be directed to open his mouth widely, and the light 
should be made to fall rather lower in the fauces than when it is de- 
sired to examine the larynx. The rhinal mirror should then be car- 
ried to the back of the throat, its upper border being a little below the 
curtain of the palate, and its face directed upwards, so as to form an 
angle of about 135° with the horizon. If the uvula happens to be 
drawn upwards and backwards, as is often the case, the patient should 
be told to expire gently, or to produce some nasal sound, such as hang. 
Straining and forced inspiration must be especially avoided. It is 
sometimes necessary to depress the tongue with a spatula, but the shank 
of a rhinal mirror generally answers sufficiently well. 
It is a good plan to pass the small mirror between the anterior pillar 
and the uvula on one side first, and then to withdraw it and introduce 
it again in the same manner on the opposite side. By slanting the 
mirror a little laterally the posterior corners of the naso-pharynx with 
the orifice of the Eustachian tubes and the folds which bound them come 
into view; the vault of the pharynx is seen when the mirror is nearly 
horizontal. When the glass is held in a nearly perpendicular position, 
the upper part of the arching posterior wall of the pharynx can be per- 
ceived, but the laws of perspective reduce this view to the narrowest 
limits. To inspect even one side of the naso-pharynx thoroughly, how- 
ever, it is often necessary to introduce the mirror several times, and to 
* Zur Laryngoscopie, Wien, 1859, p. 20. 
f Berlin, klin. Wochenschrift, 1870, No. 28. 
J Traits Elexn. de pathol. externe, Paris, 1877, t. iii., p. 752. RHINOSCOPY. 
255 
turn its reflecting surface in different directions; hence the post-rhinal 
image (Fig. 35) is a compound picture made up of many limited views. 
In the middle the septum is seen forming a thin projecting partition 
between the choange, slightly thicker above and below than in its 
central portion. The most conspicuous objects are the middle tur- 
binated bodies, which appear as two pale oblong tumors extending 
downwards and inwards from the outer walls towards the septum, and 
occupying the middle third of the choanse. Above the middle tur- 
binated bodies the superior ones are seen as small, grayish, horn-shaped 
Fig. 35. 
Post-Bhinal Image. 
s. superior turbinated body; m. middle turbinated body; i. inferior turbinated body; 
e.c. Eustachian cushion; e.o. Eustachian orifice; u.c. uvula-cushion; u. uvula; s.ph.f. 
salpingo-pharyngeal fold ; s.p.f. salpingo-palatine fold. 
projections running in the same direction as those just below them but 
not extending so far inwards. At the bottom of the nasal fossse the 
inferior turbinated bodies appear as two pale, rounded, solid-looking 
prominences, redder in color than the middle turbinated body, and 
somewhat nearer the septum. The meatuses, as might be expected by 
those acquainted with the anatomy of the parts, are not very distinct. 
The superior meatus, though actually the smallest and most shallow, 
sometimes appears, owing to the upper turbinated body being so little 
developed, as the largest. The middle meatus can generally be made 
out, but the lower one is either not visible at all or appears only as a 
narrow slit below the turbinated body and close to the septum. On the 
outer wall of the naso-pharynx the yellow orifice of the Eustachian tube 
can be seen, bounded by the salpingo-palatine fold on its inner, and the 
salpingo-pharyngeal fold on its outer side; the base of the opening 
being formed by a projection, described by Zaufal as the “ levator- 
cushion.” External to the salpingo-pharyngeal fold is Rosenmuller’s 256 
diseases of the throat and nose. 
fossa. Beneath the septum the base of the uvula containing the azygos 
muscle forms a slight projection, called the “ uvula-cushion.” When 
the mirror is held obliquely so that its reflecting surface approaches the 
horizontal position, the vault of the pharynx comes into view, and at 
its anterior part a number of pale pink elevations and depressions are 
seen together, constituting a small irregular body of adenoid tissue, 
known as Luschka’s tonsil (see Anatomy, vol. i., p. 18). Quite in the 
centre of this there is often an opening, which has been called the mouth 
of this gland, but is really a small spot free from gland tissue. Behind 
this tonsil the smooth grayish surface of the vault of the pharynx with 
its median raphe is sometimes visible. 
Posterior Rhinoscopy by Double Reflection. 
Voltolini* has suggested the use of two mirrors for posterior rhino- 
scopy, more especially with the object of obtaining a good view of the 
Eustachian orifice. One mirror with a long-curved shank bent at a 
right or even a slightly acute angle is passed well up into the naso- 
pharynx, close to its posterior wall, in such a way that the reflecting 
surface is a little above the level of the choanse; whilst a second mirror 
is introduced in the usual manner, but its reflecting surface is kept in a 
somewhat more horizontal position, so that instead of directly receiving 
the image of the posterior nares it receives a secondary image, first 
formed in the upper mirror. In employing these mirrors the uvula has 
to be held forwards by some of the special arrangements already de- 
scribed. This method is so complicated and so rarely capable of appli- 
cation that it requires only a passing notice. Voltolini has, however, 
reported one casef in which, by using two mirrors, he was able to see 
the Eustachian orifice, into which a catheter had been previously intro- 
duced. 
Auto-Rhinoscopy, Magnifying Mirrors, etc.—The observations which 
have been already made upon the kindred subject of Auto-laryngoscopy 
(see vol. i., pp. 229 and 241) apply equally here. 
* Die Dhinoscopie, etc., 1879. 
f Op. cit., p. 179. NASAL INSTRUMENTS. 
257 
NASAL INSTRUMENTS. 
Nasal Probes.—Useful information as to the condition of the mucous 
membrane, the attachment relations and density of growths, the pres- 
ence of exposed surface of bone and various other matters can often be 
obtained by examining the interior of the nose with small probes. These 
instruments may be either straight or slightly hooked at the end, the 
curved portion being somewhat broad and flat, and, of course, blunt at 
the edge. Nasal probes, in fact, resemble those recommended for the 
larynx (vol. i., Fig. 26, p. 247), as regards the distal extremity, but the 
stem is straight, and is fitted into a handle, at an angle of about 135°. 
Nasal Bougies.—These are useful, both for purposes of diagnosis and 
of treatment. They are made of gum-elastic or vulcanite, and are from 
three to four inches in length. They may be round, or slightly flat- 
tened from side to side like the oesophageal bougies (see p. 27), and I 
generally find six sizes sufficient, viz., from three to eight millimetres 
in the short transverse diameter, i. e., from one flattened surface to .the 
other. It greatly facilitates the use of these instruments if they are 
probe-pointed. In introducing the bougie the flattened sides are, of 
course, directed towards the septum and the outer wall of the nasal 
fossa respectively. 
Shields.—In applying strong caustics, or in using the electric cautery 
within the nose, shields are sometimes required to protect the healthy 
parts from injury. Shurly,* of Detroit, has invented two instruments 
for this purpose. One of them (Fig. 36) is a modification of the nasal 
dilator, or speculum, one blade being replaced by an ivory plate. The 
other instrument consists of an ivory plate, which is passed into the 
nasal fossa, and a wire spring attached to it, which is applied to the ala 
of the nose externally. Both these instruments are occasionally useful, 
but if it be possible to dispense with them it is desirable to do so, as 
any shield, however well made, impedes the view and diminishes the 
space available for manipulation. 
Insufflators.—For the application of remedies in the form of powder, 
the tube-insufflator (vol. i., Fig. 39, p. 255) may be used, or the patient 
can apply the powder himself, by means of Bryant’s auto-insufflator, f 
This consists of a bent tube, provided at one part with a corked opening 
for receiving the powder. The instrument having been charged, the 
* St. Louis Med. and Surg. Journ., Jan. 5, 1880. 
f Practice of Surgery, London, 1872, 1st ed., p. 124. 258 
DISEASES OF THE THROAT AND NOSE. 
patient puts one end of the pipe in his mouth and the other up his nose, 
when, by gently blowing, the powder is driven into the nasal fossa. 
Andrew Smith has constructed an insufflator on the model of the hand- 
ball spray-producer, which can be used either for the anterior or the 
Fig. 36. 
At the points x and z the blade and plate can be reversed. The instrument can 
thus be made applicable for either nasal passage. As a rule it is for the purpose of 
protecting the septum whilst the operator is making applications to growths on the tur- 
binated bone, that the ivory plate is required. 
Dr. Shurly’s Nasal Shield. 
posterior nares. It consists of a glass bottle, with an india-rubber stop- 
per which is perforated to allow the passage of two tubes. One of these 
reaches but a short way into the bottle, and is connected outside with 
an ordinary elastic hand-ball, by means of a piece of flexible tubing, 
Fig. 37. 
Mr. Bryant’s Auto-Insufflator. 
the other almost touches the bottom of the bottle, whilst its free portion 
is straight, and somewhat bulbous at the end, or when intended for 
post-nasal use, longer, and curved upwards and slightly backwards, as NASAL INSTRUMENTS. 
259 
shown in the cut (Fig. 38 a). The receptacle being partially filled with 
powder, the ball is squeezed once or twice, when a small quantity of the 
contents of the bottle will be forced out through the nozzle. Clinton 
Fig. 38. 
Dr. Andrew Smith’s Insufflator. 
A shows the nozzle required for the posterior nares; B, that for the anterior. 
Wagner has lately brought under my notice a still more simple and 
handy apparatus, in which a test-tube takes the place of the bottle 
above described. 
Brushes.—For the application of remedies to particular spots in the 
front part of the nasal passages a fine brush fixed to a handle at a suit- 
Fig. 39. 
This instrument shows the angle at which all nasal instruments should be bent. 
Nasal Brush. 
able curve is often serviceable. For the posterior nares and naso- 
pharynx the laryngeal brushes Nos. 1 and 2 (vol. i., p. 247) answer 
every purpose. 
Caustic Holders.—Some caustics can be applied with the brush just 
described, and nitrate of silver may be conveniently used by simply 
fusing it on a metal rod (vol. i., p. 255); but various instruments have 
been invented with the view of protecting the contiguous parts from 
the action of the caustic. A very useful instrument for the applica- 
tion of the solid nitrate of silver has been devised by Schrotter. It 
consists of a long grooved probe, provided with a turning shield, which 260 
DISEASES OF THE THROAT AND NOSE. 
covers the groove, into which the nitrate of silver is fused. The instru- 
ment should be introduced closed to the part which it is desired to 
cauterize, when the shield is turned aside, and the caustic brought into 
contact with the tissue to be destroyed. 
For applying strong nitric acid and similar escharotics Andrew 
Smith’s instrument, which has been somewhat modified and improved 
Fig. 40. 
Professor Schrotter’s Porte-Caustique (after Beverley Bobinson). 
by Beverley Bobinson (Fig. 41), is very useful. It consists of a grooved 
director, made of vulcanite, and bent at a suitable angle. Into the 
groove a slender steel wire, armed with cotton-wool, is introduced a 
short way, and a few drops of acid are placed on the exposed surface 
of the wadding. The whole instrument, after being oiled, is then 
passed into the nasal fossa, and the wire rod carried along the groove 
as far back as may be desired. On withdrawal of the wire any exces- 
sive action of the caustic is neutralized by the passage of a similar wire, 
Fig. 41. 
Dr. Andrew Smith’s Modified Caustic Holder. 
the wadding of which has been steeped in a.solution of bicarbonate of 
soda. A more simple method is that recommended by Harrison Allen,* 
who employs a tapering rod of soft iron, slightly roughened at the 
distal end, for the more secure attachment of a pledget of cotton-wool, 
which is wound round it. The proximal extremity of the rod is fitted 
into a wooden handle. The rod may be bent to any shape that may 
* Amer. Journ. Med. Sci., New Series, No. clvii., 1880, p. 62 et seq. NASAL INSTRUMENTS. 
261 
be wished, and the cotton-wool can be soaked with any solution that is 
thought desirable; the instrument should be introduced into the nose 
through a speculum. 
Hand Washes.—These require no apparatus, the medicated liquid 
being drawn up into the nose from the hollow of the hand. A small 
quantity of tepid water, in which chloride of sodium, carbonate of 
soda, or some other medicament has been dissolved, is used in the 
manner described, and when it comes into the mouth is spit out. Rum- 
bold,* of St. Louis, has shown that the direction which fluids take in 
passing through the nose depends on the position of the patient’s head. 
In order, therefore, that the wash may reach all parts of the nasal 
cavity the patient, whilst sucking up the fluid through the nose, should 
be enjoined first to bend his head forwards and downwards, then to 
keep it in a nearly erect position, and finally to throw it as far back as 
he is able whilst drawing up the medicated liquid. 
Douches.—The douche, or irrigator, was introduced by Thudichum,f 
who first applied discovery that the nasal channels act as two 
Fig. 42. 
Nasal Douche. 
Elastic tubing terminating at a in a hollow metal weight, and at c in a nozzle, whilst 
at 6 is a metal or vulcanite shoulder, fitting loosely, so that it can be run along the 
tubing, a, the metal piping is placed at the bottom of a bottle or jug containing tepid 
saline water; b rests on the edge of the vessel; and c passes into the nose of the patient. 
In order to start the current, suction must first be made at the nozzle. 
arms of a syphon, when the mouth is kept open. Thudichum’s orig- 
inal instrument consisted of a piece of india-rubber tubing, about 
four feet in length, provided at one end with a perforated weight, and 
* Hygiene and Treatment of Catarrh, St. Louis, 1880, part i. 
f Lancet, Nov. 24, 1864. J Muller’s Archiv, 1847, pp. 351-354. 262 
DISEASES OF THE THROAT AND NOSE. 
at the other with an appropriate nozzle for passing into the nostril- 
The weighted end of the tubing is put into a vessel containing the 
medicated liquid, and the latter is placed on a shelf a little above the 
patient’s head. On starting the flow by suction at the nozzle, and 
placing the instrument in the nose, the fluid will run in a continuous 
stream until it is exhausted. This instrument has since been somewhat 
improved (Fig. 42) by the addition of an arm of vulcanite or metal, 
to cover the tube where it passes over the edge of the vessel, an ar- 
rangement which prevents the tubing from being pressed upon, and 
dispenses with the necessity of a weight. 
The Parson’s douche is a still more perfect instrument, being pro- 
vided with an elastic ball, by means of which the flow can be started, 
and a tap by which the stream can be at once shut off. 
Fig. 43. 
The Parson’s Nasal Douche. 
a, elastic hand-ball; b, tap; c, nozzle. 
About a pint of water at a temperature of 90° Fahr. should be used, 
one drachm of chloride of sodium or carbonate of soda having been 
first dissolved in it. A few years ago irrigators were tried on a very- 
extensive scale, but the observations of Roosa,* of New York, and 
* Arch, of Ophthal. and Otology, vols. i., ii,, and iii. NASAL, INSTRUMENTS. 
263 
others, showed that fluids introduced through the nose occasionally pass 
into the Eustachian tube, and excite severe inflammation of the middle 
ear. The accident is most likely to occur from the fluid being driven 
through the nose with too great force, or from the patient swallowing 
whilst using the instrument. Common salt is ordinarily employed for 
the purposes of irrigation, but Weber-Liel* has found that carbonate of 
soda is less likely to produce a serious result, should any fluid find its 
way into the middle ear. Solis Cohen,f who strongly insists on the 
value of this method of treatment, has noticed that the accident gener- 
ally occurs when cold, instead of warm water, is used; and he calls 
attention to the fact that Cassels has tried it in 1500 cases, without ever 
having seen or heard of an untoward result. I do not employ irriga- 
tion nearly so frequently as formerly; not because I have noticed any 
injurious effects from it, but because I have obtained equally good 
results from sprays, which, as a rule, are much less disagreeable to the 
patient. 
Fig. 44. 
Anterior Nasal Spray-Producer. 
Though a reserve ball for continuous spray is shown in the cut, one ball 
is quite sufficient. 
Spray-Producers.—There are a great variety of these instruments, 
most of those already described in connection with laryngeal disease 
* Deutsche Zeitschr. f. prakt. Med., 1877, No. 30. 
f Diseases of the Throat, etc, 2d ed., p. 360. 264 
DISEASES OF THE THROAT AND NOSE. 
(vol. i., pp. 250, 251) being also serviceable in affections of the nose. 
As a rule, however, it is best to use an apparatus the nozzle of which 
can be passed some distance into the nasal fossa. Two kinds of spray- 
producers are required, viz., the anterior and the posterior. 
The ordinary anterior nasal spray-producer (Fig. 44) consists of a 
silver pipe about three inches long, terminating in a fine perforated 
point, and provided with a piece of tubing and an elastic hand-ball. 
The same apparatus can be used for the posterior nares, but the tube 
carrying the medicated liquid should pass in a nearly horizontal direc- 
tion from the bottle, and its extremity should be directed upwards and 
slightly backwards (Fig. 45). Lefiferts prefers a conical nozzle (Fig. 
Fig. 45. 
Fig. 46 
Fig. 45.—Posterior Nasal Spray-Producer. 
Fig. 46.—Dr. Lefi'erts’s Nasal Spray-Producer with Conical Nozzle (after Beverley 
Robinson). 
46) which accurately fits into the nostril, and thus prevents any return 
of the medicated fluid. Owing to the prevalence of catarrh of the naso- 
pharynx in America, and the necessity of thoroughly cleansing that 
cavity when diseased, great attention has been given by physicians in 
the United States to the subject of spray-producers, and both the air- 
pump and water-power have been brought into requisition to give force 
and steadiness to the spray. The most convenient pneumatic spray- 
producer is that of Livingston (Fig. 47). It consists of an outer cyl- 
indrical chamber resting on a broad iron stand, and provided with an 
air-pump and pressure-gauge, the tube of which can be shut off from 
the air-chamber when desired. To the top of the receiver is fitted a 
long piece of elastic tubing, provided with a turn-tap at its point of 
exit, which communicates at its further end with the horizontal and 
perpendicular tubes of a spray-producer. In immediate connection NASAL INSTRUMENTS. 
265 
Fig. 47. 
Dr. Livingston’s Pneumatic Spray-Producer. 
A, air-chamber; B, handle by which the condensing pump is worked; C, spray 
apparatus, consisting of two slender metal tubes, one of which issues from a test tube 
holding the medicated fluid, whilst between the other (horizontal) tube and the elastic 
pipe E, connected with the air-chamber, there is a spring-valve which is governed by 
the thumb of the operator; a, communication (fitted with a turn-tap) between the 
pump and the air-chamber; b, stopcock between A and E; D, stand; c, pressure-gauge. 266 
DISEASES OF THE THROAT AND NOSE. 
with these tubes, and intervening between them and the elastic pipe of 
the pneumatic machine, is a little piece of metal tube bent at a right 
angle, and provided with a spring-valve which controls the communi- 
cation with the air-chamber. The perpendicular tube of the spray ap- 
paratus passes into a common test-tube, which contains the medicated 
fluid, and the operator, whilst holding the test-tube with his fingers, 
can manage the valve with his thumb. The tubes of the spray-appa- 
ratus are modifications in metal of Sass’s glass tubes, and their adapta- 
tion to the air-pump permits the spray to be projected in any direction 
with an amount of force which can be accurately regulated. 
In place of the air-pump, a hydraulic arrangement can be employed, 
a cistern at the top of the house supplying the pressure. A number of 
test-tubes, containing different medicated fluids, are all in communica- 
tion with an air-chamber, kept constantly full of condensed air by the 
aid of the water-pressure derived from the cistern, and the operator, at 
a moment’s notice, can make any spray-application desired. I recently 
saw an excellent form of this ingenious arrangement in working opera- 
tion in the consulting-rooms of Dr. Cheetham, of Louisville, Kentucky, 
and it seemed to me to constitute the best method of employing sprays 
hitherto invented. 
Inhalations.—Medicated steam inhalations used through the nose are 
sometimes serviceable, although seldom so beneficial as in the case of 
inflammation of the throat. Most of the inhalers already described (see 
vol. i., pp. 250-253) are provided with a special nozzle adapted for 
nasal inhalation, but the best instrument for the purpose is one lately 
devised by Dr. Whistler.* This consists of a vulcanite mould of the 
tip and alse of the nose, from the upper surface of which project two 
hollow conical pieces for insertion into the nostrils, whilst to the under 
part is attached a cylindrical chamber, which, by means of india-rubber 
tubing, can be made to communicate with an inhaler. The patient can, 
however, use this form of medication without any apparatus whatever 
by inhaling through the mouth and forcing the vapor back through the 
posterior nares, as is often done by tobacco smokers. 
Syringes.—For the injection of fluid through the anterior nares an 
ordinary straight glass or vulcanite syringe will serve perfectly, but for 
cleansing the posterior nares Solis Cohen’s instrument, which has a 
suitably curved nozzle (Fig. 48), will be found most useful. The point 
is perforated with many small holes like a rose, so that the fluid is 
thrown out in all directions. 
* Med. Times and Gaz., 1882, vol. ii., p. 737. NASAL INSTRUMENTS. 
267 
Cutting Instruments, Forceps, etc.—For cutting away vegetations or 
removing polypi, forceps or snares may be employed. The old-fash- 
Fig. 48. 
Dr. Solis Cohen’s Post-Nasal Syringe. 
ioned forceps, still commonly used by general surgeons for the evulsion 
of polypi, are shown in the annexed wood-cut (Fig. 49). The blades 
are serrated for about half their length and are slightly curved. This 
Fig. 49. 
Ordinary Polypus Forceps. 
forceps can often be employed successfully, but it is somewhat large, 
and, the handle being in a line with the blades, both the instrument 
and the operator’s hand obstruct the view of the growth. 
Fig. 50. 
Mr. Gant’s Yine-Scissor Forceps. 
Mr. Gant has invented a scissor-forceps (Fig. 50) on the principle of 
the vine or flower-scissors, one edge of either blade being like that of 
an ordinary scissors, and the other broad and rasped, so as to insure 
firmness of grasp, and to retain the growth after it has been divided. 
This instrument may be useful when the growth is unusually hard, but 
it is open to the objection already urged against the common forceps, 
viz., that it obstructs the view. 268 
DISEASES OF THE THROAT AND NOSE. 
The instrument which I generally use, and which in my hands has 
proved thoroughly satisfactory, is my “ punch-forceps” (Fig. 51). The 
handles are placed at such at an angle as to be altogether below the 
level of the blades, so that the surgeon’s hand in no way impedes his 
Fig. 51. 
a, small ridge or “ punch,” fitting, when the blades are approximated, into b, a 
fenestra in the corresponding portion of the other blade; d and c, joints where the 
male and female blades can be removed and their positions reversed, or, if desired, 
different kinds of blades may be substituted. 
The Author’s Punch-Forceps.* 
sight when operating. The blades themselves are slender and open in 
the vertical direction, so as to be well adapted for working in a narrow 
space. The special feature of the forceps, however, is that the lower 
blade carries on its surface a small projecting bar or punch of metal, 
Fig. 52. 
The Axial Polypus Forceps. 
corresponding to a fenestrated portion in the upper blade. A growth 
seized with these blades is generally cut through at once, but, if not, 
the forceps can of course be used for evulsion in the ordinary way; or, 
* This instrument, as well as the various others which have been invented by the 
author, is made by Messrs. Mayer & Meltzer, Great Portland Street. 269 
NASAL INSTRUMENTS, 
if it be desired, the blades can be changed and blunt ones substi- 
tuted. 
For the removal of very small growths situated in the upper part of 
the nose, the axial forceps, constructed on the principle of Burge’s 
Fig. 53. 
a, lock by which the handles can be fixed together; b, separate view of one blade 
showing the grooved centre and the serrated edges. 
Dr. Beverley Robinson’s Toothed and Locking Forceps. 
oesophageal instrument, in which, whilst the blades themselves open 
widely, their shanks scarcely move, will be found useful (Fig. 52). 
Fig. 54. 
Dr. George Stoker’s Rotatory Polypus Forceps. 
A shows the instrument open ; a, the spring catch; b, slit through which a passes 
when the blades are brought together; c, double cog-screw, allowing the stem of the 
instrument to be twisted round independently of the handle. B shows the blades locked 
and partly turned round. 
Beverley Robinson has modified the ordinary polypus forceps by 
making the point longer and more slender, and providing the handles 270 
DISEASES OF THE THROAT AND NOSE. 
with a lock (Fig. 53). The inner surface of the blades, moreover, has 
a groove along the middle, whilst the edges on each side are deeply 
serrated. This feature, combined with the locking of the handles, gives 
the instrument a powerful grip, and according to Robinson renders it 
very suitable for the evulsion of hypertrophied mucous membrane. 
A rotatory forceps for the extraction of polypi has been invented by 
my colleague, Dr. George Stoker, whereby, after the pedicle of the 
growth has been seized between the blades of the instrument, these can 
be fastened together by means of a spring catch, and then twisted on 
their own axis by turning a small handle. The annexed cut (Fig. 54) 
shows the mode of action of the instrument with sufficient clearness. 
Fig. 55. 
et, central pivot, through the perforated extremity of which slides b, connected with 
the handle,/; c, upper, and d, lower blade of the forceps; e, rest for the operator’s 
right forefinger. 
The Author’s Nasal Bone-Forceps. 
For the removal of portions of the turbinated bones and nasal exos- 
toses, I have had an instrument made which combines the grasping 
power of ordinary forceps with a cutting blade. The instrument (Fig. 
55) consists of deeply-grooved blades, somewhat flattened from side to 
side, opening vertically, and constituting a tube when closed. Each 
blade, in point of fact, is a half tube, and has therefore an inner and 
an outer edge. The inner edges of each blade (those which, when the 
instrument has been introduced, are nearest the septum) are slightly 
serrated to enable the operator to seize the turbinated bone securely. 
Within the tube formed by the closed blades, a third blade, bevelled at 
its anterior extremity to a sharp edge, like a chisel, can be projected flor- NASAL INSTRUMENTS. 
271 
wards when the instrument is in position. The forceps is introduced 
with the chisel drawn back, and the tissue to be removed having been 
firmly grasped with the forceps, the cutting-point is driven home, with 
the operator’s free hand. 
Snares and Jfcraseurs.—Snares have been used for many years for 
the removal of polypi. The best known instrument of this sort is that 
Fig. 56. 
(This instrument has now only an historical interest, having been superseded by snares of 
simpler and more convenient construction.) 
Hilton’s Improved Snare. 
of Hilton* (Fig. 56), which consists of a quadrangular shank, ter- 
minating at one end in a ring for the thumb of the operator, and at the 
other in a tapering nasal portion. A cross-bar to which the ends of 
Fig. 57. 
The Author’s Polypus Snare. 
a, the wire; b, tube along which the wire is passed; c, centre-piece of the crossbar; 
e, finger-rest; d, centre-piece to which e and / are fixed; /, thumb-rest; g, ring for 
thumb. 
the wire are secured slides on the quadrangular part of the shank. The 
distal end of the nasal part is bulbous, and is perforated in the longi- 
tudinal direction with two holes, through which the wires pass to form 
* For information concerning the origin of this instrument, see the History of Non- 
malignant Tumors of the Nose. 272 
DISEASES OF THE THROAT AND NOSE. 
a loop beyond the point of the instrument. This instrument has been 
improved in recent years by Clarence Blake of Boston, Zaufal, and 
myself. The straight shank was first bent at a suit- 
able angle by Blake, an arrangement permitting an 
uninterrupted view of the entire operation of evul- 
sion. In Zaufal’s instrument the wire at its distal 
extremity rests on two little rods, and the loop is only 
formed when the rods are thrust forwards. The loop, 
therefore, is not bent or pushed on one side, as is apt 
to be the case during its introduction into the nose, 
and the wire is only “paid out” when the tip of the 
instrument is close to the polypus. 
My own improvements consist in slight modifica- 
tions of Blake’s instrument, by which it can be more 
easily held, and the wire more readily pulled home. 
In my snare (Fig. 57) the thumb of the practitioner, 
after passing through a ring on the upper surface of the 
handle, is received into a slightly concave metallic rest, 
which can be slid along the handle and fixed at any 
point which suits the hand of the operator. Below 
this rest a tapering trigger-shaped crutch projects, 
upon which the tip of the ring-finger is placed. 
The great attention which has recently been given 
to hypertrophy of the turbinated bodies has led to the 
invention of several instruments for the removal of 
the redundant tissue. Among these must be espe- 
cially mentioned a very delicate and, at the same time, 
highly practical form of snare which has been devised 
by Jarvis, of ISTew York.* 
The instrument (Fig. 58) consists of a straight 
nickel canula, seven inches in length and one-sixteenth 
of an inch in diameter. Its outer surface is smooth 
for four inches from the distal end; but for the rest 
of its length it is wormed. Over this portion is fitted 
a second canula somewhat larger in bore; this is smooth exteriorly, but 
grooved on its inner surface to prevent any rotation. Over the screw- 
thread runs a small wheel, half an inch in diameter and three-sixteenths 
Fig. 58. 
Dr. Jarvis’s Nasal 
Eeraseur (after 
Bosworth). 
* The value of the principle of this instrument may be gathered from the fact that 
within six months of its description having been published, no less than seven modi- 
fications or so-called “improvements” were brought out in America and England. NASAL INSTRUMENTS. 
273 
of an inch thick, roughened on the outer edge, and so arranged as, 
when it is turned, to push before it the movable canula. At the prox- 
imal extremity of this outer tube are two small pins, round which the 
ends of the wire may be secured after being drawn through the whole 
length of the inner canula. The loop of wire that projects from the 
distal extremity of the canula may, of course, be of any size that is 
required. The advantages of the instrument are that it can be easily 
worked, and that the loop of wire may be tightened, either sloivly by 
turning the wheel and thus gradually pushing down the outer tube on 
which the wire is fixed, or quickly by pulling back the outer tube itself. 
It is obvious that this little instrument is well adapted for removing 
mucous polypi as well as hypertrophied mucous membrane. 
Fig. 59. 
The Author’s Nasal flcrasetir. 
a, the wire passing from the end of the barrel to the two reels b ; c, cog-wheel; d, 
Stop-spring which, by pressing on the button /, is released, allowing the reels to be un- 
wound; e, tooth controlled by the spring g, which, in its turn, is acted on by lever h; 
i, spiral spring raising lever after use; j, short cylindrical portion of shaft in which 
the proximal end of the barrel is contained. 
My former assistant, Jefferson Bettman, now of Chicago, has modi- 
fied Jarvis’s instrument by having the end of the tube flattened, so that 
the point of exit of the wire can be placed in closer apposition to the 
surface on which it is desired to operate. The modified snare, more- 
over, is made in several parts, and tubes of various calibre, length, and 274 
DISEASES OF THE THROAT AND NOSE. 
shape, can be substituted for the original straight one. By this means 
the snare can be used for the posterior nares. Another advantageous 
feature in Bettman’s snare is that, instead of having to be twisted round 
pegs, the free ends of the wires are fixed by means of a clamp screw, 
which can be tightened or slackened at pleasure. 
An excellent modification of Jarvis’s snare has lately been made by 
Bosworth,* who has had it bent at the proper angle for nasal instru- 
ments. 
Ecraseurs.—For the removal of the denser varieties of polypus, I 
have found the ecraseur represented in the accompanying woodcut (Fig. 
59) very useful. In this instrument the wires are threaded through a 
barrel and wound round two reels by means of a lever, which works 
a cog-wheel. The barrel is about nine centimetres in length, and is 
flattened for about twenty millimetres at the distal end to allow of more 
easy insertion into a narrow channel. 
Electric Cautery.—The electric cautery is extremely useful for the 
destruction of polypi, of hypertrophied mucous membrane, and car- 
Fig. 60. 
Dr. Lowenberg’s Nasal Electrode. 
tilaginous outgrowths. For application within the nose any of the 
electrodes already described (vol. i., p. 488) can be employed, the wires, 
however, being previously suitably bent. For the last four years I 
have employed Schech’s admirable electrodes,f which enable the opera- 
tor to treat almost any case. For the application of cautery to the 
central portion of the nasal fossa Lo wen berg’s instrument (Fig. 60) 
has, however, the great advantage that it can be readily used without a 
shield; for the incandescent point, instead of being placed at the distal 
extremity of the electrode, is situated at the side on one of the wires, 
so that when in the nose the other wire protects the healthy parts. 
* Philadelphia Med. News, Feb. 24th, 1883, p. 230. 
f Made by Albrecht, of Tubingen, at a very moderate cost. NASAL INSTRUMENTS. 
275 
For applying the electric cautery to the vault of the pharynx, Lin- 
coln has invented an ingenious apparatus (Fig. 61). It consists of an 
electrode, around which is fixed a spiral spring, ending in a bell-shaped 
shield of bone, which projects beyond the electrode and conceals a 
FrG. 61. 
Dr. Lincoln’s Post-Nasal Electrode (after Beverley Robinson). 
A, the complete electrode, showing, b, spiral spring and, c, shield; b, portion of elec- 
trode showing the disk d uncovered; c, disk surrounded by shield. 
platina disk which terminates the electrode. When the instrument is 
pressed against the tissue to be destroyed, the shield is forced back on 
the spring, and the electrode is thus allowed to come into contact with 
the affected part. 
Post-Nasal Forceps.—For removing growths from the vault of the 
pharynx, and from the neighborhood of the posterior nares, Lowen- 
berg’s curved forceps and my own sliding forceps are both of service. 
Fig. 62. 
Dr. Lowenberg’s Post-Nasal Forceps. 
The former (Fig. 62) is an instrument with long slender curved handles 
and very short blades turned upwards from the rivet at an obtuse angle. 
The blades are scooped out on their inner surfaces, and each ends in a 
sharp, somewhat overhanging, edge, which comes into apposition with 276 
DISEASES OF THE THROAT AND NOSE. 
the corresponding part of its fellow when the handles are closed. My 
colleague, Hr. Woakes,* recommends that the cutting edges should be 
carried further round the blades than was the case in Lowenberg’s 
earlier instruments. 
My own instrument (Fig. 63) consists of a male and a female por- 
tion. The latter is a straight cylindrical tube open on the upper aspect 
throughout its whole length, and ending in a sharp spoon-shaped blade 
at the distal extremity; the male portion is composed of a solid shank 
playing backwards and forwards in the cylindrical part of the other 
limb of the instrument, and terminating in a blade of similar shape to 
the other, directed so that when the two are brought together the cut- 
ting edges correspond. The handle is fixed to the under surface of the 
Fig. -63. 
The Author’s Sliding Post-Nasal Forceps. 
proximal end of the female portion, the rivet being close to the body of 
the instrument, and the limbs placed one behind the other. The an- 
terior one is fixed, and to the posterior, which can be moved backwards 
and forwards, is attached a lever which traverses a slit in the anterior 
limb to the under surface of the cylinder, where it is fixed to a pin con- 
nected with the shank of the male portion. The opening along the top 
of the cylinder allows the upturned blade of the male portion to be 
pulled back as far as the limbs of the handle can be opened. The in- 
strument is better adapted for the removal of growths from the sides of 
the pharynx, whilst Lo wen berg’s is more suited for operating on those 
on the vault and posterior wall. 
Michael,f of Hamburg, has invented an instrument for the re- 
moval of adenoid vegetations, which he states that he has used for 
the last three years. He calls it a double chisel, but it is, more 
* Trans. Intern. Med. Congress, London, 1881, vol. iii., pp. 295, 296. 
f Berlin, klin. Wochenschrift, 1881, No. 5. NASAL INSTRUMENTS. 
277 
strictly speaking, a cutting forceps. The blades are turned up at a 
right angle from the stem, the angle, however, being well rounded, and 
the cutting edge extending three centimetres beyond that point. It 
differs from other forceps of an analogous character in the circumstance 
that the principal cutting part of this instrument is at the angle and not 
at the point as in Lowenberg’s and my own. I may add that I have 
not found Michael’s instrument at all convenient. 
In removing post-nasal vegetations, Meyer, of Copenhagen, prefers 
to use his own “ ring-knife.” This “consists, first, of a little ring of a 
transverse oval shape, its axes being 1.4 and 1 centimetre respectively, 
and its breadth 1.5 millimetre, having one edge sharp, although not abso- 
lutely cutting, and the other one rounded off; and secondly, of a slender, 
stiff, but at the same time flexible stem ten centimetres long, bearing 
the ring at one extremity, fixed into a roughened handle at the other.”* 
Fig. 64. 
Prof. Stoerk’s Post-Nasal Snare. 
Meyer’s plan of operating is to introduce this instrument through the 
patient’s nose into the naso-pharynx witli the right hand, whilst the left 
index finger is passed into the mouth behind the velum, where it is 
made to press the vegetations against the edge of the ring-knife, which 
must at the same time be drawn downwards so as to scrape away the 
excrescence. The stem being flexible, the knife can be bent towards 
one side or the other as may be necessary. 
Stoerk has had a special loop (Fig. 64) adapted to his laryngeal guil- 
lotine (Fig. 48, vol. i., p. 263) for the removal of post-nasal growths. 
By means of this instrument I have several times taken away vegeta- 
tions from the vault of the pharynx. 
For the removal of small post-nasal vegetations Capart has suggested 
the use of a sharp spoon (Fig. 65) which can be fastened on the index 
finger by means of a metallic sheath composed of two rings, held 
together at each side by rivets, so that sufficient play is allowed for 
* Med.-Chir. Trans., London, 1870, vol. liii., pp. 211, 212. 278 
DISEASES OF THE THROAT AND NOSE. 
them to be moved when the finger is bent. On the palmar surface of 
the distal ring is the spoon. The little instrument thus serves to carry 
the blade, and to protect the operator’s finger whilst it is in the patient’s 
Fig. 65. 
Dr. Capart’s Finger Sheath with Cutting Spoon. 
A, the position of the hand and finger in holding the spoon ; a, lateral view of the 
cutting spoon, b, enlarged view of the two parts of the metal sheath; a', cutting 
spoon. 
mouth. Many surgeons, however, prefer the natural cutting edge pro- 
vided by a sharp forefinger nail. 
For the purpose of removing small sequestra of bone or other broken- 
down tissue, or of “ vitalizing” the borders of an indolent ulcer within 
Fig. 66. 
Nasal Curettes or Sharp Spoons. 
a, spring-catch; b, articulation of the stem with the handle, which ends in a ring to 
receive it; the catch a is shown in position in the upper woodcut. 
the nasal cavity, Volkmann’s cutting spoons are very useful. I have 
had curettes of various sizes fitted to a handle at the proper “nasal 
angle” (Fig. 66). 
Haemostatic Instruments.—For arresting haemorrhage from the nose, 
plugging the nostrils anteriorly is often found insufficient, and it then 
becomes necessary either to close the posterior nares, or to apply press- NASAL INSTRUMENTS. 
279 
ure within the nose. Hence there are post-nasal plugs and intra-nasal 
plugs. 
Of the former kind of instrument Bellocq’s well-known sound (Fig. 
67) is the best. It consists of a piece of a watch-spring, attached to a 
stylet contained in a canula. The watch-spring is fixed by a screw to 
the proximal end of the stylet, so that the point holding the string pro- 
jects beyond the canula. After the instrument has been introduced 
through the nose, the screw is turned round, so that the watch-spring 
runs down the stylet, and becomes attached to its lower end, while its 
free extremity projects into the pharynx near the base of the tongue, 
allowing the string to be readily seized with the fingers or forceps. A 
Fig. 671 
Bellocq’s Sound. 
A, the instrument with the stylet x armed with a thread and ready for use; b, the same 
after introduction through the nares, the stylet x appearing at the back of the mouth. 
firm pledget of lint, sufficiently large to cover both choanse completely, 
should be tied to the string, which is then drawn back through the nose 
and fastened round the ears. The string should be further secured to 
the face by strips of plaster. This instrument, however, is very seldom 
at hand when wanted, and an ordinary flexible catheter will be found 
quite as useful. The most efficient post-nasal plug, however, is that of 
St. Ange* (Fig. 68). This instrument, which bears the formidable name 
of “ rhinobyon,” consists of three parts, viz., a small syringe; a tube 
opening at its distal end into an india-rubber bag; and a small pilot 
* Lapeyroux: Mbthode pour arr§ter les nasales, Th&e de Paris, 
1836, No. 314. In the original instrument there is a tap in the india-rubber tube, 
instead of the little clip above mentioned. Kiichenmeister subsequently invented an 
instrument which he called a “rhineurynter,” closely resembling the one here described. 280 
DISEASES OF THE THROAT AND NOSE. 
sound. The pilot is introduced into the tube, and the bag is thus 
passed through the nose into the naso-pharynx, when the pilot is with- 
drawn, and the nozzle of the syringe being fitted to the mouth of the 
Fig. 68. 
St. Ange’s Kirinobyon, or Post-Nasal Plug. 
A, syringe for injecting air or water; b, india-rubber tube or bag; c, pilot for bag. 
After the bag has been introduced, the point x of the syringe fits into the orifice z. 
tube, air is injected and the bag distended to such an extent as to cover 
the choana. A little clip attached to the tube keeps it closed when the 
syringe is withdrawn. 
Of intra-nasal plugs J. P. Frank* appears to have been the inventor, 
for he was the first to devise a special instrument (if such it can be 
called) to bring pressure to bear directly on the walls of the nasal fossae. 
He introduced into the nose a piece of dried hog’s intestine, tied at the 
distal end, and then injected water into the open end projecting from 
the nostril, tying up the gut as he withdrew the syringe. The best 
* De curandis liominum morbis, Mannhemii, 1807, lib. v., pars in, p. 144. 281 
NASAL INSTRUMENTS. 
form of instrument, however, for this purpose, is that invented by Dr 
Cooper Rose (Fig. 69). It consists of a thin india-rubber bag con- 
nected with a tube, provided with a stopcock. The bag is introduced 
empty into the nose and passed along the fossa, when it is inflated by 
Fig. 69. 
Dr. Cooper Hose’s Intra-Nasal Plug* (after Spencer Watson). 
A, the instrument as ready for introduction into the nose; b, the same expanded with 
air. 
blowing through the tube. The tap should then be turned off and the 
instrument left in situ as long as may seem desirable. 
Instruments for the Removal of Foreign Bodies from the Nasal Cavi- 
ties.—Gross’s instruments, shown in the annexed woodcut (Fig. 70), 
* This instrument is made by Messrs. Coxeter, Grafton Street East. 282 
DISEASES OF THE THROAT AND NOSE. 
may be found useful. They consist of little scoops, cork-screw points 
and booklets. For the extraction of small nasal calculi, slender forceps 
Fig. 70. 
Professor Gross’s Nasal Spuds (after Solis Cohen). 
(Fig. 71) have been recommended. The blades, which are scissor- 
shaped, and terminate in roughened bulbous ends, articulate only after 
Fig. 71. 
Forceps for Removing small Foreign Bodies (after Spencer Watson), 
they have been passed separately into the nose. Instruments bent at 
the proper angle (Figs. 39 and 51) will, however, generally be found 
more convenient, as they do not obstruct the view of the operator. 
Fig. 72. 
Mr. Adams’s Forceps for Breaking Down the Septum. 
Other Instruments.—For the remedy of deformities of the nose, aris- 
ing from congenital deviation or badly-set fracture of the septum, NASAL INSTRUMENTS. 
283 
Adams* employs a pair of powerful forceps (Fig. 72), with smooth 
flat blades, which can be easily introduced into the nasal fossae and 
made to grasp the partition between them. With this instrument it is 
easy either to separate the cartilaginous from the bony part of the sep- 
tum, or to fracture the former, if desired. The fragments are retained 
in their new position by means of two little splints made either of ivory 
or steel, one being placed in each nostril, and the two fastened together 
outside with strings. These splints, however, cannot be kept in appo- 
sition without a truss to make pressure on the upper fragment, and an 
ingenious arrangement for this purpose has been devised by Adams.f 
Jurasz,! of Heidelberg, was led to improve upon this plan on find- 
ing that the septum regained its wrong position when he withdrew the 
forceps, before there was time to adjust the splint. He therefore modi- 
fied Adams’s instrument by having the blades and shanks of the forceps 
separate, though screwed together. The instrument is introduced, the 
septum broken, the shanks unscrewed, whilst the blades, locked to- 
gether on the principle of the ordinary midwifery forceps, remain in 
the nose to act as splints. 
Fig. 73. 
Dr. Gottstein’s Cotton-Wool Tampon. 
A, screw armed with wadding-tampon; b, the naked screw. 
For plugging the nasal fossse in cases of ozsena, Gottstein’s cotton- 
wool tampon (Fig. 73) is extremely useful. All that is required is a 
screw about fourteen millimetres long, terminating in a shank fixed to 
a handle. Round this screw a small piece of wadding is twisted. The 
instrument is then inserted into the nasal channel, when the screw is 
reversed and withdrawn, leaving the cotton-wool accurately in position. 
Temporary Sponge-Tampon for the Posterior Nares.—In the case of 
infants and very young children sprays should not be used through the 
* Med. Soc. Proceedings, April 26th, 1875, London, 1874-75, vol. ii., pp. 99, 100. 
f Brit. Med. Journ., 1875, vol. ii., pp. 421, 422. The instrument has been consider- 
ably modified by Mr. Adams since he first published a description of it. It is sold by 
Mr. Gustav Ernst, Charlotte Street, Fitzroy Square. 
J Berlin, klin. Wochenschrift, 1882, No. 4. 284 
DISEASES OF THE THROAT AND NOSE. 
anterior nares without care being first taken to prevent the fluid from 
running through the posterior nares into the larynx. These openings 
should, therefore, be temporarily plugged. This can be most conve- 
niently effected by passing a small sponge into the naso-pharynx by 
means of the instrument shown in the annexed woodcut (Fig. 74). 
Fig. 74. 
The Author’s Temporary Sponge-Tampon for the Posterior Nares. 
a, stem; b, handle; c, holes through which the pad can be stitched to the tip; d, sponge. 
This consists of a short metallic stem fitted to a wooden handle at the 
proper “nasal angle/’ and curved upwards at its distal end into a bul- 
bous perforated point. A piece of sponge is stitched to the point of 
the instrument. 
ACUTE NASAL CATARRH. 
(Synonyms : Cokyza ; Cold in the Head.) 
Latin Eq.—Gravedo; Catarrhus narium. 
French Eq.—Catarrhe nasal. 
German Eq.—Schnupfen. 
Italian Eq.—Corizza. 
Definition.—Acute catarrhal inflammation of the Schneiderian mem- 
brane, causing sneezing, more or less obstruction of the nasal passages, 
and hyper-secretion of an irritating serous or sero-mucous fluid. 
History.—Until the seventeenth centnrv it was the belief of physicians that coryza 
was a flux of serous fluid from the cerebral ventricles, and a “ cold in the head ” was ACUTE NASAL CATARRH. 
285 
looked upon as a ‘‘ purging of the brain.” This idea prevailed till Schneider* gave a 
more correct account of the anatomy of the nose, and, in particular, of the function of 
the membrane that bears his name. Within the succeeding century several works 
were published on catarrh by Wedel,f P. Frank,J Camerarius,| Stoll,|| and others, but 
no fresh light was thrown op the subject till J. P. Frank,f towards the close of the last 
century, gave a very full account of the complaint. Several years afterwards Bayer** 
published a short monograph, in which he showed howr dangerous the affection is to 
sucklings. In the elaborate treatise on the nose by Cloquet,ff a chapter is devoted to 
coryza, which is equally remarkable for antiquarian lore and practical wisdom. In 
1837 BillardJJ followed up the clinical investigations of Rayer in relation to infantile 
catarrh. In the same year the subject was discussed by Anglada$$ at some length, but 
with no novelty of view as regards either the nature or the treatment of the malady. 
Since then the writings of Bouchut,|||| Kussmaul,ff and Kohts***have elucidated the 
affection, especially as regards infants. Vauquelinfff appears to have made the ear- 
liest investigations on coryza from the chemical point of view, but DondersJJJ was the 
first to publish a detailed analysis of the secretion. Friedreich£§| made some experi- 
ments on the inoculability of the disease, and to Ranvier|||||| we owe an elaborate account 
of coryza from the purely pathological standpoint. 
Etiology.—The causes of catarrh in general have already been dis- 
cussed in previous sections (vol. i., pp. 30 and 268), and only a few 
remarks need be made here concerning the etiology of nasal catarrh. 
As in most other diseases, there are predisposing and exciting causes. 
Among the former youth is one of the chief, children being particu- 
larly subject to coryza. The comparative immunity of the aged was 
recognized as far back as the time of Certain consti- 
tutional conditions seem to render the mucous membrane more suscep- 
tible to catarrh, and this is especially seen in the strumous diathesis. 
* De catarrhis, Wittenberg®, 1664. 
f Casus laborantis coryza, Jen®, 1673. 
J Dissert, de coryzfi, Heidelberg, 1689. \ De coryz&, 1689. 
|| Ratio Medendi, t. iii., p. 44. 
T[ De curand. homin. morbis, Mannhemii, 1794, lib. v., p. 102 et seq. 
** Sur le Coryza des Enfants a la Mamelle, Paris, 1820. 
ff Osphresiologie, Paris, 1821. 
Maladies des Nouveau-n6s, Paris, 1837, 3me ed., p. 502 et seq. * 
\\ Sur le Coryza simple, Thbse de Paris, 1837. 
1111 Traite pratique des Maladies des Nouveau-nfes, Paris, 1867. 
Zeitschrift fiir rationelle Medicin, 1865. 
*** Krankheiten d. Nase, in Gerhardt’s Handbuch d. Kinderkrankheiten, Dritter 
Bd., Zweite Iliilfte, Tiibingen, 1878. 
tff Quoted by Anglada, op. oit., p. 16. 
JJJ Nederlandsch. Lancet, 1849-50, 2 series, v., j). 312. 
\\\ Virchow’s Handb. d. Pathol, und Therapie, Erlangen, 1865, Bd. v., Abtheil I., 
p. 398. 
HI Soc. de Biologie de Paris. Summary in Lancet, 1874, vol. i., p. 687. 
Aphorism, Paris, 1844, ii., 40, Littrtfs ed., t. iv., p. 483. 286 
DISEASES OF THE THROAT AND NOSE. 
In these cases there is not unfrequently at the same time chronic en- 
largement of the tonsils, and sometimes catarrh of the naso-pharynx 
with obstruction of the Eustachian tubes. The nasal disease may be 
the cause or the consequence of these conditions, or, in some cases, all 
the phenomena may depend on a general dyscrasia. People of rheu- 
matic constitution, and those in whom the sweat-glands act feebly, are 
also prone to nasal catarrh. Alibert* maintains that persons of decidedly 
nervous temperament are especially liable to the complaint, and he 
states that he has seen extremely acute forms of nasal catarrh, with 
very profuse secretion, occur in women after convulsions. Asthmatic 
people are particularly liable to the affection, and hay fever may be 
regarded as a connecting link between these two disorders. 
Exposure to cold, under certain circumstances, is very apt to cause 
catarrh, but the exact mode of its operation is uncertain. Cold cur- 
rents of air on the head are familiarly recognized as a cause of the dis- 
order, and the bald are in this respect, of course, peculiarly vulnerable. 
Cloquetf was of opinion that the frequent occurrence of coryza, after 
getting the feet wet or cold, was to be explained by some special sym- 
pathy between the feet and the pituitary membrane, a connection which 
he attempts to support by an isolated case, in which nasal catarrh was 
always a concomitant of gout in the toe.J The truth seems to be that 
catarrh so frequently results from wet feet simply because those ex- 
tremities are exposed to wet and cold more often, and for longer periods 
than any other covered portion of the body. 
The influence of heat in producing catarrh is less generally recog- 
nized, and its mode of action is very imperfectly understood. Its 
effects are seen under two conditions: first, where the disease results 
from exposure to the sun; secondly, where it follows confinement in 
hot rooms. The catarrhal symptoms, arising from exposure to the 
sun, may be due to direct irritation by the solar rays, or it may be of 
reflex character, i. e., dependent upon the impression on the retina. 
Coryza resulting from confinement in a hot room is generally observed 
in persons of enervated constitution, whose mucous membrane has been 
relaxed by previous attacks. 
The influence of irritating vapors, or solid particles suspended in the 
air, in producing inflammation of the pituitary membrane, will be con- 
sidered under “ Traumatic Rhinitis,” and the effects of the pollen of 
certain grasses will be treated of under “Hay Fever.” In connection 
* Obs. sur les Affections Catarrhales en G4nferal, Paris, 1813. 
f Op. cit., p. 602. | Compare Stoll: Ratio Medendi, v., p. 436. ACUTE NASAL CATARRH. 
287 
with the action of local irritants it may be observed that the sensi- 
bility of the nasal mucous membrane becomes blunted in the case of 
the habitual snuff-taker, in whom also the liability to catarrh is dimin- 
ished.* 
Occasionally coryza appears to be due to epidemic influences, and 
several persons in the same house, the dwellers in a particular street, or 
even the inhabitants of a whole town, may be observed to suffer simul- 
taneously. The supposed epidemic described by Anglada,f in which 
an entire army became suddenly affected with catarrh, is, however, 
probably only an illustration of the ordinary mode in which cold is 
caught. The French troops, after spending the greater part of a very 
hot and dry summer in Andalusia, were caught in a violent storm after 
a long and fatiguing march. This was immediately followed by an 
almost universal In short, coryza can only be said to occur 
epidemically, in so far as a sudden lowering in the temperature, with 
increased humidity of the air, may cause the malady to be widespread. 
Although there is a belief among the laity that a cold can be “caught” 
from a person laboring under the disorder, there is no evidence that 
coryza is infectious, and it is very doubtful whether it is ever spread 
by contagion. Immediate contact,§ especially in kissing, is, however, 
thought by many to be a common mode of spreading the complaint. 
Frankel|| states that he has seen several cases which appeared to origi- 
nate in this way. But the only attempt at direct inoculation with which 
I am acquainted is that of Friedreich,who endeavored to generate the 
disorder in his own person, by applying the secretion taken from per- 
* Plugging the nose with tobacco was formerly thought a good protective against 
‘‘catching cold.” Sir William Temple is said to have kept a leaf of tobacco up each 
nostril for an hour every morning, in order to drain the secretion from the eyes and 
head. In this way he fancied that his sight was preserved, at the same time that lia- 
bility to coryza was diminished. (Sigmond : Lectures on Materia Medica at Wind- 
mill Street.) Lancet, 1836-37, vol. ii., p. 157. 
f Op. cit., p. 16. 
J Cloquet has alluded to an epidemic of coryza among dogs (Stoll: Ratio Medendi, 
t. iii., p. 44), and his observations have been repeatedly quoted by subsequent writers. 
On referring to the original text of Stoll, however, it is clear that the epidemic was 
one of distemper: “tussis laboriosa, spontanese vomitiones, putrilago vomitibus refusa, 
extrema macies, et tandem veluti quorundam artuum semi-paralysis, et mors.” 
\ The belief in the contagious nature of coryza appears to have existed for several 
centuries. Thus, more than two hundred and seventy years ago Crato spoke of 
“coryzse halitu etiam contagiosae. Id cum vulgus in Germanic sciat, non facile ex 
eodem poculo, e quo coryza laborans potum hausit, bibit.” (Johannes Crato in Epist. 
Philosoph. Med., Hanoviae, mdcx. Ep. cvi., p. 188.) 
|| Ziemssen’s Cyclopaedia, vol. iv., p. 117. Tf Loc. cit. 288 
DISEASES OF THE THROAT AND NOSE. 
sons in various stages of coryza to bis nasal mucous membrane. The 
results of this experiment, however, were entirely negative. 
The suppression of habitual discharges is sometimes followed by the 
development of coryza. Cloquet* mentions that the disorder may 
follow the cure of chronic ophthalmia, the stoppage of bleeding from 
piles, the cessation of the menstrual flow, or even the disappearance of 
a rash. I have myself frequently noticed an increased susceptibility 
to nasal catarrh in delicate women during or immediately after the cata- 
menial period, but I am inclined to consider the occurrence of catarrh 
under these circumstances to be due to the temporarily lowered vitality 
which affects the whole system. I have also several times seen coryza 
follow the cure of chronic otitis. 
Nasal catarrh frequently complicates the exanthemata, especially 
measles, small-pox, scarlatina, and typhus; it also accompanies facial 
erysipelas, and is nearly always one of the earliest and most marked symp- 
toms of influenza.f In measles there can be little doubt that the con- 
gested appearance of the nasal mucous membrane is, in fact, the eruption 
itself, whilst in scarlatina the coryza seems usually to be caused by an ex- 
tension of the inflammatory process from the throat. In typhus, the 
pituitary membrane merely shares in the general catarrhal affection of 
the mucous tracts. 
Nasal catarrh, as a symptom of iodism, is a familiar fact of medical 
experience.^ 
Symptoms.—A cold in the head is of such everyday occurrence that 
a very brief description of the symptoms will suffice. Like other dis- 
orders of an inflammatory nature, the first indications are those of py- 
rexia, viz., lassitude, chilliness, and occasionally, but very rarely, a 
slight rigor. The first sensation, however, which points distinctly 
to the nature of the attack, is a feeling of fulness and sometimes 
of throbbing or pain in the frontal region, and this symptom is soon 
* Op. cit., p. 602. 
f At the commencement of nasal diphtheria, coryza is occasionally present, but, as 
has already been remarked (vol. i., p. 193), the actual membrane nearly always forms 
first in the pharynx, and from thence extends into the nares. 
J In accordance with the germ theory, so much in vogue at the present day, it has 
been suggested that nasal catarrh maybe caused by a specific germ. Indeed, Salis- 
bury (Haller’s Zeitschrift, .Jena, January, 1873, p. 7) has described and figured this 
germ under the name of Asthvmtos CiUaris. It has also been seen by Ephraim Cutter 
and P. F. Reinsch (Virginia Med. Monthly, November, 1878), and, on one occa- 
sion, by Daykin, a pupil of Salisbury, who remarks that he had “ had a nice time 
looking at the animal” (see Coomes: Pharyngeal Catarrh, Louisville, 1880, p. 134). 
Notwithstanding this confirmation, minute organisms are so common even in healthy 
secretions that further observations are necessary before this view can be accepted. ACUTE NASAL CATARRH. 
289 
succeeded by paroxysms of sneezing of greater or less severity. In a 
short time the nares become blocked up from swelling of the mucous 
membrane, and after a few hours, the characteristic state of hyper- 
secretion is established. The local phenomena relating to the discharge 
from the nasal mucous membrane are seen in four stages: The lining 
membrane of the nose is first slightly swollen} then an abundant irritat- 
ing watery secretion takes place, afterwards this becomes thick and muco- 
purulent and loses its irritating quality, and finally the discharge gets 
thin again, without recovering its irritating properties, and gradually 
ceases altogether. The time occupied by these various stages differs, 
some catarrhs passing off in three or four days, whilst others last as 
many weeks. The duration of the attack principally depends on the 
length of time which the third and fourth stages occupy; for the dry- 
ness of the mucous membrane rarely continues more than a few hours, 
and the abundant irritating secretion seldom causes trouble for more 
than one or two days. 
The watery fluid of the second stage is decidedly saline, and from its 
irritating quality it often causes excoriation of the skin about the mar- 
gin of the nostrils. Together with these symptoms there is usually 
more or less impairment of the sense of smell. When the anterior 
nares are completely obstructed, the voice has a nasal twang in all its 
tones, whilst when the- stoppage is confined to the posterior nares, 
the general character of the voice is normal, but the articulation 
is defective, m becoming b, and n being sounded as d. Of course, if 
the obstruction affects the whole nasal passage, both the general and 
the special defects are present. These points have been explained in 
connection with the post-nasal growths by Lowenberg,* andSeilerf has 
recently shown that the peculiar tone of the voice caused by obstruction 
of the anterior nares is due to the fact that the nasal cavities can no 
longer act as a reverberating chamber, while post-nasal obstruction 
simply interferes with that free passage of air which is necessary for the 
articulation of the letters m and n. 
The course of a simple attack of acute nasal catarrh just described in 
detail is, however, often arrested or modified, and almost any of the 
symptoms, except the discharge, may be entirely absent. 
On the other hand, when the bony cavities communicating with the 
nose are involved in the catarrhal process, the symptoms are sometimes 
more troublesome. If the antrum of Highmore becomes affected, there 
* Tumeurs addnoi'des du Pharynx nasal, Paris, 1879, p. 26. 
f Archives of Laryngology, January, 1882, vol. iii., No. 1, p. 24. 290 
DISEASES OF THE THROAT AND NOSE. 
will be severe pain in the cheek, whilst extension to the frontal sinuses 
causes a dull pain in the forehead, and if the ethmoidal and sphenoidal 
cells become implicated, the headache becomes intensified. Ringing in 
the ears and deafness point to temporary blocking up of the Eustachian 
tube, and the occurrence of epiphora shows that the lachrymal duct is 
obstructed. Slight but painful abrasion of the nasal mucous mem- 
brane near the margin of the nostrils and herpes labial is are often 
troublesome concomitants. In infants coryza sometimes produces such 
dangerous symptoms that it will be more convenient to deal with them 
separately (see p. 293). 
Diagnosis.—An ordinary catarrh can scarcely be mistaken for any 
other affection, but it must be remembered that it is sometimes a pre- 
monitory symptom of some acute specific disease, and when there is 
much conjunctival inflammation the likelihood of the development of 
measles should be borne in mind. Still more rarely nasal catarrh may 
simulate disease of the bones. Thus Peter* relates a case in which 
there was such severe pain in the brow at the outset that the complaint 
was regarded as one of “ acute caries ” of the frontal bone, but on the 
application of a poultice to the root of the nose a profuse discharge was 
established, which almost instantly relieved the pain and proved the 
case to be one of coryza. 
Prognosis.—In the great majority of cases complete recovery takes 
place, and it is only in old people and very young children that coryza 
is attended with any danger; but it may terminate in chronic catarrh 
with much thickening of the mucous membrane, or it may lead to the 
development of polypi. 
Pathology.—The process is essentially one of active congestion of the 
pituitary membrane followed by serous exudation. The fluid is stated 
by Cornil and Ranvierf to contain lymph-corpuscles from the outset, 
and epithelial cells are found in increasing numbers as the catarrhal 
condition advances, the discharge being thus rendered at first cloudy 
and afterwards opaque. The mucous membrane is red and tumid, and 
numerous small tortuous vessels are often visible ; whilst here and there 
dark brown stains, caused probably by submucous ecchymosis, may 
sometimes be seen with occasional abrasion or slight ulceration of the 
mucous membrane. 
Treatment.—Though from an early period it has been a constant re- 
* Quoted in the article on Coryza in the Diet Encyclop. des Sci. M6d., Paris, 
1878, t. xxi., p, 3. 
f Manuel d’Histologie pathol., Paris, 1869, pp. 653, 654. ACUTE NASAL CATARRH. 
291 
proaeh to medical practitioners that they are unable to cure a “ common 
cold,” the blame really rests with the patient more than with the phy- 
sician. For as a rule, persons suffering from catarrh feel so little in- 
convenience that they are unwilling to submit to the restraint and regi- 
men which are necessary to ensure rapid recovery. The disorder may 
be treated by stimulants, by derivatives, or by one of the many remedies, 
the action of which is too obscure to permit of classification. Of all 
stimulants opium is the most trustworthy. The old physicians recog- 
nized its value in stopping a catarrh, and generally gave it in the form 
of Dover’s powder at bedtime, but the effect of the drug is much greater 
if administered in small doses during the day. Laudanum is better than 
any other preparation, and five or seven drops taken at the commence- 
ment of an attack will often cure it at once. The remedy acts more 
quickly and more certainly if taken on an empty stomach, and if one 
dose is not sufficient it may be repeated twice in the day at intervals of 
six or eight hours. If at the end of two days the catarrh still persists, 
it is useless to try to cut it short. Opium may also be administered in 
the form of a snuff containing morphia and bismuth as first recom- 
mended by Ferrier* (see Appendix). The patient ought to commence 
taking the snuff as soon as the symptoms of coryza begin to show them- 
selves, and at first it should be employed frequently so as to keep the 
interior of the nostrils well coated. Each time the nose is cleared 
another pinch should be taken. This powder may also be administered 
by blowing it into the nasal cavities with Bryant’s auto-insuffiator 
(Fig. 37, p. 258). 
Camphor has long been held in high esteem by the public as a 11 cer- 
tain cure” for incipient catarrh, and many persons find that ten drops 
of spirits of camphor taken on a piece of sugar at once arrest a cold. 
Instead of employing medicines which control secretion by acting 
through the nervous system, local stimulants may be prescribed in the 
form of inhalations. In Germany a preparation known as Hager- 
Brand’s “ Anti-catarrhal Remedy,”f and consisting of ammonia and 
carbolic acid, is largely used as a household remedy (see Appendix). 
The vapor of a few drops of this nostrum, poured into a small cone of 
blotting-paper, should be inhaled till the liquid is evaporated, and this 
may be done every two or three hours until relief is obtained, or the 
inefficacy of the remedy proved. “ Alkaram,” so extensively adver- 
tised in this country, appears to contain the same ingredients. I have 
* Lancet, April 8, 1876. 
t Wien. med. Wochenschrift, June 5, 1872. 292 
DISEASES OF THE THROAT AND NOSE. 
often seen great benefit result from smelling strong ammonia salts with- 
out the addition of carbolic acid. These “ olfactories” should only be 
employed at the moment when a disposition to sneeze is felt, for at 
other times they will often increase the catarrh by provoking an attack 
of sneezing. In some persons the inhalation of iodine vapor acts favor- 
ably, and will cut short a catarrh in a few hours. “ The inhalation of 
chloroform to the induction of anaesthesia administered after the patient 
has been put to bed will often be found adequate,” says Solis Cohen,* 
“to abort a cold by its relaxing influence upon the structures which are 
in a state of tension.” Although I do not in the least doubt the effi- 
cacy of this plan, it is obviously too risky to be adopted, unless under 
very exceptional circumstances. 
Derivative treatment may be carried out by the administration of 
diaphoretics, diuretics, or purgatives. James’s powder, of which the 
pulvis antimonialis of the British Pharmacopoeia is an imitation, was 
once a very popular remedy in England. If used, two grains should 
be given every three or four hours until diaphoresis is established. A 
mixture, consisting of five grains of nitrate of potash, twenty drops of 
spiritus aetheris nitrosi, and two drachms of liquor ammoniae acetatis is 
a time-honored remedy. If such medicaments are administered the 
patient should at the same time use the familiar adjuvant of a hot foot- 
bath. It need scarcely be added that if this form of treatment be 
adopted the patient should be confined to the house, or even kept in 
bed. His diet should be light, and alcoholic stimulants should be 
avoided, the only exception being a glass of hot spirits and water at 
bed-time. Diaphoresis may be carried out in a more energetic way by 
means of Turkish baths, a method which has the advantage of not pre- 
venting the patient from pursuing his ordinary avocations. 
The late Addington Symonds, of Clifton, widely known as a most 
accomplished and experienced physician, strongly recommendedf the 
following pill and draught as a means of preventing nasal catarrh from 
running into bronchitis : Extr. Hyoscyami, Pulv. Conii, aa. gr. iv.; 
Calomel, Pulv. Ipecac., aa. gr. j. M. ft. pil. ii. vespere sumendae. 
This was followed by a draught in the morning consisting of Rochelle 
salts (tartrate of soda) and senna, and the patient was kept in bed half 
the following day. 
Small doses of aconite have been recommended for catarrh, but I 
have frequently tried this remedy in cases where the coryza was accom- 
* Diseases of the Throat and Nasal Passages, New York, 1879, 2d ed., p. 336. 
f Ranking’s Abstracts, 1868, vol. i., p. 55. 293 
ACUTE CORYZA IN INFANTS. 
panied by high temperature, and have never been able to satisfy myself 
that it produced any appreciable effect in cutting short an attack. 
In conclusion it may be mentioned that total abstinence from liquids, 
as was pointed out by Richard Lower,* and more recently by C. J. B. 
Williams,f will generally quickly check catarrh. The coryza begins to 
diminish in about twelve hours, and a cure is usually effected in two 
days. Williams allows, without recommending, a tablespoonful of milk 
or tea twice in the day, and a wine-glass of water at bed-time. The 
system should be. put in force at the very outset of a catarrh. 
ACUTE CORYZA IN INFANTS. 
It is a matter of familiar observation that the nose is relatively 
smaller than the other features in newly-born children, but it is only 
recently that the peculiar anatomical condition of the nasal fosste in 
infants has been distinctly described. To Kohts and LorentJ we are 
indebted for showing that in these young subjects the meatuses are 
exceedingly narrow, the free extremity of the inferior turbinated bone 
being, as compared with that in the adult, longer and curved further 
round, so that scarcely any room is left for a passage at all. The rela- 
tive smallness of the passages, however, is most marked in the middle 
meatus, its direction being quite horizontal, and its anterior orifice 
being only an exceedingly minute circular opening. During adoles- 
cence this round aperture enlarges anteriorly and at the upper part, 
resulting in a kind of crook-shaped curve, which greatly increases its 
size. Now it appears from the observations of Ivussmaul§ that the 
mouth in newly-born children is almost always closed during sleep, 
that the tongue is brought into contact with the hard palate, and that 
thus even in those rare cases where the lips are open no air passes 
through the mouth. Bearing in mind the anatomical conditions of the 
nose in infants which have just been described, it can easily be under- 
stood that a very slight swelling of the pituitary membrane is likely to 
* Dissert, de Origine Catarrhi, Ed. quinta, Lugduni Batavorum, 1708, cap. vi., p. 
258. 
f Cyclopaedia of Pract. Med., London, 1833, vol. i., p. 484. 
J Handb. d. Kinderkrankheiten, von Prof. Gerhardt, 1878, Dritte Band, Zweite 
Hiilfte, p. 4 etseq. 
§ Zeitschrift f. rationelle Medicin, 1865, p. 225. 294 
DISEASES OF THE THROAT AND NOSE. 
be attended with considerable difficulty in breathing, a circumstance 
which J. P. Frank* was the first to recognize. No sooner does the 
child suffering from severe catarrh fall asleep than it is apt to be 
attacked by a paroxysm of dyspnoea, and the attempts to inspire under 
these circumstances may lead to extreme pulmonary engorgement. The 
difficulty of breathing is, according to Bouchut,f sometimes greatly in- 
tensified by the tongue being drawn down and blocking up the laryn- 
geal orifice in the same manner as it does occasionally under the influ- 
ence of an anaesthetic. These attacks frequently resemble laryngismus 
stridulus, or may even be mistaken for laryngitis. But there is another 
danger, viz., that of starvation, for the child may be unable to suck 
without risk of suffocation on account of the obstructed state of its nasal 
passages. Although, however, infants are liable to these perils it must 
be admitted that they are very rarely encountered in practice. 
Most of the remedies recommended for adults may be used in reduced 
doses, but opiates should never be administered. A small open tube 
put through the nose will sometimes enable the child to suck easily; 
but should this plan not answer, the infant must be taken from the 
breast and fed with its mother’s milk by means of a spoon, and as a 
last resource a short oesophageal tube (Fig. 11, p. 39) must be used. 
PURULENT NASAL CATARRH. 
Purulent inflammation of the nasal mucous membrane, in exceed- 
ingly rare cases, may be simply an aggravation of an ordinary acute 
catarrh. It may likewise result from injuries or from the prolonged 
presence of foreign bodies; but in this article it will be briefly referred 
to as an acute affection in which the formation of pus is the distinguish- 
ing feature from the outset. Purulent nasal catarrh may be met with 
both in newly-born children and in adults. In the former case it is 
generally thought that the inflammation results from infection of the 
mucous membrane of the nose with the leucorrhoeal discharge which 
frequently occurs in the last months of pregnancy, or in some still rarer 
* De curandis hominum morbis, Mannhemii, 1794, lib. v., pars i., p. 107. 
f Quoted by Frsinkel, Ziemssen’s Cyclopaedia, vol. iv., p. 106. On this interesting 
subject see also Henoch (Beitrage z. Kinderheilk., Berlin, 1868, p. 124) and Hauner 
(Jahrb. f. Kinderheilk., 1862, vol. v., p. 73). PURULENT NASAL CATARRH. 
295 
instances from gonorrhoea, from which the mother may have been suf- 
fering at the time of parturition. It is extremely doubtful, however, 
whether such catarrhs are really the result of maternal infection—the 
sudden exposure at birth of the delicate mucous membrane to the irri- 
tating influence of the atmosphere, or the entrance of soap into the nos- 
trils in careless washing, being sufficient to account for the occasional 
occurrence of the complaint. It may be added that the influence of 
vaginal discharges upon the mucous membrane of the eyes and nose of 
infants in the act of birth has yet to be investigated on a large scale. 
If sufficient statistical evidence can be obtained to show that the chil- 
dren of women suffering from such discharges are often affected with 
purulent ophthalmia or rhinitis, whilst the infants of women free from 
leucorrhcea show no signs of such inflammations, the question will be 
settled. At present the weight of opinion is no doubt in favor of the 
theory of contagion at the time of birth; but this view rests more on 
a ;priori grounds than on statistical evidence. Hermann Weber,* how- 
ever, has reported a case in which it is probable that direct contagion 
occurred. The mother had suffered during the last weeks of gestation 
from an abundant yellowish discharge from the vagina, and the child, 
which had not been washed for three hours after birth, was subsequently 
attacked with purulent inflammation of the left eye and of the nostrils, 
the nose being swollen and stuffed up with crusts. The nasal discharge 
varied somewhat in character, being sometimes watery, sometimes thick 
and yellow, and sometimes mingled with blood. 
There are very few cases on record in which purulent nasal catarrh 
has resulted from gonorrhoeal infection in adults. The only instances 
which I have been able to find in medical literature are the three fol- 
lowing: Boerhaavef relates that a patient of his own, after squeezing 
some matter out of his urethra for the inspection of the surgeon, 
thoughtlessly put his fingers immediately afterwards into his nose. 
Very severe rhinitis ensued, followed by extensive ulceration. Another 
case is related by Edwards| in which an elderly woman consulted him 
for inflammation of the nose with purulent discharge which had exco- 
riated the upper lip. The patient suffered so much pain and was so 
emaciated and ill that the disease was suspected to be malignant ulcer- 
ation of the nasal cavity. Edwards, however, on inquiring into the 
history of the case, ascertained that about six months previously the 
* Med.-Chir. Trans., 1860, vol. xliii., p. 177. 
f Tractatio med. pract. de lue venerea, Lugd. Batavorum, 1751, p. 41. 
J Lancet, April 4th, 1857. 296 
DISEASES OF THE THROAT AND NOSE. 
woman had wiped her nose with a handkerchief which had been em- 
ployed as a suspensory bandage by her son, who was suffering from 
gonorrhoea at the time. Five days after this occurrence the patient’s 
nose became violently inflamed. She was treated with iron and quinine 
internally, and the nasal fossse were washed out with tepid water, after 
which a mildly detergent lotion was used. Edwards, in commenting 
on the case, affirms that he has known several instances where patients 
suffering from gonorrhoea had infected their own nostrils by carelessly 
touching them with their fingers, but this was the first case in his ex- 
perience in which another individual had been so inoculated.* A re- 
volting example of direct infection of the nasal mucous membrane has 
been reported by Sigmund,f in which a man contracted purulent rhin- 
itis from introducing his nose into the vagina of a prostitute suffering 
from gonorrhoea. 
An attack of purulent inflammation of the nose is usually ushered in 
by some degree of systemic disorder, such as shivering and general fe- 
brile symptoms. In Edwards’s case, quoted above, these were very 
severe. Excoriation and ulceration are almost always produced by the 
discharge, especially at the edges of the nostrils, and on the upper lip. 
The inflammatory process is also apt to invade the eyes, if, indeed, the 
conjunctiva is not simultaneously infected. In infants the nose may be 
so plugged up by thickened secretion that respiration by that channel 
is rendered impossible, and thus the troublesome consequences described 
in the last article are likely to follow. 
The treatment should consist in cleansing the parts with a tepid alka- 
line spray or collunarium (see Appendix). Afterwards the nasal cav- 
ities should be syringed out with some mildly astringent injection such 
as alum (gr. v. ad 5j-)> sulphate of zinc (gr. ij. ad §j.), sulphate of cop- 
per (gr. ij. ad 5j.), or nitrate of silver (gr. j. ad §j.). In the case of 
infants the injections into the nose often give rise to violent attacks of 
coughing, owing to some of the fluid getting into the larynx. Under 
these circumstances it will be found convenient to use the “ Temporary 
Sponge-Tampon ” (p. 284) whilst douching or syringing is being carried 
out. Where there is difficulty of sucking from stoppage of the nose, 
the little patient should be fed in the manner recommended under 
“ Acute Coryza in Infants ” (p. 294). 
* Chelius (System of Surgery, Eng. Transl., London, 1847, vol. i., p. 177) mentions 
purulent rhinitis as an occasional concomitant of gonorrhoea, and his translator, South 
(Ibid., note to paragraph 168), quotes two examples of such an occurrence from Benja- 
min Bell. 
f Wien. med. Wochenschrift, 1852, p. 572. 297 
TRAUMATIC RHINITIS. 
Traumatic Rhinitis. 
Irritating vapors, or solid particles suspended in the atmosphere, fre- 
quently produce catarrh, and no doubt many otherwise inexplicable cases 
of coryza are due to this cause. It can be readily understood that the 
vapors of chlorine, ammonia, and iodine are extremely likely to set up 
irritation of the nasal mucous membrane. The influence of more pal- 
pable irritants is seen in the case of millers, ivory-turners, sawyers, 
brush-makers, and persons engaged in kindred employments. It is 
remarkable, however, that the nasal mucous membrane does not gener- 
ally seem to suffer in the same way as the pharynx from exposure to 
hot steam or smoke (vol. i., p. 113). 
In addition to casual sources of irritation there are certain substances 
which, when present in the atmosphere, produce a specific effect on the 
lining membrane of the nose, and amongst these bichromate of potash, 
arsenic, and mercury may be particularly mentioned; whilst osmic acid 
is stated by Seiler* to be an irritant of such strength as to be capable of 
producing coryza within one or two hours. Attention was first drawn 
to the influence of bichromate of potash by Becourt and Chevallier,f 
who noticed that certain effects were produced on the workmen exposed 
to the steam from the boilers in which that substance is made. The 
subject was afterwards taken up and investigated by Delpech and 
Hillairet,| who found that similar effects were produced on persons 
exposed to the dust of the yellow chromate, although they were mani- 
fested less rapidly, and in a much slighter degree than in the case of 
the bichromate vapor. 
The first symptoms produced by the. bichromate are a tickling sensa- 
tion in the nose, violent sneezing and an abundant discharge, which at 
the commencement is watery in character, but soon becomes thick and 
green. At a later period the discharge contains crusts, and even flakes 
of sloughing mucous membrane, but is never offensive. Epistaxis not 
unfrequently occurs, and ultimately portions of cartilage are expelled. 
Perforation always takes place at a level of one and a half, or at most 
two centimetres above the lower edge of the septum. At first the aper- 
ture is round, and very small, but as it increases in area it becomes oval 
in shape. It may thus extend to the junction of the cartilage with the 
vomer and the perpendicular plate of the ethmoid. As the lower and 
anterior part of the cartilage always remains intact, the bridge of the 
* Diseases of the Throat, Philadelphia, 1883, 2d ed., p. 204. 
f Annales d’Hygiene, Juillet, 1863, t. xx., p. 83. J Ibid., 1869, t. xxxi. 298 
DISEASES OF THE THROAT AND NOSE. 
nose never falls in. Ulcers occasionally form on the turbinated 
bodies, but they are not nearly so severe as on the septum. 
Casabianca* points out that the reason why the septum particularly 
suffers is, that, owing to the shape of the nostrils, the columns of 
inspired air, on entering the nose, first strike against that part; whilst 
the mucous membrane in that situation, being much less rich in gland- 
ula3 than that of the external wall, is not so well protected by secretion. 
The rapidity with which perforation occurs is due to the thinness of 
the mucous covering, which leads to its speedy destruction by ulcera- 
tion, coupled with the fact that the cartilage itself receives its vascular 
supply solely from this source, and therefore necessarily loses its vitality 
as soon as the membrane is destroyed. 
Snuff-takers seem to be exempt from the disease, and those who 
have once suffered from it afterwards enjoy immunity from common 
catarrh. 
Delpech and Hillairetf have reported four cases of an analogous na- 
ture, in which perforation of the septum occurred in individuals exposed 
to arsenical dust, principally those who worked with “ Schweinfurth 
green.” The same thing has been noticed among makers of artificial 
flowers and wall papers. Ulcerations of the nasal mucous membrane 
have also been among those who use bichloride of mercury 
in dyeing feathers and silvering mirrors. 
The poisonous effect of these materials in such cases is no doubt 
purely local, and is not the result of constitutional absorption. 
All persons employed in trades which cause the nasal mucous mem- 
brane to be exposed to deleterious matters should wear plugs of cotton- 
wool in their nostrils. Although when perforation has once taken 
place it is difficult to prevent the formation of a tolerably large hole in 
the septum, the morbid action is strictly confined to a small area, be- 
yond which its ravages never extend. The use of simple sprays will 
soon restore the surrounding mucous membrane to a fairly healthy con- 
dition. 
* Des Affections de la Cloison des Fosses nasales, Paris, 1876, p. 42. 
f Loc. eit. t Casabianca: op. cit. hay fever. 
299 
HAY FEVER. 
(Synonyms: Hay Asthma. Summer Catarrh. Rose Catarrh.) 
Latin Eq.—Catarrhus aestivus. 
French Eq.—Catarrhe d’ete. Catarrhe de foin. 
German Eq.—Frilhsommer-Catarrh. Heu-Asthma. 
Italian Eq.—Asma dei mietitori. 
Definition.—A peculiar affection of the mucous membrane of the 
nose, eyes, and air-passages, giving rise to catarrh and asthma, almost 
invariably caused by the action of the pollen of grasses and flowers, and 
therefore prevalent only when they are in blossom. 
History.—The first detailed account of hay fever was given by Bostock,* who, in 
1819, described a “periodical affection of the eyes and chest,” from which he was him- 
self a sufferer. In 1828f this physician published some further observations of the 
complaint, under the name of “summer catarrh.” A short paper on hay asthma, by 
Gordon,J appeared in 1829, and in 1831 Elliotsonf gave a brief description of the 
complaint. A few years later the same physician|| discussed the subject more fully, 
and with characteristic sagacity pointed to pollen as the probable cause of the affection. 
A systematic inquiry into all the circumstances of the disease was made in 1862 by 
Phoebus,of Giessen, whose own personal observation of the disease was, however, 
confined to a single case. Unlike most of the other writers upon the subject, more- 
over, he did not himself suffer from the complaint. His method consisted in issuing 
circulars and advertisements inviting medical men all over the world to send him 
answers to a series of questions so framed as to embrace every possible kind of infor- 
mation about the causes, symptoms, and progress of the disorder; its periods of prev- 
alence, geographical and ethnological distribution ; and its prevention and treatment. 
In this manner a vast quantity of facts and observations was collected, and from these 
Phoebus endeavored to extract a complete theory of the disease. During the ensuing 
ten years pamphlets on hay fever were published by Abbott Smith,** Pirrie,f f and 
Moore,dealing with the disorder from various points of view, but all, more or less, 
showing a disposition to limit the cause of its development to emanations from plants. 
In 1869 a theory of hay fever was propounded by Helmholtz,§§ who was himself a 
* Med.-Chir. Trans., London, 1819, vol. x., pt. i., p. 161 et seq. 
f Ibid., vol. xiv., pt. ii., p. 437 et seq. 
J London Med. Gazette, 1829, vol. iv., p. 266. 
§ Ibid., 1831, vol. viii., p. 411 et seq. 
|| Lectures on the Theory and Practice of Medicine, London, 1839, pp. 516-527. 
Der typische Friihsommer-Katarrh, Giessen, 1862. 
** Observations on Hay-Fever, London, 1865, 2d ed. 
ft Hay-Asthma, London, 1867. Hay-Fever, London, 1869. 
\\ Binz: Virchow’s Archiv, February, 1869. 300 
DISEASES OF THE THROAT AND NOSE. 
sufferer from the complaint. He held that the symptoms were produced by vibrios, 
which, although existing in the nasal fossae and sinuses at other times, were excited to 
activity by summer heat. He professed to have'found a ready means of relief and 
even of prevention in the injection of quinine, which Binz had shortly before shown to 
be poisonous to infusoria. Subsequent experience has not confirmed Helmholtz’s con- 
clusions. In the following year a short practical paper was published by Roberts,* in 
which he claimed to have been the first to observe that excessive coldness of the tip of 
the nose is “ the pathognomonic ” symptom of hay fever, and desired to have due credit 
awarded for the discovery. In 1872 Morrill Wymanf discussed the disease as it pre- 
vails in America, and tried to establish that two distinct forms of the complaint exist 
in that country—one occurring in May and June and corresponding to English hay 
fever, and a later variety peculiar to America, which he called “ Autumnal Catarrh.” 
In 1873 Blackley,J of Manchester, published a work which is a model of scientific in- 
vestigation. By a most ingenious and carefully conducted series of experiments he 
proved that in his own person at least the pollen of grasses and flowers was the sole 
cause of hay fever, and that in the case of two other patients the severity of the disease 
bore a direct relation to the amount of pollen in the air. His subsequent observations 
make it extremely probable, indeed almost certain, that though transient irritation of 
the mucous membrane may occasionally be caused by simple dust, pollen is in fact the 
true materies morbi of summer catarrh. In 1876 a short treatise was published by 
Beard,\ of New York, in which he dealt with the complaint as it is met with in the 
United States. His information was collected chiefly by circulars after the manner of 
Phoebus, but more fortunate than that observer,'Beard had himself seen and treated 
many cases. He received replies from over two hundred patients, and on these data 
he came to the conclusion that the immediate exciting causes are more than thirty in 
number, and that further investigations may extend the number of secondary causes to 
fifty or even a hundred. Beard showed clearly from his statistics that a large pro- 
portion of the sufferers are of nervous temperament, and that nerve-tonics are of con- 
siderable value in the treatment of the affection. In 1877 an essay was published by 
Marsh,|| in which he completely accepts the pollen theory. The influence of a morbid 
condition of the nasal mucous membrane in favoring the development of hay fever has 
Leen recently insisted on by Daly,f Roe,** and Ilack.ff 
Etiology.—In accordance with the usual method, the causes of hay 
fever may be conveniently divided into (a) predisposing and (6) ex- 
citing. 
a. The predisposing cause of the complaint is the possession of a 
* New York Med. Gaz., October 8th, 1870. 
f Autumnal Catarrh, New York, 1872. 
t Hay-Fever, London, 1873, and 2d edit., 1880. 
§ Hay-Fever, or Summer Catarrh, New York, 1876. 
|| Hay-Fever, or Pollen-poisoning, read before the New Jersey Medical Society, 
1877. 
Archives of Laryngology, 1882, vol. iii., p. 157. 
** New York Med. Journ., May 12th, 1883. 
ff Wien. med. Wochenschrift, 1882-83. HAY FEVER. 
301 
peculiar idiosyncrasy, but on what that idiosyncrasy* depends is quite 
unknown. Whether it is due to some local abnormality affecting the 
structure of the mucous membrane, the capillaries, or the periphery of 
the nerves, but of too delicate a nature to admit of detection by avail- 
able methods of research, cannot be determined. The fact, however, 
remains, that whilst millions of people are exposed to the cause of the 
affection very few suffer from it. The idiosyncrasy is generally sud- 
denly developed without apparent reason. Once acquired, however, it 
is seldom lost, the predisposition seeming rather to increase with each 
recurring summer. The circumstances which are supposed to influence 
this idiosyncrasy are race, temperament, occupation, education, mode of 
life, sex, heredity, and age. These various points may, with advantage, 
be considered in detail. 
The influence of race is seen in the fact that it is the English and 
Americans who are almost the only sufferers from the complaint. In 
the north of Europe—that is, in Norway, Sweden, and Denmark—it 
is scarcely ever seen, and it rarely affects the natives of France, Ger- 
many, Russia, Italy, or Spain. In Asia and Africa, also, it is only the 
English who suffer. As far as I have been able to ascertain, the com- 
plaint is more common in the south of England than in the north; 
whilst in the north of Scotland it is very rare. In America it occurs 
in nearly every State, though diminishing in frequency towards the 
south. I think it extremely likely that the disorder will be found in 
Australia and New Zealand, but I am not aware that any cases have 
yet been reported from those countries. In support of the view that 
race has an important influence, Beard mentions that Dr. Jacobi, whose 
practice in New York lies largely among Germans, has never met with 
a case of hay fever in a patient of that nationality, and that Dr. Chaveau, 
of the same city, has never observed the complaint among his French 
compatriots residing there. Beard himself never heard of a case amongst 
Indians or negroes, except the instance related by Wyman, in which an 
Indian child was the subject of the disease. 
The nervous temperament has undoubtedly a certain influence in pre- 
* In this respect the idiosyncrasy is like idiosyncrasies in general. The existence 
of these personal peculiarities is too well known to require much comment. Many 
people cannot eat crabs, lobsters, or strawberries without being attacked with urticaria. 
Others, again, cannot eat mutton or white of egg without being sick. One of the most 
interesting cases of idiosyncrasy, and peculiarly appropriate to the present subject, 
inasmuch as it was brought into operation through the nasal mucous membrane, was 
that of Schiller, to whom the smell of rotten apples was so beneficial that he could not 
“live or work without it” (Lewes: Life of Goethe, London, 1864, 2d ed., p. 381). 302 
DISEASES OF THE THROAT AND NOSE. 
disposing to hay fever. This, of course, does not mean that all the 
patients are highly nervous people; some are of nervo-bilious, others 
of nervo-sanguineous temperament, but nearly all belong to the active, 
energetic class of so-called nervous organization. 
One of the most singular features of this complaint is, that it is 
almost exclusively confined to persons of some education, and generally 
to those of fair social position. Whilst I have notes of sixty-one cases 
of hay fever from my private practice,* and have seen many others of 
which I have kept no record, I have not met with one amongst my 
hospital patients. Of forty-eight cases which came more or less directly 
under the notice of Blackley, every one belonged to the educated 
classes; whilst out of fifty-five cases reported by Wyman, in forty-nine 
the patients were educated people. The influence of the mode of life is 
shown in the fact that the rustic is much less subject to the affection 
than the citizen. Thus farmers and agricultural laborers, who of all 
people are most exposed to the disease, very rarely suffer from it, there 
having been only seven cases among the two hundred reports collected 
by Beard. It is not possible to tell whether the villager owes his ex- 
emption to the vigorous health maintained by an out-door life, or whether 
habitual exposure to the cause of the com plaint begets tolerance; but 
the fact remains that dwellers in towns are much more prone to the 
affection than those who live in the country. 
Sex has a distinct influence, many more men than women suffering 
from the disease. Out of a grand total of 433 cases cited by Phoebus, 
Wyman, and Beard, only 142, or about a third, were females. Against 
these statistics it may be urged that the information on which they are 
based was collected by circulars, to which, perhaps, women would be 
less likely to reply than men. This objection, however, does not ap- 
ply to my own cases, amongst which I met with thirty-eight belonging 
to the male and only twenty-three to the female sex. 
Heredity has likewise a powerful influence. This has been abun- 
dantly proved by Wyman and Beard, and it is supported by my own 
observations. In Wyman’s experience there was heredity in 20 per 
cent, and in Beard’s in 33 per cent. Out of my sixty-one cases, in 
twenty-seven one or more near relatives had suffered in the previous 
generation. I have also several times treated father and children at 
the same time. 
Age to some extent governs the disorder. In the great majority of 
cases the liability to hay fever appears before the age of forty; but 
* This was written in 1879. HAY FEVER. 
303 
several instances have been reported of the first occurrence of the malady- 
in patients as old as sixty. It is somewhat rare for this affection to 
show itself in very young children, but I have seen it in one patient at 
two years of age, and in another at three. In these cases, as in all those 
of very young patients that have come under my notice, the little suf- 
ferers were the children of parents who had themselves been victims to 
the complaint. Had not the parents been subject to the affection, it 
is most likely that the true import of the symptoms would not have 
been recognized in the children, but would have been attributed to a 
common cold. 
b. Exciting Causes.—A great variety of agencies have been looked 
upon as the direct causes of this disease, but there can now be little 
doubt that pollen is the essential factor in the case o f those ivho possess the 
peculiar predisposition. Before, however, proceeding to show that 
pollen is the real cause of the affection, it may be well to pass in review 
some of the other sources to which its origin has been attributed. The 
most important of these are heat, light, dust, benzoic acid, coumarin, 
excess of ozone, and over-exertion, or several of these influences in com- 
bination. 
Heat—Popular observation had already associated hay fever with effluvia from grass 
or hay, at the time when Bostock, from his own personal experience, put forth the view 
that the affection was due to the influence of solar heat. The obvious difficulties in the 
way of this theory led Phoebus to attribute the affection to “ the first heat of summer,” 
which, he observed, “ is a stronger cause than all the grass emanations put together.” 
Later on, however, Phoebus remarked that the “first heat of summer only acts in an 
indirect manner as an exciting cause;” and he admitted that hay and the blossom of 
rye cause exacerbations. Heat alone will not, however, produce the disease. It is not 
met with in the plains of India when the heat is greatest, though occasionally it is seen 
in the cooler months, before the vegetation is burnt up. Hay fever is also found in 
the milder climate of the Indian hills, when the grasses and cereals are in blossom. 
The intense heat of the desert does not produce the disease, nor does it occur at sea in the 
sultry equatorial regions, though the heat, when vessels are becalmed, is sometimes 
almost beyond endurance. In America, hay fever is much more common in autumn 
than in the tropical summer of that country. 
Light.—The observations as regards heat apply equally to light. Phoebus thought 
that the longer days, which produce a more continuous action of light, are perhaps to 
blame; but where the light is strongest and lasts longest, indeed in the land of “ the 
midnight sun,” hay fever is almost unknown. At sea, when the sun is bright, it is well 
known that nothing can exceed the glare; yet a sea-voyage is the best safeguard for 
the sufferer from hay fever. Persons with a sensitive mucous membrane, especially 
those subject to hay fever, are no doubt sometimes liable to attacks of sneezing from 
sunlight, and incautious observers might mistake these symptoms for true hay fever. 
Some of Beard’s patients even attributed the affection to gaslight, but gaslight is used 
much more in winter when hay fever is absent, than in the English summer and Amer- 
ican autumn, when the affection prevails. 304 
DISEASES OF THE THROAT AND NOSE. 
Dust.—This is a more difficult subject to dispose of. Most writers who accept dust 
as a cause of summer catarrh, speak of “ common dust,” but as Blackley remarks, there 
is no such thing as common dust. The constitution of dust depends upon the geological 
character of the soil, upon the vegetation which it supports, and on the season of the 
year, as well as on “the number and kind of germs and other organic bodies” present 
in the atmosphere. Beard’s statistics, if accepted without consideration, strongly point 
to dust as the most common cause of hay fever, for out of 198 patients no less than 104 
attributed the affection to dust. Of these 198 cases, however, 142 occurred between 
May and September; and it may well be asked: How was it that dust did not affect 
these patients in the winter months ? Does this not clearly point to the presence in 
the dust of some special irritant during the summer and autumn months, which does 
not exist at other times? In England, in the months of February, March, and April, 
when strong east winds often blow clouds of dust against the face, symptoms of hay fever 
do not appear, whilst in June and July, when there is comparatively little dust, hay 
fever attacks its victims. It is true that in many of Beard’s cases, collected by circu- 
lars, the patients attributed the affection to “ indoor dust,” and some even to “ cinders.” 
But as people stay in the house more in winter than in the autumn and summer, and 
use fires at that time, these agencies, if of any real power, would produce their greatest 
effect in winter. Directly the opposite, however, occurs. Is it not highly probable, 
therefore, that these patients were misled as to the real cause of the malady? We all 
know how easy it is for the trained physician to make erroneous observations, and to 
overlook important physical signs, and how much more likely is the untutored patient 
to make a mistake in the obscure and highly complicated problems of etiology! 
Ozone, Benzoic Acid, etc.—An excess of ozone in the atmosphere was suggested by 
Phoebus as a possible cause of hay fever, but Blackley purposely breathed air highly 
charged with this substance for five or six hours without effect. He, moreover, inhaled 
artificially prepared ozone, in quantities far exceeding what is ever found in the same 
volume of atmospheric air, without feeling any inconvenience. The same physician 
also studied the effects on his own person of benzoic acid,* coumarin (the odorous 
principle of many flowering grasses), and of the volatile oils which impart to many 
plants, such as peppermint, juniper, rosemary, and lavender, their characteristic per- 
fume. The results were in all these cases entirely negative. 
Over-exertion, or prolonged exexcise in the open air, never has any effect in cold weather, 
or indeed at any other time except when grass is in flower. Its influence, however, 
in aggravating hay fever, in the hay season, is very great, and will presently be con- 
sidered. 
Combined Causes of Ilay Fever.—Several writers have contended that although any 
one of the above causes may not alone be sufficient to produce hay fever, several of 
them acting together may be able to do so. Such theories are the last resource of 
those who are unable to discover the true etiology, and there is not a tittle of evidence 
in their support. 
Having shown what does not generate hay fever, its real mode of origin must now 
be demonstrated. 
Blackley’s observations leave no doubt that the cause of hay fever is 
the action of pollen on the mucous membrane. His experiments were 
* This substance has been shown by Vogel to be contained in anthoxanthum odoratum 
and holcus odoratus, the two species of flowering grasses to which the causation of hay 
fever has been in a special manner attributed. HAY FEVER. 
305 
framed on a most comprehensive plan, and carried out in a rigorously 
scientific spirit. By well-devised tests he succeeded in proving—1st, 
that in his own person the inhalation of pollen always produced the 
characteristic symptoms of hay fever; 2dly, that in his own case, and 
in that of two other persons, there was a direct relation between the 
intensity of the symptoms and the amount of pollen floating in the air; 
and 3dly, as already shown, that none of the other agents referred to, 
such as heat, light, dust, odors, or ozone, can of themselves cause the 
complaint. 
Blackley’s experiments were made with pollen of various grasses and 
cereals, and with that of plants belonging to thirty-five other natural 
orders. 
The grasses which, as already stated, were at one time considered to 
be especially active are the anthoxanthum odoratum and the holcus 
odoratus, but this idea no doubt originated in the extremely fragrant 
odor of these plants, and there is no reason to suppose that their pollen 
is more active than that of the alopecurus pratensis, and the various 
poce and lolice. The pollen of rye is, however, more potent than some 
of these, and that of wheat, oats, and barley is also very active. The 
careful observations of Blackley show that in England, during the 
season of hay fever, ninety-five per cent, of the pollen contained in the 
atmosphere belongs to the graminacece. This order generally comes 
into full blossom between the end of May and the latter part of July. 
and that is precisely the period of the year when hay fever prevails. 
If the season be wet and cold the disease usually sets in rather later, 
and is milder in character than when the weather is fine, and the vege- 
tation luxuriant. 
There are persons in whom the presence of roses will give rise to an 
attack, and in America the affection is sometimes called “rose fever.” 
No doubt it is the pollen of the rose which is the active agent. The 
celebrated Broussais* appears to have been impeded in his botanical 
studies by this idiosyncrasy, whilst the case related by Hiinerswolfff 
of a man in whom the perfume of roses invariably produced an attack 
of coryza, has been often cited by modern writers. I have myself met 
with a similar case. A lady living in Devonshire consulted me in 
1864, on account of constant severe coryza, which came on whenever 
she smelt a rose. All treatment proved futile, and she was ultimately 
obliged to banish these flowers from her garden. 
* Anglada: Du Coryza simple, ThSse de Paris, 1837, p. 14. 
f Ephem. Nat. Curios, dec. ii., ann. v., obs. xxii. 306 
DISEASES OF THE THROAT AND NOSE. 
In America the pollen of the Roman wormwood (ambrosia artemisice- 
folia) appears'to be the most common cause of hay fever. This plant 
(which belongs to the genus ambrosiacece, order composite) is not met 
with in Europe, but is extremely common in nearly every part of the 
United States. Wyman* found that when a parcel containing this 
plant was opened at White Mountain Glen, where he had retired, in 
order to avoid hay fever, he and his son were immediately attacked 
with all the symptoms of the malady. The plant blossoms in August 
and September, and it is then that hay fever most prevails in America. 
Several varieties of the artemisia, a closely-allied genus, are met with 
in England, and I think it not improbable that some cases of hay fever 
which have occurred at the seaside in this country may have been due 
to the pollen of the artemisia maritima, or its variety, artemisia gallica. 
It is curious that, except in the case of Indian corn, the pollen of 
grasses appears to have but slight effect in America, though a mild 
form of hay fever is met with in that country from May to August. 
There are certain supposed fallacies in the pollen theory which must 
be referred to. Thus a case is mentioned by Walshe,f in which the 
patient retained the symptoms of hay fever during a passage across the 
Atlantic, and another has been reported by Abbott Smith,J in which 
the disease came on at a distance of nine miles from land. These 
are, I believe, the only authenticated instances in which hay fever 
has continued to exist, or has originated at sea, and they are open 
to various explanations. It has been distinctly shown by Blackley 
that pollen may be retained in an article of dress for many weeks, and 
in Smith’s case, the patient, who was yachting, experienced the symp- 
toms after assisting “ to hoist the sails.” The attack came on on the 
13th of June* and it is not unlikely that when the sails were unfurled 
a large quantity of pollen collected in their folds was set free. In 
Walshe’s case, the symptoms may have been kept up by some other 
irritant to which the patient may have had a peculiar susceptibility, or 
the case may not have been a true example of hay fever, but of ordi- 
nary asthma, complicated with catarrh. It is not altogether impossible, 
however, that pollen may be deposited on a ship miles away from land. 
Darwin§ has shown that dust is sometimes thus deposited far out in the 
Atlantic. “ The dust,” he observes, “ falls in such quantity as to dirty 
* Op. cit., p. 101. 
f A Practical Treatise on Diseases of the Lungs, London, 1871, 4th ed., p. 228. 
J On Hay Fever, London, 1866, 4th ed. 
\ Journal of Researches, etc., London, 1845, 2d ed., p. 5. HAY FEVER. 
307 
everything on board and to hurt people’s eyes; vessels have even run 
on shore owing to the obscurity of the atmosphere.” Again, in speak- 
ing of the distribution of pollen, Darwin reminds us that the ground 
near St. Louis, in Missouri, has been seen covered with pollen as if it 
had been sprinkled with sulphur, and there is good reason to believe 
that this had been transported from the pine forests at least 400 miles 
to the south.* A shower of yellow pollen was wafted to Philadelphia"}" 
from some distant pine forest so recently as the 16th of March, 1883. 
It caused such a thick deposit as to lead ignorant people to take it for 
brimstone. These facts are sufficient to show that the influence of pollen 
may be experienced under circumstances where it would not generally 
be looked for. 
Whilst asserting that pollen is the universal cause of the peculiar 
form of catarrh known as hay fever, I do not mean to deny that other 
irritating particles might produce a similar complaint if persistently 
brought in contact with the mucous membrane. Thus, it is well known 
that powdered ipecacuanha will, in some persons, cause a peculiar form 
of asthma closely resembling hay asthma, and with many people the 
fumes of burning sulphur have the same effect. I have frequently 
observed slight attacks resembling hay fever produced by the insuffla- 
tion into the larynx of powdered lycopodium, and, indeed, I have for 
this reason been compelled to give up the use of this drug as a diluent 
for medicinal powders. Some people experience symptoms somewhat 
analogous to those of hay fever from smelling certain fruits, whilst 
others are troubled in the same way by the presence of cats, rabbits, 
and guinea-pigs, and BastianJ suffered from an affection closely resem- 
bling hay fever in dissecting the ascciris megalocephala, a parasite which 
infests the horse. If the specific exciting influence is kept in operation 
on a person subject to an idiosyncrasy of this kind, a complaint almost 
precisely similar to hay fever is produced; but as a rule, the conditions 
leading to its manifestation are exactly known by the patient, and can 
therefore be avoided. The etiological peculiarity of hay fever consists 
partly in the fact that the idiosyncrasy as regards pollen is more com- 
mon than other individual susceptibilities, but chiefly in the circum- 
stance that at certain seasons pollen exercises its influence over wide 
areas, and can be excluded only with great difficulty. 
* The Effects of Cross and Self-Fertilization in the Vegetable Kingdom, London, 
1876, p. 405. 
f Philadelphia Med. News, April 7th, 1883. 
J Philosophical Transactions, 1866, vol. cvi. 308 
DISEASES OF THE THROAT AND NOSE. 
In a recently published article, Daly,* of Pittsburgh, has endeavored 
to show that in a large proportion of cases there is an intimate relation 
between hay asthma and chronic nasal catarrh, and that except when 
disease of the nasal mucous membrane exists the alleged exciting cause 
of summer catarrh is inoperative. He reports two cases of thickening 
of the turbinated bodies, and one of polypus, in which, after the cure 
of the local condition, the patients lost their susceptibility to hay fever. 
These persons had suffered from summer catarrh for twenty-one, fifteen, 
and six years respectively. Iioef and Hack! have since enunciated 
similar views to those propounded by Daly. It is not at all unlikely 
that an unhealthy state of the mucous membrane of the nasal fossae 
may predispose to hay fever, but I may remark that I have repeatedly 
examined the interior of the nose in cases of hay fever without finding 
anything more than general congestion. 
Symptoms.—The disease shows itself under two well-marked types, 
the catarrhal and the asthmatic. In the former the onset is very sudden, 
the patient becoming conscious of an itching, smarting sensation in the 
nose and eyes, and sometimes in the fauces and roof of the mouth. Not 
unfrequently the attack commences with a feeling of extreme irritation 
at the inner canthi. Paroxysms of sneezing, often of extreme violence, 
quickly ensue, followed by an abundant thin discharge from the nose. 
The mucous membrane of the nasal fossae swell so as to block up the 
passages and make respiration through them impossible. At the same 
time there is profuse lachrymation with much pricking and stinging of 
the conjunctival surfaces and sometimes photophobia. There is often 
a certain amount of chemosis, and occasionally the eyelids become 
puffed so as almost to close the eyes. The discharge from both nose 
and eyes gradually grows thicker, and sometimes becomes even semi- 
purulent in character. There may be severe neuralgic pain in the eye- 
balls and over the back of the head. Now and then there is some 
degree of pyrexia, but this is by no means the rule. The disorder 
often varies considerably in intensity, even in the same person within 
short intervals of time, so as almost to give an intermittent character 
to the complaint. This is due to the varying quantity of pollen present 
in the atmosphere, the severity of the disease being, as a rule, in direct 
proportion to the abundance of the materies morbi. An attack lasts 
from a few hours to several days, or even longer, finally ceasing almost 
as suddenly as it set in, and leaving little or no trace of its presence 
* Archives of Laryngology, 18cS2, vol. iii., No. 2. 
f Loc. cit. 
X Loc. cit. HAY FEVER. 
309 
either in local lesion or systemic disturbance. In some patients hay 
fever is accompanied by nettle-rash. 
The asthmatic form of the complaint may be superadded to the dis- 
order just described, or may constitute the entire affection. It gener- 
ally comes on in the daytime, and the paroxysm may pass off in a few 
hours, the patient expectorating a little ropy mucus, and later an abun- 
dant frothy secretion, or there may be only a slight remission, the 
dyspnoea continuing as long as the sufferer is exposed to the influence 
of pollen. The attacks seldom produce any emphysema, and the 
patient sooner or later entirely recovers. 
Diagnosis.—From the resemblance of hay fever to common catarrh 
on the one hand, and to spasmodic asthma on the other, mistakes in 
diagnosis were formerly very common ; but the disease is now so well 
known that errors are not likely to occur. The first attack might per- 
haps be confounded with ordinary coryza; but the suddenness of the 
onset, the characteristic oedematous puffiness of the eyelids, together 
with the absence of constitutional symptoms, will speedily lead to a 
truer diagnosis. People who are prone to catarrh are very apt to catch 
cold in the changeable weather of the spring and early summer of this 
country, and these cases are sometimes mistaken for hay fever; but the 
readiness with which they yield to anti-catarrhal treatment at once 
shows their real nature. 
The asthmatic form of hay fever may, in some instances, be less 
easy to recognize; but the history of the case will generally guide the 
practitioner to a correct opinion. The fact that hay fever often comes 
on in the daytime, out of doors, and in the summer, whilst paroxysms 
of true asthma most frequently occur in the evening or night, indoors, 
and in one of the other seasons of the year, may help to differentiate 
the two complaints. 
Prognosis.—This is in all cases favorable as regards the termination 
of each attack; cessante causd, cessat effedus. When the season of 
flowering grass is past, the complaint will certainly depart; but it will 
almost as surely reappear whenever the patient is again exposed to the 
action of pollen. 
Pathology.—Hay fever leaves no permanent structural lesion behind 
it. Blackley thinks that pollen has a peculiar and specific effect in 
causing dilatation of the capillaries and exudation of serum from them; 
but it appears to me highly doubtful whether this is anything more 
than the reaction which follows the application of an irritant. 
Treatment.—In no disease is the old adage, that “ prevention is better 310 
DISEASES OF THE THROAT AND NOSE. 
than cure/’ more truly applicable than in the case of hay fever. If 
the poison be continually introduced into the system, the antidote, if 
one exists, can have but little chance of effecting a cure. The first 
measure, therefore, must be to remove the patient from a district in 
which there is much flowering grass. A sea voyage is probably the 
most perfectly satisfactory step that can be taken. Patients who are 
unable to go to sea should endeavor to reside at the seaside, where they 
will generally be free from their troublesome complaint, except when 
land-breezes blow. Dwellers in town should avoid the country, and 
those who reside in the country should make a temporary stay in the 
centre of a large town. It often happens, however, that such a change 
of abode is not practicable, and, under such circumstances, if the com- 
plaint is very severe, the patient should, if possible, remain indoors 
during the whole of the hay season. Many persons, of course, cannot 
keep the house during the month or six weeks of the hay fever period; 
and those who can, are apt to find such detention not only exceedingly 
irksome but very injurious to the health. If, therefore, a patient is 
obliged to go out of doors he should plug his nostrils with cotton-wool 
or wadding by means of Gottstein’s screw (Fig. 73, p. 283), and should 
defend his eyes by wearing spectacles with large frames, accurately 
adapted to the circumference of the orbits.* Protected in this way, 
many people predisposed to hay fever escape altogether, whilst others 
contract the affection in a very mild form. 
As the disease most commonly occurs in persons of nervous tempera- 
ment, nerve-tonics and other constitutional remedies have been used for 
the purpose of warding off hay fever, or controlling the violence of its 
attacks. Amongst these, quinine, arsenic, opium, and belladonna have 
been employed, but I have found valerianate of zinc, in combination 
with assafoetida, more valuable than any other drug. I usually give 
the remedy in the form of pills containing one grain of valerianate of 
zinc and two grains of the compound assafoetida pill. I direct my pa- 
tients to begin taking these pills as the hay season approaches, and 
under the use of this remedy, persons who formerly suffered most 
severely from hay fever have in many cases ceased to be troubled 
with it. 
When the disease is established, tincture of opium is of great benefit 
in controlling hay asthma, reducing the secretion, diminishing the 
sneezing, and at the same time bracing up the nervous system. It 
* Both the screw and the spectacles are sold by Messrs. Mayer and Meltzer, Great 
Portland Street. HAY FEVER. 
311 
should be given in the manner recommended for acute catarrh (p. 
291), but continued for a longer time. Belladonna has been recom- 
mended, but I have had no experience of its use in this complaint. 
I trust very little to local measures in the treatment of hay fever, but 
when there is profuse secretion with an excessive tendency to sneeze, 
the inhalation of strong ammonia salts often gives great relief. I have 
not found injections of quinine, as recommended by Helmholtz, at all 
useful. Though in a few cases benefit was derived, in most instances 
no effect was produced, whilst some patients were actually made worse. 
The Vapor Benzoini of the Throat Hospital Pharmacopoeia has occa- 
sionally produced a soothing effect, and I have also seen good results 
from insufflations into the nose of a powder consisting of one-sixteenth 
of a grain of morphia and one grain of bismuth. This should be 
applied several times a day. Ferrier’s snuff (see Appendix) may be 
substituted for the above formula, but it should be applied by insuffla- 
tion. 
In a few cases I have seen some benefit from the use of medicated 
bougies, such as the bismuth, and acetate of lead Buginaria of the 
Throat Hospital Pharmacopoeia (see Appendix), but, like quinine, they 
occasionally aggravate the mischief they are meant to cure. 
The upper lip and the margins of the nostrils should be smeared over 
with benzoated zinc ointment two or three times a day. 
For the relief of the irritation of the eyes, frequent very 
cold water is sometimes useful, though Roberts* appears to have found 
more benefit from warm and slightly salt water. Sulphate of copper 
(gr. ij. ad §j.) or sulphate of zinc (gr. ij. ad §j>) may sometimes; do 
good, but I have found a lotion containing two grains of acetate of 
lead with two drops of dilute acetic acid in an ounce of water, the most 
soothing application. 
Asthmatic patients often derive benefit from inhaling the fumes of 
nitrated blotting paper (see Appendix, vol. i., p. 552), the good effect 
of which is further increased by steeping the paper in a solution of stra- 
monium, datura tatula, belladonna, or lobelia. 
* New York Med. Gaz., October 8th, 1870. 312 
DISEASES OF THE THROAT AND NOSE. 
CHRONIC NASAL CATARRH. 
Latin Eq.—Catarrhus longus. 
French Eq.—Coryza chronique. 
German Eq.—Cronischer Nasencatarrh. 
Italian Eq.—Corizza cronica. 
Definition.—Chronic inflammation of the lining membrane of the 
nasal fossce characterized by swelling of the mucous membrane, by increase 
in the natural secretion, by more or less obstruction of the nasal passages, 
nasal voice, and impairment or loss of smell. The affection sometimes 
causes a watery flux, and when neglected may give rise to great hypertro- 
phy of the turbinated bodies. 
History.—Since the issue, many years ago, of Cazenave’s* two papers, little attention 
was directed to the complaint until it began to be studied by American physicians. 
Excellent practical articles have recently been published by Solis Cohen,f Beverley 
Robinson,I and Bosworth \\ whilst Rumbold|| has given his views on the disease at 
great length. In Europe the subject has been treated by Michel,If Tillot,** Lowen- 
berg,ff and Bresgen.Jj; 
Etiology.—The commonest cause of chronic catarrh is the previous 
occurrence of acute attacks. The most obstinate cases are generally 
supposed to depend on the strumous diathesis, or to occur in persons 
who have suffered from constitutional syphilis; but I have sometimes 
found the complaint very intractable when there was not the slightest 
evidence of any constitutional taint. The disease may commence at 
any period of life, but is most common in childhood, when it is occa- 
sionally caused by the presence of adenoid vegetations in the naso- 
pharynx. In the aged it often assumes the character of a mild flux, 
* Sur le Coryza chronique, Paris, 1835; another article, 1848. This physician 
practised at Bordeaux, and must not be confounded with his celebrated namesake of 
Paris. 
f Diseases of the Throat and Nasal Passages, New York, 1879, 2d ed., p. 346 et seq. 
J Practical Treatise on Nasal Catarrh, New York, 1880, p. 69 et seq. 
\ Manual of Diseases of the Throat and Nose, New York, 1881, p. 179 et seq. 
|| Hygiene and Treatment of Catarrh, St. Louis, 1880. 
f Krankheiten der Nasenhohle, Berlin, 1876. 
** Annales des Maladies de l’Oreille, etc, 1S79. 
ft Union Medicale, July 28, 1881. 
Der chronische Nasen und Rachen Katarrh, Wien und Leipzig, 1883. CHRONIC NASAL CATARRH, 
313 
producing the “bead” at the end of the nose, made so familiar by cari- 
caturists. Chronic catarrh may be induced by any of the various 
causes referred to in connection with acute catarrh, such as the inhala- 
tion of irritating vapors, or of solid particles suspended in the atmos- 
phere. Snuff-takers and spirit-drinkers are generally subject to chronic 
catarrh of the nose, and whilst the affection is occasionally the cause, it 
is often the consequence of a polypus in the nasal cavity. 
Symptoms.—An increased secretion of mucus is the most common 
symptom of chronic nasal catarrh, but the patient almost always ex- 
periences a feeling of “stuffiness” in the nose. There is often suffi- 
cient obstruction to interfere with nasal respiration, and the well-known 
alteration in the character of the voice, already described in dealing 
with acute catarrh (page 289), is produced. The patient in such 
a condition is popularly said to speak “ through his nose,” though as 
a matter of fact the peculiarity is due to obstruction of the nasal pas- 
sages. The affection sometimes extends to the naso-pharynx, and may 
even spread up the Eustachian tube, and give rise to catarrh of the 
middle ear and serious deafness.* In severe cases the tear-duct is often 
obstructed, and, as Bresgenf has pointed out, even when the complaint 
is slight the skin of the nose, especially near its tip, is generally red. 
Occasionally, on the other hand, the complaint consists of a constant 
running of watery fluid from the nose, constituting a veritable rliinor- 
rhoea, the secretion being sometimes so abundant as to cause the greatest 
inconvenience. I have treated several cases in which the patient has 
been obliged to use fifteen or twenty pocket handkerchiefs in a single 
day, and one in which from thirty-two to thirty-five were required 
daily for a fortnight. A good example of the affection is related by 
Morgagni,| ’n which a woman suffered from a discharge of “ watery 
* Dr.-Rumbold, whose work on Catarrh has already been referred to, states (pt. ii., 
pp. 239, 240) that in the course of eighteen years of practice he has “ had many patients, 
amounting to several hundred, whose mental condition has been more or less affected 
by this inflammation extending from the nasal passages to the membranes of the 
brain. . . . Uncontrollable melancholia and dissatisfaction, inability to think con- 
secutively, to recollect the common matters of life, to add up a column of figures, to 
remember immediate relations’ names,” are some of the distressing symptoms exhibited 
by Dr. Bumbold’s patients. Others forgot even their own names, whilst one unfor- 
tunate gentleman, whose nose was no doubt in an exceptionally morbid state, “ ex- 
perienced the sensation, while walking, that he was sinking into the pavement up to 
his knees.” Such complications of catarrh, however, are fortunately not met with in 
this country, 
f Op. cit., p. 70. 
J De sedibus et causis morborum, epist. xiv., sec. 21. 314 
DISEASES OF THE THROAT AND NOSE. 
fluid” from the left nostril (after the other symptoms of an ordinary 
catarrh had left her) for several months. About half an ounce passed 
every hour, and the patient, who had been fat and florid, wasted away. 
On the stoppage of the rhinorrhoea she recovered weight. The same 
writer quotes from Bidloo an instance, apparently of traumatic origin, 
in which twenty-five ounces of pale fluid were discharged from the 
right nostril in twenty-five hours. A still more remarkable case is 
related by Elliotson,* wdiere a lady on two different occasions suffered 
from profuse discharge of watery fluid from the left nostril, the first 
attack having lasted eighteen months, and the second twenty-three. It 
was estimated that during the first attack she passed one hundred and 
ninety-three gallons of fluid in all, whilst during the second, three 
quarts were discharged in a single day. On the first occasion the affec- 
tion ceased suddenly without any apparent cause; on the second it 
stopped gradually under the internal and local use of sulphate of zinc 
prescribed by Sir Benjamin Brodie,f but as no amelioration whatever 
took place during the first three weeks of this treatment, Elliotson 
doubts whether the remedy really had any effect in controlling the 
disease. 
It will be understood from the above description of the very varying 
character of the secretion that the condition of the mucous membrane 
itself must differ greatly in individual cases. On examining the nose 
in ordinary cases of chronic catarrh the mucous membrane is seen to be 
red and succulent, and covered here and there with patches of thick, 
moist, yellow secretion, or with a few thin flakes of dried mucus. In 
rhinorrhoea, on the other hand, the lining membrane is usually pale and 
sodden. If the disease exists for any length of time, some of the mor- 
bid changes described in the next article may be seen. In all cases of 
chronic inflammation, abrasions of surface are apt to occur, and these 
sometimes give rise to small ulcers, causing great annoyance by exciting 
a sensation of tingling and heat in the nose, which often leads the 
patient (especially if a child) to pick off the scabs and thus increase the 
irritation. The ulcers most frequently form in the mucous membrane 
covering the cartilaginous septum just inside the nose, and in neglected 
cases perforation may take place, and a permanent aperture result. 
Diagnosis.—If a complete examination can be made, and it can be 
ascertained that neither polypi, polypoid tumors, nor post-nasal adenoid 
growths are present, there will be no difficulty in determining the nature 
of the affection, which, indeed, is generally quite obvious. It is only 
* Med. Times and Gaz., Sept. 19th, 1857. 
f Quoted by Elliotson, loc cit. CHRONIC NASAL CATARRH. 
315 
in cases of severe rhinorrhoea that any doubt can arise, and in these it 
must not be forgotten that excessive discharge of a watery fluid from 
the nose may be caused by a polypus in the antrum,* or may be of re- 
flex character and result from disease or injury of the fifth nerve,f 
from optic neuritis,J and probably from even more remote sources of 
irritation. 
Prognosis.—With ordinary care a favorable result may always be 
predicted, but there is a great tendency to recurrence in the old, the 
very young, and in persons of debilitated constitution. It is most im- 
portant, however, to cure every case as quickly as possible, especially 
in young children, lest the disorder should lead to hypertrophy, or 
possibly to atrophy and ozsena. 
Pathology.—Little is known as to the local condition in ordinary 
chronic catarrh of the nose, but it is likely that the usual phenomena 
characterizing chronic inflammation in mucous membranes are ex- 
hibited in such cases. Infiltration of the sub-epithelial connective layer, 
with consequent thickening and induration of the membrane ami 
atrophy of the gland ulse owing to the pressure exercised on them by 
the tissues in which they are imbedded, probably constitute the sum of 
the morbid changes to which chronic catarrh gives rise within the nose, 
though the troublesome sequelae detailed in the next article are not un- 
likely to occur in protracted cases. 
Treatment.—Astringent washes, douches, and sprays are generally the 
best remedies, but it is very important to remember that the mucous 
membrane of the nose will not bear nearly such strong medicaments as 
the pharynx or larynx. Simple alkaline solutions, such as bicarbonate 
of soda (gr. x. ad §j.), often answer perfectly well, but the remedy which 
I have found most effectual is the “compound alkaline wash” (see 
Appendix, Nasal Washes). Several of the collunaria contained in the 
Throat Hospital Pharmacopoeia are sometimes of service, especially the 
coll, acidi tannici, and the coll, aluminis. If washes and douches cause 
pain, sprays may be employed, and they are likely to be most useful 
when the secretion is thin and abundant. In such cases I have known 
a spray of tannic acid (gr. iij. ad §j.)> or alum (gr. iv. ad §j.), rapidly 
effect a cure in cases that have been going on for months and even 
years. If solutions do not succeed, some of the astringent or sedative 
* Paget: Trans. Clin. Soc., 1879, vol. xii., p. 43 et seq. 
f Althaus: Brit. Med. Journ., 1868, vol. ii., p. 647 et seq. 
J Nettleship: Ophthalmic Review, Jan. 1883, vol. ii., No. 15, p. 1 et seq. Priestley 
Smith: Ibid., p. 4 et seq. 316 
DISEASES OF THE THROAT AND NOSE. 
powders, the formulae for which will be found in the Appendix, may 
be blown into the nose once or twice daily by the patient with Bryant’s 
auto-insufflator, or the same class of remedies may be employed as snuff. 
Porter,* of St. Louis, has found the frequent use of a snuff composed 
of camphor, tannic and salicylic acid very advantageous. In long- 
standing cases medicated bougies, as first recommended by Catti,f are 
often of great service, the Buginarium bismuthi, and the B. plumbi 
acetatis (Throat Hospital Phar.) being especially efficacious. Should 
there be much swelling of the mucous membrane a gum-elastic bougie 
(p. 257) should be passed into the nose every day, and at first allowed to 
remain in situ for a few minutes. This period may be gradually extended 
to half an hour, a larger instrument being used as the passage widens. 
In some cases, however, every kind of local treatment seems only to 
irritate, whilst a cure can be quickly effected by keeping the mucous 
membrane at rest. With this view it is very important that the patient 
should be directed not to blow his nose, the forcible removal of the 
mucus causing an increased flow of blood to the part, and consequently 
a more copious secretion. If the patient will submit to the slight in- 
convenience occasioned by the collection of mucus, and merely wipe the 
nose from time to time, the secretion will diminish, and will soon cease 
to be troublesome. Sneezing should, if possible, be prevented in the 
manner already recommended (p. 291). Should hypertrophy of the 
mucous membrane take place, the ease will probably require to be treated 
by some of the various measures described in the next article. 
In obstinate cases, and especially when old persons are the subjects 
of the complaint, constitutional treatment of an analeptic and tonic char- 
acter should be carried out, and above all things, such patients should 
be enjoined to seek, if possible, a warm and dry climate. Where the 
complaint is of a secondary character, the original malady must be re- 
moved before a cure can be looked for. 
HYPERTROPHY OF THE MUCOUS MEMBRANE OF THE 
NOSE. 
When chronic catarrh of the nose has existed for some years, and, 
indeed, in children of scrofulous type, when it has troubled the patient 
* St. Louis Med. and Surg. Journ., December, 1875. 
f Zur Therap. d. Nasenkrankheiten. Wien. med. Zeitschr., 1876. HYPERTROPHY OF THE NASAL MUCOUS MEMBRANE. 
317 
for only a few months, great thickening of the mucous membrane some- 
times takes place. This hypertrophy may involve either the front or 
back portion of the nasal passages. The color of the swollen mucous 
membrane is generally bright red in front, but of a duller red or purple 
tint in the posterior portions of the nose. The anterior extremity and 
the whole lower border of the inferior turbinated body is perhaps the 
Fig. 75. 
Hypertrophy of both Turbinated Bodies. (Seen from behind.) 
most common site of the hypertrophy, which in the latter situation is 
occasionally so considerable as completely to block up the inferior 
meatus. Less frequently the middle turbinated bodies are the seat of 
hypertrophy. When the thickening affects the posterior part of the lower 
turbinated bodies, instead of producing a more or less uniform swelling 
of the tissues, it more often leads to the development of numerous dark 
Fig. 76. 
Showing the Pale Variety of Hypertrophied Tissue. (Seen from behind.) 
red or purple polypoid vegetations, giving the turbinated body a some- 
what mulberry-like appearance (Fig. 75). Sometimes the growths are 
pale, and appear to hang down from the choanae towards the uvula 
(Fig. 76). These excrescences bleed readily, though only slightly, 
when touched. Whether the hypertrophy involves the anterior or the 318 
DISEASES OF THE THROAT AND NOSE. 
posterior portion of the turbinated bodies, if at all considerable, the 
swelling is almost always bilateral, and generally symmetrical. Occa- 
sionally the septum is greatly thickened, the hypertrophy usually occur- 
ring at the lower and back part. 
The symptoms are the same as those of ordinary chronic catarrh, but 
intensified, the patient being often quite unable to blow his nose, and 
being obliged to breathe entirely through the mouth. The voice is 
persistently nasal, and the patient, if a child, always keeps the mouth 
open, presenting the well-known stupid appearance which has already 
been described in connection with the subject of enlarged tonsils (vol. 
i., p. 76). It has recently been noticed by several physicians that ob- 
struction of the nasal passages is apt to give rise to very troublesome 
reflex phenomena, such as asthma, cough, and even epilepsy, complica- 
tions which will be considered in dealing with polypus of the nose (see 
p. 356 et seq.). These phenomena, however, are not nearly so frequent 
in cases of simple hypertrophy as in polypus, the probable reason being, 
as suggested by Hack,* that the morbid alteration of structure destroys 
the cavernous tissue, diminishes sensibility, and thereby lessens reflex 
excitability. 
The diagnosis is easy, for a careful examination with the speculum 
and rhinoscope will usually reveal the nature of the case. Those, how- 
ever, who are not practiced in the examination of the interior of the 
nose sometimes mistake a thickened condition of the mucous membrane 
covering the lower spongy bone for a polypus. It is only necessary, 
however, to bear in mind the fact that hypertrophy is nearly always 
bilateral, and in most cases symmetrical, a circumstance which generally 
serves to differentiate the affection from polypus. Moreover, catarrhal 
thickenipg chiefly affects the lower turbinated bodies, whilst true polypi, 
as a rule, spring from the mucous membrane covering the middle and 
upper bones or the corresponding meatuses. Cases not unfrequently 
occur, however, in which polypi and hypertrophy coexist, and occa- 
sionally one of these conditions conceals the other. Gottsteinf has 
pointed out that it is not always possible at first to distinguish between 
the swelling produced by chronic perichondritis and that due to simple 
hypertrophy. In a very instructive case related by that observer the 
appearance was entirely that of hypertrophic catarrh ; but after an ab- 
sence of two months the patient, who meanwhile had remarked no 
change in his symptoms, returned with extensive destruction of the 
septum, due to the perichondritis which had doubtless existed all along. 
* Neue Beitrage zur Rhinochirurgie, Wien, 1883. 
f Berlin, klin. Wochenschrift, 1881, No. 4. 319 
HYPERTROPHY OF THE NASAL MUCOUS MEMBRANE. 
The pathological changes which sometimes result from chronic nasal 
catarrh are no doubt largely due to the peculiarly vascular and cavernous 
structure of the turbinated bodies (see Anatomy, p. 23S). The hypertro- 
phy occasionally produces an appearance somewhat resembling in form 
the flocculus of the cerebellum, but of a bright pink or deep red color. 
This is well shown in the annexed cut (Fig. 77), copied from a speci- 
men in the Museum of the Royal College of Surgeons. The morbid 
process has been carefully studied and well described by Bos worth* and 
Seiler, f From the investigations of these observers it would seem 
Fig. 77. 
Hypertrophy of the Posterior Three-fourths of the Lower Turbinated Body. From 
Specimen No. 2201c in the Royal College of Surgeons’ Museum. 
(The outline of the nose has been added by the artist.) 
that the changes which take place are similar to those commonly ob- 
served in chronic inflammation of mucous membranes. Thus the epi- 
thelial cells are increased in number, and though showing no marked 
tendency to desquamation, are seen here and there to be undergoing 
fatty degeneration; the basement membrane is thickened, the mucosa 
densely infiltrated with small cells; the glands and their ducts are filled 
with proliferating epithelium, the bloodvessels increased, both in size 
and in number, and the trabeculae and sinuses greatly enlarged. 
* Trans. Intern. Med. Congress, London, 1881, vol. iii., p. 327 et seq.; and the (New 
York) Medical Record, June 10th, 1882. 
f Philadelphia Med. Times, Jan. 14th, 1882. See also the report of a case by Thier- 
felder (Atlas der path. Histol. Lief. 1), referred to by Seiler. 320 
DISEASES or THE TIITtOAT AND NOSE. 
There is no doubt a close connection between thickening of the nasal 
membrane and genuine polypus. The two conditions are frequently 
found associated, and a good illustration of this is afforded by a speci- 
men in the Museum of the College of Surgeons, a woodcut of which 
will be found further on (see Fig. 79, p. 361). Some cases classified 
as hypertrophy of the nasal mucous membrane are also probably of 
papillomatous nature (see “ Papilloma of the Nose”). 
The prognosis is favorable, for almost every case can be cured by 
suitable treatment. 
The treatment frequently needs to be of a vigorous character, but at 
an early stage the mildest measures are sometimes sufficient, the daily 
use of gum-elastic bougies often effecting a cure. The smallest size of 
instrument should, as a rule, be used at first, and at the beginning of 
the treatment the bougie should be left in the nose for no longer than 
five minutes at a time; after a few days, however, it may remain in situ 
from ten minutes to a quarter of an hour, and at the end of a week it 
can be easily tolerated for half an hour. Larger bougies should after- 
wards be employed, but force must be carefully avoided. Mild alkaline 
sprays or hand-washes are often of great service if the treatment is per- 
severingly carried out. Sneezing must be checked by smelling strong 
ammonia or acetic ether. 
Should this plan not succeed more active steps must be taken ; but 
a word of caution is perhaps necessary in connection with this point. 
For, though the introduction of the electric cautery and the wire 6craseur 
permits some relaxation of the rule under which surgeons were taught 
“ to cut through everything soft, to saw through everything hard, and 
to tie everything that bleeds,” the spirit of this simple instruction has, I 
fear, in recent years, sometimes influenced the young practitioner, and the 
nasal passages have occasionally been “cleared ” with a zeal and energy 
worthy of the industrious backwoodsman. In several cases that have 
come under my own care, in which severe measures had previously 
been urgently advised by others, I have succeeded in effecting a cure by 
the simple removal of all causes of irritation and the persevering use of 
gentle dilatation. I would also warn some of my younger confreres that 
as the appearance of the interior of the nose varies immensely in healthy 
persons, it is unnecessary, where no inconvenience is felt, to restore 
geometrical symmetry to the turbinated bodies, or to invest the lining 
membrane of the nose with artistic merit. But whilst deprecating un- 
necessary aggression in this tender region, I do not deny that there are 
many cases which can only be cured by active treatment. HYPERTROPHY OF THE NASAL MUCOUS MEMBRANE. 
321 
Should the hypertrophy resist the measures already recommended, 
the redundant tissue must be destroyed or removed. Destruction with 
electric cautery will be found the most simple and efficacious method. 
If the thickening is in the anterior part of the nose, the nostrils should 
be well dilated with a speculum, and the exuberant tissue carefully 
destroyed with the porcelain knob electrode, or removed with the hot 
loop (see vol. i., p. 489, Fig. 101, c and d), or a number of slight lines 
may be burnt with the spatula-like points (vol. i., Fig. 101, a). If 
the thickening affects the central portions of the turbinated bodies 
Lowenberg’s electrode (p. 274) answers well, and when the posterior 
part of the middle turbinated bodies is involved, Lincoln’s instrument 
(Fig. 61, p. 275) will be found very serviceable. In applying electro- 
cautery, as already remarked, I endeavor to avoid employing a protect- 
ive shield, the loss of space and contracted field of vision involved in 
the use of such an instrument often more than neutralizing any advan- 
tage which it may possess. Sometimes, however, when the swelling is 
very great, a shield is required, and in these cases I find Shurly’s in- 
strument (see p. 258) the best. Instead of electric cautery Paquelin’s 
thermo-cautery, as modified by Goodwillie,* can be tried ; but as this 
instrument has to be introduced red hot, it is more likely to cause acci- 
dental injury than electric cautery, and it can seldom be used except 
when the patient is under chloroform. Those who have neither this 
instrument nor any convenient electric apparatus at hand, can destroy 
the redundant tissue by means of London paste (Thr. Hosp. Ph.), 
nitrate of silver, or glacial acetic acid. The two first-named caustics 
can be readily applied with the pharyngeal spatula (vol. i., p. 25), whilst 
nitrate of silver can be brought into contact with the hypertrophied 
tissue either with Schrotter’s (Fig. 40, p. 259) or Andrew Smith’s in- 
strument (Fig. 41, p. 260), or with Allen’s wires (p. 260). Bosworthf 
has found glacial acetic acid of greater value than any other caustic, 
and Sajous| has also strongly recommended this remedy. 
Instead of destroying the hypertrophied tissue, however, it may be 
removed by a cutting operation. For this purpose either a snare or 
sharp forceps may be employed. Jarvis’s§ ecraseur (p. 272) is an ex- 
cellent instrument, whilst my own (p. 273) will be found very conve- 
nient. When the anterior part of one of the turbinated bodies is 
* Beverley Robinson : Practical Treatise on Nasal Catarrh, New York, 1880, p. 111. 
f Diseases of the Throat and Nose, New York, 1881; and New York Medical 
Record, June 10, 1882. 
J Med. and Surg. Reporter, Dec. 31st, 1881. $ New York Medical Record, 1881. 322 
DISEASES OF THE THROAT AND NOSE. 
enlarged, it should first be transfixed with a needle mounted in a light 
handle, the loop of the ecraseur being then passed over the needle, and 
gradually drawn round the hypertrophied membrane. If the posterior 
extremity of the turbinated body be the part affected, such a bend should 
be given to the loop before it is pushed through the nose that it will 
pass over the mass in the naso-pharynx. Two or three turns of Jarvis’s 
screw, or a few touches of the lever of my instrument, will suffice to 
secure the growth, which, if haemorrhage is anticipated, should be cut 
through very slowly, the operation being interrupted from time to time, 
and not completed for half an hour or even an hour. In these cases 
it will be found much more easy to remove the swollen tissue with the 
ecraseur passed through the nose than to destroy it through the naso- 
pharynx. Beverley Robinson* has successfully removed hypertrophied 
tissue from the turbinated bodies by means of his strongly-toothed 
forceps (p. 269), but this treatment appears to be much more severe 
than either the electric cautery or the wire ecraseur. 
DRYf CATARRH OFTEN LEADING TO OZ^ENA.J 
Latin Eq.—Catarrhus siccus abiens ssepe in ozsenam. 
French Eq.—Coryza sec conduisant souvent 4 l’ozene. 
German Eq.—Trockener Katarrh oft in Ozsena iibergeliend. 
Italian Eq.—Catarro secco producendo spesso Pozena. 
Definition.—Chronic inflammation of the lining membrane of the 
nose in which a thin secretion, instead of flowing away, dries on the sur- 
face, giving rise to adherent brown or green flakes or crusty masses of 
* Op. cit., p. 114. 
f Notwithstanding the recent strictures of Virchow (Address delivered before the 
Berlin Medical Society, January 24th, 1883, Med. Press and Circ., April 11th, 1883, p. 
312), principally based on etymological considerations, to the term “dry catarrh,” 
its convenience is so great that it cannot well be dispensed with. Dry catarrh 
means a catarrh in which the secretion is prevented from “ flowing away ” through its 
rapidly drying property. In other words the term avoids the use of a long explana- 
tory paraphrase. 
% Ostjj a stench. Forcellini (sub voce) states that the term in its medical sense is 
derived from ozcena, a fish, “ ex polvporum genere, caput habens gravissimi odoris 
but it seems more probable that the fish and the disease take their name from the same 
word. 323 
DRY CATARRH. 
dried mucus, which are apt to undergo decomposition and cause a dis- 
gusting and characteristic stench, known under the name of ozcena. 
There is often atrophy of the turbinated bodies and of the subjacent bony 
structures, whilst the nasal passages and meatuses are proportionately 
increased in capacity. 
History.—The relation of dry catarrh to ozsena has only been recognized in quite 
modern times, but the term ozcena is one of the oldest in medicine. As used by the 
Greek and Latin technical writers, it signified not simply a stench, but more con- 
cretely, a foul-smelling ulcer in the interior of the nose. Pliny* mentions the treat- 
ment of ozcence (ulcers) of the nose, and Celsusf quotes the Greek surgeons as applying 
the term to fetid sores covered with crusts. The etymological meaning of the word, 
however, was soon forgotten, and a century and a half after the time of Celsus we find 
GalenJ speaking of two kinds of ozsena—one being simply an ulcer difficult to cure, 
and another where the ulcer is accompanied by a disagreeable odor. Paul of 
A5gina$ defines ozsena as a “ carious and putrid ulcer, produced by saturation (of the 
nares) with acrid humors.” iEtius|| refers to ozsena as being of the nature of an 
ulcer, and advises treatment by remedies applied by insufflation through a 
reed, or by means of medicated tents inserted in the nostrils. Alexander 
in the sixth century, mentions the disease, merely, however, repeating 
the words of Galen. In the twelfth century, Actuarius** gives a clear description of 
the condition as arising from decomposed secretions, without mentioning ulceration as 
a necessary feature of the complaint. Ambroise Pareft contents himself with tran- 
scribing the words of Galen, merely adding a suggestion for a remedy of which urina 
asini appears to have been the chief ingredient. In the beginning of the seventeenth 
century, Johannes CratoJJ anticipated in a remarkable manner the most modern doc- 
trine as regards the nature of ozsena. His words are: “ Imo in catarrhosis pituitam 
putrescere, et putridum quiddam eos expirare indicio sunt coryzse halitu etiam con- 
tagiosse.” Fabricius ab seems to have been familiar with the affec- 
tion, which he looked upon as an ulceretion of the interior of the nose, often connected 
with syphilis, but not at all necessarily dependent thereon. Sir Thomas Mayern|||| 
mentions several remedies for the disease which he also considered as being most fre- 
quently due to venereal disorder, but in some cases proceeding ‘‘ab humoribus acri- 
bus et salsis.” At the close of the seventeenth century, taught that 
ftrior narium—i. e., ozsena in its modern sense—arises from the fermentative putrefac- 
tion which the mucous secretion is apt to undergo if it be retained too long within the 
* Hist. Nat., 25, 13, 102. f De Medicinal, lib. vi., cap. 8. 
J De compos, pharmacorum sec locos, lib. iii., c. 3. 
\ Opera, lib. iii., c. 24. || Tetrabiblos, ii., sermo. ii., cap. 90. 
De arte medica, lib. iii., cap. viii. 
** De methodo medendi, lib. ii., c. viii. ff Chirurgie, liv. ii., chap. xv. 
Epist. Philos. Medic., Planoviae, 1610, epist. cvi., p. 188. 
§§ Opera chirurgica, Lugd. Batavorum, 1723, p. 444 et seq. 
1111 Praxeos Mayernianae Syntagma, Londini, 1690, vol. i., cap. xvi., p. 89; also vol. 
ii., p. 261 el seq. 
f f De cerebro, cap. xvi.; in Leclerc and Manget’s Bibliotheca Anatomica, Genevae, 
1699, t. ii., p. 159. 324 
DISEASES OF THE THROAT AND NOSE. 
nose or the adjoining sinuses. Some years later Reininger* maintained that the de- 
composition of mucus within the ethmoidal, sphenoidal, and frontal sinuses, and the 
antrum of Highmore, produced almost incurable ozgena. Giinzf published some valu- 
able observations, chiefly of cases where the odor was due to disease of the sinuses 
opening into the nose. This subject, like everything else in connection with the nose, 
is treated of with his usual erudition by Cloquet in the workj already frequently re- 
ferred to. Cazenave,? of Bordeaux, studied the complaint from a scientific point of 
view, as far as could be done with the imperfect means of diagnosis at his command. 
Trousseau,|| whilst refusing to commit himself to any theory as to the origin of ozena, 
described its clinical features with remarkable clearness, and his instructions for treat- 
ment were marked by his usual sound sense. A great step in advance was made by 
Otto Weber,f who pointed out that ozena is merely a symptom, and that it would be 
better either to lay this term altogether aside, as only serving to conceal an incomplete 
diagnosis, or to retain it for those cases in which there is no trace of ulceration. In 
recent years, improved methods and appliances for the examination of the nose have 
led to a more active interest in its diseases, and a number of valuable monographs 
and papers have appeared on the subject of ozena. Of these I need only mention the 
contributions of Schrotter,** Zaufal,ff TillotU Michel,\\ B. Friinkel,|||| Rouge, 
Gottstein,*** Cozzolino,fff E. Frankel,JJJ Beverley Robinson,Stoerk,|||||| 
Franks,'Schaffer,**** Martin,f+ff Krause,and Massei.§|$§ The views of 
several of these authors will be referred to in detail in the body of the article, but I 
think it desirable to remark here that the theory of Crato and Vieussens, and the 
more precise statements of Otto Weber, attracted little or no notice; and it was not 
till Frankel, of Berlin, insisted on the view that the term ozena, if retained at all, 
* Dissert, inaugur, de cavitatibus ossium capitis, Altorf, 1722, \ xxxix., p. 31. 
f Obs. ad ozfenam maxillarum, Lipsiae, 1753, p. viii. 
f Osphrdsiologie, Paris, 1821. 
\ De l’Oz&ne non-v6n6rienne, Paris, 1831. 
|| Clinical Medicine, Syd. Soc. Transl. 1870, vol. iii., p. 59 et seq. 
f Yon Pitha u. Billroth; Chii'urgie, Bd. iii., i. Abtheil, 2 Heft, Erlangen, 1866, 
p. 187. 
** Jahresbericht der Ivlinik fiir Laryngoscopie, Wien, 1871; Ibid. 1873-75. 
ff Aerzt. Correspondenzblatt, 1874, No. 33; Ibid. 1877, No. 24. 
ff Annales des Maladies de l’Oreille, etc., 1875, t. i., p. 112 et seq. 
\\ Krankheiten der Nasenhohle, Berlin, 1876. 
1111 Ziemssen’s Cyclopaedia, 1876, vol. iv., p. 136 et seq. 
Iff Compte-rendus et Mem. du Congres des Sci. Mbdicales de Geneve, 1877. 
*** Breslau. Aerztliche Zeitsclirift, Sept. 27, 1879. 
fft Ozena, e pseudo-ozeni, Napoli. 1879. See also Ozena e sue forme cliniche, 
Napoli, 1881, by the same author. 
f+t Virchow’s Archiv, Bd. lxxv., 1 Heft, 1879. 
$1$ Nasal Catarrh, New York, 1880, p. 74 et seq. 
Illlll Laryngoscopie und Rhinoscopie, Wien, 1880. 
fff Dublin Journ. of Med. Science, June, 1881. 
**** Monatsschrift fiir Ohrenheilkunde, 1881, No. 4. 
tttf De l’Ozene, ThSse de Paris, 1881. 
ftff Virchow’s Archiv, 1881; and Trans. Intern. Med. Congress, London, 1881, 
vol. iii. 
\\\\ Giornale Internaz. delle Scienze Mediche, Anno iv., Napoli, 1882. DRY CATARRH. 
325 
should be confined to cases of dry catarrh, in which the decomposition of the retained 
secretions gives rise to an offensive smell, that a new era was established. This mode 
of regarding ozsena has since been followed by Beverley Robinson and Gottstein, both 
of whom have also made valuable suggestions as to the treatment of the complaint. 
Etiology.—Dry catarrh is pretty common up to the period of middle 
life, but it rarely gives rise to ozaena in the case of adults; indeed, in 
upwards of twenty years’ experience I can only recall five cases in 
which ozaena commenced after thirty. Oue of the patients was a lady 
fifty-three years old, and another a man aged fifty-seven. The other 
three patients were between thirty and forty. On the other hand, in 
the case of children and young persons, especially at the age of puberty, 
dry catarrh so rapidly passes into ozaena that the parched condition of 
the mucous membrane is often not observed till the foetor calls atten- 
tion to it. 
Ozaena is generally thought to be a complaint of constitutional origin, 
and those who use more precise language call it either strumous or 
syphilitic. Schaffer, who employs the term ozaena in a somewhat com- 
prehensive manner, has pointed out that the countless acinous glands 
of the Schneiderian membrane, which are so abundantly supplied with 
blood through the rich cavernous structure of the spongy bodies, afford 
a peculiarly favorable ground for the manifestation of a dyscrasia, and 
he considers the complaint as always due to struma or syphilis, heredi- 
tary or acquired. He states that in 119 cases* he found ninety-nine 
of strumous and twenty of syphilitic origin. In two cases the com- 
plaint was distinctly due to hereditary syphilis. In one of them the 
patient died at the age of four months, presenting pemphigus on the 
soles of the feet, and ulcers at the margins of the nose together with a 
fetid discharge. In a second case, the symptoms commenced when the 
child was between five and six weeks old, and were relieved by mer- 
curial treatment and carefully applied local remedies, which had been 
used without success in the other instance. Schrotter and Stoerk em- 
ploy the word oza3na in its ancient vague sense, and their recorded ex- 
perience must therefore be received subject to certain qualifications. 
Of seventy-seven cases reported by Schrotter, syphilis was the supposed 
cause in thirty-four, and scrofula in ten; whilst in the remaining cases 
the etiology could not be determined, except in two, which were of 
traumatic origin. Stoerk thinks that ozaena is always syphilitic, but 
* Schaffer actually reports 123 cases, but as in four of these there was “independent 
disease of bone,” they do not come within my definition of ozaena. In Schaffer’s cases 
the female sex was affected nearly half as frequently again as the male. 326 
DISEASES OF THE THROAT AND NOSE. 
that when it develops some time after birth, it is often difficult to prove 
its hereditary origin, and that under these circumstances, physicians 
fall back on the theory of scrofula. Of twelve cases examined by Gott- 
stein, there were only two in which it appeared probable that there was 
any scrofulous taint, whilst in none was there the slighest trace of 
syphilis. 
I do not myself consider that the disease is constitutional in the true 
sense of the word. Though scrofula probably produces a certain dis- 
position to catarrh, and renders the affection more intractable when it 
does occur, it cannot, in my opinion, be said to cause ozsena. In adults 
dry catarrh shows no special disposition to affect the strumous. 
I have met with only three cases in which there was any evidence of 
hereditary syphilis, and I only know of three in which ozsena, without 
ulceration, has followed acquired syphilis. As, however, the disease 
frequently arises in persons otherwise apparently healthy, it is obvious 
that it may occur also in those who have had syphilis. Ozsena often 
affects several children of the same family, but it is not contagious. I 
have had several negative proofs of this statement, especially in the 
case of nurses suffering from ozsena who have lived in the same family 
for years without the children under their charge becoming affected. 
The immediately exciting cause of dry catarrh is sometimes, no 
doubt, the entrance of irritating particles from the surrounding atmos- 
phere. Any condition of the nasal orifices, such as unusual size, pa- 
tency, forward direction, or absence of vibrissse, which favors the 
entrance of irritating particles, predisposes to dry catarrh. On the 
other hand, anything which prevents the expulsion of morbid secre- 
tions from the nose tends to produce the disease; especially any pecu- 
liarity of shape in the nasal chambers which hinders the free blast of 
air through them. Thus bony or cartilaginous outgrowths,* or a de- 
viated septum, may mechanically interfere with efficient blowing of the 
nose. A hole in the septum, by lessening the blast of air through 
each passage, also favors the retention of mucus. It will be readily 
understood that there must be a certain relation of size between the 
nasal passages and their external orifices, and that if the interior of the 
nose is too capacious, the blast of air may not be sufficient to clear all 
the parts of it. A relatively small size of the turbinated bodies may 
* Those hard tumors which give rise to ulceration introduce an entirely new ele- 
ment into the subject, and take the case out of the category of true ozaena. Soft 
growths, such as polypi, generally cause an increase of secretion, which, as the irrita- 
tion is constant, does not become dry. 327 
DRY CATARRH. 
be the special disturbing influence, and Zaufal considers that ozsena is 
actually due to insufficient size of the spongy bones. His views will 
be again referred to in dealing with the pathology of this disease. 
The precise conditions which cause the secretion to dry and become 
adherent to the mucous membrane are unknown; but the process is 
probably due to some chemical change in the liquid itself. It has been 
shown by Ranvier* that in acute coryza the ciliated epithelial cells are 
shed very abundantly, and it is possible, as suggested by Solis Cohen,f 
that the deficiency of the ciliary element in the nasal passages thus 
brought about may lead to the stagnation of the secretion upon the 
membrane, and consequently to the formation of dry crusts upon its 
surface. Frankel| considers that the drying of the secretion is due to 
its richness in cells and comparative deficiency in water, and that the 
desiccation is further promoted by the patient failing to clear his nose 
sufficiently. He suggests, moreover, that in these cases there may be 
diminished reflex irritability, and possibly impairment of the activity 
of the cilia. 
How it is that in some cases the retained secretions give rise to ozsena 
and not in others has not yet been determined. It may be that in some 
instances the mucus, though dry, does not remain long enough in situ 
to decompose, or the stench may, as first suggested by Vieussens-, and 
subsequently by Frankel, depend on some fermentative change which 
occurs in certain cases and not in others. In his more recent contribu- 
tion to this subject, Frankel appears to have given up this idea, and 
attributes the smell entirely to decomposition. I am still, however, 
inclined to accept his earlier explanation, for the smell seems to me to 
be produced too quickly to be the result of simple putrefaction. Thus, 
if a person suffering from ozsena has the nares thoroughly cleansed by 
a detergent spray the stench often only ceases for a few hours, returning 
within so short a period that though fermentation might have occurred, 
there would not have been time for true decomposition. Franks and 
Krause are of opinion that the smell is due to a fatty degeneration of 
the mucous cells, the fatty material subsequently becoming acid (see 
Pathology). 
It has been thought by some that the peculiar smell is not developed 
unless there be real atrophy of the minute glands of the submucous 
tissues lining the nasal cavities. That atrophy commonly exists can- 
* Lancet, 1874, vol. i., p. 687. 
f Med. News and Library, October, 1879. 
X Ziemssen’s Cyclopaedia, vol. iv., p. 138. 328 
DISEASES OF THE THROAT AND NOSE. 
not be denied, but it is not a universal law; at least I may say that I 
have seen several cases of ozsena in which no atrophy could be detected. 
Gottstein,* who has generally found atrophy, has also reported one case 
in which ozsena occurred with hypertrophy; but it must be borne in 
mind that limited atrophy might easily have coexisted in some situation 
not accessible to view, both in this case and in those observed by 
myself. 
Michel, arriving independently at the same opinion as Reininger, 
contends that the complaint is due to chronic suppurative inflammation 
of the sphenoidal and ethmoidal cells, and that the discharge from these 
cavities reaching the mucous membrane of the nose forms the charac- 
teristic crusts. Though in some rare cases this may occur, it is no 
doubt very uncommon, and has not been found to exist in the post- 
mortem examinations which have been made by Hartmann,f Krause,| 
and Gottstein (see Pathology). Massei believes that the peculiar odor 
depends on some specific transformation of the products of secretion, 
and that this alteration, probably due to some chemical change in the 
mucin, only takes place at the moment that the mucus passes through 
the epithelium. This view is, to say the least of it, somewhat speculative. 
Whilst it has appeared desirable to refer to the theories of some of 
the recent workers in rhinology, much difficulty still surrounds the sub- 
ject, owing to the fact that the term ozaena continues to be applied to 
totally different affections. Diseased bone, fetid ulcers, decomposed se- 
cretion, all give rise to a stinking odor, but there can be little advan- 
tage in bringing together such a variety of affections merely because 
they have one symptom in common. Moreover, and particularly as 
showing the inconvenience of thus classifying these conditions together, 
it may be mentioned that the stench in each of these cases is quite dif- 
ferent. The smell of diseased bone in the nose is the same as that gen- 
erated by dead bone elsewhere, but in the former situation it appears 
somewhat stronger, because its source is generally nearer to the by- 
stander, and also because it is constantly diffused by expiration; but it 
is difficult to discover any advantage in describing the odor of dead 
bone in the nose by the name of ozsena. I entirely agree with Frankel,§ 
therefore, that if the term be retained, its application should be limited 
* Breslau, aerzt. Zeitschrift, September, 1879. 
f Deutsche med. Wochenschrift, 1878, No. 13. 
$ Trans. Intern. Med. Congress, London, 1881, vol. iii., p. 311 et seq. 
I Ziemssen’s Cyclopaedia, vol. iv., p. 138. DRY CATARRH. 
329 
to those cases in which, in the absence of ulceration and diseased bone, 
the odor depends on changes in the retained secretions. 
Symptoms.—The subjective symptoms of dry catarrh vary according 
to the site and intensity of the disorder. When the affection is limited 
to the anterior portion of the nasal channels, as a rule it causes but lit- 
tle inconvenience, the patient merely feeling a slight itching sensation, 
and a desire to blow the nose. In bad cases, however, the irritation is 
so great that the patient cannot restrain himself from scratching and 
picking the mucous membrane, the annoyance being chiefly felt over 
the septum. Under these circumstances the patient will often pick the 
nose to such an extent as to produce ulcers, and .several cases have come 
under my notice in which perforation of the septum has been produced 
in this way. 
On examining the nose from the front, the observer is generally 
struck by the extreme roominess of its interior, and by the small size of 
the turbinated bodies. Indeed, in old cases the nasal canal is so large 
that on simply expanding the alee with a speculum, not only the pos- 
terior wall of the pharynx, but even the orifice of the Eustachian tube, 
may be visible. Crusts of yellowish-gray or brown mucus may be 
noticed adhering to the septum and turbinated bodies. On cleansing 
the nose with a detergent spray, the mucous membrane is seen to be 
considerably congested, but if the part be examined twenty minutes or 
half an hour later, the membrane, though swollen, is generally pale. 
Sometimes the membrane bleeds slightly when the crusts are removed, 
and occasionally, though very rarely, the dried mucus adheres to the 
surface of superficial ulcers. It is important, however, to bear in mind 
that ulceration is a purely accidental complication, and in no way essen- 
tial to the complaint. 
The symptoms of ozcena are the same as those which have just been 
described as belonging to dry catarrh, but there is, in addition, a pecu- 
liar foetor. In the ordinary form of ozsena the thin flakes of dried se- 
cretion already described are met with, but in some cases round or oval 
lumps from two to three centimetres in length, and from one to two 
centimetres in width, are slowly formed and expelled at intervals of a 
week or ten days. These masses are generally of a dirty white or green 
color, but they may be brown or even black, their color depending on 
the length of time the secretion has been retained, and on accidental 
circumstances, such as discoloration by carbon in the air, or by slight 
accidental bleeding.* They are of somewhat dense structure, moist 
* An extraordinary case is related by Gallway (Lancet, October 15,1859), in which 
a lady occasionally blew out of her nose a black sooty powder, dry, and insoluble in 330 
DISEASES OF THE THROAT AND NOSE. 
externally, but dry and very compact in the centre. When they attain 
a certain size, it would seem that by pressing on the mucous membrane, 
they excite a liquid secretion, which facilitates their expulsion. These 
masses, when they form in the nose, generally collect in its vault in the 
neighborhood of the superior turbinated body, but they sometimes ac- 
cumulate in the naso-pharynx. 
It would be no doubt desirable, if possible, to describe the stench of 
ozsena, but I know of no way in which an odor can be described except 
by comparing it with some other smell, and in this instance there is no 
stench to which it bears the faintest resemblance.* 
Diagnosis.—It is very important to distinguish true ozsena—i.e., dry 
catarrh with fetid secretions—from cases in which there is ulceration of 
the mucous membrane or disease of the bones. Careful examination 
with the speculum will usually enable the observer to detect any mor- 
bid alteration in the skeleton, but Eugene Frankel has shown that in 
some cases the necrosis may be so slight as to escape observation during 
life. Washing out the nose with a detergent spray will generally com- 
pletely remove the smell, if the case is one of true ozsena, but if there 
is diseased bone the stench, though milder, can still be detected. Fetid 
discharges occur in cancer of the nose, in tubercular disease of the pitu- 
itary membrane, and in lupus exedens of the Schneiderian membrane; 
but these diseases are happily all rare, and a knowledge of their dis- 
tinctive features will prevent the practitioner confusing them with sim- 
ple ozsena. In all cases in which there is an offensive smell a careful 
search should be made for a foreign body, several instances having 
occurred in which such a condition has simulated ozsena. A very re- 
markable example has been reported by Tillauxf where a cherry-stone 
impacted in the nasal cavity gave rise to an odor resembling ozsena, 
which disappeared on removal of the stone two years after the date of 
water. This occurred five times in the course of nine months, and was not accom- 
panied by pain or uneasiness of any kind. The patient had not used charcoal in any 
way. It may be stated that she was a woman of nervous temperament, from thirty-five 
to forty years of age. 
* The French call the complaint punaisie, in addition to the equivalent term placed 
at the head of this article, and some writers affirm that this word is derived from 
punaise, the common bed-bug, and that the stench of ozsena resembles that caused by 
the crushed insect. But there is in fact no resemblance between the smells, and the 
two words punaise and punaisie are simply derived from the same source, puer, to stink 
(adj. punais). Any person who has once perceived the characteristic odor of ozsena 
will always readily recognize it again. 
f Bull, de la Soc. de Chir., Jan. 26, 1876. DRY CATARRH. 
331 
its introduction. Cases are also related by Holmes Coote* in which a 
fetid discharge from the nose was found to depend on the presence, in 
one instance, of a plum-stone, and in another of a boot-button. On 
their removal the discharge from the nose at once ceased. 
Pathology.—The changes occurring in dry catarrh and ozsena have 
been considered, to some extent, in dealing with the etiology. Atrophy 
appears to be always a secondary affection, or, in other words, the 
changes are of a quasi-cirrhotic character, resulting from previous in- 
flammatory thickening. The recent investigations of Zuckerkandlf 
prove that not only the soft tissues, but also the bony structure of the 
turbinated body becomes thinner, more elastic, flatter, and smaller. 
The mucous membrane shrinks and becomes wrinkled, the erectile tis- 
sue disappears, and the thin, pale, shining mucosa looks more like 
serous than mucous membrane. When the morbid process is far ad- 
vanced, nothing is left but thin bands of mucous membrane, occasion- 
ally, perhaps, containing some small osseous fragments—the remains of 
the spongy bones. Schaffer, who, in some cases, has been able to watch 
the whole process, found the hypertrophic stage last from eight to ten 
years before any wasting set in. Bayer,| of Brussels, has observed hy- 
pertrophy in the children of patients who have themselves arrived at 
the atrophic stage. Both Schaffer and Ziem§ maintain that ozsena may 
exist without atrophy, and there is no doubt that atrophy may occur 
without ozsena. I have already (see Etiology) stated my own experi- 
ence as regards this matter, but may add here that I recently saw a 
girl, aged eighteen, in whom there was marked atrophy of the turbi- 
nated bones with corresponding enlargement of the nasal channels, but 
without the least trace of ozsena. Yet the patient assured me that the 
symptoms of dry catarrh had existed since she was four or five years 
old.|| 
has reported a case in which he made an autopsy on a 
patient who had suffered from ozsena. The subject was a young woman, 
twenty-four years old, afflicted with insanity, who died of caseous pneu- 
* Holmes’s System of Surgery, London, 1870, 2d ed., vol. ii., pp. 423, 424. 
f Normale und pathol. Anatomie der Nasenhohle, Wien, 1882, p. 87 et seq. 
J Trans. Intern. Med. Congress, London, 1881, vol. iii., p. 314. 
\ Monatsschrift fur Ohrenheilkunde, 1880, No. 4. 
|| E. Frankel has described, under the name of ozsena, the post-mortem appearances 
of some cases in which there was a fetid odor resulting from caries of the nasal bones; 
but such morbid conditions do not, in my opinion, belong to true ozsena (see Syphilis 
of the Nose). 
f Breslauer arztliche Zeitschrift, Sept., 1879, Nos. 17 and 18, p. 6. 332 
DISEASES OF THE THROAT AND NOSE. 
monia. During life Gottstein observed that the nasal passages were 
extremely wide, and, after the removal of a quantity of stinking crusts, 
the mucous membrane was seen to be pale, thin, and free from ulcer- 
ation. At the post-mortem examination the bones and cartilages, un- 
fortunately, could not be examined; but the mucous membrane, so far 
as it was accessible by very careful examination, showed no defect, ex- 
cept a certain thinness. On microscopic investigation the epithelium 
was found to be normal; beneath this there was a layer of small round 
cells, mixed with a few spindle-shaped cells, and beneath this stratum 
again was another of fibrillar areolar tissue generally lying parallel to 
the surface, the fibrillse being here and there collected into bundles in 
different stages of development. The vessels were richly developed, 
and the elastic tunic of the arteries thickened. The glandulse were 
numerous; their contents were hazy and infiltrated, the gland-cells not 
being recognizable in some places, whilst in others they were misshapen 
and scarcely discernible. As Gottstein* remarks, “the appearances were 
those of chronic rhinitis, with more or less advanced cirrhosis of the 
mucous membrane, and a partly infiltrated and atrophied condition of 
the glandulse.” Krausef found a horny condition of the epithelium, 
atrophy of the mucosa, and degeneration of that structure into a kind 
of dense connective tissue, diminution in the number of bloodvessels, 
more or less obliteration of those that remained, through thickening of 
the adventitia and puckering of the intima. He found the glandulae 
generally deficient, and those that were left showed fatty or granular 
degeneration. ZaufalJ is of opinion that the diminutive volume of the 
osseous structure is not due to atrophy, but to their retaining their in- 
fantile dimensions, whilst the face in general undergoes its normal de- 
velopment.! This, according to Zaufal, explains the frequent occur- 
rence of ozsena at puberty, when the arrest of development suddenly 
becomes manifest, owing to the maturation of the contiguous parts. 
The theory of non-development has, however, recently been ably com- 
bated by Zuckerkandl,|| who, in examining 252 skulls of young subjects, 
met with only one in which the turbinated bones were of insufficient 
size, and in this case there was a clear history of atrophy having taken 
place. 
* Ibid. 
f Virchow’s Archiv. f. path. Anat., Bd. Ixxxv., Hft. 2. J Loc. cit. 
\ A supposed case of non-development of the turbinated bones had been previously 
recorded by Hyrtl (Sitzungsber. d. kk. Akad. in Wien, Bd. xxxviii.), but it was not 
reported as bearing on the question of ozsena. 
|| Op. cit., p. 90. DRY CATARRH. 
333 
The mucus of ozsena has been made the subject of investigation by- 
several physicians. Frank* repeatedly examined fresh specimens from 
the nares of Michel’s patients suffering from ozsena, but he never found 
anything more than pus-corpuscles, granular debris, and some traces of 
epithelium. On the other hand, Krause maintains that the newly- 
formed mucous cells undergo fatty degeneration before they are detached 
from the surface of the pituitary membrane, rendering the secretion 
viscid, and disposed to fetid change. He observed that in the mem- 
brane thus degenerated, well-formed cells are not found, but in their 
place collections of fatty corpuscles and pigmentary molecules, which 
constitute the dried mucus of the adherent crusts. Subsequently the 
fatty matter becomes acid, and gives rise to the characteristic odor of 
ozena. In this view he is supported by Eugene Frankel, who found 
fatty acids on the surface of the pituitary membrane at the post-mortem 
examination of persons who had suffered from ozsena during life. 
Prognosis.—Dry catarrh is always a very obstinate affection, whilst 
true ozsena is rarely, if ever, cured, except in the case of young children, 
in whom the disease sometimes passes away after it has existed for a 
few weeks. Ozaena can, however, be so completely kept in check by 
the treatment hereafter recommended, that it practically causes no in- 
convenience beyond the necessity of using a detergent wash or spray 
once or twice a day, or a tampon for a few hours daily. The stench 
diminishes in intensity as age advances, and about fifty generally ceases 
altogether. 
Treatment.—In dry catarrh and ozaena the first step is to get rid of 
the crusts. This may be done by washing, douching, syringing, or 
spraying the nasal fossae (see “Nasal Instruments,” pp. 261-266). 
The best solutions for washes and douches are the Collunarium sodae, 
the C. acidi carbolici, the C. acidi carbolici cum sod& et borace, or the 
C. potassae permanganatis of the Throat Hospital Pharmacopoeia, the 
formulae for which will be found in the Appendix. As a rule I prefer 
washes, as I find them much less disagreeable to the patient, and gen- 
erally quite as efficient in their action. But when the crusts form in 
the vault of the nose both washes and douches fail. Here sprays will 
often be successful, but sometimes the simple spray-apparatus (see Figs. 
44, 45, and 46), does not act with sufficient force, and if this be the case, 
a pneumatic spray-producer (Fig. 47) should be employed. Any of the 
alkaline or disinfectant sprays of the Throat Hospital Pharmacopoeia (see 
* Michel: Krankheiten der Nasenhohle, Berlin, 1876, p. 107. 334 
DISEASES OF THE THROAT AND NOSE. 
Appendix) answer the purpose well. If the spray be used in the morn- 
ing and afternoon, it will entirely get rid of any smell, and generally 
after a few months it will be found sufficient to use it only once a day 
—in the morning. Resorcin, a derivative of phenol, allied to carbolic 
acid, but without its irritating properties or its offensive smell, has 
recently been tried by Masini,* who reports very favorably of its use in 
cases of ozaena. ' He first gets rid of the crusts on the nasal mucous 
membrane by means of douching, and then employs sprays of a watery 
solution of J per cent, of resorcin, applied twice a day during three or 
four minutes. The medicament may also be painted over the diseased 
surface in the form of a pomade, consisting of 30 decigrammes of re- 
sorcin to 10 grammes of vaseline. Masseif asserts that in some cases 
ozsena may be radically cured by means of resorcin; he prefers, how- 
ever, to use it in the form of douche—2 grammes in 600 of water— 
rather than spray. 
Gottstein has introduced an entirely novel mode of treatment. No- 
ticing that it is only the dried mucus which smells, he has devised an 
ingenious arrangement for keeping the secretion moist. This consists 
in introducing a tampon of cotton-wool into the nasal passage, the con- 
tact of which with the mucous membrane causes a slight but constant 
flow of mucus. The tampon is easily introduced by means of a screw 
(see Fig. 73, p. 283), and need only be retained for a couple of hours 
in the morning, on one side, and for the same length of time on the 
other side in the afternoon; occasionally, indeed, a shorter period will 
suffice. Should this method not succeed at first, it shows that the 
pledget of wool is not large enough. It is necessary, in fact, that it 
should be in thorough apposition to the mucous membrane. Several 
of my patients have worn these tampons for the last two or three years, 
not only without complaint, but with the greatest gratitude. It will 
be observed that this treatment is purely mechanical, but WoakesJ has 
found medicated wools still more effectual, and a number of these are 
given in the Appendix. 
The remedies which have hitherto been considered are of a palliative 
nature, but it is not surprising that, in a complaint of so intractable and 
digusting a character, a great many attempts should have been made to 
find a radical cure. Nor is it at all remarkable that iodoform should 
have been much vaunted. I have used this remedy in powder, dis- 
* Archivii Italiani di Laringologia, Anno ii., 1882, Octr. 15, p. 74-7. 
f Ibid., April 15, 1883, pp. 26-28. 
J Lancet, 1880, vol. i., p. 876. CHRONIC BLENNORRHCEA OF THE NOSE. 
335 
solved in ether as a spray, and also in the form of a nasal bougie. I 
cannot say, however, that I have found it more effectual than simple 
alkaline and detergent lotions, whilst it labors under the disadvantage 
of causing an odor which, if less disgusting than that of ozsena, is cer- 
tainly very penetrating. Remedies which stimulate the mucous mem- 
brane certainly do good, and sometimes permit the cleansing process to 
be carried out at longer intervals, though it cannot bh dispensed with 
altogether. The red gum diluted with starch (1 part of gum to 2 of 
starch) has seemed to me the most useful of all these; but Bosworth* 
speaks most highly of sanguinaria (1 part to 3 of starch), and galanga 
(equal parts of the powdered root and starch). These powders should 
be blown into the nose after it has been washed out with a detergent 
spray. Galanga and sanguinaria somewhat resemble eucalyptus in 
their action, but are much more irritating. If employed at all, I should 
advise them to be used in a considerably more dilute form than that 
recommended by Bosworth. 
The application of white heat to the mucous membrane, with the 
view of destroying the suppurating surface, has been advocated by 
Bernard Frankel, but I have not had sufficient experience of this 
method of treatment to be able to speak with any confidence on the 
subject. I may state, however, that in three cases in which crusts have 
formed quite at the anterior part of the nose, a few applications of 
electric cautery so altered the character of the mucous membrane that 
the morbid process was entirely arrested. 
CHRONIC BLENNORRHOEA OF THE NOSE AND 
AIR-PASSAGES. 
A somewhat rare form of purulent rhinitis has been described by 
Stoerk,t under the name of chronic blennorrhoea of the mucous mem- 
brane of the nose, larynx, and trachea. He says that this condition is 
common among the Polish Jews in Galicia, Poland, Wallachia, and 
Bessarabia. Most of the patients seen by him were poor, and attached 
little importance to personal cleanliness. According to Stoerk’s ac- 
count, in the first stage of this ailment there is a profuse secretion from 
* Op. cit., pp. 216, 217. 
f Kranklieiten des Kehlkopfs, Stuttgart, 1880, p. 161. 336 
DISEASES OF THE THROAT AND NOSE. 
the nose of more or less purulent greenish-yellow fluid, whilst the ab- 
sence of the vascular injection and succulence generally met with in 
acute catarrh should prevent blennorrhoea from being confounded with 
coryza. The disease shows a marked disposition to extend through the 
pharynx to the larynx, and even the trachea. In the nose the cartilages 
and bones are never involved, and the nasal affection itself is of little 
importance except in so far as it is the starting-point of serious disease 
which ultimately invades the respiratory passages. In the larynx the 
ulceration frequently commences at the stalk of the epiglottis, and this 
spreads down into the larynx, involving the edges of the vocal cords 
near the anterior commissure, and often leading ultimately to adhesion 
between the two cords. In this way the glottis is reduced to a small 
crescentic opening, the concavity of the crescent being directed back- 
wards. A web is likewise frequently formed in the larynx below the 
level of the vocal cords, and the disease often involves the wall of the 
trachea, and may even extend to the minute bronchial tubes, where it 
occasionally gives rise to luemoptysis. No treatment is of much avail, 
but tracheotomy has been performed with temporary benefit, and in 
some rare cases the induration has spontaneously disappeared. 
BLEEDING FROM THE NOSE. 
(Synonym : Epistaxis.) 
Latin Eq.—Hsemorrhagia narium ; epistaxis. 
French, Eq.—Saignement du nez; epistaxis. 
German Eq.—Nasenbluten. 
Italian Eq.—Epistassi. 
Definition.—Hcemorrhage from the nose originating either in the 
nasal cavity proper, or in the sinuses communicating with it. 
History.—Bleeding from the nose was considered by the old physicians as a symp- 
tom of more valuable import than modern practitioners usually accord to it. It is 
referred to by Hippocrates* as indicating a favorable crisis in acute fevers, or as being 
ominous of a fatal result in certain chronic diseases. He was also acquainted! with 
the frequent connection of haemorrhage from the nose with an enlargement of the 
spleen, and other abdominal viscera, and with its occasional vicarious occurrence in 
* Epidemiorum, lib. i. 
f Prorrheticorum, lib. i., cap. viii. BLEEDING FROM THE NOSE. 
337 
cases of suppressed menstruation.* Galenf considered it as a natural relief to vascu- 
lar tension in fevers, and he mentions a case in which he was able to predict a flow of 
blood from one nostril in the course of an acute fever, accompanied by delirium. He 
that epistaxis should be stopped by squeezing the nose tightly with the 
fingers, or, if this failed, by pushing a pledget of lint or a piece of dry sponge as far 
into the nostril as possible. Areteeus| regarded nasal haemorrhage as indicative of 
resolution in acute pleurisy; and he advised that, for the relief of headache, bleeding 
from the nose should be artificially induced by means of instruments devised for the 
purpose.|| It may, indeed, be gathered from the writings of Paul of that this 
was a common therapeutic measure among the ancients. In the seventeenth century 
Fabricius Hildanus** related many cases of bleeding from the nose which he had 
treated generally with a styptic powder of his own invention. Not long after Syden- 
ham,ff whilst expressing a great contempt for local haemostatics, urged that blood- 
letting was the true principle on which epistaxis should be treated. In the eighteenth 
century, the celebrated HoffmannJJ devoted a chapter of considerable length to the 
subject of nasal haemorrhage; whilst Morgagni,|| though referring to the affection 
very briefly, quotes an observation of Valsalva as to the immediate source of the bleed- 
ing in many cases, which is of great practical importance, and which will be cited further 
on. To Bellocq|||| we owe the extremely valuable invention for plugging the poste- 
rior nares which bears his name. Nasal haemorrhage was classed by the nosologists 
of last century as a substantive disease, and the term “epistaxis,” used by the older 
writers for every kind of haemorrhage occurring drop by drop, was first proposed by 
Vogelfjf to be confined to bleeding from the nose. This term was subsequently adopted 
by Cullen*** and Pinel,fff and soon came into general use. In the early part of the 
present century J. P. Frank|JJ treated the subject with great fulness and with much 
practical sense. He arrested bleeding by pushing into the nostril a piece of dried 
hog’s intestine, tied at one end so as to form a pouch like the finger of a glove, and 
distending this by injecting water with a syringe, the proximal end of the gut being 
then tied and the plug left in position as long as required. This simple appliance has 
* Aphorism, sect. 5. f De erisibus. 
J De compos, pharin.sec. locos., lib. iii., cli. iv. 
| On the Causes and Symptoms of Acute Diseases, Bk.i., cb. ix., Syd. Soc. Transl. 
|| On the Treatment of Chronic Diseases, Bk. i., eh. ii., Syd. Soc. Transl. 
f Works, Syd. Soc. Transl., vol. i., p. 326. 
** Opera Observ. et curat; medico-cliirurg. quae extant omnia, Francofurti, 1682. 
ft Med. Observ., ch. iv., 48 and 49; and Processus Integri, cli. xlv. 
Medicinte Ration. System, pars secund., sect, prirna, c. i.; Hoffmann’s Op. om- 
nia Physico-Medica, p. 196 et seq., Genevae, 1740. 
|| De sedibus et causis morborum, Epist. xiv.,.Art, 23, Patavii, 1765. 
HI I have not been able to find the exact date of the invention of this instrument, 
but it certainly was in use at the commencement of the present century, for it is men- 
tioned by Deschamps in his thesis Des Maladies des Fosses nasales, which bears date 
1804. 
Definitio generum morborum, Gottingae, 1764. The term was used by 
Hippocrates to signify bleeding drop by drop, but was not applied especially to 
haemorrhage from the nose. 
*** Synopsis nosologise medicae, Edinburgi, 1785, Ed. Quart. 
fff Nosographie philosophique, Paris, 1818, 6me ed., t. ii., p. 5891 
De curandis hominum morbis, Mannhemii, 1807, lib. v., pars 2, p. 124 et seq.. 338 
DISEASES OF THE THROAT AND NOSE. 
been frequently imitated since in more elaborate forms. A lengthy chapter, full of cu- 
rious but somewhat undigested erudition concerning epistaxis, or hsemorrhinia, as he 
preferred to call it, will be found in Cloquet’s* work, which has been already referred to 
several times in this volume. Some valuable remarks on epistaxis, especially as regards 
its connection with other haemorrhages, were made by Laycockf in 1862, and in the 
same year Rawdon Macnamaraf published an elaborate article which embodied the 
results of an unusually large experience of the complaint, and contained many useful 
suggestions as to treatment. 
Etiology.—Epistaxis is decidedly more common in men than in 
women, possibly, as suggested by Hoffmann,§ because in the ease of the 
latter there is a periodical depletion by the monthly discharge. It is 
also more frequent in childhood and old age, than in the prime of life; 
the bleeding, as will presently be shown, being usually due to plethora 
in the child, and to degenerative changes in the vascular system in the 
old. The period of life at which nasal haemorrhage is absolutely 
most frequent is probably about the time of puberty. The causes may 
be local or constitutional. Amongst the former the most frequent is 
direct violence from blows or falls, but sneezing or blowing the nose 
will often cause bleeding. “ Picking” the nose is a common cause of 
epistaxis in young persons, whilst the introduction of foreign bodies, 
such as a piece of wood or slate-pencil, has sometimes led to severe hae- 
morrhage in children. In the same way troublesome bleeding occa- 
sionally occurs from the passing of nasal bougies. If there be any 
ulceration of the nasal mucous membrane a very slight strain may cause 
blood to flow from the nose. Fibrous tumors of the naso-pharynx and 
malignant growths are especially apt to induce epistaxis. Irritant parti- 
cles in the air, such as arise from strong ammonia, jalap, and ipecacu 
anha, when drawn into the nose in breathing, often cause haemorrhage 
from the nasal mucous membrane, and strong snuff has also been 
known to produce this effect.|] Some curious idiosyncrasies are re- 
corded of epistaxis being brought on by extraordinary causes. One of 
the most remarkable of these is the case of John aQuerceto, a secretary 
of Francis I., who is stated, on good to have bled at the 
nose if he smelt an apple. 
Constitutional causes are of four kinds: 1st, the blood itself may be 
* Osphrfesiologie, Paris, 1821. 
f Lectures on the Physiognomical Diagnosis of Disease, Med. Times and Gaz., 
1862, vol. i., p. 501. 
J Dublin Quarterly Journ. of Med. Science, 1862, vol. xxxiii., p. 43 et seq. 
$ Op. cit. || Macnamara : loc. cit., p. 30. 
1 Bruyerinus: De re cibaria, Francofurti, 1600, lib. xi., cap. xvi., p. 468. BLEEDING FROM THE NOSE. 
339 
altered in constitution; 2dly, the vessels may be diseased; 3dly, there 
may be obstruction to the circulation through the lungs, liver, kidneys, 
or other organs, causing a sudden tension or strain of the whole system 
which gives way at a weak part, viz., the nose, where the vessels are 
very superficial and their arrangement is in places cavernous (see Anat- 
omy, p. 239); 4thly, the blood-flow may be a vicarious discharge. 
(1) The most common cause of bleeding under this head is the hae- 
morrhagic diathesis, or haemophilia, the nose being the part from which 
the flow most frequently takes place in such cases. Lay cock* found 
that out of 227 “ bleeders” the source of the haemorrhage was the nose 
in no fewer than 110, whilst in many of these cases epistaxis alternated 
with haemoptysis, liaematemesis, and haematuria. In all anaemic condi- 
tions of the system, epistaxis is apt to occur. Out of eighty-one cases of 
leukaemia collected by Mosler,f there was haemorrhage in sixty-four 
instances, and in thirty-five of these the blood came from the nose. 
When the blood is abnormally abundant, as in plethoric children, 
haemorrhage from the nose is not unfrequent, being often preceded by 
a sensation of fulness in the head scarcely amounting to headache. 
Owing to the intercommunication between the veins of the nose and 
the sinuses of the dura mater, epistaxis often gives great relief in these 
cases. 
In eruptive and relapsing fevers, bleeding from the nose is by no means 
an uncommon symptom. In a severe epidemic of relapsing fever, oc- 
curring in Berlin in 1871-2, which was carefully studied by Felix 
SemonJ in the Charite Hospital, epistaxis was a critical symptom in 
more than 30 per cent, of the cases. In two instances the haemorrhage 
continued for two or three days, and in the case of one extremely ex- 
hausted patient it was the actual cause of death. In scurvy it is usually 
stated to be very common. J. P. Frank§ goes so far as to assert that 
in his own experience it has occasionally been the only symptom of this 
disease, and he looked upon epistaxis as of the highest diagnostic im- 
portance in relation to scurvy when taken in conjunction with the pre- 
vious history of the patient. I am informed, however, by Mr. Johnson 
Smith,|| who has had the amplest opportunity for observation during a 
connection of fourteen years with the Dreadnought Hospital, that in his 
experience epistaxis is by no means a frequent feature in scurvy. In 
* Loc. cit. f Leuksemie, Berlin, 1872. 
J Zur Recurrens-Epidemie in Berlin, 1871-72, Inaug.-Dissert., 1873. 
\ Op. cit., p. 135 et seq. 
|| Private communication, dated December 23d, 1881. 340 
DISEASES OF THE THROAT AND NOSE. 
purpura, however, nasal haemorrhage sometimes takes place. A 
remarkable case occurred in my own practice a few years ago. The 
patient, a middle-aged man, had lived for many years in the tropics, 
and had lately returned home in bad health. He was first attacked 
with a haemorrhage from the larynx. This yielded after a time to 
spray inhalations of tannin, but the arrest of the laryngeal bleed- 
ing was followed almost immediately by such severe epistaxis that 
the posterior nares had to be plugged. After two days alarming 
haemorrhage came on from the lungs, and Dr. Walshe saw the patient 
with me. Under the use of large doses of ergot the haemoptysis ceased, 
but thirty-six hours later the patient died from sanguineous apoplexy. 
Both in acute yellow atrophy of the liver and in phosphorus poison- 
ing, the general symptoms and morbid anatomy of which bear so singu- 
lar a resemblance to each other, a rapid softening and fatty degenera- 
tion of the walls of the vessels take place, and under these circumstances 
epistaxis is not uncommon. 
(2) When the vessels have undergone atheromatous change, hemor- 
rhage from the nose is not unfrequent. This is, of course, most often 
met with in elderly persons, but it may also occur in younger persons 
who have suffered from constitutional syphilis or chronic alcoholism. 
(3) The effect of strain on the vascular system is seen even in healthy 
persons after violent exertion, such as lifting heavy weights, violent 
coughing, retching, or running.* 
This cause of nasal haemorrhage is likely to be intensified if there be 
at the same time any artificial obstruction to the return of the blood 
through the jugular veins. Epistaxis accordingly often occurred in 
the old days when tight stocks were worn. The same effect is some- 
times produced by tumors in the neck, especially goitres. Venous ob- 
struction from engorgement of the right side of the heart, emphysema, 
or severe chronic bronchitis, sometimes causes epistaxis. Diseases of 
the liver, kidney, and spleen are also frequently complicated by trou- 
blesome nasal haemorrhage. Strong emotionf sometimes gives rise to 
* In the horse, epistaxis caused by strain may sometimes be observed on the race- 
course and in the hunting-field. Mr. Doyle (Macnamara, loc. cit.), a veterinary sur- 
geon, speaks of two fatal cases of epistaxis in horses, and mentions a celebrated racer 
which never ran without bleeding from the nose. 
f Loc. cit., p. 32. The curious case related by Hildanus (op. cit., cent, ii., obs. xvii.) 
of a plethoric, newly-married young man, who was seized with furious bleeding from 
the nose immediately after coition, perhaps comes under this head, but the etiology is 
complicated by the fact that the patient had been exposed for some time to a burning 
sun. The peculiar effect of great mental emotion in producing epistaxis did not escape BLEEDING FROM THE NOSE. 
341 
hsemorrhage from the nose, the immediate cause probably being sudden 
tension of the vascular system, which gives way at the point of least 
resistance. A striking example of epistaxis from rage is related by 
Macnamara of a young man, whom profuse nasal haemorrhage seems to 
have saved from an impending fit of apoplexy. It is more difficult to 
explain another case reported by the same writer, in which a girl was 
brought to the verge of death by bleeding from the nose, which she 
attributed to grief for the death of her father. 
(4) Epistaxis sometimes occurs vicariously, taking the place of the 
menstrual flow in women, or of some periodical escape of blood from 
enlarged veins in the rectum, leg, or elsewhere. Frankel* has col- 
lected a number of interesting examples of vicarious bleeding from the 
nose. In one of these (Fricker’s case) a girl, who had never menstru- 
ated, suffered at intervals of six weeks from such profuse nasal hsemor- 
rhage, accompanied by menstrual molimina, that she finally died from 
exhaustion. In another (Sommer’s case), a woman on one occasion, 
during the entire period of gestation, had a discharge of blood from the 
nose regularly once a month. In a third instance (Obermeier’s case), 
epistaxis appears to have entirely taken the place of the normal uterine 
hsemorrhage in a young woman; it came on at regular intervals of four 
weeks with the usual constitutional symptoms, ceased during pregnancy, 
and recurred after delivery. In some of Mosler’s cases of leukaemia 
already referred to, the epistaxis was more or less menstrual in charac- 
ter. Puechf also gives several instances of catamenial epistaxis. Hoff- 
mann]; relates a case of somewhat analogous nature in which the lochial 
discharge was suppressed very shortly after parturition, and the patient 
died of epistaxis. An instance is recorded by Fabricius Hildanus§ in 
which epistaxis appeared to take the place of a periodical hsemorrhage 
from varicose veins of the leg in an old man, the flow continuing for 
twenty-four hours, and leaving the patient prostrate for months after- 
wards. Bleeding at the nose is sometimes hereditary, a fact which was 
known to Hoffmann,|| and of which a striking example has been re- 
corded by Of six female children of a woman who was 
very subject to epistaxis, three suffered from this form of hsemorrhage. 
the notice of Dickens, who, in Onr Mutual Friend, speaks of a spontaneous gush of 
blood from the nose of Bradley Headstone, when pursuing Eugene Wrayburn with the 
intention of murdering him. 
* Ziemssen’s Cyclopaedia, vol. iv., p. 152. 
f Gazette des Hopitaux, 1863, p. 188. 
§ Op. cit., cent, ii., obs. xvi. 
f Lancet, 1865, vol. ii., p. 362. 
t Op. cit., p. 200. 
|| Op. cit., p. 198. 342 
DISEASES OF THE THROAT AND NOSE. 
One of these had two daughters with the same tendency, the elder of 
whom had afterwards a son who also inherited the peculiarity. The 
authenticity of the case is vouched for by the fact that Babington him- 
self was acquainted with the mother, daughter, and grandchild. It has 
been asserted that the disease occurs epidemically, and in proof of this 
an example referred to by Morgagni* is brought forward. This epi- 
demic is supposed to have occurred in Italy in the year 1200, and it is 
stated to have proved fatal to an immense number of persons within 
twenty-four hours.f It is probable, however, that the violent haemor- 
rhage was only an early symptom of an epidemic fever. 
Symptoms.—There is little to be said under this head, except as to 
the mode in which the haemorrhage occurs, and the amount of blood 
lost. It may be remarked, however, that certain prodromata are often 
present, especially in plethoric persons and in those suffering from 
fevers. These signs consist of a feeling of fulness in the frontal region, 
flushing of the face, throbbing of the temporal and carotid arteries, 
buzzing of the ears, giddiness, and a sensation of itching in the nose. 
According to Hippocrates,J there is also abdominal distension, an ob- 
servation confirmed by Pinel,§ who adds that “ goose-skin ” and cold- 
ness of the extremities are likewise often premonitory of epistaxis. The 
ha3morrhage usually takes place drop by drop, and from this fact the 
modern scientific name, as already shown (see History), is derived; but 
sometimes the blood flows so copiously that it might be supposed that 
a large vessel had given way. The bleeding generally comes from one 
nostril, and it is only when there is some great alteration of the blood, 
as in fevers or allied conditions, that the flow is bilateral. Occasion- 
ally, however, the blood escaping from one nasal passage may find its 
way round the septum posteriorly, and issue from the other nostril, a 
phenomenon probably due to the formation of clots at the back of the 
nose. The blood is of bright red color, and the quantity lost varies 
usually from two or three drachms to an ounce, though sometimes much 
more considerable. Thus Martineau|] relates a case in which the bleed- 
ing is said to have amounted to twelve pounds in sixty hours; whilst, 
in another instance, it is that seventy-five pounds of blood 
* Op. cit., epist. xiv., sec. 26. 
f Gillchrist is referred to by Cloquet (op. cit., p. 557) as the authority for another 
supposed epidemic of epistaxis, but I have been unable to find the original report by 
Gillchrist, or any particulars of this case. 
£ Epidemiorum, lib. i. $ Op. cit., p. 591. 
|| Union M6dicale, 1868, 3me sferie, t. vi., p. 330. 
If Acta Eruditorum, Lipsise, 1688, p. 205. BLEEDING FROM THE NOSE 
343 
trickled away in the course of ten days. In a case related by Rhodius,* 
a young man is stated to have lost eighteen pounds in thirty-six hours; 
and Hildanusf reports an extraordinary instance of a man, who, be- 
sides losing several pounds of blood from his nose, in the course of a 
few hours afterwards vomited twenty-seven pounds which had flowed 
from the posterior nares, and coagulated in his stomach. There can be 
little doubt, however, that some of these statements are grossly exagger- 
ated. The haemorrhage sometimes gives rise to very alarming symp- 
toms, and the patient may pass into a state of dangerous syncope; or if 
the epistaxis occur frequently, it may cause systemic anaemia of a very 
serious character. 
Pathology.—The exposed position of the nose, and the peculiar 
cavernous arrangement of the vessels of the turbinated bodies, not leas 
than the thinness of the mucous membrane covering those structures, 
fully explain the frequency of bleeding from the nose as compared with 
haemorrhage from other parts. ValsalvaJ observed in the dead-house 
that the vessels on the outer wall of the nose at the junction of the 
lateral cartilages are often very large, and J. P. Frank§ states that he 
has noticed a varicose condition of the veins of the nasal mucous mem- 
brane in patients subject to epistaxis. 
Diagnosis.—In all cases of epistaxis it is very important to make a 
careful examination of both nostrils and of the naso-pharynx, in order 
to ascertain whether there be any local condition, such as a tumor or an 
ulcer, which may cause the haemorrhage. It is scarcely necessary to 
point out that after falls or blows on the head epistaxis may be a symp- 
tom of fracture of the base of the skull through its anterior fossa. 
Prognosis.—In giving an opinion as to the danger of epistaxis regard 
must first be had to the immediate risk from actual loss of blood. 
This, of course, will depend on the state of the pulse and the general 
condition of the patient. After this it must be determined whether the 
haemorrhage is accidental, i.e., quasi-traumatic, or whether it is the 
result of some serious degenerative change in the walls of the arterioles, 
or whether it is due to obstruction in the pulmonary or hepatic circula- 
tion, or a combination of these conditions. It must not be forgotten that 
epistaxis, as Hughlings Jackson|| has shown, may in some cases precede 
retinal haemorrhage and apoplexy. Accidental bleeding is seldom of 
* Observ. med. centuria? tres, Francofurti, 1576, cent, i., obs. xc. 
f Op. cit., cent, vi., obs. xiii. 
J Quoted by Morgagni: op. cit., ep. xiv., sec. 23. \ Op. cit., p. 144. 
|| London Hospital Clinical Lectures and Reports, 1866, vol. iii„ p. 251. 344 
DISEASES OF THE THROAT AND NOSE. 
serious import, for although amongst the older writers a considerable 
number of cases are to be found in which death resulted from nasal 
haemorrhage, the introduction of posterior plugging has to a great ex- 
tent removed all danger. In elderly people, when epistaxis occurs 
spontaneously or from some very slight cause, it is generally a sign of 
degenerative changes in the vessels, and as such must be considered 
serious. In certain cases the bleeding appears to be beneficial, and its 
sudden stoppage is not unlikely to lead to mischievous results. In- 
stances are on record in which mania,* epilepsy,f and asthma,| are said 
to have ensued as a consequence of rash interference with this natural 
depletion, and in cases of phthisis, renal disease, and cerebral mischief, 
the flow of blood from the nose sometimes appears to do good. So 
obviously beneficial, indeed, is epistaxis, in some cases, that, as already 
stated, its artificial production was a constant practice among the 
ancients for the relief of certain cerebral symptoms, and was recom- 
mended for this purpose by the enlightened Hoflmann.§ In malarial 
fevers the old physicians considered that bleeding from the nose was 
an evidence of crisis, and was usually of happy augury for the patient, 
whilst in fevers of a low type it was looked upon as of dangerous im- 
port. In diphtheria, especially, it is a most grave symptom, being 
generally quickly followed by the development of false membrane in 
the nasal fossae, if this extension has not preceded the epistaxis. 
Treatment.—Sir Thomas Watson has well observed|| that nasal 
haemorrhage is “sometimes a remedy; sometimes a warning; some- 
times really in itself a disease.” The question as to the advisability of 
arresting the haemorrhage must therefore first be considered. On this 
point some remarks by may be found worthy of attention even 
at the present day. He observes that plethoric youths, in whom bleed- 
ing from the nose is too quickly stopped, are prone to be attacked with 
pains about the head and in the ears, and with various catarrhal affec- 
tions. Hence haemorrhage in these cases should not be interfered with 
unless it is excessive and produces faintness, pallor, and coldness. 
Again, where there is great venous obstruction, as in certain cases of 
cardiac and pulmonary disease, in cirrhosis of the liver, or in women 
where the haemorrhage takes the place of the monthly flow, the phvsi- 
* VanSwieten: Comment, in Boerhavii Aphorismos, 1124. 
f Hoffmann : De Epilepsia, obs. i. 
J Raymond: Maladies qu’il est dangereux de guferir, p. 255. 
\ Med. Rationalis Systema. Opera omnia physico-medica, Genevae, 1740, p. 200. 
|] Practice of Medicine, London, 1857, 4th ed., vol. i., p. 793. 
f De morbis narium, Basilese, 1766, p. 16. BLEEDING FROM THE NOSE. 
345 
cian should be in no hurry to interfere, unless the bleeding lasts too 
long. 
When it has been determined that it is desirable to arrest the haemor- 
rhage, measures should be adopted in proportion to the activity of the 
flow. In the great majority of cases the bleeding soon ceases spon- 
taneously, or if not, it can be stopped by some simple expedient. Posi- 
tion has obviously an important influence, and nothing can be worse 
than the common practice of holding the head over a basin. Jamain* 
has pointed out that not only is the flow increased by gravitation, but 
that the flexion of the head tends to compress the jugular veins, thereby 
hindering the return of the blood from the head, and favoring the 
haemorrhage. Hildanusf appears to have placed great faith in tightly 
bandaging the forearms to the arms, and the legs to the thighs, and in 
very obstinate cases swathing the whole body in tight wrappings.| It 
is not improbable, however, that the success of this remarkable method 
was in some measure due to the fact that he used styptic powders at 
the same time. Keeping the patient on his back in the horizontal posi- 
tion is a simple procedure which I have often seen practiced with ex- 
cellent results. With the view of diminishing the flow of blood to the 
head, the very opposite plan, however, viz., that of maintaining the 
patient in an erect attitude, has been tried and found no less efficacious. 
A method has been recommended by Negrier§ as being highly success- 
ful, which consists in raising the arm corresponding to the bleeding side 
above the head, and compressing the nose with the finger of the other 
hand ; but it is probable that the pressure on the source of the haemor- 
rhage, like Hildanus’s powder, is the real influence brought to bear. 
Negrier, himself, however, considered that the extra strain put upon 
the heart to drive the blood to the end of the raised limb lessens the 
force of the current to the nose sufficiently to diminish the hemor- 
rhage. The plan has at any rate the merit of requiring no apparatus 
whatever, so that it can be practiced under all circumstances. The 
application of cold yields good results. It can be made either directly 
to the nose, or to other parts more or less remote, such as the brow, the 
nape of the neck, the feet, or hands. The time-honored household 
remedy of putting a large key down the neck acts in this manner. A 
* Gazette des Hopitaux, 1855, No. 33. 
f Op. cit., cent, ii., obs. xv. and xvi. 
J This method is still occasionally practiced. Thus Blondeau (Union Medicale, 
Dec. 8th, 1877) claims to have checked bleeding from the nose by tying tapes tightly 
round the thigh when other measures had failed, 
$ Arch. G£n. de M&h, 1842, p. 168, 346 
DISEASES OF THE THROAT AND NOSE. 
more certain plan consists in applying cold water or ice to the nose 
itself, or to the forehead. The patient may be directed to snuff up cold 
or (if it can be procured) iced water. Hildanus,* in a case which he 
considered desperate, took what he himself calls the extreme measure 
of plunging the whole body into a cold bath, with the result of in- 
stantly checking the haemorrhage. The use of hot water, which in recent 
years has been highly recommended for restraining other haemorrhages, 
has recently been advised for epistaxis by Keetley,f who says that the 
temperature of the water should be from 120° to 124° Fahr., and that 
it need not be syringed into the nasal cavity, but simply applied freely 
to the face. 
The local application of styptics is often of great use. Powdered 
tannin, alum, or matico-leaf, may be snuffed up by the patient, or 
blown into the nostril with an insufflator. This treatment is often at 
once successful, particularly if the nostril is previously syringed out 
with a little cold water. Sprays of tannic acid (gr. x. ad §j.) or per- 
cldoride of iron xx. ad Sj.) have also often proved very effectual in 
my hands. 
Pressure may sometimes be made directly on the bleeding spot by 
introducing the finger into the nostril, the source of the hemorrhage 
being, in the majority of cases, on the outer wall, just inside the nose. 
Valsalva,| who, as has already been remarked, has observed on the 
dead subject that the veins on the outer wall of the nostril were often 
enlarged, used this ready method with striking success in a most ob- 
stinate case of nasal hemorrhage. Epistaxis may sometimes be con- 
trolled by pressure on the facial artery on the bleeding side. But 
undoubtedly the most effectual method of applying pressure to the 
bleeding surface is by plugging. The bleeding nostril should first be 
plugged anteriorly, and if this prove insufficient, median or posterior 
plugging must be resorted to. 
Anterior plugging is best effected by pushing small strips of lint into 
the nose with a probe until the front part of the cavity is completely 
filled up. The lint may be used dry, or may be steeped in a solution 
of perchloride of iron, or in a mixture of the tannic and gallic acids.§ 
Josiah Smylyll found the following method of plugging very successful. 
* Op. cit., cent, ii., obs. xvii. f Practitioner, February, 1879. 
X Quoted by Morgagni, op. cit., ep. xiv., sec. 23. 
$ The gargarisma acid. tann. et acid, gallici of the Throat Hospital Pharmacopoeia 
(vol. i., Appendix, p. 553) is the best formula. 
|| In a letter quoted by Macnamara, loc. cit., pp. 53, 54. BLEEDING FROM THE NOSE. 
347 
He prepared several strips of lint about a foot in length, and half an 
inch in breadth, and wrapping about two inches of one of these round 
a slender probe, he passed it quite through to the posterior orifice of 
the nares, then withdrawing the probe, he carefully pushed in as many 
strips of lint as were required to fill the nasal cavity. He also sug- 
gested using tampons of absorbent wick, or blotting-paper. Should 
the hemorrhage continue in spite of anterior plugging, recourse must 
be had to median or to posterior plugging. 
Median plugging, as has been shown, was recommended by Galen, 
and his plan of introducing a piece of sponge into the nose may often 
be used with advantage. A uterine sponge-tent will be found very 
serviceable for this purpose, but the handiest instrument is Cooper 
Rose’s ingenious little air-plug, which has already been described (Fig. 
69, p. 281). On the whole, however, this plan does not appear to be 
so effectual as the combination of posterior with anterior plugging. 
Posterior plugging may be most readily performed with the aid of 
Bellocq’s sound ; the manner of using this instrument has been already 
described in the article on “Hasal Instruments” (p. 279 et seq.). An- 
other apparatus invented for the purpose by Martin Saint-Ange,* and 
called by him a rhinobyon, may also be referred to (p. 279). 
Unfortunately the various ingenious appliances which have been 
described are seldom at hand just when they are wanted, and, more- 
over, those made of skin or india-rubber are apt to be out of order. 
Hence, when an emergency arises, the surgeon is generally obliged to 
make use of some more simple, if less perfect, apparatus. The posterior 
nares, can, however, be easily plugged by means of an elastic, or a 
silver female, catheter in the following manner: A small piece of 
thread is fastened through the eyes of the catheter, and to this a strong 
silk ligature or piece of whip-cord is attached. The instrument is 
passed along the floor of the nose, and when the string is seen in the 
pharynx, it is seized with the fingers or with forceps, and drawn out 
through the mouth. A pledget of lint is attached to the middle of the 
string projecting from the mouth, and the nasal end is then firmly 
pulled till the plug comes in contact with the posterior nares, and 
blocks up the orifice of the affected side. The string is subsequently 
retained in position by being fixed behind the ear with a strip of 
* Lapeyroux: Mfethode pour les Hemorrhagies nasales, These tie Paris, No. 
314, 1836. A similar instrument was invented by Kiichenmeister, and called by him 
a rhineurynter (Berlin, klin. Wochenschrift, May 29, 1871). See also Closset (Ibid., 
June 19, 1871), and Bruns (Ibid., July 31, 1871). 348 
DISEASES OF THE THROAT AND NOSE. 
plaster. A small piece of string should be left hanging into the 
pharynx from the plug, by which it can be removed in due time. It 
is better to make the pledget of lint so hard as to be quite impervious, 
dnd to trust to mechanical pressure rather than to saturate the lint with 
a styptic solution. For unpleasant, and even serious consequences, 
may sometimes follow the use of a styptic plug, especially if perchloride 
of iron is employed. Even dry plugging is not altogether free from 
danger, Crequy* having reported a case in which extensive gangrene of 
the soft parts of the face came on almost immediately after this opera- 
tion. Collesf saw tetanus result from plugging, and HabershonJ states 
that he had met with a case in which pyaemia ensued. Gross§ also 
mentions that he was acquainted with several cases in which death had 
resulted from blood-poisoning after plugging. These instances, how- 
ever, appear to me only proofs of the danger of allowing the plug to 
remain too long in situ. Another possible danger is erysipelas, which, 
according to Monneret,|| has been observed in several cases. The plug 
should not, as a rule, be left longer in the nose than forty-eight, or at 
the most seventy-two hours, and it should be removed very gently, so 
as not to disturb the clot, and bring on further haemorrhage. Very 
gentle irrigation through the healthy nostril with tepid water, to which 
common salt has been added in the proportion of a drachm of salt to a 
pint of water, will assist in loosening the plug. After its removal, the 
nose should be gently washed out daily, or on alternate days, with some 
disinfectant or mild astringent solution, such as permanganate of potash 
(gr. ij. ad 5j.) or carbolic acid (gr. iv. ad 5j.). 
Constitutional Treatment.—As the control of the bleeding is entirely 
in the power of the surgeon, medical measures are seldom needed. It 
is only in cases where the haemorrhage is frequent, but scarcely suffi- 
ciently serious to call for surgical treatment, that some internal styptic 
may be required. The best of these is ergot, which may be either 
given by the mouth or injected subcutaneously. Thirty drops of the 
tincture may be taken every two or three hours, or ten minims of a 
solution (one in five) of ergotine may be administered hypodermically 
every four hours. I have frequently found this method very useful. 
Laudanum is also an excellent astringent given in small doses of five 
* Gazette des Hdpitaux, 1870, No. 56. 
f Quoted by Macnamara, loc. cit., p. 58. 
J Tlie Lancet, February 27th, 1875. 
§ System of Surgery, Philadelphia, 1882, 6th ed., vol. ii., p. 283. 
j) See Martineau: Union M&iicale, 1868, 3me sdrie, t. vi., p. 330. BLEEDING FROM THE NOSE. 
349 
to eight drops two or three times a day, but it is, of course, contra-indi- 
cated where the epistaxis originates in pulmonary obstruction. Other 
styptics, such as acetate of lead and gallic or sulphuric acid, can also 
be used for the purpose. 
With a view of increasing the density of the blood, it has been rec- 
ommended to administer sulphate of soda,* of which two drachms may 
be given every three hours, but I have never tried this remedy. Should 
the patient, when he comes under notice, be so exhausted that fatal 
syncope is to be feared, transfusion should, if possible, be carried out. 
Moslerf relates a case of haemophilia in which not only was the epis- 
taxis arrested by transfusion, but the tendency to repeated haemorrhage 
on slight occasions was altogether subdued. Both Sydenham and 
Hoffmann recommended venesection for plethoric persons who bleed 
from the nose, and it appears to have been occasionally employed by 
J. P. Frank,| but this mode of treatment is only mentioned here to be 
absolutely condemned. In illustration of its utter futility, Frankel 
relates an instance in which epistaxis actually occurred in a girl during 
the operation of transfusion, for which she had offered herself as a 
subject. 
In the plethoric cases a saline purgative taken two or three times a 
week in the morning, followed by a couple of doses of digitalis in the 
day, will be found serviceable. In the epistaxis of purpura, Macnamara 
asserts that turpentine is very efficacious, and he recommends that a 
wineglassful of spirits of turpentine in a tumbler of brandy or whiskey 
punch should be administered to the patient as rapidly as he can be 
got to swallow it. 
* Kunze: Compendium d. prakt. Med., 4th ed., p. 94. 
f Op. cit. The views attributed to the various other authors from this point to the 
conclusion of this article will be found contained in their works, which have been 
previously cited in foot-notes. 
J Op. cit, p. 140. 350 
DISEASES of the throat and nose. 
NON-MALIGNANT TUMORS OF THE NOSE. 
Polypus of the Nose. 
Latin Eq.—Polypi nasi. 
jFrench Eq.—Polypes da nez. 
German Eq.—Nasenpolypen. 
Italian Eq.—Polipi del naso. 
Definition.—New formations, nearly always of myxomatous structure 
but sometimes containing a small amount of fibro-cellular tissue, usually 
pedunculated, round, oval, or pyriform in shape, of pale pinkish color, 
semi-transparent, varyiny in size from a currant to an acorn, but occa- 
sionally larger, giving rise to more or less obstruction of the nasal pas- 
sages, with its associated symptoms. 
History.—Nasal polypi have attracted attention from the earliest times, and they 
are referred to by nearly every writer on surgery from Hippocrates downwards. The 
Father of Medicine,* indeed, must have had a large experience in connection with 
these growths, for though his classification is somewhat fanciful, his suggestions for 
treatment are of a highly practical nature, and show considerable fertility of resource. 
He directed that evulsion should be practiced in the following manner: Apiece of 
sponge of sufficient size to fill the nasal cavity having been selected, four strings, each 
one cubit in length, were attached to it, their free ends being tied together. A long 
flexible metal probe with an eye at one end was next passed through the nostril, and 
brought out at the mouth ; the united ends of the strings were threaded through the 
eye of the probe, which was then drawn back through the nose. The strings were 
now seized by the operator, and by forcible traction the sponge was drawn through the 
nose, the mass of the polypus coming away with it. Whether the growths were re- 
moved by evulsion or with the cautery, Hippocrates afterwards applied a dressing 
consisting of honey, to which there was occasionally added some strong caustic, and 
this was kept in contact with the parts by means of small leaden plates inserted into 
the nostrils. In the case of hard polypi, Hippocratesf directed that the nostril should 
be slit open, in order that the tumor might be thoroughly extirpated, and the roots 
afterwards destroyed with the hot iron. CelsusJ recommended that polypi should be 
destroyed with caustics or the hot iron, but he strongly disapproved of meddling with 
the harder tumors, which lie considered malignant. Galen| described the disease as 
a preternatural growth, resembling in its nature the flesh of a polypus, and recom- 
mended the use of astringent local remedies in preference to the knife. JEtius,|| on 
the other hand, advised that the cautery should be used for the destruction of polypi. 
* De Morbis, lib. ii., Littrb’s ed., Paris, 1851, vol. vii., p. 51. 
f Ibid., p. 53. X De Medicinfi,, lib. vi., cap. viii. 
\ De cornp. pharm. sec. locos, lib. iii., cap. iii. 
|| Tetrabibl,, ii., serm. ii., cap. lxxxix. NON-MALIGNANT TUMOBS OF THE NOSE. 
351 
Paul of Angina,* who was an advocate of the knife, recommended the operator to 
dilate the patient’s nostril with his left hand, while with the right he extirpated the 
polypus from the nasal passage by a circular sweep of a scapel of peculiar shape. The 
mass was then to be withdrawn from the nose with the other end of the instrument, 
which probably ended in a hook. Abulcasisf directed that the growth should be 
drawn out of the nose as far as possible with forceps, and then cut off with the knife. 
The stump was afterwards to be scraped, so as to destroy the roots of the polypus. 
Guy de ChauliacJ recommended that polypi should be removed by evulsion. To 
William of Salicet£ belongs the credit of introducing the plan of strangulation of nasal 
polypi by tying a ligature tightly round the pedicle. He advised that the channel of 
the nose should be widened, if necessary, by means of sponge tents, or serpentary root, 
and that the tumor should be tied tightly as near its root as possible, with a thread of 
doubled silk. In cases where this was impracticable, the growth was to be extirpated 
by evulsion with forceps. In any case, the stump was to be destroyed by means of 
corrosive applications or the actual cautery. Arantius,|| being dissatisfied with the 
treatment by the knife, also invented a kind of blunt forceps, with which he tore away 
the polypus. To obtain a better view of the parts, he always operated in a darkened 
room, a round hole in the shutter allowing the sunlight to fall into the patient’s nose; 
or, if the day was dull, artificial illumination was procured from a lighted candle 
placed behind a vial of glass containing clear water. Fabricius ab Aquapendente][ 
claimed to have invented an instrument for the removal of polypi of such excellence 
that “patients came to him from every side, with the firmest confidence of being 
cured.” His invention appears to have been of forceps, the cutting blades and 
shanks of which were deeply hollowed, so that when closed the instrument formed a 
kind of canula, through which a hot wire could be passed, or powder blown. To this 
surgeon has often been assigned the merit of having first proposed the evulsion of 
polypi with forceps; but this is certainly erroneous, for it has just been shown that 
William of Salicet** had recommended this method long before. It may be added 
indeed, that Fabricius himself made no claim to be the inventor of the method, but only 
of a particular instrument which was designed to cut polypi without the dangers attend- 
ing the use of the spatha, or ancient scalpel. He may therefore, perhaps, be termed 
the inventor of “cutting forceps.” In 1628 Glandorpff published a treatise on poly- 
pus remarkable for its erudition, and, moreover, containing a very accurate account of 
the affection. Boerliaavej;]: afterwards propounded a theory that nasal polypi are 
formed by a prolongation of the lining membrane of the pituitary sinuses. His idea 
was that the secretion in one of the cells, becoming from some cause or other too thick, 
* Lib. vi., cap. xxv. 
f Lib. ii., cap. xxiv. (Chirurgie d’Abulcasis, traduite par le Dr. Lucien Leclerc), 
Paris, 1861, p. 93 et seq. 
J Le Guvdon [Guv] en Francoys, par Maistre Jean Camappe, Lyon, 1538, fol. 198. 
£ Chirurgia Guilielmi de Saliceto, in Ars Chirurgica Guidonis Cauliaci, Venetiis, 
1546, p. 308. 
|| De tumoribus prseter naturam. Appendix to his treatise De humano fcetn, Vene- 
tiis, 1587, p. 170 et seq. 
Operationes Chirurgicse, cap. xxiv. in Opera Chirurgica, Lugduni Batavorum, 
1723, p. 438 et seq. 
** Op. cit. See also Arantius, op. cit. 
ff Tractatus de polypo, Bremen, 1628, cap. vii. 
JJ Praelectiones ad Institut. ad § 498. 352 
DISEASES OF THE THROAT AND NOSE. 
does not escape properly from the cavity, which thus becomes filled up, till its lining 
membrane is protruded into the nasal fossa, where it is suspended as a membranous 
sac, filled with fluid or semi-fluid contents. Heistgr* explained the growth of nasal 
polypi by obstruction of one or more of the glands of the pituitary membrane leading 
to the formation of a tumor. Morgagnif may be mentioned as quoting with approval 
Valsalva's practice of removing the lamella of bone on which the polypus grows, with 
the view of preventing recurrence. who was chiefly known as a very suc- 
cessful gynaecologist, seems to have been led by his experience in dealing with uterine 
and vaginal tumors, to turn his attention to nasal polypi, and he invented several in- 
genious instruments for applying and tightening ligatures. Pallucci$ soon afterwards 
attempted to improve upon Levret’s method, and, if his statements may be believed, he 
was one of the most successful operators in this branch of surgery that ever existed. 
Early in the present century Robertson|| published an account, together with a draw- 
ing, of an instrument for snaring nasal polypi. The irony of the fate of inventions is 
indeed shown in this little instrument, for Robertson’s nasal snare is acknowledged by 
Wilde to be the instrument on which he modelled his aural snare, whilst later on, 
Hilton, unaware of the original purpose of the appliance, modified Wilde’s instrument 
so that it might be used for the nose. In modern times short treatises on nasal polypi 
have been published by Gruner,f Dzondi,** W. Colies,ff Mathieu,JJ and Thudi- 
chum,$§ besides innumerable communications to the medical journals of Europe and 
America. The subject has also been treated of more or less fully in every general text- 
book on surgery, the contributions of Durham|||| and being especially 
worthy of mention. One of the most recent works which has reference to the malady 
is that of Zuckerkandl,*** whose treatise is of great value in relation to the morbid 
anatomy of the complaint. 
Etiology.—The causes of nasal polypus are quite unknown. That 
mere chronic inflammation is not sufficient to produce it is proved by 
the fact, that whilst persistent catarrh is more often met with in chil- 
dren than in adults, mucous polypi are very rare under the age of six- 
teen. In adults the affection is exceedingly common, being found, 
according to Zuckerkandlfff (if looked for) in every eighth or ninth 
autopsy. From the annexed Table (A) it will be seen that the decen- 
* General System of Surgery, English Transl., London, 1743, pt. ii., p. 437 et seq. 
f De sedibus et causis morb., Ed. sec., Patavii, 1765, epist. xiv., sec. 19-20. 
J Obs. sur la Cure radicale de plusieurs Polypes, Paris, 1771, 3d ed., p. 214 et seq. 
% Ratio facilis atque tuta narium curandi polypos, Viennse, 1763. 
|| Edinburgh Med. and Surg. Journ., 1805, vol. i., p. 410. 
f De polypis in cavo narium obviis, Lipsiae, 1825. 
** Ergo polypi narium nequaquam extrahendi, Halse, 1830. 
ff Nasal Polypi.—Dub. Quart. Journ. of Med. Sci., Nov. 1848, p. 373 et seq. 
+£ Sur les Polypes muqueux des arriere-narines, These de Paris, 1875. 
%% On Polypus in the Nose, etc., London, 1869, 3d ed., 1877. 
1111 Holmes’s System of Surgery, vol. iv. . 
ff Diet. Encyclop. des Sci. Med., Art. Nez. 
*** Normale u. pathol. Anatomie der Nasenhohle, Wien, 1882, p. 64 et seq. 
tft Op. cit., p. 70. NON-MALIGNANT TUMORS OF THE NOSE. 
353 
nium from twenty to thirty furnishes the greatest number of cases—42 
per cent. Men are more liable to the affection than women, the pro- 
portion in my 200 cases being 123 men to 77 women. The youngest 
patient I have met was a girl aged sixteen, the youngest boy having 
been seventeen. Examples of much younger patients than these will 
be found in medical literature, but I believe that in nearly all of them 
the growths were malignant or fibrous. Mason* has, however, re- 
ported a case of a boy, whose age was only twelve, from whom he re- 
moved several large polypi. The greatest age at which a polypus com- 
menced in my series was sixty-nine, but I have seen two other cases in 
which the disease originated at sixty-five and sixty-eight respectively. 
TABLE A. 
Showing the age and sex of 200 patients with nasal polypus. The table indicates as nearly 
as possible the age at which the growths commenced. 
Age. 
Male. 
Female. 
16 to 20 
9 
7 
20 to 30 . 
51 
34 
30 to 40 . 
33 
13 
40 to 50 
, 18 
13 
50 to 60 
9 
10 
60 to 70 . 
• 
• 
3 
123 
77 
The older writers, who had somewhat vague ideas in the matter of 
etiology, attributed polypi to such influences as heredity, struma, syph- 
ilis, miasma, and suppressed menstruation, but these antiquated notions 
will not stand the rigorous analysis of the present day. Occasionally 
polypi seem to arise from mechanical irritation, such as may be pro- 
duced by foreign bodies, but the case of Van Meekren,f in which the 
nucleus of a polypus was formed by a splinter of wood, is open to sus- 
picion. Gerdy| has reported a case in which a large polypus followed 
a fracture of the bony septum. 
Symptoms.—In the earliest stage the patient suffers from increased 
secretion, stuffiness of the nose, and sometimes slight pain in the frontal 
region, together with the partial and variable occlusion of one or both 
* Med. Soc. Proceed., London, 1872-74, vol. i., p. 156 et seq. The date of Mr. 
Mason’s paper is March 2, 1874. In this report the age of the patient was stated to 
have been twelve, whilst according to the catalogue of the Royal College of Surgeons, 
to whose museum the growths were presented, the age was ten. 
f Quoted by Morgagni, loc. cit. 
J Des Polypes et de leur Traitement, Paris, 1833, pp. 4, 5. 354 
DISEASES OF THE THROAT AND NOSE. 
nostrils. Polypi being generally pedunculated, a sensation like that 
caused by a foreign body moving backwards and forwards, or up and 
down, within the nasal cavity is sometimes experienced about this pe- 
riod. For the same reason these growths occasionally have a valve- 
like action, opposing the passage of air outwards or inwards as the case 
may be. They sometimes, indeed, give rise to a peculiar flapping sound, 
described by Dupuytren as the “ bruit de drapeau.” It need scarcely 
be pointed out, however, that in the presence of so many objective signs, 
this symptom is of no importance. When both the nasal passages are 
blocked up, the patient is of course compelled to breathe entirely through 
the mouth, and the usual phenomena of nasal obstruction supervene, 
the voice undergoing the characteristic modification, and the sense of 
smell being impaired or altogether lost. It is very seldom that these 
growths cause any bulging of the nasal parietes, and only in quite ex- 
ceptional cases that the tear-duct being pressed upon epiphora results. 
Owing to the fact that mucous polypi possess a hygrometric property, 
all the symptoms are generally aggravated in damp weather. The dis- 
charge from the nose is usually watery in character, and seldom offen- 
sive, whilst epistaxis only quite occasionally occurs. 
Polypi, when large, numerous, and growing from the anterior part of 
the cavity, can usually be seen by simply looking into the nose with the 
aid of a strong light, the tip of the organ being at the same time tilted 
upwards and backwards, but the introduction of a speculum will greatly 
assist the view. These growths most frequently appear to originate 
from the middle turbinated body and the parts immediately above it 
(see Table B), but the recent researches of Zuckerkandl (see Pathology, 
p. 362) show that the real origin of nasal polypi is often far deeper 
than clinical evidence indicates. 
Showing the apparent situation of 259 polypi observed by the author in 200 patients, the 
growths having been bilateral fifty-nine times. 
TABLE B. 
Middle turbinated body, . 104 
Neighborhood of superior turbinated body and superior meatus, 77 
Middle turbinated body and middle meatus, . . . .34 
Middle meatus, . . ■ . .24 
Inferior turbinated body, . . . . . . . .9 
Whole of outer wall of nose (except inferior meatus), . . 11 
259 
Only in very rare cases is the septum the site of the affection. NON-M ALIGN ANT TUMORS OF THE NOSE. 
355 
Bryant,* Leriche,f Clinton Wagner,J and Hartmann,§ each report one 
example, and Zuckerkandl|| has met with three specimens. These are 
the only authentic instances that I am acquainted with. Polypi, how- 
ever, springing from the turbinated bodies sometimes press so firmly 
against the septum that it is extremely difficult to pass the finest probe 
between the partition and the tumor, and under such circumstances a 
mistake as to the origin of the polypus is likely to be made. By means 
of posterior rhinoscopy I have seen several cases of small symmetrical 
growths on the septum, but these were always either of adenoid struc- 
ture, or consisted of simple hypertrophy of the mucous membrane. 
Mucous polypi generally remain within the nasal cavity, but when 
very large they may extend forward and even project from the nostril. 
Sometimes they grow towards the pharynx, and can then be easily dis- 
covered by posterior rhinoscopy. Occasionally a polypus in its growth 
becomes attached at several different points to the contiguous walls of 
the nares, but this result of friction and pressure is more likely to be 
seen in the case of fibrous polypi than in those of myxomatous struc- 
ture. In very rare instances a mucous polypus may by pressure de- 
stroy the periosteum, and one case has been reported by Colles in which 
the bones of the nose were separated by such a growth. 
Mucous polypi are generally multiple, and according to my expe- 
rience (see Table B), occur on both sides in nearly 30 per cent. Glob- 
ular in shape at first, they most frequently hang loosely from the nasal 
wall, being suspended by a narrow pedicle. It is thus that gravitation, 
acting on their semi-fluid contents, soon determines their characteristic 
tear-shaped outline. They do not, however, always retain this form, 
for, as Griiner remarks, the larger the size to which they attain the more 
they recede from their pyriform shape, as they are easily moulded bv 
the unyielding structures which, after a time, confine them on every 
side. 
The views which have just been expressed'are, however, opposed to 
the recent anatomical observations of Zuckerkandl,** who maintains 
* Manual of the Practice of Surgery, 3d ed., London, 1879, vol. ii., p. 7. 
f Gaz. des Hopitaux, 1874, No. 73. 
J Arch, of Clin. Surg., New York, January, 1877. 
$ Deutsch. med. Wochenschrift, 1879, Nos. 28-30. 
|| Zur path. u. phys. Anatomic der Nasenhohle u. ihre pneumat., Anhange.—Wien, 
med. Jahrb., 1879. See also Anatomie der Nasenhohle, p. 84. It appears doubtful 
from the description whether all Zuckerkandl’s cases were examples of true polypi. 
Dub. Quart. Journ. Med. Sci., No. 12, November, 1848, p. 374. 
** Op. cit., p. 78 et seq. 356 
DISEASES OF THE THROAT AND NOSE. 
that there are two kinds of polypus, viz., those of oval form with nar- 
row pedicle, and those of round shape with broad base, the former 
growing from sharp edges, the latter from flat surfaces. Zuckerkandl 
maintains that the globular tumors are never converted into the oval, 
but that each kind possesses its peculiar shape from the time of its first 
appearance. Polypi vary in size from a tare to a chestnut, but when 
requiring treatment are most frequently between a currant and a grape 
in size. I have met with one exceptional case, however, in which the 
growth, when stretched out, measured five inches in length, and was 
seven-eighths of an inch in diameter at its base (Fig. 78). I removed 
the polypus from a gentleman aged twenty-two, in the presence of Dr. 
Fig. 78. 
Polypus removed by the author. 
Snell, of Mile End. No recurrence had taken place nine years later. 
A more remarkable example still has been reported by Stoerk,* in 
which a polypus springing from within the posterior nares reached 
down to the larynx. There are often one or two polypi about the size 
of a small grape or currant, and a great number of others which are 
scarcely visible. Their color is generally dull yellow, but occasionally 
they are grayish-white or pink. Their surface is smooth and shining, 
and when touched lightly with a probe they dimple through their elas- 
ticity, returning at once to their former shape. When a strong light 
is directed on the polypus, it generally has a somewhat translucent ap- 
pearance. Mucous polypi are devoid of sensibility, the pain which is 
* Krankheiten des Ivehlkopfes, Stuttgart, 1880, p. 105. NON-MALIGNANT TUMORS OF THE NOSE. 
357 
felt on their forcible removal being clue,to their connection with the 
mucous membrane. 
The ordinary symptoms attending the presence of a polypus in the 
nose having been described, it is necessary to add a few remarks on a 
much more serious class of troubles to which attention has been called 
in recent years. Soon after Voltolini* had recorded an instance in 
which asthma resulted from the presence of a polypus in the nasal pas- 
sages, similar cases were reported by Hanisch,f Porter,J Daly,§ Todd,|| 
Spencer,Mulhall,** Joal,ff and Jacquin,|| and the reflex causation of 
asthma from nasal polypi has been discussed by Schafer,§§ Frankel,|||| 
and The whole subject of the reflex effects of nasal ob- 
struction, and especially of polypi, has been recently studied with great 
ability by Hack,*** who considers that nightmare, cough, hemicrania, 
brow-ague, certain vasomotor phenomena shown by quasi-erysipela- 
tous symptoms (in which there is temporary limited redness of the 
cheeks), attacks of giddiness, epilepsy, rhinorrhoea, and hay-fever often 
owe their origin to polypus, or tumefaction of the nasal mucous mem- 
brane. Hack gives many illustrative cases in which the various com- 
plaints referred to were cured by surgical operations within the nose, 
and it may be added that his etiological views have already received 
independent support from other observers. Lowefff has reported a case 
in which epileptic fits, which had before been of almost daily occurrence, 
suddenly ceased when the nasal passage was made clear. The obstruc- 
tion had been produced by a polypus in the left nostril, accompanied 
by hypertrophy of the mucous membrane covering the lower turbinated 
body, and adenoid vegetation about the posterior nares. When these 
sources of irritation had been removed the fits only came on under 
the influence of some extraordinary mental disturbance. 
* Die Anwendung d. Galvanokaustik, Wien., 1872, p. 246, 4 Aufl. 
f Berlin, klin. Wochenschrift, 1874, No. 40. 
J New York Med. Record, October 11, 1879; also Arch, of Laryngology, 1882, 
vol. iii., No. 2. 
$ Arch, of Laryngology, vol. ii. 
|| Trans. Missouri State Med. Assoc., 1881. 
Quoted by Todd, Ibid. 
** St. Louis Med. Surg. Journ., February, 1882. 
ff Gaz. des Hfipitaux, 1882, p. 442 et seq. JJ Ibid., 1882, p. 507. 
$$ Deutsche med. Wochenschrift, 1879, Nos. 32 and 33. 
1111 Berlin, klin. Wochenschrift, 1881, Nos. 16 and 17. 
Volkmann’s klin. Vortrage, 1882, No. 216. 
*** Wien. med. Wochenschrift, 1882, Nos. 49, 50, 51; and 1883, No. 4 et seq. 
Iff Allgemein. med. Central Zeitung, 1882, No. 76. 358 
DISEASES OF THE THROAT AND NOSE. 
In connection with this Iasi case, I may state that I have lately treated 
(with Dr. Hugh lings Jackson and Dr. Sillifant, of Barnsbury) a gentle- 
man, aged fifty-five, who had suffered for some months from attacks of 
extreme restlessness, together with such severe dyspnoea, that he was 
unable to lie down at night. He also had violent paroxysms of facial 
spasm, and on one or two occasions epileptiform seizures, during which 
he was unconscious for twenty minutes or half an hour. There was a 
mass of polypi in the upper part of the nasal passages on both sides. 
These growths having been almost completely removed, the paroxysms 
of dyspnoea entirely ceased, and the other nervous symptoms gradually 
disappeared. Elsberg* has also met with cases of chorea, epilepsy, 
supra-orbital headache, and hemicrania, due to reflex irritation within 
the nose. Seilerf has reported two cases, and refers to two others, in 
which he believes that thickening of the anterior part of the inferior 
turbinated bodies was the cause of a troublesome cough. The cases 
described are not very conclusive, but in both of them treatment of the 
nose relieved the laryngeal symptom. John has found 
cough so frequently a reflex symptom of nasal disease that he has ceased 
to regard it as a curiosity. He is of opinion that the posterior portion 
of the middle and inferior turbinated bodies with the corresponding 
part of the septum are the special seats of reflex irritability. Hack,§ 
on the other hand, concludes from his own observations that reflex phe- 
nomena, such as cough and sneezing, may be produced by irritation of 
any part of the lining membrane of the nose, but that such manifesta- 
tions do not take place until the anterior part of the lower turbinated 
body has first become turgid. 
The following examples of asthma, dependent on growths in the 
nares, occurred in my own practice: 
One of these cases was that of a lady, aged sixty-three, who consulted me in March, 
1874. She had suffered for three years from severe attacks of asthma, which came on 
nearly every night Various remedies had been used with partial success, hut the 
asthma was entirely cured by the removal of two large polypi—one from each middle 
turbinated body. 
In a second case, the patient was a gentleman, aged forty-seven, whom I first saw in 
July, 1876. During the previous five years he had suffered occasionally from asthma, 
the paroxysms, as in the last case, always occurring at night. The removal of a quan- 
tity of small growths from the neighborhood of the superior turbinated body on the 
* Philadelphia Med. News, May 26th, 1883, p. 604. 
f Arch, of Laryngology, 1882, vol. iii., p. 240 et seq. 
f Amer. Journ. Med; Sci., July, 1883, p. 106 et seq. 
§ Loc. cit., p. 36. NON-MALIGN A NT TUMORS OP THE NOSE. 
359 
right side entirely relieved the patient of his asthmatic attacks, which, however, re- 
turned, after an interval of four months. The recurrence of the dyspnoea was found to 
be coincident with a fresh development of polypi, and on their removal the symptoms 
again passed off. 
In a third patient, recently sent to me by Dr. Hughes of Llanberis, very severe at- 
tacks of asthma appeared to have been caused by the presence of polypi in the nose; 
violent paroxysms were also produced by the insufflation of tannic acid. 
Daly* has recently maintained that the disposition to hay fever must 
be sought for in chronic hypertrophy of the mucous membrane of the 
nose, and this theory has been adopted by Roe,f of Albany. My own 
experience, however, does not confirm the view. 
Whilst fully admitting that many reflex phenomena may arise from 
disease within the nose, I must caution the younger specialists that the 
various complaints, referred to as resulting from nasal disease, are much 
more frequently due to other conditions, and that every other possible 
cause must be eliminated before the nose is incriminated. 
Diagnosis.—Although in most cases it is easy to diagnose nasal 
polypi, yet mistakes do occasionally occur. The gelatinous softness, 
elasticity, mobility, and pale semi-transparent appearance of these tumors 
are, however, very characteristic features, and serve to distinguish them 
from most other swellings. Fibrous, sarcomatous, and cancerous 
growths are usually much harder, bleed easily on being touched, cause 
considerable pain, and often produce great disfigurement. Cartilagi- 
nous or osseous tumors are so hard that their real nature is at once evi- 
dent. Deviation of the septum has occasionally been mistaken for a 
polypus; but, when this condition exists, there is an irregular projec- 
tion into one nasal passage and a corresponding depression in the other, 
showing the character of the affection. Chronic abscess of the septum 
has frequently been mistaken for polypus, but it differs almost diamet- 
rically from that complaint. For, whilst a polypus hangs almost in- 
variably from the outer wall of the nasal cavity by a pedicle, an abscess 
is situated on the septum, and has a broad origin. Moreover, in cases 
of abscess there is, in the vast majority of instances, a similar swelling 
in the other nostril, the bases of the tumors accurately corresponding 
with each other on the two sides of the septum. Blood tumors present 
the same general characters as abscesses, except that they are of dark 
purple color. In both cases there is usually a history of more or less 
recent injury to the nose. In any doubtful instance, however, punc- 
ture of one of the tumors will solve the question as to its nature. 
* Archi of Laryngology, 1882, vol. iii., p. 157 et seq. 
t New York Med. Journ., May 12th, 1883, p. 509 et seq. 360 
DISEASES OF THE THROAT AND NOSE. 
The condition, most likely to be mistaken for polypus, is thickening 
of the mucous membrane covering the inferior turbinated bones. This 
mistake is frequently made by practitioners, owing to the fact that, in 
systematic surgical works, the diagnosis between these conditions has 
not hitherto been pointed out. Polypi, however, though often bilateral, 
are seldom so symmetrical as is the thickening of the turbinated bodies, 
and whilst the color of the former is pale yellow or pink, that of the 
hypertrophied turbinated bodies is either bright, or dark, red. Again, 
though the thickened mucous membrane pits a little under the 
probe, the entire body does not move as in the case of a polypus. It 
must not be forgotten, however, that polypus and hypertrophy often co- 
exist. A foreign body might possibly be mistaken for a polypus, but 
the inflammation and fetid discharge from the nose, which accompany 
it, will make the practitioner suspect something more than a mucous 
growth. Amongst rare conditions, which need only be referred to as 
curiosities, may be mentioned mucous distension of the ethmoidal cells 
and hernia of the brain. The museum of St. Thomas’s Hospital con- 
tains two examples of the former affection, in which the appearance 
during life must have closely resembled mucous polypi.* As Spencer 
Watsonf observes, with regard to these specimens, the hard wall of the 
projecting body and the escape of the pent-up mucus on puncture would 
determine their nature. A curious case was reported by Cruveilhier,| 
in which a hernia of the dura mater aud brain through the cribriform 
plate of the ethmoid bone, exactly resembling a polypus, was discovered 
at a post-mortem examination. Such a tumor, however, would move 
rhythmically with the respiration and pulsate with the systole of the 
heart ; moreover, in its development cerebral symptoms would be 
almost sure to occur. 
Pathology.—The external investment of these polypi is usually com- 
posed of ciliated epithelium, and beneath this outer layerthere are gen- 
erally a few dilated capillaries, but no nerves. The bulk of the growth 
is made up of embryonic connective tissue, consisting of a hyaline gela- 
tinous material, through which more resisting cellular trabeculae pass 
in various directions. The gelatinous substance is very rich in mucin, 
and contains in the early state round and oval cells, which at a later 
period become elongated, fusiform, or stellate, and for the most part 
* Museum Catalogue, Sec. i., Nos. 14 and 16. 
f Diseases of the Nose, London, 1876, p. 73. 
J Anatom. Pathol, du Corps Humain, Paris, 1835-1842, t. ii., livraison xxvi., 
pp. 5, 6. NON-MALIGNANT TUMOES OF THE NOSE. 
361 
nucleated and granular. According to Cornil and Ranvier,* the latter 
kind of cell is most common. The consistency of the growth depends 
on the greater or less degree in which the connective stroma or the 
mucous stroma predominates in its structure. Here and there small 
cavities, full of colorless stringy fluid, may be met with. Some observ- 
ers regard such growths as true cysts, but Follin and Duplayf consider 
that the absence of any distinct wall shows that these formations are 
not really of cystic character. however, maintains that 
he has occasionally found cysts in the neighborhood of nasal polypi. 
Fig. 79. 
From Specimen No. 2201a in the Museum of the Koyal College of Surgeons. 
a, polypus hanging from the middle meatus; b, apron-like flap hanging from the 
vault of the nose and upper turbinated body, and partly covering d, the middle tur- 
binated body, which is greatly thickened; c, portion of middle, projecting over the 
lower turbinated body. Near b are three small abrasions, possibly caused by the pres- 
sure of the inner wall. 
They are, he says, of white color, and generally the size of a bean, but 
he once saw a cyst as large as a hazel-nut growing from the anterior 
part of the lower turbinated body, and containing a honey-like fluid. 
Sometimes nasal polypi contain glandulse, but the growths themselves 
never appear to be of glandular origin. Hypertrophy of the mucous 
membrane is very frequently associated with the presence of polypi, 
* Manuel d’Histol. Path., Paris, 1869, p. 145. 
f Trait6 Elfem. de Path, externe, Paris, 1877, t. iii., p. 812. 
X Op. cit., p. 100. 362 
DISEASES OF THE THROAT AND NOSE. 
whilst, on the other hand, these growths often give rise to atrophy of 
the soft structures. 
The exact site of origin of nasal polypi is a matter of perhaps even 
more importance than their minute structure, and valuable information 
on this subject may be obtained from Zuckerkandl,* who has recently 
published the post-mortem reports of thirty-nine cases of polypus and 
polypoid thickening of the mucous membrane of the nose. The great 
value of these observations depends on their having been made after the 
gradual removal of the various bony parts which interfered with a view 
of the deep origin of the growths. In a few of Zuckerkandhs cases, 
the disease was nothing more than simple hypertrophy, one or two 
others were of doubtful character, one was a papilloma, in two instances 
the growth was really in the naso-pharynx, whilst in three, polypoid 
excrescences grew from the septum. In several instances, however, the 
polypi were multiple, so that the exact seat of attachment of forty-twof 
distinct growths could be determined. Fourteen grew from the edges of 
the hiatus semilunaris, three from the edges of the hiatus and the infundi- 
bulum, two entirely from within the infundibulum, one from the ostium 
frontale, one from the ostium sphenoidale, one from the ostium ethmoidale, 
two from the antrum, ten from the middle meatus, three from the upper 
meatus, four from the middle, and one from the upper turbinated body. 
Prognosis. —Mucous polypi cause great inconvenience and annoyance, 
but are very seldom attended with any serious risk, certain extremely 
rare reflex phenomena already described being perhaps the most alarm- 
ing features. True polypus so rarely causes any disfigurement that this 
matter may be dismissed from consideration. Even after the growth 
has apparently been completely removed, however, there is a great 
probability of the patient being again troubled with the complaint. This 
is partly owing to the fact that the real origin often cannot be reached, 
and partly to the circumstance that very small polypi no doubt often 
exist which are not visible at the time when the larger growths are re- 
moved. When relieved, however, from pressure, the minute excres- 
cences at once commence to grow. 
Spontaneous of a polypus sometimes takes place, and I 
have seen several cases where this has occurred. In my experience, 
however, it has only happened when several polypi were crowded 
* Op. cit., p. 64 et seq. 
f Op cit., pp. 64 to 84. In reality the actual number of separate growths was more 
than this, for in some cases where a single site is given there were “ several ” polypi. 
| Michel: op. cit., p. 55. is ON-MALIGNANT TUMORS OF THE NOSE. 
363 
together, and has therefore not affected the prospects of cure. Spon- 
taneous absorption is said to have occurred in one case; * but as the 
polypus (?) gave rise to most intense headache, whilst it grew with 
extreme rapidity and finally sloughed away, it can scarcely be classed 
with the disease now under consideration. 
Treatment.—Medical remedies have been used from a very early 
period with the view of drying up nasal polypi, a method of cure which 
the gelatinous nature of the growth naturally suggested. Galen advised 
the use of alum and pomegranate juice. At a later period chloride of 
antimony and sulphuric acid were much employed with the same object, 
and in modern times various astringents and caustics have been recom- 
mended. In 1821 Primus, of Babenhausen,j* reported two successful 
cases from the use of the saffronized tincture of opium of the Prussian 
Pharmacopoeia. According to that surgeon, the polypus, if painted 
with this solution several times a day for about a week or ten days, 
under favorable circumstances shrivels up and becomes detached. 
Bryant J strongly recommends the application of finely powdered tan- 
nin by means of his nasal insufflator (Fig. 37, p. 258), but though in 
the case of nervous patients who have objected to an operation I have 
tried this remedy, I cannot say I have ever found it do any good. Ni- 
trate of silver was successfully used by Nelaton.§ 
Reeder, || of Illinois, is stated to have employed strong injections of 
perchloride of iron with good effect in two cases. mentions 
that he has seen one case in which injections of chloride of zinc caused 
the separation by sloughing of a polypus so large that it blocked up the 
nostril completely and descended into the pharynx. Fredericq** claims 
to have obtained excellent results from the application of a saturated 
watery solution of bichromate of potash to the polypus. He states that 
it produces some inflammation, which is followed by absorption of the 
growth. The application may have to be repeated once or twice, but 
Fredericq affirms that he has cured several cases in this manner within 
five or six days, that he has seldom seen any recurrence, and that he 
has never known any ill effect follow the use of the bichromate. 
* Maddock: Lancet, 1836-37, vol. ii., pp. 590, 591. 
f Hartenkeil’s Medico-Chir. Zeitung, Salzburg, 1821, p. 56. 
t Lancet, February, 1867, p. 235. 
§ Pathologie Cliirurgicale, Paris, 1874, 2me ed., t. iii., p. 748. 
|| Quoted by Gross: System of Surgery, Philadelphia, 1882, 6th ed., vol. ii., p. 290. 
ff Science and Art of Surgery, 6th ed., vol. ii., p. 320. 
** M4moire a la Soci6te de Medecine de Gand. 1862. Quoted by Spiil- 
mann, Diet. Encyclop., t. xiii., p. 88. 364 
DISEASES OF THE THROAT AND NOSE. 
Donaldson,* of Baltimore, has found great benefit from chromic acid. 
The mucous "membrane is painted with a solution of lead, and a paste 
of chromic acid is applied to the polypus by burying a glass rod smeared 
with the agent in the substance of the tumor. The mass dries up, and 
can then be easily removed with forceps at the same sitting. 
The general experience, however, is that astringents offer so slender 
a chance of doing any good, that it is hardly worth while to make a 
trial of them. By the application of strong caustics or escharotics, no 
doubt nearly all nasal myxomata may be destroyed; but the cure is 
very tedious and painful, and, moreover, it is difficult to limit the action 
of the agent to the tumor. Electrolytic treatment would no doubt 
sometimes succeed in destroying these growths, but its operation would 
probably be extremely tedious. 
Surgical Measures.—There are three principal methods of removing 
or destroying nasal polypi, viz., evulsion, abscission, and electric cautery. 
Evulsion with forceps is the oldest and still the most generally prac- 
ticed method, and it must be admitted that it is a very rapid way of 
removing polypi, but the ease with which it can usually be carried out 
led practitioners in former times to suppose that the proceeding was 
equally applicable to all intra-nasal growths, wherever situated, and 
whatever the nature of their attachments. Acting on such premises, 
surgeons of the last century increased the size and leverage of their for- 
ceps, and adapted them by suitable curves for introduction, either by 
the nostril or through the pharynx, as if no more consideration were 
necessary than to seize every nasal tumor with tenacity and wrench it 
away with violence. Tearing away of the septum, and even great 
injury to the ethmoid and nasal bones, not unfrequently resulted from 
such vigorous surgery, and it is not surprising that this mode of treat- 
ment, after a time, met with opposition. 
But although the practice has since then been placed on a rational and 
scientific basis, attempts have been recently made to revive the preju- 
dice against it which was once so well founded. Whilst usually prac- 
ticed by general surgeons, and still almost universally recommended in 
our standard text-books on surgery,f some leading specialists of the 
day condemn it in the strongest terms. Yoltolini| says: “Of late 
years, the forceps has superseded all other instruments, and as the re- 
sult of its employment, severe mutilations are frequently seen in the 
* Philadelphia Medical News, May 26th, 1883, p. 597. 
f Erichsen, Gant, Bryant, Fergusson, Gross, Hueter, Liicke, Albert, and Duplay 
J Die Anwendung der Galvanocaustik, p. 243. NON-MALIGNANT TUMORS OF THE NOSE. 
365 
nose. Many distinguished surgeons admit that evulsion is one of the 
most brutal and disagreeable operations. . . . The forceps, blindly in- 
troduced, tears away or injures everything that comes in the way, 
whether it is healthy or diseased, soft or hard (turbinated bones and 
nasal septum).” He adds that, “ In operations with forceps, the greatest 
force has to be used in some cases; in fact one has to pull, as it were, 
‘for life/ in order to get away the polypus.” Michel* states that, “ as 
the result of operations by others with forceps, he has seen luxation of 
the cartilaginous septum, fracture of the bones, removal of portions of 
the turbinated bones, circumstances which increase the sufferings of the 
patients, and render the operation quite horrible.” Zaufal,f in recom- 
mending the snare, says that he hopes “ to render utterly impossible in 
the future the obsolete, barbarous forceps-operation so unworthy of 
modern surgery.” 
More recently, LemereJ has ransacked French medical literature in 
order to bring together all the cases he could find, in which bad results 
have followed evulsion. He divides them into immediate and remote. 
Amongst the immediate dangers, however, he only mentions haemor- 
rhage, and, as an illustration, adduces one case in which Gosselin had 
to plug the nares, and another case (from Gerdy) in which the haemor- 
rhage had to be stopped in the same way. In the latter case the patient 
died, but as the tumor was clearly shown to be a fibroma it does not 
bear on the question of evulsion of mucous polypi. Amongst the re- 
mote dangers he adduces the following: (1) Obliteration of the nasal 
duct, (2) injury to the antrum or frontal sinuses, (3) injury to veins, 
(4) injury to the bones of the nose and skull, and (5) rapid exuberant 
recurrence. Under the first head, only one case from Pean is given, 
which was ultimately cured. In illustration of the injury to the frontal 
sinuses and antrum, he adduces a case (also from Pean) in which a man 
suffered for twelve years from a deep-seated tumor on the cheek, which 
the patient stated commenced after the evulsion of a polypus. An ex- 
ploratory puncture gave issue to a syrupy liquid, amber in color, and 
containing cholesterine crystals. As an example of injury to the frontal 
sinus, Lemere reports two cases; one (from Broca), in which an abscess, 
which formed in the frontal sinus a few weeks after evulsion of a poly- 
pus from the nose, was cured in three months; and another case (from 
* Die Krankheiten der Nasenbolile, Berlin, 1876, p. 57. 
f Die Allgemeine Verwendbarkeit der kalten Drahtschlinge, 1878. See preface. 
| Sur les Accidents a l’Arrachement des Polypes des Fosses nasales, 
Paris, 1877. 366 
DISEASES OF THE THKOAT AND NOSE. 
Demarquay) in which the patient, aged seventy-four, was attacked with 
abscess of the frontal sinus after a polypus had been torn away. The 
bone was trephined and the patient cured. As an instance of injury to 
the veins, he brings forward the last case again, recurrence having 
taken place the following year. Evulsion again gave rise to erysipelas, 
and six months afterwards the operation was again performed with 
similar results; three months later evulsion was repeated, and the 
stump treated with nitrate of silver. This was followed by intense 
pain on the right side of the head, and violent inflammation of the 
pituitary membrane. Twelve days afterwards, the right lower eyelid 
became greatly depressed, the right eye fixed, with its pupil dilated, and 
insensible to light. Death occurred a fortnight after the operation. At 
the post-mortem examination, congestion of the meninges was found at 
the base of the brain on the right side. The body of the sphenoid was 
friable, and pus oozed through the sella turcica. The cavernous sinus 
was bathed in pus, and there was purulent infiltration of the right 
pituitary membrane. The sphenoidal, ethmoidal, and maxillary sinuses 
were full of pus. The case does not exactly seem to have been one of • 
venous infection, but rather an extension of inflammation from the nose 
to the sinuses and the brain. It is clear that the repeated operations 
ought not to have been undertaken, as the patient was an old man, ex- 
ceedingly prone to erysipelas; but as he was a medical practitioner, he 
probably insisted on measures which were clearly unsuitable, and the 
case has no bearing on the general merits of evulsion. In illustration 
of injury to the bones of the skull, Lemere mentions a case (from Til- 
laux) in which a patient applied for relief on account of a constant flow 
of liquid from the nose, which, on examination by Robin and Mehu, 
was found to be pure cerebro-spinal fluid. Evulsion had been pre- 
viously practiced on this patient on two occasions, and Tillaux con- 
sidered that, in one of the operations, the cribriform plate of the eth- 
moid bone must have been broken through by the forceps. The only 
example which Lemere gives of exuberant recurrence was clearly a 
case of cancer. 
From the above cases, collected from a treatise professedly written to 
exemplify the dangers of evulsion, it will be seen how difficult it is to 
bring forward any tangible evidence against the operation. Albert,* 
in his recent work, has defended this method against the attacks of 
specialists. The following are some of his remarks on the subject: “ In 
late years, this method (the operation by forceps) has been condemned 
* Lelirbuch der Chirurgie, Wien u. Leipzig, 1881, Bd. i., p. 305. NON-MALIGNANT TUMORS OF THE NOSE. 
367 
as brutal, painful, and inefficient. There is no doubt that it can be 
performed brutally by rough or clumsy hands; but the conservative 
surgeon does not grope blindly in the nasal cavity; on the contrary, he 
places the patient in a proper position, makes use of a nasal speculum, 
and, carefully selecting forceps suitable as regards the size and situation 
of the polypus, he seizes it by the pedicle, and extracts it by gentle 
rotatory movements.” He adds, that “the hostility to the old univer- 
sally practiced method (evulsion by forceps) is merely the outcome of 
the elaborate methods used by the specialist with an object which it is 
easy to understand.” Specialists might perhaps retort that the hos- 
tility of some surgeons to new and improved methods of cure, which 
they have themselves failed to master, has a motive which it is equally 
easy to understand. But such amenities are better avoided in scientific 
discussions. 
It is curious that the principal objection urged by Voltolini, Michel, 
and others, against the practice of evulsion with forceps, viz., that a 
portion of one of the turbinated bones is often torn away, is considered 
a recommendation by the advocates of the forceps. It has already been 
shown (see History) that in the seventeenth century, Valsalva,* for the 
purpose of preventing the recurrence of the growth, introduced the 
practice of removing, together with the polypus, the lamella of bone 
from which it springs ; and, in our own time, the two leading conserva- 
tive surgeons, Fergussonf and Pirogoff,! have advocated the same treat- 
ment. I may add, that I have myself frequently removed portions of 
the turbinated bones without seeing any evil result follow; and it ap- 
pears to me extremely doubtful whether any bad effect could be pro- 
duced by the partial removal of one of these bones. 
It is no doubt perfectly true that air breathed through the nose reaches the lungs at 
a higher temperature than when it is inspired through the mouth, and that this is due, 
in some measure, to the peculiar vascular structure of the turbinated bodies. The 
interesting experiments of Gr6hant,$ by which the temperature of air expired by the 
lungs, previously inspired through the nose, was compared with that expired after pre- 
vious oral inspiration, first proved this to be the case. The following are the details 
of the experiments: A small thermometer was inclosed in a glass tube, each end of 
* Morgagni: De sedibus et cansis morb., Patavii, 1765, ep. xiv., sec. 19. 
f Although there is no mention of it in his published writings, I often heard this 
great surgeon remark, that one could never feel sure of the complete removal of a 
polypus, unless a portion of the bone was taken away with it. 
J Klinische Chirurgie, 3tes Heft, Leipzig, 1854, p. 73. 
\ Recherches physiques sur la Respiration de l’Homme, Th&se de Paris, No. 161 
1864, p. 30 etseq. 368 
DISEASES OF THE THROAT AND NOSE. 
which was stopped with a cork perforated so as to allow free passage to a current of 
air. This apparatus was then placed inside a second tube, the space between the two 
being filled up with cotton wool. The outer tube having next been introduced into 
the mouth, with the bulb of the thermometer at a distance of from one to two centi- 
metres from the lips, air was inspired through the nose, the aperture in the outer tube 
being closed meanwhile with the tongue; finally expiration was performed through 
the apparatus containing the thermometer. Under these circumstances, the tempera- 
ture of the atmosphere being 71.6° F., that of the air expired through the tube was 
found to be 95.7°. On the other hand, when air was drawn in through the mouth (the 
tube being closed with the tongue, as before), the temperature of the air expired through 
the tube was only 93.5°. The temperature of the expired air in these experiments was 
found to vary, being lower at the commencement of the act of expiration than at its 
conclusion ; the temperature given by Grfehant, therefore, was a mean of that observed 
at three periods, viz., the commencement, the middle, and the conclusion of expiration. 
This feature, as well as some other points, not appearing quite satisfactory, I thought 
it desirable to repeat the experiment in a slightly modified form, and in the following 
investigations my assistant, Dr. George F. Hawley (U. S. A.) afforded me material 
help. Instead of expiration being made directly on the thermometer, I employed an 
india-rubber bag of the capacity of one gallon. Into the further end of the bag a ther- 
mometer was fitted, whilst to its proximal extremity a piece of tubing, which served as 
a mouthpiece, was attached. The temperature of the expired air, when previously 
inspired through the nose, was now compared with the expired air after oral inspira- 
tion. With the thermometer set at 70° F., the expired air after nasal inspiration, as 
the result of a large number of experiments, showed an average temperature of 75.1°, 
whilst the average temperature after oral inspiration was only 73.6°, or, in other words, 
nasal inspiration raised the temperature a degree and a half higher than oral inspi- 
ration. 
Such experiments are, however, always open to objection, as they do not show the 
actual difference in the air after inspiration through the nose and mouth respectively, 
but only the difference in the expired air after the two different modes of inspiration. 
It was thought desirable, therefore, to make more direct experiments. A thermometer 
was accordingly supported in such a way that it could be worn in the mouth with the 
bulb in the pharynx on one side between the uvula and the pharyngeal wall. The 
support of the instrument consisted of a wooden bar, with a hole in its centre, just big 
enough to admit the introduction of the thermometer, and retain it in position; it was 
held between the teeth, like a horse’s bit, in such a way that the subject’s lips did not 
touch the thermometer. When the instrument was placed in the pharynx, and allowed 
to attain to a temperature of 90° F., it was found as the result of a large number of ex- 
periments that gentle* nasal inspiration reduced the temperature only half a degree, 
whilst gentle oral inspiration lowered the temperature a degree and a half, showing a 
superiority of one degree in the heating power of the nasal channels as compared with 
the mouth. 
It is possible that if these experiments had been carried out in an atmosphere at a 
lower temperature the influence of nasal inspiration would have been more marked, 
but, after all, the experiments only show that when the air reaches the lungs after 
passing through the comparatively long and narrow passages of the nose, it arrives in 
the pharynx at a higher temperature than when it passes directly through the mouth. 
* Forcible inspiration produced such variable results that the experiments were un- 
satisfactory. NOX-MALIGXANT TUMORS OF THE NOSE. 
369 
The real use of nasal inspiration, however, consists probably more in 
the protection it affords against the entrance of minute foreign bodies 
rather than in its thermic effects on the inspired air. The advantage 
of inspiring through the nose, in fact, lies in the exclusion of the irri- 
tating matters floating in the air, which, if they elude the vibrissse, are 
likely to become deposited in the nasal passages, and are thus prevented 
entering the lungs.* The bad effect of oral respiration indeed is seen 
not in the chest but in the pharynx, where the mucous membrane be- 
comes dried by exposure to the air, and irritated by particles of dust 
floating in the atmosphere. 
The thermic influence of nasal inspiration is probably due to the pas- 
sage of the air through a narrow canal lined by a thin mucous mem- 
brane abundantly supplied with vessels, rather than to the special 
structure of the turbinated bodies. The peculiar erectile structure of 
these parts, moreover, is only seen to perfection in the inferior turbinated 
body, and it is not this, but the middle body which sometimes requires 
partial removal. But if, taking into consideration the peculiar histo- 
logical character of the turbinated bodies, their physiological importance 
be conceded, it does not follow that the ablation of a portion of one of 
the bones would be attended with any unfavorable results. I go further, 
however, and do not hesitate to assert that there are some polypi, which, 
from their anatomical situation, cannot be extirpated unless a portion 
of a turbinated bone is also taken away. A mere glance at the annexed 
sketches (Figs. 80 and 81) renders it evident that a polypus springing 
* Catlin (The Breath of Life, London, 1861, p. 39), the great apostle of nose- 
breathing, has carried his enthusiasm somewhat too far, and has confused cause and 
effect in a most amusing way. Thus, in the case of those people who cannot close the 
mouth, he asserts that “ the derangement and deformity of the teeth ” proves the “ long 
practice of the baneful habit” (mouth breathing), and he adds “that the mouth of the 
hyaena and donkey are agreeable, and even handsome, by the side of such people.” 
The expression of persons who cannot close the mouth is not always prepossessing, but 
it seems a little hard that they should be compared unfavorably with the donkey, and 
even the hyaena. It is scarcely necessary to point out that the deformity of the teeth 
referred to does not result, from mouth-breathing, but that in certain cases the direction 
of the teeth prevents the patient closing the mouth, and that he is thus naturally in- 
clined to use the mouth in breathing. The irregularity of the teeth commences at the 
second dentition, through the abnormal development and projection forward of the in- 
termaxillary bone. It is most frequently a hereditary peculiarity, and is in no possible 
way caused by breathing through the mouth. 
Catlin also states that deafness, dumbness, spinal curvature, and death from teething 
and diseases of the respiratory passages are almost unknown among the American 
Indians; and he attributes this exemption to the habit of breathing through the nose, 
so universally practiced by them ! 370 
DISEASES OF THE THROAT AND NOSE. 
from any of the localities marked X could not be taken away except by 
previous or simultaneous removal of a lamella of bone, especially when 
the position of the nares in relation to those localities is taken into con- 
sideration. This view is, moreover, amply confirmed by the recent 
observations of Zuekerkandl (p. 362) as regards the origin of polypi. 
The well-known disposition to recurrence of these growths, which has 
already been pointed out (see Prognosis), is one of the greatest causes of 
difficulty in dealing with them. Now there cannot be the least doubt 
that in some cases the ablation of the lamella of bone from which the 
polypus springs is the most certain method of preventing any fresh 
Fig. 80. 
Fig. 81. 
Fig. 80.—Transverse vertical section through the nasal fossae at a point behind the 
first molar teeth (after Hirschfeld). The X at four different points shows the supposed 
origin of polypi. 
Fig. 81.—Transverse vertical section of the nasal fossae in the plane of the bicuspid 
teeth (after Hirschfeld). The X at four different points indicates the supposed point of 
origin of polypi. 
development of growth, whilst in others its origin can only be reached 
by first taking away a portion of bone. In conclusion, it may be con- 
fidently asserted that if any slight trouble should arise in consequence 
of the removal of a piece of bone, this will at any rate be far less than 
the annoyance caused by a mass blocking up the nose, and perhaps re- 
quiring repeated operations for its eradication. 
The subject of the removal of a portion of one of the turbinated 
bones has been treated here because this ablation is often accidentally NON-MALIGNANT TUMORS OF THE NOSE. 
371 
effected in evulsion, but it must not be supposed that it is an essential 
feature in the operation. It is, indeed, only in quite a small proportion 
of cases that it occurs. When it is thought desirable to remove a por- 
tion of bone, it is certainly better to cut it away (see Abscission) than 
to practice evulsion, as by the latter operation the quantity of bone 
which comes away cannot be controlled. 
The gr'eat advantage of evulsion is not only the facility with which 
the treatment can be carried out, but the rapidity with which relief can 
always be obtained. More growths can generally be taken away at a 
single sitting than can be got rid of either with the snare or by electric 
cautery. Although, as a rule, celerity is not a chief consideration in 
treatment, yet cases every now and then occur in which time is a most 
important element, and this point should certainly be thought of in 
judging of the relative merits of surgical methods, when it does not 
involve any risk to life, health, or the integrity of any important func- 
tion. The operation of evulsion holds an intermediate position, neither 
deserving the extreme abuse it has received from specialists, nor the high 
encomiums of general surgeons. In my opinion it is altogether an in- 
ferior method to removal by electric cautery, and I feel convinced that 
no practitioner who has had a large experience in operating with suit- 
ably constructed electrical apparatus would ever allow evulsion to be 
performed on himself. Nevertheless, as the number of surgeons who 
have the opportunity of acquiring skill in using electro-cautery will 
always be limited, it is necessary to fall back on less perfect modes of 
treatment; and where a more refined method cannot be employed evul- 
sion may be resorted to with a good prospect of favorable results. At 
the same time I think it right to state that though I formerly practiced 
evulsion extensively, I now seldom employ it, having found that the 
electric cautery gives less pain to the patient, and causes no haemorrhage. 
Abscission with cutting forceps is also, to my mind, a preferable opera- 
tion. 
In practicing evulsion, the interior of the nose is to be first 
thoroughly exposed (see “ The Application of Anterior Rhinoscopy,” 
p. 246), the growth is then seized, the blades of the forceps firmly 
compressed, and lastly, the handle of the instrument moved up and 
down, and slightly twisted to one side. The value of this process was 
first pointed out by Dzondi, who recommended that the polypus should 
be drawn forward with one pair of light forceps, whilst with another pair 
its root was bruised as close as possible to its attachment. It is seldom, 
however, that there is room for using two pairs of forceps at the same 372 
DISEASES OF THE THROAT AND NOSE. 
time in so confined a space. An ingenious modification of the common 
forceps (Fig. 54, p. 269) has been made by George Stoker, by which the 
tumor can be really twisted off instead of being torn away. Where 
the mass is large, and situated far back, it is best to use the common 
polypus-forceps (Fig. 49, p. 267). The blades of this instrument 
should, after careful determination of the site of the growth, be in- 
troduced into the nose, when by passing the index-finger of the left 
hand round the uvula into the posterior nares, the polypus can easily 
be seized. In these cases the administration of nitrous oxide gas greatly 
facilitates the operation. 
Evulsion by means of a sponge was first recommended by Hippocrates, 
and the mode of carrying it out has already been described (see His- 
tory). In modern times the practice has been revived by McRuer,* who 
“ succeeded in at least ten cases in bringing away all the adventitious 
growths.” Voltolinif has also quite lately reported a case successfully 
treated by this method. 
When the growth is situated far back, it can sometimes be more 
easily reached through the pharynx than through the anterior orifice of 
the nose. In a case in which MorandJ had failed to get away the 
mass of a polypus with forceps, he was able to remove it through the 
pharynx, loosening it from its attachment, partly by direct pressure, 
and partly with his finger-nail. This proceeding was practiced with 
equal success in another case by Sabatier.§ Gross|| also contrived to 
remove a large polypus situated far back in the nasal fossa by “ break- 
ing it off with the index-finger introduced into the mouth, and carried 
round the palate.” 
Abscission.—This method of treatment may be carried out either with 
the snare, ecraseur, or cutting-forceps. Since Hilton (see History) rec- 
ommended the snare, it has been widely used, and observes 
that in his experience this method has proved “ more easy and effect- 
ual, and less painful, and less likely to prove mischievous than other 
methods commonly adopted.” Except when instruments provided with 
Zaufal’s arrangement (p. 272) are employed, the following is the best 
way of applying the snare: The noose, having been introduced vertically, 
should be turned into a horizontal position, and made to encircle the 
* Holmes’s System of Surgery, 1st ed., 1862, p. 216. 
f Monatsschrift fur Ohrenheilkunde, 1882, No. 1. 
J Opuscules de Chirurgie, Paris, 1768-1772. 
\ M&lecine Op6ratoire, Paris, 1824, t. iii., p. 283. 
|| System of Surgery, 6th ed., Philadelphia, 1882, vol. ii., p. 291. 
If Holmes’s System of Surgery, 2d ed., 1870, vol. iv., p. 300. NON-MALIGNANT TUMORS OF THE NOSE. 
373 
polypus, when it is pushed upwards as far as it will go, in order to 
seize the pedicle as near as possible to its root. If the growth be very 
far back, and hang into the naso-pharynx, the snare may be put around 
it by passing a string through the nose by means of Bellocq’s sound. 
The nasal extremity of the string is then attached to the noose, which 
is drawn up to the tumor by traction on the buccal end of the string. 
The loop is next adjusted with the help of the index-finger, and tight- 
ened in the ordinary way. For the slow strangulation of growths 
which show a tendency to bleed, Jarvis’s instrument, or one of the mod- 
ifications of it, is particularly useful. My nasal ecraseur (Fig. 59, p. 
273) will also be found serviceable in these cases. 
Gant has adapted grape-scissors for the removal of polypus from the 
nose, and has successfully used the instrument in several cases (Fig. 50, 
p. 267). The most convenient way of carrying out abscission will, 
however, I believe, be found in the employment of my punch-forceps 
(Fig. 51, p. 268), which is so slender that it can be easily passed along the 
nasal passages, without obstructing the view of the operator, yet so 
strong that it readily cuts through the pedicle of any polypus. With 
this instrument, the slipping-off of the wire, which, in spite of every 
precaution, must occur very frequently with the snare, is avoided. Sur- 
geons who, not having the necessary, apparatus, cannot employ the more 
perfect method of electro-cautery, will find that with the punch-forceps 
they can generally quickly clear the nasal passages. My clinical ex- 
perience of the superiority of forceps over snare and 6craseur has been 
recently confirmed by the very important anatomical researches of 
Zuckerkandl,* who, after a careful study of the deep origin of nasal 
polypi, points out that in many instances “ forceps can accomplish more 
than the snare.” 
In some case, with the view of preventing recurrence, it is desirable, 
as already remarked (p. 367), to remove a small portion of one of the 
spongy bones. This can be most easily done with my punch-forceps. 
The operation can be carried out more satisfactorily if an anaesthetic is 
given, as in removing a part of the middle turbinated bone painful pres- 
sure is sometimes brought to bear on the upper part of the nostril. 
The following cases illustrate the advantage of taking away a piece of 
turbinated bone : 
Case 1.—Mr. E. F., aged thirty-seven, consulted me in May, 1875, on account of 
polypus in the right nasal passage. The symptoms commenced in January, 1871, and 
* Op. cit., p. 81. 374 
DISEASES OF THE THROAT AND NOSE. 
he then was operated on twice with forceps by an eminent surgeon. The growth re- 
turned, and Mr. F. was again treated in the same way by the same operator, in the 
following August. The nose remained clear till July, 1872, when polypi again formed, 
and Mr. F. placed himself under another surgeon, who, in two months (twenty-five 
visits), removed a number of polypi with a snare. The patient believed himself cured, 
but remained well only seven months. He then went back to the last operator, who 
performed repeated operations with the snare through the year 1873, and indeed up to 
May, 1874, when the nose became quite clear. In December the polypus again showed 
itself, and the next month the patient applied to me. On making a careful examina- 
tion, I perceived a large polypus growing from the anterior half of the middle tur- 
binated bone. In view of the repeated recurrence, I determined to remove a portion 
of bone. This was easily done. (The appearance of the growth with a portion of bone 
after its removal is shown in the annexed cut.) The patient came to me (1880) on 
Fig. 82. 
Fig. . 83. 
Fig. 82.—Polypus with portion of bone removed with nasal bone-forceps. 
Fig. 83.—Polypus with osseous lamina removed with the nasal bone-forceps. 
account of follicular disease of the throat, when I learned that there had been no re- 
currence of the nasal polypus, nor any unpleasant effects from the removal of the bone. 
Case 2.—Mrs. L., aged fifty-nine, consulted me in July, 1878, on account of polypus 
in the right side of nose. Since 1871 she had been treated by seven different practi- 
tioners. Of these, five had used forceps, one a snare, and one electric cautery. The 
latter treatment had been carried out in 1876 and the beginning of 1877, and the poly- 
pus had been burnt sixty-four times. Mrs. L. said that this treatment was not pain- 
ful, but it caused “a peculiar sensation which went to her brain.” I removed a bit of 
the middle portion of the turbinated bone with a small polypus attached (Fig. 83). I 
saw this patient again in June, 1881. The nose had remained free from any recur- 
rence of the disease, and no inconvenience of any kind had been experienced since the 
operation. 
Electric Cautery.—This method was first introduced by Middel- 
dorpf,* and subsequently improved by Voltolinqf Thudichum,| and 
Michel,§ by all of whom it is strongly recommended. I consider it 
by far the best method of treatment which exists.|| Patients who have 
* Die Galvanokanstik, Breslau, 1854. 
f Die Galvanokanstik, Breslau, 1867. 
J Polypus in the Nose, 1st ed., London, 1869. See also 3d ed., 1877. 
§ Krankheiten der Nasenhohle, Berlin, 1876, p. 56 et seq. 
|| Those who are not in the habit of working with electro-cautery will, of course, 
find it a troublesome method, and it can really be only carried out successfully by 
those who constantly employ it. NON-MALIGNANT TUMORS OF THE NOSE, 
375 
had the opportunity of comparing this method with evulsion invariably 
prefer electro-cautery. It is much less painful, and the pain ceases the 
moment the current is turned off; it has also the great advantage of not 
causing any haemorrhage. The only drawback to the method is that it 
is tedious, and requires many sittings. I employ a flat spatula-like 
electrode, and endeavor to push it backwards over the surface of the 
mucous membrane, from which the polypus grows. The cure can be 
most quickly accomplished by using the cautery and the punch-forceps 
on alternate days, the latter being only employed for taking away the 
dead tissue. Some practitioners prefer using the electro-cautery in form 
of a loop, but the trouble of applying the snare, in my opinion, com- 
plicates the operation. Sneezing is often caused by the cautery, but in 
my experience never comes on till after the withdrawal of the electrode. 
Fibrous Polypi of the Nose. 
Though fibrous polypus of the naso-pharynx is not unfrequently met 
with, this form of tumor extremely seldom originates in the nose itself, 
the only case, as far as 1 am aware, in which such a growth has been 
actually proved to exist being one of my own, hereafter related. There 
are, however, two other instances in which there is every reason to 
believe that the tumors were fibromata. One of these was reported by 
Gerdy* as having occurred in a boy aged thirteen. The left nostril 
had been occupied by a growth for eighteen months, and endeavors had 
been made to remove it with the ligature and by evulsion, but the 
tumor was so hard that the blades of the forceps were turned. The 
patient finally died of haemorrhage, brought on by an attempt to cut 
through the base of the polypus with a bistoury. After death the 
growth was found to be attached to the posterior part of the vault of 
the left nasal fossa; its substance was very firm and elastic, and could 
not be torn with the fingers, and on section it was seen to be of purely 
fibrous structure. In the other case, which is related by Lichtenberg,f 
the polypus was found to spring from the upper turbinated body; 
there were also some polypoid excrescences, apparently independent of 
the larger growth, attached to the under surface of the cribriform plate 
of the ethmoid. The microscope does not appear to have been used in 
either Gerdy’s or Lichtenberg’s cases. 
The treatment consists in removal of the tumor, if possible per was 
* Des Polypes et de leur Traitement, Paris, 1833, p. 19. 
f Lancet, 1872, vol. ii., p. 773 et seq. 376 
DISEASES OF THE THROAT AND NOSE. 
naturales. According to its situation, it should be attacked, either 
anteriorly or posteriorly, by evulsion, abscission, or electric cautery. 
Lich ten berg, however, in order to obtain access to the growth on which 
he operated, was obliged to perform temporary resection of the bridge 
of the nose. The following are the details of my own case : 
Mrs. M., aged thirty-five, consulted me, by the advice of Mr. Crowdy, of St. John’s, 
Newfoundland, on the 12th of February, 1877. She had suffered for two years from 
obstruction of the right side of the nose. On making an examination the pharynx was 
found to be very granular, and there was general inflammation of its posterior wall. 
The anterior nares were healthy. Owing to the extreme nervousness of the patient, 
it was impossible to make a satisfactory post-rhinoscopic examination, and it was not 
until she had been under my care some weeks that I succeeded in obtaining a view. 
I then discovered a large red, smooth, irregularly oval growth, blocking up and pro- 
jecting beyond the right choana (Fig. 84). On examination with the sound, the polv- 
Fig. 84. 
Fibrous Polypus of the Nose. 
View of the growth as seen by posterior rhinoscopy. 
pus was found to be hard, but slightly elastic, and from its mobility appeared to be 
pedunculated. On the first attempt I succeeded in seizing it and tearing it away with 
short, curved, blunt forceps. After removal the stump could be felt on the roof of the 
nasal fossa, well within the cavity; the growth was the size of a pigeon’s egg, and on 
section was hard, dense, and pale. Microscopically it was seen to be composed of 
closely interlaced whitish fibres, with a few minute cells lying among them. 
Papillomata of the Nose. 
Small warty growths are sometimes found in the nose, and according 
to Hopmann,* they are much more common than is generally supposed. 
In a series of one hundred cases of growths in the nasal cavities this 
observer met with no fewer than fourteen examples of papilloma.f 
* Virchow?s Arcliiv., Bd. xciii., 1883. 
f From a more recent paper by Hopmann med. Presse, 1883) it appears 
that Schaffer, of Bremen, has found twenty cases of papilloma among one hundred and 
eighty-two nasal polypi. NON-MALIGNANT TUMORS OF THE XOSE. 
377 
These were of two pathological varieties, viz., epithelial papilloma, or 
benign cauliflower excrescence, and soft papilloma; the latter being 
subdivided, according to the predominance of gland-structure, vessels, 
areolar tissue, or proliferating cells, into adenoma, angioma, fibro- 
sarcoma, and fibro-sarcoma papillare. The growths generally varied 
in size, roughly speaking, from a pea to a hazel-nut, but Hopmann 
removed* one which measured four centimetres in length and from one 
to one and a half in breadth and thickness. In several instances the 
tumors were multiple, as many as ten or twelve being present in one 
case. They were invariably attached to the lower turbinated body, 
generally springing from its convex surface, or its lower border, but 
sometimes from its concave portion. The symptoms caused by the 
presence of these tumors were frequent cough and expectoration, dry 
catarrh, and in some cases retching of such severity as to excite sus- 
picion of gastric disease. There were also the usual signs of obstruc- 
tion of the nasal passage, and in two cases there was some bleeding. 
Had it not been that Hopmann shows himselff to be perfectly 
familiar with the appearance and symptoms of general thickening of 
the inferior turbinated body, a comparatively common complaint, which 
has already been described (p. 316 et seq.\ it might have been supposed 
that he had mistaken this condition for true papillary neoplasia. It 
would seem, however, to result from this observer’s investigations, that 
many growths which closely resemble mucous polypi, are really of 
papillary structure; this, at least, is the only way in which the wide 
discrepancy between his observations and those of other pathologists 
can be explained. For my own part I must confess, that, although I 
remove polypi from the nose almost daily, I now hardly ever make any 
microscopical examination of the growths, and this may account for the 
fact that I have met with only five undoubted examples of intra-nasal 
papilloma. In all of them the tumor was situated on the mucous mem- 
brane over the lower and anterior part of the septum, or on the inner 
plate of the alar cartilage where it joins its fellow in the middle line 
close to the tip of the nose. In no instance was the excrescence larger 
than a split pea, and in four of the cases there were at the same time 
mucous polypi in the nasal fossa. The specimen in the Museum of the 
Royal College of Surgeons, described in the catalogue (No. 2201 C) as 
a polypus, has more the appearance (see Fig. 77, p. 319) of a papilloma. 
ZuckerkandlJ met with only one example of true papilloma, and this 
was situated on the middle of the lower turbinated body; but three 
* Loc. cit., p. 225. 
f L.oc. cit., p. 247. . 
£ Op. cit., p. 70.. 378 
DISEASES OF THE THROAT AND NOSE. 
other cases which he describes as “ polypoid excrescences/’ bear a close 
similarity both to the specimen in the Hunterian Museum just referred 
to, and likewise to some of Hopmann’s cases. 
The application of strong nitric acid or electric cautery rapidly de- 
stroys these growths, but they can also be removed with the cutting- 
forceps or snare, and Fere* has reported a case in which he effected a 
cure with a ligature. 
Erectile Tumor of the Pituitary Membrane. 
An extraordinary case of this kind (probably analogous in its patho- 
logical characters to the vascular variety of soft papilloma described by 
Hopmann) was reported by Verneuil,f in 1875. The patient, a Rou- 
manian, aged fifty-two, had been subject to frequent and abundant 
bleeding from the nose since boyhood. During the ten years previous 
to his coming under notice, the haemorrhage had become so formidable 
as to have reduced the patient to an extremely anaemic condition. 
Various internal remedies were tried, without avail, and the inside of 
the nose was cauterized, with the view of healing a supposed ulcer 
within the cavity. When the eschar came away, however, the bleeding 
broke ont again as severely as before. At this time he consulted Ver- 
neuil, who, after a careful examination, found, on the left side of the 
septum, a round, dark-red, sessile swelling of the size of a cherry-stone, 
pulsating synchronously with the heart. Several other small erectile 
patches were found in various parts of the patient’s body—the right 
temple, the soft palate, etc. No haemorrhage, however, had ever been 
known to occur from any of those spots. At a second examination, 
made in the presence of M. Gosselin, Verneuil failed to discover the 
tumor in the left nasal fossa, but found a swelling exactly similar in 
character on the right side. Radical measures having been decided on, 
Verneuil laid open both sides of the nose, and destroyed the greater 
part of the septum with the actual cautery. The parts were then 
douched with cold water for some time, and the wound was closed on 
the left side, the right being allowed to remain open, and plugged with 
lint steeped in perchloride of iron. Wet compresses were kept con- 
stantly applied to the brow and nose. In spite of this there was pretty 
sharp bleeding on several occasions, and Verneuil was obliged once 
more to apply the actual cautery to the interior of the right nasal fossa. 
* Bull, de la Soc. Anat., 1880, 4e sdrie, t. v., p. 587. 
f Amiales des Maladies de TOreille, etc., t. i., p. 169 etseq. NON-MALIGNANT TUMORS OF THE NOSE, 
379 
There was no further hemorrhage, and in a short time the patient was 
able to return to Roumania. Two years after the operation the patient 
continued well, but four years later he appears to have died in a state 
of extreme cachexia; Verneuil states, however, that he was unable to 
obtain any details on this point. 
Enchondromata of the Nose, 
Cartilaginous tumors of the nose are very rare. Examples have, 
however, been reported by Erichsen,* Bryantf (two cases), Ure,J Dur- 
ham,§ Picket,|| Heurtaux,T[ and Verneuil,** and I have myself met 
with one example of the affection. The disease belongs essentially to 
the period of life when the growth of the body is most active, all the 
patients whose cases have been quoted above having been under the age 
of eighteen.lt As regards sex, the disease shows a slight preference for 
the male sex. 
The most marked symptoms are obstruction of the nasal passages, and 
deformity in advanced cases amounting to “frog-face” (see “Fibrous 
Polypi of the Naso-Pharynx”). The ordinary phenomena of catarrh, 
such as abundant discharge and sneezing, have sometimes been observed. 
In the patient I treated the discharge was of such an offensive character, 
that the disease had been mistaken for ozsena. The growth may vary 
in size from a hazel-nut to a man’s fist, or may be even larger. The 
tumor, when small, closely resembles a fibrous polypus, but it is never 
distinctly pedunculated, and usually springs from the cartilaginous part 
of the septum, although in rare cases it may originate from the outer 
wall or roof of the nose. 
The prognosis is favorable if the disease is detected at an early period, 
as the growth shows no disposition to return when once removed, but 
if it has attained large dimensions before treatment is commenced, it may 
happen that a cure cannot be effected without making an external in- 
cision, and thus causing a more or less unsightly scar. 
The diagnosis is difficult when the growth has attained a large size, 
as it may be mistaken for fibrous polypus, a malignant neoplasm, an 
* Lancet, 1864, vol. ii., p. 152. f Ibid., 1867, vol. ii., p. 225. 
J Holmes’s System of Surgery, London, 1870, 2d ed., yol. iv., p. 319. 
I Ibid. 
|| Casabianca: Des Affections de la Cloison, Paris, 1876, p. 59. 
Bull, de la Soc. de Chir., Nov. 7, 1877. 
** Quoted by Spillmann : Diet. Encyclop. des Sciences Med., t. xiii., p. 184. 
ff In Heurtaux’s case the age is stated as twenty-two, but the disease had been in 
existence for five years. 380 
DISEASES OF THE THROAT AND NOSE. 
exostosis, or an osteoma. The extreme rarity with which fibroma com- 
mences in the nose almost permits its exclusion from consideration. 
Malignant tumors have not the dense consistence of enchondromata, 
bleed more readily and grow more rapidly, whilst bony formations are 
very hard, and cannot be penetrated by a needle, like cartilage. 
Surgical treatment is alone of any service, and the snare is the best 
instrument that can be used, its employment with electric cautery being 
especially indicated. In my own case, however, which is detailed below, 
I had no difficulty in cutting through the mass with the cold wire. 
CASE OF ENCIIONDROMA REMOVED WITH THE SNARE. 
Miss E., aged thirteen, was brought to me, in September, 1874, on account of an 
offensive discharge from the nose, from which she had suffered for two years. She had 
been treated for “polypus” and “ozsena” by different surgeons, but without deriving 
any permanent benefit. There was a marked prominence of the right side of the nose, 
mid-way between the inner canthus of the eye and the upper border of the alar car- 
tilage. On examining the nose with a speculum, a round, nodulated tumor was seen 
in the right nasal fossa. The growth, which was firmly attached, was of a purple-red 
color and slightly ulcerated at its outer part. It so completely occupied the fossa, that 
it was only after repeated examinations that its origin from the upper and back part 
of the cartilaginous septum could be made out. 
A needle passed into the tumor without much difficulty, and caused but little haemor- 
rhage, and it was thought that the growth was a fibroma. 
Several attempts at removal with the forceps proved unavailing; but I ultimately 
succeeded in passing a wire round the tumor and cutting it through. Even after the 
growth was separated, however, it was impossible, owing to its size, to draw it through 
the nostriland it was only by dividing it into two portions with the snare, that it 
could be got out. After its removal, its base was seen to be about half an inch in 
diameter. On microscopical examination of the tumor, its central portion was seen to 
consist almost entirely of hyaline cartilage, but towards its circumference there were 
numerous bundles of white fibres, and a small amount of yellow elastic tissue. It looked 
as if it had originally been covered with a fibrous envelope, which had been subse- 
quently destroyed in places by erosion. The patient made a rapid recovery ; but slight 
thickening of the septum remained, and indeed had not entirely disappeared nine 
months after the operation. 
Osteomata of the Nose, 
Latin Eq.—Tumores ossei nasi. 
French Eq.—Tumeurs osseuses du nez. 
German Eq.—Knochengeschwiilste der Nase. 
Italian Eq.—Tumori ossei del naso. 
Definition.—Bony tumors, generally of exceedingly dense hut occa- 
sionally cancellous structure, varying in size from a bean to a hen’s egg, and 
sometimes even larger, having no connection with the osseous framework NON-MALIGNANT TUMORS OF THE NOSE. 
381 
of the nose, causing obstruction to the nasal passages, and if allowed to 
attain a great size eroding and frequently perforating the parietes of the 
nasal cavities. 
History.—The mention of “ osseous ” tumors of the nose is not uncommon in the 
older writers, but the actual literature of the subject is altogether modern, and, as 
might be presumed from the rarity of the affection, is also very scanty. Some doubt- 
ful cases were collected by Bordenave* in the latter half of last century, and a few 
scattered examples may be found in the medical journals of the earlier part of the 
present century. Follin.f however, appears to have been one of the first to call at- 
tention to such growths as a substantive disease, quite distinct from exostosis. Cases 
have since been reported by Hinton,J Pamard,§ and Legouest,|| and the complaint 
has been made the subject of special research by Gaubert,** and Bendu.ff 
A good chapter on nasal osteomata may be found in Follin and Duplay’sj;j; large work, 
and quite recently Spillmannf § has discussed these singular growths with great care. 
Etiology.—The causes of osteomata are quite unknown. The only 
point about which there is any certainty is that the affection belongs 
to the period of adolescence. Most of the patients who have suffered 
have been about twenty years of age, though sometimes the disease has 
escaped observation till a later period. As far as can be ascertained 
both sexes are equally liable to the complaint. 
Symptoms.—The most characteristic symptom in the early stage of 
the disease is an itching sensation in and about the affected part, which 
is sometimes so intolerable that the patient is compelled to relieve him- 
self by constantly scratching the inside of his nose. As soon as the 
tumor attains any considerable volume it gives rise to the usual symp- 
toms of obstruction. There is often impairment of the sense of smell, 
and epistaxis generally becomes frequent and severe as the growth de- 
velops. The patient usually complains of severe neuralgic pain, caused, 
no doubt, by the pressure of the bony mass on neighboring nerve-fila- 
ments. The growth, as a rule, is covered with mucous membrane of a 
* Memories de l’Acaddmie Royale de Mbdecine, Paris, 1774. 
f Des Tumeurs osseuses sans connection avec les os.—Bull, de la Soc. de Biologie, 
Paris, 1850-51. 
X Guy’s Hosp. Reports, series i., vol. i., p. 495. 
§ Exostose 6burn6e de la Fosse nasale droite.—Bull, de la Soc. de Chir., 1866. 
|| Exostose .... occupant la Fosse nasale gauche.—Mem. de l’Acad. de Med., 
1865-66. 
Sur les Tumeurs osseuses des Fosses nasales, These de Paris, 1869. 
** Des Ostfeomes de l’Orange de l’Olfaction, These de Paris, 1869. 
ff Des Ostbomes des Fosses nasales. Arch. G6n. de Med., Aout, 1870. 
Xt Traits E16m. de Pathologie externe, Paris, 1877, tom. iii., p. 839 et seq. 
\\ Diet. Encyclop. des Sciences Med., 2e serie, t. xiii., p. 169 et seq. 382 
DISEASES OF TIIE THROAT AND NOSE. 
bright pink color, but its surface is occasionally dark red or even 
purple in hue. At times the membrane is discolored or even ulcerated, 
and, in some instances, necrosed bone becomes visible. Owing to the 
ulceration or necrosis, or to the mere retention of the secretions which 
the tumor causes, there is usually a fetid discharge. As the growth 
enlarges it may press on the septum, twist the nose to one side, and 
entirely obliterate the genio-nasal furrow ; or, extending toward the 
antrum or the orbit, it will produce corresponding deformities, such as 
unnatural fulness of the cheek, or displacement of the eyeball. The 
pain in most cases becomes extremely severe, but occasionally the pres- 
sure produces anaesthesia of the adjoining parts. 
Diagnosis.—A nasal calculus or an exostosis may simulate an osteoma 
in the earliest stage of the affection. It should therefore be remembered 
that osteomata, unlike bony out-growths, can, at the outset, be moved 
when pressed on with a strong probe, and that their surface cannot 
generally be broken with a sharp needle, as is the case with a calculus. 
When, however, an osteoma is incrusted with calcareous deposit, as in 
the case of Legouest,* the diagnosis is rendered extremely difficult. 
Enlargement of the turbinated bodies might by an inexperienced ob- 
server be mistaken for an osteoma, but whilst the latter is almost always 
unilateral, thickening of the turbinated bodies almost invariably affects 
both sides. Moreover, the tissues over the spongy bones are soft, and 
quite unlike the structure of osteomata. As the disease develops, the 
severe pain caused by the pressure of the hard mass at once differenti- 
ates osteomata from any other kind of nasal tumor except cancer, from 
which, again, they may be distinguished by their much slower rate of 
growth. Fibrous tumors of the nose are so rare that they need scarcely 
be taken into consideration, but an offshoot from a naso-pharyngeal 
polypus into one of the nasal fossae might possibly be mistaken for an 
osteoma unless the naso-pharynx were explored. A digital examination 
of the posterior nares will, however, soon settle the question. Occasion- 
ally a mucous polypus may co-exist with an osteoma, and this may 
further complicate the diagnosis.f 
Pathology.—The tumors are of two kinds—the ivory and the can- 
cellous. The former are much the more common, and they are so ex- 
tremely firm in structure that the strongest forceps are sometimes turned 
by them. They are covered with periosteum, and well supplied with 
vessels, which pass into the substance of the tumor. They are gener- 
ally connected with the soft tissues of the nose by a narrow pedicle. 
* Loc. cit. 
t Legouest: loc. cit. NON-MALIGNANT TUMORS OF THE SOSF. 
383 
Although they appear to originate from the mucous membrane, it is 
more probable that they really grow from the periosteum, or that they 
commence as exostoses, their bony connection with the skeleton being 
destroyed at so early a period, that it has never been observed. It is 
possible, also, that in some cases they may be originally of cartilagi- 
nous structure, and subsequently undergo ossification. On section these 
growths are seen to consist of a number of layers of bone which cor- 
respond with the depressions and elevations on their surface. The can- 
cellous osteomata, as a rule, present the usual structure of cancellous 
bones—that is to say, they consist of an external envelope of compact 
tissue, with spongy tissue internally, between the trabeculae of which 
is contained the ordinary reddish marrow; towards the centre of the 
bone there is often a distinct cavity.* 
Prognosis.—The prospects of the patient are very favorable if the 
tumor can be removed per vias naturales ; but, if not, the observation 
made under the head of “ Prognosis ” in the last article, also applies 
here. 
Treatment.—The only treatment is extirpation. The cancellous os- 
teomata can be easily crushed with strong forceps and removed in frag- 
ments, whilst in the case of the ivory-like growths, it is generally neces- 
sary to lav open the nose. Rouge’s operation (see “ Fibrous Polypi of 
the Naso-pharynx ”) should be performed in the first instance, but if 
sufficient room cannot be obtained in this way, one of the other methods 
described in the same article should be adopted. 
Exostoses of the NosE.f 
Exostoses are not very uncommon, though they seldom attain a large 
size, and hence do not give rise to much inconvenience. My clinical 
experience had led me to believe that they most commonly spring from 
the floor of the nose, a short way from the orifice. This, however, is 
not confirmed by observations made on preserved crania, for among 
2152 skulls in the Museum of the College of Surgeons, I found 170 
examples of bony outgrowth originating from the septum, 91 being in 
the left, and 79 in the right nasal fossa. In three of these cases there 
were two distinct exostoses, both, however, being in each instance in 
the same nasal fossa. The size varied from a split pea to half a hari- 
cot bean, and they sprang, as a rule, by a broad base from the septum, 
* Richet: Bull, de l’Acad. de M6d., 1871. 
f A few forms of exostoses of rare kinds will be referred to under the head of 
“ Synechise.” 384 
DISEASES OF THE THROAT AND NOSE. 
extending horizontally towards the outer wall and terminating in a 
more or less pointed crest. The situation of the tumor was generally 
opposite the middle turbinated bone, or just midway between that and 
the lower bone, so that the peak seemed in some cases actually to run 
into the orifice by which the antrum communicates with the middle 
meatus; in a minority of instances the exostosis was opposite the lower 
turbinated bone. In many cases these prominences formed, as it were, 
the posterior spur of a bony ridge running along the septum, at the 
junction of the ethmoid and the vomer, or of the latter and the crest of 
the upper maxilla. Ridges of this kind existed in 673 skulls (31.2 
percent, of the total number examined). In 375 instances the projec- 
tion was on the left side ; in 231 on the right; whilst in 67 cases there 
were ridges on both sides. The size varied from a slightly raised 
line to a rough jagged ledge encroaching considerably on the cavity of 
the corresponding nasal fossa. It is probable that in most cases a con- 
siderable portion of the ridge would be visible from the front (see Fig. 
86, c). According to Thudichum,* exostoses sometimes grow from 
the turbinated bones, but this must be extremely rare, since in the large 
number of skulls above mentioned I only met with one example. In 
that case the growth sprang from the middle turbinated bone and ran 
horizontally across the nasal fossa almost to the septum. 
Exostoses present an irregular surface, and occasionally cause slight 
deviation of the septum. It will be found impossible to penetrate them 
with a sharp needle, a peculiarity which serves to differentiate them 
from the softer tumors. I have never met with any instance in which 
the outgrowth caused serious inconvenience, but no doubt cases occur 
in which, by blocking up the antrum, it may give rise to disease with- 
in that cavity, and there may be others in which smaller exostoses cause 
considerable irritation by their presence. If it is thought advisable to 
interfere with them, bony outgrowths would probably be best treated 
by means of the dentist’s drill, as recommended by Goodwillie,f of 
New York. Thudichum states that they can be removed by means of 
the electric cautery wire, but I quite agree with Spencer Watson,| who 
points out the disadvantages of this mode of treatment in these cases, 
and remarks that “ a pair of scissors would answer equally well, or 
even better.” The projecting piece of bone, when small, can also be 
easily broken off with the common polypus-forceps; when it is large 
* Lancet, Sept., 1868. 
t New York Med. Record, Nov. 12, 1881. 
$ Diseases of the Nose, London, 1875, p. 290. MALIGNANT TUMORS OF THE NOSE. 
385 
and is attached to the septum by a broad base, my nasal bone-forceps 
(Fig. 55, p. 270) will be found most serviceable. 
MALIGNANT TUMORS OF THE NOSE. 
Latin Eq.—Tu mores maligni nasi. 
French Eq.—Tumeurs malignes du nez. 
German Eq.—Bosartige Geschwtilste der Nase- 
Italian Eq.—Turaori maligni del naso. 
Definition.—Malignant neoplasms, mostly of sarcomatous, more 
rarely of carcinomatous nature, originating as a rule from the septum, 
but occasionally from the outer wall or the floor of the nasal fossae, giving 
rise to obstruction of the nostril, mucopurulent discharge often offensive 
in character, and epistaxis, tending as they increase in volume to encroach 
upon the adjoining parts, leading in some cases to secondary deposits in 
other organs, and finally to cachexia and death. 
History.—All the old writers who treat of nasal polypi state that these growths are 
sometimes of malignant nature. Among the five varieties of polypi described by 
Hippocrates* there is one which, he calls a “kind of cancer.” He mentions that 
this form of tumor is found “ on the side of the cartilage near its extremity,” and the 
treatment indicated is destruction with the hot iron, and subsequent dressing writh 
powdered hellebore and “flower of copper” boiled in honey. Celsnsf was strongly op- 
posed to any interference with a class of nasal polypi which he described as of ma- 
lignant nature, and only likely to be made worse by treatment. AbulcasisJ described 
cancerous polypus under the name of “ scorpion,” and other mediaeval writers, such as 
William of Salicet,£ Rogerius,|| and Bruno Longoburgensis,expressly distinguished 
between simple nasal polypi and those of malignant nature. Ambroise Pare** repro- 
duced Hippocrates’ five classes of nasal polypi, and his description of their various 
' * De morbis, lib. ii., Littre’s edition, Paris, 1851, vol. vii., p. 53. 
f De medicina, lib. vi., cap. viii.. 
J La Chirurgie d’Abulcasis, lib. ii., c. xxiv., Trad, du Dr. Lucien Leclerc, Paris, 
1861, p. 93. 
$ Chirurgia Guilielmi de Saliceto, lib. i., cxvii., Yenetiis, 1546. 
|| Rogerii medici celeberrimi, Chirurgia, cxxxiii., De cancro qui fit in naribus. 
1[ Bruni Longoburgensis Chirurgia magna, .lib. ii., c. ii., De polypo, Venetiis* 1546. 
** (Euvres Completes, livr. 6, ch. ii., vol. i., p. 378 of Malgaigne’s edition,. Paris, 
1840. The distinguished editor appears to have been under the impression that this 
classification of Park’s was original (see note, ibid., p. 379).. 386 
DISEASES OF THE THROAT AND NOSE. 
characters, including, of course, the malignant kind. Glandorp* merely echoed the 
general opinion of antiquity in deprecating any interference with cancer of the nose 
except by way of palliation. Pottf was emphatic in condemning any attempt at 
operation in the case of malignant nasal polypi, saying that he had seen an “ untoward- 
looking polypus so attached to a distempered septum ” that they were both pulled 
away together by the surgeon’s forceps. Cases of undoubted cancerous growths in the 
nose were reported by PallettaJ and Gerdy.§ Syme|| strongly disapproved of any in- 
terference with malignant nasal growths, except when the substance is so soft that it 
can be scooped out with the finger. In recent times cases of sarcoma of the nasal 
fossae have been published by FayrerA Viennois, ** Mason,ff Grynfeldt,JJ Duplay,§§ 
and IIopmann,|||| whilst examples of epitheliomatous disease of the same cavities have 
been met wdth by and Pfean***. Duplayfft mentions a case of encepha- 
loid cancer of the septum, which was mistaken for an abscess; and a case of medullary 
carcinoma of the nasal passages was reported by Neumann.JJJ 
Etiology.—Malignant disease of the nasal fossae is not of frequent oc- 
currence, carcinoma in particular being extremely rare in this situation. 
Its causation is as obscure as that of cancer or sarcoma in other parts of 
the body. Although in most of the cases on record the patients have 
been women, the number is too small to form a trustworthy index 
as to the relative liability of the sexes. It is possible that syphilitic 
ulceration may sometimes lead to the development of malignant 
disease, but this has received little confirmation from clinical facts. 
The only reported instance, so far as I am aware, in which such a 
delation appears probable, is that of Neumann. This was a case 
of medullary carcinoma, occurring in a woman, whose age is not stated ; 
there had been complete occlusion of the nostrils for eleven years, and 
there were also signs of former syphilitic ulceration of the throat. There 
was hypertrophy of the mucous membrane covering the turbinated 
* Tractatus de polypo, narium affectu gravissimo, observationibus illustratus, 
Bremae, 1625, cap. xvii., p. 47 et seq. 
f Some Remarks on the Polypus of the Nose in Chirurgical Observations, Lon- 
don, 1775, p. 59. 
| Exercitat. pathol., Mediolani, 1820, p. 1 et seq. 
$ Traits des Polypes, Paris, 1833. || Principles of Surgery, p. 493. 
Medical Times, July 4th, 1868. ** Lyon Melical, 1872, No. 18. 
ft Medical Times, May 22d, 1875. 
Montpellier Medical, Oct. and Dec., 1876. 
§3 Traitfe E16m. dePathologie externe, Paris, 1877, t. iii., p. 846. 
1111 Virchow’s Archiv., Bd. xciii., 1883. 
Iff Bonheben : De 1’Extirpation de la Glande et des Ganglions sous-maxillaires, 
Thtise de Paris, 1873. 
*** Quoted by Casabianca, Des Affections de la Cloison des Fosses nasales, Paris, 
1876, p. 67 et seq. 
tff Op. cit., t. iii., p. 788. 
CEsterr. Zeitschr. f. prakt. Heilk., 1858, iv., 17. MALIGNANT TUMORS OF THE NOSE. 
387 
bones, and on removal one portion of the redundant tissue was proved 
to be malignant. In this case I think it is clear that the disease had 
only recently assumed a malignant character. 
Symptoms.—There is at first nothing more than the symptoms com- 
mon to all growths in the nasal fossse, viz., obstruction to the free pas- 
sage of air through the channel, with the usual alteration of the voice, 
and impairment of the sense of smell. There is also some discharge 
from the nostril, which is often of a greenish tint, and extremely fetid. 
Frequent and severe epistaxis takes place in most cases, and great pain 
is often complained of in the infra-orbital region. As the tumor in- 
creases in size the bones forming the bridge of the nose may be pushed 
forward or separated from each other, and protrusion of the eyeball may 
be caused by pressure on the inner wall of the orbit, or the base of the 
skull may be eroded and even perforated by the upward growth of the 
tumor. In one of Gerdy’s cases nothing remained of the ethmoid bone 
but the crista galli, whilst in another, related by Paletta,* the cribri- 
form plate of the same bone was destroyed, and the diseased mass ex- 
tended into the brain. It is obvious that, under such circumstances, 
cerebral symptoms are likely to occur, whilst, if the growth extends 
backwards through the posterior nares, deafness, dysphagia, and diffi- 
culty of breathing may be caused. 
Although malignant tumors most frequently originate from the sep- 
tum, they may spring from any part of the interior of the nose, and 
Viennois states that he has twice seen melanotic sarcoma develop from 
the ala. In one of the cases reported by Gerdy, several polypi of ma- 
lignant nature were found, on dissection, growing from the pituitary 
membrane covering the spongy bones, whilst in another a large malig- 
nant mass was seen to spring from the mucous lining of one of the 
sphenoidal cells. 
The tumors vary in size from a pea to an orange, though, of course, 
they may attain to much greater dimensions, if not interfered with. 
Sarcomata, unlike simple polypi, are generally single and sessile; they 
are soft, smooth, and usually pinkish in hue, though sometimes dark 
brown, or even black. They are highly vascular, and bleed easily 
when touched. Cancerous formations mostly begin as small warts or 
pimples, which are reddish in color, and usually very soft and friable. 
In Pean’s case, the growth, although proved to be distinctly epitheliom- 
atous in character, had a kind of pedicle, but this is quite exceptional. 
As a rule, such tumors show a marked tendency to ulcerate, the ulcer 
* Op. cit., pp. 7, 8. 388 
DISEASES OF THE THROAT AND NOSE. 
presenting the well-known raised, hard,ragged edges and sanious base; 
after a time, there is enlargement of the neighboring lymphatic glands, 
especially of those lying below the ramus of the lower jaw. Sarcomata 
are characterized by extreme rapidity of growth, and both forms of 
disease show a marked tendency to recur after removal. 
Diagnosis.—The recognition of malignant tumors of the nasal fossae 
is not always easy in the early stage of their development. There is 
little likelihood, however, even at the outset, of their being confounded 
with mucous polypi, as the latter are nearly always attached by a ped- 
icle to the outer wall of the nasal cavity, whilst malignant tumors, in 
the great majority of cases, grow from the septum by a broad base. 
When the disease is advanced, it bears no resemblance to the benign 
growth. Though originating from the septum, the density of the 
swellings, the absence of fluctuation, and the frequent ulceration of their 
surface, will serve to distinguish them from septal abscess. Cartilag- 
inous or osseous tumors may be mistaken for malignant growths, but in 
most cases the extreme hardness, together with their slow increase in 
size, and the permanently local nature of the affection, should guide 
the surgeon to a right conclusion. 
Rhinoliths and impacted foreign bodies should not be forgotten in 
examining tumors of the nose, but the former are often movable, whilst 
their calcareous surface can generally be recognized on scraping, and 
they can often be made to sound when struck with the probe; in the 
case of foreign bodies* on the other hand, the symptoms are not pro- 
gressive, and the patients are mostly children. Great rapidity of growth, 
particularly after partial removal, is a well marked, if not quite dis- 
tinctive, feature of sarcomatous tumors, whilst epithelioma not unfre- 
quently gives rise to general constitutional infection and cachexy. In 
all cases, however, which present the least doubt, the nature of the 
growth should be established by microscopic examination of a small 
portion of its substance- 
Prognosis.—In carcinoma of the nasal fossae, the chance of the pa- 
tient’s ultimate recovery is as hopeless as in cancer of any other part of 
the body; but, in the case of sarcoma, there appears to be some ground 
for belief that, if the disease be treated early and thoroughly, the prog- 
nosis is not absolutely bad. Whilst these sheets are passing through 
the press, as an illustration of this, I may mention that I have had an 
opportunity of seeing a patient from whom Mr. Francis Mason removed 
a mass of myeloid sarcoma attached to the septum. The ala was raised 
by means of an incision carried downwards along the side of the nose, SYPHILITIC AFFECTIONS OF THE NOSE. 
389 
and the tumor completely taken away, the raw surface being then sat- 
urated with a solution of chloride of zinc (gr. xl. ad 5j.). Although 
the man is sixty-seven years of age, and has never been very healthy, 
there is no appearance of recurrence of disease in the nose, though the 
operation was done more than seven years ago. 
Pathology.—Concerning the pathology of these tumors, little need be 
said in this place. Both sarcomatous and cancerous polypi offer the 
characters common to such neoplasms in other regions of the body. 
Treatment.—The only proper method of treating malignant disease 
of the nasal fossae consists in the thorough removal of the growth where 
practicable. The plan of procedure to be pursued, however, should be 
carefully considered, as the difficulties of exposing a tumor in these in- 
tricate chambers sufficiently to allow of its complete extirpation are 
very great, and partial removal only aggravates the mischief. A “ pre- 
liminary operation” (see uFibrous Polypi of the Naso-Pharynx ”) is 
always necessary. 
Often the disease has reached such a stage before the patient comes 
under treatment, that only palliative measures are applicable. Local as- 
tringents are sometimes of use in this way by causing temporary shrink- 
ing of the mass, and I have occasionally found electric-cautery service- 
able in restraining haemorrhage. This was notably the case in a patient 
whom I recently treated, with Dr. Slimon, of Bow, where bleeding 
was a very troublesome feature. 
SYPHILITIC AFFECTIONS OF THE NOSE* 
Latin Eq.—Mala venerea nasi. 
French Eq.—Affections syphilitiqnes du nez. 
German Eq.—Nasensyphilis. 
Italian Eq.—Malattie sifilitiche del naso. 
Definition.—The local manifestation in the interior of the nose of 
constitutional syphilis in its so-called primary, secondary, tertiary, and 
congenital forms, giving rise in mild cases to slight obstruction of the 
* Syphilitic lesions of the naso-pharyngeal region will be considered further on in 
the section on Throat-Deafness. This arrangement appears the most convenient, as 
the nasal phenomena in such cases are usually of quite secondary importance as com- 
pared with the aural symptoms caused by the disease attacking the Eustachian tube. 390 
DISEASES OF THE THROAT AND NOSE. 
nasal channels by smiling of the mucous membrane, and in severe cases 
to extensive ulceration and necrosis of the bones, which may end in more 
or less complete destruction of the f ramework of the nose. 
History.—A graphic and fairly accurate description of nasal syphilis is to be found in 
the writings of the Chinese Emperor, Hoang-ty,* which date from more than 2600 years 
before Christ. Severe swelling, coryza, ulceration, ozsena, and partial or complete de- 
struction of the nose are there described as being among the consequences of a viru- 
lent sore on the genitals. This ancient writer also appears to have been acquainted 
with infantile syphilis as it affects the nose. In the writings of Susruta,f together 
with a description of other unmistakable syphilitic lesions, there is an account of cer- 
tain nasal disorders, due to the same constitutional poison. Doubtless, many of the 
severe affections of the nose described under the general names of ozcena by the Greek 
and Roman writers (see Dry Catarrh, pp. 322, 323) were of syphilitic origin, but no 
suspicion of such a relation is shown by these authors. Dion Chrysostome.J however, 
possibly intended to allude to syphilis of the nose in the following passage: “They 
say that Aphrodite, to punish the women of Lesbos, inflicted upon them a disease of 
the armpits ; it is that the Divine anger has destroyed the noses of the greater number 
among you.” After the terrible outburst of the venereal plague that followed the re- 
turn of Columbus and his companions in 1496, specific disease of the nose was dis- 
tinctly recognized by physicians,$ and the disfigurement of the unlucky feature that 
often ensued became a favorite subject of jesting among poets and satirists. Possibly 
this, as well as other serious results of syphilitic inoculation, were more common for- 
merly than at the present day, when the treatment of the disease is better understood. 
In recent years the introduction of the sharp curette by Volkmann|| has made an im- 
portant advance in treatment in the more serious cases. In 1876 a pamphlet was pub- 
lished by Clinton Wagner,'which contains some useful hints as to the treatment of 
nasal syphilis, and in the following year Schuster** wrote a valuable practical paper 
* See Fabry: La Medecine chez les Chinois, Paris, 1863, p. 260 et seq. 
f A’yurvedas, Nidanasthana, cap. ii. Translated by Hessler, Erlangen, 1844-50. 
This Indian treatise on medicine, which probably dates from about B.c. 600, is a com- 
pilation by Susruta from the teaching of his master D’hanvantare. It has been sug- 
gested (Khory, Digest of the Principles and Practice of Medicine, London, 1879, Pre- 
face, p. vi.) that the work is merelya Sanskrit version of some of the Hippocratic writ- 
ings, but there appears to be no real foundation for such a statement, and, indeed, the 
works present no similarity either in matter or form. 
X Orationes ex recens, J. J. Reiskii, Leipsise, 1784, vol. ii., orat. 33. (Quoted by 
Laneereaux, Treatise on Syphilis, Syd. Soc. Transl., 1868, vol. i., p. 15.) 
\ As nearly every author who treats of syphilis mentions the nasal form of the 
affection, it seems unnecessary to give a detailed history of the subject. The reader 
may be referred to the enormous collection of writers on venereal disease contained in 
the Aphrodisiacus, first published by Aloysius Luisini, at Venice, in 1599, republished 
and enlarged up to date by Langerak, at Leyden, in 1728, and continued by Gruner, 
down to 1793. 
|| Uber d. Gebrauch d. scliarfen Loffels, etc., Halle, 1872, and Beitriige z. Chirurgie, 
Leipzig, 1875, p. 267. 
Syphilis of the Nose and Larynx, Columbus, Ohio, 1876. 
** Beitriige z. Pathologie u. Therapie der Nasensyphilis, von Dr. Schuster u. Dr. 
Sanger, Vierteljahrssclir. fur Dermatol, u. Syphilis, 1877,1 u. 2 Heft., and Ibid., 1878. SYPHILITIC AFFECTIONS OF THE NOSE. 
391 
detailing the highly favorable results which he had obtained by Volkmann’s plan of 
treatment, and containing, moreover, a most important contribution to the pathology 
of the affection by Sanger. 
Etiology.—An instance of primary syphilitic chancre of the nostril 
has been related by Spencer Watson.* The patient was a nurse in at- 
tendance on a lady who gave birth to a syphilitic child. The sore 
could not be distinctly seen, but there was a swelling within the nostril, 
accompanied by severe pain, fever and mental depression. The ordi- 
nary secondary symptoms followed in due course. The vehicle of in- 
fection in this case was probably the patient’s own finger. The causes 
which predispose the nose to attacks of the secondary and later forms 
of syphilis are unknown, but it is probable that, in persons suffering 
from venereal disease, chronic catarrh or any other accidental affection 
of the nose tends to localize the poison. The strumous diathesis also 
seems to render its subjects particularly liable to severe forms of nasal 
syphilis. Extreme cachexia often coexists with the more advanced ter- 
tiary lesions of the nose, but it is difficult to say whether this is a cause 
or a consequence of the local mischief. There appears to be much less 
liability to the disease at the present time than formerly. It appears, 
however, that in countries where syphilis has been allowed for centuries 
to rage without the mitigation of rational treatment, the disorder retains 
an extraordinary virulence, and shows a strong tendency not only to 
attack the nose, but to do so at a very early period. The fact of rapid 
development of tertiary symptoms is well illustrated by the case of some 
patients received at the Val de Grace Hospital in Paris on the return 
of the French troops from Mexico.f The disease had been caught 
from native women, and in two cases severe tertiary symptoms showed 
themselves within a year, whilst in a third they occurred in less than 
six months from the date of inoculation. Among the modern Arabs, 
symptoms which in Europe would be called tertiary not unfrequently 
come on almost at once, the face, and especially the nose, being the 
most common point of attack. In Europe, secondary syphilis of the 
nose is generally met with from three to nine months after the primary 
sore, whilst tertiary lesions are very seldom noticed until some years 
after the inoculation of the poison. An exceptional case, however, is 
related by Mauriac,J in which the patient, who had contracted syphilis 
* Med. Times and Gaz., 1881, vol. i., p. 428. 
f Spillmann: Diet. Encyclopki. des Sciences Medicates, t. xiii., lme part, p. 39. 
\ Sypliilose pharyngo-nasale, Union Medicate, 1877, t. i., p. 342. 392 
DISEASES OF THE THROAT AND NOSE. 
in Paris, suffered from necrosis of the nasal bones in the seventh month 
from the appearance of the disease. 
Secondary phenomena are either rare in the nasal fossae, or they are 
frequently overlooked. Davasse and Deville* found mucous patches 
in the nose in eight out of one hundred and eighty-six cases occurring 
in women, the tonsils having been affected nineteen times in the same 
series. Bassereau,f on the other hand, in a hundred and ten male pa- 
tients found mucous patches at the edge of the nostrils only twice, the 
tonsils being affected in no less than one hundred instances. The ex- 
perience of Bassereau accords much more nearly with my own than that 
of the first-named observers. At the Val de Gr&ce in Paris,£ only one 
per cent, of the cases treated during five consecutive years showed sec- 
ondary syphilides of the nose. Tertiary lesions are more common, but 
even these appear to be rare at the present day, for Willigk§ met with 
only 2.3 per cent, in 218 cases. 
Symptoms.—The phenomena of nasal syphilis vary according to the 
stage and severity of the disorder. In the secondary period there is 
generally nothing more than hyperaemia of the mucous membrane, pro- 
ducing symptoms of somewhat intractable catarrh. Sometimes, how- 
ever, mucous patches can be seen at the external angle of the nostrils, 
-or just inside the nasal fossae, either on the septum at its anterior part, 
or on the inferior turbinated body. Similar patches may also be visible, 
with the aid of the rhinoscope, on the margins of the posterior nares. 
These lesions sometimes give rise to intractable coryza, with muco- 
purulent secretion, whilst at the same time roseolar eruptions appear on 
the skin. In tertiary syphilis perforation of the septum not unfre- 
quently takes place, and the carious bone exhales a horribly offensive 
odor, to which the term “ ozsena,” now limited to certain forms of dry 
catarrh (see p. 328), was formerly applied. In such cases the discharge 
from the nose is generally abundant, and is often of a blackish color, 
and the most careful washing away of the discharge by irrigation or 
spraying fails to get rid of the stench. Should the vomer be exten- 
sively involved, the bridge of the nose may fall in, causing a charac- 
teristic flattening, as if the organ had been crushed, whilst if the car- 
tilaginous portion of the septum is destroyed, the tip of the nose sinks 
in and becomes flattened, and hangs loosely from the bony part of the 
* Quoted by Laneereaux: Treatise on Syphilis, Syd. Soc. Transl., London, 1868, vol. 
i., p. 174 et seq. 
f Ibid. p. 175. J Spillmann: op. cit., p. 38. 
\ Prager Vierteljahrsschr., 1856, xxiii., 2, p. 20. SYPHILITIC AFFECTIONS OF THE NOSE, 
393 
nose (Fig. 85). Occasionally the whole substance and framework of 
the feature is disintegrated, and it is represented only by two small 
apertures surrounded by cicatricial tissue. The disease may extend to 
the superior maxilla, may destroy the bony walls of the lachrymal canal, 
or slowly eat away large portions of the ethmoid and sphenoid bones, 
the basiliar process of the occipital bone may entirely perish by slow 
caries, or large pieces of these bones may be thrown off by rapid necrosis. 
The cranial cavity is indeed sometimes laid open, and, if this occurs, it 
is generally soon followed by fatal inflammation of the brain and its 
Fn. 85. 
Flattening of the Nose from Destruction of the Cartilaginous Septum by 
Syphilitic Disease. 
membranes. In a case related by Trousseau,* a large piece of the 
ethmoid, constituting about a quarter of the entire bone, almost suffo- 
cated a patient by falling unexpectedly into his throat. He died on 
the following day with acute cerebral symptoms, due no doubt to the 
disease having spread to the brain or its coverings. Brodief and 
mention instances in which the disorder, having extended through the 
cribriform plate of the ethmoid, gave rise to epileptiform and maniacal 
convulsions which terminated fatally. A case, however, has been recently 
reported by Baratoux§ in which almost the entire body of the sphenoid 
* Clinique Medicale de l’Hotel-Dieu, Paris, 1868, t. i., p. 546. 
f London Med. Gazette, 1844. 
J Clinical Lectures, vol. ii., p. 484. 
\ Archivii Italiani di Laringologia, Anno iii., July 15th, 1883, pp. 19-21. 394 
DISEASES OF THE THItOAT AND NOSE. 
was expelled from the nose without any signs of cerebral mischief hav- 
ing been observed. 
On examination of the nose in cases of tertiary syphilis, deep foul 
ulcers with ragged edges and dirty grayish bases can often be made out. 
When caries exists the part over the diseased bone generally appears 
blackish in color, the surface being rough and uneven. Occasionally, 
however, nothing can be perceived beyond dark-colored crusts and 
greenish-yellow mucus, by which the true condition of the underlying 
tissues is quite concealed. In other cases the pieces of dead bone may 
be situated so high up in the nasal cavity that nothing can be seen, but 
even then the probe will sometimes serve to discover them. Now and 
then, however, the most careful observation may fail to disclose the 
actual seat of disease, as is well shown by some cases reported by E. 
Frankel (see Pathology). 
Diagnosis.—There is seldom much difficulty in recognizing the affec- 
tion, the only disease with which it can be confounded being lupus 
exedens when that disorder commences within the nose. The age, 
however, at which lupus begins will generally serve to distinguish it, 
showing itself, as it does, earlier than any form of syphilis except the 
hereditary disease, which, on the other hand, has symptoms quite 
peculiar to itself. Moreover, even at a very early period, the papules 
or tubercules of lupus are sufficient to identify it, whilst, later on, the 
marked preference which the morbid process shows for the cartilages 
is very characteristic. Dry catarrh accompanied by ozama is sometimes 
mistaken for syphilitic caries, but to those who have had any experience 
the smell is quite different; moreover, the stench of true ozsena can be 
got rid of by syringing, whilst the most persevering irrigation leaves 
the odor arising from diseased bone comparatively unaffected. Should 
any doubt arise, however, the use of Gottstein’s plugs will settle the 
question, for whilst they quickly put an end to the stench in true ozsena, 
they greatly intensify it if there is any necrosis or caries. 
It is important to remark here, that, though perforation of the septum 
far more often results from tertiary syphilis than from any other cause, 
it is by no means, as is often supposed, an exclusively syphilitic lesion. 
Leaving congenital deformity and injury out of the question, a perma- 
nent hole may result both from septal abscess and blood-cyst, and 
possibly also from tubercular ulceration (see “ Tubercular Disease of 
the Pituitary Membrane,” p. 401 .)* I dwell on this matter with some 
* See also perforation of the septum in typhoid fever and acute rheumatism (p. 417. SYPHILITIC AFFECTIONS OF THE NOSE. 
395 
emphasis, as I have known painful mistakes made through ignorance 
of the facts just mentioned. 
In all doubtful cases the previous history should be carefully inquired 
into, the skin should be examined for coppery patches, periosteal nodes 
sought for in the usual situations, whilst cicatrices and induration should 
be looked for in the tongue, pharynx, and larynx. In the absence of 
other evidences, the action of iodide of potassium will generally soon 
determine the nature of the case. 
Pathology.—Sanger,* who examined several specimens of polypoid 
excrescences removed by Schuster from the nasal fossae of patients 
affected with syphilis, arrived at the following results: The mucous 
membrane at one spot was greatly hypertrophied as regards all its ele- 
ments, and the fold thus formed tended to increase in size as the process 
continued, and finally, being acted on by gravitation, became pendulous. 
On section, the mass presented two clearly defined structural zones : 1st, 
an inner or erectile one, consisting of a network of venous capillaries, 
surrounded by connective tissue of dense fibrillar structure, and inclos- 
ing acinous mucous follicles, the lobes of which appeared to be en- 
croached upon by the neighboring tissue, and were undergoing atrophy ; 
2dly, an outer cortical zone, consisting of an enormous number of small 
round cells, uniform in size, and lying closely packed together in a 
stroma of very delicate areolar tissue. These cells had each a nucleus, 
and often several nucleoli, and were surrounded by bloodvessels, the 
coats of which they had, in some places, partly penetrated. Covering 
the cortical zone was epithelium of the cylindrical non-ciliated variety. 
In some parts, this epithelium had disappeared, leaving microscopic 
excoriations, and at those points the round cells were especially numer- 
ous. From these appearances Sanger infers that the process had 
consisted in a primary hypertrophy of* the mucous membrane with its 
vessels and glands, followed by formation of small round cells at the 
periphery of the tumor, which, by gradually encroaching on the vessels 
and follicles, produced obliteration of their channels at one part, with 
corresponding dilatation farther back. In this manner the cortical 
layer of round cells and the erectile zone of dilated venous spaces had 
been formed. That this infiltration of the mucous membrane by pro- 
liferating small round cells is distinctively syphilitic, was proved by 
comparison of the sections with others of undoubted syphilitic products 
found in the intestines. Sanger also concluded, from other specimens, 
* Loc. cit. 396 
DISEASES OF THE THROAT AND NOSE. 
that a similar infiltration of the mucous membrane with proliferating 
small round cells may take place without hypertrophy of the mucous 
membrane itself. In all cases the cellular infiltration extended some 
way into the neighboring tissues, so that no definite boundary could be 
traced. In other instances, true syphilitic neoplasms (condylomata) were 
found, the mucous membrane itself being entirely altered in structure, 
and the epithelium either altogether absent, or reduced to a few layers of 
poorly-nourished cells. The changes presented by the cartilages and 
bones at points corresponding to the infiltrated patches of mucous mem- 
brane consisted— 1st, in exfoliating necrosis, resulting from suppuration ; 
2dly, in rarifying syphilitic osteitis or caries sicca, the bone having been 
absorbed and replaced by exuberant granulations of the mucous mem- 
brane ; and, 3dly, in rarifying and plastic osteitis, the connective tissue 
of the periosteum and the bone having been transformed into spindle- 
shaped cells, which had become partly organized again into ordinary 
connective tissue, and partly into new bone. 
Sanger points out that the view commonly held, that ulceration of 
the nasal mucous membrane is a necessary antecedent of caries of the 
underlying bones and cartilages, is erroneous, and he maintains, on the 
contrary, that the bony framework of the nose may be the primary seat 
of syphilitic caries, in the same way that the frontal bone or the tibia 
may be attacked by primary syphilitic periostitis. 
It should be borne in mind, as pointed out by E. Frankel,* from 
the post-mortem inspection of three cases, that the necrosis of bone may 
be molecular, the ulcerations being so minute as altogether to escape 
observation during life. Frankel found cirrhotic thickening of the mu- 
cous membrane, with partial absorption of the glandulae, in addition 
to the disease of the bone. 
Prognosis.—In secondary syphilis, and in mild tertiary disease, where 
the destruction has been slight and the bodily vigor of the patient is 
but little diminished, recovery is almost certain to take place under a 
well-directed course of anti-syphilitic treatment. When, however, 
active caries is going on, the prognosis is necessarily grave, especially 
if, as is common in such cases, the patient is in a very exhausted con- 
dition. 
Treatment.—Syphilitic coryza in the adult rapidly passes away. An 
ordinary tonic may be given, whilst, locally, the use of a nasal wash of 
bicarbonate of soda or permanganate of potash will generally effect a 
* Virchow’s Archiv., Bd.lxxv., 1 Heft, 1879. SYPHILITIC AFFECTIONS OF THE NOSE. 
397 
cure in a week or two. When condylomata are present, they should be 
touched with tincture of iodine or solid nitrate of silver. In tertiary 
syphilis more active treatment is required, and constitutional and local 
measures are alike essential. Iodide of potassium must be given, the 
dose being gradually increased to ten or fifteen grains three times a 
day. If this drug, after being fairly tried for some months, fails to 
bring about a cure, or produces but slight benefit, mercury must be re- 
sorted to, either alone or in combination with iodide of potassium. 
Small doses of the corrosive sublimate may be given twice or three 
times a day in a decoction of sarsaparilla, or the cyanide of mercury 
may be administered twice a day in the form of a pill.* Considerable 
advantage will often be found in alternating the remedies. Thus, a 
case, which has improved up to a certain point under iodide of potas- 
sium, will generally make some further progress under the influence of 
mercury, whilst, after a short interval, a return to the iodide will often 
be attended with very marked and rapid improvement of the symp- 
toms. When there is cachexia, analeptic treatment must, of course, be 
assiduously carried out. 
In all tertiary forms of the affection, local ueasures are useful, and, 
indeed, frequently essential. In cases of caries of the bony structures, 
with foul-smelling discharge, the nasal cavity should be thoroughly 
cleansed two or three times a day with a lotion of detergent and deo- 
dorizing character. Any superficial ulcers, which may exist within the 
nose, will be soon brought into a healthy condition by these washes; 
but, for deep, spreading ulcers, more concentrated remedies are neces- 
sary. For this purpose, nitrate of silver, fused on the end of a piece of 
aluminium wire, suitably curved, may be used. In intractable cases, 
however, the daily application to the ulcer of iodoform, by means of an 
insufflator, will often effect a cure where more severe measures have 
failed. At the same time, stimulating and antiseptic inhalations, such 
as the Vapor Iodi, V. Creasoti, or V. Pini Sylvestris of the Throat Hos- 
pital Pharmacopoeia, may be inspired through the nose, or antiseptic 
sprays may be employed. Head bone should be removed with suitable 
forceps when the fragments are loose and within view, but it is highly 
dangerous to use much force in detaching sequestra. Schusterf has 
found the greatest benefit in cases of obstinate ulceration from the free 
use of Volkmann’s sharp spoons (Fig. 66, p. 278), even when no 
exposed bone could be detected with the sound. The ulcers are first 
* R. Hydrarg. Cyanid., gr. A; Sacch. Lactis, gr. f ; Tragacanth, q. s.; M., ft. pil. 
f Loc. cit. 398 
DISEASES OF THE THEOAT AND NOSE. 
scraped, and afterwards any indurated tissue that may remain is de- 
stroyed with nitrate of silver or electric-cautery. Schuster’s experience 
agrees with Volkmann’s* own on this point, viz., that it is precisely 
in the most severe and apparently hopeless cases of extensive destruction 
of the bony framework of the nose that treatment with the sharp 
curette yields the most brilliant results. I have employed these sharp 
spoons in a few instances, but always with the greatest care. Their 
use is not altogether free from danger, a case having recently been 
brought to my knowledge, in which death occurred from haemorrhage 
whilst the surgeon was scraping out the nasal fossae of a patient suffer- 
ing from syphilitic necrosis. 
When the diseased bone cannot be seen by the ordinary methods of 
examination, whilst the symptoms are urgent, it may be advisable to 
expose the interior of the nose in order to apply strong remedies directly 
to the affected part. Celsusf suggested the extreme measure of laying 
the nose completely open from the outside, but a sufficiently good view 
of the cavities and access to all their recesses may be obtained by Rouge’s 
operation (see “ Fibrous Polypi of the Naso-Pharynx ”). 
Should the nose be completely destroyed, an attempt may be made 
to remedy the deformity by a rhinoplastic operation, for a detailed de- 
scription of which the reader is referred to the ordinary text-books of 
surgery. Slighter disfigurement may be mitigated by an artificial nose. 
HEREDITARY SYPHILIS OF THE NOSE. 
Hereditary syphilis is apt to attack the nose at two periods of life, 
viz., at the time of birth or soon after, and later on in childhood. 
Newly-born infants are, however, its especial victims, and in them the 
disease takes the form of severe catarrh. It generally appears within 
a week or two of birth, seldom commencing after the end of the second 
month. It is probably dependent, in most cases, on the presence of 
mucous patches on some portion of the pituitary membrane, although, 
as a rule, none can be seen. The discharge may be thin at first, but it 
usually soon becomes muco-purulent. The nasal channel becomes 
blocked up to such a degree that the troubles described in connection 
* Beitrage zur Chirurgie, Leipzig, 1875, p. 267. 
f De Medicina, lib. vii., cap. ii. 399 
HEREDITARY SYPHILIS OF THE NOSE. 
with acute catarrh in infants (see p. 294) as regards sucking and sleep- 
ing are often observed. From the swelling of the pituitary membrane 
and the accumulation and drying of the mucus, the nasal breathing be- 
comes difficult and noisy, and a child thus affected is popularly said to 
have the “snuffles.” The secretion irritates the margin of the nostrils 
and the upper lip, rendering the skin and mucous membrane at those 
points red and excoriated. The malady is very chronic in its course, 
showing little or no inclination to subside spontaneously, and in most 
cases, if not subdued by treatment, it becomes gradually worse. If 
caries of the bones and cartilages of the nose ensues, the child is not 
unlikely to be disfigured for life by a flattened nose. 
Where there is caries with discharge, the sudden spontaneous cessation 
of the secretion is ordinarily, according to Hermann Weber,* the pre- 
cursor of a serious and often fatal brain-lesion. In one case related by 
that physician, as soon as the discharge ceased, cerebral symptoms 
showed themselves. Four days later the little patient was seized with 
rigors and well-marked signs of pyrexia, and on the thirteenth day 
from the first attack of shivering, death took place. At the post- 
mortem examination, thrombi were found in the cavernous sinus and 
left ophthalmic vein. There was evidence of severe meningitis, and 
the under surface of the left cerebral hemisphere was bathed in pus. 
Purulent collections were also found in the pleurae, lungs, and liver. 
Syphilitic children are mostly small and feeble, and have an aged, 
withered appearance. Their skin is of a grayish tint, if it be not 
covered with a copper-colored papular eruption or with pemphigus neo- 
natorum. Sometimes the infants are apparently healthy at birth, the 
marasmus only coming on three or four weeks later. Mucous patches 
will generally be found at the anus, and often at the corners of the 
mouth and the margins of the eyelids. 
Syphilitic coryza occurring in an infant requires both systemic and 
local treatment. Although in many cases of constitutional syphilis in 
adults I do not consider that mercury is necessary (see vol. i., Preface, 
and pp. 106, 107), yet, in this form of the disease, mercurial treatment 
appears to me to be the best that can be adopted, the administration of 
this drug having a very marked influence on the duration and intensity 
of the affection. It should be given to children in the form of gray 
powder in doses of from one to two grains twice a day, and if this is 
found to cause diarrhoea, one grain of Dover’s powder or an additional 
* Med.-Chir. Trans., vol. xliii., p. 177. 400 
DISEASES OF THE THROAT AND NOSE. 
grain of chalk should be combined with each dose of the gray powder. 
Erichsen* recommends the external application of mercury in the man- 
ner first proposed by Brodie, as the readiest way of introducing the 
remedy into the system of a syphilitic child. The following is the method : 
A drachm of mercurial ointment should be spread on a flannel roller, 
which should then be stitched round the child’s thigh just above the 
knee, the medicated surface being next the skin. This ought to be re- 
newed every day for a period of two or three weeks, after which iodide 
of potassium should be administered in milk or cod-liver oil. 
Local treatment is also required almost always, but the difficulty of 
carrying this out in infants has led to its being much neglected, and the 
ravages of syphilis in the nose in such cases are largely due to this cause. 
The following is the best method of washing out the nasal passages of 
an infant: The child should be placed in the nurse’s lap, and the naso- 
pharynx plugged by means of the temporary sponge-tampon (Fig. 74, 
p. 284). The little patient’s head should then be slightly raised, and 
the nose washed out with a fine syringe, or, if it be preferred, a spray 
or nasal douche can be applied, care being taken in the latter case that 
too much force is not used. The Collunarium Acidi Carbolici cum 
Borace, or the C. Potassse Permanganatis of the Throat Hospital Phar- 
macopoeia, may be employed in half their usual strength. 
TUBERCULAR DISEASE OF TIIE PITUITARY 
MEMBRANE. 
Latin Eq.—Tubercula membranse pituitarise. 
French Eq.■—Tubercules de la membrane pituitaire. 
.German Eq.—Tuberkeln der Membrana pituitaria. 
Italian Eq.—Tubercoli della membrana pituitaria. 
Definition.—A chronic affection of the nose, probably always 
preceded by tubercular disease of the lungs or other organs, arising from 
the deposit in the mucous membrane of tubercles which form tumors prone 
to ulceration. 
History.—Very few examples of tubercular disease of the nasal mucous membrane 
have hitherto been recorded. In the year 1853 Willigkf mentioned that he had once 
* Science and Art of Surgery, London, 1872, 6th ed., vol. i., p. 670. 
f Prag. Vierteljahrsschrift, 1853, Bd. xxxviii. TUBERCULAR DISEASE OF THE PITUITARY MEMBRANE. 
401 
found tuberculosis of the membrane covering the septum. In 1877 Laveran* described 
two cases; and in the following year, Biedelf added two more. YolkmannJ soon 
afterwards briefly referred to the subject, and expressed a belief that many cases of 
supposed hereditary syphilis of the nose are really of a tubercular character. In 1880 
Tornwaldtf published a very interesting example of the complaint; and more recently 
Weichselbaum|| has given an elaborate pathological report on two cases which came 
under his notice. 
Etiology.—Tubercular disease of the nasal mucous membrane is no 
doubt a very rare affection, but it is likely to be more carefully sought 
for in future, and in all probability some cases will be met with from 
time to time. As all these are tolerably sure to be reported, the com- 
plaint may in a few years appear to be much more common than it really 
is. Willigk found the disease once in 476 tuberculous bodies. Weichsel- 
baum noticed only two examples in 146 autopsies of patients dying 
with tubercle. In 50 bodies of consumptive patients, which E. FrankelTf 
carefully examined by Schalle’s method, the nasal cavity was in every 
case entirely free from tubercular disease. I have never observed a 
case of tuberculosis of the nasal mucous membrane, but I have no doubt 
that I have sometimes overlooked it amongst the thousands of cases of 
laryngeal phthisis which have come under my notice. I have, however, 
met with two instances in which there was a large perforation in the 
septum which may possibly have resulted from tubercular ulceration. 
There was no apparent cause for the lesion ; in particular, there was no 
history of syphilis, nor any trace of that complaint. Tubercular dis- 
ease is probably always secondary, though in Tornwaldt’s case the nasal 
symptoms preceded by a long time those subsequently developed in the 
larynx and lungs; and in one of Riedel’s cases, though the patient had 
a somewhat cachectic appearance, there were no physical signs of pul- 
monary tuberculosis nine months after the removal of a large tubercular 
tumor on the septum. 
Symptoms.—Tubercular deposit in the mucous membrane of the nose 
may be seen either in the form of tumors, varying in size from a millet- 
seed to a bantam’s egg, or there may be slight thickening and ulcera- 
tion of the mucous membrane. In either case there is generally a trou- 
blesome and more or less fetid discharge. Though the deposit may 
* Union Mfedicale, Nos. 35 and 36. 
f Deutsche Zeitschrift fur Chirurgie, Bd. x. 
J Sammlung klinischer Yortriige, Leipzig, 1879, No. 168-169, p. 31. 
\ Deutsches Archiv fur klin. Med., Bd., xxvii., p. 586. 
|| Allgemeine Wien. med. Zeitung, 1881, Nos. 27, 28. 
H" Archives of Otology, June, 1881, vol. x., No. 2. 402 
DISEASES OF THE THROAT AND NOSE. 
occur at any part, it appears to show a preference for the septum. In 
Tornwaldt’s case, however, the mucous membrane covering the turbi- 
nated bones was greatly hypertrophied, and there were two reddish- 
gray tumors of the shape and size of split peas. In Riedel’s case there 
were both tumors and ulcers. In one a raised ulcer near the left nasal 
orifice had partly destroyed the ala on that side, whilst in the other the 
ulcer had perforated the septum. In both instances large tumors occu- 
pied the septum. One was two and a half centimetres in length, two 
centimetres in height, and one and a half in thickness. In the other 
case there was a somewhat similar tumor, though considerably smaller 
in size. In both, the growths occupied the posterior part of the septum. 
Laveran found ulcers on the anterior part of the septum. They were 
about the size of a (silver) twenty-centime piece, of a grayish color, and 
not at all painful. In one of Weichselbaum’s cases there were four 
small ulcers, varying in size from a hemp-seed to a lentil, all situated 
on the septum, whilst grayish-white nodules were also seen on that par- 
tition near the floor of the nose on the right side. Similar nodules 
were present on the vault of the pharynx, whilst several of the retro- 
pharyngeal glands had undergone cheesy degeneration. In Weichsel- 
baum’s second case the patient, a woman, aged sixty-two, had a soft 
yellowish-gray nodule of the size of a hemp-seed on the anterior ex- 
tremity of the right inferior turbinated body. A grayish-white nodule 
as large as a poppy-seed wTas also seen on the anterior portion of the 
right middle meatus, and a small tumor about the size of a hemp-seed 
was situated at the anterior extremity of the left middle turbinated 
body. This small tumor was undergoing, ulceration at its apex. 
The progress of tubercular disease of the mucous membrane is gen- 
erally slow, and in one of Riedel’s cases the ulceration existed for 
twenty-seven years. 
Diagnosis.—When obstinate ulceration or growths are found in the 
nose of a person suffering from well-marked tubercle of another organ, 
it may be suspected that the nasal affection is of the same nature. Cer- 
tainty, however, can only be arrived at by excising a portion of the 
mucous membrane or growth, and submitting it to microscopic exami- 
nation. If (lupus or glanders being excluded) clusters of lymphoid 
cells with giant cells in their centre are found in a reticular connective 
tissue, there can be no doubt of the presence of tubercle. The absence 
of giant cells is not, however, to be taken as disproving it. 
Pathology.—Tubercle, when deposited in the mucous membrane of 
the nose, generally forms minute tumors, varying in size from a poppy TUBERCULAR DISEASE OF THE PITUITARY MEMBRANE. 
403 
to a hemp-seed; occasionally, however, large growths are formed, as 
in the cases reported by Riedel. The small tumors may be seen to be 
undergoing cheesy degeneration, and the mucous membrane covering 
them shows signs of softening, and commencing ulceration. In La- 
veran’s cases, tubercles and giant cells were found in the sub-epithelial 
stratum forming the base of the ulcers, and also in the tissues immedi- 
ately surrounding them. The large tumors observed by Riedel con- 
sisted in the main of very vascular granulation tissue. Gray nodules 
could be seen with the naked eye, which, microscopically, were found 
to “ consist of masses of large cells, the centres of which did not con- 
tain the giant cells so constantly met with in lupus.” 
In Tornwaldt’s case the portion of growth first excised was exam- 
ined by Faroe, of Dantzig. The specimen contained distinct groups of 
small nucleated cells, with several larger epithelioid cells in a retic- 
ular stroma. In two preparations giant cells could be clearly demon- 
strated. Other portions of the growth subsequently removed were 
examined by Baumgarten, with the assistance of Neumann. The 
following is their report: “ We conjointly agree in stating that tl e 
specimen is, as you surmised, a tubercular node. In a tissue densely 
infiltrated with small round cells, circumscribed groups of larger epi- 
thelioid cells, containing in their centre (in scanty number, it is true) 
veritable giant cells, are seen. The limited amount of the specimen 
affords some ground of objection to our diagnosis of tubercle.” 
The most detailed account of the microscopic appearance of tubercle 
in the nasal mucous membrane has been given by Weichselbaum. He 
states that the peripheral parts of the nodules are composed of lymphoid 
cells, which form larger or smaller groups, and present an interstitial 
structure of reticular connective tissue. Gland-tubes of various shapes, 
cut transversely, obliquely, and longitudinally, are scattered here and 
there in the round-celled mass. These represent the acini and excretorv 
ducts of the follicles separated by the lymphoid infiltration. The lumen 
of many of the ducts is encroached upon by “epithelia of low type,” 
whilst some of them, on the other hand, are over-distended by the quan- 
tity of round cells within them. The nodule may contain giant cells 
with oval peripheral nuclei, and a fine granular centre can be made out, 
or it may be in a state of cheesy degeneration, consisting merely of 
granular debris, indistinct nuclei, and the remains of cells. The sub- 
epithelial layer of the mucous membrane in the neighborhood of the 
nodules is densely infiltrated with lymphoid cells, the latter being 
clustered for the most part around the bloodvessels. The edges of the 404 
DISEASES OF THE THROAT AND NOSE. 
ulcers show an infiltration of round cells or of elements which in their 
form resemble endothelial cells, whilst the base of the ulcers is covered 
with a thick layer of finely granulated detritus (cheesy mass). Under 
this proliferating connective tissue endothelial cells are met with. The 
mucous follicles are seen undergoing two kinds of degeneration. In 
the one the lymphoid or endothelial elements invade the inter-acinous 
structure, encroach upon the acini, and ultimately destroy the entire 
gland, which, whilst retaining its shape, is transformed into a mass of 
cells; in the other the gland-cells are not merely pushed aside, but ap- 
pear themselves to participate in the morbid process. The sub-epithelial 
layer of the mucous membrane, not only in the immediate vicinity of 
the ulcers, but also at some distance from them, shows round-celled 
infiltration. 
Prognosis.—It is doubtful whether the disease can be eradicated when 
once deposit of tubercular matter has occurred. In Tormvaldt’s case 
the wounds healed very rapidly after the removal of the tumors, but 
subsequently new granulations appeared. 
Treatment.—If there be any troublesome discharge, mildly astringent 
or disinfectant collunaria should be used ; and if tumors of any size 
cause serious inconvenience by interfering with nasal respiration, they 
may be removed. Should much pain be felt—which, however, is sel- 
dom the case—insufflations of morphia and bismuth would probably 
give relief. 
LUPUS OF THE PITUITARY MEMBRANE. 
Latin Eq.—Lupus membranse pituitarise. 
French Eq.—Lupus de la membrane pituitaire. 
German Eq.—Laipus der Meinbrana pituitaria. 
Italian Eq.—Lupus della membrana pituitaria. 
Definition.—A deposit of “granulation-tissue,” occurring primarily 
in the mucous membrane of the nasal fossae, which slowly ulcerates. 
History.—A few cases of this rare complaint are found scattered through medical 
records, examples of the disease having been reported by Cazenave* and others. The 
disease was fully described by Hebra and Kaposif in their systematic work on cutane- 
ous affections, and afterwards by Moinelf in a short monograph. 
* Mfem. sur le Coryza chronique, 1848. 
t Diseases of the Skin, Svd. Soc. Transl., London, 1875, vol. iv., pp. 65-68. 
+ Essai sur le Lupus scrofuleux des Fosses nasales, Paris, 1877. 405 
LUPUS OF THE PITUITARY MEMBRANE. 
Etiology.—The causes producing lupus are quite unknown, but it 
generally occurs in young persons of strumous constitution, and the 
female sex is more liable to it than the male. 
Symptoms.—Lupus, as is well known, generally first attacks the skin 
of the nose, but cases are occasionally met with in which the disease 
commences in the nasal mucous membrane, and sometimes it remains 
confined to that tissue. The malady may appear as lupus exedens or 
non exedens. The former variety usually begins on the cartilaginous 
septum, where small red excessively irritable tubercles are seen at an 
early period. In the next stage ulcers appear, which have a great ten- 
dency to spread, often eating away in their course the whole of the car- 
tilaginous septum, the alar cartilages, and sometimes even portions of 
the bones themselves. These ulcers are always covered with crusts, 
under which the process of destruction goes on in one part, whilst heal- 
ing may be taking place in another. At the same time there is a foul 
discharge from the nose, which, though at first resembling that of com- 
mon coryza, later on often assumes the character of virulent ozsena. In 
lupus non exedens there is no ulceration, but atrophic degeneration and 
shrinking of all the tissues affected, including the bones and cartilages, 
occur. A disagreeable odor is exhaled, as in the ulcerative form of the 
complaint. 
Diagnosis.—Lupus is easy of recognition by a practitioner who has 
previously seen examples of the disease: the youth of the patient, 
the slowly destructive process, and the crusted ulcers showing a dispo- 
sition to heal at certain parts, being eminently characteristic. The 
malady may be mistaken for a syphilitic affection, from which, however, 
it can generally be distinguished by the curative action of iodide of 
potassium in the latter disease; it must not be forgotten, however, that 
syphilis and lupus may coexist in the same patient. It is often ex- 
tremely difficult, and sometimes impossible, to differentiate lupus in its 
early stage from epithelioma, but after a time the characteristic features 
of each affection become manifest. 
Pathology.—The microscopic characters of lupus are, briefly, infiltra- 
tion of the integument with small cells arranged in “ nests,” at first 
separate from each other, and at a later stage becoming confluent, so as 
to involve a considerable area; large numbers of cells are also heaped 
around the bloodvessels. Fatty degeneration of the cells next occurs 
and ulceration is produced. Micrococci have recently been discovered 
in parts affected with lupus by Max Schuller,* and it has been shown 
* Centralblatt fur Chirurgie, 1881, No. xlvi. 406 
DISEASES OF THE THROAT AND NOSE. 
by him that the offshoots of the micrococci spread into the neighboring 
connective tissue, the extremities of their root-like processes being 
covered with granules. These organisms are found in the walls of small 
vessels surrounded by round and epithelioid cells. 
Prognosis.—Lupus can sometimes be subdued by a well-directed 
course of treatment, but there is always a great tendency to relapse, and 
this is especially to be dreaded when the cicatrix remains indurated, and 
is of a red color or covered with arborescent vessels. In some cases 
the disease shows a tendency to pass backwards and involve the pharynx, 
and this must be regarded as an unfavorable feature. As the patient 
gets older, the disease in many instances shows a tendency to sponta- 
neous cure. 
Treatment.—The local measures to be adopted in cases where lupus 
attacks the inside of the nose, leaving the integuments unscathed, consist 
in destroying the diseased tissues by means of powerful caustics, such 
as nitric acid, caustic potash, or chloride of zinc, or by the use of gal- 
vano-cautery. All crusts should be cleared away before employing the 
caustic, the application of which generally has to be repeated several 
times. Care must be taken to destroy every portion of the affected 
part, as any place left uncauterized forms a starting-point for a fresh 
outbreak of the disease. Constitutional treatment is also of the greatest 
importance in lupus. Cod-liver oil and tonics, especially iron, are often 
useful. Hunt* maintained that arsenic is a specific in this complaint, 
and other practitioners have found this drug of service. 
RHINOSCLEROMA. 
This exceedingly rare disease was first described by Hebraf in 1870, 
and examples of it have since been published by Geber,| Tantuzzi,§ 
Mikulicz,|| Weinlechner,*f Billroth,** and CorniLff The subject has 
been full}' treated by Kaposi,|| Neumann,§§ and Pellizzari.|||| 
* Brit. Med. Journ., 1862, vol. i,, p. 8. 
f Wien. med. Wochenschr., January, 1870. 
X Archiv. f. Dermatol, u. Syph., 4 Heft, 1872. § II Morgagni, 1872. 
|| Langenbeck’s Archiv., Bd. xx. 
T[ Quoted by Neumann, op. infra cit, p. 567. 
** Quoted by Kaposi, op. infra cit., p. 635. 
ff Progres Medical, July 28, 1883, p. 587. 
Pathologie u. Therapie der Hautkrankheiten, Zweite Auflage, Wien u. Leipzig, 
1883, Zweite Hiilfte, pp..632-637. 
§§ Lehrbuch der Hautkrankheiten, Fiinfte Auflage, Wien, 1880, pp. 566-569. 
1111 II Rinoscleroma, Firenze, 1883. 407 
RHINOSCLEROMA. 
Nothing is known as to the causation of the malady, neither sex, 
constitutional disease, nor personal habits appearing to have any definite 
influence in producing it. Most of the cases on record have occurred 
between the ages of fifteen and forty-five. The climate or conditions 
of life in the southeast of Europe would appear to predispose in some 
measure to the complaint, since of a total of about forty cases hitherto 
observed, all but three were met with in Vienna or its neighborhood. 
Two of these occurred in Italy and one in France, but I am not aware 
of a single instance in which the disease has been noticed in any other 
country. Cases of “ rhinoscleroma” are mentioned by Spillmann* as 
having been seen by Verneuil and others, but from the description of 
the complaint it was evidently merely perichondritis of the septum. 
Rhinoscleroma shows itself generally at the edges of the nostril and 
on the neighboring part of the upper lip, in the form of flat, slightly 
raised patches which are smooth on the surface, and of ivory-like hard- 
ness. The integument over them is natural, or sometimes dusky red 
in hue, but round the patches it is neither thickened nor discolored. 
The swellings are tender on pressure, but otherwise the disease is un- 
attended with pain. The patches may be discrete or confluent, and the 
disease spreads by gradual infiltration of the surrounding tissues. There 
is seldom any sign of ulceration, and the growth does not take on in- 
creased activity when interfered with. Although the disorder may ap- 
pear in two or more places simultaneously, or successively, it shows no 
tendency to generalize itself, either by the bloodvessels or the lymphatics, 
and there is never any sign of constitutional infection. Its course is 
very slow, and the patient experiences nothing beyond purely local 
symptoms. The swelling may involve the septum and the alse of the 
nose, so as to make that feature feel as if it were “ made of plaster 
of Paris,” and it may invade the upper lip, spreading afterwards 
to the gums and the alveoli. The morbid process occasionally ex- 
tends back through the nose to the throat as far as the larynx and 
trachea, or through the mouth to the velum. In each case certain symp- 
toms will be manifested, such as obstruction of the nose, aphonia, or 
stenosis of the glottis. Rhinoscleroma has to be distinguished from 
syphilis, epithelial cancer, and keloid. It differs from venereal dis- 
ease mainly in its very chronic course, the absence of softening or ul- 
ceration, and its absolute intractability under every kind of medication. 
* Diet. Encyclop. des Sci. Medicates, art. Nez, t. xiii., pp. 45, 46. 408 
DISEASES OF THE THROAT AND NOSE. 
From epithelioma, again, it can be discriminated by its smooth, glisten- 
ing surface, its hardness, the absence of bleeding or ulceration, and its 
persistently local character. The history and progress of the case can 
alone differentiate rhinoscleroma from keloid in many instances. 
The prognosis is most unfavorable as regards cure, recurrence of the 
growth taking place even after complete removal.. The disease, how- 
ever, does not tend to shorten life, unless it spreads down to the larynx. 
Pathologically, the growth is allied to round-celled sarcoma, the es- 
sential feature of rhinoscleroma, according to Kaposi,* being infiltration 
of the corium and papillae with small cells. 
This observation is confirmed by Cornil, who, moreover, states that 
scattered about among the vessels there are large spheroidal cells con- 
taining one or more nuclei. These are imbedded in a reticular proto 
plasm, and in this there are also small re'fracting hyaline bodies, which 
finally, in the course of development of the cell, fill its whole cavity. 
These hyaline bodies, in some eases, pass out of the body of their parent 
cell into the surrounding tissue. They are not of amyloid or fatty na- 
ture, and, according to Cornil, do not contain micrococci. They consti- 
tute the distinctive pathological product of rhinoscleroma. True car- 
tilage was found in one instance by Kaposi,f and in Chiari’sJ case there 
was not merely cartilage, but commencing ossification. 
Medical treatment has no effect on the disease, and surgery can do 
nothing but palliate the more troublesome symptoms. The knife and 
various caustic agents have been freely employed without success, for, 
as already remarked, the most complete removal or destruction of the 
morbid formation has always been followed by recurrence of the disease. 
Temporary good can, however, often be done. If the nose becomes 
blocked up, the obstructing growth should be removed or destroyed 
with the cautery, and the narrowed passage dilated by means of lamina- 
ria tents. In threatened suffocation from invasion of the larynx, tra- 
cheotomy must, of course, be performed without delay. 
* Op. cit., p. 635. 
f Op. cit., p. 635. 
t Ibid. GLANDERS. 
409 
GLANDERS. 
Latin Eq.—Equinia; Malleus huraidus. 
French Eq.—Morve. 
German Eq.—Rotz. 
Italian Eq.—Ciamorro. 
Definition.—A contagious disease, generated by the introduction 
into the system of a specific poison derived directly or indirectly from a 
horse suffering from the same affection ; characterized by the formation of 
pustules, followed by spreading ulceration of the skin in various parts of 
the body (farcy), and of the mucous membrane of the nose and throat, 
from which a viscid, muco-purulent or sanious secretion is discharged in 
great abundance ; accompanied by the usual constitutional symptoms oj 
blood-poisoning, and ending generally in death. 
History—The earliest actual observation of the occurrence of glanders in man was 
made in 1783 by Osiander,* whilst it was not till 1812 that farcy was described by Lo- 
rin,f as affecting the human subject. The first detailed account of the whole malady 
was published by Schilling! in 1821. Five years later, three instances of the disease 
were recorded by Travers,§ who, however, does not appear to have understood the true 
nature of the phenomena which he observed. A fatal case of glanders in man was re- 
lated by Brown || in 1829. In the two or three following years the affection was in- 
vestigated by who, in a series of papers constituting a short monograph on 
the subject, described several cases which he had himself met with, in addition to a 
few which he had been able to collect from other sources. Shortly afterwards, two ex- 
amples of glanders and farcy in the human subject were published by Graves,** who 
claims to have been the first to call attention to the occurrence of “ button-farcy” in 
man.ff In 1837 appeared the elaborate report of Raver,J! which had a great effect 
in inducing the establishment of strict sanitary regulations as to infected horses. In 
1843 Tardieu$§ published his well-known essay on glanders and farcy. In more re- 
cent times, considerable attention was given to the subject by Virchow,|||| and an ex- 
* Ausfiirliche Abhandlung iiberdie Kuhpocken, 1801. 
f Journ. de Mfed. Chir. et Pliarm. Milit., Fevrier, 1812. 
X Rust’s Magazin f. d. gesammte Heilkunde, Berlin, 1821, vol. xi., p. 480. 
\ Inquiry concerning Constitutional Irritation, London, 1826, p. 350 et seq. 
|| London Med. Gaz., 1829, vol. iv., p. 134. 
Med.-Chir. Trans., London, 1830, vol. xvi., pt. i., p. 171; Ibid., 1833, vol. xviii., 
pt. i., p. 201 ; Ibid., vol. xix., p. 237. 
** London Med. Gaz., vol. xix., p. 939. 
ff Clinical Lectures, Dublin, 1848, 2d ed., vol. ii., p. 336. 
JJ Mem. de l’Acad. de M6d., Paris, 1837, t. vi. 
§$ De la Morve et du Farcin chroniques chez l’Homme et les Solipedes, Th$se de 
Paris, No. 15, 1843. 
1111 Die Krankhaften Geschwiilste, Berlin, 1864-1865, vol. ii., p. 543 et seq. 410 
DISEASES OF THE THROAT AM) NOSE. 
cellent account of the disease was published by the brothers Gamgee* in 1866 ; since 
then elaborate articles, dealing with human glanders and farcy in the fullest manner, 
have been published by Bollingerf and Brouardel.f: Quite recently the pathology 
of the disease has been carefully investigated by BendalQ and Boyd,|| whilst bacilli 
have been discovered almost simultaneously by several French and German observers 
(see Pathology). 
Etiology.—There can be no controversy as to the cause of this rare 
disease in the human subject, although there may be some difference of 
opinion as to the conditions necessary for its production. The complaint, 
as it affects the horse, is seen under two forms, viz., farcy and glanders. 
The former is characterized by inflammation along the course of the 
lymphatic vessels, leading to painful swelling of the glands, which sup- 
purate, and after a time burst, giving rise to ulcers secreting a virulent 
discharge. Glanders, on the other hand, shows itself by the deposit of 
small nodular growths in the nasal fossae, accompanied by ulceration of 
the mucous membrane, and by a discharge from one or both nostrils, at 
first very thin, but quickly becoming thick, viscous, and foul-smelling. 
Both farcy and glanders appear under the types of acute or chronic ail- 
ments; but there is this remarkable feature about each, that whilst an 
animal may be suddenly attacked by either disease in its acute form, 
the chronic malady is never found as a consequence of the acute stage, 
but on the contrary very often precedes it. Farcy and glanders fre- 
quently coexist, or the one complaint may follow the other. Their 
identity is further proved by the fact that, whilst the discharge from 
the nostrils of a glandered horse may produce an attack of farcy in 
another animal, on the other hand, the inoculation of matter from 
“farcy-buds ” may give rise to glanders. 
Both forms of the complaint are met with in man, but the affection is 
so uncommon that very few physicians have ever had an opportunity of 
observing it. Taking into account the vast number of persons whose 
business or pleasure brings them much in contact with horses, and the 
comparative frequency of the equine disease, the extremely rare occur- 
rence of glanders or farcy in the human subject seems to show that some 
special predisposition is necessary for the poison to be effective. As 
might be expected, the great bulk of sufferers belong to the class of 
* Reynolds’s System of Medicine, London, 1866, vol. i., p. 693 et seq. 
f Ziemssen’s Cyclopaedia of Medicine, English Trans., 1875, vol. iii., p. 348 et seq. 
t Diet. Encyclop. des Sciences M4dicales, art. Morve, Paris, 1876, 2e s6rie, t. x., 
p. 166 et seq. 
\ Trans. Path. Soc., 1882, vol. xxxiii., p. 417 et seq. 
Ibid., p. 420 et seq. GLANDERS. 
411 
veterinary surgeons, grooms, coachmen, and others, whose occupation 
requires much handling of horses. From a table, drawn up by Bol- 
linger,* it appears that out of one hundred and six cases of glanders, in 
forty-one the patients were ostlers, in eleven coachmen, in fourteen 
landed proprietors owning horses, in ten veterinary surgeons, in twelve 
horse-butchers, in five soldiers, in four surgeons, in three gardeners, and 
in two horse-dealers. Of the remaining four patients, one was a police- 
man, one a shepherd, one a blacksmith, and one a servant at a veteri- 
nary school. Men, being more exposed to infection, are, of course, 
much more liable to the disease than women. In one hundred and 
twenty cases, Bollingerf found only six females, and these were mostly 
wives or relatives of men whose employment lay among horses. 
The most common mode of transmission of the malady is by inocu- 
lation—that is to say, b)* the actual contact of discharge from the nos- 
trils of a glandered horse, or of pus from a farcy-abscess, with a wound 
or abrasion in the skin or mucous membrane. In a fatal case which 
occurred in my practice some years ago, the source of infection was 
traced to a diseased horse in a hansom cab. The patient, who had only 
driven a short distance, noticed that the animal sneezed, and he was 
annoyed by some of the secretion coming in his face. The infection may 
be carried by rags used to clean out the nasal fossae of a diseased ani- 
mal, or by anything on which the discharges have fallen. One case| 
is on record of the complaint having been communicated by biting, the 
poison having presumably been carried in the saliva. The disease may 
be transmitted in its worst form from man to man. There is some 
doubt whether the poison can be conveyed into the system through the 
stomach, Decroix’s§ foolhardy and disgusting experiments having 
yielded negative results. 
Symptoms.—Although, as already stated, glanders and farcy are 
merely different expressions of the same morbid condition, it does not 
fall within the scope of this work to deal in detail with the latter com- 
plaint. As a matter of fact, moreover, the lymphatic system is much 
less often directly attacked by the poison in man than in the horse. 
Glanders, as already remarked, may be either chronic or acute, and 
it will be convenient to consider the former type of the complaint first, 
* Ziemssen’s Cyclopaedia of Medicine, English Trans., 1875, vol. iii., p. 352. 
f Op. cit., p. 352. 
| Landonzy: Gaz. M6d., 1844, p. 460. 
| Bull, de la Soc. Cent, de Med. Vdt., 1870-71. This ardent seeker after truth 
devoured the flesh of diseased horses, both raw and cooked in various ways, and no 
unpleasant consequences appear to have ensued. 412 
DISEASES OF THE THROAT AND NOSE. 
as in the natural evolution of the disease it often precedes the latter. 
There is usually but little swelling or redness to be seen in the nasal 
fossae, and often no discharge, but the mucous membrane is covered with 
dirty scabs, and ulcerated in several places. The mouth and throat are 
also affected, although not often to any great degree. The breaking 
down of the nodules, however, may give rise to ulceration of the tongue, 
back of the throat, and larynx, and huskiness of voice, slight cough, 
and even some trouble in breathing may ensue. The expectoration is 
occasionally bloodstained. The complaint runs a very chronic course, 
lasting, as a rule, from four to eight months, but often much longer. 
Bollinger* relates a case in which traces of the disorder, such as cough, 
dyspnoea, and great prostration, remained after eleven years of suffering. 
The proportion of recoveries is stated by the same author to be about 
fifty per cent., but a considerable number of those that are said to be 
cured are never restored to perfect health. Of the cases that end fatally, 
in some death is caused by the exhaustion of the slow fever, with its ac- 
companying night-sweats and diarrhoea, and the septic effect of prolonged 
suppuration, whilst in the remainder the malady suddenly takes on the 
acute character. 
The acute form of the disease is almost always fatal, whether it fol- 
lows chronic glanders or farcy, or comes on as the immediate result of 
inoculation. Its onset is marked bv shivering, sudden rise of tempera- 
ture, and the usual symptoms of high fever; an erysipelatous rash shows 
itself on the face, beginning, in most cases, in the nose, but soon spread- 
ing over the cheeks and forehead. The surface of the inflamed skin 
becomes covered with vesicles, which by-and-by burst, and discharge a 
thin serous fluid, whilst patches of the integument may even show signs 
of imminent gangrene. The characteristic glander-pustules appear in 
crops on the face, intermingled with blebs. The secretion from the 
pustules soon dries up, and forms a scab, and when this separates, an 
ulcerated surface remains, which tends to spread on all sides, often with 
almost phagedsenic rapidity. The patient at the same time is afflicted 
with a painful sense of obstruction in his throat and nasal passages. 
This is due to the mucous membrane of those parts being thickly studded 
with pustules. A glairy liquid constantly flows from the nose, and is 
hawked up from the throat, and there is often a similar secretion from 
the eyes. As the disease progresses the discharge becomes thicker 
and more glutinous; it is often streaked with blood, and always 
* Op. cit., p. 350. GLANDERS. 
413 
very fetid. Occasionally there are sickness, diarrhoea, and abdominal 
pains. It should be borne in mind, however, that the discharge may 
be very scanty or, indeed, altogether wanting. When the disease is 
fully established the voice grows hoarse or may be entirely lost; whilst 
difficulty of swallowing is induced by swelling of the epiglottis. The 
expectoration generally becomes more abundant and more bloody as the 
disorder pursues its course in the larynx. Paroxysms of dyspnoea ensue 
from the partial obstruction of the glottis, and the patient gets delirious 
or falls into the so-called “typhoid” condition, which gradually passes 
into coma and death. The acute stage of glanders following the chronic 
form is much more speedily fatal than when it occurs independently, 
for whilst in the latter case the disease may last for twenty days or 
more, in the former death usually puts an end to the patient’s sufferings 
in less than a week. 
Diagnosis.—This malady probably sometimes escapes recognition, 
for unless there be a clear history of inoculation, the practitioner is not 
likely to think of so rare a disease as glanders. In all instances, there- 
fore, of nasal obstruction and discharge, especially if accompanied by 
marked derangement of the system, pains in the limbs, and abscesses 
in various parts of the body, the history of the patient should be care- 
fully inquired into, particularly as regards his occupation and habits. 
It is only from a broad view of the circumstances that a correct opinion 
can be arrived at in cases that are at all doubtful. The pustules and 
ulcers have nothing absolutely distinctive in themselves, and the general 
symptoms of both glanders and farcy bear a strong resemblance to the 
salient features of many other more common affections. Thus the pains 
about the joints which are met with in farcy are suggestive of rheuma- 
tism, until a minute examination reveals that it is not the articulation 
itself that is complained of, but the muscles and tendons surrounding 
it. The rigors and abscesses will probably lead the practitioner to 
suspect pyaemia, especially if there be a history of a dissecting wound ; 
it should be remembered, therefore, that shivering is a much less marked 
feature in farcy than it is in pyaemia, and that in many instances this 
symptom is altogether absent. When the complaint is accompanied, 
as it not unfrequently is, by gastro-intestinal disturbance, it may simu- 
late typhoid fever very closely, but the absence of the rose-colored spots 
and of the characteristic wave-like rise in temperature will serve to 
distinguish it from that disorder. Glanders is particularly likely to 
be mistaken for venereal disease of the nose and throat, but the great 
amount of constitutional disturbance in the former complaint, and the 414 
DISEASES OF THE THROAT AND NOSE. 
favorable action of iodide of potassium in the latter, afford ample grounds 
of distinction. From scrofulous eruptions and ulcers about the face 
and within the nose, the disorder can likewise be distinguished by the 
severity of the constitutional symptoms which accompany it. With 
every possible precaution, however, a certain diagnosis cannot always 
be arrived at, and a striking example of the difficulties surrounding the 
practitioner who has to deal with tins obscure disease is related by Vir- 
chow,* who records a case in which the autopsy on a patient, whose 
complaint had not been recognized during life, led to the discovery of 
a severe epizootic of the malady among horses which had been previ- 
ously overlooked. 
Pathology.—The disease is of the same pathological type as syphilis 
and tuberculosis, and it bears a close resemblance to pyaemia. The 
morbid process exhibits the ordinary sequence of phenomena due to 
blood-poisoning, viz., infection through broken skin or mucous mem- 
brane, inflammation of the lymphatic vessels connected with the point 
of entrance of the virus, swelling and suppuration of the related lym- 
phatic glands, and gradual generalization of the disease through the 
entire system. The specific morbid product, if such it can be called, of 
glanders is a nodule or tubercle, deposited on the skin and mucous 
membrane in some part of the body, notably on the face, limbs, and 
walls of the nasal passages. These nodules are usually not much larger 
than a grain of hemp-seed, and they may be scattered about, or grouped 
together in clusters. They are at first almost colorless, but, rapidly 
increasing in size, they become first red, and then gradually yellowish 
in hue, and acquire all the characters of pustules. On microscopic 
section, these bodies are found to consist of pus-cells and numerous 
small nuclei densely packed together; and, quite recently, rod-shaped 
bacteria, somewhat resembling tubercle-bacilli, have been detected in 
the pustules and ulcers of men and animals suffering from glanders, 
by Schiitz and Lofflerf in Germany, and almost at the same time by 
Capitan,§ and Charous|| in France. The nodules show a 
marked tendency to break down and become converted into small 
abscesses. These in many cases burst, and a foul sore with irregular 
edges is produced, which has little or no disposition to heal, and in the 
acute form of the malady may even spread to the neighboring parts of 
* Die Krankhaften Geschwiilste, Berlin, 1864-5, vol. ii., p. 554. 
f Deutsche Med Wochenschr., 1882, No 52. 
X Revue Med. Franpaise, Dec. 30, 1882. 
3 Ibid. || Ibid. GLANDERS. 
415 
the skin, or, penetrating deeply through the underlying tissues, may 
reach the skeleton. 
Prognosis.—Acute glanders is almost invariably fatal, but a few cases 
of recovery have been recorded.* In the chronic disease the prospects 
of the patient are less gloomy as regards the immediate issue, but the 
malady leaves ineffaceable marks of its presence, and complete restoration 
to health can hardly ever be looked for. As to the disease in general, 
perhaps the best practical guide for the physician in forecasting the re- 
sult of a case is to be found in the rule laid down by Brouardel,f that 
so long as the nose is not affected there is still room for hope. 
Treatment.—The treatment of glanders, when once the system has 
been impregnated with the poison, is confessed by all writers on the 
subject to be almost utterly ineffectual. Certain general principles 
must, of course, be adhered to, such as carefully attending to all the 
symptoms as they are developed, and watching the constitutional con- 
dition of the patient, so as to give stimulants when the strength begins 
to flag, anodynes or sedatives if there be pain, excitement, or sleepless- 
ness. Emetics and purgatives have been recommended, but the former 
should never be given, and the latter only when clearly indicated. 
Various preparations of iodine and sulphur have been at different times 
proposed as specific remedies, and recoveries have been attributed to the 
use of each of those drugs.J 
Certain local remedies should not be neglected, as, even if they fail 
to prolong the patient’s life, they may lessen his suffering, and, what is 
also of importance, diminish the risk of this loathsome disease being 
conveyed to his attendants. Elliotson § states that he succeeded in 
stopping the discharge from the nose by injecting a solution of two 
grains of creasote in a pint of water three times a day. Ulcerated sur- 
faces should be frequently dressed with lint steeped in carbolic acid 
solution (1 in 60 or 80). 
It need hardly be added that the most vigorous prophylactic measures 
should be carried out wherever the disease is found to exist. In the 
case of horses this is enforced by legal enactment, and though the malady 
is less likely to be communicated by man to man, the utmost care should 
always betaken to destroy or disinfect anything by which the virus may 
be conveyed. According to the experiments of Gerlach,|| carbolic acid 
* Brouardel, op. cit., p. 184; Harrison, Lancet, vol. ii., 1872, p. 910; Haynes Wal- 
ton, Med. Times and Gaz., 1877, vol. ii., p. 13. 
f Op. cit., p. 191. 
\ Loc. cit. 
J See Brouardel: op. cit., p 202. 
|| Quoted by Bollinger, op. cit., p. 370. 416 
DISEASES OF THE THROAT AND NOSE. 
destroys the activity of the poison, and any one who is in attendance on 
a case of glanders, whether in man or beast, should on no account 
neglect to wash his hands and instruments in a strong solution of this 
antiseptic agent after every dressing. 
An interesting observation has lately been published by Meyrick* 
which tends to show that (as might be expected) the virus becomes at- 
tenuated by long exposure to the air, and that animals inoculated with 
this milder poison suffer from a modified form of the disease. A cavalry 
party was picketed on a sandy plain in the neighborhood of Cairo, near 
to a spot which had been occupied some months before by a detachment 
of Indian cavalry, whose horses had suffered severely from glanders. 
Two horses belonging to the former contracted glanders, and several 
others had swelling of the submaxillary glands and vesicles on the 
Schneiderian membrane, which burst, but healed quickly without ul- 
ceration. The important question to be decided now is whether the 
inoculation of virus, weakened by proper cultivation, would act as a 
preservative against the effect of glanders-poison in its more active form. 
On this point there is not yet, so far as I am aware, any evidence 
whatever. 
AFFECTIONS OF THE NOSE IN ERUPTIVE FEVERS, 
AND OTHER ACUTE DISEASES. 
Measles.—In measles, serous flax from the nose, with congestion of 
the conjunctiva, is one of the earliest symptoms. Occasionally this is 
followed by severe rhinitis, and in these cases epistaxis not unfrequently 
occurs. If these acute symptoms subside, and the patient recovers, dry 
catarrh and ozsena sometimes remain behind. Ulceration of the septum 
has also been observed.f 
/Scarlet Fever.—In scarlatina anginosa the nasal mucous membrane 
is often involved. The affection may be of merely catarrhal character, 
or on the other hand, the inflammation may be very severe, and accom- 
panied by great swelling of the mucous membrane and an abundant 
irritating discharge. Ulceration sometimes takes place, and this may be 
followed by epistaxis. 
* Veterinary Journal, 1883, vol. xvii., p. 179. 
f Joffroy: Bull, de la Soc. Anat., 1870, p. 164. Also Dechant: De la Rougeole, 
These de Paris, 1842, p. 24. AFFECTIONS OF THE NOSE IN ERUPTIVE FEVERS, ETC. 
417 
Small-pox.—In this disease, especially in the confluent variety, pus- 
tules occasionally form inside the nose, causing obstruction of the 
passage, and in certain cases producing epistaxis. Complete oblitera- 
tion of one or both nostrils has more than once resulted from the union 
of the opposite raw surfaces of the outer and inner walls of the nostril 
when the scabs have come away. An instance of this kind has been 
recorded by Luc,* who succeeded in remedying the condition by in- 
cising the nostril and afterwards keeping it open by dilatation. 
Typhoid Fever.—In all adynamic fevers it is well known that there 
is a tendency to acute inflammation of tissue, with formation of ab- 
scesses. The influence of position, which in typhoid fever is so largely 
concerned in the production of throat affections, does not come into 
operation in the case of the nose, but changes are apt to occur in the 
mucous membrane from the drying of masses of mucus within the nasal 
fossse. The ulcers thus formed often spread, and necrosis of the septum 
may take place, resulting finally in perforation. Cases due to long and 
exhausting fever have been observed by Roger,* Leceeur,| Gietl,§ 
Lagneau,|| and Charcot.^ 
Rheumatism.—In rheumatic fever, severe inflammation and ulceration 
of the pituitary membrane sometimes occur, and even necrosis of the 
cartilaginous portion of the septum has been noticed. An instance of 
this kind has been related by Roger,** in which a young man suffering 
from very severe rheumatism, with well-marked cardiac complications, 
lost a portion of his septal cartilage of about the size of a grain of rice 
two months before his death. A somewhat similar case has also been 
reported by Corbel.ff 
Influenza.—It has not appeared to me desirable to treat influenza as 
a separate article, as the symptoms affecting the bronchial tubes and the 
lungs are so much more important than those which manifest themselves 
in the nose. It must not be forgotten, however, that the latter are the 
first to attract attention. 
Nasal Diphtheria.—This affection has already been fully considered 
(vol. i., p. 193.) 
* Quoted by Casabianca: Des Affections de la Cloison des Fosses nasales, Paris, 
1876, p. 17. 
f Gazette des Hfipitaux, 1860, p. 153. + Ibid., p. 214. 
§ Union Mfidicale, 1862, t. xvi., p. 523. 
1| Gazette Hebdom., 1863, p. 440. If Quoted by Casabianca, op. cit., p. 33. 
** Union M6dicale, 1860, nouvelle serie, t. v., p. 468. 
ff Gazette des Hfipitaux, 1860, p. 178. 418 
DISEASES OF THE THROAT AND NOSE. 
FRACTURES OF THE NOSE. 
Latin Eq.—Fractura ossiurn nasi. 
French Eq.—Fracture des os du nez. 
German Eq.—Fractur der Nasenknochen. 
Italian Eq.—Frattura delle ossa del naso. 
Definition.—Fractures of the hones or cartilages of the nose, often 
compound, either from a wound in the shin, qr from laceration of the 
mucous membrane, generally accompanied by considerable contusion and 
some displacement. 
History.—Fracture of the nasal bones has been familiar to practitioners from the 
earliest times of surgery. Hippocrates* discusses such injuries at some length, and 
the methods of treatment which he recommends show that he must have had a large 
experience of broken noses; and when it is remembered that he practiced among a 
people who held boxing in high esteem, this is hardly to be wondered at. Hippocrates 
mentions that fractures of the nose were done up in such an elaborate way that every 
young surgeon was anxious to meet with an example of the injury, in order that he 
might have an opportunity of showing his skill in bandaging. It may be remarked 
in connection with this subject that Hippocrates recommends the application of shreds 
of linen steeped in white of egg as the best means of keeping the bones in place—a 
remarkable anticipation of the starch bandage of modern days. In the sixteenth 
century Ambrose Par6f strictly followed Hippocrates in his mode of treatment. In 
modern times, JarjavayJ has written at some length on certain sequelae of fracture of 
the nose; and William Adams£ has published some important improvements in the 
mode of treating the injury, especially as regards the avoidance of subsequent de- 
formity. 
Etiology.—Owing to the arched form of the nasal bones, and their 
sheltered position between the prominence of the os frontis and the 
cartilaginous tip of the nose, they are seldom broken, except when a 
person falls against a sharp corner, such as the edge of a step or a table, 
or the angle of a wall, or when an angular body, such as the knuckles 
of a man’s fist, or the iron shoe of a horse, is driven violently against 
the nose. The nasal bones are, however, liable to be fractured by 
blows which fall on them sideways. In such cases both bones are 
usually broken transversely, the lower fragments being dislocated 
* De Artubus, Paris, 1844, edition, vol. iv., p. 159. 
f CEuvres, livr. 8, ch. xxvi., Paris, 1840, Malgaigne’s edition, vol. ii., p. 86. 
J Bull. Gfenferal de Thbrap., 1867, t. lxii., p. 539 et seq. 
$ Brit. Med. Journ., 1875, vol. ii., pp. 421-422. FRACTURES OF TIIE NOSE. 
419 
towards the opposite side to that on which the blow is received. Falls 
on the head sometimes produce fractures of the roof of the nose, i.e., of 
the ethmoid bone, but in these cases the injury of the base of the skull 
is, of course, very much more important than that of the nose. On 
the other hand, it has been found experimentally by Hamilton* that 
direct injury to the septum will not cause fracture of the cribriform 
plate. The nose would, however, be much more liable to fracture, 
were it not for the yielding character of the cartilage, on which blows 
mostly fall, breaking the shock in great measure. Gurltf found that 
out of a total of 225 fractures of the bones of the head, there were 
twenty-two of the nose, seventeen of the upper jaw and zygoma, and 
fifty-six of the lower jaw; whilst Otto Weber,| in fifty-six fractures of 
the cranial bones, met with ten of the nose, four of the upper jaw, and 
zygoma, and nine of the lower jaw. 
It is possible that the delicate skeleton of an infant’s nose may be 
irretrievably damaged by the blades of the forceps in childbirth, but I 
am not aware of any actually recorded case of this accident, except the 
somewhat questionable one of Tristram Shandy. Fibrous and malig- 
nant tumors of the nasal fossee or the neighboring parts sometimes pro- 
duce fracture of the bony roof or parietes of the nose, but more often 
the pressure of such growths causes absorption of the bone. 
Symptoms.—The injury varies from a simple fracture, without dis- 
placement, to complete crushing of the nasal arch. A case has come 
under my notice, in which the wheel of a tramcar passed over the face 
of a gentleman, completely crushing his nose, but doing him very little 
damage otherwise. The disfigurement, however, was so great that the 
patient had to retire from his profession. In another instance, with 
which I am acquainted, the bony part of the nose was crushed flat by 
a fall, leaving an ugly knob corresponding to what had been the tip of 
a very shapely feature, and giving the whole face a markedly simian 
expression. The sufferer, a highly popular abb6, had to hide his dis- 
figurement in a monastery. Even in the slighter forms of injury there 
is ordinarily great swelling of the soft parts, with widespread ecchy- 
mosis and oedema of the eyelids and cheeks. There is always some 
epistaxis,§ and occasionally, when the mucous membrane has been torn, 
* Practical Treatise on Fractures and Dislocations, Philadelphia, 1866, 3d ed., p. 93. 
f Handbuch der Lehre von den Knochenbriichen, Hanover, 1864, vol. ii., p. 499. 
X Op. cit., p. 179. 
§ One fatal case of haemorrhage was observed by Rossi. Quoted by O. Weber in v. 
Pitha und Billroth’s Handbuch der Chirurgie, Bd. iii., 1 Abtheil., 2 Heft, Erlangen, 
1866, p. 181. Another was recorded by West (Lancet, 1862, vol. i., p. 660). Bleeding 420 
DISEASES OF TIIE THROAT AND NOSE. 
emphysema occurs. This usually follows the accident on violent sneez- 
ing or blowing of the nose, and, although very alarming to the patient, 
is of no importance. In order to make a satisfactory examination, the 
patient should be fully anaesthetized, when the nature of the injury will 
as a rule be ascertained, although it is in most cases difficult to detect 
crepitus. By passing a small probe up the nose with one hand, whilst 
with the other the parts are gently manipulated externally, any dis- 
placement will generally be discovered. Hamilton* judiciously points 
out that a small probe is much more useful than a catheter, which is 
usually recommended, and which, from its sizef often cannot be passed, 
even when force is used. The sense of smell is frequently impaired, 
and sometimes even destroyed, from injury to the terminal twigs of the 
olfactory nerves. 
Diagnosis.—If the directions already given be followed (see Symp- 
toms), the nature of the accident will, in most cases, be recognized with- 
out much difficulty. 
Pathology.—The only special point that need be referred to in con- 
nection with the pathology is the remarkable disposition to rapid union 
in fracture of the bones of the nose. This peculiarity attracted the at- 
tention of Hippocrates,f and it is now recognized as being due to the 
extraordinary plastic power of the bones in the upper part of the face, 
a property which has been taken advantage of in the “ osteoplastic op- 
erations ” of Langenbeck, Ollier, and others, hereafter detailed. 
Prognosis.—The greatest disfigurement may always be anticipated, if 
the accident be not properly treated, and this may have the most serious 
results as regards the patient’s future career. It must not be forgotten 
that such injuries may also be attended with danger to life. GurltJ 
has shown that in cases in which at the time of the accident there was 
no evidence of injury to the brain, cerebral symptoms have afterwards 
come on. Out of fourteen examples of fracture of the nose, collected 
by Weber§in the Bonn Clinic, there were four in which there was con- 
cussion of the brain, one of them terminating fatally. 
Treatment.—The rapid union which takes place after fractures of the 
nose just referred to, though a highly conservative process, makes it of 
the utmost importance that the condition should be discovered in time 
to avoid deformity from improper union. As the tissues covering the 
recurred again and again, and the patient, a man aged sixty, died exhausted on the 
twenty-third day after the injury. 
* Op. cit. f Op. cit., p. 167. X Op. cit., p. 240. 
§ V. Pitha und Billroth’s Handbuch der Chirurgie, Bd. iii., 1 Abtheil., 2 Heft, Er- 
langen, 1866, p. 181. DISLOCATION OF THE NASAL BONES. 
421 
broken bones are usually much contused, the first thing to be done is to 
attempt to disperse the swelling by means of evaporating lotions or 
other cold applications. The fragments should then be, as far as pos- 
sible, replaced. This can generally be done by means of a pair of fine 
dressing-forceps or a female-catheter introduced within the nose, com- 
bined with manipulations with the fingers of the left hand on the out- 
side. Once restored to their proper position the fragments show little 
tendency to separate, for, as pointed out by Holmes Coote,* they are 
not acted on by any muscles. There is seldom, therefore, any necessity 
for splints or other supporting apparatus, which are, moreover, as a 
rule, intolerably irksome to the patient. If, however, the septum has 
been fractured, and displacement has been produced, Adamsf advises 
that the fragments should be forcibly restored to their proper position 
with forceps, and retained in situ by means of a special splint and truss 
(p. 283). Jurasz’s ingenious modification of Adams’s instrument (see 
p. 283), which combines both forceps and splints, may also be advan- 
tageously used for the same purpose. Mason £ has recently described a 
new method of treating fractures of the nose where the nasal processes 
of the superior maxillary bone are involved, and where, consequently, 
there is marked depression of the fragments. After reduction a needle 
is passed through the skin behind, the fragment and brought out through 
the skin on the other side of the nose. A narrow band of india-rubber 
is fastened over each end of the needle, so as to make gentle pressure on 
the sides of the nose. This makes a firm support for the broken piece, 
preventing it from becoming depressed. Evaporating lotions or other 
dressings can be easily applied without disturbing the apparatus. The 
needles are to be removed from the sixth to the tenth day. Mason says 
that the wounds produced by the needle are quite insignificant. The 
plan appears to have been tried in only one case as yet,, but the result 
was very encouraging. 
DISLOCATION OF THE NASAL BONES. 
Separation of the nasal bones from the frontal bone, or from the nasal 
process of the superior maxillary, is so rare that its occurrence lias been 
* Holmes’s System of Surgery, 2d ed., 1870, vol. ii., p. 427. 
f Loc. cit. 
J Annals Anat. and Surg. Soc. Brooklyn, New York, 1880, vol. p. 107 etseq-., and; 
pp.197-199. 422 
DISEASES OF THE THROAT AND NOSE. 
denied. Benjamin Bell* states that “ instances of it are sometimes met 
with,” but without furnishing any details. Malgaigne,f however, gives 
the particulars of a case in which the existence of luxation of the nasal 
bones was established as certainly as any form of injury can be made 
out by touch and appearance without actual dissection. A man in fall- 
ing struck the left side of his nose with great violence against the edge of 
the pavement. On examination, shortly after the accident, the upper 
third of the nose was seen to be deflected towards the right side, the lower 
part preserving its normal direction. The lower edge of the right nasal 
bone projected over its corresponding cartilage, whilst on the left side 
the inner edge of the nasal process of the superior maxillary stood out in 
sharp relief from the depression of the left nasal bone, a gap being evi- 
dent between the upper edge of this latter and the frontal bone. There 
was no fracture. It is evident from this description that whilst on the 
right side the nasal bone was only separated along its lower edge, there 
was complete luxation of the corresponding bone on the left side, where 
the blow had been received. 
In a case recorded by Longuet,J in which a soldier received a very 
heavy blow near the inner angle of the right eye, the upper part of the 
nasal bones appeared to have been pushed over bodily towards the left 
side, the septal cartilage, however, remaining in its normal position. 
The edge of the nasal bone could be plainly felt overriding the nasal 
process of the upper jaw on one side, whilst on the other the correspond- 
ing edges were visibly separated by a groove wide enough to admit the 
thumb-nail. 
It will be observed that the mode of production of the injury is 
almost identical in these two cases, viz., a violent blow striking the 
nose sideways. It was only in this manner, also, that Longuet was 
able to produce luxation of the nasal bones in several experiments 
which he made on the dead body. The nasal bones may also be pushed 
asunder by a fibrous or sarcomatous mass, giving rise to the unsightly 
“frog-face” hereafter described. (See “Fibrous Polypi of the Naso- 
pharynx.”) The symj)toms in the two cases related above were very 
much alike, consisting in epistaxis, swelling, tenderness, and a charac- 
teristic deformity. Reduction, which in Longuet’s case was exceedingly 
difficult, and only partially successful, is best accomplished by combined 
* System of Surgery, Edinburgh, 1788, vol. vi., p. 184. 
f Revue Mdd.-Chir. de Paris, 1851, t. x., p. 82. 
f Recueil de Mdmoires de Med. de Chir. et de Phar. Milit., t. xxxvii., 3e fascicule, 
May-June, 1881, No. 202, p. 284. DEVIATION OF THE NASAL SEPTUM. 
423 
manipulation of the displaced bones from the interior of the nose and 
the outside. As the pain of the operation is very great, it is desirable 
to anaesthetize the patient before the reduction is commenced. 
DEVIATION OF THE NASAL SEPTUM. 
Latin Eq.—Incurvatio septi narium. 
French Eq.—Deviation de la cloison du nez. 
German Eq.—Verbiegung der Nasenscheidewand. 
Italian Eq.—Deviazione del setto nasale. 
History.—More than a century ago, a short monograph was published by Quelmalz* 
on curvature of the nasal septum, which he appears to have considered as resulting in 
nearly all cases from injury or disease. Later on Morgagni,f who claims to have given 
special attention to this matter, was disposed to attribute the condition to too rapid 
growth of the septum in proportion to that of the upper jaw. Soon afterwards, HallerJ 
pointed out the frequent occurrence of this deformity, which he thought rendered the 
subjects of it more liable to catarrh than other people. The subject was briefly referred 
to by Hildebrandt,| and again by Yelpeau.|| In 1851 Chassaignacf dealt with devia- 
tion of the septum in its cartilaginous portion, and described a method by which he 
succeeded in correcting the deformity. Another plan of procedure was tried by Blan- 
din,** and an operation has been devised by Adams,ff and improved by Jurasz,Jj; 
for which excellent results are claimed. Theile§§ seems to have been the first who 
attempted a numerical estimate of the frequency with which asymmetry of the nasal 
septum is found in the dry skull, a matter which has recently received further illus- 
tration at the hands of Semeleder,|||| Sappey,T[f Harrison Allen,*** and Zucker- 
kandl,fff and a highly scientific anatomical work has been recently published on the 
* De narium, earumque septi, incurvatione, Lipsise, 1750. 
f De sed. et cans, morb., Lugd. Batav., 1767, epist. xiv., art. 16; vol. i., p. 207. 
X Elem. physiol, corp. human, Lausannse, 1769, t. v., p. 138. 
$ Lehrb. d; Anat., Wien, 1802, Bd. iii. 
|| Traite complet. d’Anat. Chir., Paris, 1837, 3e 6d., t. i., p. 252. 
T[ Bull, de la Soc. de Chir., 1851-52, t. ii., p. 253. 
** Compendium de Chir. Prat., t. iii., p. 33. 
ft Brit. Med. Journ., Oct. 2, 1875. 
Berlin klin. Wochenschr., 1882, No. 4. 
%% Zeitschr. f. rationelle Medicin, Neue Folge, 1855, Bd. vi., p. 242 et seq. 
dll Die Rhinoskopie, Leipzig, 1862, p. 64. 
IfH Anatomie descriptive, t. iii., 3e 6d., Paris, 1877, p. 674. 
*** American Journ. Med. Sci., Jan., 1880, p. 70. 
fft Anatomie der Nasenhohle, Wien, 1882, p 44 et seq. 424 
DISEASES OF THE THROAT AND NOSE. 
subject by Welcker.* Lowenbergf has lately written a suggestive paper on these 
deviations, and their influence on the condition of the singing voice has been pointed 
out by Walsham.f; 
Etiology.—An asymmetrical position of the septum is very common. 
Numerical observations as regards the frequency have at present only 
been made on dried specimens, in which the cartilage is very seldom 
present. In 117 skulls Theile found deviation in 73.5 per cent. 
Semeleder in 49 crania met with it in 79.5 per cent., the septum being 
bent towards the left side in twenty, and towards the right in fifteen 
cases. In four instances the curvature was of a sigmoid outline, thus 
bulging into both nasal fossae in different places. Allen, in 58, found 
the septum so much deflected in 68.9 per cent, as to come in contact 
with the upper and middle spongy bones; whilst Zuckerkandl, in 370 
skulls, met with an asymmetrical position in 140 cases, i.e., in 37.8 
per cent. In fifty-seven cases the bend was to the right, in fifty-one 
to the left, and in thirty-two it was S-shaped. With the view of in- 
vestigating the whole subject of septal asymmetry on a larger scale, I 
have lately made a careful examination of the collection of skulls in 
the Museum of the Royal College of Surgeons, with the assistance of 
Mr. C. L. Taylor. The total number of crania actually examined was 
3102, but of these only 2152 had the bony septum in sufficient preser- 
vation to be tested. In each instance of septal asymmetry, the degree 
of deflection from the middle line of the face was measured as accurately 
as possible by means of a little instrument§ which I devised for the 
purpose.. It was found that the average deviation of the septum in the 
2152 skulls was about 4 millimetres; the greatest degree being 9 milli- 
metres, and the least half a millimetre.|| Among them no fewer than 
1657, or 76.9 per cent., presented a more or less unsymmetrical position 
of the septum. In 838, or 38.9 per cent, of the cases, the deviation 
* Asymmetrien der Nase, Stuttgart, 1882. 
f Arch, of Otology, vol. xii., No. 1, March, 1883. 
t St. Bartholomew’s Hosp. l\ep., vol. xviii., p. 11 et seq. See also Lancet, April 12, 
1883, p. 705. 
$ This consisted of a couple of short metal bars supported on a cross-piece placed 
at right angles to one of them, the other being midway between the two—that is to 
say, at an inclination of 45° to each. The angle between the two little bars was sub- 
tended by a curved piece of metal constituting an arc which was graduated in milli- 
metres, so that by placing the upright bar in a position corresponding to the middle 
line of the nose, the degree of obliquity of any object within the nasal cavity could be 
easily read off on the scale. 
|| Septa showing a deviation of less than half a millimetre were counted as straight. DEVIATION OF THE NASAL SEPTUM, 
425 
was towards the left side; in 609, or 28.2 per cent., towards the right; 
in 205, or 9.5 per cent., the deflection was “sigmoid” in character, 
bulging towards both sides at different levels, whilst in 5, or .023 per 
cent., the irregularity was of a type that may be called “zig-zag,” i.e., 
the perpendicular lamina of the ethmoid and the vomer, instead of 
joining accurately to form a smooth plate of bone, lay in different 
planes, and overlapped each other at their contiguous edges. It must 
be remembered that these figures have reference only to the bony sep- 
tum, and that deviations of the cartilaginous part probably occurred in 
a large proportion of those cases in which the bone itself was straight. 
Hence the actual percentage of deflections is much higher during life 
than would appear from the above statistics. According to Zucker- 
kandl the superior races show a greater disposition to this deformity 
than those of a lower type, for in 103 non-European crania it was 
present in only 23.3 per cent. My investigations yield very similar 
results, for of 438 examples of symmetrical septa only 22.6 per cent, 
were from Europeans,* the rest being from Africans, aborigines of the 
American Continent, natives of the Polynesian Islands, and a few from 
the Andaman Islands, the New Hebrides, New Guinea, the Solomon 
Islands, and from the Island of Teneriffe. 
The cause of deviation of the bony septum is very obscure. Cloquetf 
somewhat oracularly veils his ignorance of the matter under the high- 
sounding phrase, that curvature of the septum “depends on a primary 
law of organization.” It was at one time thought that the condition 
was often of congenital origin, but according to the researches of 
Zuckerkandl the septum is always straight before the seventh year. It 
is not impossible that the deflection may result from the fact that ossi- 
fication of the septum proceeds from centres situated in two different 
bones, and that these deposits of ossific matter do not subsequently meet 
in the same plane. As regards deviation of the cartilaginous septum, 
various causes have been assigned for the anomaly, such as always blow- 
ing the nose with the same hand, or habitually sleeping with the same 
side of the face on the pillow; but the evidence in support of these 
views is, to say the least, insufficient. ChassaignacJ suggests that there 
may be a tendency to overgrowth in the vertical direction, and this 
being prevented by the firm bony attachments, the elastic substance 
* It is remarkable that nearly half of these were Italian skulls, which as a class 
were of strikingly symmetrical proportions, 
f Osphr&siologie, Paris, 1821, 2me dd., p. 165. 
J Bull, de la Soc. de Chir., 1851-52, t. ii., p. 253. 426 
DISEASES OF THE THROAT AND NOSE. 
of the cartilage necessarily bulges out laterally into one or other nasal 
fossa. 
Symptoms.—When the deflection is considerable, the whole nose is 
twisted to one side, and the most casual observer notices the disfigure- 
ment; but when the deviation of the septum is not great, it may merely 
cause a slight twist of the tip of the nose, or it may not even give rise 
to any external alteration. Anterior rhinoscopy, however, makes the 
condition at once apparent, and though the deformity scarcely ever 
(never, according to my observations) affects the posterior part of the 
septum, the rhinal mirror often reflects the deviation in the central and 
anterior portions of the nose. The tumor frequently encroaches on the 
corresponding nasal channel, and in some cases completely occludes it. 
In such instances the distortion of the septum, in addition to its un- 
sightly appearance, gives rise to functional troubles which may oc- 
casionally amount to serious inconvenience. Respiration through the 
nose is interfered with, the voice acquires the characteristic nasal twang, 
the discharge of the pituitary secretion through the nostril is prevented, 
and post-nasal catarrh, with its attendant evils, results. The turbi- 
nated bodies are not unfrequently so pressed upon that they undergo 
atrophy, and dry catarrh may then ensue. In a case recently under 
my care, the most troublesome symptom was epistaxis, caused by erosion 
of the outer wall of the nose. 
Diagnosis.—It is difficult to understand how any error could be made 
as regards this disease, except by those who do not make a proper rhino- 
scopic examination, or who are entirely unacquainted with nasal affec- 
tions. Yet the deformity has frequently been mistaken for thickening 
and sometimes for polypus.* Careful comparison of both sides of the 
septum at once determines the former point; but an ingenious “septo- 
meter” has been invented by Seiler,f which serves to distinguish 
thickening from deviation when these affections occur separately. Pol- 
ypus can be easily recognized by its comparative softness, elasticity, 
mobility, and pale color. 
Pathology.—The deviation is almost always limited to the anterior 
three-fourths of the septum. 
The bony ridges already described as being common on the lower 
half of the septum (p. 383) are frequently found associated with curva- 
ture of that partition. Thus in 673 specimens, in the Hunterian 
* Chassaignac: loc. cit., p. 256. I have myself also known this mistake to be made 
in more than one instance. 
f Diseases of the Throat, etc., 1883, 2d ed., p. 83. DEVIATION OF THE NASAL SEPTUM. 
427 
Museum, in which a ridge existed, the septum was deviated in 588. In 
414 instances the ridge was on the side towards which the septum pro- 
jected, in 107 on the opposite side, and in 85 skulls there was a ridge 
without any deflection of the partition itself. Although, owing to the 
difficulty of determining with certainty the sex from the cranium alone, 
it is not possible for me to give exact figures on the subject, I am in- 
clined to think that these bony ridges are relatively less common in 
women than in men, and that when they are present in the former they 
Anterior Nares and part of Skull, showing the Septum deviated according to the 
Sigmoid Type. 
a, upper part of the septum bent towards the left side; b, concavity on left surface 
corresponding to convex portion bulging into right nasal fossa; c, bony crest or ridge 
projecting into left fossa; dd, middle, and ee, lower spongy bones. 
(The amount of deviation here shown is seen in several specimens in the Museum of the 
Royal College of Surgeons, and bony ridges also occur in many of them. The above 
cut is a composite drawing of various deformities met with in different skulls.) 
are (as might naturally be expected) both less thick and less prominent. 
The foregoing woodcut (Fig. 86) gives a very good representation of 
such a ridge, and of septal asymmetry in general. 
Treatment.—When the bony septum is the seat of marked deviation 
it might sometimes be possible to remedy the condition by fracturing 
the distorted partition with Adams’s forceps (Fig. 72, p. 282), and 
fixing the fragments in a more symmetrical position by means of his 
splint introduced into each nostril. I am not aware that this method 
has ever been used for the rectification of natural deformity, but Adams 428 
DISEASES OF THE THROAT AND NOSE. 
has had such excellent results* from it in the treatment of fracture of 
the septum that it seems worth trying in cases of non-traumatic devia- 
tion. It is only, however, when the deflection is extreme that so severe 
a procedure would be justifiable. 
The treatment of the bony outgrowths sometimes found in connection 
with a deviated septum has been already discussed (p. 384). 
When the deviation is in the cartilaginous portion, the simplest plan 
of treatment is that of Michel,f who directs the patient to make gentle 
pressure on the nose with the finger, towards the opposite side. This 
must, of course, be done very frequently each day, and it is obvious 
that it is applicable only in the case of young persons, and where the 
deformity is comparatively trifling. Where the object of the surgeon 
has been more to remove a source of disease than to correct a deformity, 
good results have been obtained by establishing free communication 
between the unobstructed fossa and its fellow. This was first proposed 
and accomplished by Blandin,J who removed a piece of the cartilage 
with a kind of punch. Chassaignac§ relieved a very bad case by dis- 
secting up the mucous membrane, and paring off slices of the pro- 
tuberant cartilage, thus reducing its bulk and freeing the nasal channel 
from the greater part of the obstructing mass. Walsham|| forcibly 
replaced the bent septum of a patient in whom the deformity had caused 
loss of the singing-voice, at the same time incising the cartilage in a 
stellate manner to overcome its resiliency. The voice was completely 
restored. 
BLOOD-TUMORS OF THE NASAL SEPTUM. 
History.—The first clear account of hoematomata and abscesses of the nasal septum 
was given by Cloquet in 1830,1[ and three years later the affection was described by 
Fleming,** from his own observations. Examples have since been published byB6rard,ff 
Maisonneuve,J$ Velpeau,$$ and others; and in 1864 Beaussenat|||| took these affections 
* Brit. Med. Journ., Oct. 2, 1875. 
f Krankheiten der Nasenhohle, Berlin, 1876, p. 29. 
X Compendium de Chirurgie Pratique, t. iii., p. 33. 
\ Loc. cit., p. 256. || Loe. cit. 
f Journ. Hebd. de M5d., No. 91. t. vii., p 545. 
** Dublin Journ. of the Med. Sciences, Sept., 1833, vol. iv., p. 16 et seq. 
ff Archiv. G6n., t. xiii., 2e sfer., p. 408. 
Gazette des HGpitaux, 1841, p. 59. Ibid., 1860, p. 178. 
|| j| Des Tumeurs sanguines et purulentes de la Cloison, ThSse de Paris. 429 
BLOOD-TUMORS OF THE NASAL SEPTUM. 
as the subject of his inaugural thesis. A brief account of them was given by Casabi- 
anca,* in a short essay published in 1876. I have myself met with only one case of 
blood-tumor and one of septal abscess. 
Violent blows on the nose, which give rise to fracture of the bony or 
cartilaginous septum, sometimes cause blood-tumors, which collect 
within a few hours after the accident. The swelling results from the 
effusion of blood between the deep layer of the mucous membrane and 
the underlying cartilage, and as this accident seldom occurs without 
fracture, the collection of blood usually takes place on both sides of the 
septum, and a bilateral tumor is formed. Two cases of spontaneous 
unilateral hsematoma of the septum have been recorded. One was re- 
lated by Luc,f in which an Arab boy aged ten had complete oblitera- 
tion of both nostrils, dating apparently from an attack of confluent 
small-pox, from which he had suffered five years before. On dividing 
the cicatricial tissue, a blood-cyst was found in one nostril attached to 
the septum. In the other case, reported by Pean,| few details are given, 
but the tumor, which was connected with the septum, was soft, pale 
blue in color, and contained blood. Blood-tumors have a smooth sur- 
face and are purple in color, the rest of the mucous membrance of the 
nose, as pointed out by Fleming, being often of a similar ecchymotic 
hue. They are situated just within the nostrils, and in the only case 
which I have met with had very much the appearance of cysts. They 
are easily seen, and their symmetrical character, together with the 
fluctuation from one side of the septum to the other, which can be per- 
ceived when the tumor is examined with a fore-finger in each nostril, 
generally serve to determine its nature. When the swellings are large, 
they sometimes even protrude from the nostrils. Their soft consistence 
serves to distinguish them from bony or cartilaginous tumors, and their 
symmetrical origin by a broad base from each side of the septum differ- 
entiates them from polypus. It is difficult, however, to discriminate 
between these tumors and septal abscesses, into which, if not cured, they 
soon pass. The patient rarely recovers without a permanent aperture 
in the .septum. 
If treated sufficiently early, hannatomata may sometimes be dispersed 
by the free use of evaporating lotions; but if this plan does not succeed 
within a day or two, there is every chance of purulent degeneration of 
* Des Affections de la Cloison, Paris, 1876, p. 23 et seq. 
f Bull, de la Soc. de Chir., 1875. 
J Pathologie Chirurgicale, 2e ed., t. iii., p. 740. 430 
DISEASES OF THE THROAT AND NOSE. 
the extravasated blood taking place, and of the formation of an abscess. 
It is better, therefore, to empty the sacs by opening one of them at its 
most dependent part; and should this not suffice for the complete 
evacuation of the contents of both tumors, the other one should also be 
opened. Jarjavay* recommends that general antiphlogistic treatment 
should be combined with these surgical measures, especially at the outset. 
CASE OF IIJ5MATOMA OF THE NOSE. 
W. H. E., aged twenty-seven, a farrier, was brought under my notice at the Throat 
Hospital, in'March, 1863, by Dr. Frodsham. The patient stated that in shoeing a 
horse about ten days previously lie had received a slight kick on the nose, but that the 
hoof had scarcely touched him. Since then, however, he had felt a constant dull ach- 
ing sensation in the nose, which he said was “ completely stuffed up.” On examina- 
tion, both nasal passages were seen to be blocked up by dark, red, round tumors, which 
appeared rather tense. On making an exploratory puncture into the swelling on the 
right side, blood slowly oozed from the wound. A large opening was now made at 
the lowest part of the right tumor, and through it both cysts (for such they appeared 
to be) were evacuated. The next day, however, they had filled again. An incision, 
nearly half an inch in length, was next made in the left tumor, but three days later 
this also closed up. An opening was then made in both tumors, and a small piece of 
lint inserted in each. This treatment proved successful. Some sanious matter continued 
to escape from the left swelling for about fourteen days, when the wound healed. A 
purulent discharge from the right tumor gradually ceased at the end of a month. It 
was then noticed that there was a semicircular aperture in the anterior part of the 
septum, about half the size of a fourpenny-piece, the edges of which were ulcerated. 
The patient had never noticed any solid matter come away. The rest of the mucous 
membrane of the septum was rather dry and of a deep red color. With the exception 
of the opening the patient ultimately recovered completely. 
ABSCESS OF THE NASAL SEPTUM. 
(For History see last Article.) 
These abscesses may be acute or chronic. 
The Acute septal abscess is mostly of traumatic origin, and comes on 
within a few days, though sometimes not for a week or two, after the 
injury. It may result directly from the inflammation of the parts, or 
it may be due to the degeneration of a blood-tumor, as described in the 
foregoing article. Like the latter, the abscesses are generally situated 
* Bull. G6n. de Th6rap., 1867, t. Ixxii. ABSCESS OF THE NASAL SEPTUM. 
431 
at the forepart of the septum, and they are almost always symmetrically 
bilateral. They present the ordinary characters of an inflamed part, 
and may be accompanied by some slight constitutional disturbance. 
The nose is obstructed, the voice muffled, the conjunctive are red and 
extremely sensitive to light, whilst there is frequently profuse lachry- 
mation. There is often also a good deal of redness and tenderness of 
the skin of the nose itself. Chronic abscesses have the same shape and 
position as those of an acute character, and usually arise from th'esame 
causes. They are, however, much less quick in forming, less painful, 
of a lighter color, and are accompanied by little or no systemic disturb- 
ance. They have been mistaken for mucous polypi, but the points of 
diagnosis already indicated in dealing with hsematomata are amply suf- 
ficient to differentiate these tumors. Like blood-tumors, their cure is 
generally followed by a permanent opening in the septum. The only 
effectual treatment is to evacuate the contents of the sacs; and free drain- 
age can only be insured by opening both the tumors, and keeping the 
incisions patent with a small linen tent or by the occasional introduc- 
tion of a probe. 
CASE OF CHRONIC SEPTAL ABSCESS. 
Charles H., a laborer, aged thirty-one, had been under my care at the London Hos- 
pital, for a short time, in the early part of 1870, on account of general weakness after 
typhoid fever, when at one of my visits he complained of difficulty of breathing and 
“ stoppage ” in his nose. On making an examination, I found two pale pinkish yellow 
swellings, blocking up each nostril. They were rather tense, did not pit on pressure, 
nor show signs of fluctuation. The patient had at the time been convalescent from his 
attack of fever for seven weeks; that is to say, he had been going regularly out of 
doors during that period, and he stated distinctly that until a week before he had never 
felt anything the matter with his nose. On making an incision into one of the tumors, 
pus freely poured out, and on pressing the other tumor, it also was completely emptied, 
a small quantity of chalky matter coming away with the contents. On passing a probe 
an oval opening, nearly half an inch in length and a quarter of an inch in height, was 
found at the anterior part of the cartilaginous septum. An incision was made into the 
other abscess, not previously opened, and rapid healing took place, leaving, of course, 
the perforation in the septum already described. 432 
DISEASES OF THE THROAT AND NOSE. 
FOREIGN BODIES IN THE NOSE. 
Latin Eg.—Corpora adventitia in naribus. 
French Eg.—Corps etrangers des fosses nasales. 
German Eg.—Fremdkorper in der Nasenhohle. 
Italian Eg.—Corpi stranieri nelle narici. 
Definition.—Foreign substances lodged in the nose, most commonly 
gaining access by the nostrils, but occasionally passing upwards from the 
throat or penetrating the integuments. 
History.—The literature of foreign bodies impacted in the nasal channels consists, 
almost wholly of scattered cases reported in medical treatises and periodicals. Among 
the most remarkable examples on record may be mentioned one* in which a fragment 
of an explosive shell remained in a man’s nostril for seventeen years, and finally found 
its way out; and anotherf in which a musket-ball was lodged within the patient’s nose 
for twenty-five years without its existence being discovered. Several instances have 
been reported by Renard.J Boyer,$ and others,|| in which vegetable bodies lodged 
within the nose have, to the great discomfort of the patient, germinated in situ. Re- 
markable examples of the long sojourn of foreign substances within the nasal cavity 
have been related by and Tillaux,** and an interesting paper has been 
written on the whole subject by Bron.ff 
Etiology.—The accident most frequently happens to children, who 
amuse themselves by putting beads, peas, beans, and other small bodies 
into their noses. Insane people also sometimes introduce foreign bodies 
into the nasal cavity. In vomiting, hard substances, such as fruit 
stones, which had previously accidentally reached the stomach, have 
been forced into the nasal passages and have become impacted there. 
This accident is, of course, more likely to occur if the soft palate is 
paralyzed. Further, foreign bodies may occasionally be driven into 
the nares from below, when a person swallows “the wrong way,” the 
effort to prevent the foreign substance passing below the glottis causing 
it to be forcibly driven up into the nose. An extraordinary instance 
* Ephem. Nat. Cur., Dec. iii., ann. v. et vi., obs. 300. 
f Ibid., Cent, x., obs. 80. 
J Journ. de M6decine, t. xv., p. 525. 
§ Traitfe des Mai ad. chirurg., Paris, 1846, t. v., p. 65. 
|| Blasius : Obs. Med. Rarior., p. ii., No. 8; and N. Act. Nat. Cur., vol. vii., obs. 20. 
Tf Brit. Med. Journ., 1867, vol. ii., p. 266. 
** Bull, de la Soc. de Cliir., January 26, 1876. 
ff Gazette Medicale de Lyon, 1867, No. 36. FOREIGN BODIES IN THE NOSE. 
433 
is related by Hickman,* in which he removed from the posterior nares 
of a girl a steel ring, three-quarters of an inch in diameter and half an 
inch wide, which had been lodged there for thirteen years and a half. 
Portions of knives,f bayonets,J or bullets§ that have pierced the skin 
sometimes become lodged in the nasal fosste, but such bodies usually 
give rise to wounds, without becoming themselves impacted. A case 
is recorded by Legouest,|| in which a carpenter stabbed a man in the 
nose with a pencil, the broken end of which was subsequently removed 
through the nares. 
Symptoms.—Foreign bodies, when introduced by children or insane 
persons, generally lodge in the lower part of the nasal fossse, but this is 
by no means an absolute rule. The symptoms depend on the size, 
form, and nature of the foreign body. If the substance be small and 
round, it may remain for a long time in the nose without producing 
any symptoms at all. Vegetable bodies, however, such as peas or 
beans, imbibe moisture, and thus swell considerably. As already re- 
marked, they sometimes germinate in the warm, moist atmosphere of 
the nasal chambers, and they may thus give rise to very troublesome 
symptoms. In Boyer’s case a haricot bean shot out ten or twelve roots, 
and produced the appearance of a polypus, for which it was, in fact, 
mistaken. If the foreign body is sharp-pointed or irregularly angular 
in shape, it causes very great irritation, and an attack of acute rhinitis 
frequently supervenes. When the substance is large, more or less 
obstruction of the passages is produced, and the patient is obliged to 
keep his mouth constantly open. In the earlier period there is often 
intense headache with pain in the nose and cheek, and these pains 
occasionally assume a distinctly neuralgic character.. A very instruc- 
tive case of this kind has been published by Verneuil, in which the 
pain came on two or three times a month, and perfectly simulated facial 
neuralgia. If the foreign body remain in the nose for any time, the 
acute rhinitis gradually passes off, leaving, however, in its place, obsti- 
nate chronic inflammation and an extremely fetid discharge from* the 
nostrils. 
Diagnosis.—The recognition of the accident presents no difficulty, if 
* Loc. cit. 
f Legouest: Traite de Chirurgie Paris, 1863, p. 383- f Ibid. 
| Lemaistre: Bull, de la Soc. Anat, Oct., 1874, p. 632.. Lawsont Diseases and 
Injuries of the Eye, 2d ed., p 336 Gaujot, quoted by Casabianca: Des Affections de 
la Cloison des Fosses nasales, Paris, 1876, p 22. 
|| Op. cit., p. 383. 434 
DISEASES OF THE THROAT AND NOSE. 
there be a clear history of the introduction of a substance into the nasal 
passage, but in many cases such information will not be forthcoming, 
either from wilful suppression or genuine ignorance. When, therefore, 
a case of fetid discharge from the nostril is met with, especially if the 
patient is a child, the possibility of the complaint being caused by the 
presence of a foreign body should always be borne in mind, and a 
thorough examination of the nasal fossae should be made, both from 
the front and from behind. As, however, an impacted foreign body 
is very likely to be covered with mucus, the nasal passages should be 
washed out with a spray of tepid salt water before rhinoscopy is prac- 
ticed. If careful inspection should fail to detect any foreign substance, 
a search should still be made with the nasal probe; and in order that 
the examination may be quite satisfactory, it may be necessary, in some 
cases, that the patient should be rendered insensible. 
Prognosis.—The prognosis is almost always favorable, for the foreign 
body can, in the majority of instances, be easily removed, and then all 
the symptoms rapidly disappear. 
Treatment.—The foreign body should be extracted as soon as prac- 
ticable, but it should be remembered that the condition is not in itself 
dangerous, and that therefore there need be no undue haste in carrying 
out treatment. A thorough inspection of the nasal cavities should first 
be made with the help of the speculum, and if this does not prove 
successful the offending substance should be searched for with the probe. 
If the examination is badly borne, and especially if the patient is a 
child, an anaesthetic should be administered. When the situation of 
the foreign body has been accurately determined by either of these 
methods, it should be removed with fine forceps, bent at the proper 
nasal angle (see Fig. 39, p. 259). Sometimes when the foreign body 
is situated very far back, as in Hickman’s case already referred to, it 
may be more easily removed by means of forceps passed through the 
mouth behind the soft palate. Gross’s spuds and hooks (Fig. 70, p. 
282) may be useful for the extraction of peas and seeds of various 
kinds. Should it be found impossible by careful exploration to dis- 
cover the whereabouts of the foreign body, or should the latter be so 
firmly impacted that it cannot be dislodged without using undue vio- 
lence, other measures must be resorted to. If the patient be an adult, 
or a child who has attained the age of eight or nine years, it is a good 
plan to make use of the continuous douche, a little warm salt water 
being passed up the free nostril and brought out through the side where 
the substance is lodged. When the foreign body is small, a pinch of RHINOLITHS. 
435 
strong snuff will often enable the patient to expel it by sneezing. An 
ingenious, but unpleasant, method was adopted in a case related by 
King.* A cherry-stone had become impacted in a child’s nose and 
could not be dislodged; at last a powerful emetic was given, and when 
vomiting was about to commence a handkerchief was held tightly over 
the little patient’s mouth, so that the fluid was thrown through the 
nares, washing out the foreign body in its course. If it can be avoided, 
it is very undesirable to attempt to push the foreign substance back- 
wards, in the manner sometimes recommended, as there is danger of its 
hilling into the larynx; but if the body is large and tightly impacted 
in the posterior part of the nares, the practitioner may be obliged to 
risk this accident. He should, of course, take the precaution of intro- 
ducing his left index-finger through the mouth into the naso-pharynx, 
whilst with the right hand he is manipulating through the front of the 
nose. 
If the substance be large, and the symptoms caused by its presence 
very troublesome, Rouge’s operation (see “ Fibrous Polypi of the Naso- 
pharynx”) may be necessary. 
RHINOLITIIS. 
History.—The earliest allusion to these deposits is in a work by Matthias de Gardi,f 
who, however, merely mentioned, somewhat vaguely, a case at second hand. Two 
examples were observed by Bartholin,J one apparently of spontaneous origin, the other 
containing a cherry-stone as a nucleus. Clauder,§ Kern,|| and each re- 
corded one case, and Wepfer** described two instances of the complaint. In 1733 a 
case was related by the great anatomist Ruysch,ff and soon afterwards Plater;!.j dis- 
cussed the origin of nasal concretions. Other examples were recorded by Savialles,$$ 
* Amer. Journ. Med. Sei., April, 1860. 
f Pratica, Venetiis, 1502, pars ii., cap. 14, p. 308. 
J Hist. Anatom. Par., 1654, cent, i., p. 47 ; also cent, iv., p. 404. 
§ Ephem. Nat. Curios., 1685, dec. ii., ann. xiii., obs. 78. 
|| Ibid., 1700, dec. iii., ann. v. and vi., obs. 43, p. 100. 
T[ Ibid., 1706, dec. iii., ann. ix. and x., obs. 145, p. 268. 
** Observ. 192, p. 905, 1727. 
ff Obs. Anat., Amstelodami 1733, obs. 44, p. 42. 
tt De Olfactus Lesione, 1736, lib. i., c. 9, p. 264. 
H Bull, de la Facultfe de M6d., 1814, t. iv., p. 44. 436 
DISEASES OF THE THROAT AND NOSE. 
Griife,* Thouret,f Axmann.f; Brodie,£ and Demarquay.|| The last-named author, in 
describing a case of nasal calculus, which he had had an opportunity of observing 
while it was under the care of Blandin, discussed the whole question of the origin, 
symptoms, composition, and treatment of these bodies, and collected all the previously 
recorded cases that he could find. It is, in fact, to his careful account of the literature 
of the subject that I am mainly indebted for the above brief historical summary. 
Cases have since been reported by Cook,f Ko-tlin,** Rouyer,ff W. N. Browne, 
Verneuil,§§ West,|||| Hering,*** and Nourse.fff 
Rhinoliths generally owe their origin to the accidental impaction of 
small foreign bodies around which the salts of the pituitary secretion 
collect. Thus in Hering’s case the nucleus of the formation was a 
button, which had become firmly fixed in the nasal passage of a boy 
aged fourteen. Grafe suggested that rhinoliths are usually of gouty 
origin, but out of fifteen cases collected by Demarquay there was only 
one in which a gouty diathesis could be distinctly recognized. Occa- 
sionally in the centre of the calculus an albuminous liquid or a fatty 
proteine substance has been found, but it appears doubtful whether in 
these cases the matter contained in the centre of the calculus was the 
remains of the original morbid secretion, or whether it was due to the 
softening of some foreign material primarily forming the nucleus of 
the stone. Chronic inflammation no doubt promotes further deposition, 
and may in some cases give rise to the original formation. Any cause 
which obstructs the outflow of the secretion may lead to the formation 
of a calculus. In Browne’s case the nostril had been blocked up for 
some years. 
The symptoms caused by rhinoliths are similar to those already de- 
scribed as being produced by foreign bodies ; but they generally come 
on more slowly, and as the calculus continues to increase in size, in the 
end they cause more inconvenience. A fetid discharge is usually the 
* Annales d’Oculistique, 1828, t. viii., 4e et 5e livraison, p. 203. 
f Arch. G6n. de Med., 1829, t. xix., p. 27. 
£ Ibid., 1829, le s£rie, t. xx., p. 102. \ Lancet, Jan. Gtb, 1844. 
|| Arch. G6n. de Mfed., 1845, 4e sbrie, t. viii., p. 174 et seq. 
Ranking’s Abstracts, 1847, vol. vi., p. 132. 
** Wiirtemberg Corresp.-Blatt., 1854. 
ff Bull, de la Soc. Anat. de Paris, 1857, p. 60. 
JX Edin. Med. Journ , 1859, vol. v., p 50. 
Gaz des. Hdpitaux, 1859, p. 25. 
1111 Lancet, 1872, vol. i., p. 147. 
Archives of Laryngology, 1880, vol. i., No. 2, p. 149 et seq. 
*** Monatschr. f. Ohrenheilk., 1881, No. 5. 
Iff Brit. Med. Journ., Oct., 1883, p. 728. RHINOLITHS. 
437 
most troublesome feature of the complaint. The shape of the stone 
varies, but it is generally irregularly oval, and varies greatly in size. 
In Browne's case it attained the enormous dimensions of an inch and 
three-quarters in length, one inch in breadth, and nearly half an inch 
in thickness, whilst its weight was three drachms and thirty-three 
grains. When the calculus is situated in the upper and anterior part 
of the nasal cavity, it may cause a swelling on the face (see Case 2 be- 
low), and under these circumstances the lachrymal canal is apt to be 
obstructed. The stone is usually single, though occasionally, as in the 
case of Axmann and of Blandin, several calculi may be present, and in 
one of my own cases (No. 1) there were two. Their surface may be 
smooth, but, as a rule, it is somewhat rough, and mammillated,and their 
color is most frequently grayish-black. Sometimes they are partly 
covered by the mucous membrane, in which they have become im- 
bedded, the edges of the membrane being, under these circumstances, 
puffy and ulcerated, and disposed to bleed. 
The diagnosis is often very difficult; indeed, a calculus cannot al- 
ways be readily distinguished from an osteoma, and owing to the fungous 
bleeding appearance of the mucous membrane, and the great swelling 
which may be present, a rhinolith has even been mistaken for cancer.* 
If the calculus is movable, or if its surface can be penetrated by a sharp 
probe or needle, it is not likely to be confounded with an osteoma. The 
slow course of the disease and the absence of pain serve to distinguish 
it from cancer, whilst the most casual examination will at once enable 
the experienced surgeon to recognize a polypus. The composition of 
nasal calculi is very simple, for they merely consist, as Proutf has 
shown, of mucus and phosphate of lime. They are generally hard on 
the surface, and softer towards the centre, an outside wall being formed 
round them, and constituting a covering something like an egg-shell. 
This, however, is not an invariable rule, for in one of my cases the cal- 
culus was of extreme hardness throughout. The prognosis is favorable, 
as, when once discovered, the stone can nearly always be removed, and 
the patient cured. The treatment, consisting, as it does, in extraction of 
the calculus, can usually be carried out with common polypus-forceps, 
but if the stone has attained to too great dimensions to permit of its im- 
mediate removal, it should first be crushed with a lithotrite of a size 
and shape suitable for use within the nasal cavity. In one of my cases 
* Jacquemin, quoted by Spillmann: Diet. Encycl. des Sci. Med., t. xiii., p. 24. 
f Lancet, January 6th, 1844. 438 
DISEASES OF THE THROAT AND NOSE. 
the stone could only be brought away after being cut through with 
powerful bone-forceps. Hering, having failed to get the stone out 
with forceps, pushed it backwards through the posterior nares, when the 
patient himself was able to “ hawk” it out. 
The following examples of this complaint have occurred in my own 
practice: 
Case 1.—James S., aged thirty-seven, a gentleman’s servant, applied at the Throat 
Hospital in May, 1876, on account of a discharge from the left nostril, from which he 
had suffered for six years. On examining the nose, a calculus wras seen in the middle 
meatus. The stone was, in a great measure, covered by mucous membrane, which had 
grown over it. Several attempts at extinction were unsuccessful, and it was only after 
making an extensive incision along the lower border of the middle turbinated body, that 
the calculus was brought away in several fragments. The patient was subsequently treated 
with mild alkaline washes, and at the end of six weeks had completely recovered, the 
nasal passages being perfectly clear, and there being no discharge. From an exami- 
nation of the fragments, it appeared that there had been two oblong stones placed in a 
line one with the other, and touching at one end. One of them measured a centimetre 
and a half in length, and eight millimetres across, the other was rather smaller ; neither 
of them appeared to have any nucleus. The surface of both calculi was harder than 
the interior, and of a lighter color. They weighed together forty-seven grains. 
Case 2.—Mr. H. S., aged sixty-three, a government official at Jamaica, consulted me 
in June, 1882, on account of a troublesome discharge from the right nostril. He had 
previously seen several practitioners with reference to his ailment, one of wdiom had 
told him that he had a polypus in his nose, whilst another assured him that he had 
nothing the matter with him, and a third frankly confessed himself unable to discover 
the cause of his complaint. Mr. S. had resided for some years in the tropics, and had 
suffered from severe attacks of ague, but otherwise he had been a very healthy man till 
about four years before he came under my notice, when he had been treated for stone 
in the bladder, and a “ mulberry ” calculus had been removed by crushing. 
On inspection, I found the right side of the nose from near the angle of the eye to 
the upper border of the lower lateral cartilage filled out by a hard tumor, the skin over 
it being perfectly healthy. A dark brown, fetid discharge came from the right nostril, 
and on examining the interior of the nose with the speculum, the right nasal cavity 
was found to be occupied by a large calculus extending from the level of the inferior 
turbinated body to the roof of the nose. The surface of the stone was rough, of a grayish- 
black color, and very hard. On attempting extraction with forceps, some small frag- 
ments were got away, together with a little slimy grit, but no sensible diminution in 
the size of the calculus was effected. I subsequently attempted to use a lithotrite, but 
owing to the shape, hardness, and situation of the stone, I found it impossible to crush 
it; I finally succeeded, however, in dividing it with powerful bone-forceps. Even then 
the large fragments could not be extracted. As a last resource I passed a string through 
the nose into the mouth, and, having attached a strong plug of lint to the distal end, 
drew it forward again through the nasal fossa, and in this manner managed to bring 
the divided stone within reach of the blades of the lithotrite, and finally to crush it. 
On examining the fragments, no nucleus could be discovered, but if there had been 
one, it might easily have eluded observation. The total weight of the debris was seventy 
grains. Considerable haemorrhage followed this operation, and rather extensive facial MAGGOTS IN THE NOSE. 
439 
cellulitis ,* without, however, very marked pyrexia, supervened on the following day. 
This lasted for nearly a week, and recurred on four subsequent occasions at intervals of 
a few days, although no further operation was attempted. By the time Mr. S. had 
recovered from these attacks, his leave of absence had expired, and he was obliged to 
return to Jamaica. Unfortunately, a small fragment of the stone still remained in 
the extreme upper part of the nose, and this is very likely to become enlarged by 
further accretions. 
MAGGOTSf IN THE NOSE. 
Latin Eq.—Myasis nariura. 
French Eq.—Larves dans les fosses nasales. Myase du nez. 
German Eq.—Wiirmer in der Nasenhohle. 
Italian Eq.—Larve nelle fosse nasali. 
Definition.—Destruction of the soft tissues, and sometimes of the 
hones, of the nose, by maggots hatched from eggs deposited within or close 
to the nostrils by diptei'ous insects, causing gnawing pain, insomnia, and 
sometimes convulsions, coma, and death. 
Though this affection is the cause of wide-spread suffering among the 
native population of our extensive tropical possessions, it is scarcely 
referred to in any standard English work. Indeed, in the entire medi- 
cal literature of the world, there is not a single essay, dealing fully with 
the whole subject. Under these circumstances, it seems to me desir- 
able to lay before my readers an analysis of the scattered articles which 
have appeared from time to time, for the most part in rare books or in- 
accessible journals. 
* Hack (Beitriige zur Ilhinochirurgie, Wien, 1883, p. 24) has recently drawn atten- 
tion to the fact that a tendency to a low form of erysipelas of the neighboring parts of 
the face is a not unfrequent complication of inflammatory disease within the nose. 
f This subject has been briefly referred to in some textbooks under the general head 
of “ Parasites in the Nasal Fossae,” but this designation is inaccurate. Maggots can 
hardly be said to be parasites, for, as Moquin-Tandon (Elements de Zoologie Medicale, 
Paris, 1859, page 215) points out, the essence of parasitism consists in the remarkable 
fact that an individual may live at the expense of another, without any very serious 
results occurring to the animal fed upon. 440 
DISEASES OF THE THROAT AND NOSE. 
History.—Previous to the present century, there are only a few examples of myasis 
of the nose on record. Gahrlieb* reported an instance, in which a peasant, afflicted 
with great pain in the forehead and root of the nose,'made a decoction of pungent 
herbs, and inhaled the steam. Epistaxis came on, and was followed by the expulsion 
of several living maggots. The next case is that of Behrends,t who treated a woman, 
suffering from unbearable headache and slight swelling of the face, by injecting into 
the nose decoctions of tansy, rue, and absinth. Thirty maggots were brought away, and 
the patient was cured. A still more striking example of myasis was published twenty 
years later by Wohlfahrt,J in which a patient, suffering from terrific headache, was 
treated by inhalations of alcohol, and eighteen maggots were brought away. These 
were placed in a box, and in thirty days developed into flies. Fifty years later, a case 
in which an infant eight months old, expelled some worms from the nose, was briefly 
referred to by Tengmalm,§ and, towards the end of the last century, Azara|| had several 
opportunities of witnessing the effect of maggots within the nose, in Paraguay. In 
1830, MacgregorT[ published an example of the disease, which he had observed in 
British India. Cases, met with in the same country, have since been reported by 
Laliorv,** Moore,ff and Ohdedar,JJ whilst the affection was closely studied by Co- 
querel|| in Cayenne, by Morel,|||| Gonzalez,fT[ Jacob*** and Weberj-ff in Mexico, and 
by Frantzius.j;Jj; in Costa Rica. In Europe, Mankiewicz§§| reported a case, which 
had been treated by himself, Moquin-Tandonj|!||| related examples which had been 
Avitnessed by D’Astros and others, and an instance was recorded by 
which he had met with in Italy. 
Of the observations made in British India, Macgregor’s Avas the first. The patient 
Avas a man Avho for three months had felt pain in the left cheek and inside the nostril. 
On blowing his nose violently some Avorms came out, which alarmed him very much, 
* Ephem. Nat. Curios., Dec. iii., ann. vii. et viii., obs. 141, p. 280. 
f Scharschmidt’s Med. und Chir. Nachrichten, Berlin, 1743, 1 Jahrg., p. 214. 
J Observ. de Vermibus per Nares Excretis, Haise Magdeburgicae, 1788. These 
cases will all be found in Tiedemann (Wiirmer in den Geruchsorganen, Mannheim, 
1844), but the reader, who is anxious to pursue the subject, will find these and many 
other references in Ploucquet’s laborious Index (Literatura Medica Digesta, Tubingae, 
1809, sub voce Vermis). 
£ Kongl. Vetenskaps Academiens Handlingar, 1796, p. 285. 
|| Voyages dans l’Amdrique meridionale, 1781-1801, par Don Felix de Azana, 
with notes by Cuvier, Paris, 1809, t. i., p. 216. 
London Med. and Phys. Journ., 1830, vol. lxiv., p. 498 et seq. 
** Edin. Med. Journ., October, 1856, vol. ii., pp. 371, 372. 
ff Indian Med. Gazette, 1871. Ibid., 1881, vol. xvi., p. 80. 
\\ Archiv. Gen. de M4d., 1858, t. ii., p. 513 et seq. See also Annalesde la Soc. En- 
tomologique, 1858, p. 173. 
|||| Recueil de M£d. Milit., 1865, 3e s6rie, t. xiv., p. 516 et seq. 
La Mosca Hominivora. Disertacion leida en la Academia Medico-farmaceu- 
tica de Monterey la noclie del 3 de Marzo, 1865, porel Profesor de Medicina y Cirugia 
D. Jos4 Eleuterio Gonzalez. 
*** Rec. de Med. Milit., 1866, 3es6rie, t. xvii., p. 58 et seq. 
fft Ibid., 1867, 3e s6rie, t. xviii., p. 158 et seq. 
t+t Virchow’s Archiv., Bd. xliii., p. 98. Ibid., 1868, Bd. xliv., p. 375. 
|||||| E16m. deZoologie M6dicale, Paris, 1859, p. 212. 
Fricke u. Oppenheim’s Zeitschr. f. d. gesammte Med., 1838, p. 276. MAGGOTS IN THE NOSE. 
441 
but gave him some relief. Subsequently his cheeks swelled, a fetid bloody discharge 
issued from the nose, he became greatly excited, and had attacks of shivering; am- 
monia was used to excite sneezing, and about a hundred larvae were expelled. They 
were about half an inch in length, thinner at the front than behind, segmented, and 
without feet. Their color was white, but they had black spots at the posterior ex- 
tremity. 
Lahory, a native practitioner, educated in the European system of medicine, wrote 
an interesting article on “ Peenash,”* a term used in Hindostan for an ulcerative dis- 
ease of the nose in which maggots are present. He states that he has seen it in patients 
of all ages, from nine years to eighty, and that it is most common in the hot weather, 
from July to September, fie observed that bad food and dirt predispose to the disease, 
and that it is most frequently seen in persons whose noses are flattened from falling-in 
of the bridge. The symptoms which he noticed were deep-seated indescribable pain 
over the frontal sinuses, in the orbits, and in the ears, with a crawling sensation inside 
the nose. Epistaxis very often occurred. The patient had a disposition to hold the 
head down, and there was so much ecchymosis and swelling of the eyelids that vision 
was often obstructed. As the disease went on, ulceration of the nose took place, and a 
large portion of the organ frequently sloughed away. There was often high fever, 
with severe constitutional symptoms. At Allvghnr, between December, 1851, and 
March, 1855, there were 91 admissions to hospital for “Peenash.” Of these cases 46 
were cured, 14 relieved, and 29 ceased to attend, whilst 2 died. Lahory describes the 
maggots as being white or yellow, and often having black spots on the head and tail, 
their size being that of the ordinary maggots seen in putrid animal matter. They have 
a distinct head, eyes (?), mouth, body, and a tail generally arranged in eleven spiral 
turns, each spire being a separate joint, by means of which thes animal moves. The 
worms are free, or loosely confined in membranous cysts. The treatment recommended 
by Lahory consists in the injection of turpentine or infusion of tobacco, combined with 
the internal use of alteratives and tonics. 
In a case of “Peenash” recently described by Oluledar, a native surgeon in the 
Indian service, the patient was a woman, about whom a disagreeable smell was noticed, 
but whose nose only showed thickening of the mucous membrane. In the hard palate, 
however, there was an opening of the size of a four-anna piece (a centimetre and a 
half in diameter), and through it eight maggots were removed, each having a distinct 
nidus. Epistaxis occurred on more than one occasion, and there was subsequently 
oedema of the face and eyelids. The throat and nose were syringed with a weak so- 
lution of muriate of iron, and afterwards with oil of turpentine. Ulceration took place 
near the inner canthus of both eyes, and through the broken skin maggots escaped, 
causing great pain. Erysipelas of the nose and eyelids ensued, and the patient ulti- 
mately died from coma. 
Of the information collected in South America, that obtained by Coquerel is of great 
* The word is said to be of Sanskrit origin, but its resemblance to the French word 
punaisie is very remarkable, and it is not impossible that the term now used in India 
may have been introduced by the French at Pondicherry. On the other hand, it is 
possible that both words are derived from a common root (see foot-note, p 330). If 
it could be shown when the term was first employed, it would have an important 
bearing on the etymological question. It may be remarked that camels in India are 
commonly led about by a ring which passes through the cartilage of the nose, and the 
ulcerated surface is constantly covered with maggots, the animals being said to suffer 
from “Peenash” (Moore: Native Practice in Rajpootana.—Ind. Med. Gaz., 1871). 442 
DISEASES OF THE THROAT AND NOSE. 
value. This surgeon, an officer in the French naval service, temporarily stationed at 
Cayenne in French Guiana, has given the most detailed report of myasis of the nose 
which has yet been published. He does not appear to have seen any patients himself, 
the cases having been treated by his brother officers, MM. St. Pair and Chapuis, but 
he had access to their reports, and was able to determine the class of insect whose 
larva caused the disease. In his article it is not stated whether flies deposited their 
eggs within the healthy nose, or whether, as in the case of the Indian “Peenash,” the 
maggots were only found when the mucous membrane was in a morbid condition. The 
principal symptoms noticed at Cayenne were formication in the nose with severe frontal 
headache, accompanied in some cases by a sensation resembling “blows with an iron 
bar;” there was also cedematous swelling of the nose, extending over the face, and 
especially involving the eyelids. Severe epistaxis was often met with, and not un- 
frequently there was considerable inflammation of the internal tissues of the nose, 
which in some cases spread to the meninges, and thus caused death. Tumors occasion- 
ally formed on the outside of the nose, which after “ pointing” opened spontaneously, 
and from them large numbers of larva* escaped. When the nose was syringed with a 
solution of alum or a decoction of tobacco, a quantity of larvae were frequently ex- 
pelled, the aggregate number in a single case sometimes amounting to two or three 
hundred. In the patients that recovered, the septum was frequently in a great measure 
destroyed, and in many cases the nose was almost eaten away. Of six men treated by 
St. Pair, three died with symptoms of meningitis ; whilst in two of the survivors the 
nose had completely disappeared, and in one it was terribly deformed. In the fatal 
cases the meninges were found of a deep red color and full of blood, especially at the 
base of the brain. The cerebral substance itself was injected, and the ventricles filled 
with bloody serum. One patient who had nearly recovered was attacked by erysipelas 
of the face and scalp, from which he died ; and in this case, at the post-mortem, bundles 
of larvae were found encrusted in the frontal sinuses and antrum. Coquerel states that 
the surgeons at Cayenne generally insufflated alum, or injected a decoction of tobacco, 
but with indifferent success, as this treatment often made the membrane puffy, and 
closed the openings into the sinuses. He observes that if killed, the maggots no doubt 
often putrefy within the sinuses, and thus give rise to new symptoms. When there 
was reason to suspect that they had entered the frontal sinuses or the antrum, the 
Cayenne surgeons trephined these cavities. Coquerel carefully describes the insect 
which causes this fatal disease. The account of the maggot, pupa, and fly, as given by 
him, will be deferred to Etiology (p. 445), as it serves as the standard description of 
the insect. 
When it was decided by the French Government, in 1862, to send a military expe- 
dition to Mexico, the Conseil de Sante directed the army surgeons to collect all the 
information they could concerning the disease produced by the entrance of flies into 
the nose; but, as far as I have been able to ascertain, the only officers who responded 
were Morel, Jacob, and Weber. The information, however, which they collected in 
Mexico added to our knowledge of the disease, and led to more certain methods of cUre. 
Morel based his observations on five cases which had come under his own notice. 
He thinks that the fly always enters the nose during sleep, and believes that dirty 
those suffering from ozama are particularly liable to be attacked. In four 
out of his five cases such persons were the subjects of the disease, whilst in the fifth 
the patient was suffering from a boil close to the spot attacked. Morel observes that 
in the nasal fossae, the mucous membrane and all the tissues are rapidly reduced by the 
maggots to the condition of a pulp, whilst the cartilages and bones are laid bare and 
soon become necrosed. His article is specially remarkable on account of its containing MAGGOTS IN THE NOSE. 
443 
Assistant-Apothecary Dauzats’s recommendation of the use of chloroform as a specific 
for the destruction of maggots. He advised that chloroform diluted with half its 
volume of water should be shaken up and injected before the two liquids have time to 
separate. Morel observes that all the patients on whom he used this remedy recov- 
ered as if by magic, except one on whom it was tried too late. Inhalation of chloro- 
form generally detaches and brings away the larvae at once, but if they are very deeply 
situated it should be injected. 
Jacob learnt from the natives that the malady was tolerably common amongst them. 
They attributed it to a neglected cold, and hence regarded coryza with considerable 
dread. Pie reports a very severe case of myasis, which was cured by the use of chloro- 
form injections and inhalations. Pure chloroforui was injected several times. Although 
Jacob’s paper was published subsequently to that of Morel, he claims to have invented 
the treatment after trying it with Dauzats on worms. 
Weber spent a considerable time in Mexico between 1862 and 1866, especially at 
Orizaba, Cordova, and Monterey, where, though the disease is said to occur, he did not 
see any cases himself, his information being principally derived from the published 
works and oral communications of Dr. Gonzalez. The highest situation at which the 
fly is found is at Orizaba, which is 1200 metres above the sea-level, the point of 
greatest prevalence being at Acatlan, one of the hottest places in the southern part of 
the province of Puebla. The disease does not seem to be very common in Mexico, for 
in about twenty years Gonzalez had only collected fifteen cases; of these six died, four 
recovered with more or less destruction of the nose, and five were cured without any 
deformity. He points out that the most troublesome symptom is the insomnia caused 
by the movements of the worms at night. In the cases which had come under his 
notice the nasal fossae, frontal sinuses, orbits, mouth, and sometimes the muscles and 
the skin of the face, were attacked, and once the entire face was destroyed. Gonzalez 
describes a case in which a young man saw a fly buzzing round him,* and tried to drive 
it away, but did not succeed, and it flew into his right nostril with great force. In the 
act of sneezing, which soon after occurred, the fly was driven out. Formication in the 
nose immediately came on, together with a little fever, and subsequently about a dozen 
large maggots were expelled. Others could be seen moving about in the nose in the 
midst of sanguinolent mucus. The patient suffered from sleeplessness, and epistaxis 
came on after many injections had been used. Altogether one hundred and thirty-four 
maggots were expelled, in addition to those which the patient sneezed out before he 
came under treatment. He left the hospital cured on the 4th of September, having 
been admitted on the 28th of the previous month. From this it will be seen how rapid 
is the course of the disease in a favorable case. 
Before dismissing the descriptions by the French surgeons in Mexico.it may be ob- 
served that none of them appear to have made any special investigations respecting 
the natural history of the fly which causes so much havoc. The subject is indeed only 
referred to by Weber, who observes that he fully indorses the description of the fly 
given by Coqnerel. 
Frantzius, a German physician practicing in the nearly adjoining region of Costa 
Pica, published some interesting remarks on the disease now under consideration. He 
observed that sneezing was an early and constant symptom, and attributed it to the 
tickling sensation caused by the gliding movement of the larvse when they were seek- 
* Moquin-Tandon observes (op. cit., p. 225) that the gadfly can often be seen hover- 
ing round a sheep, trying to enter its nose, whilst the sheep buries its nose in the turf 
in order to prevent the insect getting in. 444 
DISEASES OF THE THROAT AND NOSE. 
itig a suitable nidus. Considerable swelling and slight redness of the face were gen- 
erally present, but the fetid, sero-sanguineous discharge from the nose, which, according 
to this observer, only becomes purulent after the expulsion of the larvse, was a dis- 
tinctive feature. The larvse showed a preference for the floor of the nose posteriorly, 
and hence swelling of the soft palate was not unfrequentlv seen. In these cases the 
voice had often a nasal tone. There was usually some fever together with loss of ap- 
petite, and occasionally diarrhoea. Frantzius considered that the frontal symptoms 
often noticed were not due to the presence of worms in the sinuses, but to the extension 
of the inflammatory process to the mucous membrane lining these cavities. In one 
instance he removed ten maggots, in others from thirty to fifty. In the only case that 
ended fatally a hundred were taken away. The patient was an old woman, and 
Frantzius observes that the presence of larvae in the nasal fossae is a very serious 
condition when occurring in the aged and debilitated. The not inconsiderable 
destruction of tissue, the incessant discharge, the violent headache, the loss of sleep, 
and the constant fever, all tend to undermine the vital powers. He recommends 
the insufflation of calomel and powdered chalk (equal parts!, and the removal of 
the larvse with forceps, pointing out that the fact of their being clustered closely to- 
gether facilitates this procedure. Frantzius does not attach much importance to the 
various remedies which have been recommended for these cases, and believes that 
many of the supposed curative agents owe their apparent efficacy to the fact that when 
they were used the maggots had attained their full duration of larval life.*’ 
In addition to the older cases already briefly referred to at the beginning of this his- 
torical sketch, four others have been recorded in the present century as occurring in 
Europe. Petrequin, whilst making a tour in Italy, observed one in a hospital at Si- 
enna. A woman, who complained of an extremely painful red swelling on the right 
cheek, and had some fever and slight delirium, passed several small white maggots 
from the nose. Curious as it seems, anthelmintic remedies were prescribed internally, 
and she was ordered to use them also as an inhalation. In the course of eight days fifty- 
eight maggots were expelled, and these subsequently developed into lucUioe. 
Mankiewicz, a medical practitioner in Berlin, was induced to publish the following 
case on reading Frantzius’ article, of which an abstract has been given : In a delicate 
boy, aged nine years, suffering from scrofulous ozsena, enormous quantities of maggots 
were seen adhering to the septum, and it was found impossible to remove them until 
they had been smeared over with a solution of balsam of Peru. A complete cure was 
effected, though the boy lost the tip of his nose. 
Moquin-Tandon also records the two following cases. In the first the patient was 
a woman under the care of D’Astros, of Aix (Provence). She had fallen asleep in a 
field, when it is supposed that a fly deposited its eggs inside the nose. Soon after 
slight pain came on in the frontal sinuses, with a sensation of formication about the 
root of the nose, and “a noise was heard by the patient and others like that produced 
by worms gnawing wood.” (!) After severe epistaxis one hundred and thirteen maggots 
were expelled. In the second case, which occurred in a girl nine years of age, the pa- 
tient suffered from intense headache and convulsions, but was cured by cigarettes of 
arsenite of soda. 
The only case recorded from the United States is one lately published by Prince,f of 
* Frantzius seems to be under the mistaken impression that maggots arriving at 
maturity quit their previous habitat in order to form a cocoon. Their natural history 
in this respect will be found explained under the head of “ Etiology.” 
t (Philadelphia) Medical News, Oct. 14th, 1882, p. 445. MAGGOTS IN THE NOSE. 
445 
Jacksonville, Illinois, in which a fly deposited its ova within the nose of an Irish 
farmer who was suffering from ozaena. In a short time maggots were developed; 
erysipelas and oedema of the nose and adjoining parts of the face supervened, and the 
patient could not breathe through his nostrils. Syringing with water proved utterly 
ineffectual, and the larvae were gradually picked out with forceps. They were found 
to have stripped bare a considerable portion of the bony framework of the nose, and it 
is asserted that the ozaena was thereby completely cured. 
Etiology.—The disease is seldom met with out of the tropics. Ele- 
vated situations, owing to their coolness, even in hot climates, are free 
from this pest, the observations of Gonzalez, already referred to, show- 
ing that, in Mexico itself the affection is not met with at a level higher 
than 1200 metres above the sea. Only a very few cases have been de- 
scribed as occurring in Europe. The disease is undoubtedly caused'by 
the hatching of eggs laid by a fly (allied to our bluebottle and meat-fly) 
within the nose, or close to its orifice. The natural situation for these 
insects to deposit their eggs is putrid meat, which affords proper nutri- 
ment for the larvae when hatched; but instinct sometimes goes astray, 
as is seen in the case of the bluebottle fly, which occasionally deposits 
its eggs on the common snake-root (Arum draeunculus), being deceived 
by the cadaveric odor which that plant emits. It is by a similar error 
of instinct that the fly of hot climates occasionally deposits its ova 
within the nose. No doubt it is the fetid discharge from the nose which 
attracts the insect, and it is probably only by accident that eggs are de- 
posited on a healthy mucous membrane. It has already been pointed 
out, that a great many morbid conditions of the nose are included under 
the head of “ Peenash.” In fact, the word corresponds to the vague 
term “oztena,”* as formerly employed in European medicine, the only 
difference being that in “ Peenash ” maggots are sometimes present. 
The following is the description of the Lueilia hominivora: The fly is 
nine millimetres in length, has tawny palps, and a light tawny face, the 
cheeks being covered with golden-yellow down. The head is large, 
wider in front than behind, the thorax being dark blue, with black and 
yellow stripes, and the abdomen of the same color. The feet are black, 
the wings transparent. The larva is dull white, fourteen or fifteen 
millimetres long by three or four broad, and narrower in front than 
behind. It is made up of eleven segments, the widest part of the body 
corresponding with the sixth. The head is indistinguishable from the 
first segment; there are no eyes; the mouth is formed by a sort of lip, 
on which are two small protuberances, at the base of which near the 
* See p. 328. 446 
DISEASES OF THE THROAT AND NOSE. 
middle line there are two corneous mandibles placed side by side, the 
mandibular booklets being very sharp and separated outside, though 
closely united in the thickness of the tissues. On each side of the first 
segment there is a brown corneous patch, which covers the orifices of 
the upper stigmata. At the base of each segment there is a projecting 
part, covered with small spines, very numerous and close together. 
Fig. 87 
Lucilia Hominivora. 
a, the fl) ; b, larva; c, a mandible; d, magnified view of the insect’s head. 
Macgregor’s account of the maggot corresponds closely with Coquerel’s, 
but the maggot described by Lahory is said to have had eyes. As these 
organs are not found either in the larva of Lucilia hominivora or in that 
© 
of Lucilia Ccesar (common bluebottle), Lahory’s maggot must have 
belonged to some other variety, or that observer must have made a mis- 
take. He also speaks of the maggots as being confined within loose 
membranous cysts, whilst Ohdedar states that in his case each maggot 
had a distinct nidus. 
There are three kinds of European flies, all belonging to the order 
of Muscidce, which may deposit their ova within the nose or near its 
entrance, viz., Sarcophagcc, Calliphoroe, and Lucilice. The Sarcophaga 
is black, its thorax, however, being streaked with gray, and its abdo- 
men chequered with white. The insect has a small head, its antennal 
bristle being hairy, but naked at the tip. The j male is viviparous, 
the larvae being hatched within the oviduct. The ovaries often contain 
as many as 20,000 eggs. The larvae are footless, white, fleshy, and nar- 
rower in front than at the posterior part. The Calliphora, or Vomitoria, 
the common large meat-fly, is too well known to require any descrip- 
tion ; its larvae are white, and obliquely truncated at the posterior ex- 
tremity. They have no feet, but have two fleshy horns on the head, 
and two fleshy booklets in the mouth. The last segment of the body 
is provided with eleven points, arranged like rays. 
The Lucilia is represented by the common bluebottle. 
The larvae of Dipterce develop in seven or eight days in Europe. In MAGGOTS IN THE NOSE. 
447 
the Muscidce the larva changes into a pupa within the larval skin, 
which contracts into a cylindrical pupariuin, corresponding in use to the 
cocoon. The flies almost always deposit their eggs in the light and 
heat of day. 
Symptoms.—After the deposit of the ova, the mucous membrane soon 
becomes irritable, a constant tickling sensation is felt, and sneezing is a 
common symptom. In a short time the tickling becomes very trouble- 
some, and a crawling feeling or formication is perceived. This is mostly 
followed after a short time by a sanious bloody discharge, and epistaxis 
often occurs. (Edema of the face, and especially of the eyelids, is a 
characteristic symptom, and swelling of the palate takes place in some 
cases. Occasionally, but not very frequently, small tumors form over 
the nose, which open and allow the larvae to escape. Severe and con- 
stant pain is generally felt, especially at the root of the nose and over 
the frontal region. The headache is often of a throbbing character, and 
has been described both in India and Cayenne as resembling the sensa- 
tion which might be caused by repeated blows with a hammer or iron 
bar. The pain in some cases never intermits, but gives rise to the most 
distressing sleeplessness; this is, indeed, sometimes so unbearable as to 
lead to suicide. Larva? are often sneezed out, or can be seen in the 
nose crawling about in the fetid mucus. When it is remembered that 
as many as from two to three hundred maggots are sometimes ejected 
in a single case, the injury and loss of substance which they can cause 
will be readily appreciated.* Not only is the mucous membrane 
destroyed, but the cartilages and bones of the nose and head become 
carious. Convulsions, followed by coma, generally terminate the life 
of the patient in fatal cases. 
Diagnosis.—Although there are many symptoms which might lead 
to a suspicion of myasis, it is only the actual finding of maggots which 
can prove its existence. 
Pathology.—The morbid changes produced by maggots have already 
been described in dealing with the symptoms, and it only remains to be 
remarked here that in cases which have not been treated sufficiently 
early, not only the soft tissues, but the ethmoid, sphenoid, and palate 
bones are often destroyed by caries, and that the meninges are found 
* Linnseus states that “three flies devour the body of a dead horse as quickly as a 
lion.” (Syst. Nat., ed. decima tertia, Lipsiae, 1788, t. i., pars v., p. 2840.) This extraor- 
dinary power of destruction is, of course, due to the rapidity with which the insect 
passes through its successive stages of development, and to the great number of eggs 
laid in each cycle when the condition of imago is reached. 448 
DISEASES OF THE THROAT AND NOSE. 
after death to be much inflamed. There is a section of a skull in the 
Museum* of the Medical College at Calcutta taken from the body of a 
man who died of “ Peenash,” in which a large number of maggots were 
found on the sphenoid and ethmoid bones. 
Prognosis.—This disease, if neglected, is probably always dangerous 
in tropical climates. Its fatality, however, seems to vary greatly in 
different countries, for whilst Lahory met with only two fatal cases out 
of ninety-one patients, of six patients seen by St. Pair three died. This 
discrepancy is perhaps to be explained by many cases having been de- 
scribed under the name of “ Peenash,” in which no maggots are present 
—cases, in fact, in which there was syphilitic disease of the nose or 
merely dry catarrh. 
Treatment.—Dauzats’s discovery of the highly beneficial effects of 
chloroform will probably cause this remedy to supersede all others. 
Inhalations of chloroform are often sufficient to effect a cure; but should 
the maggots resist this mode of administration, the patient should be 
rendered insensible by the vapor, and then equal parts of chlorformand 
water should be injected ; or should even this fail, pure chloroform may 
he syringed up the nose. The undiluted chloroform does not appear to 
do any harm to the mucous membrane, but it causes extreme pain when 
the patient is not under an anaesthetic. The remedies formerly used, 
viz., injection of turpentine, infusion of tobacco and lemon-juice, insuf- 
flations of calomel, the local application of Peruvian balsam, though 
all to some extent efficacious, do not seem to be at all comparable in 
their effects to chloroform. Constitutional treatment must not be neg- 
lected : opium should be given to relieve the pain and induce sleep; 
and if the myasis is complicated by syphilis, iodide of potassium should 
be administered. Stimulants and highly nutritious food are required 
to sustain the vital powers. 
In the above article the severe nasal affections produced by the larvae 
of Muscidce have been considered, and it is only very rarely that other 
Dipterce deposit their ova within the nose. There are a few cases, 
however, mostly reported before entomology was studied scientifically, 
* See Indian Annals of Med. Sci., Oct., 1855- MAGGOTS IN THE NOSE. 
449 
in which the larvae of the gadfly ((Estrus ovis) and of the leather-eater 
(Dermestes) are supposed to have attacked the nose.* 
The gadfly is a regular parasite of sheep and goats, in the nostrils of 
which animals the insect constantly lays its eggs. Moquin-Tandon 
denies that there is any instance on record in which a human being has 
been attacked; but the following case, reported by Razoux,f leaves no 
doubt as to the occasional occurrence of the accident. A woman was 
seized with burning fever, inflamed eyes, dry skin, and gradually in- 
creasing headache in the frontal region. Tartar emetic was prescribed, 
to produce vomiting, but with no beneficial result. Attacks of sneezing, 
however, afterwards came on, and the patient expelled from the nose 
seventy-two live worms of the gadfly. Quite recently, Kirschmann| 
has reported a case in which a peasant woman was attacked with bleed- 
ing from the nose which lasted three days. The blood came from the 
left nostril, and the corresponding side of the face was enormously 
swollen. The haemorrhage was arrested by injections of perchloride of 
iron, and this treatment was followed by the expulsion of a mass of 
maggots of the Oestrus ovis. The patient made a good recovery. Two 
cases are on record in which the maggots of the leather-eater are said to 
have been found in the nose. One§ was that of a young woman, who 
complained of great headache, which was entirely relieved by the ex- 
pulsion of five reddish-brown hairy maggots. The other|| was that of 
a man who suffered from excruciating headache, with epistaxis, which 
lasted three days. After the passage of eighteen small hairy worms 
from the nose all the symptoms disappeared. 
* A case is recorded by Hope (quoted by Moquin-Tandon : E16m. de Zoologie Med- 
icale, p. 217) in which it is stated that death resulted from the presence of a mealworm 
(Tenebrio molitor) in the nasal fossae, but as this maggot is a vegetable feeder the case 
must be looked upon with doubt. 
f Journal de M6decine (Roux), tome ix., p. 353. 
t Wien. med. Wochenschrift, 1881, Dec. 3. 
\ Paullini: Ephem. Acad. Nat. Curios, dec. ii., ann. v., append., p. 63, obs. 101. 
|| Wohlfahrt: Observ. de Yermibus per Nares excretis, Halae Magdeburgicae, 1768, 
p. 3 et seq. The case is illustrated by some good drawings. 450 
DISEASES OF THE THROAT AND NOSE. 
ENTOMOZOARIA IN THE NOSE. 
This subject belongs to the curiosities of medical literature, rather 
than to the domain of practical therapeutics, but amongst the entomo- 
zoaria which occasionally find lodgment in the nasal passages may be 
mentioned leeches, ascarides, centipedes, and earwigs. 
In former times, when leeches were so largely used, it is highly 
probable that these animals not unfrequently got up the nose. Their 
size, however, would render them easily visible, and they were no doubt 
quickly removed with forceps, or expelled by means of injections. 
That they did occasionally enter the nose is rendered more than probable 
by the animated discussions which took place in the fifteenth and six- 
teenth centuries, as to whether leeches could penetrate from the nose 
into the brain. There are, however, only two cases on record, so far 
as I have been able to discover, in which it is actually stated that a leech 
lodged in the nose. One is that of Lusitanus,* in which it is said that 
a man who suffered severely from headache, after every other kind of 
treatment had failed, had a leech applied to the anterior part of the 
nose. The animal accidentally crawled into the nasal passages, and 
could not be removed, and two days afterwards the man died. In the 
other casef a student, who had suffered for a long time from violent 
headache, accompanied by epistaxis and sneezing, was relieved of his 
trublesome complaint by the expulsion of a worm, which closely re- 
sembled a leech. 
Ascarides are occasionally found in the nose after death,| as indeed 
they are in the larynx and trachea, but in the latter case there is no 
doubt that the worms creep up into the air-passages from the intestinal 
canal immediately after the death of the patient, and it is highly 
probable that the same course of events has taken place when worms 
have been observed in the nose. There are a few instances, however, 
on record in which the worms were expelled from the nose during life. 
Thus Benevenius§ describes the case of a man who, suffering from 
* De Praxi Admirandfi., lib. iii., obs. 61, Amst. 1641. 
f Ephem. Acad. Nat. Curios , dec. ii., ann. i., obs. 99. 
J Troja (Earissiraa observatio de magno lumbrico in frontali sinu reperto et totam 
ejus cavitatem replente, Napoli, 1771) found a large ascaris occupying the entire 
cavity in one of the frontal sinuses of a corpse. Wrisberg (in Blumenbach’s Prolu- 
sio anatomica de sinibus frontalibus, Gottingae, 1779, 4 p. 25) also found a similar 
specimen. Deschamps (Maladies des Fosses nasales, 1804, p. 307) has also reported 
a case in which an Ascaris lumbricoides was found in the antrum after death. 
\ Med. Obs. Exempl., Colonise, 1581. ENTOMOZOARIA IN THE NOSE. 
451 
delirium and convulsions, appeared about to die, when he expelled a 
worm of about five inches in length from the right nostril, and made 
a good recovery. Forest,* Lanzoni,f Langelott,| Tulpe,§ Fehr,|| 
Bruckmann,** Albrecht,ff Habber,|| and Lange,§§ have also reported 
cases in which the Ascaris lumbricoides was expelled from the nose. 
Numerous instances are on record in which the centipedes have lodged 
in the nose or its adjacent sinuses for months and even years, no less 
than ten such cases having been collected by Tiedemann.|||| Most of the 
patients suffered from agonizing headaches, and some from vertigo and 
trembling. A case occurred in the practice of Marechal, of in 
which a centipede measuring six centimetres in length was expelled 
from the nose. The patient was a farmer’s wife, who had suffered 
from formication in the nostrils, and a copious discharge of mucus 
often fetid and mingled with blood, and from severe headaches, the 
sensation being compared by the woman to repeated blows with a ham- 
mer. She was also troubled with constant lachrymation and vomiting. 
The unfortunate patient often passed into a state of extreme excitement, 
and the least noise caused her great torture. There were periods of re- 
mission, but she had five or six severe attacks every day, and several 
during the night. One of them, however, lasted fifteen days without 
ceasing. The centipede was expelled alive after a year, and was pro- 
nounced to be a Scolopendron electricum. 
Earwigs, being only found in cool climates, and then only in the 
autumn months when few people live out of doors, seldom have an op- 
portunity of finding their way into the nose. The only case with 
which I am acquainted is that of Sandifort,*** in which a woman, very 
fond of smelling strongly-scented flowers, was suddenly attacked bv 
* Obs. et Cur. Med., lib. xxvii., obs. 28, p. 351. 
f Ephem. Acad. Nat. Curios., dec. iii., ann. ii., obs. 38. 
% Thomre Bartolini: Epist. Med., Cent, ii., epist. 74, p. 640. 
$ Observat. Med., lib. iv., cap. 12. 
|| Ephem. Acad. Nat. Curios., dec. iii., ann. iii., p. 261. 
Act. Physico-Med. acad. Nat. Curios., ti iv., obs. 30, p. 111. 
** Commer. Noricum., t. ix., ann. 1739, art. i., p. 113. 
ff Act. Physico-Med. Acad. Nat. Curios., t. iv., obs 51, p. 158. 
IJ Haarlem Verhadl., Bd. x., Heft 2, p. 465. 
\\ Blumenbach’s Medizinische Bibliotliek, Gottingen, 1788, Bd. iii., p. 154.. 
1111 Wiirmer in den Geruchsorganen, Mannheim, 1844. 
Moquin-Tandon, p. 217. See also Coquerel, loc. cit., p. 525. A similar case will 
be found reported in the Hist, de l’Acad. des Sciences, Paris, 1709, p. 42. 
*** Exercitatio Acad. Lugd. Bat., 1785, lib. ii., cap, xvii., p. 130 ; De forficula vivll 
naribus excussA 452 
DISEASES OF THE THROAT AND NOSE. 
great pain in the forehead on the right side, whilst at the same time a 
fetid discharge from the nose came on. After inhaling hot steam, she 
expelled a live earwig, when the pain and discharge soon ceased. 
The symptoms, caused by the various entomozoaria, usually consist 
in sleeplessness, pain in the lower part of the forehead, sanious dis- 
charge from the nose, vomiting, lachrymation, and in some cases great 
cerebral excitement. Sternutatories generally effect a cure, and in one 
or two instances the expulsion of the worm took place after spontane- 
ous sneezing. Occasionally, however, when these animals enter the 
frontal sinus, it may be necessary to trephine the bone, and Morgagni* 
reports a case, in which Csesar Magatns performed this operation suc- 
cessfully. 
ANOSMIA. 
Latin Eq.—Odoratus perditus. 
French Eq.—Perte de l’odorat. 
German Eq.—Verlust des Geruchsinns. 
Italian Eq.—Perdita del odorato. 
Definition.—Loss or impairment of smell primarily dependent on 
disease of the olfactory nerves or lobes, or of their cerebral centres.f 
* De sed. et caus. morborum, lib. i., art. ix; Lugd. Batav., 1767, t. i., p. 12. 
f A remarkable case has been reported bv Berard (Journal de Physiologic experi- 
mentale et pathologique, 1825, t. v., p. 17 et seq.), in which it is asserted that in the 
case of a man, whose sense of smell had been perfect, there was, nevertheless, found 
after death complete destruction, not only of the olfactory nerves, but also of the olfac- 
tory lobes, of the pedicles which unite them to the surface of the hemisphere in front of 
the Sylvian fissure, of the fissure itself, and, in short, thorough disorganization of the 
whole olfactory region. The grounds, on which it is maintained that the patient re- 
tained his sense of smell, are, first, that he was able to appreciate the difference be- 
tween various kinds of snuff, and, secondly, that he was annoyed by the stench of an 
abscess, from which a patient in the next bed was suffering. This evidence, however, 
appears to me to be inadequate, the pleasurable sensation, produced by snuff, mainly 
depending on its stimulating effects on the fifth nerve, the functional activity of which 
is apparently intensified when that of the olfactory nerve is abolished (see foot-note 
p.457). It is more difficult to explain away the patient’s dislike of the stench from 
the abscess, but it is possible that he objected to his neighbor on other grounds than 
those of smell. It appears that the sense of smell ioas never actually tested during life, and 
this fact, to my mind, entirely destroys the value of the observation. Desmoulins, in 
commenting on the above case, adds (loc. cit., p 17) an account of a patient, who had ANOSMIA. 
453 
History.—Several cases of anosmia, congenital and acquired, were collected by Bo- 
net,* and in 1751 a thesis on loss of smell was written by Bauer,f whilst at the begin- 
ning of the present century DeschampsJ recorded some curious instances of the affec- 
tion. The whole subject was treated in great-detail by in 1821, in a work 
specially devoted to the sense of smell. A very striking instance of the destruction of 
the sense by too powerful stimulation was reported by Graves|| in 1834, and soon-after- 
wards a case of congenital absence of the olfactory nerves, with complete anosmia, was 
published by Pressat.]f Some careful observations on senile atrophy of the olfactory 
nerves were made by Provost** in 1866, and an essay on various affections of the sense 
of smell, and the causes producing them, was written by Nottaff in 1870. Jn the same 
year an elaborate article on anosmia was published by William Ogle-tf The subject 
has recently been treated of by Althaus.£§ 
Etiology.—Any disease or injury of the olfactory nerves, tracts, or 
centres, is likely to interfere with the sense of smell, but for the satis- 
factory discharge of the function it is necessary that certain secondary 
conditions should be maintained. Not only is the integrity of the fifth 
and seventh nerves essential, but there must not be any mechanical ob- 
struction, which prevents the odorous particles from reaching the olfac- 
tory region, and the Schneiderian membrane must possess its normal 
moisture of surface. Further, it is highly probable that the presence 
of pigment in the cell-processes of Schultze is a necessary condition of 
healthy olfaction. 
lost his sense of smell on one side, although the olfactory nerves, lobes, pedicles, and 
the adjacent parts of the brain were perfectly sound. On the same side the ganglion 
of the fifth nerve had undergone degeneration, the gray matter having been destroyed 
and the nerve filament softened and altered. It is not stated what tests were used in 
this case for ascertaining the condition of the patient’s sense of smell; but, if ammonia 
or some other pungent vapor was employed, as was commonly done at that time, the 
fallacy of the experiment is obvious. Althaus has published a very complete and in- 
structive case (Med. Chir. Trans., 1869, vol. Hi., p. 27 et seq.), in which the mucous 
membrane of the nose was absolutely insensible to the contact of blunt or even sharp 
instruments, and no sneezing was brought on by snuff, yet the sense of smell was per- 
fectly normal, the patient having no difficulty whatever in recognizing the different 
varieties of scents, with which he was tested. 
* Sepulchretum, Genevse, 1700, t. i., p. 441 et seq. 
j- De odoratu abolito, Altorfii Noricorum, 1751; sometimes quoted as the work of 
Jantke, under whose presidency it was delivered. 
J Maladies des Fosses nasales, Paris, an xii. [1804], p. 56. 
\ Osphrdsiologie, Paris, 1821. 
|| Dublin Journ. of Med. Sci., 1834, No. 16. 
f Obs. d’un Cas d’Absence du Nerf Olfactif, These de Paris, December 18th, 1837.. 
** Gazette Medicale, 1866, No. 37, p. 597 et seq. 
ff Arch. Gfin., 1870, t. i., p. 385 et seq. 
Med.-Chir. Trans., 1870, vol. liii., p. 263 et seq. 
§§ Lancet, May 14th and 21st, 1881. 454 
DISEASES OF THE THBOAT AND NOSE. 
Cases are on record, in which the exposure of the olfactory nerves to the 
prolonged action of an exceedingly disagreeable smell appears to have 
been the cause of injury to the function of this nerve, and it is not im- 
probable that the mode of action of the odor consists in over-stimulation, 
in the same way that strong light sometimes produces amaurosis. A re- 
markable case of this sort has been recorded by Bauer,* in which a sur- 
geon, who dissected a very putrid body, lost the sense of smell for the rest 
of his life. Gravesf has reported an instance, in which, during the Irish 
rebellion of 1798, an officer had to take charge of some soldiers, who 
were engaged for many hours searching for pikes supposed to have 
been concealed in a very offensive sewer. Next day he perceived he 
had lost his smell. It might be thought that scavengers would some- 
times suffer in a similar manner, but, from inquiries I have made, this 
does not appear to be the case. The explanation probably lies in the 
fact that, when sewers are at all foul, the workmen remain in them only 
a very short time.! The inhalation of strong fumes of ammonia, or 
other irritant vapors, may likewise affect the terminal twigs of the 
olfactory nerves in such a way as seriously to impair their function. 
Snuff-taking sometimes acts in a similar manner.§ I have seen two 
cases, in which the use of the nasal douche has been followed by per- 
manent anosmia. Wendt|| refers to three cases, within his own knowl- 
edge, in which the sense of smell was permanently destroyed by the 
local use of solution of alum. has reported a case, in which 
the action of sulphuric ether appeared to destroy the function of the 
olfactory nerves, the patient having been an entomologist, who spent 
many hours daily in preparing insects which he killed with that vapor. 
Loss of smell sometimes follows frontal neuralgia,** and a case was ob- 
served by Maurice Raynaud,ft in which the loss of function was dis- 
tinctly periodic, the patient having been a woman, aged thirty-eight, 
who suffered from anosmia every twenty-four hours from 4 p.m., one 
day, to 10 A.M., the next. She rapidly recovered under the use of 
quinine. This patient was not in the least degree hysterical, but had 
previously suffered from crural neuralgia, which had also been cured 
* Op. cit., p. 188. f Dub. Journ., 1834, No. 16. 
J A superintendent of sewers, who had spent a large portion of his life underground, 
once informed me that the sewers were generally far sweeter than most private houses. 
§ Virchow’s Archiv., 1868, Bd. xli., p. 290. 
|| Ziemssen’s Cyclopaedia, vol. vii., p. 56. 
Tf Virchow’s Archiv., 1868, Bd. xli., p. 290. 
** Notta: Archives G6n., 1870, vol. i., p. 385 et seq. 
ft Union Mfedicale, July 10th, 1879. ANOSMIA. 
455 
by quinine. The most common cause of anosmia is prolonged catarrh,* 
few practitioners having failed to meet with some examples. In these 
cases the cell-processes of Schultze are probably destroyed by cirrhotic 
shrinking of the inflammatory exudation. A remarkable case has 
been recorded by J. P. Frank,f but without details, in which he af- 
firms that “loss of smell and taste occurred in a man from a deposit of 
rheumatic (?) matter on the nose and tongue.” Unless this was a case, 
in which a diphtheritic membrane was deposited, it is difficult to un- 
derstand its nature. 
Owing to the extremely soft consistence of the olfactory bulbs, they 
are occasionally separated from the brain by falls on the head. Some- 
times these accidents are accompanied by concussion of the brain, and 
anosmia is associated with deafness, ringing in the ears, or even bleed- 
ing from one ear; in these latter cases there is probably a fracture of 
the base of the skull, but in other instances temporary abolition of 
consciousness and loss of smell are the only symptoms. Such cases 
are by no means rare, and several have been described by Notta.| 
One instance of this kind has come under my own notice, the patient 
having been a surgeon, who was thrown from his gig with considerable 
force, and lighted on his head. He was stunned for a few minutes, 
and the next day became aware that he had lost his sense of smell. 
Although this gentleman subsequently recovered his health completely, 
the anosmia was permanent. 
Long-continued paralysis of the fifth nerve interferes with the proper 
nutrition of the mucous membrane, and peripheral changes of a sec- 
ondary character may then take place in the olfactory nerves, and thus 
cause true anosmia. In cases of paralysis of the seventh nerve (portio 
dura) the patient is unable to smell, for two reasons—first, because he 
is unable to snitf up the olfactory particles; and, secondly, because the 
orbicularis muscle of the eye being paralyzed, the conjunctival fluid 
overflows on to the cheek instead of passing through the lachrymal 
duct, causing dryness of the nasal mucous membrane, and so destroying 
the receptivity of the olfactory nerve. 
The influence of obstruction in interfering with the function of smell 
is seen in the case of polypi and of swelling of the mucous membrane 
of the nose. When the obstruction, however, is due to nasal or naso- 
pharyngeal growths, or to adhesions which block up the posterior nasal 
* Ephem. Nat. Curios, dec. iii., ann. iv., obs. 3. 
f De Curandis Hominum Morbis, Mannhemii, 1793, lib. v., p. 132. 
J Loc. cit.; see also a case, Ephem. Nat. Cur., ann. iv., obs. 3. 456 
DISEASES OF THE THROAT AND NOSE. 
openings, the patient can smell odorous substances placed near the 
nostrils, though in eating he can no longer appreciate flavors, and he 
therefore thinks he has lost his sense of taste. 
Moisture of the mucous membrane of the nose is as essential to the 
sense of smell as that of the tongue is to taste. The influence of the 
seventh pair of nerves in indirectly causing dryness has already been 
pointed out, and it is only necessary here to call attention to the arrest 
of secretion in the first stage of nasal catarrh, which often gives rise to 
temporary anosmia. 
The presence of pigment in immediate contact with the cell-processes 
of Schultze is probably essential to olfaction in many animals, but, as 
far as I am aware, Hutchison’s* case is the only one on record which 
supports this view as regards the human subject. The patient was a 
young negro in Kentucky, whose parents were both black, and who up 
to his twelfth year had the usual dark skin of an African. At this 
period a white patch appeared near the left eye, which in ten years 
extended all over the body, so that had it not been for his woolly hair 
the young man might have been taken for a very fair European. 
When he first began to change his color, his sense of smell was weak- 
ened, and by the time he had become white olfaction wras almost com- 
pletely lost. This case was passed over as a mere medical curiosity 
until its importance was recognized by William Ogle.f AltliausJ has 
recorded the case of a well-known statesman who is an Albino, in 
whose case smell had ahvays been weak, and who lost this sense entirely 
at the age of sixty-three. Althaus regarded the case as one of “ ultimate 
atrophy of a nerve which had never been highly developed.” It appears 
from the researches of Ogle§ that the pigmentation of the olfactory 
region is darkest in those animals which have the most acute sense of 
smell, and that in the colored races of men this sense acquires a much 
greater degree of perfection than in the white man. He further points 
out that it has often been observed that white animals, owing to their 
defective sense of smell, are more liable than those of a dark color to 
eat poisonous herbs.|| Thus, in some parts of Virginia, white pigs are 
poisoned by the roots of the Lachnanthes tinctoria; whilst in the Ta- 
rantino, the inhabitants only rear black sheep because the white ones 
are poisoned by eating the abundant Hypericum crispum of that region. 
* Amer. Journ. Med. Sci., 1852, vol. xxiii., p. 146 et seq. 
f Med.-Chir. Trans., 1870, vol. liii, p. 276. 
J Lancet, 1881, vol. i., p. 813. 
\ Loc. cit., p. 278 et seq. || Loc. cit., pp. 281, 282. ANOSMIA. 
457 
It is stated also that the white rhinoceros perishes from eating the 
Euphorbia candelabrum, which the dark rhinoceros refuses. 
The sense of smell generally becomes impaired in the decline of life 
—a change probably resulting from atrophic degeneration of both the 
nerve centre and its periphery. 
Defective olfaction is probably sometimes hereditary,* and cases of 
congenital deficiency of the sense of smell have been recorded by 
Frankenauf and Notta.| It is not improbable that in some of these 
instances the cause of anosmia was prolonged nasal catarrh in infancy; 
but this explanation does not always apply, for congenital deficiency 
of the olfactory nerves has sometimes been observed (see Pathology). 
In conclusion, it must be admitted that there are some cases of anos- 
mia in which it is impossible to discover any cause for the loss of func- 
tion. Several instances of this kind have been reported by Notta, 
under the term of anosmie essentielle. 
Symptoms.—Taste is so closely associated with smell that it is neces- 
sary to make a few observations on the subject of these two senses. 
The recognition of the bitter, sweet, salt, and acid characters of food 
by the tongue and fauces constitutes taste. The appreciation of the 
savor of meat, the flavor of fruit, and the bouquet of wine, depends en- 
tirely on smell. It is necessary to call attention to these facts, because 
the mistake is not unfrequently made by medical writers, of describing 
cases as loss of taste, when it is clear from the context that they mean 
loss of smell. But whilst taste is rarely impaired, smell is often al- 
together lost, and the acuteness of the sense varies very much in differ- 
ent people. It is generally somewhat feeble in young children, attains 
its greatest vigor in adult life, and, as already remarked, becomes dull 
in old age. It is only when the sense of smell is completely lost that 
the power of distinguishing flavors is destroyed; people who have no 
perception of odors diffused in the atmosphere often retaining a keen 
relish for savory food. Loss of smell may be either unilateral or bila- 
teral, and in the former case it may be of import as indicating localized 
lesion of the brain, or some disease in the upper part of one of the nasal 
channels. 
It has been remarked that in cases of anosima the sensibility of the 
mucous membrane to irritants has sometimes become even more acute 
than it was whilst the olfactory nerves were in a healthy condition.§ 
* Breschet: Diet, des Sciences Medicales, 1819, vol. xxxvii., p. 241. 
f Ephem. Nat. Curios., dec. iii., ann. iv., obs. 3. J Loc. cit. 
\ See a case related by Deschamps (Maladies des Fosses nasales, Th&se de Paris, 
1804, p. 56), in which a student who had totally lost his sense of smell became, after a 458 
DISEASES OF THE THROAT AND NOSE. 
Pathology.—The pathology of anosmia is still very obscure, though 
there are a number of scattered observations on the subject. A remark- 
able case has been related by Bonet,* in which a man who had suffered 
towards the end of his life from headache, together with blindness and 
loss of smell, was found after death to have an abscess involving the 
olfactory bulbs. In a second case recorded by the same author, an 
abscess was found involving the olfactory bulbs and causing erosion of 
the frontal and ethmoid bones. The patient was a man aged twenty- 
two, who, shortly before death from convulsions, had suffered from 
headache, blindness, and loss of smell. This was, no doubt, an exam- 
ple of syphilitic disease of the bones. It is more difficult to explain the 
pathological nature of the following case, which is also reported by 
Bonet:f “A .‘stone/ flattened like a coin but not so round, and of an 
ashy color, was found at the base of the brain, pressing on the sphenoid 
(sic) and olfactory nerves.” The patient in whom this was observed 
had been attacked with fever, accompanied by severe pain and heavi- 
ness in the head, and had died nine days after the commencement of 
the illness. I feel quite unable to make any suggestion as to the nature 
of the “ stone,” but the case seems worthy of mention as being the 
record of a fact by an accurate observer. 
As the olfactory nerve-tract can be traced to the island of Reil,| to a 
point not far from Broca’s convolution, it might be expected that in 
aphasic patients anosmia would be often present. But although such 
cases have been reported by Fletcher,§ IIughlings-Jackson,|| and 
the association of these symptoms does not appear to be common. The 
statistics of Ball and Ivrishaber,** indeed, tend to show that disease of 
time, able to distinguish one kind of snuff from another, simply from their different 
degrees of pungency. 
* Sepulchretum, Genevae, 1700, lib. i., sec. xx., obs. 1, p. 441. 
f Op. cit., obs. 4, p. 443. 
J The experiments of Ferrier (Functions of the Brain, London, 1876, p. 184) tend to 
show that the olfactory centre is situated at the tip of the temporo-sphenoidal lobe— 
the faradization of this spot in animals being followed by a sniff, which is evidently the 
outward expression of the excitation of the centre. Not only does destruction of this 
part seem to cause loss of smell, but it is observed to be much developed in animals 
which have a keen sense of smell. Injury of the external olfactory tract, which is lost 
in the island of Beil, has been shown by Serres (Anat. Comp, du Cerveau, t. i., p. 295), 
in nineteen post-mortem examinations of paralytic patients, to be associated with loss of 
smell in a much more marked manner than injuryof the internal tract. 
$ Brit. Med. Journ., April, 1861. || Lond. Hosp. Rep., vol. i., p. 10. 
1[ Loc. cit., p. 273 et seq. 
** Diet. Encyclop. des Sci. M6d., Paris, 1873, t. xiv., p. 456. ANOSMIA 
459 
the left side of the brain does not frequently cause anosmia, but that it 
is more common when the lesion is in the right lobe. Thus, out of 
seventy-five cases in which there was a tumor in the left side of the 
brain, there was not a single instance of anosmia, though aphasia was 
present in seventeen. On the other hand, out of sixty-three cases of 
tumor affecting the right side, in three of which aphasia was a symptom, 
anosmia was observed in two. Further, out of forty-seven cases of 
cerebral tumor, where the growth was median or bilateral, or where the 
exact situation was not stated, there were four cases of loss of smell; 
but it is not recorded that anosmia and aphasia coexisted. Although it 
is evident, from the above statistics, that anosmia is sometimes caused 
by the pressure of tumors in the brain, it is remarkable that abscess in 
the cerebral substance very seldom interferes with the function of the 
olfactory centre, for out of eighty-nine cases of this affection collected 
by Ball and Krishaber,* in thirty-eight of which the left side of the 
brain was affected, anosmia was not present in a single instance. In 
connection with aphasia, it must not be forgotten that anosmia, unless 
specially looked for, would be very likely to escape notice. The fact 
that the loss of smell in these cases is only unilateral would probably 
prevent the patient noticing it, but even were it to be observed by him. 
his limited powers of articulate expression would probably prevent his 
calling attention to it. In connection with this subject, it may be men- 
tioned that Hughlings-Jacksonf has shown that plugging of the anterior 
cerebral, or possibly of the middle cerebral artery, sometimes gives rise 
to anosmia. 
PrevostJ has reported fourteen cases in which he had examined the 
olfactory nerves after death. In six of these the sense of smell had not 
been tested during life, and no conclusion, therefore, can be drawn from 
the observations. In four others, in which it had been absent or defi- 
cient for some time before death, there was found distinct degeneration 
of the nerve-tissue of the olfactory bulbs. In the remaining four cases, 
however, similar pathological changes were discovered in the nerves, 
although the sense of smell had been proved during life to be perfectly 
sound. 
Congenital absence of the olfactory nerves has been observed by 
Bonet,§ Rosenmuller,|| and In Pressat’s case, at the post- 
* Op. cit. 
f Lond. Hosp. Reports, 1864, vol. i„ p. 410. 
| Gaz. Med., Sept. 15th, 1866, No. 37, p. 597 et seq. 
\ Sepulchretum, Genevse, 1700, lib. i., sect, xx., obs. 2. 
|| De Defectn Nervi Olfactorii, Leipzig, 1817. 
Op. cit. 460 
DISEASES OF THE THROAT AND NOSE. 
mortem examination of a patient who during life never had any sense 
of smell, it was found that there was complete absence of the olfactory 
nerves, and not even a trace of the bulb or roots could be discovered. 
The brain in the immediate neighborhood was quite healthy, and no 
other nerves were wanting. On the left of the crista galli there 
was a groove, but on the right side there was no trace of this. The 
ethmoid did not present the usual perforations, there being only a single 
small aperture on the left side near the ethmoidal fissure, where the 
nasal branch of the fifth nerve passed through. There was no altera- 
tion of any kind effecting the pituitary membrane. The case related 
by Bonet is somewhat analogous in character, and it possesses additional 
interest as being quoted from Schneider. In this instance the patient 
was a young man who had suffered from congenital anosmia, and it was 
found after death that the olfactory nerves did not send any branches 
to the pituitary membrane. The same author records a second case,* 
in which, in the case of a man who had no smell, the olfactory nerves 
were absent. 
Diagnosis.—It is very important to differentiate the various forms 
of anosmia. Mechanical obstructions can be easily recognized with the 
help of the speculum and mirror, and in most of the cases of a neurotic 
character there are associated symptoms which point to the real nature 
of the affection. In all cases where the patient complains of impair- 
ment of smell, the function should be tested by first closing one nostril, 
and then the other, when it will at once be ascertained whether the 
sense is destroyed on one side, or blunted on both; and it should be 
remembered that in loss of smell dependent on injury to the seventh or 
fifth nerves the affection is almost always unilateral. 
In testing the smell the patient should not be allowed to know what 
scent is presented to his nostrils, but at the same time it is important 
that the test-odors should be familiar. Oil of cinnamon, oil of pepper- 
mint, turpentine, valerian, or a well used tobacco-pipe will be found to 
serve the purpose well. 
Prognosis.—The prospect of restoration of function depends, of course, 
on the nature of the lesion. Where there is cerebral disease the sense 
of smell is seldom recovered. Nottaf has pointed out that, strange as 
at first sight it may appear, in anosmia resulting from injury of the 
head the sense of smell is more often restored when the associated le- 
sions have been severe—that is to say, when there has probably been 
fracture of the base of the skull—than when the accident has apparently 
* Op. cit., lib. i., sect, xx., obs. 3. 
f Loc. cit. ANOSMIA. 
461 
been less violent. The explanation is to be found in the fact that 
anosmia following a comparatively slight injury is likely to be due to 
separation from the brain of the olfactory bulbs, a condition which, of 
course, is irreparable. 
Where anosmia is dependent on catarrh, a favorable prognosis may 
be given, but I have never known recovery to take place in such cases 
where loss of smell has existed for two years or more. Where, how- 
ever, the loss of smell is simply the result of mechanical interference 
with the conditions necessary for the proper exercise of the function, as 
in the case of polypi and other growths, the sense, in most cases, will 
be restored when the obstruction is removed, even after a lapse of many 
years. Bauer* has reported a case which came under his own notice, 
in which a man who had lost his smell for fifteen years suddenly re- 
covered it after a voyage. The cause of the anosmia is not stated. 
Treatment.—In true anosmia—that is to say, in loss of smell de- 
pendent on loss of nerve-power—no treatment has hitherto proved of 
any avail. In cases of cerebral injury or disease, or when the con- 
tinuity of the nerve is interrupted, it is obvious also that nothing can 
be done. Where the function of the nerve is merely blunted, however, 
benefit may be looked for from therapeutical measures. Beard and 
Rockwellf have met with success from galvanism, applied both inside 
and outside the nose; but though I have employed this treatment in 
favorable cases, such as loss of smell after prolonged catarrh, I have 
never found it to do any good. Althaus| has found that a very powerful 
current is required to stimulate the olfactory nerve, no less than thirty- 
five plates being necessary to obtain any response. This, by affecting 
the contiguous nerves, causes extreme pain, dazzling flashes of light, a 
hissing noise like that of a steam-engine, together with faintness and 
giddiness—a condition which is really worse than the original complaint. 
Hence this treatment cannot be recommended. The insufflation of a 
powder containing one-twenty-fourth of a grain of strychnia with two 
grains of starch, twice a day, will sometimes do good. If no effect is 
produced, the strychnia may be increased to one-sixteenth or one-twelfth 
of a grain. This remedy, which was originally recommended by Al- 
thaus,§ has twice proved of service in my hands. Should the anosmia 
be intermittent, quinine should, of course, be given as in the case re- 
ported by Maurice Raynaud.|| 
* De Odoratu Abolito, Altorfii Noricorum, 1751, p. 192. 
f Practical Treatise on the Med. and Surg. Uses of Electricity, London, 1881, 3d 
ed., pp. 646, 647. 
I Lancet, 1881, vol. i., p. 772. 
§ Ibid., p. 815. 
|| Loc. cit. 462 
DISEASES OF THE THROAT AND NOSE. 
PAROSMIA. 
The subjective perception of a disagreeable odor is not very un- 
common. It is often a species of epileptic aura, and this doubtless 
results, as Althaus* remarks, in certain cases, from disturbances in the 
olfactory centre, and subsequent extension of the morbid impression to 
the motor centres. Parosmia is often met with in lunatics, although in 
them, as Schlaegerf has pointed out, the apparent hallucination often 
really depends on a lesion involving the olfactory centre. A case re- 
ported by LockemannJ; furnishes a good illustration of this condition. 
The patient was a woman aged fifty-five, who, after suffering from 
giddiness and epilepsy for a year, began to notice that immediately 
before a seizure she experienced sensations of “ indescribable ” smells, 
which were sometimes agreeable in character, and which ceased when 
the fit was over. This symptom gradually disappeared in the course 
of a few months, and, till the death of the patient from coma two years 
later, nothing peculiar as regards the sense of smell was observed. The 
autopsy revealed a carcinomatous tumor about the size of a duck’s egg 
in the left cerebral lobe. This growth had destroyed every vestige of 
the left olfactory tract. There can be no doubt that towards the end 
of her life this patient suffered from unilateral anosmia, although the 
symptoms escaped observation. In a somewhat similar case related by 
Sander,§ a man aged thirty-three was subject to epileptic fits, which 
were ushered in by an excessively disagreeable smell. Symptoms of 
insanity came on after a time, and before death the patient became 
totally blind. The post-mortem examination showed that a glioma of 
the size of an apple was situated on the under surface of the left tem- 
poral lobe, extending into its substance for a depth of two inches and 
a half. The growth also reached the under part of the frontal lobe, 
and the posterior part of the left olfactory tract was lost in it. It is 
not clearly stated whether the parosmia occurred only in the first attacks, 
or whether it was a constant precursor, as in Lockemann’s patient above 
mentioned. A case was recorded by Whytt,|| which has been often 
* Lancet, 1881, vol. i., p. 814. 
f Zeitschr. d. Gesellschaft d. Aerzte zu Wien., 1858, Nos. 19 and 20. 
J Zeitschr. f. rat. Med., 1861, 3 Reihe, xii. 
\ Archiv f. Psycliiatrie, 1873-74, Bd. iv., p. 234 et aeq. 
|| Observations on the Nature, Causes, and Cure of those Disorders which have been 
commonly called Nervous, Edinburgh, 1765, p. 144 et aeq. PAROSMIA. 
463 
referred to by subsequent writers. The subject was a boy aged ten, 
who, between attacks of hystero-epilepsy, used to complain of a peculiar 
smell; but as the lad had at the same time a purulent discharge from 
the nose, I do not think the case deserves the consideration it has re- 
ceived. Westphal* has reported a much more pertinent example of 
parosmia, which occurred in a syphilitic patient who suffered from con- 
vulsions. In this instance, at the autopsy, the olfactory bulb was found 
“ adherent,” and near it were seen two small gummata on the pia mater. 
In the case of a lunatic, related by Schlaeger, the patient had com- 
plained of disagreeable smells for many years, and after death a fungous 
tumor of the dura mater was found on the cribriform plate of the eth- 
moid. A patient referred to by Hughlings-Jacksonf used to be troubled 
with the smells as the epileptic fit was passing off. 
Perversion of the sense of smell, however, is not uncommonly met 
with in persons in whom there is not the slightest evidence of disease 
of the nervous centres. Sometimes the disagreeable smell is constantly 
present, but in other instances it is provoked by substances the odor of 
which is generally considered to be agreeable, or at any rate indifferent. 
In a patient recently under the care of Sir William Jenner and myself, 
the smell of cooked meat was so exactly like that of stinking fish that 
scarcely any animal food could be taken. The patient was a lady of 
about fifty years of age, in whom the menstrual function still continued 
active. She was a person of remarkable vigor, both of body and of 
mind, fond of outdoor exercise, and never having shown the least sign 
of hysteria. She was under treatment for several months. After a 
time the digestion became upset, and the function of the liver was 
somewhat disturbed; but these symptoms appeared to depend on the 
patient’s inability to take proper food, and were the result rather than 
the cause of the parosmia. Every kind of local and constitutional 
treatment was tried. After some months complete recovery took place, 
but I could not attribute it in any way to the remedies. 
In persons otherwise perfectly healthy, permanent abnormalities in 
the sense of smell may sometimes be observed. Thus a leading member 
of our profession has informed me that violets always smell to him 
exactly like phosphorus, and I know of another person to whom 
mignonette has the odor of garlic. It is not improbable that an affec- 
tion of the olfactory sense, analogous to color-blindness, may occasion- 
ally exist. 
* Allgem. Zeitschr. f. Psychiatrie, Bd. xx., p. 485. 
f Lancet, Jan. 24th, 1866. 464 
DISEASES OF THE THROAT AND NOSE. 
Anomalies in the function of smell are probably sometimes due to 
inflammatory changes in the olfactory nerve itself, or to conditions 
corresponding to neuralgia in a nerve of common sensation. A very 
remarkable example was published several years ago by Robertson,* 
in which the patient, a woman, aged fifty, a week after the removal of 
a cataract from her right eye, began to suffer from inflammation of the 
iris and choroid. This was followed by subjective sensations of smell 
of the most disgusting nature, a symptom which was at once relieved 
by a hypodermic injection of morphia. An instance has been related 
by Althaus,f in which a patient, after exposure to cold, was startled 
by perceiving a strong smell of phosphorus, which overpowered all 
other accidental smells, and never left him for six weeks. At the end 
of that time he noticed that he had become insensible to odors of any 
kind, though the function of the fifth nerve was still quite unimpaired. 
Symptoms of locomotor ataxy gradually came on, and the patient died 
eight years after the commencement of his illness. The olfactory lobes 
showed the naked-eye appearances of neuritis, but through an unfortu- 
nate accident they were not submitted to microscopic examination. 
No rules can be laid down for treatment, the great variety of the 
diseased conditions giving rise to parosmia, making it necessary to adopt 
different measures according to the circumstances of the case. 
DISEASE OF THE FIFTH NERVE, OR ITS NASAL 
BRANCHES. 
When the fifth nerve or its nasal branches are injured or diseased, 
the mucous membrane of the nasal fossae loses its sensibility. Under 
such circumstances a pungent vapor, such as ammonia or ether, is not 
perceived, and does not give rise to the reflex phenomenon of sneezing. 
On the other hand, when these nerves are subjected to abnormal irrita- 
tion, excessive sneezing may take place. In ordinary catarrh there is 
no doubt that irritation of the branches of the fifth nerve occurs, and 
that the hyper-secretion taking place is the effect of vaso-motor paralysis. 
A really typical example of the affection, however, has been related by 
Althaus,! in which the complaint was purely neurotic in character. 
* Boston Med. and Surg. Journ., 1873, vol. lxxxix., p. 280. 
f Lancet, 1881, vol. i., p. 814. 
I Med.-Chir. Trans., 1869, vol. 111., p. 27 et seq. CONGENITAL DEFORMITIES OF THE NOSE. 
465 
The treatment of conditions, the cause of which is so obscure, is not 
very hopeful. In the case of deficient sensibility, however, some good 
may possibly be done by frequent mild applications of the galvanic 
current directly to the mucous membrane. The therapeutics of catarrh 
have been already fully discussed (p. 290 et seq.), whilst for nervous 
sneezing, I can only suggest large doses of bromide of potassium, com- 
bined, in some cases, with insufflations of morphia. 
CONGENITAL DEFORMITIES OF THE NOSE. 
Latin Eq.—Deformitates nasi ingenitse. 
French Eq.—Vices de conformation du nez. 
German Eq.—Missbildungen der Vase. 
Italian Eq.—Vizi di conformazione del naso. 
Definition.— Congenital deviation from the normal shape of the nose, 
consisting in the absence or reduplication of the ivhole organ, or any of its 
constituent parts, or in complete or partial closure of its canals. 
History.*—The only case on record, so far as I am aware, of complete absence of the 
nose, is one reported by Maisonneuve.f The patient was a girl, who, when first seen 
by that surgeon, at the age of seven months, presented the following anomaly: The 
nose was represented by a flat surface pierced only by two round holes, each being 
scarcely one, millimetre in diameter. These apertures were three centimetres apart. 
It is not stated whether the internal structures of the nose were normal, or whether 
there was any coexisting deformity of any other part of the body. 
The septum is sometimes altogether wanting. An instance of complete absence of 
this partition in a still-born foetus was published by Fernet J in 1864. In this case the 
floor of the nose was also partly deficient, the palate being cleft in its whole length. 
There was besides double harelip, and the eyeballs and optic nerves were absent. The 
posterior lobes of the brain were, atrophied, and each hand and foot had six digits. 
The septum occasionally presents a deficiency of substance in one spot, so that the two 
nasal fossae communicate through a congenital aperture; cases of this kind have been 
* In dealing with the history of the subject, the bibliography has not been treated 
in the usual chronological method, hut the few scattered cases on record have been re- 
produced in the order in which they are referred to in the Definition. 
f Bull. G6n. de Therapeutique, 1855, t. xlix., p. 559. 
% Bull, de la Soc. Anat., 1864, 2e serie, t. 9, p. 130. 466 
DISEASES OF THE THROAT AND NOSE. 
recorded by Portal,* Hildebrandt,f and Hyrtl,| whe states that he has met with the 
abnormality three times in the course of his “ anatomical life.” Zuckerkandl,§ how- 
ever, who says that he found a hole in the cartilaginous part of the septum eight times 
in one hundred and fifty bodies, holds that the opening is not caused by arrest of de- 
velopment, but is really a loss of substance due to previous perichondritis. 
A remarkable example of congenital deformity of the nose was reported by Thomas,|| 
in 1873. The patient was a boy three months old, born of healthy parents who had 
previously had several perfectly formed children. On the right side of the face there 
was a triangular opening with somewhat rounded base, which corresponded to the an- 
terior orifice of the nasal fossa, the apex reaching beyond the inner angle of the eye 
almost to the upper border of the orbit. The cavity of the right fossa was thus ex- 
posed as high as the root of the nose. The opening was bounded externally by the in- 
teguments of the cheek and eyelids, which were continuous with the nasal mucous 
membrane, internally and above by the skin of the nose, which also was continuous with 
the mucous membrane at the edge of the cleft, whilst lower down the opening was 
bounded on its inner side by the mucous membrane of the right ala nasi, which was 
turned inwards and upwards. Through the fissure could be seen the lower spongy, 
bone, the upper and inner part of which was adherent to the internal surface of the 
everted ala. The right eye and orbit were normal, but the inner extremity of the lower 
eyelid with the caruncula lacrymalis was half a centimetre lower in level than the cor- 
responding part on the left side. As the upper eyelid was normal in direction, there 
was thus a gap between the right eyelids at the inner canthus of more than a centi- 
metre in width. This gap was bridged over by a strip of skin about three millimetres 
wide, which separated the eye from the nasal fissure. Along the middle line of the 
nose there was a raphe projecting to the extent of about one millimetre, which seemed 
to mark the line of union of parts originally separate. There was no deformity in any 
other region of the body. In 1859 Hoppef reported a case of congenital malformation 
of the nose, in which there was a furrow along the middle line, the nasal bones being 
entirely absent. Their place was occupied by two cylindrical pieces of cartilage, and 
a fissure existed along the middle of the nose from the root to the tip, where there were 
two round knobs. The nostrils were well formed and properly separated. 
Quite recently, Lefferts** has described a case of double septum in a man aged 
twenty-five. The upper half of the posterior edge of the partition was divided in the 
vertical direction into two distinct portions, which were separated widely enough to 
admit the end of a lead pencil between them. The space thus inclosed was triangular 
in shape, the widest part being above, and the mucous membrane covering it had a 
natural appearance. 
A case of double nose was related by Borelli,tf but without sufficient anatomical 
* Cours d’Anat. Mfidicale, Paris, 1804, t. iv., p. 481. 
f Lehrbuch der Anatomie des Menschen, Wien, 1802, vol. iii., p. 162, § 1647, foot- 
note. This writer, who was professor of anatomy at Gottingen, states that he himself 
had a congenital hole in the cartilaginous part of his septum large enough to admit a 
pea. 
J Lehrbuch der Anatomie des Menschen, Wien, 1882, pp. 576, 577. 
§ Normale und pathol. Anatomie der Nasenhohle, Wien, 1882, pp. 99, 100. 
|| Bull, de la Soc. de Chir., 1873, 3e sferie, t. 2, p. 162. 
T[ Med. Zeitung des Ver. f. Heilk. in Preussen, 1859, p. 164. 
** Philadelphia Medical News, Jan. 7th, 1882. 
ff Obs. Rarior. Medico-Phys., cent, iii., obs. 43. CONGENITAL DEFORMITIES OF THE NOSE. 
467 
details to establish the true character of the malformation. Although many of the 
cases reported by the earlier medical writers are undoubtedly fabulous, still a positive 
statement of fact by so celebrated a man is not to be too lightly dismissed. It is 
obvious, however, that a vague expression like nasus duplex might refer to a lipomatous 
tumor or elephantiasis, as well as to a veritable double organ. 
Cases of congenital occlusion of the posterior nares have been reported by Emmert,* 
Luschka,f Yoltolini,J Betts,§ Cohen,|| and In Emmert’s patient, a boy 
aged seven, there was complete bony obstruction of both choanse. Luschka’s case oc- 
curred in a female child, and the openings were also closed by bone. Thin osseous 
laminae extended from the horizontal plate of the palate-bone to the inferior surface of 
the sphenoid, to which they were united by a dentated suture. In Voltolini’s case 
only the right clioana was closed, the atresia being due to “ congenital adhesions.” 
Betts found both posterior nares closed by bony partitions in a foetus seven months old. 
In Cohen’s case the nature of the occlusion is not stated, but it was probably mem- 
branous. The example related by Bonaldson occurred in a female child, born at full 
time and presenting no other malformation, who died very soon after birth, from in- 
ability to breathe through the nostrils. The posterior nares were found to be com- 
pletely occluded by a thick membrane of such firm texture that a probe could hardly 
be forced through it. 
Plarrison Allen** has lately called attention to an occasional irregularity in the rela- 
tive size of the nasal fossae, caused not by deviation of the septum, but in congenital 
narrowness of one chamber as compared with the other. 
Etiology.—The causes of such anomalous formations are probably 
the same as those which determine imperfect or abnormal development 
of other organs. The principal theories on this obscure subject have 
already been discussed in a previous article (see “Malformations of the 
Gullet/’ p. 223 et seq.), and need not be further referred to in this place. 
With regard to the unequal capacity of the nasal chambers, Allen states 
that he has observed it chiefly in idiots, and he suggests a possible cause 
for it in the irregular depth of the depressions in the base of the skull, 
owing to unequal development in different parts of the brain. I may 
say, however, that in none of the skulls in the Museum of the College 
of Surgeons was I able to detect any inequality in the size of the nasal 
fossae not dependent on the position of the septum. 
Symptoms.—In the cases of deficiency of a portion of the nose men- 
tioned in the above short historical retrospect, no symptom was noticed 
* Lehrb. d. Chirurgie, Stuttgart, 1853, Bd. ii., p. 355. 
f Schlundkopf der Menschen, 1868, p. 27. 
X Die Anwendung d. Galvanocaustik, Wien, 1870, 2d ed., pp. 240-262. 
\ New York Med. Journ., July, 1877, p. 97. 
|| Diseases of the Throat and Nasal Passages, New York, 1879, 2d ed., p. 385. To 
Cohen I am indebted for most of the references relating to this malformation. 
If Edin. Med. Journ., 1880-81, p. 1035 (May, 1881). 
** Philadelphia Medical News, May 26th, 1883, pp. 605, 606. 468 
DISEASES OF THE THROAT AND NOSE. 
beyond the disfigurement arising from the malformation. Where there 
is atresia of the posterior nares, the child’s breathing is difficult, and 
the serious troubles attending obstruction ensue (see p. 293). 
Prognosis.—None of the deformities described can be said to threaten 
life except congenital closure of the posterior nares, and that only in 
infancy. 
Treatment.—Various plastic operations may be undertaken for the 
correction of these deformities. Maisonneuve, who claims that his case 
is the first instance on record of rhinoplasty for congenital malformation, 
has given such an incomplete description of the procedure which he 
adopted that it is useless to reproduce it; and I can find no statement 
of the ultimate result of the procedure, either as to the appearance of 
the organ, or as to its functional utility. 
In the case of fissure exposing one nasal fossa up to the root of the 
nose, Thomas made an incision along the inner edge of the cleft at the 
junction of the skin with the mucous membrane. He then dissected 
up the skin, beginning at the narrow strip between the eyelids, which, 
moreover, he detached bj” a cross-cut from its union with the upper 
eyelid. The outer edge of the fissure was then pared, and an incision 
was carried vertically up the brow from the apex of the fissure. From 
the upper end of this cut another was carried horizontally towards the 
other side for about one centimetre, the object being to loosen the in- 
teguments on the brow. The ala was next separated from the inferior 
turbinated bone, to which it was adherent. The integuments of the 
nose having been dissected up towards the middle line, the parts were 
made sufficiently movable to enable the operator to bring the ala over 
into contact with the outer edge of the fissure without using undue 
violence. The surfaces thus brought into apposition were fixed together 
by a pin passed through the upper lip and the ala, whilst a suture held 
the cheek and the inner edge of the fissure in position. The narrow 
strip of skin between the eyelids, which had been separated from the 
upper eyelid, was then drawn up with forceps, and inserted between 
the edges of the vertical incision previously described, being fastened 
to its new connections by sutures on each side. Finally, the upper 
angle of the original fissure was closed by a suture passed through its 
borders just under the lower eyelid. The sutures were removed in four 
days, when it was found that the ala was firmly united to the outer 
edge of the nostril, but there was no union at the upper part, a circum- 
stance which Thomas attributed to the somewhat rough usage which 
the small transplanted flap had received in the course of the dissection CONGENITAL DEFORMITIES OF THE NOSE. 
469 
necessary to loosen it. In a fortnight the lower part of the nose was 
almost normal in appearance, but the lower eyelid was still too widely 
apart from its fellow at the inner canthus, and a fissure from two to 
three millimetres in width remained between the inner angle of the 
right eye and the nose. The patient was then unfortunately lost sight 
of, and nothing seems to be known as to the ultimate result of the case; 
but, as Thomas remarks, a decided improvement in appearance had so 
far been achieved, and a subsequent operation for the purpose of rem- 
edying the remaining defects would have been much less difficult and 
severe. 
In cases of congenital occlusion of the posterior nares, treatment is 
imperatively called for, and no time should be lost in carrying it out. 
A passage must be forced through the obstructing membrance with a 
strong probe, as in Ronaldson’s case, or with the galvanic cautery, as 
was done by Voltolini, and the opening should be gradually dilated 
and kept open by the passage of bougies. Tracheotomy is advised by 
Ronaldson, but this measure would only be justifiable as a last resource. 
Congenital deficiency of the olfactory bulbs has already been described 
under the head of Anosmia (p. 459). 
Synechia: of the Nasal Fossa:. 
Under this terra Zuckerkandl* has described certain anomalous con- 
ditions which may be briefly referred to here. As the name implies, 
these consist of connecting bands of tissue between particular portions 
of the interior of the nose which are normally separate. The junction 
is sometimes made merely by continuity of the investing membrane, 
and sometimes by true bony union. Four chief varieties of “synechia” 
appear to occur: (1) membranous bridges spanning the interval between 
two opposite surfaces—e.g., between the middle turbinated body and 
the septum; (2) broad membranous junctions between the mucous cov- 
ering of one of the turbinated bodies and that of the outer wall of the 
nasal fossa, or between the corresponding angles of neighboring tur- 
binated bodies; (3) osseous bridges connecting one of the turbinated 
bones with the septum ; (4) wide bony union between the edge of the 
lower turbinated bone and the floor of the nose. It must be understood 
that all these varieties or any number of them may coexist, and that 
* Anatomie der NasenhShle, Wien, 1882, p. 95 et seq. 470 
DISEASES OF THE THROAT AND NOSE. 
any one of them may be found in several places. In one case Zucker- 
kandl found synechise between the lower turbinated body and the floor 
of the nose, between the middle turbinated body and the septum, and 
again between the same body and the outer wall. In 2152 skulls 
examined in the Museum of the College of Surgeons I met with but 
four instances of bony synechia. In one, the lower turbinated bone 
was greatly enlarged and adhered to the septum. In a second, in which 
the septum was deviated to the left, two thick osseous bands, not con- 
nected together, ran across from the convexity of the deflected part to 
join the lower turbinated bone and the portion of the outer wall above 
it. In a third case, in which there was no septal deviation, there were 
two bony plates bridging over the space between the left side of the 
septum and the corresponding outer wall; one was narrow and ran 
horizontally across from the middle of the septum to the upper part of 
the lower turbinated bone, whilst the other crossed from the lower edge 
of the middle turbinated bone to join the septum bv an attachment one- 
third of an inch in width, and sloping slightly upwards from behind 
forwards along the septum. In the fourth instance the edge of the 
vomer projected somewhat into the right nasal fossa and from the lower 
edge of the ridge thus formed an osteo-cartilaginous plate extended 
horizontally across to the under edge of the lower turbinated bone; 
this plate ran backwards in the nasal fossa for about an inch, and 
converted the inferior meatus into a covered way. 
I have also recently seen a patient in whose case a firm membranous 
band, covered with mucous membrane, passed across the cavity of the 
right nasal fossa from the lower turbinated bone to the septum. 
Synechise are occasionally symmetrical, being present in both nasal 
fossse in corresponding situations. It is probable that the condition is 
nearly always congenital, though it is, of course, possible that it may, in 
certain cases, be due to morbid outgrowths followed by ulceration and 
subsequent adhesion of adjacent parts. This latter view is, perhaps, 
somewhat confirmed by the fact that synechise have been found asso- 
ciated with perforation of the septum. 
The condition is, in most cases, little more than a pathological curi- 
osity. In the example referred to above, which came under my own 
notice, the patient experienced great difficulty in blowing his nose on 
the affected side. Should treatment seem desirable, any abnormal piece 
of bone may be removed by dividing both its attachments with my nasal 
bone-forceps (Fig. 55, p. 270), or, in the membranous cases, a cure CONGENITAL DEFORMITIES OF THE NOSE. 
471 
may be effected by means of the galvano-caustic loop. Even osseous 
bands, when slender, may be got rid of by this method, a case having 
been reported by Brandeis,* in which a transverse bony synechia, that 
caused obstruction of the nasal canal, was removed with the electric 
cautery. 
* New York Med. Kecord, November 12th, 1881. 472 
diseases of the throat and nose. 
SECTION VI.—DISEASES OF THE NASO-PHARYNX. 
The anatomy of the naso-pharynx has already been given in the 
first volume of this work, while the instruments required for the ex- 
amination and treatment of this part have been described under “ Na- 
sal Instruments.” It only remains, therefore, to consider the few but 
very important diseases which occur in the post-nasal region. 
CHRONIC* CATARRH OF THE NASO-PHARYNN. 
(Synonyms: Post-nasal Catarrh. Retro-nasal Catarrh. 
Follicular Disease of the Naso-piiaryngeal Space. 
American Catarrh."j") 
Latin Eq.—Catarrhus longus pharyngis nasal is. 
French Eq.—Catarrhe chronique du pharynx nasal. 
German Eq.—Chronischer Catarrh des Nasenrachenraumes. 
Italian Eq.—Catarro cronico della faringe nasale. 
Definition.—Chronic inflammation of the lining membrane of the 
naso-pharynx giving rise to a more or less viscid secretion, the adhesion 
of which to the part causes a most disagreeable sensation, and induces 
the patient to make frequent efforts to get rid of it by “ hawking ” and 
“ clearing the throat.” 
History.—The disease was first described by J. P. FrankJ as a form of chronic ca- 
tarrh, the seat of which is the pharynx. Many years later, a detailed account of the 
* As acute catarrh of the naso-pharynx either rapidly disappears or passes into the 
chronic form of the disease, it has not been thought necessary to treat it separately. 
f The complaint is so extraordinarily prevalent in America, as compared with any 
other country, that it may be regarded with all propriety as a national affection. 
X De Curand. Homin. Morbis, lib. v., pars i., pp. 124, 125, Mannhemii, 1794. CHRONIC CATARRH OF THE NASO-PHARYNX. 
473 
affection was given by Dobell.* The complaint has been familiar to all those who 
study throat-diseases from the time of the invention of the laryngoscope, and, since I 
commenced teaching at the Throat Hospital in 1863, I have constantly called the at- 
tention of students to the various features of this important malady. In 1874 Wendtf 
described both the moist and the dry forms of the affection in considerable detail. 
Lennox Browne,% in 1878, gave a description of the disease, in connection with nasal 
catarrh and ozsena. Two years later, Beverley Robinson,$ of New York, published a 
work on catarrh, in which, under the title of “Follicular Disease of the Naso-pharyn- 
geal Space,” he gave a very complete account of the complaint. Since then, the disor- 
der has been incidentally referred to by Woakes,|| Bosworth,** and by 
every writer on nasal catarrh. The latest contributor to the literature of the subject 
is Bresgen.ff who has recently brought together the views of nearly all preceding writers 
on this matter. 
Etiology.—The causes of catarrh in general have been frequently dis- 
cussed in this work, but for my views on the subject, I would refer 
especially to the remarks made in connection with acute catarrh of the 
larynx (vol. i., p. 268). The affection is exceedingly common in America, 
indeed so much is this the case that the term “ catarrh,” as commonly 
used in America, means post-nasal catarrh, i.e., catarrh of the naso- 
pharynx. It is possible that a review of the conditions under which 
post-nasal catarrh exists in America may throw some light on the etiology 
of the complaint. Unfortunately, however, up to the present, American 
physicians, though assiduously studying the therapeutics of the disease, 
have given little attention to its causes. Indeed, the only practitioner 
who appears to have seriously investigated this subject is Beverley 
Robinson,|| who, in a thoughtful and suggestive work, remarks: 
“In New York, Boston, and Philadelphia, in many of our western 
cities, on the seashore, and in the interior, in fact, over widely extended, 
and very different sections of our country, post-nasal catarrh prevails 
to an extent which originates much inquiry, and occasions more than 
* Winter Cough, London, 1866, 1st ed., appendix, p. 172 et seq. Dr. Dobell states 
that he had already called the.attention of the profession to the subject of “ post-nasal 
catarrh” in a paper read before the Abernethian Society of St. Bartholomew’s Hospi- 
tal in 1854. 
f Ziemssen’s Ilandbucli, Leipzig, 1874, Bd. vii., erste Hiilfte. 
J The Throat and its Diseases, London, 1S78, p. 153 et seq. 
\ Practical Treatise on Nasal Catarrh, New York, 1880, p. 117 et seq. 
|| Deafness, Giddiness, and Noises in the Head, London, 1880, 2d ed., p. 178 et seq. 
f Hygiene and Treatment of Catarrh, St. Louis, 1881, part ii., p. 237 et seq. 
** Manual of Diseases of the Throat and Nose, New York, 1881, p. 179 et seq. 
ft Der chronische Nasen- und Rachen-Katarrh, Wien und Leipzig, 1883, p. 41 et 
seq. 
Nasal Catarrh, New York, 1880. See the article on Follicular Disease of the 
Naso-pharyngeal Space (Post-nasal Catarrh). 474 
DISEASES OF THE THROAT AND NOSE. 
passing anxiety to those who have observed its course. Vast numbers 
of people are already affected with it. Men, women, and children are 
alike its prey. All ages and professions are subjected to its symptoms 
and complications. Moderate differences or changes of climate only 
partially affect its growth ; for while in individual instances its onward 
and rapidly progressive march appears to be somewhat delayed, if not 
completely arrested, by breathing a high, equable, and dry atmosphere, 
or by the respiration of air impregnated with balsamic odors, other and 
numerous examples there are, when once the catarrhal affection has 
become firtnly seated, but little influenced for the better by the most 
rational hygiene and an ambient medium seemingly the most perfectly 
adapted to their individual needs. Usually speaking, however, a cold 
damp atmosphere, subject to sudden and great changes of temperature, 
is supposed to be a general and efficient, if not exclusive, cause of the 
production and extension of post-nasal catarrh. No doubt this accepted 
belief has some basis in fact, and yet the more closely I have been able 
to investigate the subject, in its multiple aspects, the more thoroughly 
am I persuaded that the received opinion is in part erroneous. The 
development of the malady is not much affected by habit or occupations, 
and strong and weak organizations are similarly attacked. No consti- 
tution is entirely exempt, but certain persons are more disposed to con- 
tract it than others.” 
Though I would not for a moment place my experience of American 
catarrh on a level with that of any of the eminent specialists who have 
given attention to the subject in the United States, I may remark that 
in a recent tour through that country I had a very favorable opportunity 
of studying the complaint. For I not only saw examples of the dis- 
ease over a very wide tract of country, but also observed the atmospheric 
conditions under which these cases occurred, enjoying, moreover, the 
great advantage, in many localities, of discussing the subject and hear- 
ing the views of able physicians who had been studying the disorder on 
the spot for many years. I was greatly astonished at the extremely 
wide diffusion of the affection. I met with it all over the Eastern States, 
it was very common in Chicago and St. Louis, which may now be called 
the central cities of America, I found it prevalent in Nebraska and to a 
slighter extent in Utah, and again I encountered it on the Pacific coast, 
finding it of frequent occurrence in San Francisco. I had not the op- 
portunity of seeing any patients in Nevada, as I merely travelled 
through that State without stopping, but in London I have treated 
many American travellers for post-nasal catarrh who had acquired the CHRONIC CATARRH OF THE NASO-PHARYNX. 
475 
disease on the alkaline plains of the Silver State. I also saw a good 
many patients suffering from catarrh of the naso-pharynx in Colorado. 
In Southern California and Arizona I scarcely met with any cases, and 
in Canada the affection, though much more common than in Europe, 
did not seem to be so universal as in the States. American catarrh, it 
would seem, principally prevails between latitudes 44 and 38. 
My travels in America were made in the latter end of August and 
in September and October—that is, during the most favorable season 
of the year; and I have little doubt that had I been there in the winter 
I should have seen a great deal more of this wide-spread ailment. In 
many of the regions referred to there are local conditions which tend 
to irritate the mucous membrane. Thus, all along the eastern seaboard 
the atmosphere during the winter months is cold and moist, whilst in 
the summer it is excessively hot. In San Francisco fogs prevail in the 
summer in the early part of the day, whilst in the afternoon a cutting 
wind blows continuously. In Colorado, on the other hand, the climate 
is so extraordinarily dry that only those who have been there can 
thoroughly appreciate it. The inhabited portion of the country con- 
sists of extensive plains situated at an elevation of 5000 or 6000 feet 
above the level of the sea. The dryness of the climate may be gathered 
from the fact that not a drop of rain falls during nine months of the 
year, the result being that no trees can flourish, the scrub oak being 
almost the sole representative* of our forest trees, and this being only 
found in the narrow valleys or canons, as they are called. Indeed, so 
dry is the soil that not unfrequently all the prairie grass perishes. The 
atmospheric conditions, though admirably suited for some forms of 
consumption, are nevertheless extremely irritating to the mucous mem- 
brane of many persons. The white alkaline dust which covers hun- 
dreds of miles in Nevada is also met with here and there in Colorado. 
In the winter and spring the winds are often rather strong, and it will 
easily be imagined that at such times the abundant dust of this extra- 
ordinarily dry country is very irritating. 
The soil of the American continent varies so widely in different parts 
that it is impossible to suppose that it is concerned in the etiology of 
the affection. Again, it will be readily understood that the meteoro- 
logical conditions over this vast area are so various that they cannot be 
regarded as a cause acting with anything like uniformity. The general 
* The cotton tree, though indigenous in certain parts of South America, appears to 
be an exotic in Colorado, and I only saw it as an ornamental tree in the streets hnd 
gardens of some of the cities. 476 
DISEASES OF THE THROAT AND NOSE. 
character of the atmosphere of the American continent, as compared 
with that of Great Britain, and also with most parts of Europe, is that 
it is drier, that the changes of temperature are more sudden, and the 
extremes of heat and cold much greater. There is nothing, however, 
in these conditions to account for the localization of the complaint in 
the naso-pharynx, and it would seem that post-nasal catarrh is not due 
to what may be strictly called climatic influence, but to something 
which is accidentally introduced into the atmosphere of widely differing 
localities. In other words, that there must be irritant particles floating 
in the air over very wide areas. This is actually the case, for dust is 
to be found everywhere in America. 
The universal prevalence of catarrh is indeed fully explained by the 
abundance of dust, both in the country and the cities. Owing to the 
immense size of the country, and its sparse rural population, the country 
roads have not, as a rule, been properly made, and except in some of 
the older States are merely the original prairie tracks. In the cities, 
notwitstanding the magnificence of the public buildings, the splendor 
of many of the private houses, and the beauty of the parks, the pave- 
ment is generally worse than it is in the most neglected cities of Europe, 
such, indeed, as are only to be found in Spain or Turkey. It must be 
recollected also that whilst in the decayed towns of the Old World there 
is very little movement, in the American cities there is a ceaseless 
activity and an abundance of traffic. Hence, the dust is set in motion 
in the one case, but not in the other. The character of the dust, of 
course, varies greatly according to locality. In some parts it is a fine 
sand, in others an alkaline powder, whilst in the cities it is made up of 
every conceivable abomination, among which, however, decomposing 
animal and vegetable matters are not the least irritating elements. An 
idea may, perhaps, be formed of the state of the atmosphere from a 
consideration of the fact that in many cities the functions of the scav- 
enger are quite unknown. 
That a dusty atmosphere is the real cause of post-nasal catarrh is 
rendered probable by a consideration of the anatomical relations of the 
naso-pharynx. For owing to its being a cul-de-sac out of the direct 
line of the respiratory tract, particles of foreign matter which become 
accidentally lodged in its upper part are got rid of with difficulty— 
most likely by an increased secretion, which, as in the case of the con- 
junctiva, washes away any gritty substance which may temporarily 
alight on the membrane. In the larynx, irritating dust is dislodged 
by coughing, which may be either reflex or voluntary; and again in CHRONIC CATARRH OF THE NASO-PHARYNX. 
477 
the case of the nasal passages, the minute particles of matter which 
constitute dust are expelled, if they happen to be obnoxious, either by 
sneezing or blowing the nose. But reflex acts, such as coughing and 
sneezing, have no effect on the upper part of the naso-pharynx, and it 
is only by a voluntary effort, known as “ hawking,” that this cavity 
can be partially cleared. It is probable also that owing to the sensi- 
bility of the naso-pharyngeal mucous membrane being less acute than 
that of either the nose or the larynx, minute foreign bodies accidentally 
lodged in the vault of the pharynx do not cause an amount of discom- 
fort at all corresponding to that in the adjacent parts; hence particles 
of matter are more likely to remain in situ for a long time in the post- 
nasal region than in either of the other parts, and are, of course, very 
apt to set up disease. In this country the complaint is most common 
in persons whose pharynx is large in the antero-posterior direction, a 
form of throat which facilitates the entrance, without favoring the ex- 
pulsion, of foreign particles. It will be readily understood that any 
morbid state of the posterior nares may lead to chronic inflammation, and 
thereby establish a catarrhal condition of the naso-pharyngeal region. 
In young subjects, adenoid growths are often a source of irritation. In 
such cases, however, the discharge which is set up does not tend to 
become adherent, as in true post-nasal catarrh, but flows away with 
comparatively little inconvenience. In fact, the catarrhal affection is 
altogether different from the idiopathic post-nasal catarrh which is met 
with in its typical form in America. 
Whilst, however, it is highly probable that dust is the most frequent 
cause of post-nasal catarrh, no doubt it is not the only one. Many cir- 
cumstances favor its development. Thus I have noticed that in many 
cases the sufferers have been persons who partake largely of pungent 
condiments, and the habit (almost universal in America) of taking 
sauces and pickles with every dish may be concerned in the production 
of the disease. The national dyspepsia is also probably a most pow- 
erful factor, and a well-known American statesman tells me that he has 
known many cases cured by “ abstemiousness and farinaceous diet.” 
Some physicians have attributed the complaint to the custom of over- 
heating houses by hot air and steam, as is commonly done in America. 
In the winter the temperature is never allowed to fall below 70° Fahr./ 
and is generally much higher. The sudden passage from "this temper- 
ature to that of the street is not unlikely often to set up catarrh, but 
as the same mode of heating is used in Russia without, as far as I am 
aware, giving rise to any post-nasal affection, its influence cannot be very 478 
DISEASES OF THE THROAT AND NOSE. 
great. The importance of heredity in the etiology of catarrh has been 
recently strongly insisted on by Bresgen,* and although no extensive 
series of exact observations has yet been made on this point, there is 
every probability that a disposition to catarrh may be inherited. I 
have seen so many instances, however, in which foreigners making a 
short stay in America have become affected with post-nasal catarrh, 
that I think there can be little doubt that atmospheric conditions—and 
those, let me add, of an accidental and controllable character—are much 
more powerful than heredity. 
It is supposed by some that catarrh is contagious, but though the 
popular belief is strong on this point, there is very little scientific evi- 
dence in its favor. On this subject Beverley Robinsonf asks : “ How 
is it that a disease which is so prevalent in many sections of our country 
is certainly less known and familiar in England and on the Continent? 
Certainly, if the extensive propagation of this affection is merely a di- 
rect consequence of intimate contact, there would be just the same proba- 
bilities of the increase there as here.” It is somewhat remarkable, that 
at the present time, when germs are supposed to give rise to so many 
diseases, post-nasal catarrh has not been referred to this source, to which 
it may be remarked coryza has been attributed. Failing to discover 
any atmospheric cause for American catarrh, Beverley Robinson;}; sug- 
gests that “a special constitutional tendency exists in the individual.” 
He observes that “ post-nasal catarrh must not be confounded as it 
almost universally is with ordinary rhinitis. It is not simply an acute 
or chronic inflammatory condition of the pituitary membrane, nor should 
it, therefore, be treated in the same way; for if it is, signal failure 
almost will follow our every effort. An acute or chronic coryza is, 
without doubt, a predisposing and at times a proximate and 'partially 
efficient cause of its becoming manifest. But in order to effect the graft- 
ing of post-nasal catarrh, a certain diathetic condition is essential.” He 
proposes to call this diathesis “ catarrhal,” and appears to think that 
there is some relation between it and the herpetic disposition. In put- 
ting forward an hypothesis which has no facts to support it, Robinson 
appears to have adopted the fallacies of the French School (see Vol. i., 
p. 45, footnote). I certainly agree with him, however, that catarrh of 
the naso-pharynx very frequently commences in coryza; and notwith- 
standing his views as to the “catarrhal diathesis,” it would appear that 
he does not attempt to circumscribe the diathesis too closely, for in 
referring to this complaint he observes that “ while follicular disease is 
* Op. cit., p. 47. 
f Op. cit. 
X Op. cit., p. 145. CHRONIC CATARRH OF THE NASO-PHARYNX. 
479 
at times due to the catarrhal diathesis pure and simple, so it may be and 
frequently is attached to the gouty, herpetic, syphilitic, scrofulous, and 
tubercular. The malarial influence may likewise be evident ” 
Lennox Browne* considers that the diathesis of patients suffering 
from catarrh of the naso-pharynx is “ generally of a scrofulous char- 
acter.” Seeing, however, that the complaint is so very common in 
America, that it affects people of every temperament and constitution, 
and that it is readily acquired by visitors to the United States, it more 
probably depends on atmospheric conditions than on any diathesis. 
Symptoms.—In slight cases the patient is troubled with a disagreea- 
ble sensation, as of something sticking in the upper part of the throat, 
which has to be frequently cleared away from the back of the nose. 
Distinctness in articulation is often interfered with. There is, in fact, 
a want of resonance or definition, more especially in the pronunciation 
of gutturals. This may be so slight as to be inappreciable by any one 
but the patient himself, who, if he is an educated person, and one who 
has to employ his voice in public, is almost sure to complain of it. 
When the disease is more severe the mucus is often extremely tena- 
cious, and the patient has then to make the most violent and frequent 
efforts to “hawk” it from the naso-pharynx, a proceeding which is as 
disagreeable to the patient as it is disgusting to those about him. The 
effort to get rid of the mucus is often accompanied by nausea, and in 
some cases by actual sickness. A very unpleasant sensation is con- 
stantly felt at the back of the throat, and in severe cases the patient ex- 
periences a dull aching feeling in the upper part of the throat, and oc- 
casionally weight or pain is complained of in the occipital region. On 
looking into the naso-pharynx moist yellowish white masses of mucus 
are seen adhering to the posterior wall and sides of the cavity. Post- 
nasal catarrh is often the cause of throat-deafness, and in some cases it 
gives rise to slight haemorrhage, which occasionally stains the patient’s 
pillow, or occurs when he wakes in the morning; the source of the 
blood is apt to puzzle physicians who do not examine the naso-pharynx. 
The mucous membrane, after it has been cleansed with a spray or 
syringe, generally looks very red, but if a short time, say fifteen or 
twenty minutes, is allowed to elapse, much of the congestion, which is 
evidently due to the cleansing process, disappears. Raised red granu- 
lations can then be seen on the posterior wall and sides of the naso- 
pharynx. Sometimes they are small, oval or round in form, but not 
unfrequently those situated on the sides of the naso-pharynx are long 
* The Throat and its Disease, London, 1878, p. 163. 480 
DISEASES OF THE THROAT AND NOSE. 
and narrow, often from five millimetres to a centimetre and a half in 
length, and from three to five millimetres in width, but only slightly 
raised above the surface. In severe eases small erosions may be seen 
here and there, and occasionally ecchymotic spots. In young subjects 
adenoid growths are sometimes present, or there may be simple enlarge- 
ment of Luschka’s tonsil. Congestion and swelling of the Eustachian 
orifices are often apparent, and now and then one or both of the openings 
are completely blocked up by adherent mucus. The oro-pharynx will 
generally be found more or less congested, and presenting in places a 
granular appearance. Varicose veins are also often visible on the pos- 
terior wall, whilst the pillars of the fauces are infiltrated or thickened. 
Pathology.—The morbid changes which take place in the naso- 
pharyngeal region have not hitherto been studied on the dead subject, 
but no doubt they are identical with those which usually occur in ca- 
tarrhal inflammations. As far as can be seen during life, the morbid 
process seems to be the same as has been described under the head of 
“Hypertrophic Granular Pharyngitis” (Vol. i., p. 48). 
Diagnosis.—Post-nasal catarrh is occasionally altogether overlooked 
by medical practitioners who are unacquainted with the affection, but 
those who have studied rhinoscopy are unlikely to make any mistake. 
When the patient is a young subject, catarrh of the naso-pharynx will 
sometimes be found to be due to adenoid growths; but, as already 
pointed out, the secretion differs altogether from that of true post-nasal 
catarrh. These formations, moreover, can generally be easily felt with 
the finger, and seen with the mirror. The possible presence of polypi 
should be borne in mind. Syphilis, likewise, both in its secondary and 
tertiary manifestations, may cause symptoms analogous to catarrh. 
If the naso-pharynx is well cleansed, however, condylomata or ulcers, 
if present, can usually be seen. In cases of tertiary disease, the ad- 
ministration of iodide of potassium will soon set the question of diag- 
nosis at rest. 
Prognosis.—The disease is not dangerous, but it is often a lasting 
inconvenience, and, if it has existed for several years before it comes 
under observation, it is seldom cured; in recent cases, however, the 
complaint may occasionally be completely eradicated, and. old-standing 
cases can, as a rule, be kept under control by judicious treatment. 
Treatment.—This may be constitutional or local, or may combine 
both systems. Those who believe in the diathetic origin of the com- 
plaint naturally recommend internal remedies. Beverley Robinson* 
has found benefit from sulphur, cubebs, and ammoniacum ; the sulphur 
* Op. cit., p. 146. CHRONIC CATARRH OF THE NASO-PHARYNX. 
481 
may be given in the form of Harrogate waters; cubebs may be admin- 
istered in a tincture with an equal part of tincture of orange to cover 
the taste; and ammoniacum may be prescribed in very small doses— 
one, two, or three grains—combined with ipecacuanha. Other writers 
have recommended cod-liver oil and phosphate of iron. Of course, in 
any case in which there is marked debility, tonics are likely to do good. 
In my experience, however, little benefit is, as a rule, derived from 
general remedies, whilst local treatment affords much relief. The first 
thing to do is to completely remove all the mucus from the naso- 
pharynx ; or, in other words, to cleanse the parts thoroughly. If this 
can be accomplished by the use of sprays, it is the most advantageous 
method for the patient; but both anterior and posterior sprays are 
likely to be required. One of the best solutions is that introduced by 
Dobell (see Appendix); but, if the carbolic acid is objectionable or ir- 
ritating, the “compound alkaline wash” (see Appendix) may be sub- 
stituted. If the secretion cannot be removed by spraying, the post- 
nasal syringe must be used; and, if this again does not succeed, a 
medium-sized laryngeal brush should be employed. After the mucus 
has been got rid of I have found most benefit from astringent insuffla- 
tions. Of these, pale catechu, persulphate of iron (one part to three 
of starch), and eucalyptus are the most efficacious, but the eucalyptus 
(one part of the gum to two of starch) is the preparation that I most 
rely on. The patient can often cleanse the naso-pharynx with a hand- 
wash or nasal douche, and may be taught to insufflate the powder 
himself. 
In those fortunate cases in which great benefit has resulted from 
these measures, a complete cure may sometimes be effected by winding 
up the treatment with a course of Mont-Dore or Bourboule waters. 
The diet should always be non-irritating, strong drinks and pungent 
food being carefully avoided. Lennox Browne* thinks that “ it is 
advisable to restrict the amount of fluid food to a minimum.” I have 
no experience of this method of treatment, and do not see how it could 
have much effect on a complaint of so chronic a type as the one under 
consideration. In all cases the'use of tobacco should be given up, par- 
ticularly the smoking through the nose, which is the practice of those 
who indulge in cigarettes. 
Persons who show a predisposition to post-nasal catarrh should take 
special precautions against it. Travellers in dusty places—especially 
* Op. cit., p. 164. 482 
DISEASES OF THE THROAT AND NOSE. 
if the dust is of an alkaline character—should wear Gottstein’s tampons 
(Fig. 73, p. 283) in the nose, and should also make use of respirators 
or keep the mouth constantly shut. Irksome as these measures may 
be, they are less troublesome than the annoying complaint against 
which they are meant to guard. 
DRY CATARRH OF THE NASO-PHARYNX. 
This disease closely resembles dry catarrh of the nose, and to the 
article on that subject (p. 322 et seq.) the reader must be referred for a 
detailed description of the etiology and pathology of the disease. Like 
dry catarrh of the nose, it very frequently leads to ozsena. It is prob- 
ably in most cases a sequel of moist catarrh, but sometimes it appears 
to be dry from the commencement. As in the case of moist catarrh of 
the naso-pharynx, it is most common in persons who have a somewhat 
roomy pharynx. On looking into the throat the buccal pharynx may 
be simply dry and shiny, but on examining the naso-pharynx flakes of 
dried mucus of a dark-brown or black color are often seen. It is char- 
acteristic, however, of this form of catarrh for the objective symptoms 
to be very slight. When the complaint has reached the stage of ozfena 
a disagreeable smell is noticed in the breath, and every few days a 
round or oval mass, from two to three centimetres in length, and from 
one to two centimetres in width, is expelled. These lumps of inspis- 
sated secretion are generally of a dirty-white or green color, but they 
may be brown, or even black ; they are of somewhat dense consistence, 
moist externally, but dry and very compact towards the centre. Some- 
times on section they show a sort of concentric arrangement, as if they 
were made of successive deposits. Their probable mode of detachment 
has already been explained in dealing with the nasal form of the com- 
plaint. Occasionally, by digital examination, one of these lumps can 
be felt in the naso-pharynx, occupying a corner of the vault on one side 
of the median raphe, or even extending right across it. The disease is 
frequently associated with a similar condition of the nose, but in some 
cases it is limited to the post-nasal region. On cleansing the mucous 
membrane it generally presents, after a short interval of time, a pale 
and atrophied appearance. 
The remarks which have been made on the diagnosis and pathology 
of dry catarrh of the nose (see p. 330 etseq.) are applicable to the naso- ADENOID VEGETATIONS OF THE NASO-PHARYNX. 
483 
pharyngeal region. Dry catarrh of the naso-pharynx is extremely 
obstinate, and the prognosis, as regards cure, is very unfavorable. 
The treatment must be carried out in the way recommended for moist 
catarrh, but disinfectants are even more necessary. Dobell’s solution, 
which has been already mentioned (p. 481), is one of the best sprays, 
but, if continued for any length of time, the proportion of carbolic acid 
should be reduced by one-half. The Nebula Alkalina of the Throat 
Hospital Pharmacopoeia will also be found very serviceable. 
ADENOID VEGETATIONS OF THE NASO-PHARYNX. 
Latin Eq.—Tumores glandulosi pharyngis nasalis. 
French Eq.—Tumetirs adenoides du pharynx nasal. 
German Eq.—Adenoide Vegetationen des Nasenrachenraurnes. 
Italian Eq.—Tumori adenoidi della faringe nasale. 
Definition.—Minute, glandular vegetations growing from the vault 
and sides of the naso-pharynx, causing the voice to be dull and nasal in 
tone, the respiration to be buccal, frequently inducing deafness by setting 
up inflammation of the middle ear, and, in the case of children often giv- 
ing rise to the constitutional phenomena which follow prolonged nasal ob- 
struction. 
History.—In the year 1860 Czermak* observed two small tumors at the upper part 
of the naso-pharynx on the left side, close to the opening of the Eustachian tube, one 
portion of which somewhat resembled a “ cock’s comb.” These were probably the 
first adenoid growths ever seen. Five years later, Voltolinif reported the case of a 
* Der Kelilkopfspiegel und seine Verwerthung fiir Physiologie und Medizin, Leip- 
zig, 1860. Soon after, Semeleder reported some eases of growths in the vault of the 
pharynx, but they seem to have been rather of the nature of fibrous polypi than ade- 
noid vegetations (Die Khinoscopie, etc., Leipzig, 1862, p. 46 et seq.). 
f Allgem. Wien. med. Zeitung, No. 33, 1865. In the previous year, Andrew Clark 
published a short article on “Nasopalatine Gland Disease” (Lond. Hosp. Reports, 
vol. i., p. 211), which, I have no doubt, was the same disease as that subsequently de- 
scribed by Meyer under the name of “ Adenoid Vegetations.” Clark remarked that 
this disorder can be “ demonstrated only by rhinoscopic examination,” but an otherwise 
accura te description of adenoid vegetations is marred by the statement that “ fetid cheesy 
masses ” are sometimes contained in the cavities of the glands. It is probable, there- 
fore, that Clark’s cases were complicated by the “ exudative form of follicular pharyn- 
gitis.” (See Vol. i., p. 48 of this work.) 484 
DISEASES OF THE THROAT AND NOSE. 
man, aged forty-one, who had come under his care two years previously, on account of 
extreme deafness. Under various treatment the patient’s hearing had greatly im- 
proved, but in the summer of 1865 Voholini, on making a rhinoscopic examination, 
perceived “ stalactite-like growths projecting into the free cavity of the naso-pliarynx.” 
These tumors having been destroyed in three sittings, by means of electric cautery, 
further improvement took place in the hearing. In the same year Lowenberg* pub- 
lished three cases, in which he had found vegetations in the naso-pharyngeal region 
of patients suffering from deafness, which, he pointed out, were probably identical in 
their nature with the hypertrophied mucous glands characterizing granular pharyn- 
gitis. In 1868 Wilhelm Meyer,f of Copenhagen, for the first time, gave a complete 
picture of glandular disease in the pharyngeal region, under the name of “‘Adenoid 
Vegetations.” Whilst fully describing the symptoms and progress of the affection, he 
detailed the microscopic appearance of the growths, and pointed out a mode of surgi- 
cal treatment, which he had found highly effectual. Meyer had already at that time 
examined 2000 children in the National Schools of Copenhagen, and had met with the 
affection in 1 per cent, of the cases examined. Indeed, he may be justly considered 
the discoverer of adenoid vegetations in the vault of the pharynx; for, although not 
the first to observe these growths, he certainly first realized their importance, and fully 
described them. Subsequent workers have done little but confirm Meyer’s observa- 
tions. A short paper on adenoid tumors was presented to the International Medical 
Congress at Brussels, in 1875, by Guye,J of Amsterdam, and in the following year the 
subject was still further elucidated by Carl Michel,§ of Cologne. A short note was 
published in 1879 by Victor Lange,|| of Copenhagen, in which he suggested a modifi- 
cation of Meyer’s method of operation, and in the same year an excellent account of 
the disease was given by Solis Cohenf in the second edition of his valuable work. 
Lowenberg,** moreover, returned to the subject in 1879, when he published a very 
complete monograph on the disease. Special mention may also be made of a paper by 
Tauber,ff of Cincinnati, who found .6 per cent, of adenoid growths amongst his cases of 
nasal and pharyngeal disease. Adenoid vegetations were made the subject of public 
discussion at the International Medical Congress, held in London, in 1881, when most 
of the above-mentioned writers gave the result of their increased experience, and Ca- 
part, of Brussels, who has been very successful in his treatment of these growths, ex- 
hibited several hundred specimens—or, to speak more correctly, several large bottles 
filled with vegetations. On the same occasion, WoakesJJ read a paper founded on the 
* Archiv. fur Ohrenheilkunde, 1865, Bd. ii., p. 116 et seq. These Archives are pub- 
lished in parts, vol. ii. covering the years 1865, 1866, and 1867, but Lowenberg’s ar- 
ticle appeared in 1865. As, however, the whole volume bears the date 1867, it has 
been erroneously supposed that JLowenberg's article was not issued till that year. In 
his recent work, Lowenberg calls attention to these facts, which, on investigation, I have 
found admit of no dispute. 
f Hospitals Tidende, November 4th and 11th, 1868; also, Trans. Med.-Chir. Soc., 
London, 1870, vol. liii., p. 191 et seq. 
J International Med. Congress, Brussels, 1875. 
\ Krankheiten der Nasenhohle und des Nasenrachenraumes, 1876, p. 77 et seq. 
|| Note stir les Tumeurs adenoi'des, Copenhague, A out, 1879. 
Diseases of the Throat and Nose, New York, 1879, 2d ed., p. 253 et seq. 
** Tumeurs ad4noides du Pharynx nasal, Paris, 1879. 
ff Cincinnati Lancet and Clinic, April 24th, 1880. 
Trans. Intern. Med. Congress, London, 1881, vol. iii., p. 291 et seq.; see, also, 
this author’s work on Deafness, Giddiness, etc., London, 1880, p. 32. ADENOID VEGETATIONS OF THE NASO-PHARYNX. 
485 
observation of one hundred cases, and, in opposition to the usual opinion that they are 
of adenoid structure, maintained that these growths are mainly papillomatous in tex- 
ture. 
Etiology.—The disease is more commonly observed in the young 
than in adults. The great abundance in the naso-plmrynx of children 
of lymph-follicles, some of them solitary, and others united to form the 
tonsil of Luschka (Vol. i., pp. 17, 18), explains the frequent occurrence 
of allied morbid growths in early life. That lymphoid tissue is also 
easily excited to active growth in young subjects is seen in the case of 
the tonsils and cervical glands, and it is highly probable that very 
slight catarrh of the naso-pharynx often leads to the excessive develop- 
ment of the tissue in question. It must not, however, be forgotten that 
vegetations which in children would cause marked symptoms, might 
produce but little inconvenience in the larger naso-pharynx of the adult, 
and hence that they may be easily overlooked in the latter case. Sex 
has no influence: out of one hundred and two cases observed by Meyer,* 
fifty-two belonged to the male and fifty to the female sex; whilst 
Woakesf found the complaint almost equally prevalent in the two 
sexes. In eighty-two cases | seen by myself, forty-seven were females 
and thirty-five males. Between the ages of five and ten there were 
fifty-one; between ten and fifteen, twenty-seven; between fifteen and 
twenty, two; and at the ages of twenty-four and twenty-seven, one. 
Dr. Felix Semon has furnished me with a table of fifty-six cases ob- 
served by himself, in fifty-three of which the patients were under twenty 
years of age. Dr. Semon, however, thought that in all these cases the 
disease commenced in the first decade of life. Golding Bird§ has re- 
cently reported two cases in which the first symptoms of the complaint 
showed themselves after the age of forty. The number of observations 
hitherto collected, however, with reference to age and sex is at present 
too limited to furnish any trustworthy conclusion, and it may be re- 
marked that for statistics as to age to be of any value etiologically, it 
would be necessary to ascertain when the growths first commenced. 
It is likely that the acute exanthems, and whooping-cough which so 
frequently gives rise to a catarrhal condition of the lining membrane 
of the throat, may have some influence in producing adenoid growths.|| 
* Loc. cit., p. 208. f Loc. cit. 
X These were all observed before the end of 1879. Since then I have of course seen 
a great many additional cases. 
§ Guy’s Hosp. Reports, 1881, 3d series, vol. xxv., pp. 441-443. 
|| See Yol. i., p. 302. 486 
DISEASES OF THE THROAT AND NOSE. 
It has been suggested that those who inherit a scrofulous constitution 
are more liable to the development of the disease than others, but in 
connection with this point I may remark that my experience is quite in 
accordance with that of Meyer, for I have noticed that children suffer- 
ing from adenoid vegetations seldom show any other marked sign of 
struma, such as enlarged cervical glands, ophthalmia tarsi, or otitis. In 
some of the cases published by Lowenberg* heredity appears to have 
had a marked influence, but here again the statistics are too limited, 
and, moreover, attention has been directed to the subject too recently for 
satisfactory observations to have been collected. In the next generation 
this point will be more easily determined. A cold moist climate has 
probably a considerable influence in the production of the disease, which 
is much more prevalent in the north than in the south of Europe. 
Meyerf points out that in three out of four cases of cleft palate 
which came under his notice, these growths were present, and he at- 
tributes this to the direct irritation to which the mucous membrane is 
subjected from food and cold air. Oakley Coles,J who has had an 
exceptionally large experience in connection with cleft palate, has 
noticed the extremely frequent association of adenoid vegetations with 
this deformity. I do not know what the cause of the occurrence of 
these growths maybe in these cases, but I may add that I have scarcely 
ever met with an example of cleft palate without finding a profusion of 
adenoid growths in the naso-pharyngeal region. 
Symptoms.—In infants the first symptom to attract attention is, as a 
rule, “ hard ” breathing or snoring during sleep, sometimes even such 
attacks of dyspnoea as have been described under the head of “Acute 
Coryza in Infants ” (p. 293). In older children it is the dull voice and 
deafness which generally claim our notice. It will mostly be found 
that symptoms of chronic catarrh of the nose and naso-pharynx exist; 
and on looking into the throat, a yellowish-green secretion may be seen 
trickling down the back wall of the pharynx. In the morning, the 
child’s pillow is occasionally found stained with dark mucus, and some- 
times with a little blood, which has dribbled from the mouth during 
sleep. In rare cases, indeed, the patient expels a small quantity of pure 
blood. The constantly open mouth and a certain stupid expression of 
countenance are, in the absence of enlargement of the tonsils, character- 
* Op. cit., p. 12. f Loc. cit., p. 209. 
t Proc. Royal Med.-Cliir. Soc. of London, Nov. 23d, 1869; Brit. Med. Journ., 1869, 
vol. ii., p. 619. See also Cole’s work, Deformities of the Mouth, London, 1881, 3d ed., 
p 51 et seq. ADENOID VEGETATIONS OF TllE NASO-PHARYNX. 
487 
istic symptoms of post-nasal growths. David* has recently gone so 
far as to assert that these formations reveal themselves externally by a 
modification of the physiognomy, which consists essentially in a de- 
formity of the upper jaw, with projection of the incisor teeth and 
narrowing of the palatine arch. He holds that the patient being only 
able to breathe through the mouth in such cases, the palate (still in 
course of development and comparatively soft) is subjected to constant 
pressure on its buccal surface, and thereby pushed unduly upwards. 
This, however, is evidently an erroneous explanation of an irregular 
mode of development well known to dentists, f The deformity of the 
chest which has been described (Vol. i., pp. 77, 78) as occasionally 
associated with chronic enlargement of the tonsils, is not unfrequently 
present when post-nasal vegetations block up the naso-pharynx. Noisy 
respiration whilst the child is awake, and, as already observed, snoring 
Fig. 88. 
Vegetations overshadowing Left Eustachian Aperture. 
during sleep, are also common symptoms of the affection. When the 
child is old enough to talk, it not only speaks “through its nose,” as 
the term is popularly employed, but, in addition to this, the voice is 
muffled, or, as Meyer terms it, “dead.” In adults, this is sometimes 
the only symptom of the complaint, the other troubles having dis- 
appeared with the enlargement of the naso-pbarynx. In cases of long 
standing, deafness often results from mechanical closure by the growths 
of the Eustachian orifice, a condition well exemplified by a case which 
I recently treated with Sir William Jenner and Dr. Gimson, of 
Witham (see Fig. 88). The hearing may also become impaired in 
consequence of the vegetations causing catarrh of the tube or even of 
the middle ear. (See “ Throat-deafness, p. 527.”) 
* Revue Mensuelle de Laryngologie, etc., 1883, No. 12, pp. 380, 381. 
f See Oakley Coles, op. cit., p. 86 et seq. 488 
DISEASES OF THE THROAT AND NOSE. 
On making a rhinoscopic examination, the growths can often be seen 
partly covering the posterior nares. They are generally of a pale color, 
but are sometimes pink, and even bright red; as a rule, they are 
rounded in form, and vary in size from a hemp-seed to a currant, but 
are occasionally much larger, and often occur in clusters. In some 
cases they hang down from the roof of the pharynx (Fig. 89) likestal- 
Fig. 89. 
Adenoid Growths in the Vault of the Pharynx. (From a young woman.) 
actites, and, more rarely still, they are flat, like the granulations often 
seen on the posterior wall of the pharynx ; sometimes a broad pad-like 
growth will stretch almost across the naso-pharynx. The vegetations 
are most abundant on the vault and upper part of the posterior wall 
of the naso-pharynx, but they are not unfrequently grouped round the 
Fig. 90. 
Adenoid Growths in a Child. 
Eustachian orifices. Occasionally they cover the entire mucous mem- 
brane of the posterior nares, but the septum is seldom attacked. Owing 
to the difficulties which have been already described (see “ Rhinoscopy,” 
p. 250 et seq.), it is not always possible, especially in young children, 
to make a rhinoscopic examination, but by passing the index finger 
behind the uvula the growths can generally be easily felt, when they ADENOID 'VEGETATIONS OF THE NASO-PHARYNX. 
489 
are found to be smooth, soft, and yielding to the touch, and prone to 
bleed. 'When they are abundant, as was first pointed out by Meyer,* 
they give a sensation very much like a bunch of earthworms. Not 
unfrequently, however, separate vegetations oan be felt. 
Diagnosis.—The morbid conditions with which adenoid growths may 
be confounded are: chronic catarrh, general hypertrophy of the mucous 
membrane about the posterior nares, polypus, and post-pharyngeal ab- 
scess. It is very unlikely that the merest tyro would confound fibrous 
or bony tumors or exostoses from the walls of the naso-pharynx with 
the complaint now under consideration. The condition of the mucous 
membrane of the nares can usually be ascertained by anterior rhinos- 
copy, and hence catarrh and thickening can generally be readily elimi- 
nated. In cases, however, where these conditions coexist with adenoid 
growths, the diagnosis can only be made by direct observation, or digital 
examination. Those who are inexperienced in rhinoscopy should look 
for the upper arches of the posterior nares, for if their sharp outline is 
obscured by any tissue hanging down over them, this is exceedingly 
likely to be of adenoid nature. This is the plan which Dr. Felix Semon 
informs me he is in the habit of recommending to his class, and it ap- 
pears to me to be an exceedingly good one. Polypi are extremely rare 
before the age of sixteen, and retro-pharyngeal abscess, though often 
insidious, is accompanied with pain and difficulty in swallowing, and 
the symptoms come on much more rapidly than those caused by adenoid 
growths. The abscess, moreover, in most cases comes into view, or, at 
any rate, can be felt with the finger, and there is usually some tender- 
ness on pressure. Fibrous tumors of the naso-pharynx rarely com- 
mence before the age of fifteen, and it is only in their very earliest pe- 
riod that they can be confounded with adenoid growths, for as a rule, 
they grow rapidly, and soon cause so much displacement of the sur- 
rounding tissues that their nature cannot be mistaken. Osseous tumors 
are seldom, if ever, met with except in adults, and, when large enough 
to give rise to obstruction, generally cause pain and haemorrhage. 
Digital examination also at once enables the practitioner to recognize 
their nature. 
Notwithstanding the number of diseases with which it is possible that 
adenoid vegetations might be confounded, yet, taking into consideration 
the age of the patient and the marked symptoms caused by the growths, 
there is practically very little likelihood of a mistake occurring. 
* Loc. cit., p. 193. 490 
DISEASES OF THE THItOAT AND NOSE. 
Pathology.— Microscopic examination of these naso-pharyngeal 
growths shows that they consist of cylindrical and sometimes ciliated 
Fig. 91. 
Showing a small portion of the cylindrical epithelium (whether ciliated or not can- 
not be determined) covering the surface, the vascular nature of the growths, the vast 
number of cells of which they are composed, and two follicles (similar to those seen in 
the tonsil), one of which is filled with cells, whilst the other is empty. 
Section of Adenoid Growth (X 60). 
epithelium, with an abundance of the retiform adenoid tissue of His, 
containing in its meshes quantities of lymph cells. True follicles are 
Fig. 92. 
Portion of the same growth as Fig. 91, but more highly magnified (X 240\ 
(The lymphatic or adenoid character of the tissue is very evident.) 
also met with and occasionally a conglomerate gland, and the structures 
are generally highly vascular. The glandular element is, as a rule, ADENOID VEGETATIONS OF THE NASO-PHARYNX. 
491 
more marked in growths taken from the vault of the pharynx, whilst 
in vegetations removed from the lateral walls, the stroma of His is 
found in greater abundance. I am indebted to Mr. Butlin, of St. Bar- 
tholomew’s Hospital, for admirable microscopical drawings (Figs. 91 
and 92) of an adenoid growth which I removed by means of the “slid- 
ing forceps ” from the extreme upper part of the vault side of the 
pharynx of a boy, aged ten, who suffered from deafness and a thick 
voice. 
Prognosis.—Considering that these growths can produce such grave 
evils as have been described, they ought not to be regarded too lightly; 
but, on the other hand, as frequently happens in the case of recently- 
discovered diseases, there is at present, perhaps, a slight tendency to 
exaggerate their importance. Although the complaint may justly be 
looked upon as serious when the vegetations are large enough to inter- 
fere with nasal respiration or to cause inflammation in the neighborhood 
of the Eustachian tube, it need not, as a rule, give rise to much anxiety. 
It is, indeed, highly probable that in many cases the growths sponta- 
neously undergo atrophic changes in early adult life, whilst, as already 
pointed out, the larger size of the naso-pharynx makes their presence 
less injurious. Before adolescence has been reached, however, perma- 
nent deafness, defective articulation, and a lasting deformity of the 
thorax may have been produced. 
Dr. Meyer informs me that in his experience the growths have a 
tendency to sprout up anew in greater luxuriance than before if the 
whole mass be not thoroughly cleared away, but I do not think that 
this observation accords with the experience of others who have given 
attention to the subject. 
Treatment.—This consists in the removal or destruction of the growths. 
When they originate from the vault, removal can best be effected with 
the cutting forceps of Lowenberg (see Nasal Instruments) or Solis Co- 
hen.* Both these physicians appear to have suggested this mode of 
removal at about the same time. Cohen observes, “ I have long used 
a gouge-cutting forceps, modelled on Mackenzie’s similar instrument 
for cutting off laryngeal growths, with the shank curved to suit the 
anatomical disposition of the parts over which it must be passed.”f The 
shape of Lowenberg’s instrument with Woakes’s modification of the 
cutting edges appears to me rather more convenient than that of Cohen, 
* Diseases of Throat and Nasal Passages, New York, 1879, 2d ed., p. 262. The au- 
thor gives a woodcut of his instrument, 
f Op. cit., p. 262. 492 
DISEASES OF THE THROAT AND NOSE. 
the blades being shorter and forming a rather more obtuse angle with 
the shaft. In children who are likely to struggle much during the 
operation, or to resist its being repeated—that is to say, in those between 
eight and thirteen or fourteen years of age—I generally have chloroform 
administered. For younger children, however, and for adults I do not 
employ any anaesthetic. It is seldom that forceps can be used while 
the mirror is in position, and it will mostly be found sufficient first to 
make an accurate diagnosis and then immediately to introduce the 
forceps. Some operators guide the instrument with the index finger of 
the left hand ; but this procedure is seldom necessary except when the 
patient is under an anaesthetic. For removal of growths from the 
lateral walls Lowenberg recommends a modification of Volkmann’s 
sharp spoons, suitably curved for introduction into the posterior nares. 
In operating with this instrument, the index finger of the other hand 
should be used for the purpose of firmly adjusting and securing the 
growth. For these vegetations, however, my sliding forceps (Fig. 63, 
p. 276) will be found to answer well. Meyer lately recommended a 
somewhat similar instrument, but he still strongly advocates the use of 
his “ ring-knife” (p. 277), and employs it almost exclusively. In this 
country, however, patients greatly dislike the passage of instruments 
of any size through the nose, and nearly all operators effect removal of 
the growths through the posterior nares. 
Zaufal* has succeeded in removing vegetations from the naso-pharynx 
by passing through one of his funnels (Fig. 28, p. 245) a steel wire 
which, by an ingenious contrivance, is pushed out so as to form a loop 
and catch the growth. Capartf has adopted this method of expanding 
the loop and applied it to electric cautery. The latter physician also 
often uses a sort of ring-knife or sharp scraper, carried on a metallic 
finger-shield (see Nasal Instruments, Fig. 65, p. 278), whilst Guye,| of 
Amsterdam, uses his finger-nail for the same purpose. 
In the course of operations on these growths there is often pretty 
free bleeding, and in some cases a haemostatic is required. The nasal 
douche may be employed, cold water being passed through the nares, 
and powdered tannin or matico leaf may be insufflated behind the 
uvula. As a matter of fact, however, 1 have never met with haemor- 
rhage profuse enough to require the use of any styptic. 
* Prag. med. Woclienschr., 1878. 
f Bull. Acad. Hoy. de M6d. de Belg., 1879, 3me sdr., xiii., 1151. 
J Trans. Intern. Med. Congress, London, 1881, vol. iii., p. 290. 493 
FIBROUS POLYPI OF THE NASO-PHARYNX. 
If the electric cautery is used, Lincoln’s instrument (Fig. 61, p. 275) 
would, no doubt, be found very convenient. 
In order to re-establish respiration through the nose, it is most im- 
portant to teach patients to keep the mouth shut, and, during sleep, a 
chin-piece, with tapes to tie over the head, as recommended by Lowen- 
berg,* may be worn, or a respirator, as suggested by Guye, of Amster- 
dam.f Lovvenberg’s plan appears to me most suitable for young 
children, and I have put it in practice once or twice with satisfactory 
results. 
FIBROUS POLYPI OF THE NASO-PHARYNX, 
Latin Eq.—Polypi fibrosi pharyngis nasalis. Polypi naso-pharyugei. 
French Eq.—Polypes fibreux du pharynx nasal. 
German Eq.—Nasenrachen poly pen. 
Italian Eq.—Polipi fibrosi della faringe nasale. 
Definition.—Tumors of fibrous structure, generally springing from 
the vault of the naso -pharynx, often extending into one of the nasal fossce 
or even into the antrum, or reaching down in the pharynx to the epiglottis, 
and when of large size giving rise to great disfigurement of the face, to 
obstruction of the nose, and sometimes to considerable dyspnoea. These 
tumors, which are nearly always found in males between the ages of fifteen 
and twenty-five, are generally solitary, bleed very readily when touched 
and sometimes spontaneously, have a marked tendency to recur after re- 
moval, and show a disposition to arrest of development or even atrophy 
after the age of twenty-five. 
History.—Although mention is frequently made by the older writers of polypi hang- 
ing from the back of the nasal passages into the pharynx, the literature of naso- 
pharyngeal fibromata may be said to begin with Manne’sJ account of his method of 
removing such growths, which was published in the early part of last century. Soon 
after the subject was briefly referred to by Garengeot,$ and a few years later Manne|| 
* Op. cit., p. 70. f Intern. Med. Congress, Brussels, 1875. 
J Dissertation curieuse au sujet d’un Polype extraordinaire qui occupoit la Narine 
droite, qui bouchoit les deux fentes nasales, et qui descendoit par une grosse masse 
extirp6e a tin pastre du Avignon, 1717. 
\ Traite des Operations de Chirurgie, Paris, 1731, t. iii., p. 50 etseq. 
|| Observation au sujet d’un Polype extraordinaire, Avignon, 1747. 494 
DISEASES OF THE THROAT AND NOSE. 
published a second tract containing some additional cases. Examples were recorded 
by Taranget* and Eustache.f and a somewhat elaborate memoir on naso-pharyngeal 
polypi, valuable even now for the number of carefully related cases which it contains, 
was presented to the Royal Academy of Surgery of Paris by Icart,| in 1731. In 
Levret’s£ work on polypi some valuable suggestions were made for the removal of 
fibrous growths of the naso-pharynx, chiefly by means of ligature, of which method 
this ingenious surgeon was the inventor. Morand|| afterwards succeeded in removing 
a polypus with his fingers alone, by what he called “ febranlement ”—that is to say, by 
rocking the tumor on its base between one finger introduced as far as possible into the 
nostril, and one or two fingers of the other hand passed up behind the soft palate. A 
few years later Nannonilf removed a large naso-phar\Tngeal growth by Manne’s method. 
Early in the present century Whately** devised an ingenious plan for guiding scissors 
or cutting-forceps to the base of such tumors. In 1816 Ansiauxff reported a case in 
which he used Manne’s method, and failing to get the growth away with forceps, de- 
stroyed it by repeated cauterizations. In 1832 Svme,|| in dealing with a naso-phar- 
yngeal polypus, for the first time removed the upper jaw as a preliminary step towards 
extirpation of a tumor not connected with that bone itself. Mott,§§ of New York, 
was referred to by Syme as claiming to have excised the upper jaw for naso-pharyngeal 
polypus at about the same date, but I have not been able to find any record of his case. 
In 1834 Dieff'enbach|||| published a number of cases in which he had removed fibro- 
mata with the bistoury, scissors, and forceps, generally dividing the soft palate as a 
first step. This, as already shown, had been frequently done before, but solely for the 
purpose of opening a freer way of access to the tumor, whereas Diff'enbach was, so far 
as I am aware, the first to point out how valuable this measure may be in itself for the 
relief of the urgent dyspnoea often caused by the presence of a large fibrous polypus 
in the naso-pharyngeal region. put in practice with some success a method 
which is merely Morand’s “ 6branlement” carried out with forceps instead of the fin- 
gers. In 1840 Flaubert*** removed the whole of the upper jaw for the eradication of 
a growth which had baffled several previous attempts to remove it by ordinary means. 
He was apparently under the impression that his was the first operation of the kind, 
and, in fact, ablation of the superior maxillary for disease unconnected with that bone 
is, even now, spoken of by French writers as “ Flaubert’s operation.” It has been 
shown, however, that he was anticipated, both in the conception and the performance 
* Documents de l’Acadfemie R. de Chirurgie, republished by Verneuil; 
see Gaz. Hebd. de Med. et de Chir., June 15th, 1860, p. 388. 
f Ibid. 
J Ibid., July 20th, 1860, p, 465. 
\ Obs. sur la Cure radicale de plusieurs Polypes, Paris, 1771. 
|| Opuscules de Chirurgie, Paris, 1772, 2me partie, p. 196. 
<[ Nessi: Istituz. di Chirurgia, Venezia, 1787, p. 228. 
** Cases of two extraordinary Polypi removed from the Nose, London, 1805. 
ff Clinique Chirurgicale, t. viii., Li£ge, 1816, p. 137 et seq. 
Edin. Med. and Surg. Journal, vol. xxxvii., p. 322. 
Ibid. The statement rests on a private letter from Mott. 
1111 Chirurgische Erfahrungen, Berlin, 1834. Dritte und Vierte Abtheilung, p. 236 
et seq. 
Diet, de M4d. et de Chir. prat., art. “Polypes,” Paris, 1835, t. xiii. 
*** Arch. G4n. de M£d., 1840, 3me sferie, t. viii., p. 436 et seq. FIBROUS POLYPI OF THE NASO-PIIARYNX. 
495 
of this operation. Adelmann* reported a case of a very large naso-pharyngeal 
polypus which (besides other ravages) had perforated the hard palate. This opening, 
enlarged by division of the soft palate with the knife, was used as a way of access to 
the tumor. This possibly suggested to Nelatonf his plan of trephining the hard pal- 
ate, which, though rarely if ever practiced in this country, has apparently found great 
favor among French surgeons. N51aton devoted much attention to naso-pharyngeal 
growths, their attachments, and the means of extirpating them. Although little is to 
be found on the subject in his own writings, his views have been fully set forth, and 
his cases and methods of treating them have been related by several of his pupils.% 
Chassaignac,! Langenbeck,|| Huguier,f Demarquay,** and Ollier,ff have invented 
different methods of “ temporary resection ” of the bony roof of the nose or of part 
of the upper jaw, whilst Roux|J has suggested a method of “ mobilizing ” the whole 
of the upper jaw, enabling the surgeon to separate the two maxillaries, and thus ob- 
tain the widest possible view of the pharynx and base of the skull. This formidable 
procedure, however, has never been attempted on the living subject. The operations 
performed by Langenbeck and von Bruns were described in 1872 by Paul Bruns, §§ 
who claimed for these surgeons the merit of devising the methods which are generally 
attributed to Huguier and Chassaignac. An elaborate article was published by Gos- 
selin and Denonvilliers,|||| which has served as a very useful storehouse for subsequent 
writers on naso-pharyngeal growths. modified Manne’s operations 
by making a “button-hole” in the soft palate instead of completely dividing it. On 
the other hand, Nelaton’s procedure was altered by Richard,*** who trephined the 
hard palate without dividing the velum. A very full account of naso-pharyngeal 
growths was given in 1864 by Robin-MassGfff who wrote as a professed follower of 
N6laton. Several English and American surgeons have reported cases of naso-pharvn- 
geal polypi, for the removal of which severe surgical measures were found necessary ; 
among them may be mentioned Bryant,JJJ Cheever,§§g Rouse,|||||| Thomas,' 
Waterman,****Clark,fftt Cooper Forster,Whitehead,Sands,|||||||| Berkeley 
* Untersuchungen fiber Krankhafte Zustande der Oberkieferhohle, Dorpat und 
Leipzig, 1844. 
f Botrel: D’une Operation nouvelle dirig4e contre les Polypes naso-pharyngiens, 
Paris, 1849. N61aton’s first operation was done in 1848. 
t Botrel, Desgranges, D’Ornellas, Vautliier, Bobin-Mass^. 
§ Traitd des Operations chirurg., t. ii., p. 448. 
|| Deutsche Klinik; No. 48, 1859. 
f Bull, de l’Academie de Med., Paris, May 28th, 1861. 
** Gazette Hebdoinadaire, Aug. 29th, 1862, p. 554. 
ft Bull, de la Soc. deChir., 1866, p. 263 et seq. 
Gazette des H6pitaux, July 30th, 1861. 
\\ Berlin klin. Wochenschrift, vol. ix., pp. 138 and 149. 
1111 Compendium de Chirurgie pratique, vol. iii. 
Iff Gazette Hebdomadaire, Sept. 2d, and Sept. 10th, 1859, p. 612. 
*** Beuf: Des Polypes fibreux de la Base du Crane, These de Paris, 1857. 
fft Des Polypes naso-pharyngiens, Paris, 1864. 
++J Trans. Path. Soc., London, vol. xviii., p. 107. 
§$§ Boston Med. Surg. Journ., March 11th, 1869. 
Illlll Lancet, Feb. 27th, 1869. fff Ibid., May 1st, 1869. 
**** Bost. Med. Surg. Journ., April 8,1869. ftff Ibid., Oct. 19th, 1871. 
J+++ Lancet, May 20th, 1871. §§§§ N. Y. Med. Record, Jan. 2,1872. 
|| || || II Brown-Sdquard’s Arch, of Med., June, 1873. 496 
DISEASES OF THE THROAT AND NOSE. 
Hill,* MacCormac,f Eatton,J Ogilvie Willand Henry Morria.|| A good description 
of the various operative methods of dealing wfith these growths was published by 
Sands,1in 1873, and in the following year Cheever,** in describing a new plan of 
temporary displacement of the upper jaw, compared the different “ preliminary opera- 
tions” together in a very judicial spirit. A short but complete essay on naso-pharyn- 
geal tumors was published in 1878 by Bensch,ff and Spillmann’sjf recent article on 
the same subject is full of information. The latest contribution to the literature of 
these growths is an instructive paper by B. P. Lincoln,§§ giving the results of different 
modes of treatment in fifty-eight cases. 
Etiology.—The disease is decidedly rare. Paget|||| states that he has 
never had an opportunity of examining any of these growths in the 
fresh state, and indeed that he has seen very few of them in any con- 
dition. It would appear, however, from the numerous cases recorded 
by French surgeons, that the affection is less uncommon among their 
countrymen than it is with us. Fibrous tumors of the naso-pharynx 
generally originate between the ages of fifteen and twenty-five, but they 
occasionally commence in infancy, and more rarely after the period of 
adolescence is past. has collected 118 cases of tumor in the 
naso-pharynx, many of which, however, for various reasons he excludes 
from consideration. Some were clearly of malignant nature, others 
cartilaginous or simply mucous in structure, whilst many of the cases 
were too incompletely reported to be made use of. Allowing for these 
omissions, there remain 66 cases, and in 58 of these the patients were 
males from eleven to twenty-five years of age; 7 of the remaining 8 
occurred in boys under ten years of age, whilst in the eighth case the 
patient was a girl of fourteen.*** Bensch’s table contains examples of 
patients of both sexesfff over twenty-five years of age, but even when 
* Lancet, June 20th, 1874. 
f St. Thomas’s Hospital Reports, 1875, p. 65 et seq. 
J Lancet, Nov. 3d, 1878. § Ibid., Dec. 6th, 1879 
|| Med. Times and Gazette, June 4th, 1881; and Ibid., June lltli, 1881. 
Loc. cit. 
** Boston Med. Surg. Journ., 1874, vol. xc., p. 545 et seq. 
ft Beitriige zur Beurtheilung der chirurg. Behandlung der Nasenrachenpolypen, 
Breslau, 1878. 
Diet. Encyclop. des Sciences Med., 1881, 2me serie, t. xiii., art. “ Nez.” 
\\ Archives of Laryngology, 1883, vol. iv., No. 4, p, 258 et seq. 
1111 Lectures on Surgical Pathology, London, 1870, 3d ed., p. 475. 
Op. cit., p. 106 et seq. 
*** This case is reported as that of a woman aged twenty-five, but she had suffered 
from the complaint eleven years. 
ftf Among these is one of Verneuil’s (Bull, de la Soc. deChir., 1873, t. ii., 3me stirie, 
p. 347), in which the patient was a woman aged sixty-two. FIBROUS POLYPI OF THE NASO-PHARYNX. 
497 
the tumors were fibrous in structure, these cases had not, according to 
Bensch, presented the clinical features which are considered to be truly 
characteristic of naso-pharyngeal fibromata. Lincoln’s statistics com- 
prise 58 examples of naso-pharyngeal tumor, reported in the period 
from 1867 to 1873, and of these probably not less than 38 were genuine 
fibromata, in all of which the patients were males under the age of 
twenty-five. Ndlaton,* indeed, went so far as to say that he did not 
know of a single authentic example of true naso-pharyngeal fibroma 
becoming developed in a female of any age, or in a male over thirty- 
five. Whilst granting that the law thus laid down is too absolute, the 
fact remains that instances of the disease occurring in women must be 
looked upon as altogether exceptional. 
There is no evidence that the affection is hereditary, though one 
congenital case has been recorded.f 
The causes which lead to the development of naso-pharyngeal fibro- 
mata are unknown, but the disease is probably due to an irregular 
evolution, during the growing period, of a tissue which under normal 
conditions is exceptionally abundant on the under surface of the base 
of the skull. The age (fifteen to twenty-five) at which these growths 
are most prone to originate is precisely the time at which many of the 
fibrous tissues of the body are in the' most important stage of their 
development. It is then that the articular ligaments are acquiring 
their full firmness, and it seems not unlikely that it is to an exaggerated 
plastic activity during this phase of development that these terrible 
growths owe their origin. 
Symptoms.—In the early stages of the complaint the patient becomes 
aware of some obstruction of one or other nostril, and suffers from a 
disagreeable feeling at the back of the nose. As the disease develops, 
both nasal passages generally become completely obstructed, and if the 
growth hangs low in the pharynx there is often considerable dyspnoea. 
There is usually deafness of one ear, and sometimes both sides are 
affected. The articulation is frequently indistinct, and even unintelli- 
gible, from pressure on the soft palate, whilst dysphagia is occasionally 
a troublesome complication. A curious symptom which has been ob- 
served in many of these cases is drowsiness, the patient sometimes 
* Rapport sur les Px-ogres de la Chirurgie, by MM. Denonvilliers, NGaton, Velpeau, 
etc., Paris, 1867, p. 325. 
f Yoisin: cited by Verneuil, Gaz. Hebd., 1860. From Documents in6dits tirbs des 
Archives de l’ancienne Acaddmie de Chirurgie. 498 
DISEASES OF THE THROAT AND NOSE. 
falling asleep even when standing upright. Whately* gives remark- 
able illustrations of this symptom in the case of his patients, one of 
whom would fall asleep in his shop in the act of serving a customer, 
or even when on horseback in the street; whilst another, who was a 
barber’s apprentice, went to sleep when curling a customer’s hair, and 
dropped the hot iron on his head. A great sense of fatigue usually 
accompanies this drowsiness. There is generally an abundant purulent 
secretion, which is sometimes of a fetid character. Epistaxis is of 
almost constant occurrence, and is often very severe. Thus Whatelyf 
mentions that in one of his cases the patient bled at the nose on three 
different occasions at intervals of a year, the haemorrhage each time 
lasting six days, and the amount of blood lost being between four and 
five pints. The bleeding is in many instances so frequent and profuse 
that the patient is reduced to a dangerously anaemic condition. 
By means of posterior rhinoscopy the growth can be seen at an early 
period of the disease, and it can also be felt with the finger. It is 
generally smooth, hard, and unyielding, red or purple in color, and 
often ulcerated and covered with sanious secretion. The tumor is 
usually pedunculated, the stalk, however, in most cases being broad. 
There has been much controversy as to the exact seat of implantation 
of these fibromata. The usual opinion is that they may spring from 
the vomer, the inner surface of the pterygoid processes, the front of the 
upper surface of the upper cervical vertebrae, or, in fact, any part of 
the roof or lateral walls of the naso-pharyngeal cavity. 
however, whose teaching has been widely accepted in France, holds 
that the primary point of origin is in all cases the periosteum covering 
a limited area on the under surface of the base of the skull correspond- 
ing to the basilar process of the occipital and the body of the sphenoid 
bone. He maintains that where the tumor appears to be attached to 
other parts, either in the naso-pharynx or the nose, these are merely 
points where secondary adhesions have been contracted in the course of 
expansion of the growth.. It may, at least, be admitted that this view 
is correct in the great majority of cases. In order to ascertain its exact 
origin, it is often useful to introduce a probe through the nostril while 
the finger is in the mouth, for by this means the polypus can be moved 
and its relations more easily made out. As the mass enlarges, it be- 
comes visible in the pharynx, whilst in other cases where it hangs down 
* Op. cit, pp. 3 and 20. 
J Robin-Mass6, op. cit., p. 12. 
f Op. cit., p. 2. FIBROUS POLYPI OF THE NASO-PHARYNX. 
499 
into the throat, additional room can be obtained by drawing the velum 
forwards (see p. 251 et seq.). 
The subsequent symptoms depend on the direction which the tumor 
may take in its development. If it extends towards the throat, it 
presses the soft palate forwards and interferes with deglutition. At 
the same time it generally causes inflammation, which may spread along 
the Eustachian tube, set up catarrh of the middle ear, and thus give 
rise to considerable deafness. If the tumor grows into the nose, it may 
separate the nasal bones from each other, flatten out the bridge, at the 
same time pushing the eyes further apart and making them bulge 
almost out of the orbits, thus producing the hideous deformity known 
as “frog-face.” It may also press on the lachrymal canal and cause 
epiphora. Should the mass extend outwards it may displace the eye- 
ball, causing exophthalmia, and even setting up destructive inflamma- 
tion of the eye, or it may reach into the antrum, giving rise to a large 
swelling in the cheek. A similar effect is produced when the growth 
projects through the pterygo-maxillary fissure and extends to the cheek 
beneath the zygoma. The most dangerous extension is upwards through 
the base of the skull, the cranial cavity being opened, and the substance 
of the brain pressed on or destroyed by the invading mass. It is re- 
markable, however, that the cranium may be perforated or eroded over 
a considerable area by the tumor without any cerebral disturbance 
being produced.* 
Diagnosis.—In the early stages the disease can generally be recog- 
nized with the rhinoscope and by digital examination, and when well 
advanced it can scarcely be mistaken for any other affection. It is 
often impossible to distinguish between fibrous tumors and sarcomata 
except by microscopic examination, but the age and sex of the patient 
greatly assist in arriving at a correct opinion. Cartilaginous tumors 
are so rare in the naso-pharynx, that they may be excluded from con- 
sideration, and bony growths have never been observed in that region. 
Occasionally curious and almost unavoidable mistakes have been made. 
An instance of this is the well-known case in which Vacca-Berlinghierif 
endeavored to remove what appeared to be a polypus, but proved to 
be a neuroma of the size of a peach on the second division of the fifth 
nerve. The case already mentioned (p. 360), in which a hernia of the 
brain simulated a polypus, may be again referred to. Sometimes the 
* See several cases in a thesis by Petit; De quelques Considerations snr les Polypes 
naso-pharyngiens et leur Propagation au Cerveau, Paris, 1881, pp. 25, 26, 32, and 37. 
f Arch. Gen , t. xxiii., p. 431. 500 
DISEASES OF THE THROAT AND NOSE. 
ophthalmoscope may reveal evidence of pressure on the optic nerve, 
but in a case reported by Ollier* cerebral symptoms occurred without 
any atrophy of the disk having been observed. 
Pathology.—Fibrous tumors of the naso-pharynx present the ordinary 
characters of fibromata. They are exceedingly dense, and only differ 
from similar growths in other situations in being, as a rule, destitute of 
elastic fibres. The vessels in the substance of the tumor are usually 
small, whilst those of the investing membrane are often of large size. 
According to Gross,f all these vessels have very brittle walls, and it is 
to this peculiarity that he attributes their proneness to bleed, a tendency 
which is further favored by the fact that the vessels are imbedded in a 
dense fibrous network which does not allow of their retraction when 
cut. Muron,| who made a careful examination of a growth removed 
by Verneuil from a boy between fifteen and sixteen years of age, states 
that in that case the vessels, which were exceedingly numerous, had for 
the most part a more or less embryonic structure. The walls of the 
smallest consisted merely of a single row of slightly fusiform cells, others 
had two such rows, whilst some had three or four. The vessels pre- 
senting a fully organized structure with the ordinary three coats were 
extremely few in number. Occasionally a considerable portion of the 
tumor may be of true erectile and in such cases haemorrhage 
is, of course, particularly likely to occur. Virchow|| suggests that this 
is in some cases due to an extension of the cavernous structure normally 
covering the turbinated bones. 
Prognosis.—This is unfavorable, unless the disease be recognized and 
treated at a very early stage. The only satisfactory feature in these 
growths is that they do not tend to increase, but rather show a disposi- 
tion to become absorbed, after the age of twenty-five. If, therefore, by 
repeated removal, the spread of the disease can be kept within bounds, 
its spontaneous arrest may fairly be looked for when the period of ado- 
lescence is past. An example of the disappearance of a fibroma without 
any treatment whatever has been related by The patient was 
a man, aged twenty-four, who had suffered from the characteristic 
symptoms for three or four years, and who when seen had a large naso- 
pharyngeal growth with prolongations into the nose and cheek. As 
* Bull, de la Soc. de Chirurgie, 1866, p. 264. 
f System of Surgery, Philadelphia, 1872, 5th ed., p. 371. 
t Bull, de la Soc. de Biologie, July 3d, 1869, p. 223. 
§ E. Neumann : Virchow’s Arcliiv, Bd. xxi., p. 280. 
|| Die Krankhaften Geschwiilste, Bd. iii., p. 463. 
T[ Gaz. Hebdoin., January 15th, 1875, p. 37. FIBROUS POLYPI OF THE NASO-PHARYNX. 
501 
the symptoms were not urgent, surgical measures were postponed, and 
a few months later the patient returned with hardly a trace of the tumor 
remaining. Fibrous tumors of the naso-pharynx have also sometimes 
sloughed away. In an instance related by Birkett* this took place 
after repeated haemorrhages, for which deligation of the left common 
carotid had been necessary. Another examplef of sloughing of a naso- 
pharyngeal growth, which had recurred after evulsion with forceps, was 
seen in a woman in St. George’s Hospital. In this case it is stated 
that the tumor disappeared “so entirely .... that no trace could be 
discovered of any part remaining.” 
Treatment.—The method of dealing with these growths is likely to 
undergo a fundamental change. Until a comparatively recent period 
they had, as a rule, attained considerable dimensions before their true 
nature, or, in some cases, their very existence, was discovered. Now, 
however, that the nose and naso-pharyngeal region can be thoroughly 
examined by direct inspection, fibromata are sure to be observed at a 
stage when they are amenable to treatment of a tolerably mild nature. 
It is not improbable, therefore, that the severe “ preliminary operations” 
presently to be described, may, after a time, become almost obsolete, 
and that electric cautery applied per vias naturales will, in great measure, 
supersede all other methods. Should the growth, however, have reached 
a large size before the patient comes under observation, the first ques- 
tion which the surgeon will have to decide is whether an attempt at 
radical cure should be made, or whether merely palliative measures 
should be adopted. The natural tendency of the disease to come to a 
standstill after the twenty-fifth year affords a strong argument in favor 
of doing nothing in the way of active treatment beyond what is abso- 
lutely required for the relief of urgent symptoms. An excellent illus- 
tration of this has been furnished by Gosselin4 The disease had first 
attracted the patient’s attention by the usual symptoms, when he was 
between sixteen and seventeen years of age, but it was not till three 
years later that he sought medical advice. Almost every method was 
employed for the radical extirpation of the growth, but recurrence was 
very rapid after each operation, and Gosselin was finally obliged to 
allow the patient to leave the hospital for the ostensible purpose of re- 
cruiting his health before submitting to further measures. But at this 
* Brit. Med. Journ., February 13th, 1858, p. 119. 
f Ibid., January 23d, 1858, p. 61. 
J Clinique Chirurgicale de U16pital de la Charity, Paris, 1873, t. i., Lepon 8me; 
p. 92. 502 
DISEASES OF THE THROAT AND NOSE. 
time his faee was hideously deformed, there was distinct evidence of 
commencing pressure on the brain, and his vita! strength was at the 
lowest ebb. Gosselin owns that he looked upon the lad as inevitably 
doomed to death at no very remote date. He saw his patient once more, 
however, when he had reached the age of five-and-twenty, and was 
astonished to find that, although no treatment whatever had been at- 
tempted in the mean time, all trace of the growth had disappeared. 
Gosselin is, therefore, strongly of opinion that whilst urgent symptoms, 
such as difficulty of breathing or swallowing, or great loss of blood from 
the nose, should, if possible, be palliated by the removal of part of the 
growth, the bulk of it should be left alone. If, when adolescence is 
complete, the mass is still unabsorbed, thorough eradication may be at- 
tempted with a fairly well-founded hope that there will be no return of 
the disease. 
Electric cautery is', as already remarked, the plan of treatment which 
will probably prevail in the future. It is safe and easy of application, 
and Lincoln’s* recently published results conclusively show that it is 
thoroughly effectual, when the growth is of moderate size. He has used 
it in three cases, in none of which has there been any sign of recurrence 
since the time of operation. Two of the patients have remained free 
from the disease for more than eight years, and the third has continued 
well during nearly eleven months. It is to be noted that the ages of 
those patients were respectively fifteen, seventeen, and twenty-one, so 
that all were within the period when the growth of fibromata is, as a 
rule, most active. Lincolnf quotes cases treated by electric cautery by 
Gulcke and Roth ; in the former there had been no recurrence during 
four and a half years, whilst in the latter the patient had remained free 
from disease for two and a half years. 
The best method of using electric cautery in these cases is, if possible, 
to remove the growth with the galvanic ecraseur passed through the 
nose or mouth. The stump should afterwards be thoroughly destroyed 
by electric cautery applied at such intervals of time as may seem desir- 
able; once a week will be sufficient in most cases. The simplest and 
most convenient instrument for this purpose is Lincoln’s post-nasal 
electrode (Fig. 61, p. 275). 
Amongst other modes of treatment may be mentioned electrolysis, 
ligation, removal with the ecraseur, evulsion, excision, crushing, gouging, 
actual cautery, and the application of escharotics. 
* Archives of L.'uyngology, 1883, vol. iv., No. 4, p. 258 et seq. 
f Archives of Laryngology, 1883, vol. iv., No. 4, pp. 274, 275. FIBROUS POLYPI OF THE NASO-PHARYNX. 
503 
Electrolysis can be carried out by means of any battery generating a 
continuous current of moderate strength. The operator should intro- 
duce one or more curved needles connected with the negative pole into 
the tumor behind the uvula, whilst the current from the positive pole 
is conducted to the growths by means of a needle passed through the 
nose, or a sponge-electrode placed in contact with the sternum. A con- 
venient needle for the purpose of applying electrolysis to post-nasal 
tumors has been invented by Cohen.* The operation should be con- 
tinued for ten or fifteen minutes at a time, and it may be made every 
day, or on alternate days. Very successful examples of this mode of 
treatment have been recorded by Velaton,f Paul Bruns,J Ciniselli,§ 
Fischer,|| and In Nelaton’s case a bulky growth which bled 
very easily, and which had resisted the cautery and eseharotics, was dis- 
persed by electrolysis in six sittings. In that of Bruns, a large tumor, 
which had baffled previous efforts to remove it with the snare, was de- 
stroyed by electrolysis. In this instance, however, the treatment had to 
be continued for eleven months; and one hundred and thirty sittings, 
each lasting about a quarter of an hour, were required. In Lincoln’s 
case electrolysis was used as a palliative measure, the patient’s weakness 
making a radical operation unadvisable. There were twenty-two 
sittings, the treatment being continued for about a year. At the end 
of that time the tumor had “shrunk very much in all dimensions, 
and the patient’s health was so much improved that the remaining por- 
tion of the growth could be removed with the ecraseur.” In Gosselin’s** 
case, already referred to, electrolysis was one of the methods resorted 
to, and it was tried under fair conditions. It was found, however, that 
although some diminution in the bulk of the tumor was effected at each 
sitting, this was so slight as to be regained by the natural process of 
growth by the next time electro-puncture was applied, so that no real 
progress was made. It may be added, that in this case the operation 
was so painful as to be extremely dreaded by the patient, who, never- 
theless, had borne, without much complaint, repeated examinations and 
many attempts to remove his growth by cutting, ligature, and caustics. 
* Diseases of Throat and Nasal Passages, New York, 1879, 2d ed., p. 270. 
f Robin-Mass6: Des Polypes naso-pharyngiens, Paris, 1864, p. 78. 
X Berlin klin. Wochenschr., July, 1872, No. 27, p. 321; No. 28, p. 336. 
$ Gazette Medicale, 1866, p. 223. 
|] Wien. raed. Wochenschr., 1865, No. 61. 
T[ Naso-pharyngeal Polypi, St. Louis, 1879, p. 6 etseq. Reprinted from the St. Louis 
Medical and Surgical Journal. 
** Loc. cit. 504 
DISEASES OF THE THROAT AMD NOSE. 
Ligation.—Ligatures have been employed for the removal of these 
growths from an early period in the history of surgery. When the 
tumor has been thoroughly exposed by a “ preliminary operation,” a 
ligature can usually be applied with ease, but when strangulation has 
to be done per vias naturales there is often the greatest difficulty in 
placing the ligature round the stalk of the growth. To accomplish this 
an immense variety of instruments have been invented; indeed, almost 
every surgeon who has had occasion to apply this method has devised 
some fresh arrangement. Perhaps the simplest plan is that recom- 
mended by Dubois.* This consists in passing a double ligature through 
a piece of elastic catheter fifteen to thirty centimetres in length, to which 
a piece of colored thread is attached. As the ends of the ligature are 
gradually drawn out through the nostrils by means of Bellocq’s sound, 
the surgeon, with his fingers in the patient’s mouth, carries the open 
loop over the pedicle of the growth. When the loop is in position, the 
piece of catheter is removed by means of the colored thread. An ob- 
vious objection to this method is that it is useless in the numerous cases 
where it is impossible to reach the pedicle with the finger. In carry- 
ing out ligation, there is some danger, if the tumor be large, that when 
it separates it may fall down into the throat during sleep, and cause 
death by suffocation. In such cases, therefore, a thread should be 
passed through the body of the tumor, and brought out by the mouth, 
the two ends being tied round one of the ears. During sleep the pa- 
tient must be watched in order that the polypus may,be at once with- 
drawn should it become detached. 
The great advantage of the ligature is that the danger from haemor- 
rhage during the operation is reduced to a minimum. The disad- 
vantage is that it is often extremely difficult to apply the ligature, 
except after a “ preliminary operation,” and that when the mass has come 
away a stump is left behind from which the growth may sprout anew. 
Removal with the Leraseur.—For this purpose a strong, slightly 
curved instrument must be used, and a loop of suitable size having 
been made, it should be directed upwards behind the uvula, and made 
to encircle the growth as close to its root as possible. In some cases it 
will be found easier to pass the wire round the tumor by pushing it, 
bent double, through the nose. In either case, when the wire is round 
the growth, its ends should be threaded through the eyes of the ecra- 
seur, and the loop gradually tightened. 
* Gazette des Hopitaux, February, 1863. FIBROUS POLYPI OF THE NASO-PHARYNX. 
505 
Evulsion.—As in the case of mucous polypi, evulsion with forceps 
has its advantages. Instead, however, of the delicate instruments which 
are used in dealing with soft growths, very powerful forceps are re- 
quired for fibrous tumors. They must be curved at an obtuse angle, 
and the blades should be rough, or even toothed, to enable the operator 
to get a firm grasp of the tumor. 
It is desirable to seize the growth as near its base as possible, and 
twist the pedicle as much as the space will permit. Such is the resist- 
ing character of these growths, however, that even when very strong 
forceps are employed, their blades are often wrenched so as to become 
useless. Occasionally the tumor may be seized with the fingers and 
torn off, but this can seldom be done until the origin of the polypus 
has been well exposed by a “preliminary operation.” 
In any case it is most important to follow any offshoots of the growth 
which may project into the nose, sphenoidal fissure, or antrum, and to 
root them out thoroughly. The great advantage of evulsion is that 
when the tumor is not very large it can be removed in this way without 
any “preliminary operation,” and that it can often be torn away by the 
roots. The objection to it is that the growth is sometimes so extremely 
dense that it altogether resists any reasonable degree of force,* and 
serious accidents may result from injudicious violence. Though Icartf 
has related an instance in which he brought away a fragment of the 
ethmoid bone as large as a shilling, without any bad consequences ensu- 
ing, it must not be forgotten that two of Ollier’s | patients died from 
cerebral complications after evulsion. In one of these, however, the 
growth was found, on post-mortem examination, to have invaded the 
middle cerebral lobe. Cooper Forster § also lost a patient twelve days 
after evulsion, and the necropsy showed fracture of the cribriform plate 
of the ethmoid with general arachnitis and localized sloughing of the 
cerebral substance. A great part of the tumor having been left behind, 
it appears probable that these lesions were due to the operation. 
Excision with a curved blunt-pointed bistoury was frequently per- 
formed by Dieffenbach, who, though he sliced these growths in the freest 
manner, did not meet with any dangerous haemorrhage; this experience, 
* This has been especially observed by M. Ollier, the well-known surgeon of Lyons, 
who, considering their great rarity, has had an unusually large experience of these 
tumors, 
f Loc. cit. 
J Spillmann : Diet. Encvclop. des Sciences Medicates, 2e s6rie, t. xiii., p. 100. 
\ Lancet, May 20th, 1871. 506 
DISEASES OF THE THROAT AND NOSE. 
however, is of a very exceptional character, for Deguise,* Verneuil,f 
and Dumenil J have reported cases in which death occurred from the 
furious bleeding which took place when the tumor was divided. 
Whately succeeded in curing a very severe case by excision, or rather 
amputation, with a curved knife. His mode of operation was ingeni- 
ous, and at the same time simple. A string was first passed through 
the nose round the growth, and into the pharynx, from which it was 
drawn out of the mouth. The end of the string was then threaded 
through a small eye near the point of the knife, and the nasal extremity 
of the string being pulled tight by an assistant, whilst the other was 
held in the surgeon’s left hand, the knife with its point carefully 
guarded was run along the string to the upper part of the pharynx, 
where the edge was guided to the base of the tumor, which was cut 
through. Although the diameter of the growth at the point of section 
was 2 by If inches, there was no serious bleeding.§ In spite, however, 
of this experience of Dieffenbach and Whately, the danger of haemor- 
rhage renders their plan of treatment unworthy of imitation. 
Crushing.—This method has never been extensively practiced. It 
was tried by Velpeau|| with very powerful forceps armed with strong 
teeth. Different portions of the growth were successively seized, and 
violently compressed, and in this way a considerable portion of the 
tumor was destroyed. The crushed portions, together with some of the 
immediately adjacent parts of the polypus, subsequently sloughed away. 
Although cases have been reported by Dolbeau*[[ and Jarjavay** in 
which this treatment was successful, it is so apt to give rise to septic in- 
fection that it has fallen into disuse. 
Gouging.—This mode of treatment was once much in vogue. But 
though a favorite practice in the sixteenth and seventeenth centuries for 
the destruction of every kind of tumor, it does not appear to have been 
employed for the removal of naso-pharyngeal polypi till it was advo- 
cated by Borelli.ff The method has since been followed by Guerin, 
Bonnes,§§ and Herrgott,|||| but it requires the performance of a “pre- 
liminary operation,” except in cases where the growth is attached to the 
* Bull, de la Soc. de Chir., March 13th, 1861. 
f Ibid., 1870. t Ibid., June 18th, 1873. 
\ Cases of two Extraordinary Polypi, etc;, London, 1805, p. 14. 
|| Bulletin de Thferapeutique, 1847. 
f Spillmann: loc. cit., p. 101. ** Ibid, 
ff Gaz. des Hopitaux, 1860, p. 179. 
ft Bull, de la Soc. de Chir., June 24th, 1866. §§ Ibid., July 14th, 1869. 
DU Quoted by Postel: Des Polypes naso-pharyngiens, Th&se de Paris, 1867. FIBROUS POLYPI OF THE X ASO-PHARYNX. 
507 
base of the skull. Under these circumstances the plan is most conve- 
niently carried out by passing an extremely tine chisel through the 
nose, and pushing it along the vault of the pharynx. 
Although gouging is of very limited application for the actual re- 
moval of growths, it has been extensively employed for destroying the 
stump when the bulk of the tumor has been taken away by some other 
plan. Baudrimont,* however, says that out of eight cases operated on 
by Dieffenbach, recurrence took place in seven, in every one of which 
gouging had been carried out; whilst in the eighth case, in which cau- 
terization was used instead of gouging, there was no recurrence of the 
disease. Ollier.f on the other hand, affirms that he has no confidence 
in any method of treating naso-pharyngeal growths except by evulsion 
followed by vigorous gouging, and he is never satisfied that the latter 
procedure has been thoroughly carried out, unless he can feel that the 
bony tissue of the basilar process of the occipital bone has been .scraped 
quite bare. Whilst admitting that the periosteum which furnishes the 
elements for the reproduction of the tumor must be destroyed as com- 
pletely as possible, a word of warning seems to be called for here against 
a too energetic use of the gouge. A case has come to the author’s 
knowledge in which a distinguished surgeon, now deceased, actually 
drove the chisel into the patient’s brain whilst scraping the vault of 
the pharynx. 
Thermic Cautery.—The red-hot iron used by the older surgeons has 
been abandoned in favor of improved methods of applying the actual 
cautery. 
Paquelin’s thermo-cautery is available in some cases, and Nelaton 
successfully employed a simple gas flame for the cauterization of the 
stump of a tumor which had been removed. For this purpose he used 
a small india-rubber ball full of gas, connected with an elastic tube, to 
which suitable nozzles of varying degrees of fineness could be adapted. 
The nozzle was provided with a stop-cock, so that the flame could be 
exactly regulated in its application. By this means it was found pos- 
sible to cauterize the parts very quickly and thoroughly, whilst radia- 
tion was so slight that the finger could be held at a distance of a centi- 
metre and a half from the flame without any heat being perceived. 
Escliarotics.—Various agents of this kind have been employed in 
different ways. Nelaton treated some cases by the application of nitric 
* De la M6thode nasale dans le Traitement des Polypes naso-pharyngiens, ThSse 
de Paris, 1869. 
f Traits exper. et clin. de la Regeneration des Os, Paris, 1867, p. 485. 508 
DISEASES OF THE THROAT AND NOSE. 
acid passed through a suitably curved glass tube. In spite, however, 
of every precaution, the vapor of this acid is apt to escape and give rise 
to violent dyspnoea. Moreover, to produce any real effect, the remedy 
must be applied daily for months. In France chloride of zinc paste 
(pate de Canquoin) has been recommended by several surgeons, and a 
special apparatus has been devised by Desgranges* for maintaining the 
caustic in contact, as long as may be necessary, with the part to be 
destroyed. This consists of a thin metal plate, on the upper surface of 
which is placed the caustic agent, whilst the apparatus is kept in position 
by metallic bands which go round the head. Although I have never 
had an opportunity of trying them in a case of naso-pharyngeal fibroma, 
I think the caustic dartsf which I am in the habit of occasionally using 
in cases of fibrous bronchocele might also here prove of service. 
French surgeons distinguish two methods of employing cauterization, 
viz., the rapid process and the slow process. The former consists in 
freely cauterizing the stump of a polypus immediately after the bulk 
of it has been removed. The slow cure consists in keeping the base of 
the growth accessible for some weeks after a “preliminary operation” 
has been done, and applying the caustic every second or third day. 
The slow cure can be most conveniently carried out through the wound 
left after Nelaton’s “palatine operation.” This procedure, however, is 
objectionable, as almost necessarily leaving a permanent fissure of the 
palate; whilst, in the case of operations on the face, the prolonged 
maintenance of an open wound is likely to lead to hideous deformity. 
Preliminary Operations for gaining Access to Naso-pharyngeal Tu- 
mors.—Although attempts have been made to dilate the orifice of the 
nostril by means of serpentary root, gentian, sponge, and more recently 
by laminaria, these methods are practically of little value, and, owing 
to the frequently inaccessible situation not less than to the large size 
and numerous offshoots of the growths, it often becomes necessary to 
expose the tumor by a preliminary surgical operation. This necessity 
was perceived at a very early period, and on referring to the short 
historical retrospect prefixed to the article on “Nasal Polypi” (p. 350 
et seq.), it will be seen that Hippocrates recommended that the nasal 
cavity should be laid freely open in cases where the application of the 
actual cautery was judged necessary. An operation of this kind seems 
to have been frequently done in the sixteenth and seventeenth centuries, 
* Gazette Hebdom., June 30th, 1854, p. 633 et se<j. 
f These consist of one part of chloride of zinc to one or two parts of wheat flour. FIBROUS POLYPI OF THE NASO-PHARYNX. 
509 
but it had fallen into disuse until revived by Dieffenbach.* It has 
since been often performed with various modifications according to the 
exigencies of particular cases. The older surgeons carried the incision 
down the centre of the nose, but, with the view of concealing the scar 
as far as possible, Garengeotf suggested that the cut should be made 
along the genio-nasal furrow. 
At a later period more severe procedures came into use, the naso- 
pharynx being laid open by resection of the upper jaw, or the growth 
being reached by division of the hard palate. Hence the following 
preliminary operations for the removal of naso-pharyngeal tumors have 
come to be recognized, viz., 1, nasal; 2, maxillary ; and 3, 'palatine. 
These procedures are in themselves attended with considerable risk. 
S6dillot| and Demarquay§ each lost a patient from haemorrhage in the 
course of the “ preliminary operation/’ and in twenty-one cases collected 
by Lincoln,|| in which a “preliminary operation” was done,death took 
place on the table in three,whilst in a fourth,** the patient succumbed 
within a few hours. In a fifthft instance haemorrhage very nearly 
proved fatal during the operation. If Lincoln’s statistics are accepted 
in the gross, they show still less favorable results, for in thirty-nine 
cases in which “preliminary operations” were performed, death quickly 
ensued in eight. In some of these, however, the disease was decidedly 
malignant, and they have, therefore, been excluded from consideration. 
Even as regards the twenty-one cases of undoubted fibroma, it must 
not be forgotten that a “preliminary operation” was presumably judged 
necessary because the tumor was very large, and the mortality may, 
therefore, have been in great measure due to the unavoidable violence 
which must sometimes be used in separating the mass from its attach- 
ments. The feeble and anaemic condition of the patients in such cir- 
* Op. cit. 
f Traite des Operations de Chirurgie, Paris, 1731, 2e fed., t. iii., p. 53. 
J Spillmann: op. cit., p. 145. \ Ibid., p. 146. 
|| Loc. cit., pp. 264-281. Lincoln’s tables include altogether fifty-eight cases of 
naso-pharyngeal tumor. Of these seven were unquestionably malignant, three were 
fibro-mucous, whilst in ten the nature of the growth is either not stated, or from 
internal evidence (age or sex of the patient, cause of the disease, etc.) may be judged 
to have been not truly fibromatous. I have, therefore, reckoned only thirty-eight of 
Lincoln’s cases as examples of the disease treated of in this article, and even a few of 
these must be looked on with some suspicion. 
T[ Verneuil: Gaz. des Hopitaux, Aug. 9th, 1870; Berkeley Hill: Lancet, June 20th, 
1874; H. Morris: Med. Times and Gaz., June 4th, 1881. 
** Katton: Lancet, Nov. 3d, 1878. 
ff Sands: Brown-S6quard’s Archives of Scien. and Pract. Med , June, 1873. 510 
DISEASES OF THE THROAT AND NOSE. 
curastances has also to be taken into account. It is hardly fair, there- 
fore, to compare the statistics of cases in which “ preliminary operations ” 
have been performed with those in which a cure has been effected by 
means of electric cautery or any other simple method of treatment. 
The various “preliminary” procedures must now be described in 
detail. 
Nasal Operations.—Dupuytren* suggested opening the nasal fossa 
by an incision carried round the base of the nose, detaching the carti- 
lages from the bone, thus enabling the operator to tilt up the tip of the 
organ and explore the anterior orifice of the nares. Syme enlarged the 
aperture of the nostril by dividing the upper lip in a vertical direction 
from a point midway between the septum and the ala of the affected 
side. The two flaps were then dissected well back on each side. A 
procedure, however, which, besides exposing the nasal cavity more 
freely, has the advantage of not causing an unsightly cicatrix, has been 
proposed by Rouge.f The following is his own description of this 
operation: “ The patient is anesthetized, and placed with his head 
bent towards the right side to allow the blood to escape, whilst the 
operator stands at the right side of the bed. Seizing the upper lip, 
near the commissure, with the thumb and index-finger of the left hand, 
I lift it up a little, whilst an assistant does the same on the other side. 
The lip being so held and stretched out, I incise the mucous membrane 
in the gingivo-labial groove from the first molar tooth on the left side 
to the corresponding point on the right, the centre of this incision being 
at the frenum of the lip, which is divided at the root. I rapidly cut 
through the tissues in their whole thickness, and reach the anterior 
nasal spine, over the prominence of which the knife should be carried, 
detaching the cartilaginous part of the septum at its base. This often 
suffices, for by raising the nose there is room to introduce the finger into 
the nasal fossa, and a good view can be obtained of its cavity when the 
blood has been sponged out. If, however, this does not suffice, the alar 
cartilages should be separated from their attachment to the upper jaw 
with scissors, and the nose being thus completely detached, should be 
thrown upwards upon the forehead, when the whole extent of the 
anterior opening of the nares will be exposed. If the uncut portion of 
the septum prevents the turning back of the nose, it should be divided 
with scissors. When the operation is finished, the wound should be 
carefully cleansed, the blood and clots being washed away with water; 
* Journal de la Clinique, 1830, t. ii. 
f Nouvelle M4thode Chirurgicale pour le Traitement de l’Ozene, I.ausanne, 1873. FIBROUS POLYPI OF THE NASO-PHARYNX. 
511 
the lip is then replaced, and union takes place without any sutures 
being required.”* 
It is sometimes, however, necessary to open the nasal cavity from the 
face. This may be partially done by slitting the nostril in the middle 
line from below up to the lower edge of the nasal bone. If this does 
not afford sufficient space, die skin incision should be prolonged to the 
root of the nose, and the nasal bones separated from each other in the 
middle line with scissors or bone-forceps; the whole side of the nose, 
consisting of the nasal bone, the os unguis, the nasal process of the 
upper jaw, with the lateral and alar cartilages, can now be pressed out- 
wards upon the cheek, and held there by an assistant, whilst the surgeon 
examines the attachments of the growth and attempts to remove it 
through the gap thus formed. As Roserf says, “ operations of this 
kind are rendered more easy by the fact that the patients are young, 
and their bony sutures soft, yielding, and easily dislocated.” 
Langenbeck’s operation, which is practiced by many surgeons, is 
done in the following manner: The patient lying on his back, an in- 
cision is carried from the junction of the nasal and frontal bones down- 
wards along the middle line of the nose to the upper margin of the alar 
cartilage, from which point a second incision is made outwards along 
the upper edge of the cartilage of the affected side. The triangular flap 
thus formed is dissected back, care being taken to avoid injuring the 
periosteum. The cartilage is next severed from the bone and the os 
nasi separated from its fellow with bone-forceps. Part of the nasal pro- 
cess of the superior maxillary should then be separated from the body 
of the bone, the line of section being kept to the inner side of the orbital 
ridge, in order to avoid injuring the lachrymal canal. The quadrilateral 
osseous plate thus marked out is now connected with the frontal bone 
only by the natural suture and by the periosteum and mucous mem- 
brane, and it should be forced upwards with an elevator so as to lay 
open the upper part of the nasal cavity. When the operation has been 
completed it is recommended that the wound should be kept open for 
some months, in order that any recurrence of disease may be at once 
observed. MacCormac| has performed a similar operation on both 
* This operation has been done several times in England, but chiefly for the pur- 
pose of removing diseased bone from the nasal cavity. See in particular one very 
successful case by Harrison Cripps in Lancet, May 5th, 1877, p. 643 et seq. 
f Quoted by Spillmann : Diet. Encyclop des Sciences M&licales, 2e s6rie, t. xiii., 
p. 131. 
J St. Thomas’s Hospital Reports, 1875, p. 65 et seq. 512 
DISEASES OF THE THROAT AND NOSE. 
sides, but he carried the vertical incision down the cheek instead of 
along the middle line of the nose. 
Chassaignac’s operation consists in loosening the attachments of the 
nose on one side, so as to allow of its being turned over on the opposite 
cheek. The following are the steps of the procedure: A transverse 
incision is made across the root of the nasal prominence from the inner 
angle of the orbit on the right side to the corresponding point on the 
left; a seconcl cut is next made from the left extremity of the first in- 
cision to the outer margin of the left ala at its lower part; lastly, the 
knife is carried across the upper lip close under the nose to the external 
edge of the right ala. The nasal walls are now drilled through in the 
direction of the first incision, and, a chain-saw having been introduced 
through the aperture thus made, the upper part of the nasal processes 
of the superior maxillaries and the ossa nasi are divided from behind 
forwards. The saw is then carried downwards in the direction of the 
second incision, cutting through the osseous wall on the left side, whilst 
the septum and the bones on the right are snipped through with scis- 
sors or cutting forceps. Care must be taken not to injure the skin or 
soft tissues on the right side, as it is on the integrity of these that the 
vitality of the feature depends when it is replaced. The nose, having 
been detached in this manner on three sides, can be turned over towards 
the right “ like the lid of a snuff-box,” leaving free access to the naso- 
pharyngeal cavity. When the tumor has been extirpated the parts are 
to be carefully replaced, and the edges of the wound accurately brought 
together with sutures. 
© 
Ollier’s operation, which he calls “ vertical and bilateral osteotomy 
of the bones of the nose,” is performed as follows: An incision, some- 
what resembling a horse-shoe in outline, is made through the skin from 
the outer edge of the ala upwards along one side of the nose to its root 
and down to the edge of the other ala. The knife should be carried 
at once through all the soft tissues. The bones of the nose are next to 
be divided in the direction of the first incision with a fine Butcher’s saAv, 
held parallel to the plane of the patient’s forehead, whilst the cartilages 
of the septum and aim should be snipped through with scissors. If 
necessary, the two small internal nasal arteries must be tied. The nose 
can now be pulled down, leaving free access to the naso-pharyngeal 
cavity. When the growth has been removed, the nose is replaced, and 
the edges of the wound brought together with fine wire sutures. Ollier* 
points out that this procedure does not endanger the vitality of the 
* Bull, de la Soc. de Chir., 1866, p. 264. FIBROUS POLYPI OF THE NASO-PHARYNX. 
513 
nose, as its chief arterial supply is left intact. Union takes place very 
quickly, one patient having been able to blow his nose on the fourth 
day after the operation.* Ample room is afforded for the treatment of 
the tumor, Ollier himself having removed one weighing more than six 
ounces and a half,f which he says is perhaps the largest naso-pharyngeal 
fibroma that has ever been removed. He| is careful to point out, how- 
ever, that all noses are not equally suitable for this operation, the long 
narrow ones being especially unfavorable, and generally rendering it 
necessary to sacrifice the turbinated bones. When the tumor is at all 
large, however, the pressure of the mass usually dilates the nasal pas- 
sages much beyond their normal width, which makes the operation easier 
and more effectual. 
A somewhat analogous method was carried out more than twenty 
years ago by Lawrence,§ who, however, loosened the nose from below, 
leaving it attached only at the root, so that it could be thrown upwards 
on the brow. He made a cut from the inner edge of each lachrymal 
sac downwards along the naso-labial furrow to the point of junction of 
the septum with the upper lip, where the two incisions met. The bones 
of the nose and the septum were then divided from below with forceps, 
and the whole feature thrown upwards. The nose was afterwards re- 
placed, and fixed with sutures. Union took place in a few days. The 
only disadvantage of this plan, as compared with Ollier’s, is that the 
pedicle of the displaced mass is less vascular, and gangrene is, therefore, 
more likely to take place. 
A procedure which may fitly be classed under the head of nasal 
operations was proposed and carried into execution almost at the same 
time by two Italian surgeons, Palasciano|| and This may 
be briefly described as follows: A small incision is made to the inner 
side of the lachrymal sac, which should be partly dissected out and 
held aside by an assistant; the inner wall of the tear-duct, formed by 
the os unguis, is then pierced with a curved trocar and canula, which 
is to be pushed into the nasal fossa by the superior meatus. The trocar 
is next withdrawn, and the canula is twisted so that its concavity looks 
upwards and passed into the pharynx. Through it a ligature is then 
* Ibid. f Ibid, 
f Traite expdr. et clin. de la K4gen6ration des Os, Paris, 1867, t. ii., p. 484. 
§ Med. Times and Gaz., 1862, vol. ii., p. 491. Lawrence’s operation was undertaken 
for the removal of mucous polypi. 
|| Moniteur des Sciences, August 25th, 1860, p. 393. 
f Bull, de la Soc. de Chir., March and May, 1860. 514 
DISEASES OF THE THROAT AND NOSE. 
passed, which is made to encircle the tumor. The results of the opera- 
tion have not been brilliant, one of the four cases in which it has been 
practiced having ended fatally, whilst in another abscess of the eyeball 
ensued, and in the remaining two the growth speedily recurred. The 
plan has been tersely described by Robin-Mass6* as simple ligation 
applied in the most inconvenient way possible. 
Maxillary Operations.—These consist of excision, and temporary 
resection of the superior maxillary bone. The history of these pro- 
cedures has been already given (p. 494 et seq.). 
The superior maxillary bone may be removed in its entirety, or par- 
tially, or it may be temporarily displaced. Excision of the upper jaw 
is done in the following way: A cut is made from the inner canthus 
along the side of the nose and carried through the whole thickness of 
the.upper lip at its middle part; it is sometimes necessary to make a 
second incision from the upper extremity of the one just described, 
horizontally outwards, about half an inch below the lower margin of 
the orbit to the malar prominence. Although this second cut is recpiired 
for removing the superior maxilla when a large tumor springs from any 
part of that bone itself and causes considerable projection of the cheek, it 
can generally be dispensed with when the excision is performed for a naso- 
pharyngeal growth, and thus a very unsightly cicatrix can be avoided. 
The remainder of the operation cannot be better described than in the 
words of Heath :f “ The skin having been reflected in the manner 
described above, the incisor teeth of the side to be removed are ex- 
tracted, and a narrow saw with movable back is passed into the nostril. 
With this the alveolus and hard palate are divided, and the small saw 
is then applied to the malar process of the maxillary bone (or, if need 
be, to the malar bone itself), and to the nasal process of the superior 
maxilla, so as to notch both these points of bone, the division being 
completed with the bone-forceps. With the ‘ lion-forceps/ devised by 
Sir William Fergusson for the purpose, the jaw can be now grasped 
and broken away from the pterygoid process and the palate bone, any 
detaining point being severed with the bone-forceps. Lastly, when the 
bone is quite loose, the infra-orbital nerve is to be divided, and the soft 
palate dissected off the bone so as to leave as much as possible of it 
uninjured.” Haemorrhage should be controlled by means of ligatures 
or the actual cautery, and at the conclusion of the operation the edges 
of the wound should be brought accurately together with hare-lip pins 
and the interrupted suture. 
* Op. cit., p. 60. 
f Diseases and'injuries of the Jaws, London. 1872, 2d ed., pp. 275, 276. FIBROUS POLYPI OF THE NASO-PHARYNX. 
515 
A method of partial and temporary resection, as already mentioned, 
was proposed and carried out by Hugnier in the following manner: A 
transverse slit having been made in the soft palate, a thread is carried 
through one nostril by means of Bellocq’s sound, and brought out 
through the wound in the palate; to the end of this thread is fastened 
a string, which is to serve for making traction on the loosened piece of 
bone in the way to be presently described. An incision is next carried 
through the whole thickness of the cheek, from the corner of the mouth 
to the anterior border of the masseter; a second cut is then made from 
near the inner corner of the eye, along the genio-nasal furrow, detaching 
the ala of the nose, and ending in the middle of the upper lip. This 
triangular flap is dissected back and thrown outwards. The saw is 
afterwards to be carried horizontally through the upper jaw from im- 
mediately above the maxillary tuberosity to just above the floor of. the 
corresponding nasal fossa. The first incisor of the opposite side should 
be displaced with the elevator, and the floor of the nose sawn from 
before backwards, but not completely through. The base of the ptery- 
goid process should next be cut through with bone-forceps, thus leaving 
the lower portion of the superior maxilla separated from the bones of 
the face, and only connected to them by the mucous membrane covering 
the palatine vault, which was spared in the division of the floor of the 
nose. With the forceps used as a lever, traction being at the same time 
made on the separated portion of bone by means of the string previously 
passed through the nose and the soft palate, the lower part of the upper 
jaw can be dislocated into the mouth. The nose and naso-pharynx are 
now fully exposed, and after the growth has been removed, and the 
bleeding stopped, the loosened maxillary bone should be replaced, gags 
should be put between the molar teeth on each side, the wound closed 
with hare-lip pins, and a bandage passed round the chin and fastened 
over the top of the head. Considerable trouble is sometimes caused by 
the displaced fragment not uniting and showing a tendency to fall into 
the mouth. Huguier, however, secured perfect union by means of a 
gutta-percha splint, carefully moulded to the alveolar border, and worn 
for a month or two; he states that the disfigurement left by the opera- 
tion was slight.* 
A procedure has been invented by Cheeverf for the partial resection 
* Kobin-Masse, however, states (op. cit., p. 86), that, from an examination of the 
patient, made a considerable time afterwards, it appeared that the bone had never 
firmly united, and that all the teeth growing from it were carious, so that the replaced 
maxillary simply served as an indifferent obturator, 
f Boston Med. and Surg. Journ., 1874, vol. xc., p. 547. 516 
DISEASES OF THE THROAT AND NOSE. 
of both upper jaws, of which the following are the steps: An incision 
is made front the inner canthus through the soft parts on either side, 
and carried downwards along the genio-nasal furrow to the middle of 
the lip. These flaps are next to be dissected back as far as the malar 
prominences. The body of the superior maxillary must then be cut 
through with a narrow saw, the line of division passing from the tuber- 
osity forwards under the zygoma into the middle meatus on each side. 
Lastly, the septum and thealae should be snipped through with scissors. 
The upper jaw, which is noA attached only at the back part, is to be 
forced downwards, and the growth removed. The bone is then put 
back into its place, and firmly fixed in position by wire sutures passed 
through the malar bones on each side. Cheever claims for this plan 
that the vascular supply of the bone is not interfered with, since the 
palatine arch and the alveolar border are left uninjured. 
A case which is probably altogether unique has been recorded by 
Ollier,* in which he performed temporary resection of an upper jaw of 
new formation. He had removed the superior maxillary more than 
three years previously in order to gain access to a naso-pharyngeal 
polypus. When the patient again presented himself, a solid bony bridge 
was found joining the malar bone to the anterior nasal spine. This was 
divided at each of the points named, and raised, being afterwards re- 
placed when the growth had been extirpated. Union was complete in 
thirty days. 
Palatine Operations.—Division of the soft palate was, as already 
stated, performed by Manne as a “ preliminary operation” for the re- 
moval of a naso-pharyngeal polypus. He gives a very meagre descrip- 
tion of his procedure, but appears to have divided the velum in its 
whole length near the middle line, cutting from below upwards with a 
curved bistoury. This method was subsequently practiced by Petit,f 
Morand, Nannoni, Ansiaux, Dieflenbach and others. Levret proposed 
the division of the pillars of the fauces on each side with the view of 
making the curtain of the soft palate more movable. JobertJ appears to 
have modified this plan by incising the vehyn, beginning at the base of 
the pillars on each side and cutting upwards as far as seemed necessary. 
Maisonneuve§ improved Manne’s operation by leaving the lower edge 
of the velum undivided. He made a longitudinal incision through the 
* Traits expfer. et clin. de la Kdg6n6ration des Os, Paris, 1867, t. ii., pp. 492, 493. 
f Quoted by Garengeot: Traitfe des Operations de Chirurgie, Paris, 1731, t. iii., p. 51. 
J Gazette des Hopitaux, July 22d, 1858. 
| Gazette Ilebdomadaire, September 2d, 1859. FIBROUS POLYPI OF THE NASO-PHARYNX. 
517 
soft palate, commencing close to the posterior edge of the palate bone, 
and carrying the knife to within one centimetre of the edge of the velum. 
This aperture he calls the “ palatine button-hole.” The finger is passed 
through it to explore the shape and attachments of the growth, which 
is then drawn through the “ button-hole,” the sides of which are very 
elastic. Round the sort of pedicle formed in the mass by this procedure 
a wire noose is placed, and pushed as far back through the velum as 
possible; it is then tightened, and kept in position till the tumor is cut 
through. Huguier* used a transverse “ button-hole” in connection with 
his method of temporary resection of the upper jaw, and Beginf em- 
ployed this method in combination with division of the nose in front. 
AdelmannJ also practiced it as part of an extensive operation for the 
removal of a growth which had depressed the hard palate and caused 
perforation of the bone in the middle. Nelaton§ subsequently proposed 
trephining of the hard palate combined with division of the velum as a 
means of reaching the tumor to be extirpated, and of watching for any 
sign of recurrence after removal of the mass. His plan of procedure is 
as follows: The soft palate is divided, from its bony attachment to its 
free border, the cut being carried through the middle of the uvula. This 
incision should then be prolonged through the tissues covering the hard 
palate for the posterior half of its extent. From the anterior end of 
this cut two others should be carried outwards and slightly backwards 
on each side. These incisions should be made with a strong sharp 
knife, so as to cut through the periosteum and reach the bone. The 
posterior layer of the velum being next divided with the bistoury, the 
soft parts should be raised from the bone, and the two flaps thus formed 
should be held aside by assistants. The hard palate should be bored 
through with a perforator at the front part of the space thus exposed, 
the holes being made at about one centimetre from the middle line. 
Into these holes the blades of a pair of fine bone-forceps are then in- 
serted, and the intervening portion of the palate is broken through, the 
separation of the osseous plate being completed, if necessary, by dividing 
the bone on each side.|| The fragments of bone, which generally include 
* Bull, de l’Acad. de Med., May 28th, 1861. 
f Nouveaux Elements de Chir. et de M4d. Oper., Paris, 1838, t. ii., p. 586 et seq. 
J Untersuchungen fiber krankhafte Zustande der Oberkieferhohle, Dorpat und 
Leipzig, 1844. 
§ Botrel: D’une Operation nouvelle contre les Polypes naso-pharyngiens, 
Thfese de Paris, 1850. 
|| This operation is not so difficult in actual execution as may appear from the de- 
scription. When the bones are pressed on by a polypus, they are usually so atrophied 518 
DISEASES OF THE THROAT AND NOSE. 
part of the vomer, should be carefully detached from the mucous mem- 
brane, so as to allow of subsequent repair. Through the opening thus 
made the polypus is removed in whatever way the surgeon may prefer, 
the wound being subsequently kept open as long as may be desired in 
order to allow of thorough destruction of the roots of the growth, and 
the immediate treatment of any recurrence. Botrel* suggested Maison- 
neuve’s u button-hole ” method in combination with Xelaton’s trephin- 
ing of the hard palate as affording more hope of ultimate perfect heal- 
ing of the wound. 
The great danger of haemorrhage both during the “ preliminary oper- 
ations ” and the actual ablation of naso-pharyngeal fibromata has been 
already mentioned, and it now only remains to make a few remarks on 
the best wray of meeting these complications. It is most important to 
proceed with deliberation, securing tlje vessels, if possible, as they are 
divided; and it has been pointed out by Spillmannf that it is very de- 
sirable not to attack the polypus till the patient has recovered from the 
anaesthetic, so that he may be able to expectorate any blood which may 
How into his trachea. In some cases it may be well to perform trache- 
otomy and use Trendelenburg’s instrument (Vol. i., p. 495) before the 
“ preliminary operation ” is commenced, but one case| proved fatal in 
spite—possibly in consequence—of previous laryngotomy. Tying the 
carotid is seldom of any use unless it has been found beforehand that 
pressure on the vessel will stop the blood; and in very severe cases 
the actual cautery is more to be relied on. Ollier plugs the naso- 
pharyngeal space with sponges after the operation, and this plan is 
generally adopted by English surgeons. 
Notwithstanding all precautions, however, fatal syncope sometimes 
occurs after removal of these growths, probably owing to the sudden 
withdrawal of a large mass of blood from the immediate neighborhood 
of the brain.§ 
as to make it an easy matter to break or perforate them. Ollier (Trait6exp£r. et clin. 
d‘e la R5g6n6ration des Os, Paris, 18f>7, t. ii., p. 487) mentions a case in which the hard 
palate was so thin that it could be pierced with an ordinary pin. 
* Loc. cit. 
f Diet. Encyclop. des Sciences Medicates, t. xiii., p. 150. 
X Ratton: Lancet, November 3d, 1878. 
\ Pozzi’s experiments on dogs (Gaz. Hebd., September 4th, 1874, p. 576) clearly show 
that death is more rapidly caused by the escape of a comparatively small amount of 
blood from the carotid artery than by the withdrawal of a much larger quantity from 
the femoral. 519 
FJBRO-MUCOUS POLYPI OF THE NASO-PHARYNX. 
FIBRO-MUCOUS POLYPI OF THE NASO-PHARYNX. 
These tumors vary in size from a pigeon’s to a hen’s egg, and are 
generally smooth, dark red, and more or less ovoid in form. Though 
certainly rare, they are more common than true fibromata in this situa- 
tion. I have notes of only seven cases, though I have seen two or 
three others. The symptoms to which they give rise are principally 
those proceeding from nasal obstruction, but occasionally they cause 
deafness. They do not lead to haemorrhage, nor do they tend to destroy 
the bones with which they come in contact; and these points will serve 
to establish a diagnosis between such growths and true fibromata. 
The pathology of these tumors has been rendered interesting by the 
researches of Panas,* who has shown that the mucous membrane round 
the posterior nares, and in the immediate neighborhood of these orifices, 
presents a kind of transitional form between the mucous membrane of 
the nasal fossae, and the dense closely adherent fibro-mucous lining of 
the pharyngeal vault. Growths in these situations are composed, to a 
great extent, of the structural elements of the tissue from which they 
originate, and whilst a polypus springing from the pituitary membrane 
may be expected to be of mucous texture, one from the under surface 
of the basilar process is likely to be fibrous, and a tumor taking origin 
from the membrane round the posterior nares, where the fibrous and 
mucous elements are mingled, will probably present a corresponding 
fibro-mucous structure. This observation, however, must not be inter- 
preted as being the statement of an absolute law, for, as has been already 
seen, polypi of purely fibrous structure may be found within the nasal 
fossae, and, on the other hand, growths of genuinely fibro-mucous char- 
acter have been seen arising from near the roof of the pharynx. In 
those cases in which the tumor has branches extending both into the 
pharynx and into the nasal fossae, the pharyngeal part is, as a rule, 
altogether fibrous, whilst the nasal otfshoot is mucous in character. 
Panasf himself, who had been led by his anatomical investigations to 
conjecture that such mingled forms of polypi would be found in the naso- 
pharynx, met with an example in 1865. The patient was a man, aged 
sixty-eight, who had suffered from obstruction in the left nostril for 
three years. On examination by anterior rhinoscopy only a small red- 
* Bull, de la Soc. de Chir., 1873. The original statement, according to the author, 
was made in 1858, but he gives no reference, 
f Ibid., p. 378 et seq. 520 
DISEASES OF THE THROAT AND NOSE. 
dish protuberance could be seen far back into the cavity, but on look- 
ing into the mouth, the soft palate was seen to be pushed down by a 
tumor of whitish appearance. This was found to be extremely hard to 
the touch, and to be distinctly pedunculated. Panas divided the velum, 
and removed the polypus with scissors, having previously twisted the 
pedicle to prevent haemorrhage. The growth was round, smooth, and 
of fibrous appearance, both externally and on section, except the part 
that had blocked up the nostril, which was mucous in structure. In 
another instance recorded by Panas* the patient was a woman, aged 
twenty-six, who had suffered from obstruction of both nostrils for two 
years. Nothing could be seen by anterior rhinoscopy, but with the 
finger passed up behind the soft palate, a somewhat hard, pedunculated, 
and movable tumor was found hanging from the posterior nares into 
the pharynx. This mass was removed in the same manner as in the 
previous case, and it was found to consist of two polypi, each attached by 
a pedicle to the posterior edge of the vomer. Each tumor closed one 
posterior orifice like a lid, and part of the larger one of the two rested 
on the soft palate. They were reddish in color, in density intermediate 
between a fibrous tumor and a myxoma, and on section a certain quan- 
tity of serosity escaped. In addition to these, Mathieuf has collected 
four cases belonging to Legouest, Bonnes, Dumenil, and Tr6lat, in which 
growths originating from the base of the skull were apparently of a 
fibro-mucous character, but in only one of these instances was the struc- 
ture accurately determined by microscopic examination. In two other 
cases! (viz., those of Trelat and Labbe), where the growths originated 
from the upper part of the posterior nares, careful examinations by 
Cornil and Coyne proved that the polypi were of truly fibro-mucous 
character. 
The prognosis is very favorable, as fibro-mucous polypi show but 
little tendency to recurrence after removal. The treatment should be 
to extirpate the polypus by the most suitable operation that offers itself. 
I have generally effected a cure by evulsion with forceps introduced 
through the mouth, as that is the readiest and most efficient method; 
but in some cases a wire can be passed through the nose round the 
pedicle, and in others the tumor can be attacked in the naso-pharynx 
by electric cautery. For this purpose Lincoln’s post-nasal electrode 
(Fig. 61, p. 275) will be found very useful. Of the seven cases that I 
* Ibid. 
f Sur. les Polypes muqueux des Arri'&re-narines, Th£se de Paris, 1875. 
X Ibid. ENCIIONDROMA OF THE NASO-PHARYNX. 
521 
have met with, I succeeded in curing five; in one instance the disease 
recurred, but I heard that the patient was afterwards cured by another 
practitioner. The seventh case was lost sight of, and its ultimate result 
is unknown to me. Severe “preliminary operations,” such as are 
usually necessary for the removal of fibrous polypus of the naso-pha- 
rynx, are never required in the case of the growths now under consid- 
eration. 
ENCHOXDKOMA OF THE XASO-PHARYNX. 
A case of true cartilaginous growth springing from the basilar pro- 
cess of the occipital bone has been reported by Max Muller.* From 
the history of the case it appears that the patient, a man aged twenty- 
four, had noticed some obstruction in his nose five or six years before 
lie came under observation. As the malady progressed he began to 
suffer from excruciating pain, together with frequent drowsiness, and 
occasional loss of consciousness. The growth increased in size, pressing 
the soft palate downwards, completely filling both nostrils and displacing 
the nasal septum. The pressure of the mass produced absorption of the 
lamina papyracea of the ethmoid, and the tumor extended into the 
orbit. Muller removed the growth with a wire loop, having first per- 
formed temporary resection of the nose according to Langenbeck’s 
method. The tumor, which was found to be attached to the basilar 
process, was of the size of a man’s fist, and weighed about four ounces. 
It was proved by microscopic examination to be of truly enchondroma- 
tous nature. 
This is the only instance, so far as I am aware, in which a cartilagi- 
nous growth is stated to have originated within the naso-pharyngeal 
cavity. Two cases, however, are on record in which a tumor primarily 
fibromatous in constitution is said to have become wholly or in part 
transformed into cartilage. In one of these the patient was a boy, aged 
twelve, who died whilst under the care of Samuel Cooper.f The face 
was shockingly disfigured, the nose being bulged out on the left side 
to an extreme degree, and the eyes being four inches apart. The pha- 
rynx was so filled with the tumor that feeding even with the help of a 
* Langenbeck’s Archiv. f. klin. Chirurg., 1870, Bd. xii., p 323. 
f Diet, of Pract. Surgery, edited by Lane, Lond,, 1872, art. “ Polypus,” vol. ii., p. 463. 522 
DISEASES OF THE THROAT AND NOSE. 
spoon was most difficult, and it was impossible to examine the hard 
palate. The left eye had been completely blind for some time; and a 
week or two before the jiatient’s death paralysis of the legs and bladder 
came on. At the autopsy “ a good deal of the tumor was found to be 
of a cartilaginous consistence.” A piece almost as large as an orange 
had penetrated the skull and destroyed the anterior lobe of the left 
hemisphere of the brain. All the neighboring bony structures had 
been more or less absorbed, so that it was impossible to discover the 
point of origin of the tumor. A most remarkable feature in this case 
is, that in spite of such extensive cerebral lesions the patient had felt 
no pain, and had not lost consciousness till the last moments of life. 
The second case is that of a boy, seventeen years of age, who had suf- 
fered for some time from the usual symptoms of naso-pharyngeal 
polypus. He was operated on by Le Dentu* according to Nelaton’s 
palatine method; and the growth, which was found to spring from the 
basilar process, and presented all the naked-eye appearances of a fibroma, 
seemed to be completely destroyed. Recurrence, however, took place 
within a twelvemonth, and Le-tDentu performed a second operation, 
this time gaining access to the tumor by laying the nose open from the 
front. In this manner he removed a cartilaginous growth as large as 
a date, which was attached to the posterior edge of the vomer, and sent 
branches into each nasal fossa. Behind this, and connected with it, was 
another cartilaginous mass, which seemed to be attached to the base of 
the skull. It was not judged safe, however, to meddle with this por- 
tion of the growth. The patient appears to have made a good recov- 
ery, but the ultimate issue of the case is not stated. With reference to 
the nature of the tumor in this instance it is to be noted that no micro- 
scopic examination was made of the mass removed at the first opera- 
tion. It is, therefore, at least possible that it may have been of enchon- 
dromatous nature from the outset. Petitf suggests that the transformation 
may have been due to irritation of the neighboring osseous tissue. The 
fact, however, that no such sequence of events has been observed in 
similar cases, makes this hypothesis somewhat difficult of acceptance. 
* Petit: De quelques Considerations sur les Polypes naso-pliaryngiens, These de 
Paris, 1881, p. 32 et seq. 
f Op. cit., p. 34. MALIGNANT TUMORS OF THE NASO-PHARYNX. 
523 
MALIGNANT TUMORS OF THE NASO-PHARYNX. 
Cases of malignant disease, in this situation, were mentioned without 
any details by Otto Weber;* and instances have since been related by 
Verneuil,f Rabitsch,]; Gross,§ Demarquay,|| and whilst a short 
monograph on the subject has been published by Veillon.** The causes 
of such growths are utterly unknown, and the disease itself does not 
appear to be very common. The rarity of the complaint, however, is 
probably not so great as might be inferred from the extremely small 
number of recorded cases; the affection, no doubt, having in some cases 
been mistaken for simple fibrous polypus. In certain rare instances a 
growth of the latter kind may gradually become transformed into 
genuine sarcoma.ff 
The symptoms are those characteristic of all tumors which obstruct 
the nasal channels, viz., an annoying sense of impeded respiration which 
may gradually increase to actual dyspnoea, occasional epistaxis, more 
or less constant coryza, post-nasal catarrh (the secretion being often 
extremely fetid), alteration of voice, and imperfect articulation. Great 
pain is a frequent, but by no means invariable, accompaniment of ma- 
lignant tumors in the naso-pharynx ; it is often described by the patient 
as “ shooting through the ear/’ and is, as a rule, most troublesome at 
night. As the tumor increases dysphagia may be produced, and finally 
general cachexia may supervene. Anterior rhinoscopy will probably 
show that there is an obstructing mass in one or both of the nasal 
channels, and a careful use of the probe will enable the surgeon to 
ascertain whether this substance is attached to the septum or any other 
part of the fossa. On looking into the mouth the velum will prob- 
ably be seen to be tense, and perhaps bulged forwards at one part; if 
the tumor is of considerable size part of it may be visible on drawing 
* Pitha u. Billroth : Chirurgie, Bd. iii., 1 Abtheil, 2 Heft, Erlangen, 1866. 
f Bull, de la Soc. de Biologie, Paris, 1869. 
J Allgem. Wien. med. Zeitung, 1869, No. 42. 
$ Gazette Med. de Strasbourg, 1872, No. 2. 
|| Bull, de la Soc. de Cliir., June 18th, 1873. 
T[ Arch. f. klin. Chirurg., Bd. xvii., 4 Heft, p. 562. 
** Contribution a l’Etude des Tumeurs malignes naso-pharyngiennes, These de Paris, 
1875. 
ff Otto Weber: op. cit., p. 207. See particularly Fig. 37 (ibid.), which is a repre- 
sentation of a naso-pharyngeal fibrous polypus that had undergone sarcomatous de- 
generation. 524 
DISEASES OF THE THROAT AND NOSE. 
aside or raising the soft palate. Sarcomatous tumors of the naso-pha- 
rynx are not unfrequently pedunculated and somewhat pyriform in 
shape, whilst occasionally they are more or less distinctly lobulated. 
They are covered by the mucous membrane of the pharynx, and present 
no special features bv which the eye or the touch can detect their true 
nature. These tumors have the usual characteristics of malignancy, 
viz., rapidity of growth, recurrence after removal, and in many cases 
a disposition to form secondary deposits in other organs. The diagnosis 
can seldom be made with certainty, except by microscopic examination. 
A very practiced and delicate sense of touch might possibly enable the 
surgeon to distinguish the moderate density of a sarcoma from the ex- 
treme hardness of a true fibroma. Tactile investigation, however, is a 
most untrustworthy guide in such cases, as it has to be exercised under 
difficult conditions, and, moreover, the structure of tumors in the naso- 
pharyngeal region is seldom uniform throughout their whole mass, 
both fibrous and sarcomatous growths having frequently a certain ad- 
mixture of mucous tissue. The prognosis in cases of malignant growths 
of the naso-pharynx is altogether hopeless. As regards the pathology 
of such tumors, they appear to be mostly of sarcomatous nature. They 
often, however, present a considerable amount of mucous or fibrous 
tissues, in addition to the characteristic round or spindle-shaped cells; 
and it is possible that in such cases the malignant growth may have 
supervened on what was originally a mere hyperplasia. Sometimes, as 
in cases recently reported by Thornley Stoker* and McDonnell,f car- 
tilage-cells are contained in the tumor. If the disease be met with in 
an early stage, the treatment should consist in the entire removal of the 
mass with the snare or electric cautery. In most cases a “ preliminary 
operation” (p. 508) will be necessary to expose the tumor. The surgeon 
should carefully watch for any signs of recurrence, in order that he 
may at once attack the disease again, if necessary; but the best that 
can be done is often merely to prolong a miserable existence. 
* Brit. Med. Journ., Jan. 19th, 1884, p. 113. 
f Ibid. THROAT-DEAFNESS. 
525 
THROAT-DEAFNESS. 
Definition.—Deafness caused by morbid conditions in the naso- 
pharynx near the orifice of the Eustachian tube, or by changes in the 
walls of the tube itself, which interfere with the free passage of air to the 
tympanic cavity. 
History.—Many of the older writers have mentioned that deafness may be caused by 
mechanical obstruction of the pharyngeal orifice of the Eustachian tube, or inflamma- 
tion of its interior, resulting from syphilitic disease. Thus Valsalva* speaks of deaf- 
ness arising from obliteration of the tube by ulceration of specific origin. Van Swietenf 
describes the extension of venereal ulceration from the pharynx along the Eustachian 
tube to the internal ear, and Plenck J mentions stricture of the tube dependent on the 
same cause. Similar observations were made by Nisbet,$ B. Bell,|| Swiedaur,f Saun- 
ders,** and Cullerier.ff The actual term “ throat-deafness ” was first employed in 
comparatively recent times, and was applied to a form of deafness which was supposed 
to be due to enlargement of the tonsils. This view was strongly insisted on by Years- 
ley J! in 1853, but was successfully combated by Harvey,who showed on anatomical 
grounds that it is impossible for the Eustachian orifice to be blocked up in this way, 
and suggested that the affection might be due to an extension of the inflammation of 
the mucous membrane covering the tonsils to the contiguous lining of the Eustachian 
tube. This theory soon gained general acceptance, and nearly all cases of throat- 
deafness were looked upon as examples of catarrh of the middle ear, originating in the 
naso-pharyngeal region. From the more accurate knowledge gained in late years; 
however, throat-deafness has come to be attributed to various other diseased conditions 
of the Eustachian tube. In 1862 Hinton|||| distinguished two forms of throat-deafness, 
one dependent on inflammatory thickening of the palato-pharyngeal region, the 
other on relaxation of those parts. The recognition of the importance of adenoid 
growths in the naso-pharynx as a frequent cause of deafness by in 1869, marks 
an epoch in the history of throat-deafness. In 1873 a most important work was pub- 
lished by Weber-Liel,*** who brought forward a considerable amount of evidence to 
show that what had hitherto been looked upon as a catarrhal affection of the Eusta- 
* De aure Humana, Bologna, 1704, p. 90. 
f Comment, in H. Boerhaave Aphorismos, Lugd. Batav., 1772, t. v., pp. 369, 371,373. 
X De morbi venerei doctrina, Viennre, 179, p. 89. 
I First Lines of the Theory and Practice of Venereal Disease, Edinburgh, 1787, p.330. 
|| Treatises on Gonorrhoea, Edinburgh, 1793, vol. ii., p. 65 et seq. 
f Traite de la Maladie venerienne, Paris, 1801, t. ii., p. 144. 
** Anatomy of the Human Ear, etc., London, 1806, p. 79. 
ff Journ. de Medecine, 1814, t. xlix., p. 202. 
Throat-Deafness, London, 1853, 1st ed., p. 2 et seq. 
§§ The Ear and its Diseases, London, 1856, p. 157. 
HI Holmes’s System of Surgery, London, 1862, 1st ed., vol. iii., pp. 159-162. 
ff Med.-Chir. Trans., 1870, vol. liii., p. 192 et seq. 
*** Ueber das Wesen u. die Heilbarkeit der haufigsten Form progressiver Schwer- 
horigkeit, Berlin, 1873. 526 
DISEASES OF THE THROAT AND NOSE. 
chian tube and middle ear was in fact a neurosis, the chief feature of the complaint 
being paralysis of the tensor palati—the muscle mainly concerned in maintaining the 
patency of the Eustachian canal. According to Weber-Liel the paralysis of this im- 
portant muscle leaves the tensor tympani unbalanced, a condition producing many 
evils, which will presently be referred to. In 1879 Woakes* described, at the annual 
meeting of the British Medical Association, a form of throat-deafness in which both 
the tubal muscles and the tensor tympani are paralyzed. 
Etiology.—The disease may depend on a paretic condition of the 
Eustachian tube, on chronic inflammatory thickening of its lining mem- 
brane, or on any morbid state of the naso-pharynx which gives rise to 
obstruction of the Eustachian orifice. These three factors in the pro- 
duction of throat-deafness will now be considered in detail. 
In the nervo-muscular cases the immediate cause of the affection 
seems to be paralysis of the tensor palati, a lesion which, according to 
Weber-Liel, may be either central, reflex or vaso-motor in its origin. 
The impaired contractility of the tube most frequently results from 
morbid conditions of the fifth nerve, but in like manner, neuroses of 
the facial, glosso-pharyngeal, vagus, and spinal accessory, and of the 
sympathetic plexuses in the naso-pharynx and neck may lead to atrophy 
and fatty or fibrous degeneration of the muscles. The remote causes 
of these nervous affections are usually mental strain, depressing emo- 
tions, excessive exertion, parturition, and, speaking generally, all un- 
healthy modes of life. Weber-Liel’s work contains examples of 
throat-deafness following phthisis and typhoid fever. Diphtheritic 
affections of the naso-pharynx would, of course, be likely to lead to 
disease of the Eustachian tube and middle ear, and that this complica- 
tion is not uncommon may be inferred from the fact that Wendtf found 
the middle ear involved in two-fifths of the cases in which there was 
false membrane in the naso-pharynx. Rheumatism, progressive mus- 
cular atrophy, chlorosis, and even extreme anaemia may likewise impair 
the muscles. Weber-Liel is of opinion that paresis is sometimes fa- 
vored by congenital defect in the development of these muscles. 
Chronic inflammation of the Eustachian tube sometimes follows 
catarrh of the naso-pharynx, but it must not be forgotten that catarrh 
is extremely likely to occur in parts whose innervation is impaired, and 
that in many cases of catarrhal affection of the middle ear, the neurosis 
has been the starting-point. According to Zaufal,J however, dry catarrh 
* Brit. Med. Journ., 1879, vol. ii., pp. 328, 329. 
f Ziemssen’s Cyclopaedia, vol. vii., p. 71. 
J Die allgenieine Verwendbarkeit der kalten Drahtschlinge, Prag., 1878. TH HO AT-D E AFXESS. 
527 
frequently brings on deafness by extension of the unhealthy condition 
to the Eustachian tube. He states that he found this complication in 
as many as 80 per cent, of the cases of oztena which he had examined. 
I have not myself met with deafness in patients suffering from ozeena 
in anything like the same proportion, though I have occasionally found 
the two conditions coexistent. 
The disease of the naso-pharynx which most frequently interferes 
with the Eustachian orifice is the presence of adenoid growths in that 
region. Among 175 patients suffering from these vegetations in the 
naso-pharynx, Meyer* found associated defect of hearing in 130. 
Syphilitic lesions may also occur in the neighborhood of the Eustachian 
tube, and lead to impairment of hearing by mechanical obstruction or 
inflammation of the canal. This, as already remarked, was noticed by 
several of the older writers. In recent years Zaufalf has called attention 
to the frequent occurrence of gummata in the immediate neighborhood 
of the Eustachian tube. Among more obscure forms of throat-deafness 
may be mentioned phlebectasis of the mucous membrane covering the 
Eustachian cartilage, which, according to von Troltsch,| may narrow 
the lumen of the tube to a degree sufficient to diminish the power of 
hearing. Zuckerkandl§ states that the veins of the internal pterygoid 
plexus may, if enlarged, produce the same effect by their pressure on 
the Eustachian cushion. Schwartze|| asserts that oedema of the tubal 
prominences, and consequent partial occlusion of the Eustachian tube, 
may be caused by obstruction to the blood-current in the superior vena 
cava. The Eustachian canal is, in certain instances, blocked up by 
exostoses situated in the vicinity of the tube; von found this 
condition produced in one case by hypertrophy of the posterior ex- 
tremity of the inferior spongy bone, and in another by a bony outgrowth 
from the septum. 
Symptoms.—Throat-deafness being dependent on so many different 
conditions, the symptoms vary considerably. The phenomena even in 
paretic cases differ greatly, one set giving rise to distressing symptoms, 
and tending to get worse in spite of all treatment, whilst the other causes 
much less inconvenience, and generally yields to remedial measures. 
The first class is that described by Weber-Liel. One of the earliest 
* Arcliiv fur Ohrenheilkunde, 1874, Bd. viii., p. 243. f Loc. cit. 
X Lehrbuch der Ohrenheilkunde, 1877, p. 310. 
\ Monatsschrift f. Ohrenheilkunde, Jahrgang x., Sp. 52, p. 231. 
|| Pathol. Anatomie des Ohres, p. 104. 
Archiv fiir Ohrenheilkunde, Bd. iv., p. 140. 528 
DISEASES OF THE THROAT AND NOSE. 
signs is fatigue in listening. It shows itself by the patient perceiving 
a difficulty in hearing after a prolonged conversation, the auditory 
power being good at the commencement, but gradually failing as the 
strain continues. The patient finds it particularly difficult to hear 
when general conversation is going on, though he can do so with ease 
when one person is speaking alone. The difficulty in the former case 
arises from a loss of the “power of accommodation,” the tympanum 
being unable to adapt itself readily to the different sounds caused by 
voices of varying quality and intensity proceeding from persons situ- 
ated at different distances and in different directions in relation to the 
listener. Together with this, noises are frequently perceived in the 
affected ear, whilst snapping sounds are heard by the patient in chewing 
and swallowing. As the disease advances, giddiness is sometimes felt. 
The patient often complains of an uneasy tickling or scratching sensa- 
tion in the throat, and on inspection, paralysis of one or both sides of 
the pharynx may be noticed. Though Weber-Liel* first called atten- 
tion to this paralysis, Woakes has rendered good service in insisting on 
the great importance of carefully examining the soft palate in every 
case of deafness in order to ascertain whether its innervation is normal. 
This examination is of the utmost importance in the cases here described, 
as the neurosis does not of itself attract notice, the paresis being seldom 
sufficiently severe to modify the patient’s voice by giving it the peculiar 
intonation so characteristic of paralysis of the soft palate. On exam- 
ining the ear, the tympanum is often seen to be retracted, and some- 
times opaque and thickened. Owing to the collapse of its walls, the 
Eustachian tube cannot be inflated with Politzer’s bag, but the catheter 
can be passed with ease. 
The affection just described most frequently begins on the left side, 
and it shows great intractability. According to Weber-Liel the trouble- 
some character of the symptoms is largely due to the unbalanced action 
of the tensor tympani, causing an intense strain on the drumhead and 
the ossicles. A much milder neurosis has been described by Woakes, 
in which, however, the innervation, both of the tubal muscles and the 
tensor tympani, is impaired. The obstruction of the Eustachian tube 
is only partial, for the two sets of muscles being alike affected, they 
balance each other exactly, and on examining the ear, the drumhead is 
seen to be normal or only slightly flattened. In these cases noises in 
the head and giddiness are not perceived, but the deafness is marked 
* Op. cit., pp. 33-36, 529 
THROAT-DEAFNESS. 
from the very commencement of the affection, which, however, shows 
a tendency to recovery. 
Throat-deafness dependent on any of the morbid conditions of the 
naso-pharynx already described, presents the symptoms of those affec- 
tions with the addition of deafness. 
Diagnosis.—A careful examination of the palate, .the naso-pharynx, 
and the auditory canal will serve to determine whether the disease is 
Eustachian in its origin. The state of tension of the membrana tym- 
pani will enable the practitioner to discriminate between the different 
kinds of paresis, and it must not be forgotten that in the severer form 
structural disease of the middle ear is very apt to be set up. 
Pathology.—The pathology of the various affections of the naso- 
pharynx, which may accidentally lead to obstruction of the Eustachian 
orifice, has been considered in its appropriate place, and it now only 
remains to make a few remarks on the paretic forms of throat-deafness. 
In the severer cases, through collapse of the tube, the air in the tym- 
panic cavity becomes unduly rarefied, whilst the tensor tympani being 
no longer balanced, tension of the tympanic membrane takes place, the 
chain of ossicles is put on the stretch, and the stapes is pressed into the 
labyrinth. Secondary changes soon follow: passive congestion of the 
tympanic cavity leads to trophic changes of a more or less cirrhotic 
character, consisting at first in the growth and afterwards in the atrophy 
of a low form of connective tissue. Adhesion takes place between 
parts normally separate, the stapes becomes fixed in the fenestra ovalis, 
and the labyrinth becomes the seat of disease. As already remarked, 
Weber-Liel thinks that the starting-point of these serious changes may 
be either central, reflex, or vaso-motor. The less severe complaint 
described by Woakes is, according to that physician, always of vaso- 
motor origin. He believes that in such cases the nerve-force, especially 
of the sympathetic system, is exhausted. 
Prognosis.—In the nervous cases the age and condition of the patient 
must be taken into account. If the subject of the affection be a person 
worn out by disease, overwork, or anxiety, the prognosis is very unfa- 
vorable. The tendency towards permanent loss of hearing is indeed so 
marked in this class of cases that Weber-Liel, who first described them, 
calls the affection “progressive deafness.” The presence of tinnitus 
must also always be a matter of serious import. 
When the disease is due to adenoid growths a favorable prognosis 
may be given, as the vegetations can always be got rid of. In other 530 
DISEASES OF THE THROAT AND NOSE. 
cases of a mechanical nature, the prospects of the patient must depend 
on the possibility of removing the cause of the obstruction. 
Treatment.—The nervous cases should be treated in the early stage 
by inflation of the Eustachian tube by Politzer’s method, if the tube 
responds to that treatment, and if not, by means of the catheter. Intra- 
tubal galvanism has been found useful by Weber-Liel in the com- 
mencement of the more severe type of the disease, and Woakes asserts 
that it is of very great service in the slighter cases. Von Troltsch* 
maintains that the act of gargling, by exercising the palato-pharyngeal 
muscles, is often beneficial. In the later period of the disease, when 
secondary changes have taken place in the middle ear, nothing remains 
but the doubtful operation of paracentesis of the tympanum and tenot- 
omy of the tensor tympani. Long before the complaint has reached 
this stage, however, constitutional treatment should have been carried 
out. The patient ought, if possible, to be relieved from worry and 
anxiety; if overworked, he should diminish his labors or desist from 
them altogether and seek change of scene, whilst his system should be 
invigorated in every possible way. Verve-tonics, especially phosphorus 
and strychnia, are useful in some cases, whilst for the anaemic prepara- 
tions of iron are more beneficial. 
Where the disease depends on actual obstruction the cause must, if 
possible, be removed. Adenoid growths must be got rid of in the 
manner already indicated (p. 491 et seq.). Syphilitic webs and enlarged 
veins should, if possible, be destroyed with the electric cautery, oede- 
matous swellings must be scarified, and exostoses, if they can be reached, 
should be broken off with curved forceps. 
* Arcliiv f. Ohrenheilkunde, Bd. iv, p. 140. APPENDIX. 
SPECIAL FORMULAE FOR TOPICAL REMEDIES, 
MOST OP WHICH ARE CONTAINED IN THE “THROAT HOSPITAL PHARMACOPCEIA.” 
Those Formulas which are printed in black (Egyptian) type have been found 
of especial use by the author. 
Formulae for Inhalations have already been given (Yol. I., pp. 549-552), 
and for Lozenges (Ibid., p. 553). 
BUGINARIA. 
Medicated bougies are useful in chronic affections of the nasal 
passages. The indications for the use of the different kinds of bugi- 
naria will be gathered from their constitution. The basis of the bougie 
is “ gelato-glycerin,” which consists of gelatin, glycerin, and water, in 
the following proportions: 
Refined Gelatin (by weight),.... §v. 
Glycerin (by weight), ..... §vj. 
Water (by weight), . . . . . 5vj. 
Soak the gelatin in the water for twelve hours, with occasional stirring, 
add the glycerin, dissolve in a water-bath, and evaporate to produce 
fifteen ounces by weight of the gelato-glycerin. In making bougies 
the gelato-glycerin must be melted, the medicament added, and the 
substance poured into moulds of such a shape that each bougie has a 
length of eight centimetres, and is of a tapering form (Fig. 93), the 532 
APPENDIX. 
diameter of the larger end being eight millimetres, and that of the 
smaller extremity three millimetres. The annexed wood-cut shows the 
shape of the bougie as it is made in the mould. 
Fro. 93. 
The Nasal Medicated Bougie. 
When required for use it can, of course, be shortened or pared down 
if desired. The following may be taken as a typical formula: 
Iodoform, in fine powder, . . . . gr. ss. 
Glycerin, ....... nyj. 
Rub together, and add the mixture toGelato- 
glycerin, melted in a water-bath, . . gr. xl. 
Mix and pour into the mould. When solidified, remove for use. 
Euginarium Acidi Carbolici (Acid. Carbol. gr. ss., Gelato-Glycerini, 
gr. xl.). 
“ Bismuthi (Bismuth. Subnitrat. gr. v., Glycerini nyiij., 
Gelato-Glycerini gr. xl.). 
“ Cupri Sulphatis (Cupri Sulph. Pulverisati gr. Gelato- 
Glycerini gr. xl.). 
** Iodoformi (Iodoformi Pulverisati gr. ss., Glycerini tiyj., 
Gelato-Glycerini gr. xl.). 
“ Morphiae (Morph. Acetat. gr. ,’¥, Gelato-Glycerini gr. 
xl.). 
“ Plumbi Acetatis (Plumbi Acetat. gr. ss., Glycerini 5ij., 
Gelato-Glycerini gr. xl.). 
<c Thymolis (Thymol, gr. ,’g-, Sp. Vin. Rect. nyss., Gelato- 
Glycerini gr. xl.). 
“ Zinci Sulphatis (Zinc. Sulph. Pulverisati gr. T Gelato- 
Glycerini gr. xl.). 
COLLUNARIA—NASAL DOUCHES. 
Not more than twenty ounces of fluid should ever be used for a nasal 
douche, and ten ounces are generally sufficient. If an apparatus on APPENDIX. 
533 
the syphon principle be employed, it should be placed just above the 
level of the patient’s head, in order to avoid too great force of current. 
The temperature of the fluid should be about 90° Fahr. 
Astringent. 
Collunarium Acidi Tannici (Acid. Tannic, gr. iij., ad gj.). 
“ Aluminis (Aluminis gr. iv., ad gj.). 
Zinci Sulplmtis (Zinc. Sulph. gr. ss., ad gj.). 
Detergent. 
Collunarium Acidi Carbolici cum Soda et Borace (Acid. Oarbol. 
gr. iv., Sodae Bicarb, gr. xij., Boracis gr. xij., 
Aquae gj.). 
“ Potassae Permanganatis (Sol. Potass. Permang., 
B.P., njzyj., Aquam ad gj.). 
“ Sodae (Sodae Bicard. gr. xxx., ad gj.). 
Antiseptic. 
Collunarium Acidi Carbolici (Acid. Carbol. Puri gr. iij., Glyce- 
rini rtyxx., Aquam ad gj.). 
Zinci Sulpho-Carbolatis (Zinc. Sulpho-Carbol. gr. ij., 
ad gj.). 
Useful in Hay Fever. 
Collunarium Quiniae (Quin. Sulph. gr. ss., ad gj.). 
The solid ingredient must be dissolved by the aid of a gentle heat. 
LOTIONES—NASAL AV ASHES. 
These lotions should be sniffed up into the nose from the hollow of 
the hand, or gently injected by means of a small glass or India-rubber 
syringe. The fluid should be made to traverse the whole length of the 
nasal fossae till it trickles into the pharynx, when it must be spit out. 
The lotions should be used at a temperature of about 100° Fahr. 534 
APPENDIX. 
Detergent. 
Lotio Alkalina (Sodae Bicarb, gr. xij., Acid. Carbol. gr. iss., Aquae 
5j.). 
“ Ammonii Chloridi Alkalina (Sodae Bicarb, gr. vj., Ammon. 
Chlorid. gr. vj., Aquae gjj.) 
“ Potassae Chloratis Alkalina (Sodae Bicarb, gr. vj., Potass. Chlor. 
gr. vj., Aquae gj.). 
“ Alkalina Composita (Sodae Bicarb., Sodae Biborat., Sodii 
Chlorid. aa. gr. vij., Sacch. Alb. gr. xv.). 
The powder thus formed should be dissolved in about half a 
tumblerful of tepid water.* 
Astringent. 
Lotio Aluminis (Alum. gr. vj. or more, Acid. Carbol. gr. iss., Aquae Sj.). 
“ Ammonii Chloridi Astringens (Ammon. Chloridi gr. vj., Alu- 
minis gr. vj., Aquae gj.). 
“ Zinci Sulphatis (Zinc. Sulph. gr. vj., Acid. Carbol. gr. iss., Aquae 
Sj.)* 
NEBULAE—NASAL SPRAYS. 
In using these the ordinary hand-ball spray-producer answers well. 
Besides a long tapering straight nozzle for the anterior part of the nasal 
fossae, another, curved upwards almost at a right angle about an inch and 
a half from the point, will be required for the posterior nares. 
Antiseptic. 
Nebula Acidi Carbolici (Acid. Carbol. gr. iij., ad §j.). 
“ Acidi Sulphurosi (Acidi Sulphurosi q.s.). 
Forty to sixty drops should be used at a time. The spray 
should be inhaled very slowly. 
“ Iodi cum Acido Tannico (Tr. Iodi rqjiij., Glycerini Acid. 
Tann. rtyxij., Aquam Destill, ad §j.). 
" Iodoformi (Iodoform, gr. xl., Athens, sp. gr. .735, gj.).. 
* The author has constantly prescribed this lotion during the last few years for 
chronic inflammatory conditions of the nares and naso-pharynx, and with very satis- 
factory results. APPENDIX. 
535 
Nebula Potassse Permanganatis (Potass. Perrnang. gr. v., Aquse Destill. 
Sj.). 
“ Sodse Benzoatis (Sodse Benzoat. gr. xx., Aquse Destill. Sj.). 
“ Zinci Iodati (Iodated Zinc Caustic nyij. or more, Aquam 
Destill, ad Sj.). 
Nebula Acidi Tannici (Acid. Tannic, gr. v., Aquae Destill. §j.). 
“ Aluminis (Liq. Aluruin. Chlorid. rrj^iij.? Aquam Destill, ad Sj.). 
u Aluminis (Alum. gr. viij., Aquae Destill. §j.). 
“ Ferro-Aluminis (Ferro-Alum. gr. iij., Aquae Destill. Sj.). 
“ Ferri Perchloridi (Ferr. Perchlor. gr. iij., Aquae Destill. §j.). 
“ Ferri Sulphatis (Ferr. Sulphat. gr. ij., Aquae Destill. Sj.). 
“ Zinci Chloridi (Zinc. Chlorid. gr. ij., Aquae Destill. 5j.). 
“ Zinci Sulphatis (Zinc. Sulph. gr. v., Aquae Destill. 5j.). 
Astringent. 
Nebula Alkalina (Sodse Bicarb, gr. xv., Boracis gr. xv., Acid. 
Carbol. gr. iv., Glycerini npdv., Aquam ad Sj). 
And the following, which is alluded to in the body of the work as 
“Dobell’s Solution.” * 
Boracis, ....... 5j. 
Glycerini Acidi Carbolici, . . . . 5jj. 
Sodse Bicarbonatis, . . . . . 5j. 
Aquse, ........ Oss.f 
Nebula Potassse Chloratis (Potass. Chlor. gr. xx., Aquse Sj.). 
“ Sodii Chloridi (Sodii Chlorid. gr. v., Aquse destill. Sj.). 
Sedative. 
Nebula Potassii Bromidi (Potass. Bromidi gr. xx. ad Sj-)* 
Useful in Diphtheria. 
Nebula Acidi Lactici (Acid. Lactic., U.S.P., Aquam Destill, 
ad Sj.). 
“ Calcis (Aq. Calcis q.s.). 
“ Sodse Salicylatis (Sodse Salicylatis gr. xx., Aquse Sj.). 
Determent. 
* Winter Cough, 3d. ed., London, 1875, p. 211. 
f The water should be warm. Chloride of ammonium, chlorate of potash, or Condy’s 
fluid may be substituted for the borax in the above formula. 536 
APPENDIX. 
GOSSYPIA MEDICATA—MEDICATED COTTON WOOLS. 
Nasal plugs of unmedicated cotton-wool have been used for some 
time by Gottstein with the happiest results in cases of simple ozaena. 
A full description of his method of applying them has already been 
given in the body of the work (p. 283 and p. 334). In cases of active 
inflammation or syphilitic ulceration affecting the interior of the nose 
or' the naso-pharyngeal region, medicated wools, as proposed by Dr. 
Woakes, answer best, the remedy being by this means brought into 
direct and constant contact with the diseased part. The ingredients are 
first mixed together and dissolved, the wool is then to be saturated 
evenly with the solution and dried by exposure to the air with a 
moderate heat. 
Astringent. 
Gossypium Acidi Tanniei (Acid. Tannici gr. xxx., Glycerini uyx., Aquae 
5vj., Cotton Wool, in a thin sheet, gr. lx.). 
“ Aluminis (Alum. gr. xxx., Glycerini tt£x., Aquae Sj., Cotton 
Wool as above). 
“ Ferri Perchloridi (Liq. Ferr. Perchlor. Sss., Glycerini Tiyx., 
Cotton Wool as above). 
“ Cubebae (Tr. Cubebae Sj-, Glycerini riyx., Cotton Wool as 
above). 
“ Hamamelis (Tr. Hamamel. Sss., Glycerini nyx., Cotton 
Wool as above). 
“ Krameriae (Tr. Krameriae Sss., Glycerini Cotton Wool 
as before). 
Antiseptic and Disinfectant. 
Gossypium Acidi Boracici (Acidi Boracici gr. lx., Glycerini 
Aquae Syj., Cotton Wool as above). 
“ Camphorae (Camphorae gr. xxx., iEther. Pur. Sj., Cotton 
Wool as above). 
N.B.—This wool should be prepared in a room where 
there is neither artificial light nor fire. 
“ Iodi (Tr. Iodi Sss., Glycerini tiyx., Cotton Wool as before). 537 
APPENDIX. 
Gossypium Iodoformi (Iodoformi gr. lxx., ASther. Pur. fl. 5x., Al- 
coholis fl. 5ij., Glycerini nyx., Cotton Wool as be- 
fore). 
N.B.—This wool should be prepared in a room where 
there is neither artificial light nor fire. 
Sedative. 
Gossypium Opii (Tr. Opii §ss., Glycerini Cotton Wool as 
above). 
OLFACTORI A—OLFACTORIES. 
These are dry inhalations of the nature of smelling salts, and should 
be used in the same way, i.e., a little cotton-wool or sponge should be 
saturated with the medicament and placed in a stoppered glass bottle. 
The remedy is to be sniffed up the nose. 
The following is very popular in Germany, and has been alluded to 
in the body of the work (p. 291) as the “ Hager-Brand Anti-catarrhal 
Olfactory.” 
Acid Carbolici, 
Liq. Ammon. Fort.,. . . . . aa §v. 
Alcoholis, ...... 5ij. 
To be kept in a dark place or in a tinted glass bottle. 
PASTILS. 
This is a soft variety of lozenge, somewhat resembling in appearance 
and consistence the “jujubes” sold by confectioners. The basis of the 
preparation is glyco-gelatin, a compound much employed in the manu- 
facture of pessaries and soluble bougies. Its adaptation to the present 
purpose was advocated by Dr. Whistler {Med. Times and Gaz., Nov., 
1878) as a means of applying iodoform to the throat, and as affording 
a ready method of prescribing lozenges to meet the requirements of in- 538 
APPENDIX. 
dividual cases. Pastils are especially suited to cases of inflammation of 
the tongue or palate, and their mucilaginous nature gives much relief 
in dryness of the throat. Their soft consistence renders them particu- 
larly useful in cases of oesophageal disease. 
No substances, such as tannin, rhatany, or kino, which are chemically 
incompatible with gelatin, can be employed with the basis. 
The following is the formula for the glyco-gelatin : 
Refined Gelatin, . . . . . . Sj. 
Glycerin (by weight), ..... siiss. 
Ammoniacal Solution of Carmine, . . . q. s. 
Orange-flower Water, ..... 5*iss. 
The process to be pursued in making the basis is as follows: Soak 
the gelatin in the water for two hours, then heat in a water-bath till 
dissolved ; add the glycerin, and stir well together. Let the mixture 
cool, and when it is nearly cold add the carmine solution ; mix till uni- 
formly colored, and set aside to solidify. After medicating, as directed 
in the following formulte, it is cooled by pouring into an oiled tray, and 
when solidified, cut into the required number of pastils. One ounce of 
the mass will make twenty-four. 
The following is a typical formula, iodoform being taken as an ex- 
ample : 
Iodoform, in fine powder, .... gr. j. 
Glycerin, . . . . . . . ffgj. 
Rub together and add the mixture to the 
Glyco-gelatin (melted in a water-bath), . . gr. xviij. 
Mix and set aside to cool, and make one pastil. 
Antiseptic. 
Pastillus Acidi Boracici (Boraeic Acid, in fine powder, gr. ij.). 
“ Acidi Carbolici (Carbolic Acid, gr. ss.). 
“ Iodoformi (Iodoform in fine powder gr. j., or more or less 
if prescribed). 
Stimulant. 
Pastil 1 us Ammonii Chloridi (Chloride of Ammonium gr. ij.). 
“ Bismuthi (Carbonate of Bismuth gr. iij.). APPENDIX. 
539 
Pastillus Bismuthi et Potassse Chloratis (Carbonate of Bismuth gr. iij., 
Chlorate of Potash gr. ij.). 
Sedative. 
Pastillus Bismuthi et Morphise (Carbonate of Bismuth gr. iij., Acetate 
of Morphia, gr. ■%■$). 
INSUFFLATIONES. 
(See also “ Snuffs.”) 
The general composition of powders for this purpose has already been 
described (see voh i., p. 555). Most of those which are there mentioned 
are also available for the nasal passages and the naso-pharynx. The 
following are a few additional formulae which I have found very useful. 
Where a vehicle is required for the medicinal agent, I generally prefer 
dried maize starch. Powdered myrrh and phosphate of lime are also 
occasionally serviceable in order to give bulk to the powder. The indi- 
cations for use are clearly shown by the nature of the remedy. Two or 
more may sometimes be advantageously combined together, e.g., a little 
acetate of morphia or bismuth may be added to catechu or eucalyptus 
if these powders are found too irritating. 
Insufflatio Bismuthi Oxychloridi (gr. £-§).* 
“ Aluminis Exsiccati (gr. ss.-j.) 
“ Catechu Pallidi Pulverisati (gr. |-f). 
“ Gummi Rubri (one part to two of dried maize starch). 
Ferri Persulphatis (one part to three of dried maize starch). 
Ferro-Aluminis (with an equal quantity of dried maize 
starch). 
Iodoformi (gr. with an equal quantity of dried 
maize starch). 
* This is a more impalpable and less irritating preparation than either the carbo- 
nate, subnitrate, or oxide of bismuth. Tt is also less soluble, which renders it more 
adapted to produce the mechanical effect of forming a coating over inflamed or raw 
mucous surfaces. 540 
APPENDIX. 
SNUFFS. 
(See also “ Insufflationes.”) 
These are chiefly useful for checking catarrh in its initial stage. 
They should be used frequently, but not for more than forty-eight hours 
continuously. 
fy. Morphiae Sulph., . . . . . gr. ij. 
Bismuth. Subcarb., . . . . • 5j- 
M. ft. pulv. 
The following is the formula known as “ Dr. Ferrier’s Snuff/’* or 
Pulvis Bismuthi Compositus. 
Morphiae Hydrochlorat., .... gr. ij. 
Pulv. Aeaciae, . . . . . • 5'j. 
Bismuth. Subnitrat., ..... 5vj. 
M. ft. pulv. 
One-quarter to one-half may be used in twenty-four hours. 
The following snuff is recommended by Dobell f in chronic post-nasal 
catarrh : 
Camphor, 
Tannic Acid, 
White Sugar, 
High-dried Welsh Snuff, . . . . aa 5j. 
M. ft. pulv. 
A pinch to be taken once in the morning and evening, and once or 
twice during the day. The snuff is to be discontinued if a fresh attack 
of nasal catarrh sets in, but should be resumed on the subsidence of in- 
flammatory symptoms. 
* Lancet, 1876, vol. i., p. 525. 
f Op. eit., p. 211. INDEX OF SUBJECTS. 
Abscess of nasal septum, 430 
Abscess, perioesophageal, 69; history, 70; etiol- 
ogy, 71; symptoms, 72; diagnosis, 74; pa- 
thology, 74; prognosis, 75; treatment, 75 
Acids, oesophagitis from swallowing, 54 
Acute oesophagitis, 41; history, 41; etiology, 42; 
symptoms, 43; pathology, 44; diagnosis, 45; 
prognosis, 46; treatment, 46; cases of, 47 
Adams’s forceps for breaking down the septum, 
282 
Adenoid vegetations of naso-pharynx, 483; his- 
tory, 483; etiology, 485; symptoms, 486; di- 
agnosis, 489; pathology, 490; prognosis, 491; 
treatment, 491 
Adenoma polyposum in gullet, 113 
Affections of the nose in eruptive fevers and 
other acute diseases, 416 
Agger nasi, 236 
Air-passages, chronic blennorrhcea of, 335 
Alkalies, cesophagitis from swallowing, 54 
Allen, Harrison, his caustic-holder, 260 
American catarrh, 472; history, 472; etiology, 
• 473: symptoms, 479; pathology, 480; diag- 
nosis, 480: prognosis, 480; treatment, 480 
Anatomy of the gullet, 17 
Anatomy of the nasal fossae, 235 
Anosmia, 452; history, 453; etiology, 453; symp- 
toms, 457; pathology, 458; diagnosis, 460; 
prognosis, 460; treatment, 460 
Antimony, cesophagitis produced by, 55 
Asthma, hay, 299; history,*299; etiology, 300; 
(a) predisposing causes, 300; (6) exciting 
causes, 303; symptoms, 308; diagnosis, 309; 
prognosis, 309; pathology, 309; treatment, 
309 
Auto-rhinoscopy, 256 
Auscultation of the oesophagus, 23 
Baber, Cresswell, his nasal speculum, 242 
Bellocq’s sound, 279 
Bleeding from the nose, 336; history, 336; eti- 
ology, 338, symptoms, 342; pathology, 343; 
diagnosis, 343; prognosis, 343; treatment, 344 
Blennorrhcea, chronic, of the nose and air-pas- 
sages, 335 
Blood-tumors of the nasal septum, 428 
Bougies, oesophageal, 26; method of passing, 27; 
nasal, 257 
Brushes, oesophageal, 33: nasal, 259 
Bryant’s nasal auto-insufflator, 258 
Bulla ethmoidalis, 237 
Calcification of oesophagus, 109 
Cancer of gullet, 83; history, 84; etiology, 85; 
symptoms,90; pathology,97; diagnosis, 102; 
prognosis, 103; treatmen t, 104; table of cases, 
86; most frequent seat of, 99; sarcoma, 109 
Cartilaginous stricture of oesophagus, 109 
Catarrh, acute nasal, 284; history, 284; etiology, 
285; symptoms, 288; diagnosis, 290; prog- 
nosis, 290; pathology, 290; treatment, 290; 
American, see American catarrh; chronic, 
of naso-pharynx, 472; history, 472; etiology, 
473; symptoms, 479; pathology, 480; diag- 
nosis, 480; prognosis, 480; treatment, 480; 
chronic nasal, 312; dry, 322; history, 323; 
etiology, 325; symptoms, 329; diagnosis, 
330; pathology, 331; prognosis, 333; treat- 
ment, 333; dry, of naso-pharynx, 482; 
purulent nasal, 294; summer, 299; history, 
299; etiology, 300; (a) predisposing causes, 
300; (6) exciting causes. 303; symptoms, 308; 
diagnosis, 309; prognosis, 309; pathology, 
309; treatment, 309 
Caustics, oesophagitis from swallowing, 54 
Choanse, nasal, 235 
Chronic blennorrhoea of the nose and air-pas- 
sages, 335 
Chronic oesophagitis, 59 
Chronic catarrh of the naso-pharynx,see Catarrh 
Cicatricial stricture of the gullet, 139; etiology, 
140; symptoms,140; position, 141; diagnosis, 
141; pathology, 142; prognosis, 143; treat- 
ment, 144; gentle dilatation of, 144; forcible 
dilatation of, 145 
Cohen, Solis, his post-nasal syringe, 267 
Coin-catchers, 35 
Compression of the gullet, 167 
Congenital deformities of the nose, 465 
Corrosive sublimate, appearance of oesophagus 
after poisoning by, 57 
Coryza, 284; acute, in infants, 293 
Curette, nasal, 278; Capart’s, 278 
Cysts in gullet, 112 
Czermak, his palate hook, 250 
Deformities, congenital, of the nose, 465 
Deviation of the nasal septum, 423 
Dilatations of the oesophagus, 125; simple, 126; 
(a) primary, 126; (b) secondary, 130; sacci- 
form, 132; symptoms, 135; pathology, 136; 
mortality in, 136 
Diphtheria of the gullet, 82 
Disease of the fifth nerve or its nasal branches, 
464 
Diseases of the gullet, 41 
Dislocation of the nasal bones, 421 
Diverticula, traction-, 136 
Douche, nasal, 261; the Parson’s, 262 
Dry cartarrh, 322; history, 323; etiology, 325; 
symptoms, 329; diagnosis, 330; pathology, 
331; prognosis, 333; treatment, 333 
Dry catarrh of the naso-pharynx, 482 
Duplay’s oesophageal resonator, 34; nasal spec- 
ulum, 243 
Dysphagia lusoria, 217 
Ecraseur, nasal, 271; Jarvis’s, 272; the author’s, 
273 
Electrode, oesophageal, 33; nasal, 274: Lowen- 
berg’s nasal, 274; Lincoln's post-nasal, 275 
Elsberg’s nasal speculum, 244 
Enchondromata of the nose, 379 
Enchondroma of the naso-pharynx, 521 
Entomozoaria in the nose, 450 
Epistaxis, 336; history, 336; etiology, 338 ; symp- 
toms, 342; pathology, 343; diagnosis, 343; 
prognosis, 343; treatment, 344 542 
INDEX OF SUBJECTS. 
Erectile tumors of the pituitary membrane, 378 
Ethmoidal fissure, 237 
Examination of gullet, 23 
Exostoses ot the nose, 383 
Feeding bottle, rectal, 39 
Feeding tube, oesophageal, 39 
Fibromata in gullet, 113 
Fibro-mucous polypi of the naso-pharynx, 519 
Fibrous polypi of the naso-pharynx, 493; his- 
tory, 493; etiology, 496; symptoms, 497; di- 
agnosis, 499; pathology, 500; prognosis, 500; 
treatment, 501; electric cautery, 502 ; elec- 
trolysis, 503 ; ligation, 504; removal with the 
•Jcraseur, 504; evulsion, 505; excision, 505; 
crushing, 506; gouging, 506; thermic cau- 
tery, 507; escharotics, 507; preliminary op- 
erations for gaining access to naso-pharyn- 
geal tumors, 508; (a) nasal operations, 510; 
(6) maxillary operations, 514; (c) palatine 
operations, 516 
Fifth nerve, or its nasal branches, disease of, 
464 
Fish-hooks, removal of, from gullet, 198 
Fistula, tracheo-oesophageal, 96 
Follicular disease of the naso-pharyngeal space, 
see Post-nasal catarrh 
Foreign bodies in the gullet, 190; history, 190; 
etiology, 191; symptoms, 194; pathology, 197 ; 
diagnosis, 197; prognosis, 198; treatment, 
198 
Foreign bodies in the nose, 432 
Fractures of the nose, 418 
Frankel.his nasal speculum, 241; his post-rhinal 
mirror, 250; his palate hook, 250 
Forceps, oesophageal, 35; ordinary polypus, 267 ; 
Gant’s vine scissor, 267; the author’s punch-, 
268; the axial polypus, 268 ; Beverley Rob- 
inson’s toothed and locking, 269; Stoker’s 
rotatory polypus, 269; the author’s nasal 
bone, 270 ; post-nasal, 275 ; Lowenberg’s 
post-nasal, 275; the author’s sliding post- 
nasal, 276; Adams’s for breaking down the 
septum, 282 
Gant’s vine-scissor forceps, 267 
Gastrostomy, 155; history of operation, 155; 
method of performing operation, 156; man- 
ner of feeding after operation, 159; statis- 
tics of operation, 160; advantages of opera- 
tion, 160; disadvantage of operation, 161 
Glanders, 409; history, 409; etiology, 410; symp- 
toms, 411; diagnosis, 412; pathology, 414; 
prognosis, 415; treatment, 415 
Goodwillie’s nasal speculum, 242 
Gottstein’s cotton-wool tampon, 283 
Grate’s coin-catcher, 36 
Gross’s nasal spuds, 282 
Gullet, abscess of, 69; etiology," 71; symptoms, 
72; diagnosis, 74; pathology, 74 ; prognosis, 
75; treatment, 75; adenoma polyposum in, 
113; anatomy of, 17 ; aphthae of, 76 ; auscul- 
tation of, 23; experiments on, 171; cancer 
of, see malignant tumors of; calcification of, 
109; calibre of, 18,19,20; cartilaginous stric- 
ture of, 109; cicatricial stricture of, 139; eti- 
ology, 140; symptoms, 140; position, 141; 
diagnosis, 141, pathology, 142; prognosis, 
143; treatment, 144; case of, 162; gentle di- 
latation, 144 ; forcible dilatation, 145 ; com- 
pression of, 167; cysts in, 112; dilatations 
of, 125; simple dilatations, 126; (a) primary, 
126; (6) secondary, 130; sacciform, 132; symp- 
toms, 135; pathology, 136; mortality, 136; 
diphtheria of, 82; diverticula in (traction), 
136; examination of, 23; fibromata in, 113; 
foreign bodies in, 190; history, 190; etiology, 
191; symptoms, 194; pathology, 197; diag- 
nosis, 197; prognosis, 198; treatment, 198; 
inflammation of, see OEsophagitis, 41; lipo- 
mata in, 113; malformations of, 220; history, 
220; etiology, 223; symptoms, 225; pathol- 
ogy, 225; diagnosis, 227; prognosis, 228; 
treatment, 229; ease of, 230; malignant tu- 
mors of, 83; history, 84; etiology, 85 ; symp- 
toms, 90; pathology, 97; diagnosis, 102; prog- 
nosis, 103; treatment, 104; table of cases of, 
86; most frequent seat of, 99; myomata in, 
113 ; neuroses of, 203; lion-malignant tumors 
of, 110; polypi, 110; warty growths, 112; 
cysts, 112; fibromata, 113; adenoma poly- 
posum, 112; lipomata, 113; myomata, 113; 
ossification of, 109; paralysis of, 203; history 
of, 203; etiology, 203; symptoms, 206; pa- 
thology, 207; diagnosis, 207 ; prognosis, 208; 
treatment, 208; case of, 209 ; perforation of, 
96 ; polypi of, 110; post-mortem softening of, 
232; relations of, 21; removal of fish-hooks 
from, 198; rupture of, 169; position, 172; 
history, 169; etiology, 170; symptoms, 178; 
pathology, 178; diagnosis, 179; prognosis, 
180; treatment, 180; table of cases, 185; 
Boerhaave’s ease of rupture, 181; Fitz’s case 
of rupture, 183; sarcomata in, 109; simple 
stenosis of, 165; sounding the, 26; spasm of, 
211; history, 211; etiology, 212; symptoms, 
215; diagnosis, 217; pathology, 217 ; prog- 
nosis, 218; treatment, 218; spasmodic stric- 
ture of, 102; structure of, 22; syphilis of, 116; 
thrush of, 76; traction-diverticula of, 136; 
traumatic stricture of, 103; tubercular dis- 
ease of, 123; ulcer of, 52; varicose veins of, 
64; warty growths in, 112; wounds of, 187 
I hematoma of the nasal septum, 428 
Haemostatic instrument, nasal, 278 
Hay fever, 299; history, 299 ; etiology, 300; (a) 
predisposing causes, 300; (b) exciting, 303; 
symptoms, 308; diagnosis, 309; prognosis, 
309; pathology, 309 ; treatment, 309 
Hereditary syphilis of the nose, 398 
Hiatus semilunaris, 237. 
Hilton’s improved snare, 271 
Hypertrophy of the mucous membrane of the 
nose, 316 
Infants, oesophagitis in, 49 
Inhalations, nasal, 266 
Injectors, oesophageal, 33 
Insects, oesophagitis caused by stings of, 59 
Jarvis’s combined tongue-depressor and post- 
nasal mirror, 249; nasal ecraseur, 272 
Leffert’s spray producer, 264 
Lincoln’s post-nasal electrode, 275 
Lipomata m gullet, 113 
Livingston’s pneumatic spray producer, 265 
Lowenberg’s nasal electrode, 274,289; post-nasal 
forceps, 276 
Maggots in the nose, 439; history, 440; etiology, 
445; symptoms, 447; diagnosis, 447; pathol- 
ogy, 447; prognosis, 448 ; treatment, 448 
Malformation of oesophagus, 220; history, 220; 
etiology, 223; symptoms, 225; pathology, 
225; diagnosis, 227; prognosis, 228; treat- 
| ment, 229; case of, 229 
Malignant tumors of the gullet, see Gullet 
Malignant tumors of the naso-pharynx, 523 
Malignant tumors of the nose, 385 
Massei’s modification of Duplay’s nasal specu- 
lum, 244 
Mucous membrane of the nose, description of, 
238, 239; hypertrophy of, 317 
Myomata in gullet, 113 
Nasal bones, dislocation of, 421; bougies, 257; 
brushes, 259; catarrh, acute, 284; history, 
284; etiology, 285; symptoms, 288; diagno- INDEX OF SUBJECTS. 
543 
sis, 290; prognosis, 290; pathology, 290; treat-1 
ment, 2iX); catarrh, chronic, 312; caustic- 
holders, 259 ; choanse, 235 ; curette, 278; Ca- 
part's, 278; douche, 261; the Parson’s, 262; 
eeraseurs, 271; Jarvis’s, 272; the author’s, 271; 
electrodes, 274; Lowenberg’s, 274; Lincoln’s 
post nasal, 275; forceps, 267; Gant’s vine 
scissor, 267; the author’s punch, 268; the 
axial, 268; Beverley Robinson’s toothed and 
locking, 269; Stoker’s rotatory, 269; the au- 
thor’s bone-, 270; Lowenberg’s post-nasal, 
275: the author's sliding post-nasal, 276; 
Adams’s for breaking down the septum, 282; 
fossse, anatomy of, 235; synechia: of, 469; 
haemostatic instruments, 279; inhalations, 
266; inhaler, Whistler’s, 266; insufflators, 
' 257; plugs, 280; Cooper Rose's, 281; Frank’s, 
280; Gottstein’s, 283; St. Ange’s, 280; probes, 
257; septum, abscess of, 430; blood tumors 
of, 428 ; deviation of, 423; shields, 257; snare, 
271; specula, 241; Cresswell Baber’s, 242; 
Duplay’s, 243; Elsberg’s, 244; Frankel’s, 241; 
Goodwillie’s, 243; Massei’s modification of 
Duplay’s, 244; Schuster’s, 244; Spencer Wat- 
son’s,242 ; Thudichum’s,243 ; Yoltolini’s, 244; 
Von Troltsch’s modification of Frankel’s, 
242; Zaufal’s funnel, 245; spray-producer, 
anterior, 263; posterior, 264; Leifert’s, 264; 
Livingtone’s pneumatic, 265; spuds, 282 ; 
syringes, 266 ; tampon, Gottstein’s, 283 ; the 
author’s temporary sponge, 284 
Naso-pharynx, adenoid vegetations of, 483; his- 
tory, 483 ; etiology, 485; symptoms, 486; di- 
agnosis, 489; pathology, 490 ; prognosis, 491; 
treatment, 491; chronic catarrh of, 472; his- 
tory, 472 ; etiology, 473; symptoms, 479; pa- 
thology, 480; diagnosis, 480; prognosis, 480 ; 
treatment, 480 ; dry catarrh of,482; enchon- 
droma of, 521; fibro-mucous polypi of, 519; 
fibrous polypi of, 493; history, 493; etiology, 
496; 'symptoms, 497; diagnosis, 510; pathol- 
ogy, oOO; prognosis, 500: treatment, 501; 
electric cautery, 502; electrolysis, 503; liga- 
tion, 504; removal with the ecraseur, 504; 
evulsion, 505; excision, 505 ; crushing, 506 ; 
gouging, 506; thermic cautery, 507 ; escharo- 
tics, 507; preliminary operations for gaining 
access to naso-pharyngeal tumors, 508; (a) 
nasal operations. 510; (6) maxillary opera- 
tions, 514; (c) palatine operations, 516 ; ma- 
lignant tumors of, 523 
Neuroses of the gullet, 203 
Non-malignant tumors of nose, see Nose 
Nose, affections of, in eruptive fevers, and other 
acute diseases, 416; influenza, 417; measles, 
416; rheumatism, 417 ; scarlet fever, 416; 
small-pox, 417 ; typhoid fever, 417 ; anatomy 
of, 235; bleeding from the, 336; history, 336; 
etiology, 338; symptoms, 342; pathology, 343 ; 
diagnosis, 343; prognosis, 343; treatment, 
344; chronic blennorrhcea of, 335; congen- 
ital deformities of, 465 ; enchondromata of, 
379; entomozoaria in, 450 ; exostoses of the, 
383; fibrous polypi of, 375; foreign bodies 
in, 432; fractures of, 418; hereditary syph- 
ilis of, 398; hypertrophy of mucous mem- 
brane of, 317; maggots in, 439; history, 440; 
etiology, 445; symptoms, 447 ; diagnosis, 447; 
pathology, 447; prognosis, 448; treatment, 
448; malignant tumors of, 385; non-malig- 
nant tumors of, 350; enchondromata, 379; 
erectile tumors of the pituitary membrane, 
378; exostoses, 383; fibrous polypi, 375 ; os- 
teomata, 380; papillomata, 376; polypus, 350; 
osteomata of, 380; papillomata of, 376; poly- 
pus of, 350; history, 350; etiology, 352; symp- | 
toms, 353, diagnosis, 359; pathology, 360;: 
prognosis, 362; treatment, 363; (a) evulsion, , 
364; (6) abscission, 372; (c) electric cautery, 
374; syphilitic affections of, 389; history, 
390; etiology, 391; symptoms, 392 ; diagnosis, j 
394; pathology, 395 ; prognosis, 396; treat- 
ment, 396 
CEsophagostomy, 149; history of the operation, 
149; method of performing, 151; advantages 
of, 154; disadvantages of, 154 
CEsophagotome, 37 
CEsophagotomy, external, 201; internal, 145; ad- 
vantages of, 147 ; disadvantages of, 147 
(Esophagus, abscess of, 69; etiology, 71; symp- 
toms, 72; diagnosis, 74; pathology, 74; prog- 
nosis, 75; treatment, 75; adenoma polypo- 
sum in, 113; anatomy of, 17; aphtha of, 76; 
auscultation of, 23; calcification of. 109; 
calibre of, 18; cancer of, see malignant tu- 
mors of; cartilaginous stricture of, 109; cica- 
tricial strictures of, 139; etiology, 140; symp- 
toms, 140; position, 141; diagnosis, 14l'; pa- 
thology, 142; prognosis, 143; treatment, 144; 
case of, 163; gentle dilatation of, 144; forcible 
dilatation of, 145; compression of, 167; cysts 
in,111 
(Esophageal abscess, 69; bougies, 26; method of 
passing, 27; brushes, 33; electrodes, 33; feed- 
ing tube, 39; forceps, 35; injectors, 33; per- 
manent tube, 38; resonator, 33; sound, 24 
CEsopliagism, 211 
(Esophagitis, acute, 41; history, 41; etiology, 42; 
symptoms, 43; pathology, 44; diagnosis, 46; 
prognosis, 46; treatment, 46; cases of, 47,48; 
chronic, 59; etiology, 59; symptoms, 61; 
pathology, 61; diagnosis, 62; prognosis, 62; 
treatment, 62; from stings of insects, 59; 
from swallowing acids, 54; from swallowing 
alkalies, 54; in infants, 49; phlegmonous, 
51; produced by antimony, 55; traumatic, 
53; history, 53; etiology, 54; symptoms, 54; 
pathology, 56; diagnosis, 57; prognosis, 58; 
treatment, 58 
CEsophagoscope, Bevan’s, 29; Semeleder’s, 29; 
Stork's, 30; the author’s, 31; Waldenburg’s, 
30 
(Esophagoscopy, 29 
(Esophagus, dilatations of, 125; simple, 126; (a) 
primary, 126; (b) secondary, 130; sacciform, 
132; symptoms, 135; pathology, 136; mortal- 
ity in, 136; diphtheria of, 82; examination 
of, 23; fibromata in, 113; foreign bodies in, 
190; history, 190; etiology, 191; symptoms, 
194; pathology, 197; diagnosis, 197; progno- 
sis, 198; treatment, 198; lipomata in, 113; 
.malformations of,220; history, 220; etiology, 
223; symptoms, 225; pathology. 225; diag- 
nosis, 227; prognosis, 228; treatment, 229; 
case of, 229; malignant tumors of, 83; his- 
tory, 84; etiology, 85; table of cases, 86; 
symptoms, 90; pathology, 97; diagnosis, 102; 
prognosis, 103; treatment, 104; most frequent 
seat of, 99; myomata in, 113; noil-malignant 
tumors of, 110; adenoma polyposum, 113; 
cysts, 112;. fibromata, 113; lipomata, 113; 
myomata, 113; polypi, 110; warty growths, 
11!; ossification of, 109: paralysis of, 203; 
history, 203; etiology, 203; symptoms, 206; 
pathology, 207; diagnosis, 207; prognosis, 
209; treatment, 208; case of, 209; perforation 
of, 96; polypi of, 110; post-mortem softening 
of, 232; relations of, 169; removal of fish- 
hooks from, 198; rupture of, 169; position, 
173; history, 169; etiology, 170; symptoms, 
178; pathology, 178; diagnosis, 179; progno- 
sis, 180; treatment, 180; table of cases of, 185; 
Boerhaave’s case of, 181; Dr. Fitz’s case of, 
183; sarcomata in, 109; simple stenosis of, 
165; sounding the,26; spasm of, 211; History, 
211; etiology, 212; symptoms, 215; diagnosis, 
217; pathology, 217; prognosis, 218; treat- 
ment, 218; spasmodic stricture of, 102; stric- 
ture of, 21; syphilis of, 116; thrush of, 76; 
traction-diverticula in, 136; traumatic stric- 
ture of, 103; tubercular disease of, 123; warty 
growths in, 112; wounds of, 187; ulcer of, 52; 
varicose veins of, 64 
Ossification of oesophagus, 109 
Osteomata of the nose, 380 
Ostium maxillare accessorium, 237 544 
INDEX OF SUBJECTS. 
Palate hooks, 250 
Papillomata of nose, 376 
Paralysis of the gullet, 203; history, 203 , etiol- 
ogy, 203; symptoms, 206; pathology, 207; di- 
agnosis, 207; prognosis, 207; treatment, 208; 
case of, 209 
Parasol-probang, 34 
Parosmia, 462 
Peri-oesophageal abscess, 69 
Pharyngeal sound, 24 
Phlegmonous oesophagitis, 51 
Phosphorus, poisoning by, 55, 58 
Pituitary membrane, lupus of, 404; tubercular 
disease of, 400 
Plugs, nasal, 280; Cooper Rose’s, 280; Frank’s, 
280; St. Ange's, 280 
Poisons, oesophagitis caused by corrosive, 54 
Polypi of the gullet, 110; fibro-mucous, of the 
naso-pharynx, 519; fibrous, of the nose, 375; 
fibrous, of the naso-pharynx, 493; history, 
493; etiology, 496; symptoms, 497; diagnosis, 
499; pathology, 500; prognosis, 500; treat- 
ment, 501; electric cautery, 502; electrolysis, 
503; ligation, 504; removal with the 6c ra- 
seur,504; evulsion, 505; excision, 505; crush- 
ing, 506; gouging, 506; thermic cautery, 507; 
escharoties, 507; preliminary operations for 
gaining access to naso-pharyngeal tumors, 
508; (a) nasal operations, 510; (6) maxillary 
operations, 514; (c) palatine operations, 516 
Polypus of the nose, 350; history, 350; etiology, 
352; symptoms, 353; diagnosis, 359; pathol- 
ogy, 360; prognosis, 362; treatment, 363; (a) 
evulsion, 364; (b) abscission, 372; (c) electric 
cautery, 374 
Post-morte*m softening of the gullet, 222 
Post-nasal catarrh, 472; history, 472; etiology, 
473; symptoms, 479; pathology, 490; diag- 
nosis, 480; prognosis, 480; treatment, 480; 
electrode, Lincoln’s, 275; forceps, 275; Low- 
enberg’s, 275; the author’s sliding, 276; mir- 
ror, Frankel’s, 250; Jarvis’s, 249; plug, St. 
Ange’s, 280; snare, Stork's, 277 
Post-oesophageal abscess, 69 
Post-rhinal image, 255 
Probang, parasol-, 34; sponge-, 37 
Rectal feeding bottle, 39 
Resonator, Duplay’s oesophageal, 33 
Retro-nasal catarrh, see Post-nasal catarrh 
Retro-oesophageal abscess, 69 
Rhinal mirror, 249 
Rhinitis, traumatic, 297 
Rhinobyon, 279 
Rhinoliths, 435 
Rhinoscleroma, 406 
Rhinoscopy, anterior, 240; the application of, 
246; median, 248; posterior, 248; the appli- 
cation of, 254; by double reflection, 256 
Robinson, Beverley, his toothed and locking 
forceps, 269 
Rose catarrh, see Hay fever 
Rupture of gullet, 169; history, 169; etiology, 170; 
symptoms, 178; pathology, 178; diagnosis, 
179; prognosis, 180; treatment, 180 
Sarcoma in gullet, 109 
Schrotter’s porte-caustique, 260 
Schuster's nasal speculum, 244 
Shurly’s nasal shield, 258 
Smith, Andrew, his nasal insufflator, 259; his 
modified caustic-holder, 260 
Snare, Jefferson Bettman’s modification of 
Jarvis’s, 273; Hilton’s improved, 271; Jarvis's, 
272 ; the author’s polypus, 271 
Sound, pharyngeal, 24: oesophageal, 24 
Sounding the oesophagus, 26 
Spasm of the oesophagus, 211; history, 211; eti- 
ology, 212 ; symptoms, 215; diagnosis, 217; 
pathology, 2i7; prognosis, 218; treatment, 
218 
Sponge-probang, 37 
Stenosis, simple, of gullet, 165 
Stoker's rotatory polypus-forceps, 276 
Stricture of the oesophagus, cicatricial, 139; eti- 
ology, 140; symptoms, 140; position, 141; 
diagnosis, 141; pathology, 142; prognosis, 
143; case of' 163; treatment, 144; gentle 
dilatation of, 144; forcible dilatation uf, 
145; malignant, see Cancer; spasmodic, 102; 
traumatic, 103 
Summer catarrh, see Hay fever 
Syphilis of the gullet, 116; hereditary, of the 
nose, 398 
Syphilitic affections of the nose, 389; history, 
390 ; etiology, 391; symptoms, 392 ; diagnosis, 
394; pathology, 395; prognosis, 396; treat- 
ment, 396 
Synechiae of the nasal fossae, 469 
Tampon, Gottstein’s temporary wool-, 283; the 
author’s temporary sponge-*, 284 
Throat-deafness, 526 
Thrush of the gullet, 76 
Thudichum, hxs nasal speculum, 243 
Tongue-spatulas, 254 
Traction-diverticula, 136 
Traumatic (esophagitis, 53 ; history,53; etiology, 
54; symptoms, 54; pathology, 56; diagnosis, 
57; prognosis, 58; treatment, 58; rhinitis, 
297 
Tubercular disease of the gullet, 123; of the 
pituitary membrane, 400 
Tumors, erectile, of the pituitary membrane, 
378; malignant, of the gullet, see Gullet; of 
the nose, 385; of the naso-pharynx, 523; non- 
malignant, of the gullet, see Gullet; of nose, 
see Nose 
Turbinated bones, structure of, 239: occasional 
fourth, 236; arrangement of veins over, 239; 
erectile tissue covering, 239 
Ulcer of gullet, 52 
Veins, varicose, of gullet, 64 
Voltolini, his nasal speculum, 244; his palate 
hook, 250; his uvula noose, 252 
Von Troltsch’s modification of Frankel’s nasal 
speculum, 242 
Warty growth in gullet, 112 
Watson, Spencer, his nasal speculum, 242 
Whistler, his nasal inhaler, 266 
Wounds of the gullet, 187 
Zaufal, his funnels, 245 INDEX OF AUTHORS REFERRED TO. 
Abercrombie, 70, 74 
Abulcasis, 351, 385 
Actuarius, 323 
Adams, 170, 282, 283, 418, 421, 423 
Adelmann, 191,193, 495, 517 
AStius, 203, 323, 350 
Albert, 155, 158, 364, 366 
Albrecht, 451 
Alibert, 286 
Allbutt, Clifford, 23 
Allen, Harrison, 260, 423, 467 
Althaus, 453, 456, 461, 462, 464 
Amory, 218 
Anders, 155 
Andral, 78, 80,123 
Andrew, 197 
Anglada, 285, 287, 306 
Annandale, 95,151,154, 222 
Ansiaux, 494, 516 
Arantius, 351 
Arbuthnot, 76 
Aretseus, 337 
Arrowsmith, 111 
Atherton, 200 
Audibert, 64 
Avicenna, 84 
Axmann, 436 
Ayres, 221 
Azara, 440 
Baber, Creswell, 242 
Babington, 341 
Bailey, 170 
Baillie, 77, 84, 111 
Baizeau, 193 
Ball, 458 
Ballot, 70, 76 
Baraffio, 192 
Baratoux, 393 
Barras, 45 
Barthez, 71, 73, 75 
Bartholin, 435 
Basham, 141 
Bassereau, 392 
Baster, 209 
Bastian, 307 
Baud, 193, 199 
Baudrimont, 507 
Bauer, 453, 454, 461 
Baum5s, 248 
Baxt, 254 
Bayer, 331 
Bayle, 140 
Beard, 300, 301, 461 
Beaussenet, 428 
Becourt, 297 
Begin, 201, 517 
B<5hier, 54, 76, 84, 87, 88, 140 
Behr, 451 
Bell rends, 440 
Be If rage, 52 
Bell, 84, 125, 140, 192 
Bellocq, 279, 337 
Belz, 136 
Bendall, 410 
Benevenius, 450 
Bensch, 496 
Benson, 52 
Berard, 428, 452 
Berg, 78 
Bert, Paul, 66 
Bertier, 77 
Bettali, 214 
Betts, 467 
Beutel, 84,139 
Bevan, 30 
Bidau, 154 
Bierfreund, 193 
Bigelow, 239 
Billard, 42, 49, 78, 117, 285 
Billroth, 107, 118,133,193, 406 
Birkett, 501 
Blache, 78 
Blackley, 300 
Blake, Clarence, 272 
Blandin, 423, 428, 494 
Blasius, 125,126,165, 220, 432 
Bleuland, 41, 70, 77, 80, 211 
Boehm, 41 
Boerhaave, 77,117,169,179,181, 295, 351 
Bollinger, 410, 411, 412 
Bonet, 453, 458, 459, 460 
Bonnes, 506, 520 
Bonnet, 84 
Bordenave, 190, 381 
Borelli, 466, 506 
Bostock, 299 
Bosworth, 274, 312,319, 321, 335, 473 
Botrel, 495, 517, 518 
Bouchard, 414 > 
Boucher, 222 
Bouchut, 285, 294 
Boulard, 193 
Bourceret, 169 
Bourneria, 191 
Bouteille. 214 
Bowman, 172 
Boyd, Stanley, 170, 410 
Boyer, 187, 432 
Bozzini, 248 
Bradley, 155 
Brandeis, 471 
Braune, 18, 27 
Brazier, 131,212 
Breschet, 457 
Bresgen, 312, 313, 357, 473, 478 
Bretonneau. 82 
Brinton, 213 
Bristowe, 64 
Broca, 219 
Brodie, 220, 393, 436 
Bron, 432 
Brouardel, 410, 415 
Brown, 409 
Browne, Lennox, 168, 473, 479, 481 
Browne, W. N„ 436 
Bruckmann, 451 
Bruns, 149, 347, 495, 503 
Bruns, Von, 495 
Bruverinus, 339 
Bryant, 118, 155, 355, 363, 364, 379, 495 546 
INDEX OF AUTHORS REFERRED TO. 
Bryk, 150, 523 
Buchanan, 155 
Bucking, 135 
Budd, 232 
Bugantz, 155 
Butlin, 85,88, 97,100,151 
Callender, 155 
Camerarius,285 
Canton, 222 
Capart, 484, 492 
Capitan, 414 
Carmichael, 74 
Carron, 214 
Casabianca, 298, 417,429,433 
Casper, 54, 57 
Cassan, 165 
Castresana, 193 
Gatlin, 369 
Catti, 316 
Caulet, 71, 72 
Gayol, 140 
Cazenave, 312, 324,404 
Celsus, 77, 323, 350,385, 398- 
Chapman, 109 
Charcot, 417 
Charles, 170 
Charous, 414 
Chassaignac, 423,425,426,428,495 
Chauliac.Guy de, 351 
Chauveau, 208 
Cheever, 150, 496,515 
Chelius, 297 
Chevallier, 297 
Chevers, Norman, 193 
Chiari, 408 
Chrysostome, Dion, 390 
Chvostek, 123 
Ciniselli, 503 
Clark, Andrew, 155, 484, 495 
Claubry, Gauthier de, 194 
Clauder, 435 
Cloquet, 285,286,287, 288, 324, 338,425,428,453 
Closset, 347 
Coats, Joseph, 97, 111 
Cohen, Solis, 263, 292,312, 327, 467,484, 491, 503 
Coiter, 84 
Coles, Oakley, 486 
Colles, W., 348, 352, 355 
Cook, 436 
Coomes, 289 
Cooper, Sir Astley, 70,158 
Cooper, Samuel, 521 
Coote, Holmes, 331, 421 
Coquerel, 440,451 
Corbel, 417 
Comil, 60,290, 361, 406, 408 
Courant, 211 
Courvoisier, 155 
Cozzolino, 324 
Crato, Johannes, 323 
Crdquy, 348 
Cripps,Harrison, 511 
Cruveilhier, 78,130,165,221,360 
Cullen,337 
Cullerier, 525 
Cumin, 140 
Curling, 155 
Cusack, 117 
Cutter, Ephraim, 289 
Czermak, 241, 248,251,483 
Czerny, 107, 142,146 
Dallas, 110,112 
Daly, 300, 308, 357,359 
Darwin, 306 
Davasse, 392 
David, 487 
Davis, 221 
Davy, 128 
Daykin, 289 
Dechant, 416 
Decroix, 411 
De Gardi, Matthias, 435 
De Graef, 110 
Deguise, 506 
Delle Chiaje, 127 
Delpech, 297, 298 
Demarquay, 436, 495, 509, 523 
Dendy, 135 
Denonvilliers, 495 
Desault, 209 
Deschamps, 451, 453, 458 
Desgranges, 193, 508 
Deville, 392 
Dewar, 140 
Dieffenbach, 494, 507, 509,516 
Dionis, 240 
Dobell, 473 
Dolan, 213 
Dolbeau, 38,146, 506 
Donaldson, 364 
Donders, 285 
Dryden, 169 
Dubois, 111, 115,504 
Dumenil, 506, 520 
Dupareque, 71, 73 
Duplay, 72, 241, 254, 361,364,381, 386 
Dupuytren, 187, 200, 354, 510 
Du ret', 64 
Durham, 39,155,187,352,372, 379 
Durston, 220 
Dusaussay, 61 
Dzondi, 352,371 
Eberth, 64, 111 
Ebstein, 64 
Eckhold, 190, 201 
Edwards, 296 
Egeberg, 155 
Elias, 155 
Elsberg. 23,146,358 
Elliotson, 299, 314, 409,415 
Emmert, 466 
Emminghaus, 168 
Erichsen, 363,364,379, 400 
Escher, 155 
Espagne, 82 
Esquirol, 203 
Eustache, 494 
Evans, 120 
Fabricius ab Aequapendente, 323,351 
Fabricius Hildanus, 337, 341 
Fabry, 390 
Fagge, Hilton, 90,111,165 
Fauvel, 64 
Fayrer, 386 
Fenr, 451 
Fglizet, 157 
Fenger, 155 
Fer<?, 133, 378 
Fergusson, 364, 367 
Fernel, 84 
Fernet, 465 
Ferrand, 82 
Ferrier, 291,459 
Fischer, 503 
Fitz,170 
Flaubert, 494 
Flaudin, 204 
Fleming, 70,71,74,428 
Fletcher, 458 
Follin, 72, 85,117,149, 154, 212, 361,381 
Foot, 212 
Forcellini, 323 
Forest, 451 
Forster, Cooper, 92,155, 495.505 
Fournier, 192 
Fowler, 155,157 
Fox. 155 
Frank, 333 
Frank, J. P.,41, 64, 285 , 294, 337, 339, 343,349, 555, 
472 547 
INDEX OF AUTHORS REFERRED TO. 
Frank, P., 285 
Franks, Kendal, 140,145, 324, 327 
Frankel.B., 241, 324, 327, 328, 335, 341, 349, 357 
Friinkel, E„ 324, 330, 332, 333, 396, 401 
Frankenau, 457 
Frantzius, 440, 444 
Frt'dericq, 363 
Fridberg, 126,137 
Friedrich, 285, 287 
Fritsche, 88, 89 
Fugier, 141 
* 
Gahrlieb, 440 
Galen, 41, 64, 70, 84, 203, 323, 336, 350 
Gallway, 330 
Gamgee, 410 
Gant, 267, 364 
Garengeot, 493, 509, 517 
Gassner,135 
Gaubert, 381 
Gautier, 71, 73, 75 
Gay, 192 
Geber, 406 
Gebser, 191 
Gendron, 140 
Gerdy, 353, 375, 386 
Gerlaeh, 415 
Gernet, 221 
Gianella, 125 
Gibb, 159 
Gietl, 417 
Gillette, 71 
Glandorp, 351,*386 
Godinet, 196 
Godou, 118 
Golding-Bird, 95,155, 485 
Gonzalez, 440 
Goodwillie, 242, 384 
Gordon, 53, 299 
Gosselin,49o, 502, 503 
Gottstein, 283, 318,325, 328, 332, 334 
Gouguenheim, 131 
Grademvitz, 131 
Grafe, 35, 436 
Grammatzki, 170 
Grashuis, 125 
Graves, 42, 393, 409, 453, 454 
Greenhow, 82 
Greliant, 367 
Griffin, 170 
Gritti, 155 
Gross, 151, 162, 281, 348, 364, 372, 500, 523 
Gruber, 241 
Griiner, 352, 355 
Grynfeldt, 386 
Guattani, 201 
Gubler, 64, 65, 218 
Guerin, 506 
Guersant, 169 
Guise, 188 
Gul eke, 502 
Giinz, 324 
Gurlt, 419, 420 
Guye, 484, 492 
Gyser, 88,109 
Habber, 451 
Habermann, 241 
Habershon, 46, 87, 99, 348 
Hack, 300, 308, 318, 357, 358, 439 
Hadden, 64 
Hadlich, 151,168 
Haken, 191 
Haller, 423 
Hamburger, 23, 42,88,180, 212, 215 
Hamilton, 419, 420 
Hanisch, 357 
Hannay, 127 
Harrison, 192, 193, 415 
Hartmann. 328, 355 
Harvey, 525 
Heath, 146, 221, 514 
Hebra, 404,406 
Hedenius, 52 
Heister, 190, 352 
Helmholtz, 299 
Henech, 89 
Ilenocque, 186 
Bering, 436 
Herrgott, 506 
Heurtaux, 379 
H6vin. 190,192,193,200 
Heyfelder, 170 
Heymann, 168 
Hickman, 432, 433 
Hildanus, 341, 343, 345, 346 
Hildebrandt, 423, 466 
Hill, Berkeley, 120, 496, 509 
Hillairet, 297, 298 
Hilton, 381 
Hinton, 525 
Hippocrates, 77, 211, 285, 336, 342, 350, 385, 418, 
420 
Hirschsprung, 220, 221, 224 
Hjort, 155, 
Hocken, 72 
Hoffmann, 203, 211, 233, 337, 338, 341, 344, 349 
Holmes, Timothy, 151,154, 229 
Holmer, 151,193,194 
Home, Sir Everard, 84, 99,165, 214 
Honkoop, 41 
Hope, 449 
Hopmann, 376, 376, 377, 386 
Hoppe, 466 
Horsey, 143,150 
Horteloup, 187,188 
Houston, 221 
Howse, 158 
Howship. 84, 213 
Hueter, 364 
Huguier, 495, 517 
Hume, 155 
Hiinerswolff, 305 
Hunt, 106 
Hutchison, 456 
Hyrtl, 332, 466 
Icart, 494,505 
Ilott, 222- 
Jackson, V.. 155 
Jackson, Hughlings, 333, 458, 459, 463 
Jacob. 440 
Jacobi, 155,157 
Jacquemin, 437 
Jacquin, 357 
Jamain, 158 
Jarjavay, 426, 430, 506 
Joal, 357 
Jobert, 189, 516 
Joffroy, 416 
Jones, Sydney, 92, 155 
Jouon, 155 
Jurasz, 283, 423 
Kappeler, 107, 150, 155 
Kaposi, 404, 406, 408 
Keller, 54, 140,143 
Keetley, 346 
Kern, 435 
King, 435 
King, Wilkinson, 170 
Kirschmanm, 449 
Klebs, 65, 99, 127 
Klose, 135 
Knott, 42, 52, 117, 123,127, 168, 187 
Kohler, 204 
Kohlrausch, 239 
Kohts, 285, 293 
Kolliker, 224 
Konig, 65, 85, 100, 151 
Kbstlin, 436 
Krause, 324, 327, 328, 332, 333 548 
INDEX OF AUTHORS REFERRED TO. 
Krishaber, 38, 458, 459 
Kronlein. 155 
Kiichenmeister, 280, 347 
Kiihne, 135 
Kunze, 349 
Kuster, 155 
Kussmaul, 285, 293 
Labbe, 520 
LaboulbSne, 42, 43,45, 55, 71 82,113, 120,123 
Lafont, 500 
Lagneau, 417 
Lahory, 440 
Lallemand, 221 
Lamb, 222 
Lancereaux, 392 
Landouzy, 412 
Lanelongue, 146,155 
Lange, 451 
Lange, Victor, 484 
Lange) ott, 451 
Langenbeck, Von, 191,192,200, 202, 495 
Langenbuch, 157 
Langton, 155 
Lanzoni, 451 
Lapeyroux, 280,347 
Laprade, 193 
Larrey, 187, 195, 204, 217 
Lawrence, 513 
Laurent, 199 
Lawson, 433 
Lavacherie, 149 
Laveran, 401 
Lay cock, 338, 339 
Lebert, 85, 88,96,101 
Lecoeur, 417 
Lediberder, 64 
Le Dentu, 155,522 
LefFerts, 264, 466 
Legouest, 381, 382,383,433,520 
Lehmann, 222 
Lelut, 78 
Lemaistre, 433 
LdmeriS, 365 
Leriche, 355 
Leroux, 90,140 
Leroy, 193,199 
Leube, 40 
Le villain, 187 
Lev ret, 352, 494 
Levy, 221 
Lichtenberg, 375 
Lieutaud, 84 
Lincoln, R. P.,496,502,503,509 
Lindau. 130 
Linnseus, 447 
Little, 37 , 
Little wood, 155 
Lockemann, 462 
Loffler, 414 
Longoburgensis, Bruno, 385 
Longuet, 422 
Lorent, 293 
Lorin, 409 
Low, 155 
Lowe, 357 
Lowenberg, 274,289,312,424, 484,486,498 
Lower, Richard, 293 
Lazach, 221 
Luc, 417, 429 
Liicke, 155. 364 
T.udlow, 125,135 
Luschka, 129, 222, 223, 4oi 
Lusitanrus, 450 
Luton, 54, 85,118, 200 
MacCormac, 155, 496, 511 
MacGregor, 440 
Mackenzie, John, 358 
Macnamara, Rawdon, 338,339,549 
Macquart, 111 
Haddock, 363 
Maisonneuve, 123,146, 428, 465, 495, 516 
Malgaigne, 422, 423 
Mankiewicz, 440, 444 
Marine, 493 
Marchant, 130 
Mart'chal, 451 
Markusovzsky, 240 
i Marriques, 221 
Marsh, 300 
Martin, 191, 220, 324 
Martineau, 342 
Maschka, 221 
Masini, 334 
Mason, 155, 353, 386,421 
Massei, 244, 324, 328, 334 
Mathieu, 352, 520 
Mauriac, 391 
Maury, 118,155 
Maydl, 151,155,158,161 
Mayern, Sir Thomas, 323 
Mayo, 126 
McCarthy, 155 
51c Donnell, 524 
McGill, 155 
McKibben, 218 
McRuer, 372 
Meckel, 223, 224 
Menzel. 150 
Mellor, 221 
Mdplain, 193 
Merkel, G„ 138 
Messenger, 155 
Meyer, 170.197 
Meyer, H„ 237 
Meyer, Wilhelm, 277, 484, 486, 489,525, 527 
Meyrick, 416 
Michael, 276 
Michel, Carl, 241, 249, 312, 324, 328, 333, 363, 365, 
367, 374, 428, 484 
Middeldorpf, 17, 111, 374 
Mignot, 192 
Mikulicz, 32, 406 
Moinel, 404 
Moller, 155 
Mondiere, 42, 43, 46, 71, 72. 84 , 96, 168,191, 203, 
212 
Monneret, 65, 348 
Monod, 149 
Monro, 84, 111, 130,169, 203, 209, 212,214 
Montaut, 204 
Monti, 193 
Moore, 299, 440 
Moore, Milner, 155 
Moquin-Tandon, 440, 444,449 
Morand, 372, 494,516 
Morel, 440 
Morgagni, 70, 84, 89,109,125,140,168, 203, 313,337, 
312, 352, 452 
Morris, Henry. 496, 509 
Hosier, 339, 349 
Mott, 494 
Motta, 99 
Moure, 77 
Mouton, 17.19, 228 
Moxon, 117, 130,168 
Mulhall, 357 
Huron, 500 
Nannoni, 494, 516 
Ndgrier, 345 
N(Slaton, 364, 495, 497, 498,503,517 
Nessi, 494 
Nettleship, 316 
Neumann, 90, 386, 406, 500 
Nevot, 191 
Nicoladoni, 131, 150 
Niemeyer, 77 
Nisbet, 525 
Notta, 453, 455, 457,460 
Nourse,436 INDEX OF AUTHORS REFERRED TO. 
549 
Ogle, 129,134, 221, 453, 456, 458 
Olidedar, 440 
Ollenroth, 205 
Ollier, 495, 509, 505, 507, 512, 516, 517 
Ollivier, 381 
Oppolzer, 123,127,170 
Osiander, 409 
Padieu, 221 
Padova, 42, 43 
Pagenstecher, 221 
Paget, 496 
Palasciano, 513 
Paletta, 45,117, 386, 387 
Pallucci, 350 
Pamard, 381 
Panas, 238, 519, 520 
Pare, Ambroise, 187, 323, 385, 418 
Parkes, 188 
Parrot, 78, 80, 81 
Paul of JEgina, 323, 337, 351 
Pawlikowski, 191 
Pean, 386, 429 
Pellizzari, 406 
Perier, 222 
Peter, 290 
Petit, 155, 499. 516, 522 
Petrequin, 440, 444 
Petri, 87, 88, 99 
Petrunti, 70, 71, 72,76 
Peyer, 344 
Phcebus, 299 
Pinard, 221 
Pinel. 337, 342 
Pirogoff, 367 
Pirrie, 299 
Plater, 435 
Plenck, 525 
Pliny, 323 
Ploucquet, 440 
Podrazki, 118,150 
Poinsot, 95,150 
Polaillon, 222 
Porro, 222 
Portal, 64, 466 
Porter, 316, 357 
Postel, 507 
Pott, 386 
Power, 218 
Pozzi, 518 
Pressat, 453, 459 
Provost, 453, 459 
Primus, 363 
Prince, 444 
Prout, 437 
Puech, 341 
Purton, 125,127 
Pye -Smith, 155 
Quain, 17 
Quelmalz. 423 
Quincke, 233 
Rabitsch, 553 
Rampolla, 513 
Ranse, 33, 59 
Ranvier, 60, 285, 290, 327, 361 
Ratton, 496, 509, 518 
Rayer, 285, 409 
Raymond, 345 
Raynaud, Maurice, 212,254, 461 
Razoux, 449 
Reeder, 363 
Reeves, 151,155 
Reimer, 118 
Reininger, 324, 328 
Reinsch, 289 
Renard, 432 
Rendu, 381 
Rhodius, 117, 343 
Richard, 495 
Richet, 149, 379, 383 
Riedel, 401 
Riedlinus, 435 
Riesel. 155 
Rilliet, 71, 73, 75 
Rindfleisch, 99 
Roberts, 300, 311 
Robertson, 352, 464 
Robin, 78 
Robin-MassC, 495, 498, 514, 516 
Robinson, Beverley, 269, 312, 321, 322, 324, 473, 
47s, 480 
Rockwell, 461 
Roe, 37, 148. 300, 308, 359, 436 
Roederer. 221 
Roger, 417 
Rogerius, 385 
Rokitansky, 64, 99,101,103, 111, 126,137 
Ronaldson, 467 
Roosa, 262 
Rose, 155 
Rose, Cooper, 281 
Rosenback, 109 
Rosenmuller, 459 
Rosenthal, 216 
Roser, 511 
Rossi, 222, 420 
Roth, 502 
Rouge, 324, 510 
Rouse, 495 
Roux, 212, 495 
Rouyer, 436 
Runibold. 261, 312, 314, 473 
Ruysch, 117, 435 
Ryan, 49 
Sabatier, 372 
St. Ange, 279 
Sainte-Marie, Gaston, 29 
Sajous, 321 
Salisbury, 289 
Sampson, 109 
Sands, 496, 509 
Sander, 462 
Sandifort, 451 
Sanger, 395 
Santorini, 236 
Sappey, 18, 111, 423 
Saunders. 525 
Savialles, 435 
Schiifer, 357 
Schaffer, 324, 326, 331, 377 
Schilling, 4u9 
Schilz, 146 
Schlaeger, 462 
Schmieder, 110 
Schneider. Ill, 285 
Schnitzler, 285 
Scholler, 221, 223 
Sehdnborn, 155,157 
Schrotter, 241, 324 
Schuller, Max, 405 
Schuster, 244, 390, 398 
Schiitz, 414 
Schwartze, 527 
St'dillot, 95, 155, 209, 229, 509 
Seiler. 289, 297, 319, 358, 426 
Seitz, 82 
Semeleder, 29, 248, 423, 484 
Semon, 102, 339, 485 
Seney, 215 
Serres, 459 
Seux, 78, 80 
Severinus, 116 
Shaw, John 214 
Sigmund, 296 
Smith, Abbott, 299, 306 
Smith, Andrew, 155, 215 
Smith, Johnson, 339 
Smith, Priestley, 316 
Smith, R. \V„ 123 
Simon, 191 
1 Smyly, Josiah, 346 550 
INDEX OF AUTHORS REFERRED TO. 
Smyth, Carmichael, 169 
Sommerbrodt, 168 
Sonderland, 221 
South, 297 
Spencer, 357 
Spengler, 127 
Spies, 203 
Spillman, 352, 381, 392, 393, 407, 437, 496, 506, 507, 
511, 518 
Spitta, 198 
Squire, 82 
Steenberg, 221 
Steffen, 50, 79, 80, 82,118 
Stevenson, 212 
Stork, 29, 30, 249, 253, 254, 277, 324, 325, 335, 356 
Stoffel, 149 
Stoll, 285 
Stoker, Thomley, 524 
Strieker, 454 
Studsgaard, 146,151,155 
Sundewall, 222 
Susruta, 390 
Swiedaur, 525 
Sydenham, 337, 349 
Syme, 140, 386, 494 
Symonds, Addington, 292 
Taendler, 170 
Tantuzzi, 406 
Tardieu, 409 
Tarenget, 149, 494 
Tauber, 484 
Tay, 155 
Taylor, 54, 55 
Temple, Sir William, 287 
Tenon, 220 
Tengmalm, 440 
Terrier, 150,154, 201 
Theile, 423 
Thomas, 466, 495 
Tliouret, 436 
Thudichum, 241, 261, 352, 374, 384 
Tiedemann, 440, 451 
Tilanus, 221 
Tillaux, 134, 330,432 
Tillot, 312, 324 
Todd, 172, 357 
Tonoli, 111 
Tornwaldt, 401 
Trallianus, Alexander, 125 
Travers, 168, 409 
Trelat, 38,146, 520 
Trendelenberg, 82,155,159 
Troup, 155 
Trousseau, 324, 393 
Tulpe, 451 
Tiirck, 249, 252 
Turtle, 197 
Ure, 379 • 
Vacca-Berlinghieri, 152, 201, 499 
Valleix, 78, 80 
Valsalva, 343, 346, 367, 525 
Van Cruyck, 221 
Van Helmont, 212 
Van Meekren, 353 
Van Swieten, 41, 84, 89, 345, 525 
Van Thaden, 155 
Vater, 111 
Vauquelin, 285 
Veillon, 523 
Velpeau, 423,428, 506 
Verduc, 201 
Verneuil, 155, 158, 378, 379, 386, 433, 436, 497, 506, 
509, 523 
V6ron, 78 
Viennois, 386 
Yieussens, 323 
Viraont, 111 
Virchow, 117, 409, 414, 500 
Vogel, 55, 337 
Voisin, 497 
Volkmann, 390, 401 
Voltolini, 239,241, 246, 248, 249, 251, 252,256,364, 
367, 372, 374, 467, 483 
Von Langenbeck, 191,192, 200, 202 
Von Troltsch, 242, 527, 529 
Wagner, 81 
Wagner, Clinton. 259, 355,390 
Waldenburg, 30,135 
Wales, 253 
Walsham, 424, 428 
Walshe, 85, 196, 306 
Walton, Haynes, 415 
Ward, 221 
Warner, 221 
Waterman, 495 
Watson, 149 
Watson, Spencer, 360, 384, 391 
Watson. Sir Thomas, 77,131, 344 
Weber, 261 
'< Weber, 440 
: Weber, Hermann, 295, 399 
Weber-Liel, 241, 263, 525, 527 
Weber, Otto, 324, 419, 420, 523 
Wedel, 285 
Weichselbauni, 401 
Weigert, 113 
Weinlechner, 406 
Welcker, 424 
Wendt, 454, 473, 526 
Wepfer, 204,435 
Wernher, 168 
Wertheim, 248 
West, Charles, 82 
West, of Birmingham, 117,131, 420, 436 
Westbrook, 222 
Westphal, 463 
Whately, 494, 498, 506 
Whistler, 266 
Whitehead, 495 
I Whytt, 462 
I Wilks, 117, 130,131,165,168 
i Will, Ogilvie, 496 
! Willett, 150 
Williams, C. J. B„ 170, 293 
William of Salicet, 351, 385 
Willigk, 123, 221, 292, 400 
Willis, 203, 205 
Wilson, 204 
Woakes, 276, 334, 473, 484, 485, 526 
Wohlfahrt, 440, 450 
Wolff, 140 
Wolzendorf, 140,144 
I Worthington, 125 
: Wrisberg, 450 
Wyman, Morrill, 300, 306 
i Wyss, 111 
Yearsley, 525 
Zaufal, 241, 272, 324, 327, 332, 365. 492,526 
Zenker, 45, 52, 04, 75, 81, 85, 88, 96. 97, 99, 113, 123, 
126, 127, 133,136, 138,151.165, 175, 212 
Ziem, 331 
Ziemssen, 45,52,82, 85, 87, 90, 97, 99,100, 111, 113, 
123, 126, 133, 136,138,174, 175, 222, 234 
Ziesner, 71 
Znckerkandl, 236, 331, 332, 352, 355, 356, 361, 362, 
t 373, 377, 423, 466, 469, 527