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I Kegi>'t«reil iit Stntloiiers Hall. I^>nili>ii, Kii; l*liiliidel|ihia, P«.. V. S. A. : The Medital Bulletin PrititiiiK-liniise, 1111 1-IC Chun-) Street. V'S\ IN l.'KCOdMTloN OF HIS UNTIKINci KNi:i{(iV IN TM|.: INVMSTKiATIOX OF SCUFNTIFIC TIM Til HIS FMINFNT SKKVICKS IN TIIK \l>\ ANCF.M FN I OF LARYNGOLOGY AND RHINOI.OGY THIS VOLUMH n Al'KKi TI(»N.\TKI.Y DkiHi a IKIi TO PROF. E. L SHURLY, M.D., ■ir Ills SINCKliF FiilFNK: THH AUTHOR. ri{Ki-Aci<:. In Jildiiij,' (iiif iiMMv |i. the Inii^r 1,^1 ,,1 u.uk.-, llial liiiM' Ix.'uii j)ulj- li.-litd iiiM.ii iliscascs nl" Hi,, nose iiiid tlin.at tlu' iiiithor is iiwHrc that lie iias iiiKlcrtakcn iicillior a li^^lil ikh- aii irri'sponsihlt' task; and wcro it not Jur llic fact that tlu-nj is a ])i»)l" siuiml field in a hir-;c mcasiirt' still linon ii)Hc<| lie would not have vciiliind to present to the mtdiiii! piililic; lUiotluT Noiiiiiii' upon this suhjccl. ■*.^ ii pnicliiioiicr ulio foi' nearly iwenty \r,ir> was eiii^aired in ^'eii- <'ral 1)111(1 ICC, an ha- devoted hiin>elf ex- ••lusncly lo nose-and-tliroat work, he ha.- fre(iiieiill_v been struck witli the small aiiKUinl of knowledjie possoMd \,\ the jirid'ession at largo upon tli( diseases of these iiiijiortant or-ans. Tatients are sent to the speeiali-l n|' acknowledged skill, hy i)hysieian- of towns and cities far renioi.. in, in iIk residence of the speeiali>t himself. I'.iit these patients are the Inriiiiiale few: those who have coiiifortahle lioines with all that gooil lo(d. kind friends, and liygieiiie surroundings can do to re.-tore them tn health, a> well as means i.. pay the sjieeialist whose serviiT.s Ihey re(piirc. What ahoiit the larger nunihery the imju'cunious? the }K)or? Iho.-e who might pay a small fee for relief from constant siill'er- ing, hut who are iimihle to make hmg journeys, and to meet the obliga- tions rtupiircd hy staying in the city and remunerating the laryn- gologist for liis work? It is for physicians and surgeons who so fre- quently iiiict patients of this class and for students preparing for the regular practice of their prcd'ession that this hook is written. In this rushing age, when a thousand and one things demand the attention of the Inisy praelitioiu-r, any work of this kind to he of real nise must he terse and to the poiid. At the Siime lime, when the j)ro- fcssion is overcrowded, and the ]diysician's fees often small and dilli- cult to eollect. a large jiricc for a hook is often out of the question. 'lo meet these re«iuirenients in a reasonahle ami candid way lias heen the author's aim. Jn order to do this he has left out certain subjects which are n.su- ally considered to belong to this specialty. For this, however, there ia ample reason, as some of these are dealt with in works on general medi- cine, and others in works on ophthalmology and otology. This may be said of descriptive anatomy of the nose and throat, which is touched (V) VI I'liKT \ri:. ll|Mi|l ii|||\ .11 liir i|> ll I'clilli'. In llli |i|';li'l Kill I ri'ilt IIK'lll n|' illsriisc: ,,\' tllCSC nririlMS. I>i>('l|srs ul' lllr Ircillljll >lllll> ilinl lllr liHI \ lllill filllill, idlllllli: ll>-llilll\ limlrl' the iliiliiiliti III llli' (irllli>t. Ilil\(' IkiII left rlllil'i'lv lo iiit) cart'. Siill t'liitlirr. (Ii«fii>(« ol' ihr car iirc im! >|ii.k.'ii dt', r\((|it to Uic cxlcnl lliiit iinsii-|ilijir\ iiirtal (liM ii-t - iillVci ihr hlii^tiiiliiini tulic. Astliiim. too, is (lixiissnl irmri' cxlinii.-l i\r|\ m wi'll-irrn^'nizi'il wnrks (III •rcllcral llli'iiirilK' tllilll it cnllld lie within the lilllil> of tln'M' |l.'i;.r('>. iiml ciillMilMCIll ly llll> iml licrll tlrillid nl. Ill OIK citlur poilll it l.« Ii(»|mmI tlic |in)r»'-sii)ii will iijircc willi llii' iiiitlmr. aiiil tliiit is in tlif (VcliiMiiii (if ili|ilitlii'riii rrniii tlii> voIiiiih'. 'I'Ih' iin'iliciil litcriitiirr i<\' llic (liiv i> lull of till' >ulij((i. j'',\( ry nicdicjil joi.ritnl ol' iiiiy >liiiiiliiiu (llli tell till' liitrsi with rciranl to this iliscasr. Toxins iiml iiiitiloxin> iiioiii'|inli/c the iittciition ol' tlir iiicdiciil world, and yet tlic rviict ^^hihis id' oiir ami of ihr ollirr in rr^anl to thr |iro|)ajrat ion and picvriiii.iii of disrasf it may take another lialf-( mt iiry to fiillv and ali-ojulcly dclitic. It IS not thr authoiV de-ire |o *|ieak in any \\a\ »li^hli!i;^ly of the iiii|iortaii(e and interest i>\' lliese siil«Jee|-, or of the aii.«o|iite necessity fd' iiivcsiiiMl in;; to the ulniost all that « the de.-ire to enter as fully as s|tiice would |icriiiit into the many subjects within its ran.iie, iiiid to do so in accordance with the results of the most recent scientific invosti.iiatioiis. Iiriii<:in,ir the recoril (d' the art ami science of laryri^cdojry and rliino|o;,fy down to llie iiiiiiieilinto iresent Another ih'partiirc from tlie ordinary rule in works cd' this kind has hcen luade. It is one, however, for which, in the minds of most thinkers, tlie time has arrived. 'I'liis is the snhstitntion throuuMioiit the work of the metrical system of weights ami niea.-iirc.- for the (dd Koinan, which is gradually losing its grasp among the civilized nations of the world. in one otlicr point luis lie straycfl from the idd and well-heaten way, and that is by <>ntirely leaving out the eniinieration of synonyms. In carefully s(decting in eacdi case the title tliat lie deemcHl most ap- propriate, ho trusts that lio has made a selection thiit will l>e sufli- ciontly distinguishing, and at the same tiiiu' fully aece])tah]o to the r( ador. 1 rKKFACK. Vll In «nti(lnsion, tlic nudior. with imuli might mention particuhirly llishop, ('a.sselherry, l)ehivan, l''raenkel, (ileitsmann, (Jrant, (iriinwald. ileiyng, Ingals, .lonathan Wriglit, Knight, Kyle, Lake, Max 'I'horner, Myles, Morell Mackenzie, Noland Mackenzie, l{oe, Sajous, Semon, Shurly, Wagner, and Zuckerkandl. In his own city of Toronto he is umh'r ohligation to Professor Primrose fnr ihr serie> of frozen sections which he kindly permitted him to ohtain from the Museum of the Anatomical Department of the I'niversity of Toronto; and to Mr. Arthur Bensley, also of the nni- versily, for pictures of patliological sections furnislied hy the author. Ife would also acknowledge his indehtedncss to Jliss Wrinch for the care and skill with which she prepared many colori>d and Tndian- ink illustrations. Drs. Aniyot, Sweetnam, Caven, Carveth, and Wilson also cordially oontrihutcd a share to the pathological work required. To the F. A. Davis Co. the aiitlmr owes much for the unfailing promptitude and kindness with which he has always heen treated; and for the suggestion^ and e(>-()]K'ration which they have ever heen willing to grant. (viii) MKTinCAl- WKKiins AM) MKAM R|;s A\ri riiK.ijt K\(ir,IS|l IK^nVALKNTS. 1 ^riiii.iiir iiiiirkcd tliii.< I nuiiil.- l."..i;i; 1 tfiiti>;riiMiinc luarkt'd tini.s. . (il (t|ii;il« ' ,, (,, I millignimiiic inaikcl thus.. jOOl ».(|i!;il, ,il„Mii I •••■nti^'iaimiio is '/,„„ part of j. ^r,j,,nnw. 1 iiiilli'M-jii yiiiins. 1 ;:rain. L'raiii. i^M-ainuiu is V,o„„ pari r5.| fliiidoiinccs. 1 niftri' ('(jijals 3!>.;{7!t:!» inches. I c'lihic (cntiiMotrc, marked 1 c. inc In d li(iuids. as weil :■., cqiiai^ I ispcnsin^', n(>oordin/,' fo the m.ti iniiiirib a I as so lid.' "Vstciii. ill terms ;:ramn:o, eeiiti^'rammo, and mill are snppo.iiiii(l. 7: t'llliniiitl cells. 7; iiiaxilliUX' sinus. S ; ncrxcs. 11: liluod vessels. 11; f,'lan(ls. 11. CllAl'TKlt II. i'llVSIOI.()(a Ol 1111, .NdsK AM) .\( CKSSOKV Sl.MSK.S Sense of smell. I'J: llii' nose in plioi ation. I'J: the nose in respira- tion. i:i. ( iiAiTKi! III. — Instiu mi:n rs Iskd loit iiii-; F.xamina iion and TiiKM Mi:\T OK DtSKASKS OK TIIK Nosi; AM) 'I'mioAr I'",leetrie lani|i. 1."): lieadiuiirois. 1(1: .Mackenzie eoni-cntiator. 17: nasal s]ieculum. 17: Kosw ortli'-. IS: Slmrly's. IS; ( loodw illie's, IS; Myles"s. IS: Sincrock"s. IS; jiost rliinal mirror. I'.l; self- retaininir jialali' retriictor. 1!': roiioii a|i|iliciitors. 2(1; tonjiue- (le])ressoi"s 'Jl : atomi/e|s. -Ji' : insullialor-i. 'I'.l: jiost-nasal syriiifjfcs. 2.'!; coin|ire<>c(l air apparatiw. 'J.'i : uasiil ^aws, 21; <'liisels, 2"); iliills. 2('); cold w ire snares. 2(i: j.m1\ aiiocaufery siiiires, 27: spokcsliaves. 2S ; |iunclies. 2S: curelles, curved sci-sois. nasal hiiri*. etc.. 2S ; antciior rliinoscn|iy. 2!!; ))osteri(>r lliilloseo|iy. ;!(t. l)isKAsi:s Ol- IIII' NdsK. ClIAl-lKl! I\'. .VciTK IJlllMTlS I'alliolofry. ■i'2: cliolo^iN. .{2; syin|ptoniiilolo>,'y. .",2: dia^ruosis. '.V.\: |)roji;nosis. ;!;! : |)ro|iliyla\is. ;{,'! : treatment. .'!t. ClIAlTKIt \'. ClIliONK HlIIMIlS I'atliolofT.v. ;i7 : etiolojiy, ;f7 ; syiu|)tomatoloi.'y. .'(7; diafrnosis. 3S ; )irojj;iiosis. ;{S; treatment. .'^S. ( IIAI-IKU \l. I'lItCI.KNl KlllNiriS OK ( 11 1 1.DliKN I'atlioliifjy. 41; etiolofry. 42; symptomatoloe-y. 12; diajruosis, 42: [iroefnosis. (ili: treatment. 43. ( uvri Kii \'II. II vi'Kitritoriiic KiiiM ris I'at lioloify. 4,"): etiolofjy. 47; syni|itomatol()f>y. 4!t; dii\;rnosis. ")(); profrnosis. ft\ : treatment. 51; ojieration by eliromic acid. 52; i>|)eralion liy fralMinoeaiitery-knife, 52: ^'alvanoeaulerv snare, 51: operation l)y electrolysis. 55; turhineetoiny. 5(i: olectro- eauterv ]iiinctiire. 57; snhmucous knife incision. 57. (X) 12 32 37 41 45 (ON I lA IS. M 12 i:> .^2 37 n »,") t'HAPTEK VIII ATUOI'HK KlIIMTIS l*ath(>liij,'y, r»H: t'tiiiloj,'.v, riil; syinptiniialolu;,'^ till; (liii;:iiii>i->. (il ; luujriiuMs, »i2: trratnu'iit. tl2: use lt>tfiirs |(lii;is, t;J: tn-almt'iit h\ u\A<-i;{<:i\ M. CllArTKIl l\. (KdIMAKH S l!lll.MTI^*. I'A(.K. ."iS t'llAl'TKH X. I'lUUINDl s KlIlM I l> Ndii ili|ilitliriiiic. T'l: tiaiiitialic iiifiiiliiiiinni-. iliiiiii i-;. 72: t|ii(-< 'lion III' iili'iility of liliriiioiis i'liiniti-< with ili|>litlii ria. Tii. (.HAiTii! XI. l)i:i oKMiriKs ()!• iiii': N'asai. Ski- mm I'lcxaltiiic of -ciital (Icfni nlilit■•^ anmn;: rivili/id ray niptoinatolo^'y, SI: (lia^'no>is. SI; |.!otrno>is, S2 ; Irciilincnl. s-J : liy us*- of saws, s;{ : knixt's. S;{; liuns. s;i ; ln;;al>'s incllioil. S;i ; LoolTs indlioil. s;{ : liy i lc<)rolysis. S4 : liy n-c of sihcr tnla's, H't; liy Watson's nictliod. St!; hy usi- of inliltcr splints. SS. CiiArri'.u Ml. DisToimoN oi riii: Coii mnak (aim ii ai.i: CiiArir.n XIII. I'i:iti iiitATiiiN oi- nii: Scrii m Kliolo>:y. Ill : tifatnicnt. ill. .Mis.c-^ of the M'plnni. !I2. I'lci ra- tion of tlic septum. '.12. • >7 70 CiiAi'TKU Xl\. II. XV l"i:\ i:ii. (lit \ .< sdNKmiu ItniMiis I'at lioloj.ry. li.'t: ctioldi.'y. !I4; alinonnally sennit i\i' nci\ i' rcni ii'^. !I4; liy|i('iii'>tlu"»ia of tlic pt'iiplirral tciniini. '.14: |irt's»uri' of an irrita* injr aircnl . '.i.'i: tlic polirn IIh'oi'v, H."); llic uric acitl theory, !lti: syniptonia1oloinia. 1(15; fnnini ulosi-.. Id,"). CiiAi'i iii X\l. I'.nsi .WIS I'atholo<,'y, 1(1(1; etioloi.'y. l(l(i: syniploiiial(Ooi;y. HKi; diai:iio--is, 107: jiroijiiosis. |II7: treatment. Iti7. C'lIAI'Ill! X\II. li'lllNninils: I'ditl.It.N r.oliIIS: I ' \I!.\Si 1 i:s IJIiiiioliths. llii; >ym|itomatoloi_ry. IK): diaj.'nosis. 111; prot;no>is, 111; treatment. 111. l'orei;;n liodie-. 1 12; syniptoinatoloiry. ||2: dia;.'-|i"sis, 112: treatment. II.'!. .trasiics. li:t; Miiscii innii- tiiiiii. riiiniisiiiiniiii iinifti Ihirin. Ill: symptomatology. 111: I reatment , 1 1,'). CiiM'iKii Will. Nasai, I'm vim I'alholo^'y. 11(1: site of attaelimeiil . 117: eiinloMy. IIS; v\m|ii(im atolooy. 1111; dia;,'iiosi<. pJl; proe;Mo-i<, 121; treatment. 122; li.\ snares. l-_'2; liy the use of foicep-. i2."i: liy clectroh si<. |_'."(. ('HAi'lllt XIN. r.\l'Il.l()M.\ Sit ',11 '.i;! 1()» Hill I'atholojL'V. 12(1; treatment. 127. Ililateral tumors of tli l.xMiphoid \: ■rci't 1 \ariei\. 1: 'pi iim. treatment , CllAI'lKIt .\X. I'lltlidMA I'atholoe-y, 12S: eliolocry, IJS; syinptomatolojry. 12S: dia>riiosi I2!l: piojriiosis. 12!».; treatment. I2!l. History of a case, Kid. 12S xn CONTKNTS. PAOE ClIAI'TKK XXI. ADKNOMA: AsiiHiMA KVi Adciioniii, l.'12; an^rinniii. I.'t.'j. ClIAI'TKK XXn. -CY^ST()MA Ol Till-: NosK 134 ClIAl'TKU XXIII. ('MO.N'DIiOMA : ( )sTi;().\l A 130 C'lioiidroiiia. \'Mi. (Islcnina, l.'{(»; patliolciifv. l.'JT: cliolngy, l-'?7: Kyiii|il()inat<)I()}fy, l,')"; f rcatniciil, ]'M. ClIAI'TKK X.\l\'. SaU( .>.MA 13» l'atli!o;.'v. 144: diaj^iiosis, 144; profjiiosis, 144; Iroatinciit. 14"). ClIAI'TKK XXVII. 1,1 IT.'^; (Jl.ANDKKS 14(> l,ll|ilis, 14ti: iialliolofty, I4('>; ct inl(i!,'y. 14ti: sy ni])lomati)lny;y, 14tl; (liajfiiiisis, 147; prognosi's. 147; trratinciit. 147. ( ihindcrs, I4S. ClIAPTEK XX\I!I. - l{lllNOS(I.KKOMA 149 CiiAPTKK XXIN. SYriiii.i.>< 151 Muc()\H patch. I.'il ; siipt'i'lk'ial iik-cr, ir>I ; bony iiporosis, ir)l ; patli(>liiy:y, ir)2; symptoiiiatolofry. \'>'l: diafriKPsis, 153; proj^ iKisis, 153; trt'atiiicnt, 153. ClIAI'TKK XXX. roNCKMTAI. SY1'IIII.I.>< 155 Sviiipt<)inatol()fj;v. 155; diagnosis, 155; i)ro<;iio«is. |.")(i: tifalinoiit. ■l5(;. DiSKASKS OK ACCESSOKY Sl.MSKS Ol TilK No.SK. CHAI'TKK XXXI. ACITK SlMSITIS 1 i")9 Ktiolofry. I5!»; syinptoniatolofiy, Kid; tnatnicnt. Mil. ClIAI'TKK XXXIl. ClIKOMC DiSKASK OK TIIK AXTKIM OK Ill< IIMOKK lti2 Patliolofjy, Itlli; ctiolofry. I(i5; syiuptoniatolopy. lt»5; diafiiiosis. 1(1(1; pidjriiosis, l(i!); trcatinciit. Id!); first, by direct irrijiiitimi thioii>rli the ostiimi. 1(!!»; second, by o|ipiiin(j (hroiiffh (ho in- ferior meatus. Kilt; tliiid, by removini; a tooth and washing tliiongh (he alve(dus. 170; fourth, by opening (ho canine fossa, 170; tiftli, bv the condiined method. 171. ('\st of (he antrum, 174. ■ CllAI'TKI! XXXIII. IvrilMOll) DiSKASE 175 I'adiology, 175; eliology. 17(i; syuiploniatology. 177; diagnosis, 77: ]>rognosis. 177; (rendiient, 17!^. ClIAI'TEK XXXIV. Sl'IlK.NOin DISKASK 180 Frontal-sinns disease. IS I. SKCTION II. DISKASKS OK rilK I'llAKVNX. ClIAI'TKK XXXV. .\NATOMY OK TIIK PlIAKYNX 185 Houndaries, 1H5; openings in(o (ho jiharynx. IS5; mucous mom- hraiio, IH!); jdiaryngeal glands, l!t(l; arteries. IJtfl; veins, 100; nerves, 1!(0; naso pharynv, l!tO; faucial tonsils, 101; lingii.nl tonsils, 101. ^ Itl coNrKNTs. xi'i l»AOE ('IIA|-Ii:it XXWl PllYSl()l.()(iY Ol TUK I'lIAItYNX Ut.'J Division into niiso pharynx and oropharynx. 1!>.'{; the soft pahito, Mt.'i; lissnos of (he oro-pliarynx. 1!)3; (h'fjlutit ion. 1!>3: physio- h)^nral fnnctioim of the tfinsils, H14. DlSKASKS OK Tin: \AS0 I'HAHYNX, ClIAI'TKK WWII. NaSO lMIAUYN5 Pathology, lO'i: otiolofjv. |!MI; syni|iloni:ilnlofr\ . ijiS; diaHiui.sis, l!t!t; I'lroffnosis, 1 i'hauynx 223 Patholon-y, 22.3; etiology. 223; symptomatology. 224: diagnosis, 224; prognosis, 224: treatindit, 224. CiiAi'TEU XI.I.-Mai.ki.nant Diskasks (11 Tin: .Va.so i-iiauynx 227 Sarcoma, 227; jiathology. 227; etiology. 227; syinptomatologv, 227; diagnosis. 227: prognosis, 228;' treatment, 228. Carci- noma. 220. ( hondroniii of tho nasopharynx, 2.30. Foreign bodies. 2.30. l)isi:ASi:s OK TiiK Oho riiAHYNX. CHAI'TKK XIJI. .\( ITI- rilAIlYXOITIS 231 rathr)logy. 231; etiology, 231; symptomatology, 2.32; (iiagno.sis, 233: jirognosis. 2.33; treatment". 233: comparison of the values of eoeaine and eueaine. 233. CiiAPTKif XI, III. CiiHoxic riiAinX(;iTis 237 Pathology. 237: etiology, 237: symptomatologv. 2.3.S : diairnosis, 238; prognosis, 238; treatment! 23!t. TiiAi'TKi! XI. I\'. ToMK iT.Ai! I'll A H Y .\(irns 240 Pathology. 240; etiology, 240; symptomatologv. 241: diagnosis, 242; prognosis. 243: treatment, 243. CiiAi'TKit XLV. .VciTi: 'roNsii.i.rn.s. or (^iinsv 24.5 Pjithology. 24;"); site of abscess. 24t!: etiology. 247: svmittom- atology, 247: di.ignosis. 248; prognosis. 24!'t; treatment. 240. (Question of the time the abscess should be incised. 2.')0. Chapter XLVI.— Diseases ok the Cvi i a; (Kdema; Ki.onoation. 252 (Kdema. 252; etiology. 2.V2: symptomatologv. 2.")2 ; jirognosis, 252; treatment. 2.52. Klongatinn" of (he uvula." 253; patholngv,' 253; e(iology. 253; symptomatology. 2,")4 : diagnosis. 2.54; prognosis', 254: treatment, 255. Chatter XL\'ir.- Rethopiiaryxoeai, Ans( kss 258 Pathology. 258; etiology, 2.58; symptomatologv, 2.50: diagnosis, 2.50: prognosis, 200; treatment". 200. 1 XIV (II A I ClIAl (11 A I (11 A I (11 A I (HA I ClIAl ( IIAl ClIAl C'lAI ClIAl ClIAl CONTKNTS. PA (IE IKK XI.Nlll. lIvrKiM lioi'iiv ()!■ nil-: FAitiAi Tonsils •2(i2 l'iillit>lnj,'y. 2(i2: ct ioliifry, 2(14; syiii|it4iiiial<>l«i;x\ . 2(i4 : (liiif;iiii.-iiH, 'M't'y. ]niij;m>sis. 2(l(i; t icat miciiI. liliT : iiit'dical. 2(17: ^ur^'iciil, 2(17; toiisillotoiiiy. 2ti7 : sccniiilarv liii'imii rlia;.'i' at'tcr tonsil lotoiiiy, 2(>!l; (>|i<'i'ati()ii liv colilw ire snare. 27(1; sci.-sors. 270; caiitciy, 271. TKK XLIX. — LAtlNAll 'r<).\sii.i.iTis 272 l'atlii)l<)<.jy, 272; t'Molofry, 27:i: syni|>t()iiiati>|iiu:y. 27;{: (lia>;iir.,is, 274; ]ir; IrcatiiH'iit, 27'). ii:ij L. I'liAUVNCiKAi, .My( osis 277 J'afli;>l<)- cault'ry, 2S8; by liii<;nal tonsillotonic. 2HS: 1)\- hot or fold siiaio. 288. TKU lAl. — HK.NKiN Tr.MOHS Ol' TIIK IMlAUYNX 2!H) l*a|>iIloiiia. 2!M1; iiliroiiia. 2!t(): oju'iativc (rcalniciit. 2!il. .Vdcnoiua, 2!)l. Dermoid Imiiors. 2!t2. •ii:k I,1II.--Ti iii;i{< ri.osis oi- riiK I'iiauv.nx 293 I'alliolo<,'y, 2!t;{; etiolo{;y, 2!>.'{; syin|i1oinalolo<,'y. 2!14: (lia<;iiosis, 2!t4; profTiiosis, 2itr); treatment, 2!tr». TICK 1,1V. l.iiMs or Tin: I'iiaiiynx 297 Patliolojry, 2!I7: et ioloiry. 2!IS ; syinplomatolojry. 2!t8 ; diaj^nosis, 2!>!>: ilrof;>-osis. :{(l(»: 'treat iiiciit'. :{(»(). 1 Kit l,V. Syimums ok nil': I'hauynx .'?0I I'atliolojfy. .'{(tl ; primary, secondary, and tertiary lesions. :!()l: e(i- olorof5nosis. 323: treatment. 323. I SK( T|()\ 111. I)|SK.\SKS OK riiK i,.\i;ynx. ClIAl .'{ 1,X. .Anatomy ok tiik Fakynx 327 Anatomy of the eiieoid. 327; the thyroid, 328; the arvtonoids, 320; the epifrloUis. 3,30; the lifrinnents. 331: (he articulations. 3,34; the muscles. 3,3.'); (ho arteries. .33,"); the lyuipludics. 33'); the ni'rve-i. ;i3,") : (he mucoui mcmhranc. ,3.3,">. (()Nri:M>. XV r.xf.i: ClIAriKK LXI. I'lIVSlOl.iX.Y OK TllK I-AKY X .'!.'17 iMHictioiis of llio liirvnx. .'f.'!7 : ic«i|iiratiiiii. ;i;!7 ; )iliiiiial inn. ;f:fS; pitch, :VM: intensity. :i:i!i: ciu:ility, :!.{!•. C'iiAiTKii LXIF. LAUV\(ios( oi-v ;j4it The use of tlic tliroat-niinor. :{KI; t'xainiiiation of tin- laryn\. .'ftii; lioldinfif the tonf^iH", ;{4i'al conls. :\\2: po^ilioii of the ('[liirlottis. :iA2: piclnrc of tiic larynx. .'U:!: po-iiion of pa- tient in laryiif;oiiiffieal examination. ."{44. <'iiAi>Ti:u lAili. AfKiscoi'Y :il.') Chai'iku I.XIW Inti iiation :!.")(• < IIAl'IKK lAV. — 'JllA( 111:0 If)MY: TllYKoroMY ;!.")! Instruments re(|uire(l. ;i.")4: iliseases for wliieh tlic operation may l)f' re(|uireil. .'{.")4: nci'essity for anii'stlii"»ia. ;!.").">; eiioice of allies- tlK'tics. ;!.").■); tlie use iif eoeaiiie. 'iM; the hiirh op<'iation. :!.")7 : tlie low operation. .'!.")S ; thyrotomy, .'!.")S. ( llAl'TKI! I.XVf." ACI TK l,AltYX(UTIS I'.CrJ I'atholoMfv. ;{()2: etiolo}.'y. 'M'fl: symptomatohi;;y, :!();{; diagnosis. ."Ui.'J; ])ro1!i:n :!(i7 l'atliohi<,'y. ;i(i7; etiolojr.v. •iliS: liiaj^iiosis, .'{(iS: I'lrojrnosis. .'!()!»: "treatment", .'iti'.t. <'iiAi'Ti;i{ i.XVIII. — .\( iTK (Kdkmatois Lahymutis .{71 I'atliolofry. 1^71; etiolojry. .'i7l; symptoma1ol(ij;y. :','-2; cliaj;iiosis, 'M'2: ]ir(i^nosis. .'i7."{: treatment, .■{7."i. f'llAlTEU I, NIX. ."^IMlM.l. (Kni.MA OI- Till'. l.AHY.NN ^^7't I'atliolo^'y, .'?7"): etiohijry. •■!7"): symptoniatoloMy. .'!7">: ; jirojfiiosis. ,'i7(l: tieatnieiil . .■!7t>. CiiAiTKi! lA'X.- ( iiitoMc LAiiYNciiris ;!77 l'allioh]S4 ; iliaj;nosis, ;i,s."> ; jiro^fiio-is. .^S-); treatment.' 38,"). CiiAiTri! lA'Xir. l'A(iiYi)i:nMiA I,auyn(;is :!S7 I'atholooy. .'!S7: etiolojry. .'t.S7 : symi>toinalolofry. 3,SS: (]ia;.'nosis. ."iS.S: pi«ies of motion, 42.S. Spasm of the ghjttis, 42H ; i'liolofjrv, 423; symplomatolofry, 42.'V; (liatrnosis, 424; prognosis. 424; treatment. 425. I'aralysis of the laryn.x, 420. Alidiutor par;ilysis. 42t). Hilateral |iaraly«is, 427; treatment, 428. ClIAl'TKK LXXX. — XO.NMAI.ICNANT TlMOHS OI- 1 HE LaUYNX 429 I'aftilloma, 429; fibroma. 429; cystoma. 430; lipoma, 4;>it; an gionia. 430; sym])tomatology, 430; diagnosis. 431; prognosis, 432; treatment. 432. Knehondroma, 433; midtiple papillomata of children, 434; treatment by trucheotomy, 434. CiiAi'TEU T>XXX[. — Mai Ki.NANT Tr.Mo»8 ok the Larynx 436 J'athology, 437; symptomatology, 437; diagnosis. 438; jirognosis, 438; treatment, 438; endolaryngeal ojK'ration, 439; hnyngec- tomy by Solis-Cohcn o|K-rntion, 440; l)ehivan"s rules for gniil- ance, 440; Middiemas Hunt's case, 441. Ciiai TER LXXXIL — Foreign Hodies in the Laisynx 442 Svmplomatologv, 443; diagnosis. 443 ; pi'ogno>is, 444; treatment. ■ 445. Chapter LXXXIIL- Hoentoen Kays in Larynoeai, Sltroeuy 447 Chapter LXXXIV.- Operations for Nasai, Deformities 449 Annandale's operation. 450; Ellet's operation, 450; Roe's subcuta- neous operations, 451. Chapter IAXXV. -(H'krations for Ci.eft Palate 454 Stapliylorrhaphy. 455; MacDonald's opc'ration. 455. rrano])la8ty, 450; Ferguson's opei-ation, 450; Mason Warren's method, 450; lirophy's mctiiod. 457; before operation. 457; operation, 458; aft«r oj)oration. 45S: Owen^'s opinion. 459. Index to Literary Kei krinc ks 461 General Index 464 I-IST OF IIJ.rSTKATlONS. 11(1. I. s. it. Id, II. 12. 13. 14. 15. Hi. 17. IS. IS). 20. 21. 22. 23! 24. 25. 2fi. 2fiff. 27. 28. 28«. 28h. 28r. 29. .•to. 31. 32. 33. 34. 35. 3(). 37. 38. 39. 40. 41. Ciirtiliifjci of tlu' iiosc xM'ii ill |iri)lili' Sagittal section of skull, just lo the ri;,'lit of the septum, show int; ii;,'lit nasal fossa ^ Anterior section of the nostrils The ]>osterior rhiiiosco|iie iiiia<;e Frozen section of head of adult 1 color <-ut ) IMiillips's <>Iectric |ihoto|ilii.ne, willi adjusliiiciil for focusin<{ light.. Head iiiiiro.r '. ll( ad-mirror in posit ion Laryngoscope, gas stand, mirror, condenser. ;iiid liihiiig liosworlli's hirge and small nasal <<|(ecnla ressor Davidson's atomizers, to he useti liy eoni|u-essed air or hand-bull). . . . Hurgcsa's nielaltulie atomizers: straight, up, and down Mosworth's atomizer Compressed-air apparatus Powder-hlowor with mouth-jtieee and tube Powder-blower w ith bulb Powder-blower with tubing and bulb Powder-blower with scoop IJosworth's nasal saws Mial's reversible saw Hartmann's nasal chisels Freeman's drill Hosworth's nasal polypus-siuire Sajous's nasal polypus-snare Hall's nasal i)olypus-siiare Deneh's nasal polypus-snare Universal cautery and snare-handle, with cannula and snare Cautery-electrodes Nasal burrs Nasal trepliines Beren'a and Nichols's spokeshaves (xvii) I'Al' 111 II.M>II! \ll(tNS. no. r.\(iK •lii. Aiitciiiir iliiiiii^ii ni' the IkmiI I'm iii-ptii iti;,' tlic wnll nf llic |iliiii viix lliniii;:li the iiiwal iPiixwiijri's 29 ■4.'!. I'ltstt'iidr rliimisrii|iic iiiiii;."' 'M) 44. Jl v|i('ili<>|iliy nf mi. Idle :iii(| iiifi'iinr t iiiiiiiiiil« 45 4r>. Si'fliiJii nf iiUVriiir tinliiiiiilccl {■!'> iliiiiiicl(i-.i 40 4<1. I,!ir;fi' iiiii^scs nf liy|M'it ni|iliii'(l iiH'iiiliiiuic nil llic |)()>ti'riiir tcniiinii- tinll (if (he liivvcr t iirltilUltcil Ikhics, iikiic (if less coiiiiilcUly lillin;,' tin- |iii-i«ii(ir iiiiic-; 47 ■l(i»/. Aiilci inr |iiirliiin nf iiifciinr tiiiliiiial ('/..iiuli nliiccliNci 48 4(i/». l'(i>l('iior iiititidii (if iiiiVriiii- linliiiial (l-iiicli (iLJcctiN ci 4H 47. lialluiil },'al\aniu-aiit('ry lialh ry. with fiml. liamlli', and knife 53 4K. Knif>lit'N n!i>ial scissms fiCi 4!». Sliiirly's nasal forcc|i« 57 51). I'ost na-al --yrin;.'!' (i;{ 5((. I,t|il■///( r , illi ll iilijccl ixc; ccilul- cut I i'S Hti. Kfiiilosis of tnii-^il «illi liptdt liiix ('/,;iiicli (it)j('clivi': ((iliirciit i . . 27!> k7. llypt rlmiiliy "t tlif Nil liii;iiiiil tonsil 2M H'a. I'.ilatciiil li\ |ititroi)liy of liiiyfiinl Inn-il , . .• 284 HH. I.iii^iiial \;iii\ (lolo'r-rut ) 285 8!t. .Mil ros('o|)i(al section of iolif of lin^niiil tonsil 280 !)(). Itoc's lin;;iiiil ton>illoti.nH' 288 !•!. I.nims. I'alntiil a|i|icaiancc 2f)7 \t± l.n|iiis of linjrinl tonsil ('/.riiidi olijcdivc; Klirlich-lUondi stain: color-cut ) -Jiis 'Xi. Lupus of lin^'ual ton-il (' iiidi olijiiiivc; I'lirlicli lUonili ^-tain; color. Ml I •-'!"•» !tt. Malijiuanl i iiitliclionia, cxtcnilinj; fn ui rij,'lit tonsil to liasc of 1oii;.'U(' . . •'Ml !»"). Stialilii (1 c|iitliclioiiia of lon-ils (''.-inch ohjcclivci ,\\'l !)')(/. Kpitliclionia show inj; cell iicsts ('/..-incli olijcctixc i :i\'A (tli. ]{()l)crt son's calculus fimn ri^zlil ton-il .'!'J"J !•?. 1 lu' laifilafiinous frame of iIk' larynx, with the hyoiti Imne ami li^'amcntous atlachiiients .'t2S ftS. 'I'he crii'oid, seen anteriorly .■{2i» fli>. The cricoid, u]i|ier surfiiee .T2!l KM). The cricothyroid niuscle, \ic\\ed anteriorly 'V,W lOtV/. 'J'he \copv. 'MS 111. O'Duyer's int nhal ion-set '. ." " " . 350 112. Instruments for intwliation 351 113. Plated iraeheotoiiiy-tnlK" 354 114. Hard rnldier tracheotomytulie 355 115. Klsl)er 350 'J'lnrotomv (eolor-cnt i 350 I'. I, 1. iiryufroscopK' appearance 123. l.upns of the opifflottis (Vn-i'H'h objective; Khrlidi-Hiondi stai eoloi- cut ) 400 407 124. I.upus of the epijjlottis ('/.-inch ohjective; Khrlicli-Miondi slain: ef)Ior-eut.) 408 125. l.ejirosy of the tonijue and epiglottis 413 12(!. Destnietion (,f cpifrlottis from s\philitie ulceration 415 41(1 410 127. ( ieatricial stenosis of larynx, tlie result, of syiihilitie idceratic 128. Lennox Browne's hollow larviiwal dilator with enttiiifr-tjlade 129. P«i)illonui of cord during rps))iration 420 XX LIST (»K Il.I.USTHATlONS. no. 130. 131. 132. 133. 134. 135. 130. 137. 138. 139, 140. 141. 142. 143. 144. Sumc during plionalitui Fibroma situatt-d hcncutli tlie rifjiil vonil lord Chondroma of Mip epiglottis Angioma of the left arjepiglottic fold Kxtirimtion instruments Sarcoma of tlie larynx, as seen from heliiiid Tooth-jihite in glottis Tooth-iilate removed ; ; / ; • Laryngeal polypus forci-ps, Maeken/.ie'.-,, revolving, with three altaeli- ments r.aryngeal polypus forceps, \\ axliam's Laryngeal polvpus forcc)s, I'raeiikcrs, culling jaw Laryngeal polypusforcf ps, Mackcii/.ic's, articulated Load iilate for nasal uveli Steel pill for nasal transfixion Nasal ajiplianie in i"Hit ion '.VOB 429 43U 431 431 433 43(i 442 443 444 444 44r) 445 449 449 451 r.voK 421) . 4ao . 4:u . 4:u . 4:j:» . 431) . 44-2 . 4»;j 444 . 444 445 . 445 44» , 44i> . 451 S1{(TI{)N I, Diseases of the Nasal Passams. f I llAITKIf I. ANATOMY OF TlIK KXTKKVAl. NOSH, NASAI. PASSAGES, AM) A( ( KSSOIiY SINLSKS. TilK outer iKxi' ('(insi.-ls nf ilic \i«ililc jinriiim nT that organ, t'omposed of lioiu's, cartilajics, lilmtii.-; tissue, umsck's, integument, and mucous inemhraiu". It contains, within, the two vestihulae, sepa- rated from eaeh other perpentlieularly hy tlie anterior portion of tlie trianguhir cartihige (Fig. 1) and tlie iiiti'rnal union of tlie h>wer lateral cartilages. The lateral wall.s are Torined liy tin' nasal hones, and the nasal processes of the superior ma.xillary Ixmes, together with the upper and lower lateral and sesamoid cartilages. The septum dividing the two nas^al cavities from each other is formed directly helow the triangular cartilag<\ already mentioned, hy an additional narrow slip of cartilage at the entrance of the nostrils, termed the "columnar cartilage." The openings of the anterior nares are usually on a lower level than the floor of the nosi"; and they are also ]»rotectod hy a " "her of stilf hairs, or vil)rissa>, which line the nostrils and the vesihuio. The various muscles of the nose are attached to the external walls and are for the i)urpo.>o of dilation and contraction of the nostrils and for the elevation and depression of the orjran. The nasal fossa3 are two cavities ahout equal in size, extending from the nostrils, or anterior nares, directly hackward to the naso- pharynx, and entering it hy the posterior nares, or choanas, as they are sometimes called. These cavities vary very much in size, the average depth from heforc hackward in the adult heing ahout 5 centimetres, and the height 3.5 centimetres in the centre of the fossie. The sum- mit of the vault on each side is only a narrow chink, arching from the front to the hack; while the floor runs almost horizontally hack- ward, with a surface varying hetween 1 and 1 Vj centimetres in width. The external walls of the passages slant irregularly outward and downward (Fig. 2). (3) 4 i)isi;.\si;s OK jin: ^.\^Al. tassagls. Tlio si']iliiiii divides the fossji' fi'oiii caoli other from front to back. ]{ is fiiniicil of ilic Iriaii.uuhu' cartila.L; ■ in front, the pcrpen- dicidar ]ihitc of the I'thiiuiiil in ihc nppi'r portion behind, with tlie vomer inuiicdiately heiicatii it. In eaily lilV the septum usually oc- cujiies its natural eeniral jiosilion; diii'iiii;- youth and eonimeneing Jiiaturity it very fre(iuently heeonies delleeted in some part of its course. Fig. 1. — (■utiliiLic^ 111 I III' iiiiM', x'cii ill ]ircililL' (Ijapin'yj. 1, Right lateral cartilage, li, Its aiiterim- lionler. ."i, .\n aecofsory cartilaginous nucleus attadied tii. I. Iiui-dv cidinl. i?, limd palate. :t, 4, Parts of median cnis of thr caiiila^r,. ,,f tlic a]iiitiiiv. .">. Aiitciidi- part of tlio same eartilaf;,-. (I, Caiiila^.'c <>i the sc|itiiin. 7. (iniuvc 'cadin;,' to niidilio meatus. 8, Aa-;y,T nasi. !i. |-nni(ai sinus. 10, Inferior etlmioid eomlKi. 11, Superior etlunoiil eonelm. 1',/^ Snperinr meatus or etlimoid fissure. 12, Recess of uiner meatus. i;{. Vjitranee t<> spliemiid sinus. 14, Pituitary fos.sii. 15, Sphenoid sinus, id. inferior turliinal (nnixilhiry eoneha). 17, Rod passed into Kustaeliian tube. IS, Salpinj.'o-])lnuyn-roal fold. 10, Soft palate. 20, Ivulji. 21, Tonjiue. (.\fl.r henm.x Hrow tie, IS't!).) 6 ])isi;.\si;.s oi' thk nasal passaciks. one. extends right through tlio nasal cavity from front to back along the hony wall, and is attached to tlie othiiioid, the superior maxillary, the lacrymal. and the j)alate hones. The s])ace between the sujierior turbinated and the middle one is called the sujterior meatus; tliat be- twci'U the luiddle and iul'crior tuiliiuateils. the uiiddie meatus; and the lloor of the passage behiw the inferior turbinated, the inferior meatus. Tlie roof is formed by the up))cr portion of the nasal bones in front, and the cribriform plate of the cthmoii! behind: the lloor by the liori- 12 — Fifj. 3. — Anterior scctidii nt' tlic iiostiils ( Liisi'hka). 1, Septum of llie narcs iit position of tut)er(le. li. Micklli' luibinatcd l)0(ly. ',i, Inferior t ,- binated l)0(ly. 4, Suiicrior turl)iiiat(' nares. 9, Olfac- tory portion. 10, Floor of the nares. 11, Cavity of right antrum. 12, Opening from antrum to nostril. i;{, Kthnioid eells. 14, Hoof of the nasal f()Msa>. If). Floor of the nnsal fossa'. 10. Cavity of oibil. (After Lennox l^rowne, 18(10.) zontal processes of the suj»erior maxillary aiul [)alate bones (Figs. 3 and 4). The. accessory cavities or sinuses are the frontal sinuses, the sphenoid sinus, the ethmoid cells, and the antra of Highmorc, all opening into the nasal cavities. I'.acu frontal sinus opens into the corresponding middle meatus by a luirrow canal called the infundibulum. I ANATOMY OF THE NOSli. 7 The sphenoid sinus is divided into two irregularl} -snaped cavities, situated in the body of the splienoid; Ihoy are separated from each other by a tliin septum of bone. The canal into each communicates with tlic superior meatus of the corresjuuidinir side. Tlie opening is usually not more than a millimetre in diameter; and the roof, sepa- rating the sinus from the brain, nut mure than two millimetres in thickness (Fig. 5). This sinus stands alone; and, while it is more difficult to reach, its isolation, fortunately, renders it less liable tu disease. The two divisions of the sinus are rarely equal in size; and the septum is frequently to one side of the centre. The ostium on each side is high, although less elevated relatively than the ostium maxillare. An important feature to remember about the sphenoid sinus is 'n the all Fig. 4. — The posterior rliinoscopic iiiiayc. i, St'pluni. 2, Middle tur- binated bone. 3, Inferior turbinuted bone. 4, Superior turbinated bone. 5, Superior meatus. G, Middle meatus. 7, Inferior meatus. 8, Main passage of nostrils. 9, Vault of pharynx and pharyngeal tonsil. 10, Cushion of soft palate. II, Posterior surface of uvula. 12, Jtidgc formed by levator palati. 13, Salpingopharyngeal fold. 14, Salpingopalatine fold. 15, Eustachian pioniineiice or cushion. 1(1, Fossa of Rosenmiiller. 17, Eustachian orifice. (After Lennox IJrosMU', 18!)!>.) its near rel-ation to the cavernous sinus and nerves i)assing into the orbit. The ethmoid cells, situated in the lateral ma.i>«tcri driven tlirough them; wliile the cliaracter or individuality of the voice itself is dependent largely upon the mouth, pharynx, and the formation of the nasal ciuunbers. Tlie soft palate has a great deal to do with correct phonation, and, to perform its duties well, should be perfectly free from ob- structive lesions, either in tlie naso-pharynx above or the tonsillar region beneatli. TlIH XOSE IX IJESl'inATIOX. is Tile triple function of saturating, cleansing, and heating the uir of respiration, as it passes through the nasal fossic to the throat, is probably the most important of all the duties which Nature has assigned to this organ. It luis been i)roved by experiment, over and over again, that ordinary dry air, containing only a minimum of moisture, becomes saturated as it passes through the nose during inspiration. This added moisture is olitained from the serous exuda- tion of the mucous membrane of the turbinateds. This fluid exudes from the cavernous sinuses, caused by the stimulation of the air as it ])asses over them, and is sliglitly diluted by the mucus from the tubular glands. These venous jilexuses, which perform so important a function, are named by Zuckerkandl Scliicellkorper, or swell bodies. In a healthy condition they are fully surcharged with blood, and the serum passes out by transudation, to be absorbed by the air during inspiration. The amount of moisture thus given of! by the healthy nose in twenty-four hours is estimated at about one-third of a litre and, as can readily be seen, plays an important part in the ])henomcna of normal breathing. To in,sure this supply of serum, the sinuses of the turbinateds are always filled with blood, yet this hypera?mic con- dition, normally, is not sulTicient to produce stenosis of any part. Kverywhere throughout the nose, however tortuous, these narrow passages are open; and the air of respiration becomes saturated while ]iassing through them. At t'.'" same time the air becomes elevated in temperature by contact wiui the hot, moist walls, being many degrees nearer blood- heat by the time it reaches the pharynx than it was on entering the anterior nares. n DISEASES OF Tllli NASAl. I'ASSAtiKS. Tlien, also, tlie air is inirificd as it passes throu]ij:]i the nasal })a?sagc>. Insects, heavy dust, and minute foreign hodics are hirgcly kept out by the fringe of vibrissa', wliieh stands guard over tlic en- trance to eacli nostril. It is, however, the moist nasal mucosa which does the chief part of tiie cleansing, the myriads of leucocytes and mucous cells acting as phagocytes and destroying the invading hosts of noxious germs as they advance backward from the vestibule. U. L. AVagner says: "The action of these leucocytes docs not consist in their total destruction, but in greatly diminishing their activity." Whether the normal mucous secretion is a germ-destroyer or not is still, in some degrees, an open question, pathologists differing upon the sul)ject. Still, one thing is certain, that, whereas the mucus of the vestibule is always loaded with microscopical germs, that in tlio back ])arts of the normal nasal passages is almost, if not entirely, free from them. It is possible that a great deal of the cleansing process is (Inc. however, to the oft-repeated etTorts of Xalurc to eject, by forcible exjtulsion, anything that irritates the nasal passages. The special function of tlu' large antra of Ilighmore is probably one of jilionation. Filled, as they are. by air when in a healthy con- dition, with free openings into the na«al chambers, they may give additional vibration and tone to the voice, whether in vocal exercise or ordinarv use. ■:* CHAl'TKK IIJ. INSTRUMENTS USKI) FOR JllK KXA.M I NATION AND TKi: \T- iAIKNT OF Dl.SEASFS OF TlIK NOSE AND TIIHOAT, Fou tlie successful examination and treatment of nasal iliseascs we require the aid of arfiflcial light, either reflected from an electric lamp i)laced on the forehead of the surgeon (Fig. 0) or from hricrht Fig. C.-Phillips's electric pl.otophone, with adjustment fm- focusing liglit. "light of some kind placed on either side of the patient and relh^.ted, from the head-mirror of the operator, upon the part to he examined (tigs. 7 and 7a). The ordinary plan, and the one largely adoj.ted hy specialist^ Jip the present date, is the latter one. The light should he on a level with the patient's nose, and on a plane a little posterior to it Ihe surgeon sits immediately in front of the patient, and hy adjust- (15) 1 IG DISKASKS OF TllK NASAL I'ASSAdKS. Fi". 7. lli'iid niirrcr. i 1 Fig. 7«. — Ilead-niirror in position. ing the head-mirror the fociis of light is thrown directly upon the spot to be observed. The advantage of this arrangement is that, by INSTIMMIAIS AM) TIIICIK ISi:!*. 17 looking' with oiie I'Vc lhroii;rh the hole in tiic mirror and with tlic otluT past its odjic, lie ciitiri'Iy escapes any direct rays of the lij^ht from falHn^ upon his own retina. The eiiaracter of the lif^dit used is of some ini]»ortan('o. An inclosed li^dit in a dark corner of tlic room is host. The li<,dit itself shoidd he hri<:ht, clear, and steady, placed, if possihle, in a MacKeiizie concentrator or one of the more modern forms (Kijr. >^). It may he hy electricity, gas, or nil. I'lven a Fig. 8. — Laryngoscope, gas-stand, mirror, condcnsiT, and tubing. (After MacKenzie.) tallow candle, if notliin;;- l)etter can be obtained, may be of good sen-ice. For anterior rhinoscopy tlic nasal speculum is rccjuired, the ol)- ject being to open the nostril painlessly to its widest capacity for the admittance of light. Of this instrument there arc many varieties, of Avhicb Figs. 9 to 13 are samples. Each surgeon must make his own choice. I have found those of an ovoid, cylindrical form much the most convenient, protecting the nostril and admitting abundance of 18 DISEASES OF THE XASAE PASSAGES. liglit. Some like a spring-wire instrument. Shurly considers a spe- cial protection to the nasal wall opposite to the side operated on to Fi witliui the nasal cavities, anteriorly Fig. 21.--Tongiie-(lci) J)i-c.ssor. Fig. 22. ' rongne-depiosaor. Fig. 23.-Sass'.s tonguo-doprcssor. '■" H.o purpose (Fis. Jy'"'''"'''"'^ «"■ f™m f=nl-s specially devised t; 1 1 i 1' 22 DISKASKS or TIIK NASAL I'ASSAGES. ■ I Fig. 24- Tiirck's tongue-depressor. Kig. 25.^ — Davidson's atomizers, to be used l)y compressed air or hand-bulb. Fig. 26. — Burgess's metal-tube atomizers: straight, up, and down. IN'STRt'MRN'TS AVP THKIK fSKS. '2-3 Fig. 2r)«.- liosworth'a afomizor. Comprpssod-air iipparatus. 2. Insufflators, or powder-blowers, of wliicli also there are uiany in the market (FigfJ. ^8, 2S«, 281), and 2Hr). 'I'he name is indicative of their utility. Also post-nasal 8yrinp;es. I " .;m 24 DISEASES OF THF NASAL PASSAGES. i H"! ^'^' Fig. 28. — Powder-blower with inoutli-piece and lube. Fig. 28«. — Powder-blower with bulb. Fig. 28ft. — Powder-blower with tubing and bulb. Fig. 28('. — Powder-blower with scoop. 3. Nasal saws, of wliicli l?os\vorth's is the model upon which most of the others are founded (Figs. 2J> and 30). They are used INSTRUMENTS AND TIIKIU USES. gg to remove segments or sections from tlie nas-,1 senfnm t? » • Fig. 29.^-]5os\vortl,'8 nasal sau.. Fig. SO.-Alials reversible saw. Fig. 31.— Hartniann's nasal chisels !|J; ill 2G DISEASES OF THE NASAL PASSAGES. Fig. 32.— Freeman's drill. Fig. 33. — Bosworth's niisal polypus-snare. Fig. 34. — Snjoiis's nasal polypus-snare. 5. Cold-wire snares of many varieties are exceedingly valuable for removal of polypi, as well as other growths within the nasal cavities (Figs. 33 to 36). INSTRUSfENTS AXD TIIKIR USES. 27 Fig. 35.-nall's luisal polj pus snare. Fig. 36.-Doneh's na.sal polypua-snar Fig. 37.-UniversaI cautery and snare-handle, ^^i th cannula and snare. :% ii ble isal Fig. 38.— Cautory-eleetrodoa. 6. The galvanoca-utery-siiare is also receivofl ulH, u Quartpf'? ^FJfr •?7\ +1 i , ittcnoa with iavor in some i'j V'S DISKASKS Ol' TIIH NASAf, I'ASSA(iKS. l-'or the latter, ("annaiilt Jones's spokesliavc, with various mollifica- tions of it, has hocn received with marked favor in iMiglaiid, wliile on this continent it has nsuallv not Ix'cn Vidiicd so IiiLxhlv (I'Il:. II). E D m B l-'ig. 31). — Xa*il huiTH. Q I'ig. 40. -Nusal tn'pliiiK'ss. (Cuiiisa.) ]''i;^. 41.- Hcri'iTs (1) ami XicliolsV cii sjidkcsliavi s. 'J'o the above might be added punches and curettes, curved scis- sors and knives, forceps and clamp.s, a? well as other instruments spe- AMKUIOlt UlllNOSCOI'V 'J!» ciiiDy (lovi.-('(l I'or uso in partiiiilnr cnscs. Nasal burrs for antral as well as sL']ital uuil: tiiav also he inciilioiicd ( l'"i>.'. |ieiu- liiiii ( Fi,u'. 1'.') i- iiniy liniiled, when eonlined to one pnsilion; init l)y niiivinix tlie iiead in dilfeieut direelions, a ,ixreater part (d' tlit.' na.-al (•avity can l)e Krought siiceessively into view. 15y looloiTza or dist'liarizc Froquontly the iuilaiuniatnry aclidii extends to the jiharynx: and soineiiines. thouiih unt very ol'teu. to the var lOU?: accessory vi\\ liie: and lu' lacrvnial ( Uiet. Pathology. — The coninieiuenient of the disease is the period of con,i:!'estion, with arrest (>•' secretion, and is common, during the lirst stau'c. til all inllanimalions of nnicous mcnihrane. This is followed hv transu(hition from the uorsied venous sinuses and increased seere- lidii of mucus from the glandular structures, Tl lesc her urae on the exfoliative processes of the niGmhrane, and leucocytes, as widl as epithelial cells, are thi'own off in vast numhers. ju'oducing niuio- lundent discharae durimi' t le la iter staii'c of the disease Etiology. — The most common cause i-; exposiire to cold. This is particularly the lase with susceptible ])ersons. In these the su(hlen impression of a fall in temperature seems to paralyze the vasonuitcn* lu'rves of the naso-mueosa: and, the control of the capillary circula- tion beiuLT lost, the nu'ndtranes become congc-^ted. The extent to which this congestion occurs before the inhibilnry power is restored wiiuld imlicate the severity of the disease, in some casi'-: acute rhinitis is caused by exposure to acrid vapors and irritants of one form or another; while in not a few instances it is primarily due to the pr^- existcMice of chronic rhinal disease. It is also one of the early indica- tions of certain of the exanthemata, particularly in the case of measlo?. Acute rhinitis is more prevalent among children than nnumg adults. Wagner believes that it is often produced by migraiions of micro- organisms from diseased tonsils into the nasal cavities. Syinptoiiiatology. — 'i'lie first symiiiom is nsually that of dryness ACU'"1-: HHINITIS. X\ of the nostril?, at'cumpauiod liy iiioie or loss frontal '■ pi\ision and sneezing. There may he ehilliness, lassitude, and slight I '/file action. The tingling si'nsation within the nostrils is (jnickly followed hy sero- mucous discharge. The llux may he serous at lirst, then sero-mucous, and finally muco-pus hefore the discharge ceases. Tsually a certain amount of febrile action takes place. If the frontal sinuses are affected, frontal oppression and head- ache are the result, wliile the extension to the luistachian tubes and pharynx render syinpt(uns in connection with these organs apparent. Irritation of the coiijiiiuiiva, with discharge of tears over the cheek, would indicate that tlu' hurymal duct was sutl'cring from tein[)orary occlusion. Sometimes the nasal stenosis is very distressing, necessitating oral breathing. I'Lxcoriations of the lips and al.T, by the discharge of acrid secretions, are likewise often jiroductive of much discomfort. The sense of snu'll may also be alVeeted during the severity of the attack. Diagnosis. — Tiie group of sym])toms descril)ed are so character- istic llial diagnosis should l)e easy. The mucous meml)rane is at first >\vellcd ami red; then bathed in serum; and gradually, as tlie color becomes lighter, muco-pus takes its place. 'I'be jwistcrinr clioana^, examined by the rliinoscnpe. reveal the niidille and inferior tnr- binateds swelleil, l>athcd in disciiarge, and lu-aclically tilling up the nares. Other mucous membranes involved in tlie intlammalory action all jiresent a similar pink and swelled condition. Prognosis.- — Kavoralile in a large majority of cases. It involves no danger to life, and usually disaj^pears in about a week. '^Fhe real danger lies in allowing colds to f(dlnw each other in such quick suc- crssicm as to prevent the nasal mucosa from resuming its normal 'one. IVrmewan and Carter have also reci'utly drawn attention to the possibility of severe systemic' infection neiuLT induced liy ibis disease, cases being rcporteil in which |)i'(d(>i \L;ed illtn.-s and continued fever, otherwise unaccountable, were entirely removed by antiseptic intranasal treaiment. Prophylaxis. — To tb.ose inclined to the disease regular habits of life are impiu-tanf. Daily cold bathing either by plunge or sponge, when followed by promiit reaction, is an important ]>reventive. Clothing shoidd be comfortable and equally dividcfl over the body. Heavy neck wrappings are always ol)jectionable. Heavy furs worn bv the ladies while callimr and left on in hot rooms often have :■! u 34 DISEASES OF TUE NASAL PASSAGES the effect of producing cold on returning to the street. Wearing of wet garments, which tlie exigencies of weather or occupation so fre- quently render necessary for the time, will rarely during active exer- cise produce injurious effects, but it is the continued wearing after the exercise is over that does the harm. In short, if people would systematically use good common sense in their daily walk of life, the colds from which so many people suffer would be very much rarer than they are. Treatment. — ISTothing seems to check the general feeling of malaise, attendant upon acute rhinitis, so quickly as quinine in ^7^- gramme doses. 1 prefer to give it in capsule form, repeating the dose each morning while the disease lasts. In strong vigorous adults a gramme might bo given to commence with, taking the smaller amount after the first day or two. In young children Y^ or ^/g gramme, ac- cording to age and bodily habits. A saline cathartic is al.-;o beneficial; and the feet put in hot water at bed-time, followed by a stimulating drink of ginger-tea or hot lemonade. The object aimed at is diaphoresis and restoration of the nf.tural equilibrium of the whole body. If there is unrest and wake- fulness, with flushed face, acetanilid in V^-gramme dcses might be repeated once or twice during the night-time. For the same purpose minute doses of morphia and atropia in tal)let form arj often given; the combination has the advantage of the astringent effect of the atropia upon the mucous membrane: — 1. R Atropia aulph |0013 ilorph. sulph |0(i5 M. Fiat in pil. x dividenda. Sig. : One to be taken every four or six hours if required. For Local 'Treatment. — 2. 1} Menthol |0 Alholonc 001 M. Sig. : To be used with an atomizer to tlie nostrils several times a day. 1. H Atropia sulph gr. Vbo. Morphia sulph R"". j. AT. Fiat in ])\\. x dividenda. 2. 1\ Menthol gr. x. Albolene Sij. M. ACUTE RUINITIS. 33 Or 1. H Thymol 1 12 Menthol \:i Albolene tio'j M. Sig. : To be used with an atomizer to the mintrils several times a day. Eitlier of these will be found an excellent remedy in this disease. Bishop, in his recent work on "Kar, Nose, and Throat," strongly recommends 3 per cent, of camphor-menthol in lavolin as a spray in acute rhinitis. It has a similar action upon the inilamed mucosa to the ones just referred to. Lennox Browne, in the new edition of his valuable book on "Diseases of tlie Xose and Throat," speaks emphatically of the value of menthol in the treatment of diseases of these organs. Speaking of this "remarkable drug," he says: "1. It stimulates to contraction the capillary blood-vessels of the passages of the nose and throat, always dilated in the early stages of the head-cold and influenza. 2. It arrests sneezing and rhinal How. 3. It relieves pain and fullness of the head by its pain-killing properties. 4. It is powerfully germi- cide and antiseptic." All these statements, with the exception of the one referring to sneezing, I have agreed with for years. The sternutatory effort is frequently produced by the first api)lici ns of the menthol-spray to the nose; but the mucous membrane soon becomes accustomed to the slight irritation, and subsequent applications will be borne with- out difficulty. When the symptoms show tardiness in abating, recovery may often be hastened by using stronger solutions of the stearoptenc-! in the hydrocarbon menstruum. For instance, the menthol mnv be doubled or tripled to the same ijuaiitity of albolene, mid the ame may be said of thymol. In this case, however, they sliould be inhaled directly into the mouth from the atomizer, and, the mouth being dosed, exhaled through the nofic. When there is much nasal stenosis, there is sninetinies a teiii|iia- tion to use cocaine, owing to its ])o\ver as an astringent in producing immediate relief. It is unwise, however, ever to place this remedy 1. IJ Thymol pr. ij. I\Ien1 liol trr. v. Albolene 5ij. M. 3 36 DISEASES OF THE XASAL I'ASSAfiES. in the paliont's hands. The relief it afrords is only temporary, and the more frequently it is used, tlie more rapidly does reaction take jilace, with return of the swelling. The danger of forming the co- caine-hahit makes it imperative to confine the use of this drug to the doctor's olTice. After the vascular ])letliora has passed away and the exudation diminished Bosworth rccummends tlie application of chromic acid to the still swelled memliraiie. After coeainization he apjilios minute crystals of tlie acid to the promiiuuit portions of the inferior turbi- nateds, with the view of pinning down tiie parts and so securing con- traction. AVherever I have fouiul cautery treatment necessary, it has always been in ca>es in which some previously existing hyper- trophy denunuled the operative treatnu-nt. Dry lieat api)licd to the forehead is sometimes of benefit in the later stages, relieving tlie frontal headache ami taking away the full- ness wliicli so often is feU over the root of the nose. ClIAPTKK V. (TrHOXFr HinxiTis. 'J' 1 1 IS i> a chrniiic intljiinination (>( the na>al imicnsa licarinir a direct, relation to the aeiite disease. Some oliservers lielieve it to he the cause of the oft-repeated occurrenee.s of the hitter, while others look upon it as the elTect. The last mentioned is prohal)ly nearer the truth. The entire mucous membrane nuiy he involved, and tlie dis- ease may extend to the iMistaehian tul)es, the lacrymal ducts, and, as in the acute ilisease, to the accessory sinuses. Pathology. — The mucous memhrane is thickened and puffy, while tiie venous sinuses are chronically relaxed. Interstitial infil- tration is the result, hut of a changeahlc character. Freciuently will one nasal fossa he affected, closin<^- it sulhciently hy cedema to pro- duce complete nasal stenosis, while fin- the time the other is free enou jircsence of slriictnral lesions and hy[)ertrophies. Symptomatology. — The most prominent symptom is a constant nasal discharge, chiefly of a muco-jiurulent character, whicli induces oft-repeated efforts at blowing and hawking. In aggravated cases the nares are filled with a pasty, yellow matter; and the constant efforts to void the discharg(\, in some cases, produce swelling and redness of the nose, as well as eczema or ulceration of the anterior nares. Owing to the limited proportion of serum exuded, the secretion often be- comes dry, resulting in crust-fornuition about the nostrils. To liberate thi.s, j)icking is resorted to, with gradual destruction of the (37) illi 38 DISEASKS OF THE NASAL I'ASSAUES. il I "^ 1§ mucous nionibrane; and, in some cases, the septal cartilage eventu- ally becomes perforated by this digital irritation. The disease occurs most frequently between childhood and early maturity. Diagnosis. — There is sometimes a nice distinction to be made be- tween chronic rhinitis and Jiosworth's purulent rhinitis of children. In the former the disease may occur any time after early childhood, but rarely during that period, while in the latter it always occurs during early life. In the former there is less purulent discharge than in the latter, while, owing to the shorter period of its exist- ence, there is less likelihood of its culminating in atrophy. The diagnosis between this and hypertrophic rhinitis is more easily made. The application of a 4-per-cent. solution of cocaine for the time will shrink away the infiltration of chronic disease, which it cannot do with the enlargements arising from hypertrophy. On the other hand, when of long duration, it may resemble and even be the initiatory stage of atrophic rhinitis. Prognosis. — In the region of the great lakes of this continent chronic rhinitis is very prevalent, owing to the humidity of the at- mosphere and the variability of temperature. As these cannot be avoided, the prognosis as to permanent result is not very encouraging. If proper means are adopted, however, a cure can be accomplished, though the tendency to return may still exist. When long continued, the disease is likely to culminate in clironic hypertrophic rhinitis. Consequently a guarded prognosis as to ultimate results should always be given. Treatment. — Regulation of the pmnce vice and toning up the general system are in many cases necessary and can be done on the principles of general medicine. Locally, the nasal ])assages will require systematic cleansing. For tliis, alkaline sprays will be required; and, of these, what is called Dobell's may be considered the best type. All modern English writers on disease of nose and throat acknowledge the utility of DobcU's solution, and give credit to Dobell for introducing it to the world, yet scarcely two of them agree upon its formula. I have be- fore me the most recent works of Sajous, Bosworth, and Bishop; and in giving ihe formula of Dobell's solution, while they all agree as to ingredients, they all differ as to quantities. Here, I think, lies the intrinsic value of the preparation as a type, the combination re- maining intact, while the proportions are varied, according to the judgment of the physician in charge. CHRONIC RHINITIS. 39 (or sh of Ihe lee les je- ll e My own rendering of Dobell's solution is the following: — 1. R Sodii bicaili 21 I Sodii bibor 2 Aeidi earbol 1 Cilyei'iin 15 Aquuiii ad 250 ;M. Sig.: To be used with llif atoinizpr to thr iioso, as re- quired, several times a day. The advantage of this and similar preparations, used freely as sprays to the nose, is that they are l)oth alkaline and disinfectant, acting as solvents to the muco-purulent secretions, which require to be removed. After clean.sing, oleaginous sprays are indicated for their sooth- ing, protective influence upon the mucous nu>ml)rane. The oil used as a menstruum slimild be one of the recently-discovered hydrocarbons, as from their mineral origin and chemical composition they can never become foul or rancid. It matters not whether it be liquid vaselin, lavolin, glycolin, albolene, or any other of the many that are in the market, so long as it is pure, colorless, inodorous, aiul unirritating; but these requirements arc essential. The one I have generally used is albolene. The medicament dissolved in the oil should be of a slightly stimulating and antiseptic character. For instance, 1 to 2 per cent, of menthol in albolene, ^/^-peT-ccni. thymol in alliolene, 1 to 2 per cent, of eucalyptol in albolene, 1 per cent, of crcasote in albolene, or 1 to 2 ])er cent, of camphor-inonthol in alljolcne. The first and second of these I have used moro extensively than tiie others, the treatments being repeated from one to three times a day. The treatment of atrophic rhinitis by massage, introduced several years ago ])y Braun, of Italy, induced me to try it also in simple chronic rhinitis. He used probes with olive-shaped tips; and. passing one into the nostril, guided by iiead-mirmr aiul nasal speculum, would, by tremulous pressure of the hand, ]U'odiico vibration over the diseased tissue. The method T have followed, though copied from Braun, has been of a simpler nature, and would be practiced on each visit of the patient for treatment. R Sodii bicarb frr. xxx. Sodii bibor ,!-'r. xxx. Aeidi earbol ptt. xv. Cilycerin 3iv. Aqiiani ad Jviij. M. m 10 ])lSi;.\SKS OF THE NASAL PASSAOKS. Tlic end of an ordinary nasal cotton-carrier would l)e wrapped firmly with a small })ledget of cotton, the thickness of the temporary tij) beintf made to accord with the width of the crevice in the nasal ])assa\ })roper care, coml)ined with gentleness of touch, massage of the whole mucous membrane can he done without the use of cocaine, and with very little discomfort to the patient. With eacli ajiplicalion the used pledget is stripped olf and a new one aj)j)lied almost in a moment — three or four being required for each nostril at one sitting. After massage a spray of alholene or sinular oil is all that is needed. ]n a large uumber of cases this treatment has been attended with very satisfactory results. The usual ollice-forraula has been: 1. Cleansing the nasal fossiu by a free spray of DobelTs solution. 3. Massage of both jiassages. '•>. Application of a spray of alljolene to each, for iHUiie-trcatment the patient has been instructeil lo use simple ch'ansing sprays, as required, between the visits to the ollice for massage — the latter being re])eateil every second or third day, a few treatments oidy being required. Of the two methods, 1 have looked upon the massage treatment as more elfectual than that of simple medication. In the posterior thickening of the septum, which so frequently occurs in the chronic rhinitis of adult life, we have a combination of oedema with epithelial cell-proliferation. It is usually bilateral, ami exists in the form of a perpendicular ridge, a little in front and on each side of the posterior edge of the vomer. The hypertro])liy is, in some cases, so great as to seriously interfere with the nasal breath- ing and to necessitate operative treatment. This is best done l)y the galvanocautery. After cocainization the l)lade is passed into the nostril and, guided by the post-rhinoscopic mirror, the membrane is freely singed. No special after-treatment is needed; and after a week or so, by which time the surface will have healed, the operation can be re])eated if required. CIIAITKU VI. PURULENT KIILNITIS 01" ( HILDREX. lioswORTii was the first to clearly and di'Cmitcly outline i)iiruleiit rliinitis and to place it on the list of representative nasal diseases. Other writers had spoken of it before, jtarticidarly MacKenzie, Stoerck, Fraenkel, and Cohen, but it remained for ]>oswor(h to recog- nize its lull importance and to intimate the position which he believed it to occupy in the etiology of atrophic rhinitis. Pathology. — As described by him, it is a disease peculiar to the earlier years of childhood, its prominent feature being tiie chronic discharge of purulent nuilter from the anterior nares. This discharge is purely local, and not dependent on constitutional diathesis. In the earlier stages there is increased secretion of mucus, with ra|)iii ^\c!^- (piamation of epithelial cells. The discharge gradually assumes a pu- rulent form, and after lasting a nuiidicr of years results in the shrink- age of the turbinated bodies and the development of atrojiiiic disease. In support of this theory J3oswortli says: "That in youth the epi- thelial structures are especially liable to become the seat of diseased action, whereas in adult life this tendency seems to disappear, and in place of it there obtains a tendency to the involvement of the con- nective-tissue structures. Thus, in the earlier years of life we notice this tendency in the development of enlarged tonsils and follicular disease of the upper air-tract, as well as in the vulnerability of the lymphatic glands, wliei'i>as, in adult life, inflammatory changes in the mucous membranes result in true connective-tissue hypertrophy." Wagner also expresses the same opinion when he says: "During childhood the skin and mucous membranes are more excitable; more prone to disorders of the circulation. The function of the lymjihatic glands is prominent in childhood; the cpiantity of lym])h is increased; the lymphatic glands at this time have their greatest development." Hence the tendency during childhood would appear to be toward the abnormal development of glandular, adenoid, and lymphatic tis- sues in the throat and naso-pharynx, and to proliferation and des- quamation of epithelial cells in the nose itself. (11) n 48 DISEASKS OF TlIK NASAL PA88AOKS. Etiology. — Tlie literature regarding the etiology is very scant; but, as it occurb in otlicrwise iicaltliy and rugged children, struma and hereditary syphilis are not considered potent factors in its pro- duction. Bosworth ascrihcs taking cold from unhygienic conditions, and also neglect of the ordinary rules of health, as the only assignable causes. From my own experience, I believe we frequently have more direct causes, and that the pathological tendencies already referred to as incidental to childhood are suflicient to produce the disease. In many cases th*at I have seen the purulent rhinitis has been associated with hypertrophy of the faiicial and pharyngeal tonsils. These bodies have been so large as to interfere seriously with nasal respiration. In these cases the adenoid enlargement and the epithelial desquama- tion ran side by side; but, owing to tlie stenosis, it was impossible for the purulent discharge to make its escape. Like a ilowing well, it ebbed out and over the surface, while the retained discharges produced irritation and continued development, as a consequence. That the adenoid enlargement was the real cause of the purulent rhinitis seemed verified by the fact that the removal of the tonsils and ade- noids would be followed by cessation of nasal discharge and restora- tion of normal breathing. Some cases undoubtedly do occur with- out the co-existence of tonsillar hypertrophy, but the majority that I have seen have, at least, been associated with adenoids. This view is borne out by the experience of Lennox Browne upon the same subject. Symptomatology. — The chief symptom is the continued discharge of yellow muco-pus from both nostrils. During the night-time con- siderable quantities flow out aiid are deposited upon the pillow. On examining the pharynx, the V.'ce discharge, perhaps slightly grayer in color, may frequently be seen trickling down behind the soft ]ialato, the yellower color as it exudes from the anterior nares being due to freer oxidation. The blocking of the nostrils necessitates mouth- breathing, which is still further aggravated when adenoids are present. Fcetor is of rare occurrence, except late in the disease, when it is gradually assuming the atrophic form. Diagnosis. — The continued presence of the anterior nasal dis- charge is a strong point in diagnosis. Another one is that it is bi- lateral and odorless. In scrofula and syphilis the discharges are offensive in odor and often are bloody, and accompanied by systemic manifestations indicative of the disease. The presence of a foreign IMUll.KN T IIIIIMTIS OF CHII-DUEN. 43 body or rhinolitli would 1)o dit^tinfruiplied hy being unilateral and the discharge accompanied by malodor. Sometimes ]iurulent nasal dis- charges accompany the develojimont of exantheniatous diseases; but in these cases the history proves the relationship, and the unpleasant symptoms are short lived. Rhinoscopic examination anteriorly, after the removal of the dis- charge, will reveal a slightly swelled and reddish condition of the turbinateds and septum, but without ulceration; while, posteriorly, grayish or yellowish-green mucus will be observed in the naso-pharynx. Prognosis. — Without appropriate treatment tlie prognosis is bad. There is no danger to life, and it is a self-limited disease; but the limit extends over so many years that serious results of a permanent character follow, unless the limit be l)roken. When adenoids co- exist, they naturally comnumce to shrink away about the tenth or twelfth year; and with the shrinkage comes freer nasal breathing and drying of the mucosa. r>ut during the years of the purulent rhinitis the epithelial layer has slowly wasted away, and the follicles and mucous glands and venous sinuses have all been involved in the shrinkage, while the relief from the adenoid absorption has come too late to prevent the occurrence of the dreaded atrophy. In the early stages, however, before the vitality of the mucous membrane has become exhausted, a hopeful prognosis may be given, provided proper treatment is instituted and carried out. Treatment.— The first step in treatment is to ascertain whether adenoids are present or not. If present, even if not very large, they should be at once removed; as a limited ])ost-nasal swelling, coupled with the purulent inflammatory cfuidition, will ])roduce severe steno- sis. The removal of these growths lias a double cirect: First, by direct depletion of the parts by the liaMuorrhage resulting from the operation, and, second, by the permanent removal of the obstruction; both of which have the effect of checking the purulent inflammation. Consequently the su])sequent treatment which I have found most effective has been of the mildest character, sprays of albolene alone, or of 1 per cent, of menthol in albolene, or Vj P^i' cent, of thymol in albolene, two or three times a day, for a short while, to the nostrils, being all that has been required to effect a cure. In cases where it is inopportune to operate, or in which an operation is not required, the nostrils should be thoroughly cleansed by the use of a good atomizer several times a day, using either a mild saline or alkaline solution. Dobell's solution to which has been added 44 MISKASKS OK llli; NASA I, I'ASS \(i KS. V4 pci' cent, of tliyiiiol is an I'll't'ctivc! cloniLsiT. Of others. 1 per cent. of chloride' of sodiiiiii in water, or 1 per cent, of chlorate oi iiota.ssa in water, will either of them do ^.'ood service, a few drops of ^.dycerin being aiUlcd to give softness to tiie soliilidM. Tlie spraying of the nose siionld each time he followed hy forcible blowinir to remove the pus. After this IJosworth I'ecommends spray- ing witi: mild astringent solutions for the purpose of controlling cell- I)roliferations, and he iu.-luuces the following nuuuig others: — 1. It (llycciol laiiiiiii 4' Aquiim ad UUi M. 2. U Arj,'ciil. iiilnit 12 Aiiuiiiii ad ;((»[ M. 3. U Alnniiii-. |((o A(iuam ad .'idi M. Altlu)Ugli I have often tried them, 1 have never heer favnrahly impressed by the \i>o of a(|ueous sprays in this disease, ^'oung chil- dren are exceedingly averse to the irritation jtrodnccil hy tluMu. The objection is frei[uently so greai that to secure tlu' successful use of tlie atomizer tbe pbysician is obliged to apply it himself, wbicli is usually impracticable, when it reiiuircs to he \\>r(\ more than once a day. The sprays of bydrocarbons, on tbe other hand, arc so line and imirrilating that they can be borne by tbe child with impunity, and the parents or guardians can ajtply them without any ditViculty. They possess this advantage, too, that a single preparation will answer all purposes, thus simjdifying the treatment. In some cases sprays of albolene or glycolin alone, repeated several times a day, have been sufTicient, while in others 1 to 2 ))cr cent, of menthol in the bydro- o;irbon and ^/., to 1 per cent, of thymol in the like menstruum have been required. Other drugs as well — as eucalyptol, oil of caraway, creasote, etc., in small quantities in tbe neighborhood of 1 ]ier cent. — could also be used to advantage in these only ajiparently intractable cases. The use of these preparations, however, do not detract from the importance of the removal of obstructive lesions when they exist. 1. B Glycerole of tannin 3i to Jj. 2. R Ardent, nitrat. t;r. iii to ,?j. •'). B Aluininis trr. \ to Sj. ,;! " {•ii.\rri:i{ vii. iivrKUTiioi'inc miiMTis. This is a rlironic iiilliiiimiiitinii of tin- iiiiicnii.^ mombrano of the uusal passii^ii's all'cctiiiji ihii'tly tliu turltiiiatL'il Ijodics ami ueeurriiig most i'l'L-iiiU'iitly during tlu' early years of maturity. Pathology. — 'l"lic iiiiicou> nii'iiilniiiit' of the miiMle ami inferior turbinatods, particularly tlic latter, is tbiekeued and eorniyated (Fig. 44). The snrfafe-epitlicliiiin is hypcrtropliicd, sninetiiiies extt'iiding ii IH Fiff. 44. ilv|icrtin|iliy nf iniiliilc mikI inferior tnihinals. i.\l't<'i- l!iis\\(i)tli. I in a .stratiiied form into the eoimcctivc-tissiu' layiT lieiicatli. Tbis secoml biyer is lil\e\\i>e eiilargt'd, owing to ])roliferation of new tis- snc-elements, wbieb freipieiitly become fibrous in character. The cavernous sinuses below, together with all the Idood-vessi^ls of the miicnsa, may bcciune permanently ililated. the glandular elements likewise being affected, the racemose glamls having increased in num- bers. With all tliis coud)ined bypertropby. there is little epithelial desquamation. In advanced stage~ nnective cells, produc- ing the want of tendency of these hypertrophies to undergo spon- Fig. 4r).— Section of inf.rior (iirliiiialid iLT) diainetiMs). o, Stratified ciliated opitlielium. b, (Jlitnds of siil)imi(osa. c. Sinus of erectile tiaauo. d, irter\. t', Vtlii. f. ]|y|icitrc])liie(l (nil)iiintt'(l Imne. fAnthor'a speci- men by Ik'nsley.) llYrKIlTROPHlO imiNITIS. 47 taneous resolution. In some cases the hypertrophy involves the tur- binal bone also, as shown in microscopical section (Fig. 45), Of the inferior turbinatcds, all parts are about equally liable to enlargement, with possibly a predominance of tendency in the pos- terior end (Fig. 46), while in the middle turbinated it is the anterior end that is usually involved. The Figs. 4Ga and 4G& give histological sections of portions of tlie anterior and posterior ends of the inferior turbinated. Etiology. — Anything which will produce continuous partial ste- nosis in the anterior end of one nostril has a tendency to produce m Fig. 40. — Large niassos of hypertrophied niembnane on the posterior termination of the lower turbinated bones, more or less completely filling the posterior narcs. (After Uosworth.) turbinai li\])ertrophy on the same side. A little consideration will make the I'cnson of tliis iilaiu. Inspiration of air ihroiiiih the nar- rowed inlet iiiiMiediately produces rarefaction Ixliiud the obstruction, owing to the forcible manner ii! wliich the air i.s drawn through the passage. This rarefaftiou means diminished atniospher.c pressure, repeated with each inspiration, and, acting on the soft tissues of the turbinatcds, it produces a tendency to abnonnal congestion. Consequently any malfmination of tlie front end of the septum, whether of traumatic origin or not, wbich has the olTect of making one nasal passage materially narrowc than the other, is likely to cause a gradual, but pernumenl, enlargement of the turbinai tissues behind it. If, on the other band, the closure of the passage from septal 48 DISKASKS OF line ^■A^.V^ PASSAIiKS. deformity is so complctL' ii.< to jirodiice actuiil stonosis, there can be no hypertrophy on tlic iilTectcd side; but tliere may l)e on the opposite one, owing to tlio extra lalior ot inspiration through the single channel. ]''ig. 4Gy closing the lower nostril the upper one will be found to be doing nearly all the breathing, while closiin' of the upper oiii' will reveal the fact that little air passes through the one beneath. Ifeversing the position to the oi)])osite side will further substantiate the same law. The conse(juence is that, l)y persistently placing tlie child on the one side while sleeping, t!'e mother is continually pi'oducing con- gestion of the same set of turbinateds, forcing the infant to do the greater part of its respiration through tlie upper nostril. It is only reasonable^ to conclude that, in a healthy, rapidly-growing child, con- tinual hypera'mia of one set of turlnnateds would lead to their hyper- trophy. l)Ut this is not all; the rarefaction nf the air upon the lower side of the soft cartilagiiu)us septum of the infant, with the full pressure of fifteen pounds to the inch on the upper side, will have a tendency to slowly, but surely, dellect it toward the least resistance, thus jK'rnianently narrowing the nostril and tending to hypertrophic onlargenient. (}uite fre(|UenlIy, liyperl rophic rhinivis owes its origin to other jauses. Strumous habit may ]iro(luc(^ it. particularly when attended by injudicious exjiosure. Sudden changes of temperature oft re- peated, particularly when the patient is unwisely or inedlciently clothed, nuiy also give rise to it. Tiong-continued chronic rhinitis may also, in certain cases, culminate in hypertrophic disease. Symptomatology. — The most ludniimuit symptom in hyper- troidiic rhinitis is the olistnu^tion to nasal resjiiration ])roduced by the enlarged turbinal tissues. Together with this, there will be a change in the normal secretion and its reti'iition to a more or less extent within the nasal cavity. The discharges are thicker and more opiupii'. owing to lessened exwdation of serum and increased seereticu of innco-pus. The ditliculty in luisal respiration and the 50 DISEASES OF THE NASAL I'ASSAOKS. amount of discliarge are both variable, being controlleil, to a certain extent, by the temperature and humidity of tlie atmodpliere. In warm dry weather the nasal passages are freer, with less abnormal secretion, while in damp and cold seasons of the year there is greater swelling, increased stenosis, and more profuse muco-purulent discharge. When tins occurs, the pharynx also becomes involved, becoming dry and irritable, on account of the oral breathing which has become necessary. Crusts do not form in this disease, except occasionally around the anterior nares and the front ends of the inferior turbinateds. When they do occur, it is due to the drying effect of the atmosphere, com- bined with deficient serous effusion from the affected membrane. There is rarely any odor with this disease. When, however, the dense secretion is retained among the deep crevices for an unusual length of time, mild putrefaction may set in; but the odor is very different from the more offensive one of atrophic rhinitis. The sense of smell is often notably impaired, owing to occlusion of the nasal chambers. The voice becomes thickened and nasal, while impaired hearing and occlusion of the lacrymal duct may occur as results of the disease. Headaches may arise from hypertrophy of the middle turbinateds, and in these cases the enlargement is likely to press upon the se])tum. ITay fever and asthma are also, in some cases, attributed to it. Diagnosis. — For this, rliinoscopic examination is necessary. Symptoms may indicate in a general way, but they cannot alone give a ]>ositive diagnosis. On examination, the turbinateds will l)e found to be more or loss swelled, and the mucous membrane covering them of a bright-roddish color. A certain amount of muco-pus will always be present. The lower turbiiuited is usually the most swelled, some- times almost filling the inferior meatus. The anterior end is the reddest, the color gradually assuming a grayer hue toward the middle and ])osteri()r end of the bo.ly. Tlie enlargement of the turl)inateds is Uf^ually somewhat irregular, nodules often standing out jiromi- ncntly in dilTcrent parts. Occasioiuilly the hypertrophic masses have become united lo the septum by bridges or syuecliiie of fibrous tissue. This is more likely to occur in hypertrophy of the middle turbinated than of the inferior, owing to its closer proximity to the septum and the greater tendency to enlargement of the anterior end. The nasal speculum, aided by reflected light and the use of the head-mirror, is always essential lo examination. In posterior hypertrophies the post-rhinal mirror reveals the condition, the end uyi'Ektkoi'Hic uiiimtis. 51 of the inferior turl)inated assuming a corrugated, swcllctl appearance, almost like a wliitc strawberry, and in some cases entirely tilling the posterior clioana (I'ig. -KJ). In a few instances the posterior liypertrojiliy lias a reddish hue. Sometimes an (edematous congestion, as in rhinitis auleniatosa, might he mistaken for a true hypertrophy; hut the application of a r)-j»er-cent. solution of cocaine will soon remove the (loul)t. In either ease the swelling will be reduced; but in true hypertrophy the re- ♦luction will be limited, the abnormal librous tissue of the body still leaving it in a swelled condition, while, in the other, the cocaine will soon shrink the (edematous tissue down to even a subnormal state. Prognosis. — Under pro])er surgical treatment, wlien the disease is • me ol' simple hypertrophy, the prognosis is always favorable. Without surgical treatment it is a prolonged disease, the ultimate result in many ca.^istance-coil. are always ready for use. In urlian sections, where storage-l)atteries cannot be regularly charged, the plunge-batteries 1. R ('aniiilior-incnthol gr. xv. Alholono 3j. IlYl'KHTHOI'llK' HIIINITIS. 53 answer a very ji;oo then turned on at a bright-red heat and an incision made into it from behind forward. When the turbinal hypertroi)liy is very large, jiresenting a round j)rojecling surface, J have usually applied the ilat side of the instrument, cutting in jiretty deeply. 1 know this is contrary to the ordinary teaching, but I have found, after the slough has separated, tliat there has still been abundance of my.xomatous tissue and epi- thelial coating to heal perfectly, without leaving a scar. In doing this care must be taken not to have too wide a blade, and to confine the application to the one width of the llattened surface of the elec- trode. On the other hand, when the hypertrophy is less prominent and less enlarged, a slight knife-edge cauterization will produce the best result. It is well in either case not to operate too extensively at one sitting; and we should always be as conservative in our operations as the nature of tlie case will allow. After operation the passage should lie s[)rayed out with albolcne or glycolin, fur its cleansing and pro- tective effect; and a tampon dipped in the same hydrocarl)on should be inserted between the cauterized surface and the sei)tum. This will prevent any possibility of adhesion, and it should be left /'/( .s(7« for thirty-six to forty-eight hours. The best iiu'thod (if (ipeiatiiig upon large hypertrophy of the posterior end of the inferior turbinated is sometimes a vexed cpieslion. Many authorities advise removing the hypertrophy with the cold snare. This done by the slow turning of a Jarvis snare is a tedious and painful process, even after free cocainization, ])articularly as it may take from half an hour to an hour to separate the mass. Any severe traction or ])ulling upon the jiarts is likely to do serious harm, as, if resorted to, it may loosen the attachment ox the turbinated bone itself. Other authorities advise the galvanocautery-snare as being speedy and cflfectual. The olrjection may lie nrgcd that the large surface exposed during the operation to the action of the heated wire contains a considerable element of danger, particularly when we remember the close proximity of the growth to the Eustachian tube. When resorted llYl'KHTUOriUC imiMTis. to, tlie lingor should invariably be passed behind tiio i)alat(', to adjust the wire and insure the safety of the tube itself. In my own experience, I have had better results in the treat- ment of ordinary posterior turbinal hypertropliies by operation witli the tliit electrode than by any other niclhod. After ai)plying a 10- or lo-jicr-ccnt. solution of cocaine freely, I have jiasscd the electrode back through the nostril to the growth, guiding the application of the cautery liy the post-rhiiial mirror. 'J'his sometimes r('(|uir('d a little training of the patient; but I would not venture to o])erate without I could see the point of the instrument clearly rellecled in the glass. This being recngtiized, a lirm hand, guided by a knowledge of tlic anatomy of the part*, -should ])erl'orm the operatimi without risk. The growtli is large and vascular, and, pressing the electrode flatly upon the centre of its inner side, you can burn dnwii ih'eply into it without producing pain. The one cauterization is all that should be done at one sitting. In this case tamponage is not neces- sary. It may be followed by swelling, but scarcely enough to touch the septum; and a daily sjiray of weak solution of cocaine, followed by albolene, will help to kct'p it open. In three or four (lay< the mass will slough away, aiul the o])eration can be repeated carefully at intervals until the turbinated returns to its normal ;■!/(•: l)ut one or two rc'jietitions are all that arc ever required, and in >onie cases a second burning is not needed. I have never known niiddle-ear disease to arise from tbif method of treatment, but 1 have seen several instances in which tinnitus aurium and slight deafness have been removed l)y it. Of course, tliis nH.'thod of reducing the hy[)ertropliy shoidd not be attempted by the inexperienced operator. ^Vilat may he one man's food may be another man's liane, and any individual, by constant ])ractice, may liecome so skillful in the use of a sinu'le instrument as to prefer it to all others in the performance of certain operations. Ifelot, of l?ouen, recommends the use of electrolysis by the bi- polar method for the treatment of posterior hypertrophy. The parts are first cocainized, and then the electrodes are passed through the anterior naris and inserted side by side into the enlargement. 'l"he si'dinrs last five minutes or more, and are repeated at intervals of several days until the hy]iertrophic tissue shrinks away. During the last two years a new method of treating severe cases of this disease has been discussed and practiced by many l-'nglish and I'hiropean rhinologists. On this side of the oc(>an the ])lan, although m 50 DlSKA^^Kt* ()!• Till-; NASAI. I'AISSACKS. iiccoptod ill a iiiodilicd di-gn'o, luis not been j)ructice(l in its entirety to any great exleiil. This is o])eration by tiirbineetoniy, or removal of the tiirl)inate(l body. The term "turbinotomy"' has also been ap- jilied indiseriniinatt'ly to tliis operation; but as this term, from its derivation, really mean.- simple incision ol' tlie Uultiiiated, its ase is searcely appi'opi'iate, and i'onse(|iiently should not be applie(l to the operation at all. Tiirbineeltiiiiy may lie partial "or eomplele, and it is the latter that has been so strongly ai' oeated in certain cases by Carnialt Jones, Dundas (iranl, Jiaber, and bers. For this a sjieeial instrument has been made: L'arnialt Jones's spokeshave, modilieations of wliieb are re])resented in Fig. II. After cocainization the entire turbinated can be removed by it. its n>e i> only adNocated in <'.\trciiK. cases, where milder opei'ative measures have failed to give the nninired relief. This .severe and I'lidical operation is opposi^l by many surgeon.-, par- l''iji. 48. — Kiii;;lifs nasal si'issiois. tieiilarly in .\nierie-a. on aceount of the imimrtant posilinii which the inferior turbinattd occupies in normal respiialion. !Modilletl turbinectomy, on the oilier band, is accepted by all rhinologists. and, in ajipi'ojiriate eases, is constantly being done. F^re- (piently the anterior cud of the middle turbinated, bulging and press- ing n]ion tlu' .-cptum, can be better excised than binned away. And can be removed ell'edually by means ol' serrated scissors (Fig. 48). The anteriiu" end of the inferior turbinated, likewise curled upon itself and filling the whole of tlie inferior meatus, can often be best removed by cutting instruments; and partial turl)inectoniy in either case would be unattended by the intlaniniatory swelling which might be expected from extensive cautery operation. The same applies, tliough in a modified degree, to the posterior end of tlie infeiior turbinated. Fig. id shows forceps specially designed for nasal work tlie spring closing the instrument, and pressure opening it. MYl'KinilOI'llK KIllNII IS. • )« Tlio.se vjuidu.s uji(.'iiilii)ii» can bo |K.'rl'i)riiii(l iiiulor cociiiiic iiiia'.— tliL'^^ia by jiicans of various iiistruiiu'iils, such as curvrd .scissors, knives, ])uneli-l'oi\' the I'nited Stales and Canada it can rarely, ii' ever, be rei|uired. It is quite jiossible thai entire removal wouhl leave >iich an atrophic condition thai ihe cure would be worse than the disease. A method (d' trt'atmcnl has been advanced by j,eiuii)\ Umu ne diirini;' ;he last year which is wni'thy uf 11111113 c\tcn>i\e trial. It is ]'ijr- ^!'- ^llUllv"s Ilil-ill fci|rc|i-.. by clectroeantery-i)uneture elow this the cuboidal ejiitheliuni, the adenoid or hyaloid layer, the acinus glands, the blood-vessels, and eavenious sinuses, all gradually shrink away, losing their power of physiological engorgement and collapse, so essential to the proper performance of the respiratory functions. This atrophy of all the special tissues of the mucous meml)ranc is ac- companied by formation of abnormal connective tissue, though in a minor degree than when the result of hypertrophic disease. Notwithstanding the shrinkage of the turbinated tissues, Win- grave, on microscopical examination, fouiul imbedded in the inter- lobular tissues of the glands, in the lymphoid tissues, and sometimes in the stratified epithelium, small, round, refractive cells \vhicl' he called hyaloid bodies. They varied in size from one-eightieth to one-thirtieth of a millimetre. Those bodies increase in numbers as the disease advances. Finally they break up into minute refractive bodies, resemhling spores. The question of the nature of these bodies (58) ATROPHIC imiNITIS. 8» is still undecided. Some biologists believe Ibem to be the bacteria of atrophic rhinitis. Klebs-Loefller l)ueilli iiiid also staphylococci have been found in large numbers in certain cases of atrophic rhinitis without develop- ing either diphtheria or general suppuration. Microscopically, multinucleated lymjihocytes arc found in the atrophic discharges as well as the bacillus fu'tidus and bacillus of Friedliinder. Aecfirding to Tjcnmix iJrowne, tlio crusts consist of mucin, cell-globidin, and serum-albumin, with traces of suli)hur and l»hosphorus. l-'raenkel and Loewenburg have discovered a diplococcus which they claim In have an induciicc in (he etiology of the disease. Xolanil Mackenzie maintains that atrophic rhinitis is a sclerosis — a chronic intlammation in which there is an atrophy of specialized tissue, accompanied by mild liypertropby of cfninective tissue; that this eonditidii is present in hypertrophic as well as atrophic disease; that the two (lill'er not in kind l)uf in degree, the one being hyper- trophic sclerosis, llie other atro])hic sclerosis. v.. T-. Shurly believes tlie disease to be a pure neurosis of central origin. Incidental jialhological changes occur in a majority of cases. Out of (»(» recorded, the ]iliaryngeal and fnucial tonsils had entirely disappeared in 50; while in the remaining 4 they were small, thiis indicating a direct relationship between the surrounding lymphoid structures ami the atroiiiiic disease. Perforation of the cartilaginous septum is of frequent occurrence. It is, however, geiu'rally Ix'lieved to he. not so much the direct result of the disease itself, as of digital picking. Tn my own experience, I do not remember a case of jierforated septum co-existent with atrophic rhinitis in which I could not trace the origin of perforation to the period of childhood. When it comes under the notice of the physician, the margin of the perforation will usually be found coated with tenacious mucus, overlying a layer ol' ju-oliferated epithelium. The whole history of these cases of ])erforation would appear to support Bosworth's theory, that purulent rhinitis in children was the fore- runner of the subsecjuent atrophic disease. Etiology. — Perhaps there are few subjects in medical science upon which there exist so many dilFerenccs of opinion as upon the origin of atrophic rhinitis. Fraenkel was the originator of the idea that it was a sequel of hypertrophic rhinitis, and a large number of 1 II Si ■4 m till DISKASKS (M' Tin: NASAI. I'ASSACi KS. (ilwcrvLTs art' still of tlu' same oj)iiiic)ii. Scilur says tliat, wiiili! il may l)e till' result (if liyjxMti'ophy, it may also be atrophy from the start. J)rakt' claiiiis dn'oiiii- |iiiiiik'iit iiillaiuiiiatioii ol' the accessory sinuses as the cause, (lottsteiii holds that (lei'eetive development of the tur- liinated hollies may be responsible for the disease. ]\layo Collier has thrown out the suggestion that it may yc: he diseovered that the initial (li>ease was degeneration df the lU'i'vo-ganglion and nerve-ilhres supplying the pai'ls. !•]. L. Shiirly soiiu'what I'avors Collier's idea, for he has long been of the opinion that it was essentially a tro])hic neurosis of central origin. r>osworth, on the other hand, in his recent i>sue of liSiKI, expresses as em]ihatically as ev ■]■ the belief that the disease is the result of a previous attack of infa. .ile purulent rhinitis. (ielli als,) favors Ibis theory. Personally J have seen a great many case> in young ])eople which could I'e 1 ! iced back direcily to jmrulent rhinilis of childhooil. In examining these cases there was no history whatever of previous hyjiertrop e disease: but there was the history of chronic ])urulent discharge, dating hack as far as ineinoi'v could reach. 1 helicve, loo. thai it i^ ]H)s.-ible for atrophy to \)v a seiiuel to hypei'trojtby, for I have seen cases in whicii the relationship ap])eared to exist; b\it 1 do not bcli(>vo that i' is. hy any means, the rule. \\'c rircly meet with bypc'trophy of the turhinaieils during childhood: as a I'ule, it is a disease of early adult life; and il is 'Veil to icniemher that llie majoiily of eases o\' atrophic distvise like- wise otcni' in young men and women. Jt would seem impossihlc for a slow liypei'ti'oj)hi(' process to have time for development, and that to oe followed by suilicieiit shrinkage to jiroduce afro])hy at the lime of life when ue ai'i' usually called in to treat these cases. (^hiili' fi'iMpienlly alro|ibic rhinitis is unilati'ral. intirely conllned to the one nasal cavity, and that one the widest, with a curved .-ep- tum, the convex surface within the narrow nostril. There may lia\e been no prcvicuis purulent disease; and lln.' c(Miclusion seems reasmi- ahle that the great width of the fossa had allowed free breathing. whil(> pcrmiiliiig the retention of di>cliai'ge. 'The retained secre- tions would, in time, become iiuiulcnt. Criist-fin'malion would fol- low, Mhieli eventually, hy it> repeated presence and ])ressure, would produce greater slirinkage (d' ti. I'C ciihirized to a greater or less extent, acc'ordin>i' to the severity nl' tlic disease. the enlargement being due to the shi'ink.ige nf the middle and in- fei'ior turbiiiate(l bodies, (ireeiiisii-vellow eiiisi-. \\iih a eliai'aeter- • istic. oU'ensive ud(ir, will partially hll the |ia.-sage>; and mi the I'e- niii\al of the.-e llu' ;niiei)us mendiraiie. although nnlu'oken by uleei'a- lioii. will jiresL'iil an unwontedly sep.nken and pallid appearance. .in this disease the nnrmal >ei'(ius discharge iiec(inie> limited, and iiually almost ceases, having the air diy and I'nul by the time it reaches the thi'oat. With diuiiiiutioii nf seiniis thud theri' i> iii. These tngelher iiieru-t ai. 1 (leg up tiie pas.-ages. In Imig-slanding ease- anosmia i^ <>[' Ireqiieiit oei-urreiice. while in many the seii.-e of ta,-te i.- like\\i>e impaireil. I>i'yness id' throat, or phaiyngiti.- >ieca. i- alway.- a ic-ult in ad- sarii'ul eases; ami. as C(dlateral events, the I'aucial and pharyngeal Icuisils n.-ually ln'c(une atrnphie; ihe eontigiMUs siiiu>e> mil inlVe- ([Uently beeonu' involved, and the Mu-tacdiian tidies ni;iy also be all'eotcd. A\'liile the oll'ensi\e l\elor pi-culiar to .Urophic rliinili.- is usually lielieved to ari-e from putitd'action of the retained sei-reii(ms. '\"in- gra\e has advanei'd a new and somewhat jilausible theory: lie ,-ays that, as the mueous membrane i> a tran^foi'med epidermal -iruitiire, having with its glands a common origin with the skin; so iii this dis- ease we have a structural rever;-ion, in the .-iratilication of ihe siii-face epitlioliiim. to the pi'imiti\c type: and in the glands there i- estab- lished a perverted function, the miicou- membrane being convertt'd into cutaneous structure, .villi a cori'e-poiiding change in s.^crelion. Fli('d by care- ful and thorough treatment, carried out for years in many cases. Fracnkel, of Berlin, says,, referring to atiopliic rhinitis: "A cured case of oza'iia is unkiu)wn to me." liosworlh, in bis la.-t edition, says: "In the early stages of the disease, before the ftttid symptoms set in. T have seen cases recover. In the advanced stages characterized by fo'tor, and in wliieh the turbinated boues have ahnost entirely disap- jieared, I have not seen a case cured. :'' ''y cur(,' is meant a conilition secured in which there remains no neci'ssity t'oi' any measure of local treatment." Sajous says: "Atrophic rhinitis is, perhaps, the most un- satisfactory of the na.-al alfectious to treat .-ut-cessfuUy."' All, however, agree that much can lie done In amcliorair the symptoms and make life comfortalile Treatment. — The ini.ial step is always to tlnuouglily cleanse the uasal and naso-pharyngca.' cavities, rcnuiving completi'ly all incrusta- tions wlicrever located. This is best accomplished i»y the use of aqueous alkaline s))rays, such as Dobell's .-dluiinu. to iln^ anterini- nares; and the i;se of the post-nasal spray-syringe, by which water at the temjjcrature of 100° V. can be thrown forcibly through the nostrils from behind. For the latter purpose a Davidson syringe with a curved spray-tube attached is an admirable instrument. Tlie tube l)eing jias.-ed up behind the palate and the patient's head tii)ped well forward over a receiving-bowl, a constant stream id' a piiit (U* more may lie readily thrown througli. This not ludy loosens the concretions witliiu the nasal passages, but also those beliind the ])alate; and. even if it does not bring them all away, it materially softens them and facilitates their removal. Other iii-t ■timcnts ( l''igs. .')() and od*;) act upon the same principle, although le-s ell'cctively. The method of using the nasal douche, and instructing tlu' pa- tient to pass 1 or 3 (piarts of hot, medicaleil thiid daily through the nose, up one nostril and down tlu' other, wliich is often recommended, only accomplishes jiart cd' tlie object in view. It Hoods the nasal passages. l)ut not the na-o-pharyn\; ami in this disease it is as im- I ATKOPIllC lUIIMTIS. 03 portant to cloan.se the uno as the other. If the iio.-e during the douch- ing is elevated enougli to allow the tluid to pass beyond the soft palate, there is serious risk of flooding the Miistachian tul)es, an accident involving much danger to the inner car. Tlic use of the post-nasal syringe, carefully adjusted well up beliind the soft palate, with the head tipped forward, is dcvuid of this danger, while, as Hi Fig. 50. — Post-nasiil syringe. already stated, it cleanses the combined nasal and post-nasal region, and conse(iucn(ly is preferable to the former method. It also simpli- fies the treatment, as ])aticnts cnn be taught to i)ractice tlie one as readily as the other. The anterior na.'-al spray from a good atomizer is a good adjunct to the post-nasal treatment. Still, when tlie disease is severe, the two .^ffi" ^ (*W«LL SU" -w»t .0 Fip. iV-W. — Postnasal syringe. together will not elTectually cleanse the jarts from crusts. Tn com- plete the removal, the nasal cotton-carrier by the anterior nar.'S, and the curved cotton-carrier by tlie nnso-pharynx. will 1)oth l»t' required In first treatments especially tiiis should i)e done in a painstaking and thorough manner, and always by the aid of anterior and posterior rhinoscopy with a good refiected light -■ ■,<),. J i i i< . ,1 y 64 i)i>i;Asi;s OK riii: nasai, passack.s. This stcj) liiniiiL;- liccn ;u(()iii]»lislR'(l, it is; generally coiioodod tliiit till' next one i< tn siiniuliite tlie atrophic inenil)rane to a bettor ])erfonnance of its natnral riiiiciinn df secretion. To this end (iott- stein reeonmiends jihiggiiiii the mi^li'ils Inr twcnty-rour lionrs witli cotton tani|HMis. When ihcv me iciniivcd a How of mucus Inllows the siiinuhiliim. A\'heii the llnw -iih-ide-. tlic cavities ar,' cleansed a.^rain and l'f( sli tainjiniiv inxitcd 'I lie whole procedure is I'epeaii'd as i'rc- (jUenilv and for as Ion,::' a |ieriod a.> recpiired. A\'oakes uses (iott^tein".- |)lni:s foi' tin' pni'pose of applyinu' pow- ders of a .-tininlatinu' cliaracler to liie uiseaseil niendirane. Sajons advises the n.-i' of tlie iialvanocjinlery passed rapidly over the snrfaces, and T>enno.\ lirowiie favors the .-aine plan with snhseipient insnillation of iodol or iodohu'n). Shindy and ISryson l)(devan reeoniniend the galvanic enrri'iit. tlie jiositive eh'ctrode being ])laced on the napo of the iieek. and the negative, wrapped in alisorbent eotlon. to the in- t( rior of the no-e. Hidevaii uses fr(nn l to 7 niillianiperes with a duration of from -even to lifteeii minutes at eaidi sitting, until serous discharge occur>. Other method- of tri'atment are the n>e of stimulating s[irays after the clean.-iiig. -iicli as -(dntions of thynio]. creasote, argent niti'ate. etc., of varying strengths; but these are of donbtfiil value. Another method of treatment originated by IJraun, of Trieste. several yeai's ago. and which from its enthusiast ii' acceptance by his cotuitrynieii. might lie calleil the Italian method, is that of vibratory massage of the miicou- membrane. Outside of Italy either in Kurope or Amei'ica it lias not lieen received with any marked favor; but I am glad to -ee that r>isho|i. ir, his recent work, speaks faviu'ably of ]iiassage. i'er.-onally. from my own expi'rienee. I indorse his views, though each of ns has niodilied bis practice to suit his own individual eases. As reeoinnieuded by Ib'anu. an olivo-poi]ited probe is passed within the nostril. It is held b(>tween thumb and linger like a pen, aud the vibrations are in-odiiced by the clonic rhythmical niovemeiits of the hand and forearm of the opcM'ator as he ])rosses the olive jioint against the uiucous niembraue. i>y practiic these contractions are said to mimber aliout fmir hundred per minute. The mucous membrane end of ilie liolder, in the form of an olive-siiapcd lip. 'i'liis is dipped in aJlHilene and \\raun"s inetliod. A tier each viltratory move- ment the cotton is .~lippeil olf: and with a fi'W twii'ls lietween tluimli and finger anotiu'r one applied. One advantage cd' tiiis nu'tliod is that the firm cotton tip can he made of any simpe aud sizi> to suit the various crevices within the nasal cavity. I may also add that, for nuissage so applied, 1 never tind ii necessary to us(> cocaine. Sometimes after removing the ineiii.-taf ion- a- tiioroughly as possilde. even with the after-i reatmeid of massage, a thick layer id' tenaciniis e)iitheliiiin. ]ii'ojecting from llie lower border of the middle or inferior tui'liinatc(ls, will still <]:(}■ nil clVorts at cleansing. To remove this tlii' application of a Iti-per-t cut. soluti(Ui of nitrate of silver ti» the spot will sonu'timt'S he suiluient: hut 1 have usually oli- taincd the best results hy singeing the proliferation with the galvano- cautery. This should never he carried to the extent of destruction of the whole epithelial coaling. As a result, the pale, bloodless, striivjy membrane would give place to a pinkish one of more healthy color. One pecidiarity of formation I have observed in several instances. In each case it was confined to the side alfectcd by the more marked atrojdiy. This was the attachnuMit. by a cicatricial liand. of ])art of the inferior border of tlu^ middle turbinated, either to the upper part of the lower one or to the external wall of the middle meatus. These special instances seemed to owe their origin to a ]n'e\iiiu- hypertrophic condition. Tn treating thon. affer ajiplying cocaiu(\ I liavc separated the attachment by the galvanocautery with advantage to the ])rogress of the case. One thing more T may add: that for years now, after cleansing and massage, instead of com]deting each treatment by the use of some stimulating spray, I have obtained the 1 f t is t I,. (JG DISEASES 01' THE NASAL I'ASSAGES. most satisfactory results to my patients by simply fini.shing with a spray of one of tlie hydrocarbons. As said before, these bland, in- odorous, aseptic j)reparations are soothing and grateful to tlie patient, and act as protectives to the whole lining of the mucosa. For home-treatment the patients are directed to U:^i^ the post- nasal .syringe first, at least once a day; and follow this up with sprays of albdlene or glycolin at intervals of several hour:;, until they return to the ofTico again for more thorough treatment. The solutions nsed in the post-nasal syringe may consist of 1 per cent, of any of the folhiwing, in water at a temperature of 100 degrees: — ]\luriate of anunonia. Chlorate of potassa. ( hloride of sodium. Boric acid. IJesorcin. Oi' '.' per cent, of JUborate of soda or Bicarl)onate of soda. Or a -"i-jier-cciit. solution of jxToxidf of hydrogen. Those answer very well for a time, until the patients have be- come familiar with the jio.st-nasal method of treatment. 1 have sub- secpiently obtained ])etter results l)y having them nse simple clear water at as high a temperature as they could comftji'tably bear. ClIAl'TKK iX. (EDEMATOUS KIIINITIS. 1 i , 1 ■' u! 1 Tiiic earliest mention I can iiml of iliis ili.sea.«e is jn the report of the American .Laryngologieal Association for 181J;). Jn his jjaper J. C. Mulhall dcscrihes it as a serous inlilti'atioii of the middle or in- ferior turhiiiateds. It is remittent in eliaraeler am! may ije unilateral or iiilateral. It may aho be migratory and either acute or chronic. When punctured, serum slowly exndes. lie says cocaine has little or no influence over it. It may be associated with broncliial asthma, but only in a minority of cases. It is considered to bo a neurotic aireciioii, yet distinct from tlie neurotic diseases which are caused by extrinsic excitants. In treatment ]\lulhall says that sprays are contra-indicated, and that the best results are obtained by scarification. If nasal deformi- ties are present they should be removed. In treatment the alimentary canal and the general system should be carefully attended to. This is a rare disease, and I have only seen one well-marked case. The ])atient is a young man, aged 2(i years, of sedentary occupation. A number of vears aao I removed a larue spur for him, and also cleared the naso-pharynx of adenoids, to remove the stenosis from which he was suifering. For a couple of years lie was free from any difliciilty in nasal respiration. Tlu'ii the stenosis commenced to recur again, sometimes very suddoily. Previous to the attack tin septum and turbinateds would appear perfectly normal, and there would be no dilVicuUy whatever in breatliing through either side. Then from cold taken from exposure, or su(Men dropping of oIlicc-tcmpiTalure, one nostril, within an hour oi' so, would bn-nine completely blocked. I'xamination wonld ri'veal one fossa (juite (bar, ili>' oilier absolutely closed, a pale, serous-looking onlenia distcmling the mucosa of both the s( ptum and inferior turbinated of the alfected side, and the parts bathed in muco-serum. On examining the throat, the posterior rhino- scofte would reveal the corresjionding choana tilled by the gray, swollen, inferior tur])inated body. m HCH 68 i)isi:.\si:s or riiic nasal tassacucs. Unlike Miilliall, I found the niiplicalidii nf a l-per-cent. solution of cofjiinc, passed slowly ilir were of a niildly- ^\i[ Ih'un .Murdoch, at the laryngological section of the British ^ledical Association, reported a case of recurrent nunnbranous rhinitis wliich dccurred in a female aged ,'5o years. During a little more than a year she suffered from six different attacks without any indications of true diphtheria. A number of bacteriological exami- nations of the false membrane were made; but all failed to show any Klebs-Loenier bacilli, although a number of micrococci of no special 'moment were ])vesent. The symptoms weie at lirst those of slight head-cold, rapidly getting worse and continuing for several days, with complete occlu- sion of nostrils. Abmit the fifth day white membrane would appear in the anterior iiares. This would scale off, leaving the parts some- (70) IIHUIMM h ItlllMTlS. 71 wlial raw and tlic iinsc swollen, 'riu'ix' was no rise of ti in|>(,'raUnx'. but sovort' sneezing. Tiic wliole attack would last al)out a I'ortnighl. Jlot bathing, iodolVtrni, menthol in iluid vasclin, cocaine, I'lc, only sliglitly relievtd the syiii|itoMis. .\t diu' time i^'aUanocjiiitcrv- singeing produced partial relict. In the same year Si-hillVr read hd'orc tlie Uclgiaii Socii'ly ol' Otology and i.iiryngology a papi'r on the "Pathogenesis (d' N'on-in- fectiotis Croup (d' the Nasal Mucous Mend)ranc,"' with lin' histoiy id' a case. 'J'he mcndtranc was ciinlincd to llic nasal cavitic?-. The general symptoms were slight, save for the iiiisal mendiranous ohstrnetioii. !Microscoj)i(al examination pioved the ahseiu^e of the Klei)s-L(i(dller liacilliis. 'I'Ik le was no si^n id' the disease lieiivi infection-;. In 18!ts Middlemas Hunt, in a paper nn "''I'lie lielatioii of l'il)ri- nous TJhinitis in r)iphtheria,"' reported four cases . In two of tliese ther,' were no indications of Klebs-Locdiler liacilli. in the other two, although none was discovei'cd at the time, diphtheria followed in the one ])aticnt two weeks later, and in the i'amily id' the other after a similar interval. In cdiieludiiiL:' his artiide ilnni uses tliese words: "T am afraid there are no elinieal characters on which we can rely in distinguishing the two diseases, and our one method i.- to turn for help to tiie skilled bacteriologist." Richard Lake, of still later date, gives ihe history (d' a case of clironic pseudomcndn'anous rhinitis, occurring on the right ^ide. in a man aged 5-1. He was a hay-fever subject. Treatment had only a temporary otf'ect: and when he returned for examination, ten months later, the membranous disease had increased in severity. Microscnjiical examination revealed the staphylococcus pyogenes aureus in abun- dance, but no Klebs-Loefller bacilli. In March, 1S!)S, I reported an idiopathic case of membranous rliinitis to the Toronto ^ledical Society. It occurred in a young lady, aged IT years, an abstract account of which appeared in the Journal of Lari/Hffdhifjj/. May, 1899. This was unilateral. alTecting and closing, for the time, the left nasal fossa. Tlic membrane was whitish-} ellow and inodorous throughout. It extended to the jiosterior naris, l)ut not into the ii.iso-pbarynx. The treatment consisted of applications of cocaii. e, sol'itions of nitrate of silver, and albolene. There was no fever. Microscopical examination discovered no Klebs-Ijocdller bacilli, but a large and jntre culture of staphylococci was made from the membrane. The cure was completed in about three weeks of regular treatment. \m f IMAGE EVALUATION TEST TARGET (MT-S) /> 1.0 I.I 11.25 l^|2£ |2.5 |io "^" SiflH U£ 1^ |2.2 U 11.6 £f liii £ us — 6" Photographic Sciences Corporation 33 WEST MAIN STREET WEBSTER, N.Y. UiSO (716) 873-4503 37 \^ iV :\ \ rv 6^ «■ ■<<^;* # '.«^ ^ %^ middle bodv. When she returned to the ollice on the following dav the old con- dition was repeated. The whole mucous membrane on each side was coated with white, fibrinous nu-mbiane. and the treatment and history was but a repetition of what occurred two years before. On both occasions it was undoubtedly traumatic pscudonu'mbranous rhinitis, but it was unaccompanied by fever. 1 regret tha. lu. bacteriological e.\aniinatit)n was made on either occasion. Other writers have re- ])orted similar ca.scs resulting from cautery-work. HCTff- 1 I FIBIUNOUS RIllMTIiS. 73 In dosuv^r this chapttT I inny, perhaps, vfiiturf to draw the follow- ing conciiihions: — 1. That non-(li|ihthcritif i)scMi(loiiu'iiihranous rhinitis doi's soino- tiiiK's occur, and, thoii^i^^h a very rare discas... it is probably as frequent as primarif nasal diphtheria. 2. That on clinical grounds alojio it is possible, in a niajoritv of cases, to distinguish it from genuine diphtheritic disease. 3. 'J'hat, owing to a possible mi.es of which he can find a record, totalling 98: (JU with Klebs-Loelller bacilli and l>!» without. In conclusion, while he recognizes that many observers consider fdn-inous rhinitis a distinct disease, he believes that the accumulated evidence proves the following points: — 1. Fibrinous rhinitis and dii.hlheria are not distinct diseases. y. All cases of fibrinous rhinitis need the same preciiutions as to isolation that diphtheria requires. * f. 11 II iti \1' M. i' DKroliMITIKS OF TIIK NAS.M. SKITI.M In adult lil'f ^('|ilal ilcfdrmit ics arc tlic iiih>i rrr(|iii'iit caii-r, ii'U only "if calanliiil aUV'ctions ol' tlic; nasal passajrcs, but also of (k'fcftivc and iunt|iial nasal lircatliinLT. What seems .eti'an;j;e is that these deviations from the normal in symmetry should ho conlincd so largely to the civilized raees of mon. This is borne out by examinations of the skulls of civilized and aboriginal races. In the museum of the lioval College of Surgeons, I^ondon, out of '-.Mo".' skulls, it is reported, on reliable authority, that over TO per cent, have irregularities of the se|»tuni. ( ►n the other hand. Sir Morel Mackenzie and Zuckerkandl, after carefully examining a large luunber of the skulls of the al)origines of America, Africa, and Australia, found only •?<• per cent, of the nasal cavities presenting osseous abnormalities. Allen examined the skulls of !•!} negroes, and found dcthntions and irregu- larities iji only I'l per cent. liecenily, in Toronto, at the Arclutological Museum of Ontario, whicli eontains the most ' \haustivc collection in Canada, I examined 220 Indian >kulls. by far the largest number of tiu'm being llurons and Irf)(|uois. One hundred and eight were all in wiiich the septa were sutliciently well marked to base a judgment upon. The result, however, was diil'erent to that of the observers already mentioned. Of the lOS, 51 had deviated septa and 51 had straight ones, or 50 ])cr cent, of each. Of the number I were Flatheads from British Colum- bia; 2 had deviated septa, 2 had straight. Two others were Mound- builders from .Arkansas, of ]>re-Columbian history. 1 liad deviated septum and 1 straight. I miglit add, as a curiosity, that, among a number of skulls of Egyptian mummies, only one was suHiciently unwrajjped to admit of examination. In this the septum was straight; but the left inferior turbinated was wedged against the j)osterior end of the vomer. This archaeological specimen, three tliousand years old, was an exlremi' exception to the general rule; for almost invariably when the septum was straight and centrally situated there was nothing abnormal in the condition of the turbinated bones. (M) iii;i i»i{Mri'ii:s or iiii: nasai, skitim. «t> '( To iiini ill tlic cdndilions in iicliuil life, ('nlli<'r ri'|)orts that, out (if ](•*)() iuliilt |iiitifiits cMiMiiiicd iii(lisci'iiiiiiiitlt'ly at tlic Xortliwcsi- Loiidoii lldsiiital, only lid, or alioiit 1(1 per cent., had iiorniai nnso. a lariro propoilion licitiLr aircclcd hy pi^pial doviatimis. In cliildron np to the aizf ol" ('ii:li( (ir ten years tlic scpla as well as t iirltiiiatods wcit generally normal or ahnost so- any olistriiriioii nt that early aire hein^ usually eansei y lesions other than bony. Fijrs. 51 and i)\(K taken from a fro/en seetiim cd' a eliilil a,;:e(l .") years, is a striking e.\eo|»tiiin to this rnle, the deviation and the spur to the left heing stron,i:ly marked. in the nni'iiial nnse tin- -eptiim is .-imply a hony and eartikminoii.-. Willi, dividing,' it e(|nally into two symmetrieal fos-sa*. In all tin' lower animals, in ynnnir children, and in the lower untutored races of men. this is still, in larj'e measure, the ease. I'ul. !is you a]tproaeli aduli life amotiH- the eivili/ed races, septal deformities appear in lari^e iium- hers, until, as repoi'ted hy so many oh-ervers. the percenlanile freipiently the septum is not thiekciu'd. Init the car- tila.irinous portion makes a full convex curve into one or other na-al fossa. In other cases witli the curve there will also he a nuirked jjrojection or spur (Ui the convex side. Ajrain. spurs or conical projections nniy ajipcar on (/ite or hotli si(h's of the lower end of the triaiiLMdar cartila^a' without an; curvature of the ujiper septal wall. In other instances a longitudinal ridi:e will appear in oiu^ fossa, ox- teinling backward along the hase of the cartilage and involving also the lower jiart of the vonuT. while the upper part of the septum retains its integral position. Sonu' septa ' i.v" a douhle curvature, or ccHwavo-convex form, from before hackwanl; iind still others have a sharp longitudinal notch on one side, like the i ieho of an open book, with a })rojocting pcriiendicular ridge on tin, ojiposite si(h' of the sep- tum. Synechia\ or brid^'.s connecting the bony septum with the middle or lower turjiijuited of the sanw siih", are jiot infretpuuit. There is often, too, a combination of several irregularities in the one nose; while last, but not least, almost any deformity on the one sidi of the septum is atl(>iuh'd by sonu' deviation from the normal on the other. Etiologfy. — This is a niany-si(h'd (piestion. and many diverse views are held upon it. Some authorities, I»os\vorth among the num- ber, bcdieve that the large majority of cases owe their origin to trau- f h' ll l)l IJISKASKS OK TIIK NAS.vl. TASSAiiKS. Iliati>lll. Ins iiiillior "}•• 'I'l II- |M)iiit (in wliic'li \ny ■ pec ial (■iii])li;isis is tliiit tlic (Icforinily i?; [iriiiiarily tlic result ol' tniimiatism, and. sccdndarily, of a slnw inllaniniatdry proci's.s which results thore- rnini."" /uckcikandl lias jioiiitcd out tliat in many instances a narri)w .-triji of cai'tila^^e lies between the iirrpendienlar plate of the ethmoid and the vomer, due to defective ossili/ation, and in eases of -eptal injniv this mi,iihl readily ^i\e ri,-e 'm lid.ijes fdiiml in this I'eninu. Iloe draws attention to the fact that in early 'ife the vomer is divided into two lamina', separated from each other hy a thin layer of eartilaL^i', which is prolonjred forward to form the cartila^'inous por- tion of the septum. Ossilieation hejiins in the second week of infantile life in each plate, hut i> not eiunplete ui 111 luhert V. About tl I bird year union eomnieuees beiween the plates frum behind forward. in this ease, too, it is not complete until adidt life, and sometimes never. lliMiee many (d' the deformities may arise from overirrowth (d" the anterior or free portions of the plates. This would also account for the rarity with which we meet this deformity of the |)ostcrior end. Trcndeletd»urj; bidieves that many cases arise from llu' upward pressure of a hi^bly-arclu'd jialate. Other writers believe that the deformity is produced hy overj;rowth of the septum in a confined spai'C. iJarvis ailirins that many cases owe their origin to heredity. and reports four cases (tccurrini: in one family in support of liis view. It is easy to believe heri'dity to he an important factor in producing intrana.sal deformity, just as it is a ])olent element in pro- ilucing ty|H's of feature and id' form. As an instance, I might men- tion that one of my patients, a boy of lU years, has developriig a curvature of the septum to the left. His father had a curvature to the ieft. also, large enough to jiroduce almost complete stenosis on that side. On further ini|uiry, 1 was informed that the grandfather had been a great snulT-taker, but that he always took it through the one uosfril. The conclusion is obvious: the grandfather had trans- mitted the tendency to the son and grandson. With all this mxdtiplicity of views as to causation, it is possible that ^Fayo Collier's researches, founded upon Zeim's experiments on young animals, may have struck the kt-y-note. He claims that these deformities are largely due to tit the elTects of atmospheric ])ressure, badly eiiualized wilhin the nasal cavities. In his investigations Zeim would completely block one nostril of a young animal with some soft substance, efTectually stopj)ing the respiration on that side. This would be left in for a long time. The result in everv instance. 1 -., 2 . a t — 4- 5 9 4 J G hi,:;. .■)!. I'm/iii -iilimi ,,f iMr Inad i>l ii iliiM ,i^ci| :i \i-ir~, I. Sn-- lioii ili:nii:,'li liii.k |iiiil (>l i-\r. _'. l'(.-icTii.i •iliiiioiil cclN. li. Siipciinr lur- iMliiiIrd Imiiic. 4. Miildlc liirliiiMl( (I Ipniif, .".. .\m1iiiiii n\ lli;;liin(nv, ti, Sep- tiiiii ciirxril III ilic liii, 7, Inriiiiii I iirliiiiiiiiil. s, Sii|H'iiiir iiumIii-. !I. .Miildlf iiiciilii-.. Ml. Iiiini ,,|||~. .(■■rniii l'iiini.i-i'> Aimimnii mI .Mnsciini. I 'iii\ci-.ii \ ni ruiiiiiin. i " III Ml Fig. .">!<(. I'lip/i'ii -I'ciidii (if «iiiiir child, liikfii two rent iiiii'l ri'> an U-rior t<» Vifi. T)!. I. Anifii ir ctliiiioiil cclU. 2. Miiidic tiirhitiatcii lionc ;{. Scptmn curved In (he h'ft. \. Inl'crior tniliiiiiilcd lioiic. .">. Aiilriiiii nf lii^'hiriiirc (>. Hard pahitc. 7. Niiiilt nt' inoiiih. i l''i'iiiii l*riiiii' the ainsi of tln' (li'Vi'lippnicnl (Ml that side, with delU'i'tinn nl' the SL'iitinn, the |iiilati'. the intci'inaxil- larv and fmntal hones, all toward the IdocktMl cavity. At the same time, tile nnolistructed cavity wonld lie lamer than natural ami more fully develo|ied. 'Die reason i^ the rarrl'aelinii dt tlie air in the closed nostril during inspiration, caused hy the ru-li nl' air throu<^h the open one. with the conse(|U('nt atmospiicrie j.re,--iirt iipnn all .-idcs of I lie closed cavity. Collier applies the same jiriiiciple in unilateral na.-al ohsl ruction oceiirrinj,' in men as Zeini docs in hi> cxpciiniiiits on aninuils. Of <'oiirse, hid'ore the cirects of rarei'actidn cniild dccur, iliere must arise i'l-Din sdiiie cause partial stenosis of mic nasal fn.-sa. 'riien, in due time, tliouAtli:s. I'liMiiil iiiirrnr niiiy nil \>v n'muifil. A [iraitiinl kn<»\vlf(l<.'t! of tlic |iarl.« shdiilil then remove all (luiilit. Soinclimcs a mistake may be iiiadc liv llii' aiilcrior I'lul dl the iiiidiilt' tiirliinatcd heiiii.' on a line witli llie s('|i|iiin. At this spni ;rni i|i III' |iroje('tiri|r ji;lamls may liiih the point of scparalion. Cre.-Wfll liakci' call.- this spnt '•tuliiMVuliiiii scjiii.'' Carel'iil e.xaniiMatinn. li(o\c\cr. will ca.-ily rrmovc llie doiilit. Nasal po|\|iiir; ami lilnonia i<\' tlio .-('pliiiii ar*' hotli m>ivaiil(\ while llic sepliini is not. 'Tlie rnrnicr. too, is lijilitif in cnlnr .md sdl'tcr. while the latter i- darker and . .dijrct to lia'inoiiliai:e nn the .-li;:hte>t ftHlcli. Prognosis. 1, It to itself, ni •plal de\ ialinn or dri'orniity wil inipiiAf, and the symptoms produced hy it arc likely (o remain un- relieved. Jn eases wli'.ic ilic .-yiiipiuin> arc nci-ily ealarrhal. wilh partial stenosis on the allVcted si
  • ea-e, tuo. ari.-in^- from this cause, hcnelit may he expected, fnun -imilar tieatnient. Tharyn^'eal catarrh is also ^really hcnedled hy rci-ioralion (d' normal hreathin<;. In hay i'ev( r and asthma, these disease- lieinj,' so frctpienlly I'cilcx in origin, improvement will often fnlhiw operatinii. thoiiirh the proj.Miosis should always he iruarded. Treatment. — The removal of the stenosis produced hy the de- formity is the mr-st essential IV-ature of treatment, and the methnd.roducing distress; and n week or ten davs" immohilitv will sired union. Thick i)i;i'uiiMriii:s of tiik nas.m, skittm. 83 riibliiT splints III' iiK'diuiii sdl'tni'sti, carcl'iill} adjii.-ttil to -iiil tlu' oi/c jiikI (•(imlitiuii of the pints, arc also in many cases of ruivatun' of (lie fciO|iliiin t'.\c;('i'(lin;.'ly n.-cful. If \\<)ni for a niiinlitr of \U'tks, llic coii- stanl .*u|i|K)rl tlifV cllcc t will restore tli<' |ias>a^'e to an alnio.-t n'T- innl eontJition. Tlieir usefniness is Iiiirhly ajipreeiated iiy Lalie ami oilier writers. Consolidiil.d (Icformit'i s of the .-epiiini are treatid in \ar;on.s ways liv (liil'erent aiiliu.i.-. \\ here projeetiii!' .^j'tirs ami n(l>;es pro- duce .ilistriiction, idl a;?ree that tlie exostoses and liyperelmndria slioiild lie removed. Many believe, witli Mosworlli. thai tiioy -honld he excised hy means of saws. 'l"i intention is to lca\e a smooth, ))lano .snrfaee over which mueoiis ni inhrano will ijniekly form with little or no cicatrix. W hen tl'.e distortion propciil.s its'M' in the form of an hyper- frophied rid;.'e or spur npon tlie eartilnir.iii.iis portion of the septum, this can freqiionlly lie removed hy means of a sharp, iiarrow-hladed knif''. leavin.ir. as a r<'snlt, a smooth surface and ;in opi n pa>.-aLre. A reeoatinu' I'f new mueons memliraiie (|uiekly foilnw-:. The aeconi- Ijanyinj: microscopical section was t;iken from n -pur iinuned in this way from a irentleman, ajred TiS, who had lieeu siill'crine, and it enabled the patient to breathe freely through it. The bulge kept it in position. The wearer takes it out every morning as a matter of toilet, and at once returns it. He has worn it now for five years. Since the opera- tion he has resumed his position as leading tenor in a large church. m Hi ■f.v 8() UlSKASKS OF Tllli NASAL TASSAGEH. ^W^ III'' ill' which he had been compelled previously to resign, on account of j)ost-nasal catan-h caused by the unilateral stenosis. 1 expect in time the artificial opening will remain permanent, without the use of the instrument. In a somewhat similar case, in which traumatic adiiesions had formed from the lioor to the middle meatus, Myles succeeded in a (liU'orcnt way. Ifc trephined along the iloor of the nose, and then iii.-ertcd a rubber tube. This was retained until a new passage had formed. The subsequent operation was the removal of the cicatricial tissues l)ctw('('n the superior meatus and the new opening. When till' enlargement would iudicati' increa>:cd Ictigtli or height of septum, Arthur Watson advocates removing an elliptical or wedge- shaped portion, as the ca?e might requiix', cutting through the se])- tuni, but leaving the mucous meinlirane on the opposite side entire. Cutting forceps could be used if retpiiicd. The piiit- iirc then |>ressed into position and held by pins, the ends of {Uc pins liciiig piidiled to lU'cvi'iit ulcirjition. 'J'hey may in position fur three weeks, when union uili Ite aeconi|ilislied witii cure of the deformity. The sp(di- or 4-per-cent. sidulion of cocaine should be thrown into the nostril by an atomizer. Then a stronger solution, of 10 or 15 per (lilt. -Iioiild he iipjilicd by a curved cotton-ludder to the sep- tum. This iniiy be re|teated two nv three times. In live to eight minutes the parts are ready for operation. Two saws are required; one with teeth on the upper i'^lixc. the otlier with teeth on the lower. It is always better also to have the handle of the saw at an angle of forty-live degrei's to tlie central line of the shaft, 'i'he lower lilade is insei'tid first and ttie cutting is always done parallel to the axis (d" the cpfiiiii. Then the cut downward with the upper sa.v is made to mi'i't exactly with the inferior incision. 'i\) ]H'rform the opera- tion reipiires a good s])ecidnin and a good reflected light. The word- ing of the operation is sim]de. but. to do it successfully, care and ])atience are reijuired. When the exostosis is large and bard, the operation nuiy be tedious, necessitating several stop]iages before com- pletion, in order to arrest or remove the blood. There is also danger from fainlncss, diuj to the action of the cocaine conddned witli tlie DKKOaMlTlKS or THE NASAL SEl'JTM. 87 shock of the ojRTiition. 'J'hcTc is likewise diuij^or of flitting throiigli tliu tfcptimi, ami, althuuirh this was tiio approved ineliiotl of ti'cat- niont at oiio time for tlie relief of one-sided stenosis, it is something which the can'ful surgeon wi.-hes to avoid imw . With judicious management, it is an accident of e;.eeedingly rare occurrence. J.ittle after-lieatment is necessary. Jf liieinorrhage arising from the operation does imt at on^e sui-side, it is better to pack the blecd- ing-sjiot with cotton tampons. These may he left in for one, two, or evi'u three days witiiout producing any evil elfect. They may be renewed entindy or in [)art at any time, as llie tendency to bleed- ing may direct. One uf the main objects after operation is to pre- vent the anterior part of the cut surface from beconung dry, as any liard crust forming upon it would retard the proces.', of healing. 'J'o avoid this the patient should ))e directed to aj)ply vasclin to the septum several times a day. This should be done particularly before retiring for the night. In the majority of ca?es a few weeks will sullice to recoat the raw surface with mucous membrane. It gradually forms from the border-line, usually covering the wound without leaving any cicatrix to nuirk the site of the operation. Occasionally unpleasant sequels follow operations upon the nasal septum: such as severe luemorrhage, which may recur at intervals for several days before it entirely ceases; formation of synechia; between the septum and the inferior turbinated; and tlie production of excessive granulations. Careful treatment will avoid or at least overcome all these dilhculties. ^"ery rarely even a septal abscess has been the result of septal operation. Ledernuui recently reported a case of this kind. It occurred in a young woman aged 22. Ordi- nary antisejitic precautions were taken. The first saw operation upon an extcTisive ecchondrosis gave some relief and healed well in two weeks. A second operation to complete tlie removal of a remaining exostosis was tlien done. In four days an abscess of the septum com- menced to form and had to be lanced several times iK'fore it entirely healed. In dealing with these cases it is not tlu> operative, but the post- operative, treatment that I have usually found the most troublesome. By saw or knife, drill or scissoi-s, or curette, single or combined, the projecting spur or ridge might be removed; synechia' connecting the turbinated with the septum could be excised; or a partial turbincctomy when necessary might be performed; but to procure smooth equal)le in 88 i)isi:asi;s ok thk xasal I'assaoes. M support for tlu' iiuisud tissues duriiij: tln' procop? of hcalin^r has been a mucli harflor matter. 1 think tliat ruhher splints, niaih' as Lake advises, from thick rubber sheetinjr, do bettor work than anylliing else we have at our com- mand for many of tliosc cases. Their surfaces are smootli. C'om|)res.^ible, and ehistic; tliey can be readily cut to the required shape, and they can be obtained of any thickness we desire. .\rter cncaini/.ini: the ]iarts and coating the plug with va.selin it can readily be placed in position. Once in, it will not only retain its ])la(e. but l>y elastic pressure give a smooth and even fjupjxirt to the raw surface to which it is applied, as well as prevent that profuse granulation which otherwise would sometimes occur. At the same tiuie it does not retard the gradiuil exteii-ion of the im'vv mucous mem- l)rane, while it molds the tissues into a smooth and regular form. The stiir plial)le ruhlier, although TU)t so hard on the surface, nor possessing the j)oIisli of the vulcanite, is proliablv Just as imperviouh to bacterial invasion. Souu'tinus, however, after prolonired u-^e it will accpiire a peculiar, unpleasant odor, in part arisiug- from the rubber itself. In these cases new splints or tajupons should be substituted for the old (Uies. The lenglli ('!' time during wliicli the splint will rcipiirc to be worn will depend upiui the particular condition of each case. On ])lacing it in ]iosition it may usually be allowed to remain in from two or three days to a week witliout removal. The chink above the splint can be washed out each day with a weak sju-ay of cocaine, followed by one of albolene; so that there is no danger of retention of septic secretions. Quite frequently, too, when once removed, there will be no necessity for a replacemenl of the tampon. t CHAPTER XIT. DISTORTION' OF THE COLl'.MNAl! CAKTILAGE. ' BoswouTH was (lie firt^t to draw attention io the dislocation of this hddy. Tn hoth the ease:? of which he iravc a detailed report the disjilaceiiienl was cxtrciiic. >eriMii>ly iiiii il'crir.u' "ill) respiration thi'niiu;h the e()rresp()iulin<; naris; ami in each, iii (Hilcr id i^ive ade- ([iiate relief, conijdete removal ni' the lartilaue hecaiiie necessary. A small incision was made alnng the axis of the cartilage and the car- tilage itself removed through the opening. Then the redundant por- tion of the nuicons niemln'aiie was excised and the edges united with fine sutures. The result was satisfactory in each case. Although extreme caM's are rare, dis]ilacement of the columnar cartilage, to a more or less degree, is not hy any means infrequent. 'J'he columnar cartilage is a little column of cartilage placed directly anterior and inferior to the triangular cartilage of the sep- tum, it is loosely attached to it hy connective tissue in the centre and mucous memhrane on the two sides, a is very movahlo, covered hy integument, and foiin~ the septal division of the two anterior nares. The anterior end, placed just hcneath the tiji of the nose, is almost invariahly in position. It is the lower, or ]iosterior, end that so fretpiently hecomes distorted; and, heing displaced to one side, may have the efTect of almost comi)letely closing that nostril. The cause of the distortion is somewhat ohscure; as displace- ment of the septum in infancy is almost unknown, displacement of the cartilage at that early age would he even more rare. The proh- ability is that the distortion is in every instance acquired. It may owe its origin to i)icking the opposite nostril or placing the finger in the wider cavity, to which some children are addicted. From personal observation I believe, too, that it sometimes arises from the habit, acquired during childhood and practiced on through life, of invariably twisting the nose over to one side when using the pocket- liandkerchief. One of my earliest cases was a gentleman of 40 years. He had (89) 90 DISKASKS OF TJIK NASAL I'ASSAUKS. a good (leal of septal deformity, but the columnar eaitila<;f wa.s the worst of all. It was doubled on itself and almost filled the right naris. I observed his use of tiie Inndkerchief, and he informed me that he had always pulled the nose over to the right wlieii wiping that organ. Treatment.— Ill cxlrcme cases IJosworth's method would prob- ably be the best tiiat could be followed. In milder cases, however, the treatment might be materially modified, and, allhougb. I have operated on a number of cases, I have never found entire rennival of the cartilage necessary. The treatment consisted, first, in producing local anaesthesia by injecting a few drops of r)-per-cent. solution of cocaine beneath the cuticle of the septum, followed by the local apjilication of a stronger solution to the mucous menil>rane. Then, by ])rcssing the skin of the septum toward the opposite nostril the cuticle of the cartilage was put on the stretch. Thereupon, with a sharp, nari'ow-bladed knife, the prominent portion, membrane and cartilage together, was split off from end to end. By this means a ])ortion of the cartilage was in each case saved. There was no redundant mucous membrane left, and that jjortion which had been pressed f)n the stretch over to the opposite nostril slipped back, in great measure, over the raw surface and covered it. Sutures were not required, and in a few days by simple vaselin dressing tlie wound healed, leaving the nos- tril patulous and the naris almost in a normal condition. II ' 1 'I CIIAPTKH XIIT. rEiiror.ATJONS of thk s^ki'tum. This usually occurs throui^h the triangular curlilaj^c; sometimes, though rari'iy, tlirnujjh the vomer. When in the latter situation, it is believed to l)c the result of syjiliilis, serol'ula. or nialijrnant disease, or else of traumation. Perforations of liie cartilage are u.-ualiy of local origin; and, as the majority of cases occur during the hiter years of cliildhood, they are probably the result of digital erosions, made during that period, when purulent rhinitis is being gradually transformed into atrophic disease. 1 look u])on this as probal)le from the fact that the nuijority of cases that have come under my obser- vation have been atrophic cases, and yet in wliich the patients could not tell when the perforation had taken jdace. Another cause in the scrofulous subject is the projection of the triangular cartilage into one nostril. In this case dust-laden air re- peatedly inhaled im])inges upon the prominent spot, gradually pro- ducing erosion of the mucous membrane and cartilage. r)y and by crusts form; and the removal of these crusts leaves an ulcerated sur- face which continues to develop until perforation is the result. Bosworth looks upon the erosion and ])erforation as an efTect of Nature to remove the obstructive lesion, and the result as beneficial rather than injurious to the health of the patient. Treatment. — In this matter very little is required. The main point is to keep the perforation free from accumulation of secretions, and not to allow crusts to form upon its margins. If the outline is irregular and jagged, this can be trimmed to produce an even sur- face, and, as l^ishop says, if the perforation produces a whistling sound in breathing, the shape can be altered to allow the air to pass through the opening less noisily. Sometimes the posterior half of the opening will become thick and granular, rendering that part of the septum unusually thick and with a tendency to bleed ujion pressure. In this case the parts can be reduced by knife or cautery operation to the respiratory advantage of the patiiuit. Accidental perforation of the bony septum during operation for the removal of spurs, etc., will sometimes produce severe shock; but (91) fl i: tk • i\ ■iml II I 1)2 DISKASKS Ol- TUK NASAI. I'ASSAUKS. I lit' iiflcr-i'tlVits iiiv not vt'i'v sLTiouri. Still, it is tlic tluty of every sur- f,'con to do all that he car. lo avoid an accident of this kind. French perforates the sei)tuni to improve the breathin^^-spaee when necessary. Wright insists upon proper antiseptic treatment before and after all operative work ii|)on the nose, with which all surgeons, no doubt, agree. Abscess of the septum is an exicedingly rare disease, but wiicn il does occur it is usually the result of traunuilism, and should bo treated upon ordinary, antiseptic, surgical principles. riceration of ihe sejitum. a])art from its occurrence as a i)relude to jierforation, is also a vi ly rare disease. Still, in scrofulous and syj)!)- ilitic subjects il docs sometimes occur. Likewise in young children, victims of Ascaris rcniiicularis, itt-hing of the nose may be produced by reflex irritation, leading to picking and scratching of that organ until septal ulceration is the result. In all these cases systemic as well jis local treatment may be icijuired to cure the disi'ase. li ! ; It' '1 I .1 :. i 1 ., il f< i ■ C'llAlTK't XIV. HAY FKVKU, OU VASUMUTOK lailMllS. JiosTOCK, of Luiulon, in ]81!) was tlu; liol amoiiy uiodtini writcis In dniw attention to tliis disease, alllii>uv the previous two centiirie,*. It was observed by liim to occur during tiie summer months ,iion;i persons worlcing in Die vicinity of jiew-mown hay. l''rom iliis Imt it derived the name which it still t)ears. That there are two varieties of this disease, one occurrin<; in June ami the other in .\uuust, and that till' symptoms may be provoked by emanations from a multitude of substances, have not militated against the title, inasmuch as the symptoms are in all cases alike.- J lay fever may be defined as a periodic disea.se occurring an- nually at a fixed period of the year, an I attended by intense liyper- sensitiveness and hypersecretion from the mucous membrane of the nose, eyes, and throat. Pathology. — The pathological changes occurring in this disease have long been the subject of careful investigation. During the most aggravated exacerbation there is little, if any, rise in tempera- ture. There is no jirevious chill. There is no febrile action, and yet the wliole system is affected by the violence and suddenness of the explosion. Suddenly, and without warning, a vasomotor i)aresis is induced. The blood-vessels and venous sinu.^es of the turbinateds become relaxed and surcharged with blood. There is complete pa- ralysis of the nerves which control exosmosis, and the serum is tran- suded freely from all the pores of the mucosa. The length of time during which the veins remain in this state of dilatation depends, according to some writers, upon the ([uantity of irritant present within the nasal passages. The exciting raii.se being over, the ve.-j.sels contract, the exudation ceases, and the parts return to their normal ((111(1111011, the nnieo.-a relainiiig only an ana'tnic apjiea ranee. It is generally believed now that this disease is essentially a neu- rosis. It affects chiefly jiersons of a nervou.- temperament. The y ': !( ,m ■>', i::i III! !)l i»isi:.\si;s ni iiii; s.\s\t, I'assaoks. luTvo iiirciiiil iirc llic >viii|i;iilici ic iiiid liii:t'iiiiiiii>. which idiiiiol the VllSdiiinlnr .sVsli 111 (if the lliisc. .Idhll .Mili'Kcll/.ii' lirlirvcs it to he: "'A (lisdiilricd rimctiniial iittivitv nl' tlic nervous ccntn's"; .loiil, l.flhiivo. ami i( r.« that it i- a irih'v neurosis; Dehivaii that unilerlviii'' tliat iieiii(i.-i> ihi ]•(• are ''eiieral or diatlietic coiulilioi IS Wll ich leliil to ih prndiii tioii of the disease. Hence it is jjn'tty fieiierally looked upon as a timet ioiial neurosis, l)Ut, like other functional neuroses, it never destroys lite, and the neuropath(do,i.'ist in eonseiinenee is d(^i)rivi'd of the opportunity of iiost-iiiorteni iiivestijiation. Etiology. — Misliop presents the following' as a summary of our present knowlcd.ire ni)on this ])ranch of the subject: "Tlius, it ap- pears, from the manner in whicli paroxysms of hay fev{>r arc started and developed, that there are three ecuiditions njion which the ex- istence of the disease depend.-: 1. Alinornially-suseeptihlo nerve- centres, l*. Hypor.Tsthcsia of the peripheral termini of the sensory nerves. 3. The presence of one of a larire variety of irritating ajxents. Kxcludc one of these conditions, and the paroxysms are prevented. Allay the susee])til)ility of the nervous centres l)y certain central sedatives and an attack is averted or arrested, ana'sthetize t'u^ nerv- ous supply of the oversensitive areas and the result is the same. He- move the patient beyond the reach of exciting causes and he is as comfortable as any mortal."' Bosworth also gives three conditions as essential to the produc- tion of an attack of hay fever, l)ut they differ somewhat from Bishop's, and they are given in an inverse order. They are: "1. The presence of pollen in the air. 2. A neurotic habit. 3. .\ morbid con- dition of the nasal mucous membrane." 1. "Abnormally-susceptible nerve-centres" and the "neurotic habit" may be taken as essentially the same thing, and is probably the primary cause of the disease. Witliout its presence, to cominenco with, hay fever would be an impossible thing. What the essential pathological condition is that we term the neurotic element would be difficult to ox])lain. Still, it is well known from extensive clinical examination of hay-fever subjects that the family history, in a majority of instances, justifies the opinion of the presence of ab- normally-sensitive nerve-centres in other members of the family like- wise, though it may not liave been manifested in the same way. 2. ITy])er{rsthesia of the jieripheral termini of the sensory nerves may arise from dilTerent causes: such as a morbid condition of cer- tain parts of the nasal mucosa, hypersensitive areas, obstructive 1 V WAV i"i;vi:i(, Oil vasomotor hiiinitis. 95 lofinns of tlio sopttim or turltiiiiitfflH, or llio pressure of overgrowth upon adjoiTiinj^ lissiic-j. ',h The presence of nii irritiitinj,' ngent will include Hosworlh's first ciius(>: the pollen-in-thc-;iir theory, \r,\y about the tenth they would have increased ahout tcnf(dd, and the hay fever wnidd have eoniincTU-ed. Inside the next three weeks the grains of pollen would agaiti he tripled, with niaiknl iiurease in ilie severity of the symp- toms, from this time forward tlie pollen, and with it the hay fever, W(udd -uliside. until hy .\ugust Isj imth would disappear. If h(>avy rains occurred during the prevalence (d' pollen, they would tempo- rarily dimiiiisli in nuudier. aiul the symptoms for tlie time l)eing would also suhside. while hoth would return as soon as there was a chance for the grains to rise acain iji the air. Isxperience. liowevcr, does not condne the local irritant by any means to pollen. AVe tind many of our cases residents of our large cities, where little pollen can be possible in the air of respiration; no doubt the coincidence of the prevalence of hay fever at the period of the year when the atmosphere is most loaded with it would indicate a causative relatioji as existing between the two. But there are many irritants, ])hysical and even mental, which may induce an attack. The presence of feathers, odor of aninmls, ])erfumes; hot, impure air; sudden change of temjierature, mental worry, even exposure of the spinal column to the air have all induced exacerbations of the dis- ease. So true is this that a violent attack has been known to be in- duced in an old hay-fever patient by merely gazing upon a })icture of a field of new-mown hay. Although we can understand the jircsence of an irritant to l)o the original exciting cause of the first attack, yet it is diHicult to bc- ]i':'ve that each exacerbation is dependent upon the same exciting cause. For instance, a patient, after a paroxysm of sneezing, and profuse flow of serum from +he nostrils, and profound tickling irri- tation of the palate, will retire to hed under a sense of complete relief. iii 1} if I r' :w\ (■■J .ft ih' fit "1 Im; |)|si;.\si:s or riii; n asai, I'assa(ik.s. Kv(i>tliiii;,' is (liiiic h) Miiihr lliu air ol' tiiu rnom pini' imd t'icf I'min irritiitil>. 'I'lic iii;;lil is hot ami he can hrar iiothiii;^ but a .sheet over him. 1 am s|ieal\iii;; ol' a east; wilh uliicli I am perfeetly i'amihar. 'I'iiat |ialiiiit kiiowfi by e.vperieiiee thai il' he lies perfeetly still ii|»on his hack, wilii all his body, hands, and I'eet covered with the' sheet. he will he able to lie for hours, and even tu sleep, btd'ore another e.\- aeerbalioM will appear. Iiut. warm as it is, if hi; e.\pose.s a foot or a hand fnmi beneath the co\eiiii^'. he knows that another attack of biioezinj? will come on at once, and lli.it he will saturate two or three more handkerehii'fs before it subsides. What has pollen, or dusi, or foul air. or feathers, or animal o(h»r lo do with this? J know a case, alu, of a ^^'nileman who has a periodic attack of hay fever for a month every year, eonimencin;,' near the end of Au^usl. Ili.s worst exacerbations occur durin;^ the iii«rht-time; but he can j;(i daily and sit to ri'ad in a larjre |)nblic garden, (illcd with llower-bed,-> and exotics, without feeling any inconvenience from the jiolleu rising from them. I do not wish in any way to dei)recate the importance of poUon or any other irritant us e.xeiting eause.s of this disease, but 1 do wish to emphasize the fact, that there must be something inherent in the system, when the disea.se has once developed, which itself j)roduees these periodic explosions, from which hay-fever patients so severely siifTer. Shaw Tyrrell, of Toronto, and IJisliop, of Chicago, have for years, independently of each other, been advoraliiig a new theory as to the cause of hay fever. They believe that to some extent it is caused by the presence of an abnormal amount of uric acid in the blood. According to this theory, the fonnation and retention of uric acid in the tissues docs not produce hay fever, but the presence of uric acid in the blood does. 'J"he majority of cases of this di';ea.se occur between, the ages of ten and forty years, and, in accordance with Bosworth's statistics, the majority, in the ratio of two to one, are nuiles. Another important point, u]ion which all writers agree, is that it is a disea.se incident to the educated cla.sses and sedentary life. This is what we might expect when we remember that hay fever is so largely a neurosis. Symptomatology. — Slight premonitory symptoms in the form of tingling or itcdiing of the eyelids, nasal passages, or soft palate may IIAV IK.VKH, n|{ VASO.VtOIOK l(IIIMII>. n; |tros('iil tliciiisclvo f(ir tliiv.- licfurc tlu' iliscjisc fully ilfVi-lops. 'riicn hpiisiiHidic riilliit'Sn dl' tlic nose will occur, -ncc/in}; will coiiir on, iiml the c<)n{,'cstit(ini. nlii n |irr,-( nt. Ih an intense tickling irritatidii f the sneezni;:. 'J'lie hydrostatic eondilion of tlic iiirhinated> i- partiiMilai ly mani- fest (hiring an atlari\ of hay I'eNcr, the par^-is h,i\iiiL: deprived tln' tissues of their normal power of resistance. \a\ the |iali(iit lie on one side, in a very few moment> the ( nrre^pondin;: iio.-tril will lie coiiiplclely stenosed. Let him turn to the othei'. and the condition will he at onct! reversed. Let him lie on his liack. and I lie posterior onds of the two inferior tiirhiiiateds will liecoine ^o -uolleu iLat iliey will iili hotli p(jsterior choana', and hreathiiiL; thioiieh tlie no.-c will he an impossihility. Many eases of hay fever, after the lirst few year.-, al-o taki' on the element of asthma, to increase the sidlerer's mi.-eiy. This comes on two or three weeks after the (■ommeiiceiiicnt of the symploms; and iji some cases will last for weeks after the hay fever proper has Ml lis i (led. It is a question whether the a.-lhma owes its origin to hay fever, or whether they are not hoth the products of the one cause, pro- ducing vasomotor rhinitis in the upjicr ri'^ioii and vasonintur hnm- C'hitis in the lower. One remarkahle peculiarity of hay fever is its exact periodicity. Quite frecpiently it will come on year after year almost to the very day, usually ahout the '^Oth of August, and last for four or six weeks, or nntil the advtnt of cold weather, and then di>appear aliiio.-l a> sml- denly as it came. K.xamination of the nasal passages during an attack reveals the turljinated bodies swollen and water-soaked and of a grav or pur- plish hue. The mucous memhrane is painful and sensitive, while the necessity, which so often exists, of sleeping with the mouth ojien renders the throat dry and i)arched. Througliont the Ignited States and Canada the usual period of attack is during the latter half of .\ugust; hut with some people, r: M fii »!»*; !i.s iii>i;asi.s ui I mi; n asm, r.\s>Atir> i ^>' \\\o\\ixh tilt y arc {greatly in tlic iniiioiily, tlu' attack (•(uncs oii in June- licnriiiLT IIk- iiimic nl' "rdsc-cditK" t'rnm tlif I'licl of r uses iiKKiininir al lliat tiiiic 111 nllicr iiisliiiiccs, tiKMiL'li llicsc ii (•nines (111 sciiii aiiniiiillv I. likewise I'iire. Ilie nlliick li.-ive (Hie liidv pill lent wIid Iui' years !i:i(l ii liiilit attack in Miircli, to lie rollowed iiy a severe one in Ahl'IisI. 'The latter still coiiliiuies, t'ollowed or accoiiiiiiiiiieil liv a-llini.i, wliilc the rorincr lias diiriiiLT receiil years d :sa|i|ieared Willi regard In f;coL:ra|ihi(al area, il is I'diiiid on lliis conliiicnt oxeraliiiosl all parts (d' the I'nilcd Slates and ('aiiada. 'I'lierc are cer- tain rei^ioiis, liowcver. said to lie excnipl, siicli as the While Moiinl- aiiis, the Adirondaeks, Maniloidin Island, jiarls (d' Miiskoka, lli(> vicinity (d' (j)iielicc, etc. I'liil il is said, also, thai, as iirhan life cn- lends into tlii'sc regions, their loinier iiiiinnnily may madiially pass away. Diagnosis. J'tM-haps aciile rliiniiis is llie niily disease thai it is likely to he niistaken for. in this, howoer, the chances of error are slii^ht. In iiciitc rhinitis the niiicoiis meinhraiic is hriglit and rod, with no great ainoiinl of swelling, in hay fever the color is a grayish or purplish red, and the swt lling a leading feature. The discharge in aeiit(> rhinitis is iiiuco pus (d' a yellowish color; in hay fever it is liltl(> hut ('(dorless seriini. Prognosis. Hay fever rarely, if ever, produces a fatal result. Still, while it lasts it causes iiuicli intense sulTcring. In some cases (luring the process of years the attacks of themselves hecoine gradually ligliUM" and iinally disappear; hut in the majority, if uurelieve'l hy ireatniiMit, llicy culminate in asthma .d a severe and ('(nitinued form. 'I'lie disease is, however, more or less amenahle to treatment, and a large jiercentage of cases have Ikhmi reported cured. Preventive Measures. -.\s a preventive ineasurt\ nothing occu- pies .so |)roniiiiciit a position as the removal fr(Uii home-surroiindiiigs to a locality where hay fever is said not to exist. Of such regions those already named hear a high repulalimi. particularly tlio While .M(nintains. l>etlileliem seems to he a favored spot in these nuniut- aiiis. The cle\;iti(Hi is less than *.'(l(t(> feel, hut large niiinhers (d" people annually spend the wlude of the hay-fever season there, and claim, during their sojourn, almost complete immunity. The Muskoka islands and lakes hav(> also during recent yoar.'? re- ceived a good deal of attention as a !iay-f(n-(>r resort. The elevation of 1000 fopf above the sea. the purity of the waters, the rooky and . II. \v i'i;vi;if, ou \ ASdMoTou itiiiNiris. ;»:* ) siiiid}' liiiliii'c (if llic soil, lli(> iiliiiiulaiicc nf Wdiidhind, iitid liic l(!Utii~ iii^ varii'l}' III' llu' iMiniiiH'i'.'dili' i>liiiids liavr all liclpcd to iiiakc it an ideal r(';;ioii I'nr llic iiicvciil inn, ;is udl as t irai inr'il , dl' this di.-i'aM'. Till' ti|p|irr \\alri'.-> 111' llir Sa;4iitiia_\ . iIhmil'Ii Iduci' in clrNalinn, is also ;;aiiiiiiu iii rrpiilal mii, |iail iiidai ly ai'mn;; .-iilVrrns dirrrlly Id t III' Miiil li i.r I lii> ii una 111 II' ir;;iiiii ; as aUn i~ (lcurL'i;i ii liav, Willi ils jiiu'c, (lr\ al iii(i |i|ii-ii', ami I lhiii,-aiiil> nf rnck\ i-|;iiiil,. 'I'lir iiiii.-l iinpnrhiiit I'mcI to lie ciuiMilriTil, in iiiinii rl kui willi lliis \ir\\ III' |ii i'\ I III iiiii. IS llir ad\ isaliilil y nl' iiihn in;.'; I" iIh' iIhl^i'Ii s|iiil lii'l'dTc Ihc rdimiu'iu'riiiriil id' llic animal allaik. 'I'lir oiiji'cl is 1(1 ^rl llic ciilii-c licndil 111" the rliiiialic rlian,L:c; In |iri'\cnl the dis- ease I'liini dc\clii|iiMji;, muI to hi'cak il ii)! aflcr it has made its appear- ance. Annlller pnilll wllicll cannnl lir Inn st l'nM;dy em [lliasi/.i'd : if llic palicnl Udcs hy railmad to tlic ravdicd rcsni'l, livfurc tin- time nl" llie annual attack, even if that pciind i.- nidy a Few day-^, tlu' syiiiplnins will not, dc\el(ij) dnrin;;' llic jonriiey; hut it' the lii|i is made (ij'lar the hay-fever symptoms have commeneed, they will he nialerially agf^ravalcd hy the time he reaches his destination. 'The rcsnits arising from this inclhdd of prcvcnliiin ditl'cr ma- terially. In some cases the occurrence of the disease for I he season is lirokcn entirely; in dthers the severity is weakened and tlu! period of the attack shnrlcncd; while in others lilfh; or no salutary etreet, is produced. They may i^o the round of all the resorts lliey can hear (if, and yet tlu! liay fever will e.xhihil itself with its (dd-time foreo and duration. Treatment. — 'I'liis will frciiuenlly require to Ik; of a threefold eharaeler. 1. ( 'onslit utioiial Ireatmeid, for tin; correction of the ikmi- rotie liahil. ^1. Treatment of the diseased condition of the nasal pas- sages. ;{. 'I'reatnient of the spasmodic attack. 1. Coiistitulional treatment. In this, rcfrulatinii of the ali- irienlary eamd and the urinary system may he of prime iniportanc(!, and should he followed hy Ihc administration of nerve and syslenne Ionics, such as iron, (pnnino, stryehnino, arsonie, and |ihosphide of zinc, ('old hathing |tractiee(l daily is an excellent adjuvant, as is also sysloniatized exorcise. liishop, basing his eoiicliisions upon liis own theory of the pres- ence of uric acid in tlu; Mood as tin; real eanse of the disen.so, ad- ministers systctnie treatment liiider the title of ))reventive treatment. In the first place, he reduces as raueh as possible the supply of foods that increase the formation of uric acid, such as meats, sugar, beer. , Jc ' if 100 |)|si;.\m:s or tiik nasai. I'AssAtJKs. wine, etc.: nJid limits the did larirdy to rriiits, vogclablop, milk. I'iits. ol(\; 1111(1 ill tho siuiu' tiitu' iKlmiiiislcrs salicylatci' for several weeks ]iri(ir io the onset of the dij-ease. in order to diminish the iirie aeid as it forms. Tlie moment. ho\\e\ci-. ihal ^\ni|tlonis of hay I'ever show Iheni- selvrs, he drops the salicxlalis and r(>\erls lo acid treatment, .\fter numenms evperiments. he |iitfers llorsl'ord's aeid phosphates, which he i;i\es in l-uiamnie dosis two im' three times a day. lie claims that this prexeiits lhi> solntion of uric aeid in tln^ hlood. and at (Mice checks the di><'ase. while, on the other hand, if alkaline treatment wei'c re>ort(Hl to at this time it wonld produce iiricaciihemia ami pre- cipitate an attack of the lr(ndde he is trying lo prevent. ".*. Treat nuMit of the discasi'd condition of the nasal passages, in many cases the hypera'sthetie eondition (d' the mncosa depends upon intranasal lesions of one torm i>r another. It is self-evident that this discasi'd (dmlilion slnndd he removed and the passages rendci'cd nor- mal if possiidc. neilcctions o\' the septum, hypertrophic rhinitis, nasal pidypi. ])rcssnr(> of the niiddl(> fnrhinated npon the se|)lnm may any of tlnnn re(piire o]ieralive interference: and the trealinent should he dire(t(>d toward the riMiioval of these ediiditiinis when present, ac- ('(M'ding to tlie methods already indicated in prcviims chaplers. .\s regards the period l)est suited \i\ operatimi. it wonld, without donht, he hetter to remove all ohslruetive lesions pri(M' \o the annual onsi>t of llu^ disease. .\s a ruK'. however, the patient docs not prcsi ut liimsidf for trc.-itmcnl until the se\(M'it_\ (d' the exaccrhations impid him \o s(M'k r(di(d'. ^^ hen he (hies cimie. his case should he i>\amined into tlKM'iMighly, with lhi> aid id" the neee-^sary rliim^scopic instrii- iiienls. This can always he accomplished, even in the most sensitive eases, after ajiplying a ■I-p(>r-eenl. siduti(ni of cocaine. The essentia! th'Mn-y is, {\y<{. to remh-r ea(di nasal passage fre(> enough to allow of normal re>pirati(ni through it. and. second, to nunove any pressure upon the septum arising fioni turhinal hypiM'trophy. .\t the same time it is always well to he guarded against too extensive operative interference, and, except in extreme eases, it would he heller not to o))(>rale during the actual presence of this periodic disease. Sajoiis and ^racKenzie Ixdieve that there are sensitive areas, in- dependent of hy])ertrophy. and that slight galvanoeautery operations upon thorn will destroy llio terminal filaments of tho nerves for tho timo being and thus cheek the exaeerhations. 'A. 'I'roatmont of the spasmodic attack. No troatnieiit while the ! I, \ ': HAY I'KVKIt, OK VASOMOTOR lllllMrif-. 10 1 oxnccrbiitioii is acliuilly nii will ^ivc siuii j mmpt relief as i\ spray of a sdliilioii of I'ocjiine. At the same time im driiir is more (latif^erous to liie palieitt, if lie Iteeomes aililiileil |o its iiidiserimiiiate use. \Vherever tliere is vascular tiir^esceiue of the iKt>al iiiiicosa, from any cause, the appli<'at ion of w solution of cdiaine will ai once remove it; ami in hay fever the ailemlant symptiuu> arc. for the tiuu", re- lieved likewise. In nmst cases the followinj: pre-^cri|ili(Ui will he ijuite stroiiji: on()n;ih: - 1. U (''xniiii' li\ (Imclildr !M .Anuiioii. cliliniil l.'l A.iiiu :i(t| M. Si^',: S|ir;iy imiIi iii'^llil willi :i >iiki1I .|ii;oilil\ .\\\i\ iilln.v i) 111 lie rcliiiiii'il. Any <,'oiiil iidiiiii/cr im-; V\\i^. -•"•, l!(i, iiiid L'7) wimld iuiswcr I'nr ^juiiy I iciil mint. OiH' dinicul'.y, apail from the ilani;cr of actpiiriuLj the cocuine Iiahit. which can oidy he slii;ht in the use nf rapid and iioticcaiilc. That is, the tisstics swell up aiiaiii even more ipiickly than they did hcfoi'c ils w^v. Here, a,L;ain, to prohmi; the ellicacy of the cocjiinc. i,rood results can he olitaincd from a 'v*-per-cent. solution of menthol in alholcne. thrown up the nostrils hy a second atiuni/cr, a- .-ooti as the cocaine has heen ahsorlicd. There is another method of IrentmenI I have found very salis- faclory, in which cocaine has not heen use(| at all, except for the purposes of examination. 'I'his is hy usimr a much stroii^rer solution (d" menthol in adiolene as sjiiay to the Ihroat only — inhalin;:f it forcihly diiriui;' a full ins]»iration, and then elosimr the mouth and lireatliinir out fhrouuh Ihe nose. This is repeated over and over aLrain until relief is ohtained. 'IMio stremrfli id' Ihe sidution mi^ht he :5, ■1, or "t |)er cent, as the ease miii'lit rcipiire, repeated, irrespective of time, ni^ht or day, upon tlie approach of each threatened o.xaeer- hation. Tliere are a niiinher of mentliol-inlialers in Ihe market, hut usually the n.«o nf tlie spray is nttonded hy hetter results. Bishop advocates the n.'^e of a 1-per-cent. solution of eamphor- 1. rt Cocniiic livdroclilor pr. v. Anunoii. clilorid pr. ij. Aqua Sj. M. imw ■■»-i 102 DISKASKS OK THE NASAL I'ASSACJKS. menthol in lavoliii as a sjumv to thu iU)so in tliis disease, gradually increasing the strength to ;5 ])er cent, it' retjuired. lie claims it to be blander and more sootiiing tiian menthol ahjiie. 1 have used it on many oeiasions, but still jirel'er the menthol ami ihyniol-nienthol prejiarations. Of the latter the following is a good fornuila: — 1. U 'lliyiiiol 15 Mclltliol 15 All.oU'lU! 30| This should be used as a spray {o the throat and dinunished to one-half strength when iist'd to the nose. Lennox Urowne has moie failh in ilie local a|i|ilieation of men- thol than of any other iliiiu' in the relief of this disease. K. li. Sluirly lias found .-nulT of datnrine in >tarch a very etli- cie.'U remedy; while Fletcher Ingals. after eautei ization. adnnnisters tonics, together with the loral a|i|ilieation of eoeaine, to relieve the exacerbations. In severe cases, when, from liusiness engagements or other cir- cumstances, it is im]iossible to use spray-treatment of any kind to relieve the exacerbations, minute crystals of menthol dissolved in the mouth will elVieicntly keep the sym]itoms under control. As direct sedatives to the nuifuns mend)rane administered in- ternally ]ierha]is none are better than a eond)inatioii of atmpia and morphia in minute doses. They have a ([uieting elTect upon the nerv- ous -ystcin. as well as an astringent etfect ujion the mucou> membranes. The fcdidwing is a good formula: — 2. H Atrojiiii siilph (ii:{ M(>r|)liia sulpli ,05 M. Miikc into 100 taliK-ts. Sig. : One to be taken every two, three, four, or six hours ag required. Still, as with all narcotic sedatives, cocaine included, considering the danger that is always present of forming a habit, the less of these medicines tiiat are given to the jiatient. the better. When 1. B Til yniol pr. ij. Menthol pr. xxij. Alholene 5j. M. 2. It Atropia stilpli gr. %',. ^Iult was a great improvement of the I'oniliiion, with almost com])lete >uli>idcnce of the attacks. St. Clair 'i'hom>oii has very recent Iv di-awn attention (n jht^ pos- sibility of mi-taking escape of cerein'o-spinal tliiid for nasal hydror- rlnea. the s\mptoins being somewhat alike. A number of cases are recorded in which, in otherwise pei'lVctly healthy sultjects. cerebro- spinal fluid W(ndil escape almost continuously from the one nostril, the intermissions being rare. ]n trui' nasal hydidrrlnea the discharge* is more irrciihjeets. Aii- othei' Wiiy is liy perversion of the natural function. The olfactory impi'is.-ions iii iMses of tiiis kind arc usually of an unpleasant char- acter. The odors complained of ai'c disaiirecnhlc. .-ucli as carrion, kerosene, fi'reasy raid's, etc. It is >aiil that this perverted olt'actory function is )iot infre(|uently fiiuud .■iuioml;' epileptics and the insane. Treatment. — This .^IkiuM he dii -iniilar lines to those recpiired in the treatment of anosmia. Still, as its oi'igin is move likely to he central, the jiroLinosis is not so favorahle. Is l'"ri;r\rri.(isis. Small hoils within, the anteiim' nares arc nni hy any means in- freipient. 'i'licy ju'oduce sor<'ness, redness, and swellim:' of the !nd of the nose. 'J'hcy occur most fretpiently at ihe outer mar^iin of the vestihnle or the inner side of the ala, havin.ir their (n'igin in disea.-ed hair-follicles. The nmst notahle sym])tom is general soreness of the part, with sharp jiain produced hy Idowing or handling the nostril. Treatment. — Systemic and local treatment, hased on general principles, is recommended. .\ local application of a '-iO-jjer-cent. solution of camphor-menthol in lavolin is recommended hy Hishop; also a 12-por-ccnt. solution of carholic acid in glycerin. When pus is found, he recommends evacuation, followed hy a])plieation of yellow-oxide-of-mercury ointment. I have found a simpler treatnuMit speedily ethcacious. When the little hoil, or furuncle, is fm'ming. Iiefore pus can have developed at all, a sharji needle should ])0 pressed deeply into its centre. This can he done hy the patient without the aid of the surgeon. Tlien, by vigorously blowing, blood is freely evacuated. This blowing should ho repeated a lunnber of times in (piick succession. If blood does Tiot appear, the little operation should he repeated until it does. The evacuation will have relieved the congestion, and healing takes place at once without after-treatment. I t CIIAITKIJ XVl. . Kl'lSTAXlS, i 'Tills term is ii|)|)li('(l to iiU cases ol' luisiil liii'iiiorrhiijii! wliatovcr the origin iiiny lie. It is ol' rrt'cuu'iit oc-ciirrrncc in childhood; I)ut imich rarer in ndiilt life. Pathology. — The hh'cdin.u nsually arises from erosion or rupture of tlic minute blood-vessels, and in the majority id' cases comes from the lower ]iortion of the cartilaginous septum. Cliiari believes the majority of cases, particularly in adult life, are tubercular, lie gives a record of si.x, in all of which the niicroscope proved the lul)ercular nature (d' the disi'ase. Hard granulations or tumors had formed on the septum and from these the bleeding had occuri'i'd. In malignant disease luvmorrhage may be severe, from any part of tlu> neo])lasm, and the same is true of fibroma, only that in the latter spontaneous haMuorrhage is more rare, owing to the deii.-ity of tiie fibrous tissue. I'ndoubtedly many lasi's occur without the system in any way being involved. Etiology. — In cbildren the most fretpient I'auses are falls and blows ujioii the nost'. Ticking the nose and the insei'tion of foreign ))odies also give rise to if. In deviaticm of the septum the erosi(m of the prominent point of tlu' cartilage by particles of dust may proiliicc bleeding, as also may fi'acliii'cs of the nose m the base of the skidl. Sometimes the hjcuKU'rhage may lie vicarious in plaee n\' su<- peniled intMistruation. W'licn occurring after th<^ nieiinpaii-e. it may lie considerc(l an elVort to !'clie\i' the di-teiided biddd-vc.-.-els. At other times il may aii-e from const il ut i(Uial cachexia, .-iicli as pei'iiicious aiia'iiiia or pui'pnra lia'inoi'i'hagica. or again fiom organic llli'l'c >l|nlllil lie 111) (lillicllll y h 11 lllc hli'C(M!|i| ncclllS while Ihr |illllt'lll 1- 111 ;l CollscKUIS I'nIHill Kill. I' l('( | llcllt Iv. Iiiiw cvt'i'. >li,L;lil liu'iiinirliiiuc \\in ncciir in ilic iii^iht. If llir |i;iti('t'i is ;i>l('('|i ill the ,-ii|iiiii' |i()silii)ii iin diM-liMrui' iiiiiy r.-cii|i(' Iroiii ilic jinlcrinr iiiiic.-. I'd-trrior rliiiiiis((i|iy cscii in llicsc ca-r^ slioiiM H'- IllOVC t 111' lidlllll. Prognosis.^ In inillnr lilcnlill^- lIlc |l|nnni]ease ami |iiir|iiiia may he (■n|i>i(|ere(| ii~ II |l j'a \Oialile i 111 I ical idllS. Treatment. If the altack is mild. siniiiL: i|iiielly in a chair with the lu'.iii tilteil .-liuhlly liarkwanl will nl'leii arre,-l the hleediiiLi-. If tlie jialieiii heiids his head fnrward tn elean.-e tlie iin^lriN id' the eliilled lilnnd. lia'imirrhaLJe will eiimmellee auaiii: lint, let him iilnw (lilt the ai i'nMinlatinii> and at miee roiime the fdrimi {i(i>itinii, it will lie likely tn sdon eeax'. I 'dill Id the .■•|iine. Iidt a|i|ilieal idii- tn ihe eMeriial iid.-e, Imt- waler ddiiehes In the lid.-tlil, |i|edn(.is df cdttdii snaked ill i;lyeern- laiiiiin iir tincture n\' inm ha.ve all lieeii recninniended. It is I'arc, liowt'Vcr. that activt' treatiiieiit will he necessary. When hIeediiiL;- threatens tn he severe, il i- Well liy meaii» (if the nasal <|iecnliiiii and rellected lii:ht tn search fnr the lileediii,i:- Jinint and tn |iack the >|ini lirmly with cnlldii |i|edL;'ets ahme or saturated with astriiiLi'enls ali'cady iiienliniied. In these cases kite- tailed tiiin])()ns answer an excellent |iiir])nse. Small )iieces i)\' aseplie nlisnrbeiit cntdni are tied inn;ether hy a striiia' at inti'i'vals nf one inch and a half frnin each nther. 'They are all then, after cncaini/.in^ the imicniis ineniiirane. packed mie after aiidtlier intn the hleedint: nnstril liy means nf enllnn-hnliler nr small curved fiirceps. until liy pressure the Inemorrhaiie ceases. 'I'lie pliiu' is lelaineil fnr tweiity-fniir nr fnrty-eiii-ht hniirs. .\fter thai the wlmle nr part nf the pieces may he withdrawn hy t:-entle tractinii. a pnitidii liciii^ retained tn the third day if the return nf ha'innrrhaii'e appeared tn lie pi'dliahlc. In anlicipatinii nf the latter. In^als siiLiui'^t- the u~e nf a strip nf '"odofnrni izaiize as less likely tn heenme oll'eiisive dnrinu' a prnlniiLred retention. Vnr deep packing (ileasnn also iis(>k a lon^' strip nf iraii/e. snaked in one of the hydrocarbon oils and packed, fold after fold, hack as II ■!■'.:« »»^WJ.-g<»^;«'Yv>-i it ahmi;' the iiilViior nu'atns to the pos- terior iiaiis, as in tlic lirsl iiicthutl. llo ehiiins tliat l)y tliis moans posterior |iaekin,:i can Ik- avoided. In poi'l'' «'i,!y. r„!|nur.| |,v iiii'iiiorrliii^rc. 'AlKitlirr |il;m of Ifcjlli 109 ii'i"i'''liiitr (TssiilinM ,,]■ the ;;;.;;;:;':::;;;:;::;;::r,^:::j:';;:-:: ■ 4 1 CIIAI'TKR Wll. luiiNoi.iriiS; i()i;i;i(..\ uodiks; i'akasitks. TilllNOI.IIIIS. A i!ii iNni.iiii i- a iiii>al (alculii-. It is rorincd l)_v tlic u'i'ailiial (Ifjiosit (if till' iniiicial cdiistil iiciils nf llic iioriiial iuimiI socrclioiis U|)(iii the >iii-|'aii' (if sniiic lorci::!! Iiody, li)cnti'il witliin tlio nose iiiid lu'tiii.ir ;i> a nucleus. 'I'lic rarlir-i rccdiil tpf (Uic liciiiu' I'l'inovrd \\a> n'|Mi|-t('tl liv (Jardi ill 1A(i".'. It \\a- indcliiiiudy dc-ciilii'd a- liciii^' a- lar,m' as a lii'-coiu'. Dui'iiij.' the Iniir cciiturii'- li'iuii ilicii until lunv uuut than a humlrud liavc 1u'cn ilii'niiirlcd. SiiU. rliinolitlis arc of rare occurrcMcc and tlu\v nccni' so inri(M|Ucnlly that each individual i^ase is usuallv coa- sidorod Wdrlhy dl' a ri'cni'd hy itself. In the mailer id' hi-tury, ihey I'nlldw the same law that jxtiverns tile I'dMuatinn nf calculi in the hladder and olhcr orirans of the hody, and in most instances snnie trace of iiucleiis can he round. It usually tiikos many years from the insertion of the oriirinal I'oreijxn hody in the nasal cavity to the full development of tlio rhinolith, as seen when the patient applie- to ihe siiruciin for relief. Symptomatology.- Someiimes from their size and position they '/wo rise to great deformity. In llendloy's case the nose was swollen and there was an external >inu>. Iroiii which jius exnded; in UovilTs case facial ]iaialysis ami destruction of the hard palate. In Ilill'.? case the rhinolith wa- veiy larLie and had caused extensive rhinitis caseosa. In .Mar.-ITs case there was marked deviation of the septal cartila.u'c to the left, heliind which the calculus lay concealed. One of ihe writer's ca.-e-. a . 1 1 filled llir wlinlt' III ilic iiili'iiiii' lui'iitii^ iiml iiail li> ln' lii'ukt'ii ii|i liit'ort' it foiiM III' rciiinvnl. 'I'lic initlcii> \\;i> II liiiitiiii, US .-littwii in tlu' iipjifi* rif^lit ciiil III' ilii' lii:iii('. One |)I'iillli||rlll .-yill|itiilll illtrllllin.L:' nil cm-.'- nf Inllif -tlllnlillU' is a siininiis. iiiiico-ituiiilfiil ili-ili;ir::r n| |ir(iiliiiil\ iin|i|('n«iuil ihIhi-. It is aliiiDst cliariirtcrislic nl' tlir ili^'ii-r iiml (jiiiir ilill'i'iTiii rniiii tiiat |irniliiici| liy ntrojiliir iliiiiili-. Diagnosis. A- ilir ilr\r|ii|inii'iii nf ilnniilitli- i- a -Inw iiniccss. tlicv I'jii'rly iMiiiic iiinlci' iiliM'i'\aI lull iiiilil ;iiiiill lilr. I'.y lliis liiiH', I'i'iiiii llirir ^izi'. till' >yiii|itiiin~ Kriniiii -iM IT. In iliilillimul iiiiv liaiil siilisiaiicr I'liiiiiil within llir nn-i' i- likrly tn ln' a I'nrcii^ii luuly, witlinnt ilic calcafrniis ilr|iii«it. altlnMi^li Imtli (.'lark ami Jtabur rcpDfl ca.scs oi-i-urrinu' in rhiMiTn. In (liiTci r.Viiniinatinn tli'' urilly -riisniinn lU'ndniril liy tlir tmi'-li (if tlu' |ii'(i!ir i> inilii-at i\i' III' raliiilu-. Wlim ciiivat ur<' ni ilir M'ptiiiii. as ill tlic IW'i ca:-!'-- rrlalcil. Iiiilr~ tlir -tiuir rrniii iiii-irvat inn, the illi- i i ; '1 ! YiiS. .")(!. liliiiiojilh rciiiii\ cil irmii the Ift't iia-iij |i:i--ii^'i' ui' a laily, ajri'd -^. niiictcrn M'ais afli r (lie in-crliiin nf tlii' Iniltiiii iiitn the iiii<|iil. podimoTit may rci|iiir(' to lie rcrmivi'il licfnn' the (liai:iin-is can lie niadi' sni'c. Prognosis.- -Til (• I'ldar-vd (■alciilns can never lie reimived e\ce|it ])y o)H>rat ion. Siiri:ical relief liy one means or dtlier i- always ])os>il)|c. Treatment. — This is simply the removal of the ihiiioliih like any other forei,<.ni lindy. 'i'his can rarely he acc(mi])li.-lied without thi> enisliiiiji' or hreakinu'-np process. l-'ortiinately they are not often dense enonuh to resist the force of com|iressinn-l'orceps. and wlu'ii that ilensity (\n^^> exist small lithofriies may he \\|I(HI|1. J most cases occurring in young childrfU, but in some complete aniws- thosia may not be necessary. The ajijilicalion of a drop or two of .solution of cocaine to the mucous memhrane will shrink the tissues and facilitate i'.\tra;lii)n. Fig. 58.- -I'osw drill's ua^a' fureeps. A nasal spoon (Fig. 51) in ilie majority of instances will readily remove the object, ■ hough sometimes mouse-toothed or curved nasal forcejis may bo re^'.'ircil (Figs. oS to (iO). When these fail a snare may possibly be slipped ovi'r some projecting point, and render the extraction easier than by any otlu^r method. r.vn vsiTi:.'^. The presence of extraneous or jiarasitic life within the nasal cavities is very rare in temjierate climate?, so rare that many rhinolo- K 114 DISEASES OF THK XASAL PASSAOKS. I'll gists linvc iiovor scon a riisc, wliile in trnjiical countries it is compara- tively fro(iucnt. In Jndia alone Laliory collated 91 cases, 2 of which were fatal. Jn ("hxinet's case, a man, after slee])ing in an open field, was seized with severe pains in the foreliead and with swellino; of the face. He was taken to a hospital. Worms commenced to crawl about his nostrils and ears; and on lancing the swollen tissues several platefiils are said to liave been taken away (l'»osworth). The i)atient recovered Mith tlie loss of his eyes. Fraenkel says that in teni])erat(! climates the presence of ozainn is favorable to the gnnvlli of parasites, ami that the most active enti- ties in producing tiie malady are the Mitsca romiloria, the Muf^ra carnaria, and the gadfly. fjoldstcin, in tiie Laryngnscope lor December, 1897, graphicabv Fig. GO.— Hiirtniann's foitciis. !:lr:: ( .'1 introdnci's a new insect to tlie notice of his professional brethren. This is tiie Cotupsoniijia macceUaria, or Texas screwwo:;u-fly. Pro- fessor Williston. of Yale, says that it prevails everywhere from Canada to I'atagonia. Til is ]Hst n>nally confim^s its ravages to cattle, b\it sometimes it invades the nasal passages of human beings. Several deaths have been recorded from its effects. In all the known instances, bow- ever, in wliich the (>ggs of the screwworm have l)een dejiosited in tin; nose or ear there has been either ]U'c-existing oza^na or otorrhn^a. Tlie lly deposits its eggs upon decaying anhual or vegetable matter, and upon this tlie lly feeds voraciously. Symptomatology, — The symptoms in all cases are pretty nearly alike. These are excessive irritation, excruciating pains, formication, and the ajipcarance of the maggots craMling within the nasal cavities. PARASITES. 115 Tlicy arc very tenacious of life, and wil! stick to tlie walls of the passages with great tenacity. Muco-i)uriilent and bloody discliarges soon follow, accompanied by headache, fever, and other constitutional symptoms. When death occurs it is probably due to the supervention of cerebral meningitis, possibly aided by the development of septi- ca'mia, from the extensive supi)urations which sometimes occur. Treatment. — -'J'he best treat n'.eut is to curette and pick out the larva". The scrttwworm i.s said to be so tenacious of life that it will live for several minutes in pure carbolic acid. The vapor of chloro- form, if conconlrated, will kill them; but care would be required lost in zeal to destroy the parasite the patient shoidd be sacrificed. Ordi- nary washes and s])rays are useless. Rigid watchfulness, with oft- repeated extractions of the gnd)s, aided by cocaine and retlected light, would appear to be the best treatment. Scbappegrell advises the use of warm oil. He says it destroys the larvse by occluding their respiratory organs. He ])laces the i)a- tient in the horizontal position, and fills the nostril with the lluid: olive-oil, albolene, glycolin, etc., and claims to eradicate the worm by careful and painstaking use of this means. 'Mr 'J i 1 !( .M it. t m pi Ml! ■J WW 11 1 1 I i'- ('IIArTKJi XVII I. NASAL roLYI'I. TiiKSE arc tiiinur= nf ihe 7iii^e, luescnting several marked char- acteristics. Tlu'V liavc smooth surfaces, arc lobiilatetl, but usually are rcirujar in form, each hcini: attached by its own Itmad or narrow ])cdicle. The color is jirayish hluc, sometimes slightly jiink. They are tense .id elastic to the touch, and arc of jelly-like consistency. i. ^ •: t ' i^ Fig. 01. — Xasal polypi. (After 15osworth.) They rarely appear simultaneously for the first time in both nasal fossa\ but attack one nostril first. Sometimes, through a long course of years, the other one is never invaded. In other instances the de- velopment of polypi on one side is quickly followed by their forma- tion on the other (Fig. ('•>]). Pathology. — This is a subject in which there exists, particularly among recent writers, a considerable difTerence of opinion. Biibroth classes nasal polypi with the adenomata; Bosworth, (lUi) XAiiAL roLYri. ii: Kri(li.>-rii, and Hiitlcr consider tlu'm to be nivxoma; wliilo J. X. ^lae tliat the cli til )t i.s 1101 iiiyxomatous, hut that of simple inllanunation. He says that the ordinary mucous poly- pus is an (edematous fihroma, not a myxoma. Jonathan Wright also, al'ter extensive niieroscopieni exaiiiiniitions, has arrived at the eon- cdusion that true myxomata are never found within tlx! nasal eiiam- bers, and that the growths usually called t)y this name are simply the results of chronic intlammation. lie finds that, in addition to the degeneration of the stroma and tlii> ledumatous iMiiltralion so generally ])reseiit in nasal ]iolypi. there are also occasionally hyaline bodies (U* berries. They are conlimd ;dmo>t entirely to the struma, and vai'y in sixe from that of a round, white blood-cell to three or four limes thiU dianiclci'. "'riii-c liodirs are ilivide(l symmetrically by sulri, wiiicli I'clracicd the light strongly into lobules. comiM'essed into polygonal shapes. a]i|iarently liy a limiting membrane"" (donatlian Wright)?' Swain has proved histologically that ]tolypi having surface cor- rugations contained a lari:-e amount of fibrous tissue, and that, whether in their origin they had a purulent basic foumlatioTi or not, no bacilli, cocci, or jiarasitic bodies seemeil to be present in their tis-ue. Swain's observations seem 1o have brought out an addifiomil fad: that tiie histological character of the polyp beais a direct relation to the density of the tissue upon which it grows, lie also believes their origin to be inflammatory, invohing the pre -existence of an hyper- trophic condition of the mucous membrane. Xotwithsfaiiding dilferences of opinion upon fundamental ])rin- ciplcs, there are certain pathological comlitifuis in which all agree. The external surface of the polypus is composed of an epithelial layer similar to that of the ordinary mucosa; it may b(,' mixe(l in character, or either s((uamons or ciliated, according to circumstances ami situa- tion. Within this there is hypertrophy of the stnu'tuial elements of the mucous mem!)rane and connective tissue, giving a fine reticular frame-work, the me.isi:.\si;> Ob' Tin; nasal passaciks. Etiology.— Altlioii'ili tliis sulijoft lias engaged tlio atteiiliou of so many keen ()l)servers, as has already been said, they do not all agree. The probability is tliat there are many causes which may lead to tlic develoinnciit oi' this disease'. 'I'he fact tliat tiie mucous mem- Fi}T. 02. — ]\Iici'os(.M)]ue-iil scctiuii of iitusal iiolypus ("ilMI (lianiptors). a, Stratified ciliated I'liitlicliiini. h. I'cticular fraino-work. c, rolyiiuclear leiic'Ot'ylo. (/, Yascular iciitic. c, liadiaUiig blood-vessels. (Aulliov'a speeiiDcn by ]?ensley.) brane of tlie middle turbinated is of softer and more delicate con- sistency than that of the lower, and composed of a liner reticular tis- sue, may make it more liable to this so-called myxomatous hyper- trophy. In a normal condition the tissues of the middle turbinateds NASAL rOLYl'l. Hit are in constant condition of scroud oxo.sniosis. The inenibrano in some cases may be easily overdistended, and, if from any cause in- liibition is lost at a given ])oinl, ibere is notiiin^if to prevent tlie dis- tension increasinf?, with proliferation of cell-elem(>nts. Woakes believes the large majority of cases to be tlie result of necrosing etlimoiditis, while (iriinwald considers the formation of polypi to be secondary to enij)yema of tiio accessory cavities, ^fc- ]Jride considers tbcm to be simply (edematous iiljromaia, to be dis- tinguished from papillonnita by their density, color, and site of origin, but to \)e the same in character and cause. Zuckerkandl suggests that they originate as adenomata, but that during development some of the ducts become occluded, resulting in myxomatous (le_ luM'ation of glandular tissue. Somewliat in opposition to all these views, Jonathan Wright and Swain, of this continent, nuiintain that the disease is, in all cases, a result of chronic inllammation of the mucous membrane. ]My own conviction, based on i)ersonal clinical experience, is that the etiology cannot be contined to any one cause. In the large ma- jority of cases that I have seen, where the polypi were large and numerous, there was no sinous disease. On the other hand, cases of antral disease that 1 have attended were usually alfected also with polypi of tlie adjoining middle turbinated; but these polypi were always small, and after the healing of the sinus the poly])i ceased to return. Hence they were ]mrely secondary results, quite dilferent from mulliple myomatous disease. Nasal ])olypi are ^^nid to occur more frequently among males tiuin females. Tliey rarely occur in early life, although one of the most severe cases 1 ever saw occurred in a little girl aged 7 years, from whom 1 removed about twenty from the two nostrils; Fig. 03 gives a microsco])ical section. Her mother stated that she had been troubled with them from the age of two and a half years; and that for more than a year after that she was un(h'r the constant care of a specialist, who reniovt'd tiiem as rapidly as they apjieared. This case, I think, was undoubtedly congenital. The rarity of these cases is evident from ]\lour(!'s statistics, for, out of 10,5'v'O cases of na.-^al polypi, only o occurred among children. This is strikingly brought out by Dtmbar Roy in an aide article reporting a case. Symptomatology. — Two noted authors give directly opposite statements as to tirst sym})toms. iiosworth says: "The first and earliest symptom is tense irritation in the u])per air-passages of the cavity, manifesting itself in more or less violent attacks of sneezing. r.'d l)isi;.\si:s OF TilK N.\s,\[. i'.\s>.\(ii:s. 'I li i :■! ili!^ :! t i,| {U'((iiii|iiiiiic'il uitli wiitciy (liscliiirirc."' liCimnx Urdwiic says: '"Sucoz- in<^' is seldom cxhiljitcd, imiiiuiiity irom tliis tlisajii't'cnlili' symptom licinir (loiihrk'ss due In a liluiitiiii,' ol' the sciisiliility of tlii.' iktvc- c'iidiii