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MANUAL OF DISEASES OF THE

THKO AT AND NOSE

A MANUAL OF DISEASES

THROAT AND NOSE,

INCLUDING THE

PHARYNX, LARYNX, TRACHEA,
(ESOPHAGUS, NOSE, AND NASO-PHARYNX.

>rt*i i

MOKELL MACKENZIE, M.D. LOND.,

CONSULTING PHYSICIAN TO THE HOSPITAL FOB DISEASES OP THE THROAT,
LECTURER ON DISEASES OF THE THROAT AT THE LONDON HOSPITAL MEDICAL COLLEGE.

AND CORRESPONDING MEMBER OF
THE IMPERIAL ROYAL SOCIETY OF PHYSICIANS OF VIENNA.

VOL. II.— DISEASES OF THE (ESOPHAGUS, NOSE,

AND NASO-PHARYNX.

53. S

LONDON :
J. & A. CHURCHILL, NEW BURLINGTON STREET,

1884.
[All -rights reserved.]

i n

PEEFACE.

IT is now nearly twelve years since this work was
commenced, and during that period there is scarcely
a page that has not been written and re- written many
times. This slow rate of progress has been due partly
to the inevitable delay caused by the many other
demands on my time, and in part also to the rapid
development of a new specialty involving frequent
modification of views, and bringing constant additions
to the literature of the subject.

No one can be more keenly aware than myself how
great a gulf is fixed between the conception and the
actual execution of my design, and in a book of such
extent numerous errors must, in spite of the utmost
vigilance, have escaped my notice. I confess that had
I foreseen how much time and trouble the work, imper-
fect as it is, would have cost me, I should never have
had the courage to undertake it. Even now I am
unable to issue the volume in its integrity as originally
planned, the section of Diseases of the Nose and Naso-
Pharynx having grown under my hands to such dimen-
sions that it has been found impossible to include
Diseases of the Neck. I hope, however, that this
division, the greater part of whicli is already in print,
will shortly appear in a separate form as one of my
series of " Essays on Throat Diseases."

VI PREFACE.

I have once more to express my thanks to several
friends and assistants who have aided me in clinical
iiivcsti^jitidiis ;in<l literary researches, .-nnl in ].;ir-
ticular I must acknowledge my deep obligations to
Mr. C. L. Taylor for his invaluable help during the
last four years. Mr. Mark Hovell has again been
good enough to prepare an index to the book, and the
careful way in which he has performed this most
useful task cannot fail to be gratefully appreciated by
those who have occasion to refer to these pages.

Dr. Felix Semon's translation will be published
simultaneously with the original, and it is, naturally,
a source of much gratification to me that my labours
should be made known to my fellow-workers in
Germany by so thoroughly able an exponent.

M. M.

19, HARLEY STREET, CAVENDISH SQUARE,
April,1 1884.

1 The appearance of the book has been delayed for several months
in consequence of the entire edition having been destroyed, on the
very eve of publication, by a disastrous fire which consumed the
premises of the printers, Messrs. Pardon. The r< printing has been
carried out with all possible rapidity from proof-sheets in my
possession. I think it necessary to make this statement in order
to explain how it is that several valuable writings, published within
the last few months, are unnoticed in the present volume.

CONTENTS.

SECTIpN IV.— THE GULLET.

PAGE

Anatomy of the Gullet ; Examination of the Gullet ; (Esophageal
Instruments ; Diseases of the Gullet : Acute (Esophagitis ;
(Esophagitis in Infants ; Phlegmonous (Esophagitis ; Ulcer
of the Gullet ; Traumatic (Esophagitis ; Chronic (Esopha-
gitis ; Varicose Veins of the Gullet ; Peri-(Esophageal
Abscess ; Thrush of the Gullet ; Diphtheria of the Gullet ;
Malignant Tumours of the Gullet ; Cancer of the Gullet ;
Sarcomata ; Non-Malignant Tumours of the Gullet ; Syphilis
of the Gullet ; Tubercular Disease of the Gullet ; Dilatations
of the Gullet ; Simple Dilatations ; Sacciform Dilatations ;
Tractiou-Diverticula ; Cicatricial Stricture of the Gullet ;
Simple Stenosis of the Gullet ; Compression of the Gullet ;
Rupture of the Gullet ; Wounds of the Gullet ; Foreign
I'KII lies in the Gullet ; External (Esophagotomy ; Neuroses
of the Gullet : Paralysis of the Gullet ; Spasm of the (Eso-
phagus ; Malformations of the G«llet ; Post-morteni Soften-
ing of the Gullet 1

SECTION V.— THE NOSE.

Anatomy of the Nasal Fossae ; Rhinoscopy ; Anterior Rhinoscopy ;
Median Rhinoscopy ; Posterior Rhinoscopy ; Posterior Rhino-
scopy by Double Reflection ; Nasal Instruments ; Acute
Nasal Catarrh ; Acute Coryza in Infants ; Purulent Nasal
Catarrh ; Traumatic Rhinitis ; Hay Fever ; Chronic Nasal
Catarrh ; Hypertrophy of the Mucous Membrane of the Nose ;
Dry Catarrh often leading to Ozsena ; Chronic lilennorrhcea
of the Nose and Air- Passages ; Bleeding from the Nose ;
Non-Malignant Tumours of the Nose : Polypus of the Nose ;
Fibrous Polypi of the Nose ; Papillomata of the Nose ;
Erectile Tumour of the Pituitary Membrane ; Enchondro-

Vlll • "N TENTS.

mata of the Nose ; Osteomata of the Nose ; Exostoses of tin-
Nose ; Malignant Tumours of the Nose ; Syphilitic Affec-
tions of the Nose ; Hereditary Syphilis of the Nose : Tulx-i
cular Disease of the Pituitary Mi tnlinmc ; Lupus of tli«-
Pituitary Meiulirane ; Rliinoscleroina ; Glanders ; Affec-
tions of the Nose in Kruptive Fevers and other Acute
Diseases ; Fractures of the Nose ; Dislocation of the Nasal
Bones ; Deviation of the Nasal Septum ; Blood-Tumours of
the Nasal Septum ; Abscess of the Nasal Septum ; Foreign
ll.i'lies in the Nose; Rhinoliths ; Maggots in the Nose;
Entomozoaria in the Nose ; Anosmia ; Parosmia ; Disease
of the Fiftli Nerve, or its Nasal Branches ; Congenital De-
t formities of the Nose ; Syuechiae of the Nasal Fossae .

SECTION VI.— DISEASES OF THE NASO-PHABYNX.

Chronic Catarrh of the Naso- Pharynx ; Dry Catarrh of the Naso-
Pharynx ; Adenoid Vegetations of the Naso- Pharynx :
Fibrous Polypi of the Naso- Pharynx ; Fibril-Mucous Polypi
of the Naso- Pharynx ; Knrhondronia of the Naso-Pharynx ;
Malignant Tumours of the Naso-Pharynx ; Throat-Deafness 482

APPENDIX.

Special Formulae for Topical Remedies : Bugiuaria ; Collunaria —
Nasal Douches ; Lotiones — Nasal Washes ; Nebula — Nasal
Sprays; Gossypia Medicata — Medicated Cotton - Wools ;
Olfactoria — Olfactories ; Pastils ; Insufflationes ; Snuffs . 545

A MANUAL OF

DISEASES OF THE THEOAT AM) NOSE.

VOL. II.
SECTION IV.— THE GULLET.

ANATOMY OF THE GULLET.

THE gullet or oesophagus is that portion of the alimentary canal
which connects the pharynx and the stomach. It commences at«the
lower border1 of the cricoid cartilage on a level with the inferior margin
of the body of the fifth cervical vertebra, and passing downwards
behind the trachea in an almost vertical direction, traverses the lower
part of the cervical region and the whole of the thorax, and after
piercing the diaphragm opposite the ninth dorsal vertebra, terminates
in the stomach opposite the tenth (ninth dorsal spine). 2

1 Ths- distinction between the pharynx and the gullet is, of course, purely arbi-
trary. Most anatomists consider that the oesophagus commences on a level with
the lower border of the cricoid cartilage, but Quain ("Elements of Anatomy,"
vol. ii. p. 821) makes the cricoid cartilage generally, without specifying any
border, the limit of the upper extremity of the oesophagus. Mouton (" Du
Calibre de 1'CEsophage," Paris, 1874), in his laborious measurements of the gullet,
does not clearly define its upper limit, but he appears to take an imaginary
transverse line running across the middle of the posterior plate of the cricoid
cartilage as the point of origin of the oesophagus. It would, however, be much
more convenient to make the upper border of the cricoid cartilage the boundary
line between the two sections of the food-tract. The sudden diminution in the
calibre of the canal at this point makes, as it were, a natural division. At present,
however, the lower border of the cricoid cartilage is so much more commonly
accepted as the level at which the gullet commences, that I have thought it
better to adhere to it. From the fact, however, that the cricoid cartilage moves
up or down, according to the position of the head, some anatomists object to
taking any portion of it as the upper limit of the oesophagus. Middeldorpf
(" De polypis oesophagi," Vratislavise, 1857, p. 2), indeed, goes so far as to say
that the extent of movement amounts to four centimetres when the head
is thrown far back. This circumstance has led some writers to make one of the
vertebrae the limit marking the upper extremity of the gullet, but the difficulty
of recognizing the exact position of the cervical vertebrae during life more than
neutralizes any advantage gained by this means.

2 It may be useful to note that as the spinous processes in the dorsal region
are directed downwards, the spine of one vertebra corresponds with the body
of that immediately below. There is often some difficulty in counting the
spinous processes, especially in the early stages of disease when there is but little •
emaciation, and it may therefore be well to remember that the oesophagus com-
mences about an inch above the vertebra prominens, and terminates a little below
the level of the inferior angle of the scapula.

VOL. II. B

DISEASES OF THE THROAT AND NOSE.

The oesophagus is often described as following the antero-posterior
curves of the spinal column in its descent. This is true in the cervi< -al
region, but the backward curve which is usually described as occurring
in the dorsal region does not exist in the erect position of the body.
I n the upper part of its course the gullet is in the median line, but as
it descends it curves slightly to the left until it reaches the root of tin-
neck ; at this point it inclines again towards the middle of the spinal
column, which position it reaches opposite the fourth or fifth dorsal
vertebra. Immediately before traversing the diaphragm it makes a
short curve forwards and slightly to the left. Owing to the very loose
attachments of the oesophagus, the relations of the tube are apt to vary
to some extent, its position being dependent on slight variations of the
adjacent organs, scarcely amounting to abnormalities.

The length of the oesophagus varies according to the stature of the
individual, but in an adult male it generally measures from about
twenty-four to twenty-six centimetres. The diameter of the tuW
varies at different levels, and, according to Sappey, it diminishes
insensibly ' ' from its upper extremity to the fourth dorsal vertebra,
and increases again from that point in an almost insensible manner
to its termination. It is therefore composed of two truncated cones
united at the apex."1

Braune's sections2 support this description in the main, but the
measurements of the diameter of the gullet made by Mouton* from
plaster of Paris casts give quite different results : —

Superior orifice of the oesophagus 14 millimetres.

At 1 centimetre below superior orifice .... 19

„ 3i „ .... 15

,,4 „ „ .... 15

At rather less than 7 centimetres from

superior orifice 14

At 11 centimetres from superior orifice ... 20

' 14 17

15
17
21
22
25

21
20
12
12
12
14

With the view of determining still more accurately the calibre
of the gullet in its whole extent, I performed some experiments
suggested by that of Mouton, but more elaborate and on more than
one subject. The following were the methods adopted. In the first
case the body was securely fixed, with the head downwards, ujx>n a
board placed perpendicularly on the ground. The mouth and pharynx
were then tightly stuffed with tow so as to close the upper outlet of
the food-tract, the stomach laid open, a ligature passed loosely round
the cardiac opening, and the ends held outside the wound so that they
could be tightened at once when required. The nozzle of a large
anatomical syringe, previously charged with a mixture of plaster anil

, 1 " TraiW d'Anatomie Descriptive," t. iv. p. 150. 3me Mition, Paris, 1879.

- ''Atlas of Topographical Anatomy," translated by E. Bellamy. London,
1877. See plates vii. viii. ix. x. and xl.
3 " Du Calibre de I'ffisophage.' Paris, 1874, p. 17.

ANATOMY OF THE GULLET.

water of about the consistence of cream, was next introduced into
the lower orifice of the gullet, and the contents were injected with as
little force as possible into the canal. When a sufficient quantity of
the material had been used, the ligature was tightened round the
cardiac aperture of the stomach, and the body was left undisturbed
for nearly eighteen hours so as to allow full time for the plaster to set
firmly. On the next day the whole length of the gullet thus injected
was removed from the body by a dissection conducted with the
utmost care so as to avoid the least injury to the cast. The cesopha-
geal wall was then carefully divided by a vertical incision earned
along its whole length, when an accurate cast of the gullet was found
to have been obtained.

SUBJECT I.

A large-framed, muscular man, 6 ft. in height. The injection was
made at the London Hospital in the early part of January, 1881.
The length of the oesophagus was 27 centimetres. The other measure-
ments were as follows : —

Point of Measure-
ment.

Lower edge of cricoid
1 centim. below
2
3
4
5
6
7

10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

Transverse
Diameter.
25 millim.
25
23
23
24
24
21
22
22
23
24
24
24
26
27
26
27
25
24
23
25
24
24
24
27
29
31
31

Antero-Posterior

Diameter.
14 millim.
14
18
19
17
18
19
18
18
19
18
18
20
21
23
23
22
21
20
20
20
21
23
23
22
21
22
25

Although the subject experimented on was a large man, the
dimensions of the oesophagus at different levels were so much greater
than those given by Mouton that I thought it possible some artificial
distension had been effected by a too forcible injection with the
syringe. In the second case, therefore, the liquid plaster was poured
down the gullet from the stomach with the aid of a filler.

I'I>KA>KS «'F TIIK THH'iAT AM> M»K.

SUBJKCT II.

A man, 5 ft. 4 in. in height. The oesophagus was injected with
plaster of Paris on January 21st, 1881, in the mortuary of the London
Hospital. Death had taken place three days before, but tin- wi-iitln-r
was very cold, and rigor mortis had not (jnite passed away. Tin-
length of the oesophagus was 25$ centimetres. The following wen-
the other measurements : —

Point of Measure-
ment.
Lower edge of cricoid.

1 centim. below ,,

10
11
12
13
14
15
16
17
18
19
20
21
22
23

Transverse
Diameter.
21 inilliiu.
19
22
22
19
18
18
19
18
19
21
23
22
23
23
25
25
24
22
21
19
16
16
17

Antero-Posterior

Dial i

10 milliin.
15
15

14 „

In the second experiment the measurements are much smaller than
the first, but the body was not nearly so large. Even in this instance,
however, the standard of size is throughout very much greater than
in Mouton's subject. The practical outcome of my experiment -
to show that the transverse diameter of the gullet is very consider-
ably greater than the antero-posterior measurement.

When not distended in the act of swallowing, the mucosa, whii-h
is only very loosely connected with the submucous areolar tissu
thrown into longitudinal folds, which project into the lumen of tin-
canal, and at certain points fill it up altogether. It is only near its
origin, however, and at about seven centimetres lower down, that
this juxtaposition of the internal walls of the oesophagus closes tin-
canal ; at other levels it is probably always jwirtially patent. As is
shown by my experiments, the oesophagus is symmetrically flattened
between the trachea and bodies of the vertebrae in the antero-pos;
direction in the neck ; and lower down, though its canal occasionally
approximates to a circular form, it generally retains a kidney-shaped
lumen,

i It would be highly desirable that these experiments should be repeated on an
extensive scale.

ANATOMY OF THE GULLET.

In its cervical and thoracic portions the gullet comes into relation
with important adjacent structures, which must be borne in mind in
the diagnosis and treatment of its diseases. In its brief abdominal
course its relations are of minor practical interest.

In the cervical region the gullet is in relation, anteriorly, with the
membranous portion of the trachea, to which it is bound by loose
areolar tissue. Posteriorly, it is separated from the vertebral column
by the longi colli muscles. Laterally, it is in relation with the thyroid
gland, especially its left lobe, with the common carotid arteries, and,
more externally, with the pneumogastric nerves and internal jugular
veins. In the angle between the trachea and oesophagus lie the
two recurrent laryngeal nerves. Owing to its curve to the left, the
oesophagus comes into more intimate relations with the left carotid
artery than with the right, and for the same reason the left recurrent
nerve is, at the root of the neck, almost in front of the tube.

In the thorax, the oesophagus is contained in the posterior medias-
tinum ; it is in relation, anteriorly, from above downwards with the
following parts: viz., the trachea, the left carotid and subclavian
arteries (near their origin from the left side of the transverse portion
of the arch of the aorta), the bifurcation of the trachea (opposite the
third dorsal vertebra), the left bronchus (which crosses it obliquely),
the bronchial glands; below this the posterior surface of the commence-
ment of the arch of the aorta, and the posterior surface of the left
auricle, or rather the corresponding part of the pericardium, are in
near relation to the gullet. Posteriorly, the oesophagus is at first in
close contact with the spine and longi colli muscles, but in its descent it
becomes separated from these by loose connective tissue, by the right
intercostal arteries, the vena azygos, and the thoracic duct as it
passes obliquely upwards from right to left. Just before the gullet
leaves the thorax and on a level with the eighth dorsal vertebra, it
comes into relation, posteriorly, with the descending aorta, the
opening for which in the diaphragm is almost immediately behind
that for the cesophagus. Laterally, the thoracic portion of the oeso-
phagus is in contact with the pleurae, with the vena azygos major
on the right side, and on the left with the descending aorta. The
pneumogastric nerves lie at first one on either side of the tube, but
in their descent they pass, the left in front of it, and the right
behind it.

The abdominal portion of the oesophagus is of very minor impor-
tance ; it is covered by the peritoneum both anteriorly anol pos-
teriorly.

Like the rest of the alimentary tube, the oesophagus consists of three
coats — mucous, submucous, and muscular. The mucous layer is of
moderate thickness, and is mainly composed of loose connective tissue,
which contains a large proportion of loose elastic fibres. Its surface is
closely studded with delicate papillae, which, together with the inter-
vening oppressions, are covered by a laminated pavement-epithelium.
Between the mucous and submucous coats is a layer of plain muscular
fibres, the muscularis mucosae, which is imperfect in the upper part
of the tube, but attains a considerable development inferiorly, where
it forms a continuous investment, arrangeol in longitudinal folds.
The submucous connective tissue is considerably thicker than the
mucous coat, and so loosely attached to it as to allow very free move-
ment of the latter, and to admit of its being arranged in longi-
tudinal folds when the tube is in its natural state of contraction.

6 DISEASES OF THE THROAT AND NOSE.

The constituent bundles of the submucous, like those of the mucous
coat, include a considerable number of elastic fibres, and form a
nil supporting the vessels and nerves. The muscular iu,it U
i-.iinjHisrd nt two layers of fibres, a circular or internal, and a longi-
tudinal or external. The latter is the thicker, especially at tin- n>in-
meuccmeut of the tube, but it diminishes in thickness as it descend*.
It consists of three divisions — an anterior and two lateral. Tin-
former, winch is by far the strongest of the three, is attached above
to the ridge on the posterior surface of the cricoid cartilage by i:
of a triangular elastic ligament, while the lateral portions take origin
fn»m the elastic expansion of the palato-pharyngei muscles. In it*
course downwards the longitudinal layer often derives a small mus-
cular slip from the left bronchus — the broncho-cesophageus muscle,
while similar additions to the circular layer are described as 1>« -in-;
occasionally obtained from the left lateral wall of the {xwterior m<
tinum. The muscular coat of the oesophagus consists, in its upper
fourth, mainly of striated fibres ; in its second fourth, of about equal
proportions of voluntary and involuntary muscle ; while in the
remainder of its course it is constituted almost entirely of unstriped
fibres. The muscular coat is attached to the adjacent structures by
a loose areolar investment, which contains a large proportion of
elastic fibres.

The (esophagus contains a considerable number of mucous glands
of the acinous, racemose, and compound tubular varieties.

These glands are lined with cylindrical epithelium, and are for the
most part imbedded in the submucous connective tissue. They are less
abundant in the human gullet than in that of many of the lower
animals, and occur in greater numbers at the lower than the upper
part of the tube. The vascular supply of the oesophagus is derived
mainly from the thoracic aorta, inferior thyroid artery, and coronary
branch of the cceliac axis ; the vessels have mostly a longitudinal
direction, and anastomose freely with one another. At the lower
part of the oesophagus, the veins communicate pretty freely with the
coronary veins of the stomach, and are thus brought into relation
with the portal system.

The lymphatics differ in their arrangement from those in other
parts of the alimentary canal by forming only one layer, which is
placed internal to the muscular coat. They communicate with neigh-
bouring glands, and near the root of the lungs terminate in the
thoracic duct after having anastomosed with the pulmonary lym-
phatics.

The nerves are derived from the pneumogastric, recurrent laryngeal,
and sympathetic, offshoots from which join each other in a com-
plicated network (plexus gulae), which encircles the oesophagus,
lying for the most part between the longitudinal and circular layers
of its muscular coat.

EXAMINATION OF THE GULLET.

The gullet can be examined during life by auscultation,
by sounding, and by direct inspection with the cesophago-
scope. Palpation also should not be neglected, for although
tin' oesophagus itself cannot be felt, useful information may

EXAMINATION OF THE GULLET. 7

sometimes be obtained as to the condition of the neighbour-
ing parts. Thus deep-seated abscess of the neck, enlarge-
ment of the glands, fibroid thickening of the thyroid body,
or the pulsation of an aneurism may be detected, whilst the
negative evidence afforded by the absence of swelling or
tenderness in the cervical region may in certain cases be
important.

Auscultation of the (Esophagus. — This consists in listen-
ing either through the stethoscope or directly with the ear
over the course of the gullet, whilst the patient swallows
some fluid. The proposal of this method of examination is
entirely due to Hamburger, and the short articles since pub-
lished by myself,1 Elsberg,2 and Clifford Allbutt3 are little
more than epitomes of Hamburger's4 essay. CEsophageal
auscultation is easily carried out, but it requires considerable
practice and much patience : practice, because it is requisite
to get the ear well accustomed to the normal oesophageal
sounds; patience, because in each case it is necessary to
apply the stethoscope successively down the whole length
of the oesophagus, and to listen attentively at each spot.
Before attempting to apply the method in disease it is
essential to become acquainted with the normal sounds
produced in deglutition ; and for this purpose repeated
examinations should be made on healthy persons. The
following is the best way of practising the art. The
individual to be examined should be directed to take a
mouthful of drink — water does very well for the purpose,
but a thickened fluid, such as gruel or arrowroot, answers
better. The stethoscope is then applied over some portion of
the food-tract, the person is directed to swallow, and the sound
produced in the act of deglutition carefully listened to.
As the small portion of fluid, or, as it has been somewhat
arbitrarily called, "the morsel," passes down the throat it
produces various sounds, and conveys certain impressions
to the mind of the listener. The proper interpretation of
these sounds constitutes the art of oesophageal auscultation.
If the stethoscope be applied to the side of the neck, on
a level with the hyoid bone, and the person be directed to
swallow a morsel, a loud, gurgling noise is heard, which

1 " Lancet," May 30, 1874.

2 " Auscultation of the (Esophagus. " Philadelphia, 1875.
"British Med. Journ." 1875, vol. ii. p. 420.

4 " Klinik der (Esophaguskrankheiten, " Erlangen, 1871. Ham-
burger's views, however, had been developed previously in a series of
papers in the " (Esterreich. Med. Jahrb.," 1867, 1868, 1869.

DISEASES OP THE THROAT AND NOSE.

may be called the " pharyngeal sound." The word "gli> u-
glou " has been said to represent the plmmi^-al sound;
but in order to get an idea of it, "glou^'lou" slumld In-

FIG. 1. — DIAGRAM SHOWING THE SITUATION AND CURVES OF THE
(ESOPHAGUS AND ITS RELATION TO THE SPINOUS PRO<
SCAPUL.E, AND BIFURCATION OF THE TRACHEA.

a. inferior curved line of occipital bone about five-eighths of an inch below the
occipital protuberance, indicating the commencement of the pharynx ; b, fifth
cervical vertebra, at which spot the oesophagus commences (this spinous process
can l>e easily recognized from its relative position to the vertebra prominens,
usually the seventh) ; c, second dorsal vertebra ; d, sixth dorsal spine ; e, ninth
dorsal spine. The upper third of the gullet therefore corresponds to the distance
between b and c, the middle third to the distance between c and d, and the lower
third to the distance between d and e. The position of the bifurcation of the
bronchi from the trachea is seen to be in the middle third.

pronounced in a loud whisper ; and it must be admitted
that in many healthy persons the sound does not bear
much resemblance to this word. If instead of listening
in the neck, the stethoscope be applied to the left side
of one of the dorsal vertebrae, the true "oasophageal

EXAMINATION OF THE GULLET. 9

sound " becomes audible. The pharyngeal sound, which is
due to the sudden passage of air and liquid 'into the
pharyngeal cavity, is sometimes so loud, and so distinctly
conveyed down the oesophagus, that it obscures the true
oesophageal sound. In these cases it is better to let the
patient take a continuous draught of water, as by tliis means
the intermingling of air and water is greatly diminished,
and the true oesophageal sound may often be detected. The
sound which is heard conveys the idea of the rapid passing
downwards of a "small spindle-shaped body of fluid con-
sistence." The sound is sharp and sudden, and ceases
abruptly. Hamburger describes it as being suggestive of an
egg-shaped body, about an inch in length, and half an inch
in breadth, the small end of the egg being above and the
large end below. He is also of opinion that the shape of
the morsel affords a strong indication as to the condition
of the muscular Avails of the oasophagus, the lower end of
the morsel or egg-shaped body being blunted or truncated in
proportion to the feebleness of the muscular action. These,
however, are refinements which it is difficult to arrive at.

The principal points which have to be considered are —
first, the character of the oesophageal sound ; and, secondly,
the quickness of the act of deglutition. In some cases the
sound is very feeble, and occasionally altogether absent ;
•sometimes, and this is often the case in organic strictures,
a confused and continuous bubbling noise is heard, which
lasts for several seconds ; sometimes a grating sound may be
perceived at the same time. The quickness of the act of
deglutition is also of some importance, and can be determined
by placing the hand on the hyoid bone whilst the stethoscope
is applied over the oesophagus posteriorly ; as the patient
commences to swallow, the operator feels the hyoid bone rise,
and can thus estimate the length of time which elapses
before the morsel reaches that portion of the oesophagus
which is being auscultated. The rapidity of the act varies
in different people in a state of health, and it can always
be made to take place quite slowly. This will be at once
apparent on directing a healthy man to continue for a few
minutes swallowing some rather difficult substance, such as
a mealy potato. Under ordinary circumstances the lapse of
time between the entrance of the morsel into the gullet
and its arrival opposite the stethoscope placed at the side
of the eighth dorsal vertebra is so short that it cannot
be determined ; but after swallowing several mouthfuls of

10 DISEASES OF THE THROAT AND NOSE.

potato without drink, two or three seconds elapse before the
morsel arrives at the lower part, of the oesophagus.

imitation can also l>e perceived when t'mni any i-au>«-
the food cannot descend into the stomach. Tin- mode in
which this takes plan; sometimes enables us to distinguish
1 iet ween a spasmodic and an organic stricture ; for whilst in
the latter case an appreciable time elapses before the f"»d i>
forced upwards, in spasmodic stricture the regurgitation is
instantaneous. According to Hamburger, when the oesopha-
gus is pressed upon by a tumour in the posterior media.--
tinum, the sound may l)e heard more distinctly on tlie right
side of the vertebrae than on the left.

Sn, i //' /i//i/. — This method of exploration is carried <>ut
with the aid of /tn/tijii:-; and is employed for the purpose of
determining the calibre of the gullet. It should lie borne
in mind, however, that much harm is often done by the
introduction of these instruments. They should, there!
never lie used unless other means of investigation fail to
give the desired information. Two kinds of bougies are
employed under different circumstances, viz., those made of
gum-elastic, and those in which there is a slender whalebone
stem, terminating in an olive-shaped ivory knob. Ordinary
gum-elastic bougies are cylindrical1 in form throughout the
greater part of their length, but the distal end is more or less
conical. From the experiments, however, already detailed
(pages 3 and 4), as well as from the appearance in frozen
sections,2 it is clear that the sectional outline of the gullet is
oval or kidney -shaped, the diameter from side to side being
greater than from before backwards. I have, therefore, arrived
at the conclusion that bougies somewhat flattened antero-
posteriorly would most easily adapt themselves to the lumen
of the tube through which they are meant to be passed, and
this view has been confirmed by experience. Thirteen sizes
are made, the measure of each one being based on the number
of millimetres in the transverse, i.e., their long diameter.
The sizes are reckoned from Xo. 3 to Xo. 15. Thus, Xo. 3
measures three millimetres from side to side, Xo. 4 four

1 In some cases, however, tapering ami the so-called " radish -
shaped " instruments may be useful. The tapering bougie is small
at the distal end, and gradually increases in size for about three or
four inches till the maximum diameter is attained ; and the radish -
shaped instrument is slender at its further extremity, then becoim-s
somewhat suddenly greatly enlarged, again returning to the smaller
dimensions.

3 Braune : Op. cit. pi. vii. viii. ix. x. and xi.

EXAMINATION OF THE GULLET.

millimetres, and so on throughout the scale. Nos. 1 and 2
are not made, as they are too small to be of any use.

The ivory-knobbed bougies are
sometimes useful when the ob-
struction is of a spasmodic charac-
ter, the spasm occasionally yielding
to a knob whilst resisting a cylin-
drical body. The knob at the end
of the whalebone stem resembles
an olive in shape, the small end
being directed downwards. The
same whalebone rod can be used
for several knobs of various sizes,
as they are made to unscrew.
These instruments have not
hitherto been made according
to any scale, and I very seldom
use them on account of the risk
there always is of the ivory
knob becoming separated from
the stem. Although in the ordi-
nary course the little point
would pass into the stomach and
do no harm, there is some danger
of its being vomited or hawked
upwards, and finding its way into
the air-passages. It is obvious
that the danger is much increased
where there is a stricture of the
gullet, as under such circum-
stances the knob cannot pass
downwards, and it will most
likely be thrown violently up-
wards by sudden spasm of the
muscular walls of the oesophagus.

When a gum-elastic bougie has
to be passed it should be warmed
and then dipped into water or
glycerine (not oil, as that is often
very disagreeable to the patient),
and then slightly bent at about
an inch from its extremity, so

that when introduced into the throat the point of the bougie
presses slightly by its own elasticity against the posterior wall

if.

12 DISEASES OF THE THROAT AND NOSE.

of the pharynx, and is thus unlikely to enter the larynx.
The patient should sit with his neck stretched out and
his head thrown slightly back, whilst the operator standing
in front depresses the tongue with the forefinger of his left
hand, and directs the point of the instrument downwards in
a slanting direction against the middle of the posterior wall
of the pharynx at its lowest part. In introducing tin- bougie
about four inches of its length should extend beyond tin-
hand, and it should be pushed slowly and gently down tin-
throat. When tin- instrument is judged to have entered the
oesophagus, it is a good plan to tell the patient to bend his
head a little forwards, and to perform the act of swall"\\
Should any obstruction to its course be encountered, the
instrument should be withdrawn and again carefully passed
into the gullet.

If it be again arrested at the same point and the employ-
ment of very yentle pressure and manipulation fail to pass
it beyond the obstacle it should be altogether withdrawn,
and a bougie several sizes smaller introduced. Proceeding
in the same manner and with like precaution, the operator
should, if the attempt does not cause any great disr< mi-
fort or irritation, try a third or fourth instrument, as the
case may be, until he either penetrates the .stricture or
concludes that it is impermeable. Should the bougie be
found to pass beyond the point at which the first instrument
was arrested, it should be pushed steadily downwards until it
reaches the stomach, whilst the character of the surface
over which it glides, the direction in which it goes, the
distance traversed, and the contractile power of the oeso-
phagus at different levels should be carefully noted. It is
necessary to take the precaution of passing the instrument
quite down to the stomach, as there sometimes exists a second
stricture below the first. On withdrawing the bougie the
distam-c from the patient's teeth to its extremity shoidd always
be measured. It should be remembered, however, that tin-
distance from the incisor teeth to the orifice of the oesophagus
varies from 15£ to 17 centimetres, and in estimating tin-
situation of an obstruction this length must be always de-
ducted from the length of the bougie passed into the body.
If a good-sized bougie can be passed without encountering any
obstacle, a larger on«- may be employed at the next visit if
any symptoms of obstruction continue. If, however, a Xo. 15
(see scale, p. 11) can be passed through the whole length of
the canal it may be concluded that there is no medianii-al

EXAMINATION OF THE GULLET. 13

obstruction — i.e., no organic stricture. An instrument has been
invented by Dr. Gaston Sainte-Marie,1 by means of which
it is proposed to measure the calibre of the gullet through-
out its entire extent, or at any given point. It consists
of a hollow sound, at the lower end of which is a small
olive-shaped bag made of india-rubber, so that its capacity
is diminished by very slight pressure. Into the upper
extremity of the sound is fitted a graduated glass tube,
abovit ten centimetres long, provided at its upper part with
a stopcock and a metallic funnel. By this means water, or
some coloured liquid, can be poured into the instrument,
thus distending the bag at the other end to the fullest
extent. It is obvious that any pressure on the walls of the
bag will cause the fluid to rise above its original level in the
glass tube, and the greater the pressure the higher will the
contained fluid be forced. I am not aware that this instru-
ment has ever been tried in actual practice, and it is evident
that it would be difficult to use in such a way as to obtain
any trustworthy results.

(Esophayoscopy. — This method consists in the visual
examination of the interior of the gullet by means of
suitable instruments. These must necessarily be in the
form of tubes, and their use is always likely to be
attended with considerable difficulty ; for, unlike the
larynx and trachea, which are nearly always open to
inspection, the orifice of the gullet is closed, and lower
down the walls of the canal are usually in more or
less close apposition. Further difficulty arises from the
spasmodic contraction, so easily set up, of the muscular
tunic of the oesophagus, and also from the pharyngeal
irritation which almost unavoidably occurs in introducing
instruments.

The older surgeons do not appear to have endeavoured to
overcome these difficulties, and the first attempt to examine
the gullet during life would seem to have been made by
Semeleder and Stoerk in 1866.2 This experiment, however,
yielded only negative results. The instrument employed
appears to have consisted of a forceps with spoon-shaped

1 "Des differents modes d'cxploration de 1'CEsophage. " Paris,
1875, p. 21.

2 Private letter from Professor Stoerk, November 13, 1880. Dr.
Stoerk has since published an account of this experiment in the
article in which his more recent invention is described (" Wien. kliii.
Wochenschrift," No. 8, February, 1881).

14 DISEASES OF THE THROAT AND NOSE.

blades. The idea of the instrument originated with
Semeleder, who offered himself to Stoerk for experiment.
After the introduction of the instrument, tin- laryn^eal
mirror was placed in the ordinary position, but it wa> ;tt
once found that the view was obstructed by a kiml <>f
figure-of-eight projection of the mucous membrane between
each blade of the forceps.1

Two years afterwards the late Dr. Waldenburg - invented
an oesophagoscope. This instrument was a gum-elastic tul>e,
eight centimetres in length. It was slightly conical in shape,
the diameter above being one centimetre and a half, and
below, one centimetre. It was connected to the extremity
of a two-pronged-fork, fourteen centimetres in length, in such
a way that considerable movement was permitted between the
fork and the tube. After the introduction of the instrument it
was held with the left hand, and the tongue being slightly
pressed down, the laryngeal mirror was put into the mouth.
In the case in which Dr. Waldenburg used the instrument
there was a pouch at the upper part of the gullet on t In-
left side, and he was able to keep the instrument in situ for
ten or fifteen seconds, and to see that the mucous membrane
of the o?sophagus was not ulcerated or in any way diseased.
On introducing the speculum into the diverticulum itself,
that cavity was seen to contain a small quantity of food.
Afterwards Waldenburg had an instrument constructed of
metal instead of gum-elastic, consisting of two tubes arranged
telescopically, each tube being six centimetres in length, one
playing on the other by means of a slot. Waldenburg's

1 In 1868, Bevan ("Lancet," vol. i. April, 1868) published a
description of various instruments for examining the pharynx, larynx,
and posterior nares, fitted to a lamp, on the principle of the endoacope.
In this paper there is no detailed description of the cesophagosr
but merely a few lines describing the figure which illustrates it. As
far as I can make out from this drawing, the u-sophagoscope appears
to be a straight tube, four inches long by three-quarters of an inch in
diameter, which has attached to its upper extremity, by means of a
wire on each side, a riii£ slightly larger in diameter and about one
inch in length. This nng is placed at an angle of about forty-tin-
degrees to the tube, and to it the pharyngoscopic tube of the endo-
scope was, to use the words of the inventor, "very easily applied."
It is not stated that any mirror was used, but as a reflector is seen
in the drawing of the pharyngoscope it was probably employed for
inspecting the gullet. A penisal of Bevan 's paper will convince any
reader that the experiments were the results of work in the library
rather than in the wards of a hospital ; and, in fact, that the instru-
ment is of no practical value.

2 "Berlin, klin. Wochenschrift," No. 48, November 28, 1870.

EXAMINATION OF THE GULLET. 15

instrument was exhibited and used on a patient by Professor
Stoerk, before the Society of Physicians of Vienna.1

Subsequently Stoerk employed an instrument resembling
Waldenburg's, but consisting of three tubes. In February,
1881, Professor Stoerk2 described a new cesophagoscope,
which consists of a lobster-jointed tube, covered with
india-rubber, with a small mirror attached to its upper
extremity, and with a handle, consisting of a two-pronged
fork like that of Waldenburg. This tube is provided with
a pilot, or director, consisting of a piece of elastic tubing,
terminating in a small bag which projects beyond the end
of the oesophagoscope, the diameter of the bag being a little
larger than that of the tube. The ball being inflated, the
instrument is passed into the gullet, when the air is allowed
to escape, and the pilot withdrawn.

My own attempts to examine the gullet with an oesopha-
goscope were first made in February, 1 880. From the follow-
ing description it will be seen that the instrument which I
have introduced3 is altogether different from those hitherto
employed. It consists of two parts — a stem and a skeleton
tube. The stem is made up of a handle and a shank,
between which there is a hinge. The skeleton tube is only
formed when the instrument has been introduced into the
gullet; before that, it consists of two flattened wires placed
anteriorly and posteriorly, connected above and below, and
at certain intervals between the extremities, by rings. When
the rings lie in the vertical position the wires are separated
from each other only by the thickness of the rings, but when
the latter are thrown into the horizontal position the two
wires become separated, and, with the rings, constitute a
kind of skeleton speculum.4 At the top of the back wire
there is a slot into which the stem of a laryngeal mirror is
fitted. In the upper figure (A) of the annexed cut it will be
seen that the handle and shank are almost in a line — a

1 Letter before quoted. The Professor does not recollect the exact
date of the exhibition of the patient, but no doubt an account of it
would be found in the "Transactions of the Imperial-Royal Society
of Physicians of Vienna" in or about the year 1871.

2 Loc. cit.

3 This, as well as most of my other instruments described in this
work, were made for me by Messrs. Mayer and Meltzer, Great
Portland -street.

4 In the earlier instrument which I employed there were a great
number of rings, and the speculum was opened and closed by means
of a movable slide on the upper part of the shank, the handle
remaining fixed.

I'ISKASKS (>K TIIK TIIHOAT AM. .\o>K.

position wliicli greatly facilitates tin- iiitnidiietii.n of th,-
instrument. "VVlien the vertical portion ha.s been passed down
the oesophagus, the operator, holding tin- handli- in his hand,
but leaving the index-finger free, presses with the latter on

FIG. 3.— THE AUTHOR'S CE.SOVHAGOSCOPE.

The instrument is seen in A ready for introduction,
the handle being almost in the same line as the
stem. When the instrument has been passed
down the gullet, as seen in B, the handle is
depressed, and the moving rod a t>eing thus
drawn back, the lever b elevates the small ring
with which it is connected, and raises the
mirror to its proper place whilst it expands
the skeleton tube, and thus -dilates the oeso-
phagus.

the upper part of the shank near the handle. The result of
this is to turn the rings from the vertical to the horizontal
position, and thus to open the speculum and expand the
gullet. With the view of causing as little irritation as pos-
sible, the operator should, before withdrawing the instrument,
close the speculum by pressing the under part of the shank
(near the handle) with his thumb, and at the same time
raising the handle.

In November, 1880, I had attempted to use the instru-
ment on fifty patients, and I had succeeded thirty-seven
times. Subsequently I have employed it from time to time,
whenever a suitable case has presented itself.

Endeavours have recently been made to examine the interior
of the gullet with the help of the electric light, and Mikulicz 1

. med. Presse." 1881, Nos. 45—52. Mikulicz, who has
lately been working with the assistance of Leiter, of Vienna, appears

(ESOPHAGEAL INSTRUMENTS.

claims to have made some very important clinical observa-
tions by this method.

(ESOPHAGEAL INSTRUMENTS.

Brushes. — These are of little use for apply-
ing remedies to the interior of the oesophagus,
as the medicament is to a great extent lost
before it reaches the affected part ; but they
are sometimes of service when the disease is
situated quite at the upper part. The kind
of brush which should be employed for this
purpose is one similar to those used for the
larynx, but about two inches longer than
No. 1 brush.

Injectors. — For applying solutions to the
interior of the gullet the " oesophageal injec-
tor" is the most useful instrument. It con-
sists of a long leaden tube, from sixty to
seventy-five centimetres in length, and two
to three millimetres in diameter, to which is
welded a bulbous terminal portion, made of
silver. The silver extremity is perforated
by a number of fine holes, and the fluid is
injected by means of a minute pear-shaped
india-rubber ball. The tube is passed down
to the desired spot ; the nozzle of the elastic
ball is then introduced into the upper end
of the pipe, which is slightly funnel-shaped,
and the fluid injected by pressing the ball.

The (Esopharjeal Electrode. — This instrument is similar to-
the laryngeal electrode (Vol. i. p. 252), but should be about
twenty-six centimetres in length below the handle, and
pliant in the stem, so that it may more readily adapt itself
to the natural curves of the gullet.

The (Esophageal Resonator. — For the discovery of small
foreign bodies, such as pins or other metallic substances, pieces
of bone, &c., an ingenious instrument has been devised by

to have improved the apparatus of that instrument maker (see Vol. i.
p. 502, Note 2). When, however, Leiter's earlier specula were ex-
hibited in Paris, Dr. Ranse (" Gazette Medicale," No. 25, p. 331, 1880}
maintained that the invention was little more than a reproduction
of Trouve's " polyscope, " without some of the advantages of that
instrument.

VOL. II. C

FIG. 4.

CESOPHAGEAL
INJECTOK.

18 DISEASES OP THE THROAT AND NOSE.

H°

M. Duplay.1 It Consists of a stem of very flexible steel, about
eighteen inches long, covered throughout
with india-rubber; to the lower end «if
this is screwed a hollow olive-ahaped
ball of ivory, which may be of various
sizes, whilst to the upper end uf this is
£ attached a "drum" of copper, about six
» inches long, to serve as a sounding-box.
? To the pri'xiinal end of the drum is fixed
« tin india-rubber tul)e, provided with an
| ivory ear-piece. The instrument is ]
•2 . into the gullet in the ordinary way, and
« | the ear-piece placed in the ear. Very
J & slight scratching sounds, such as would be
£ £, produced by the olive-shaped ivory ball
^ | coming in contact with a foreign body, can
2Tr then be readily distinguished. If the stem
| * of the instrument lie properly graduated
g-l the situation of the foreign substance
•§5 can also be ascertained with tolerable
= § accuracy.

It should be added that the instrument
s.g can be used as a common sound by de-
"-5 taching the sounding-box and ear-tube
AO from its upper extremity and screwing on
f§ a metallic ring, to serve as a handle.
•g'S CEsopliayeal /•'"/•'•/yA-. — For the removal
J-^> of foreign bodies from the gullet, a pair
M* of long forceps may suffice, or special ly-
SS devised instruments, such as the parasol
| g, bougie, or the so-called "coin-catcher" may
.«rf be required. The forceps should be about
j" thirteen inches long, the two blades crossing
3 each other at a point equidistant from the
extremities. The curve should be very-
slight (Fig. 6). Forceps with a flexible stem
£ may also be useful in extracting foreign
3 bodies from the gullet, or Burge's forceps,
« of the same shape as that used for the nose,
may be employed. The mode in which this
instrument acts will be understood by refer-
ring to the woodcut representing the Axial

" Bull, de k Soc. do Chir. de Paris." Oct. 7, 1874.

CESOPHAGEAL INSTRUMENTS.

Nasal Forceps (see
Xasal Instruments).
The Parasol Pro-
bang. — This instru-
ment consists of a
whalebone rod, ter-
minating in a twist
of stiff horse-hair,
which is capped at
the extremity by a
small metal knob or
sponge. The whale-
bone rod is enclosed
in an outer gum-
elastic tube. The in-
strument should be
passed in the same
manner as the ordi-
nary bougie, if pos-
sible, beyond the
supposed position of
the foreign body.
Holding the gum-
elastic tube in the
left hand, the sur-
geon should then
slightly draw up
the whalebone rod
with the right
hand, the horse-hair
portion being thus
made to expand
like a parasol. In
withdrawing the in-
strument with both
hands, the whole

interior of the oesophagus is thus swept
out, and any small foreign body is almost
certain to be entangled in the meshes of
the expanded web of horse-hair. If the
resistance is so great as to cause risk of
injury to the soft structures, the whale-
bone rod controlling the parasol should be
released and the instrument withdrawn

20 DISEASES OP THE THROAT AND NOBB.

with its expansile portion closed. In the probang, as com-
monly made, the knob is aTxnit the size of a bullet, but it
should not be larger than a good sized pea — the object of
the instrument not being to push the foreign body down,
but to pull it up.

Coin-Cafchent. — There are two kinds of coin-catch < T-.
One (Fig. 8 A) consists of a small whalebone rod, about
fifteen inches long, with a flexible metal plate one inch am!
a half in length securely fixed to its lower part. The distal

Fio. 8.

A, Orftfe's coin-catcher, holding a coin ; it, ring coin-catcher.
/

extremity of the metallic plate is attached by means of a
cross rivet to the interior of a small hollow metal cone about
its middle. Free play is thus allowed to the cone on either
side of the stem, so that a little cradle is formed, the con-
cavity of which looks upwards. The surfaces of the coin-
which correspond to the metallic part of the stem are fenes-
trated, whilst the rim of the cradle is slightly notched at
each side. Another form of coin-catcher (Fig. 8 B) which is
perhaps more commonly employed, consists like the above,
of a whalebone rod, to which a short plate of flexible metal

(ESOPHAGEAL INSTRUMENTS.

is attached. This plate, however, ends in a small
metal ring, to the lower part of the circumference
of which another ring of similar size is securely
welded so as to form an angle of about 45° with
its fellow.

Both these instruments easily slip down at the
side of a small foreign body, but on being with-
drawn, a piece of money or any other object
lying loose in the canal, such as a fruit stone,
or a set of artificial teeth, is very likely to be
caught. Even when such a body has passed into
the stomach it may sometimes be fished up ! A
remarkable case of the kind has been recorded 1
in which Mr. L. S. Little, formerly of the London
Hospital, succeeded in removing a set of false
teeth with a gold plate from the stomach of a
woman who had swallowed them during an
epileptic fit.

The Sponye-Probang. — This instrument is
merely a gum-elastic bougie, tipped at its distal
end with a piece of sponge securely tied on. It
is used for pushing down into the stomach any
substance of the nature of food which has stuck
in the gullet, or a foreign body of any kind
which cannot be extracted.

The (Esopftaf/otome. — For the internal division
of strictures of the gullet, various instruments
have been invented, particularly by French
surgeons. I have devised a very simple instru-
ment (Fig. 9) which has been successfully used,
both by myself2 and by Dr. Roe,3 of Roches-
ter (U.S.) It consists of a gum-elastic bougie
about fifteen inches long, terminating in a small
metal cap about one inch in length and of slightly
larger calibre than the rest of the instrument.
Through the interior of the bougie passes a wire,
the lower end of which is attached to a small
cutting blade, whilst its upper extremity is con-
nected with a spiral spring. By pressing a

1 "Royal Med. and Chir. Soc. Proc." Feb. 8, 1870 ;
"Lancet," Feb. 19, 1870, p. 268.

2 For details of my case see " Cicatricial Stricture of
the Gullet."

8 Ibid.

S3 .2

J3 O,

.2 "
-a 8

c .-3

•

...
JB M

1: H

p -*2

DISEASES OF THE THROAT AND NOSE.

metallic button at the top of the bougie,
the knife is projected through a slit in
one side of the metal cap. A little notch
in the edge of the button corresponding
to the slit guides tin- operator as to
the position of the knife. Instruments
with two blades cutting sideways have
been used by Trelat l and Dolbeau- for
the division of lesophageal strictures, Imt
a single blade seems to me preferable,
and the close proximity of the in-
ternal and common carotid arteries at
the upper part of the gullet on both
sides and of the aorta lower down on
the left side, makes it desirable that tin-
knife should cut only in a backward
direction.

TJie Permanent (Esopliayeal Tnl ><•.--•
This instalment (Fig. 10), which I
have used for several years with consi-
derable success, consists of two parts; tin-
lower portion being a fine gum-elastic
catheter, of No. 6 size (English), about
six inches in length. To the upper end
of this tube are attached two strings,
about one foot long, and loaded at their
free extremity with small shot. The upper
part of the instalment is a solid stem,
made of vulcanite or whalebone, the
lower extremity of which is pointed so
as to fit loosely for about an inch into
the upper orifice of the catheter. The in-
strument should be passed down the gullet
in the manner recommended in describ-
ing the use of solid bougies, the strings
being held close to the upper part of the
whalebone guide, so as to keep its point
inside the catheter. When the latter has
been passed through the strictured portion
of the canal, the solid stem or handle
should be withdrawn, care being taken to

1 "Bull. Therap."Mars 30, 1870, t Ixxviii.
p. 252.

2 "Soc. de Chir. de Paris," Mars 16, 1870.

05SOPHAGEAL INSTRUMENTS. 23

release the strings so that the catheter may not be pulled
out at the same time. The strings should then be fastened
round the patient's ears or the back of his head. The
catheter is thus left in the narrowed part of the gullet, and
liquids can be swallowed with comparative ease. The great
advantage of the instrument is, that it causes no pharnygeal
irritation. It can generally be allowed to remain in situ
for five or six days, when it should be removed by means
of the strings, as the gum-elastic is likely to be decomposed,
or the tube itself clogged up. Another instrument may
then be substituted for it in the same manner. It is to
be remarked that I only employ this instrument where
absolute aphagia exists, and that generally the catheter lias
to be pushed through the stricture with force.

Dr. Krishaber,1 of Paris, has lately recommended that in
cases of advanced stricture of the gullet a common gum-
elastic catheter of suitable size should be passed into the
patient's stomach through one of his nostrils,'2 and left per-
manently in situ. The instrument is fixed in position by
means of a strong needle transfixing the catheter near its
mouth, and having attached to its ends two strings, which
are fastened to the brow with strips of plaster. A plug
should be left in the upper end of the tube, except when
the patient is being fed. By means of this instrument
Dr. Krishaber has been successful in prolonging for several
months the lives of patients who must otherwise inevitably
have died of starvation. In one case, indeed, life was
maintained in this manner for the greater part of a year
(305 days). Mr. Durham 3 has successfully tried the same
plan, but prefers passing the catheter through the mouth,
as being less disagreeable to the patient.

The (Esophayeal Feeding Tube. — This instrument is very
useful when there is a fistulous communication between the
gullet and the air-passage, which allows the ingesta to find
their way into the larynx or trachea. The instrument con-
sists of three portions : first, a gum-elastic tube of the size

1 "Trans. Intern. Med. Congress." London, 1881, vol. ii. p. 392,
et seq.

2 In insane persons, or others who perversely refuse food, this
method of administering sustenance is most efficacious, as any diffi-
culty in opening the patient's mouth is thereby avoided, and he is
unable to apply his . teeth to the instrument, or to the fingers of the
operator.

3 "Proc. Clin. Soc. Lond." Nov 11, 1881, reported in "Lancet,"
Nov. 19, 1881, vol. ii. p. 873.

•24

DISEASES OF THE THROAT AND NOSE.

of a No. 8 English catheter, terminating at one end in a
slightly bulbous extremity perforated laterally by two rather
large holes, and at the other in a metal ring and bayonet
joint ; secondly, a pear-shaped india-
rubber bottle ; thirdly, a connecting por-
tion of metal tubing provided with a
screw and a tap. The mode of using this
instrument is as follows : — The connecting
portion is first unscrewed ami the nutri-
tive fluid poured into tin- bottle, when tin-
metal tubing is again screwed on, and the
tap closed. The practitioner now intro-
duces the gum-elastic tube into the oeso-
phagus, and an assistant at once hands
him the feeding bottle, which lie quickly
adjusts to the bayonet joint, and turning
the tap, injects the fluids. As there is

FIG. 11.

CEsopHAGEAL FEEDING
TUBE.

Fir.. 12.

THE RECTAL FEEDING
BOTTLE.

generally great irritability of the throat in such cases, the
success of the operation largely depends on the quickness
with which it can be performed. In cases of emergency, where

(ESOPHAGEAL INSTRUMENTS.

this instrument is not at hand, a common catheter and an
ordinary enema-bottle can be used, but the tap and bayonet
joint greatly facilitate the operation of feeding.

The Rectal Feeding Bottle. — It so often happens that in
diseases of the throat feeding per rectum becomes necessary,
that this seems to be the appropriate place for describing
the instrument which will be found most serviceable for the
purpose. The ordinary liquid injections, such as beef-tea,
eggs, milk and brandy, have proved so unsatisfactory in my
hands that I have for a long time employed the panada first
recommended by Leube (see Appendix, Vol. i. p. 580). As
this panada, however, will not pass through an ordinary
enema pipe, it is necessary that the elastic bottle should be
furnished with a short vulcanite tube, having a bore of not
less -than half an inch. The difficulty of drawing up the
nutritive fluid through the tube by the common vacuum
process, makes it requisite that the vulcanite nozzle should
be capable of being easily unscrewed, in order that the bottle
may be filled with a spoon or funnel.

26 DISEASES OP THE THROAT AND NOSE.

DISEASES OF THE GULLET.

ACUTE (ESOPHAGITIS.

Latin Eq. — CEsophagitis acuta.

French Eq. — (Esophagi tc aigiie.

German Eq. — Acute Entzumlung der Speiserohre.

Italian Eq. — Esofagite acuta.

DEFINITION. — Acute idiopath i<- inflammation of flu- mat
ii/i'inbrane of the oesophagus, f/irin*/ rim- tn ^stri-mr /*///«-
pfiar/ia, and often to apJiayia. Tin- disease is attrmli'il //-/f//
some danger, but generally ends in resolution, an<1 <>n/i/ in
extremely rare cases terminates in ulcer, abscess, <>,• i/rint/r-

History. — Amongst the ancient physicians Galen1 alone appears
to have recognized this disease. After referring to difficulty of
swallowing caused by tumours and paralysis, he observes that when the
oesophagus is affected by inflammation the condition of the part itself
acts as a hindrance to the passage of food ; deglutition, moreover,
being accompanied by excruciating pain. In 1722 Boehms called
attention to the complaint, especially dwelling on the pain and heat
which "reach even down to the stomach, accompanied by hiccough
and a constant flow of serum from the mouth." In 1745 Van Swieten s
gave a short account of the affection, obviously based more ui>on
literary research than experience. Honkoop * published a thesis on
inflammation of the gullet in 1774, and in 1785 Bleuland 5 described
the disease in his short treatise on the oesophagus. Bleuland's
remarks are entitled to special weight, inasmuch a8 he had himself
suffered from a violent attack of the disorder, whereas the previous
accounts of this rare affection appear to be entirely founded on
Galen's description, which is admirably accurate so far as it goes,
bnt necessarily incomplete. Besides his own attack Bleuland states
that he was acquainted with the details of four other cases of
the complaint which had occurred in the practice of his master Van
Doeveren. A good description of the disease was given in 1792 by
John Peter Frank,6 who first proposed to designate it by the name
" oesophagitis. " Some years later the pathology of inflammation of

1 " De locorum affect, notitia," lib. v. cap. iv.

2 " Dissertatio de morhig oesophagi." Haltc, 1772. This was a thesis presented
by Boehm for the doctor's degree, under the academical presidency of the cele-
brated Hofmann, to whom the work has generally been ascribed by subsequent
writers.

3 "Comment, in H. Boerhaave aphorismos." Lugduni Batavorum, 1745,
t. ii. p. 662, § 804.

4 " Diss. de morbo oesophagi inflammatorio." Lugduni Batavorum, 1774.

•'• " Obs. anat. med. de sana et morbosA oesophagi stnictura." Leidae, 1785.
« " De curandis hominum morbis," lib. ii. pp. 104, 105. Mannhemii
Tubingse, Vienna;, 1792—1821.

ACUTE (ESOPHAGITI8. 27

the gullet as it is met with in new-born children was studied with
great zeal and ability by Billard,1 who in 1828 published a number of
very interesting cases of the affection, together with some important
observations as to its etiology. In 1829 Mondiere2 who, like Bleu-
land, had had an opportunity of observing the disorder in his own
person, chose it as the subject of his inaugural thesis, and described
the symptoms and course of the affection very accurately. He founded
his pathology, however, entirely on Billard's description of the ap-
pearances in fatal cases occurring in new-born infants — cases which
differ widely as to their etiology, nature, and course, and cannot be
accepted as affording a satisfactory basis for the pathology of idio-
pathic cesophagitis in adults. In 1831 Mondiere3 returned to the sub-
ject, treating it with fuller learning, but with no further novelty.
In 1835 Graves4 made some remarks on oesophagitis in commenting
on a case of the disease which he had been called upon to treat.
The subject has received additional illustration from Hamburger,5
Padova,6 and Laboulbene.7

1 " Maladies des Enfants nouveau-n&s." Paris. 1828. See also 3rd edition,
1837.

- " Sur I'lnflammation de 1'CEsophage." These de Paris, 1829. Mondiere
afterwards studied diseases of the gullet in general with much assiduity, and
collected a large amount of material scattered through various writings.
Although his laborious compilation shows more industry than discrimination,
his essays are of very considerable value even at the present day, for, in
spite of his somewhat unwieldy erudition, he was a shrewd observer. His
writings have been the source from which much of the literature of oesophageal
disease has since been drawn. Thus in Velpeau's article ("(Esophage " — "Diction-
naire en Trente Volumes "), in Follin's essay ("Sur les R£trecissements de 1'CEso-
phage "), in Copland's Dictionary, and lastly in the highly creditable work of
Knott on the "Pathology of the (Esophagus," Dublin, 1878 (published whilst
the author was still in gtatu pupillari), we find the cases of Roche, Bourguet,
Broussais, Paletta, and several others collected by Mondiere, constantly referred
to, with very few original illustrations of the disease. On the other hand, but
scanty justice has been done to Billard, whose work in this field was the fruit of
careful independent investigation.

» " Arch. G«?n. de MM." 1831, t. xxv. p. 358.

4 "Clinical Lectures." Dublin, 1848, vol. ii. p. 199. 2nd edition. Previously
reported in " Lond. Med. and Surg. Journ." No. 172.

1 " Medicin. Jahrb." Bd. xviii. and xix. December 8 and 22, 1869.

« "Annali Universal! di Medicina e Chirurgia." Milano, Aprile, 1875, vol.
ccxxxii. pp. 17 — 24.

7 " Nouveaux Elements d'Anatomie Pathologique. Paris, 1879, p. 84.

Etiolof/y. — This affection is certainly very rare, but not so
rare as the exceedingly brief description, and frequent com-
plete omission of the subject from the ordinary text-books
of surgery and medicine, would lead the student to imagine.
It is highly probable that the very insufficient way in which
the subject has been handled is the cause of the complaint
often not being recognized, and I venture to hope that in
future the true nature of some cases will be appreciated which
might otherwise have been overlooked.

There are not sufficient examples on record to enable us
to arrive with any degree of certainty at the cause of this
affection in adults. Occasionally it appears to originate in the
pharynx and to spread downwards, and in some epidemics

28 DISEASES OF THE THROAT AND NO8B.

of "angina" this tendency has been very remarkable ; l in one
instance the disorder seems to have extended upwards in
the course of a general inflammation of the intestinal tract,
but the disease in this case was complicated by ague.-' In
an example related by Laboulbene,3 the drinking of culd
water was the only assignable cause. Mondiere 4 reports "in-
case in which the disease followed an attack of inflammation
of the stomach, but the actual occurrence of the ujsopha-i -;d
mischief was attributed to a dose of castor oil. Another
instance is on record5 where the onset of the complaint was
attributed to violent muscular exertion in a fit of passion,
but the nature of the case was somewhat obscure, and by
some physicians it was thought that there was partial rupture
of the muscular fibres of the oesophagus. Out of five cases
which I have myself met with, in one the disease was caused
by direct application of cold to the lining membrane of the
gullet through eating ices; in a second the supposed cause
was the abuse of alcohol ; in a third the attack followed
accidental immersion in a river ; whilst in the remaining
two the malady occurred in patients who were subject to
rheumatism.

Symptoms. — In adults the most marked symptom is
odynphagia, the pain on attempting to swallow being often
of a most excruciatingly burning or tearing character, and
sometimes reaching such a degree of intensity that tin-
patient is obliged to desist altogether from taking food or
even drink. Even when he is not swallowing there is often
a dull aching sensation in the pharynx behind the jugular
fossa or the ensiform cartilage. Pressure made by the surgeon
on the larynx or trachea from before backwards intensifies
this uncomfortable feeling. The patient generally complains
of stiffness of the neck, and holds his head in one position,
the least movement aggravating his suffering.

He is usually unwilling to speak on account of the pain
caused by any action of the laryngeal muscles. There is
not unfrequently a sensation as of a foreign body in the
throat. Padova's 6 patient described a feeling like a hint in
the throat, whilst in Graves's " case the sensation was that of
a ring, beyond which the food could not pass. The patient

1 " Annales de Montpellier," t. iv. p. 87.

2 Paclova : "AnnaliUniv. di Metl." Milano, Aprile, 1875.

8 "Nouveaux Elements d'Auatoinie Pathologique. " Paris, 1879,
p. 84.

« "Arch. Gen. de Med." t. xxiv. 8Ibid. 8Loc. cit 7 Loc. cit.

ACUTE (ESOPHAG1TIS. 29

almost always experiences great thirst, and being unable
to get relief by drinking, he is much tormented by this
distressing symptom. The earlier writers lay great stress on
hiccough as an unfailing accompaniment of this malady, but
it has not been present in any of the cases that have come
iinder my notice. When the inflammation is slight, it may
give rise to spasm of the oesophagus, a condition which will
be hereafter considered. If the mischief extend to the
ary-epiglottic folds, dyspnoea may supervene. In adults the
constant expuition of frothy or glairy mucus is very charac-
teristic. In all my five cases this symptom was present.

The general symptoms are those of irritative fever, but
not of a high degree ; in no case that I have met with has
the temperature been above 102° F., and the pulse has not
exceeded 130. Occasionally, however, there is some delirium.
Bleuland l himself suffered from this complication, and it
was present in one of my cases.

It is probable that in some instances the inflammation be-
comes really purulent in character, but this has not occurred
in my own experience, and I have not met with a single
recorded example of idiopathic origin in which it was ob-
served. Should the inflammation, however, result in the
formation of an abscess, rigors occur, and the local symptoms
generally become intensified for the time. When the abscess
bursts, blood and pus are expectorated, and a rapid recovery
usually takes place. When the disease is confined to a par-
ticular portion of the gullet, its situation can be ascertained
by auscultation, the cesophageal sound abruptly terminating
immediately below the point of inflammation.

When once a favourable change has set in, convales-
cence is generally pretty rapid, although Mondiere asserts
that he was obliged to take his food cold for many months
after recovery from the acute symptoms. If, as is usually
the case, the inflammation gradually subsides, the difficulty
of swallowing and other symptoms pass off; but if ulceration
shoidd take place, the symptoms persist in full force, the
pain becoming more severe and more constant. If the
expectoration is frequently tinged with blood, ulceration
may be suspected.

Pathology. — It is probable that in acute cesophagitis the
usual phenomena of catarrhal inflammation of mucous mem-
brane are present — that is to say, there is great redness of the
membrane, together with succulence of the epithelium and
1 Loc. cit.

30 DISEASES OP THE THROAT AND XOSE.

increased secretion of watery fluid containing imperfecily-
developed epithelial cells. The abundant secretion which
occurs during lift- conies not only from the oesophagus hut
from the pharynx and the salivary glands, which appear
to be sympathetically stimulated. Zenker and /icinsscn,1
following Klebs, assert that inflammation of tin- gullet is
altogether different from inflammation as it affects other
mucous membranes, but this view is not borne nut by tin-
only case of idioputhic cesophagitis in which the /«->/-///<,/•/' ///
appearances have been recorded. In this instance the follow-
ing changes were observed chiefly at the upper and Imvi-r
ends of the tube : — "The mucous membrane was red but ii"t
ulcerated, extremely congested and thickened ; the glands
were more prominent than usual, the mucous mend mine was
covered in several places with a glutinous grey, or greyish-
yellow coating, which could be washed off. On section the
submucous tissue appeared to be thickened and in tilt rated
with liquid. Strong pressure between the fingers made it
thinner. There was no pus to be seen. Microscopically, the
viscous coating was found to consist of mucus with abundant
epithelium cells and pus corpuscles." 2

Although as a rule the acute inflammation rapidly sub-
sides, yet occasionally it leads to ul-c<erati<m. This appears
to have occurred in the case recorded by Paletta,3 in which
a young woman who died from extensive inflammation <>f
the throat, involving the pharynx, larynx, and cesoph;
was found to have a large ulcer on the anterior wall of the
gullet. Mondiere4 also mentions the case of a woman who
succumbed to an attack of oesophagitis, terminating after
four months' illness in ulceration of the oesophagus, for which
there appeared to have been no other cause than simple
inflammation.

It rarely happens that the inflammation leads to the for-
mation of a distinct abscess, though this sequel is common
enough in cases of traumatic origin. Three instances, however,
are on record, in which u-sophagitis terminated in abscess;
in one5 of these the sac was accidentally opened by the pressure
of a bougie, whilst in the others spontaneous rupture occurred,
and pus was continuously expectorated, in one case6 for three
or four days, and in the other " for a fortnight.

1 On. cit vol. viii. p. 135. 2 Laboulbene : Op. cit. p. 84.

3 "Exercit. Pathol. 1820, p. 228. 4 "Arch. Gen. <lo Med.'f t xxiv.
* Bourguet: "Gazette de Sante." 1823, p. 221. • Padova : Loo. cit.
7 Barras: "Arch Gen. .1.- .M.'il." 1825.

ACUTE CESOPHAGITIS. 31

More rarely still the disease ends in gangrene. I know
of only two instances in which this termination is recorded.
In one l of these the patient was a man, aged thirty-eight,
who was suffering from purpura and general inflammation of
the gastro-intestinal canal, and the mucous membrane of the
oesophagus was found thickened and of an inky-black colour.
The other2 occurred in a man, aged sixty, in whom the
gullet was found to be gangrenous from its upper extremity
to within an inch of the cardiac orifice of the stomach. The
whole thickness of its wall was sphacelated, the lining
surface, however, being most involved.

It is possible that there may sometimes be a myalgic
condition of the oasophageal walls rather than actual inflam-
mation, but such a disorder would of itself give rise to no
appreciable pathological change.

Diagnosis. — The extreme odynphagia and the absence of
all inflammation of the pharynx, or of the framework of the
larynx, as ascertained with the help of the laryngoscope,
strongly point to acute disease of the oesophagus. The pain
which is experienced on pressure of the larynx and trachea
backwards, is more marked than when the air-passages are
themselves inflamed. Mondiere attaches much importance to
the sensation of heat which is felt at the lower part of the
neck, when, at the same time, there is entire absence of any
redness in the throat. The same author also refers to the
intense anxiety often manifested by the patient, a symptom
which is usually aggravated by attempts to swallow even
fluids. This has sometimes led to the disease being mis-
taken for hydrophobia. In that complaint, however, solids
can often be swallowed when the very sight or even the
sound of fluid will bring on a severe spasm. Moreover, the
general hypersesthesia, asphyxial paroxysms, and psychical
phenomena of hydrophobia are all so characteristic that,
when once seen, little confusion is likely to arise between
that disease and oesophagitis. Pericarditis with abundant
effusion sometimes causes pressure on the cesophageal canal,
and occasionally gives rise to dysphagia, but seldom to
any considerable amount of odynphagia. In pericardial
affections, moreover, the pain is generally limited to the
epigastric region ; in these cases the physical exploration of
the chest at once determines the nature of the affection.
It need scarcely be said that in acute inflammation of

1 Habershon: "Diseases of the Abdomen." 1878, 3rd ed. p. 53.

2 "Arch. Gen. de Med." t. xxiv.

32 DISEASES OP THE THHOAT AND NOSE.

the gullet neither the oesophagoscope nor the bougie can
be used.

Prognosis. — This is generally favourable, but in at least
two cases, viz., in that of Padova and in one of my own,
the patient was in a very critical condition. In Lalxmllit n^'s
case, the patient died suddenly from cerebral haemorrhage.

Treatment. — The most important element in successful
treatment consists in maintaining the oesophagus in a state of
absolute rest. It does not require any persuasion on the part
of the physician to secure this condition, for if the symptoms
are at all severe the patient is quite unable to swallow.
Nutrient enemata should be administered, unless the inflammu-
tion rapidly subsides, and morphia must be given hypodermi-
cally. Poultices should be applied along the upper part of
the spine ; or if there be much pain, anodyne embrocations,
such as the oleate of morphia (gr. y1^ ad §j.) and belladonna
liniment may be nibbed into the back. Mondiere insists
on the importance of venesection, cupping, leeching (from
twelve to thirty leeches being applied to the side of the
neck), counter-irritation (mustard poultices and moxas), and
derivatives. General bleeding, however, or even the local
abstraction of blood to the extent recommended by Mon-
diere, is not likely to be carried out in the present day, and
I have not found any benefit from counter-irritation. Deriva-
tives, on the other hand, especially very hot pediluvia, are
often of signal service. Bleuland used blisters " loco dolenti "
between the shoulders with success.

Pagenstecher1 has reported two cases in wliich he attri-
buted considerable importance to the internal use of hydro-
chlorate of ammonia. It may be remarked, however, that
fifty years ago this drug was highly lauded by physicians
(especially the Germans and Dutch) as a remedy for almost
every kind of disease.

The passage of bougies can only do harm, and should never
be attempted, in spite of a case related by Mondiere,2 in which
an abscess was accidentally ruptured in this way, and t In-
patient thereby cured.

When convalescence commences the change from a liquid
to a solid diet should be very gradual, and should pain in
deglutition recur, the patient must be again immediately
restricted to fluids.

1 " Joumal von Hufeland." 1827, p. 51.
3 See antea, case of Bourguet.

ACUTE (ESOPHAGITIS. 33

CASES ILLUSTRATING ACUTE (ESOPHAGITIS.

Case 1. — Mr. A. W., aged twenty-six, applied to me in July, 1868,
on account of great pain and difficulty in swallowing. He stated that
he first noticed this two days previously, and that it came on the
morning after he had been at a ball where he had eaten several ices. He
acknowledged that he had become very hot in dancing, and had gone
out of the ball-room into the open air though the evening was fresh ;
but he attributed the throat affection to eating ices, because he had
once before had a similar attack produced in that way, whilst he had
often exposed himself to cold after dancing without any ill effects.
He said that he had scarcely been able to swallow any food for the last
two days, having been quite unable to take solids, and fluids causing
great pain. He had slept very badly the last two nights, owing to
the quantity of saliva, which repeatedly woke him by giving rise
to attacks of coughing. When first seen by me, his condition was
as follows : — He swallowed some water, which caused great pain
opposite the seventh dorsal vertebra, and which he said darted
upwards to the back of his throat. His power of deglutition was then
tested with solids, and it was proposed that he should try bread,
meat, and potato. He succeeded in getting down a small piece of
stale bread, but was obliged, at the same time, to drink water ; the
effort, however, caused him very great pain, and he was unable
afterwards to swallow either the meat or the potato. On exami-
nation with the laryngoscope, the pharynx and larynx were seen to
be quite normal. This patient was treated with hypodermic injec-
tions of morphia, but they were used only five times. For two days
nutritive enemata were employed, but afterwards the patient sucked
ice and swallowed iced milk and cold beef-tea. Nine days after the
first occurrence of the inflammation he was able to take semi-solids,
and a few days later he could swallow any cold or tepid food. At
the end of a month he was still obliged to be careful in his diet.

Case 2. — Charles E., aged forty-one, night watchman in a ware-
house, came under my care at the London Hospital in February, 1873,
on account of chronic rheumatism affecting the right knee and left
ankle. The patient had suffered from two attacks of acute rheuma-
tism, for both of which he had been treated in the hospital. He was
placed on iodide of potassium and bicarbonate of potash. After being
under treatment for a month with slight benefit he was suddenly
attacked by severe odynphagia, together with a constant flow of glairy
saliva. He experienced, just above the level of the upper border of
the sternum, a burning pain, which was greatly increased by pressure
on the front of the trachea. For three days the patient was unable
to take any food or drink, and he was scarcely able to sleep at all
owing to the mucous secretion passing down into the larynx, when-
ever he began to lose consciousness, and giving rise to paroxysms
of coughing. He was obliged constantly to sit up and support his
head between his hands. The pharynx and upper part of the larynx
were seen to be healthy. Nutrient enemata were administered en
two occasions, but the patient objected to them so much that they
had to be discontinued. Subcutaneous injections of morphia relieved

VOL. II. D

.". t DISEASES OF THE THROAT AND NOSE.

the constant burning pain, but did not produce sufficient ana-sthesia
of the uesophagus to allow deglutition. On the fourth day tYoin tin-
establishment of the severe symptoms the patient was able to swallow
a little milk, and at the end of a fortnight could eat almost any-
tiling when cold, though hot food still caused jwin.

Case 3. — Henry E., aged twenty-three, consulted me on June 24,
1875, on account of difficulty of swallowing. He stated that two days
previously he had been upset from a boat on the Thames, and that it
was some time before he was rescued. After being brought to tin-
shore he became insensible, and remained in this condition for m<>rv
than half an hour. Next day he was very feverish, and in the after-
noon felt difficulty in swallowing. In the evening, whilst trying to
take some soup, it was violently thrown back through the n
The same night he was slightly delirious ; he was scarcely able to
sleep, being obliged to sit upright and expectorate saliva. The next
day, when I saw him, he was feverish, the pulse being 120 and the
temperature 101 '5° F. He was spitting up large quantities of ropy
mucus. The lower part of the pharynx and the epiglottis were •
to be slightly inflamed, but the interior of the larynx and trachea was
normal in appearance. The patient swallowed a little water in my
presence, but declined to take a second spoonful on account of the
great pain it caused. The following day the difficulty of swallowing
still continued ; the patient complained of severe thirst, but was
unable to swallow little lumps of ice, or even iced water. On the
morning of the fourth day he was able to get down a small quantity
of cold sou]), and a few hours later he took a large drink of milk.
From this date he rapidly improved, and at the end of a week from
the commencement 01 the attack he was perfectly well. The only
treatment in this case consisted in subcutaneous injections of morphia.
Case 4. — Mr. W., aged forty-seven, who had a short time before
been suffering from subacute rheumatism, sent for me on May 27,
1879, on account of difficulty of swallowing which had come on tlm
previous evening. Examination with the laryngosco]>e showed that
the larynx was healthy, and the pharynx also appeared quite normal.
Mr. W. said that he could swallow, but that it caused him great pain
at a point which he indicated midway between the cricoid cart
and the upper edge of the sternum. There was no exjiectoration. I
ordered the patient to suck ice. In the evening, feeling much v.
Mr. W. sent for me again. He informed me that he was unable to
take the ice, as it caused him so much pain. He had begun to
expectorate frothy mucus. I administered morphia subcutaneously.
The next day he felt better, but could not yet swallow at all. The
subcutaneous injection was repeated, and a nutrient enema was
administered. (See Vol. i. p. 580.) The patient was fed by i-Tn-nt.-it.-i
for five days ; after this he began to swallow, but for three week- In-
experienced difficulty at times. Indeed, one month after the date
of the attack, whilst swallowing a piece of potato he felt so much
pain and difficulty that he thought his old symptoms were returning.
This, however, did not prove to be the case.

Case 5. — There was nothing remarkable about this case. The
patient was a lady aged twenty-seven, who had recently suflm-il
from rheumatism and pleurisy. The attack of nesophagitis occuin-.l
in November, 1880, ana was not so severe as those above dcsrril»-<l.
Belladonna plasters applied to the back between the shoulders gave
much relief, and no hypodermic injections were used.

GESOPHAGITIS IN IXFAXTS. 35

(ESOPHAGITIS IX INFANTS.

As already remarked, Billard 1 was the first to call
attention to this affection, and soon afterwards Ryan 2
described it in almost identical terms. Though his lectures
contain no reference to Billard, there can be little doubt
as to the source of his information. Subsequent English
writers have altogether passed over the disease.3

The predisposing cause of the affection in infants appears
to be the physiological hypersemia of the gastro-intestinal
mucous membrane which exists at birth. Out of 200 bodies
of newly-born children, free from any sign of disease,
Billard 4 found the mucous membrane of the oesophagus, as
well as that of the isthmus of the fauces, more or less con-
gested, 190 times; no ramifying vessels could be seen, but the
mucous membrane presented a uniform redness, which did
not extend deeper than the epithelial layer. Billard considers
that in these cases there was passive congestion due to the
imperfect establishment of the relation between respiration
and circulation. Indeed, autopsies made on newly-born
infants show conclusively that when the circulation through
the lungs, heart, or liver is obstructed, hyperaemia of the
oesophagus is almost always present. In older children the
same condition is brought about by morbid conditions of the
blood, as in fevers and diphtheria. Even when the first
months of infantile life have been safely passed through,
the cesophageal veins readily become gorged in various
affections of the more important organs, as well as in cases
of severe general disease. Thus, Steffen 5 reports 10 cases of
hyperaemia and 6 of ulceration of the mucous membrane of
the oesophagus, out of 44 cases of fatal disease in infants and

1 Op. cit. p. 278.

1 "Lectures on Diseases of Infants" — "Lond. Med. Journ."
July 18, 1835.

* This is probably to be accounted for by the fact that even in
children's hospitals patients under two years of age are not admitted.
Within the last two years, however, a hospital has been established
in Boston (U.S.) by Dr. Havens, which is exclusively devoted to
infants under this age. Much valuable information concerning the
maladies of early infancy is likely to be obtained at this institution,
whilst the problem of artificial feeding will be worked out in .t
scientific manner hitherto impossible.

4 Op. cit. p. 274.

e " Jahrb. fur Kinderheilkunde," N. F. 1869, Bd. ii.

36 DISEASES OF THE THROAT AND NOSE.

young children. In most of these there was circumscribed
pneumonia, whilst in 2 there was enteritis, and in 2 ch»l<-r<i
a/ funt a in. In some of Billard's cases, however, it would
appear that the morbid changes had actually commenced
before birth. The exciting cause of the complaint seems U>
be sore nipples or a defective quality of milk on the part of
the mother or nurse, or improper food.

The principal symptom of cesophageal inflammation in
children is an unwillingness to suck. When the child,
however, can be induced to take the breast it leaves oil
sucking after a second or two and commences crying. Most
of the milk is immediately returned, quite unchanged, ;i
very small quantity probably reaching the stomach. Gentle
pressure on the lower part of the trachea will, as Billard r
has pointed out, often make the child cry.

The diagnosis of this affection is very difficult. If occur-
ring at the time of birth, it may be confounded with ;i
congenital malformation of the oesophagus. In the latter
case, however, all the milk is rejected, and paroxysms of
suffocation are brought on by attempts to swallow. On
the other hand, in the affection now under consideration,
although the child cries after trying to suck, a small quantity
of nutriment is retained.

The pathological changes vary in different cases. Some-
times the whole lining membrane is inflamed, whilst n
sionally the hyperaemia affects only a limited surface. Ecchy-
motic patches are often present. Sometimes the inflammation
goes on to ulceration. The ulcers vary in form and size. Thus,
in one of Billard 's2 cases the upper part of the oesophagus
was highly injected, and there were two sharply-cut ulcei
oblong shape, each measuring about four lines in its longest
diameter. In another of Billard's3 cases the whole of tin-
upper third of the gullet showed erosions of the epithelium,
whilst in a third instance portions of the epithelial layer
were expectorated as broad yellowish shreds ; on potf-morii-m
examination the mucous membrane exhibited large patches
of a bright red colour, which appeared to correspond with the
membranous material expectorated during life. Ulcers, when
present, generally affect only a limited portion of the oeso-
phagus— the upper or lower part — and, according to Steffen,4
their number is in inverse proportion to their size. It
not unfrequently happens that the inflammatory process is

1 Op. cit. p. 290. a Ibid. p. 276.

8 Ibid. p. 279. * Loc. cit.

PHLEGMONOU8 (ESOPHAGITIS. 37

confined to the follicles, the orifices of which are often
slightly ulcerated, and are surrounded by red rings, which arc
much brighter than the general purple hue of the rest of
the mucous membrane. Occasionally the disease goes on
to gangrene, one case having been reported by Billard,1 in
which the lining membrane of the oesophagus presented
large loose irregular eschars, the intervening surface being
highly inflamed and traversed by deep excoriations.

The prognosis is generally unfavourable in these cases, not
only on account of the very tender age of the patient and
the extreme difficulty of carrying out suitable treatment,
but because the oesophageal inflammation is so often asso-
ciated with pneumonia and gastro-intestinal irritation.

In the treatment of this affection it is most important to
pay attention to the quality of the milk and the condition
of the mother's nipples ; or, if artificial nutriment is used,
the cooking utensils and feeding bottles should be carefully
looked to. As regards medicine, the remedies found useful
in thrush, such as chlorate of potash dissolved in milk, and
borax mixed with honey, may be employed. Dr. Ryan 2
strongly recommended antiphlogistic remedies, such as
leeching, but it must be remembered that this advice was
given nearly fifty years ago, and that the views then in vogue
have completely passed away. There is less objection to this
author's other suggestion, viz., the application of warm
fomentations to the neck.

PHLEGMONOUS (ESOPHAGITIS.

It is exceedingly doubtful whether acute inflammation of
the submucous areolar tissue ever occurs as an independent
affection. It was first described by Belfrage and Hedenius,:J
as occurring in a case in which a fish-bone had become
impacted in the throat, and it has since been observed in
a case of poisoning by sulphuric acid, but as a rule the
injury proceeds from without. Zenker and Ziemssen 4 have

1 Op. cit. p. 288.

2 Loc. cit.

"Schmidt's Jahrb." Bd. clx. p. 33.

4 "Cyclopaedia of Medicine," vol. viii. p. 151, et seq. English
Transl. 1878.

38 DISEASES OP* THE THROAT AND NOSE.

reported a number of cases, in most of which the morbid
condition resulted from the penetration of abscesses (gene-
rally of scrofulous glands) through the external coats of the
gullet. The condition is not likely to be recognized during
life, and at present must be regarded as a pathological
curiosity — the result of the burrowing of pus between the
constituent parts of the oasophageal walls. As such it will
be referred to in connection with those diseases (traumatic
ossophagitis, perioesophageal abscess) in which it is occasion-
ally observed after death.

ULCER OP THE GULLET.

Although ulceration is present in almost every case of
prolonged obstruction of the gullet, there is no conclusive
evidence that it ever occurs as an independent disease.
None of the cases hitherto recorded present any analogy
to the "simple perforating ulcer of the stomach." When
a limited surface of the latter viscus is deprived of its
supply of blood by embolism or through any other morbid
condition, the solvent action of the gastric juice comes
into operation, and an ulcer can quickly form. It nr»-d
scarcely be pointed out that a lesion of this nature could
occur in the gullet only under very exceptional circum-
stances, if at all, during life, and that the oesophageal mucous
membrane can, as a rule, be acted on by the gastric juice only
after death (see " Post-mortem Softening of the Gullet ").
The cases of "simple ulcer of the oasophagus" which
have been reported by the older writers are too incomplete
to 1)e relied upon, whilst many modern cases, nearly all of
which have been carefully collected by Knott,1 are open to
the objection that the disease may have been of malignant
nature, the ulcerated surface not having been submitted
to the test of microscopic examination. This observation
applies to a case of my own,2 and to another of Dr. Benson.3
Again, in other cases of so-called " simple ulceration " there
is not the slightest evidence that the morbid process com-
menced in the gullet. In some of the supposed examples
the disease probably originated in the trachea. Thus, in ti

1 "Pathology of the (Esophagus." Dublin, 1878.
3 "Trans. Path. Soc." vol. six. p. 213.
8 Kuott : Op. cit. p. 73.

TRAUMATIC OESOPHAGITIS. 39

case occurring in the practice of Dr. Gordon l the patient
had suffered from repeated attacks of dysjmoea a considerable
time, before dysphayia supervened. In other cases,2 in which
the early history is obscure, it is quite possible that the
original lesion may have been due to the temporary impac-
tion of a foreign body, to a peri-oesophageal abscess, or even-
to the penetration of a scrofulous gland. In any of these
instances, by the time the autopsy is made, there is often
nothing which can reveal the original cause of the malady,
and there is at present no ground for considering that ulcer-
ation of the ossophagus can take place as an independent
process. Ulcers of the gullet may follow oesophagitis,3 and
they are certainly found in cancer, syphilis, and phthisis,
as well as in thrush, diphtheria, variola, typhoid fever, and
in cases of traumatic lesion.

TRAUMATIC (ESOPHAGITIS.

Latin Eq. — CEsophagitis traumatica. .

French Eq. — CEsophagite traumatique.

German Eq. — Traumatische Entziindung der Speiserbhre.

Italian Eq. — Esofagite traumatica.

DEFINITION. — Acute inflammation of the oesophagus caused
by caustics or irritants,4 giving rise, when very severe, to com-
plete destruction of the walls of the (jullet, in slighter cases to
limited desquamation, and when mild to active hyperwmia.

History. — Inflammation of the gullet from the action of caustics
has been more or less known to physicians since the earliest dawn of
scientific medicine, but it is only in modern times that the special
effects of the various irritant and corrosive poisons on the mucous
membrane of the alimentary canal have been attentively studied.
Less attention has, however, been given to the action of such sub-
stances on the gullet, probably because its resisting lining membrane,
its freedom from recesses, and its perpendicular direction combine to
make it much less vulnerable than the mouth or stomach. A mere

1 Knott : Op. cit. p. 68.

2 Ibid. p. 75.

3 See page 30.

4 (Esophagitis set up by the impaction of foreign bodies is purposely
omitted here, the condition of tne gullet under those circumstances
being so dependent on the nature, position, and ultimate course of
the foreign body that it can be best considered in connection with
the accidents which give rise to it.

40 DISEASES OF THE THROAT AND XO8E.

reference to the various ancient writers who have mentioned cases of
uesophageal injury from this cause would possess but little interest.
Those, however, who care to look more closely into this matter may
roiisult a list of cases of oesophageal strictures given by Behii-r. '
many of which are the result of traumatic cesophagitis, and several
typical instances may be seen in Luton's2 article on the cesophagus.
Both Casper3 and Taylor 4 contain much valuable information on this
subject.

i "CliniqueMe'dicale." Paris, 1864, p. 113.

» " Nouveau Diet, de MeU et de Chfr." Paris, 1877, t. xjdv. p. 416.

» " Handbook of Forensic Medicine." New Syd. Soc. TransL 1862, vol. It p. 55,
et seq.

* "Principles and Practice of Medical Jurisprudence." London, 1873, vol. i.
p. 211, et seq. 2nd edition.

Etiology. — The disease is nearly always caused by acci-
dental or suicidal swallowing of corrosive poisons, or highly
irritant solutions, but occasionally these fluids have been
administered to young children with murderous intention.1
Sulphuric acid, from its common employment for domestic
purposes, is often used by poor and ignorant persons for
suicide, better educated people generally seeking a less painful
poison. Nitric acid is not very easily obtained, and is there-
fore not so frequently used. Accidents often occur through
swallowing soap-lees, a mixture generally consisting of about
three parts of caustic soda to eight of water. These strong
alkaline solutions appear to be very carelessly used in some
parts of Austria, for in five years Keller 2 treated no less than
forty-six such cases amongst children in the Mariahilf Hos-
pital at Vienna.

Symptoms. — The specific action of many of the poisona
has already been described under "Traumatic Pharyngitis"
(Vol. i. p. 101, et seq.), but a few additional remarks must
be made here. In the first hours after the accident the
special lesion of the oesophagus does not attract particular
notice, the mouth, pharynx, and stomach being generally
simultaneously involved, and all claiming attention. If a
strong irritant has been swallowed, the mouth is excoriated ;
the surface of the tongue, when the agent is sulphuric acid,
being white, and when nitric acid, yellow. In both cases the
tongue is swollen, the uvula oedematous, and the pharynx
greatly inflamed, and presenting numerous bleeding excoria-
tions. If a laryngoscopic examination can be made, the

1 Casper ("Handbook of the Practice of Forensic Medicine," Ne
Sydenham Soc. Transl. 1862, vol. ii. pp. 75, 78, and 84) reports three
cases (Nos. 188, 191, 198) in which mothers killed their infants by
administering sulphuric acid.

2 "(Ester. Zeit. fur prakt. Heilkunde," Nos. 45—47, 1862.

TRAUMATIC CESOPHAGITIS. 41

epiglottis and arytenoid cartilages are seen to be red, and
enormously oedematous, or not much swollen, but covered
with loose dark-coloured shreds and blood-stained mucus.
At a later stage of the case, however, morbid changes result,
which give rise to very marked cesophageal symptoms. This
remark especially applies to the weak alkaline solutions,
which often produce cicatricial changes in the oesophagus,
whilst the pharynx, probably owing to its greater lumen, may
escape injury altogether.

A peculiar form of cesophageal inflammation is occasionally
produced by the action of antimony, which in some cases
appears to have a special action on the mucoiis membrane
of the oesophagus even when administered in medicinal
doses. There is a specimen in University College Museum
(No. 1052) which is a good illustration of this. Antimony,
in ordinary doses, had been given to a patient exhausted by
pneumonia, and after death the mucous membrane of the
epiglottis and pharynx was seen to be destroyed, and the
epithelium stripped off at the upper part of the oesophagus,
while at the lower extremity the mucous membrane was com-
pletely ulcerated through, the circular muscular fibres being
laid bare. There were likewise some smaller patches of
ulceration above this point. Vogel l has reported a case of
poisoning by antimony in which ulcers were found in the
oesophagus. Sometimes, however, the effects of the poison
are shown in the production of pustules. A remarkable in-
stance of this kind is described and figured by Laboulbene,2
in which the pustules were found scattered throughout the
gullet. The action of antimony on the oesophagus is, how-
ever, by no means uniform. Thus, in three cases of poisoning
by that agent reported by Taylor,3 in which large quantities
were taken, the oesophagus is described as being uninjured in
every instance, although in one of them a " burning sensa-
tion down the gullet " was complained of during life. In
this instance the patient was a girl, aged sixteen, and from
forty to sixty grains of antimony had been taken, whilst in
the other cases, occurring in young children, ten grains of the
poison had been swallowed.

In briefly describing the effects of poisoning by phosphorus
in the article "Traumatic Pharyngitis" (Vol. i. p. 103), I
omitted to mention two very characteristic symptoms, viz.,

1 "Lehrbuch der Kinderkrankheiten," p. 99.

2 Op. cit. p. 87.

3 Op. cit. vol. i. pp. 309, 310.

42 DISEASES OF THE THilOAT AND NOSE.

the belching forth of bluish-white fumes luminous in the
dark, and the evacuation of primrose-col oui-ed stools.1

In cases of injury by irritants the symptoms depend "n
the strength of the poison. When the mineral acids, chloride
of zinc, ammonia, or some other solutions in a concentrated
state, are swallowed, they corrode, the mucous membrane, and
give rise to the most serious and painful symptoms, whilst
the dilute acids and weak alkaline solutions set up «'•///>, or,
in some cases, only suit-acute inflammation.

Immediately after swallowing a pon-fffnl <•(//•/•</.-•/'•< />« •/*««,
or strong caustic, the patient experiences a burning sensa-
tion in the fauces and stomach, or he may complain of an
agonizing pain at the root of the neck or between the
shoulders. In some of the most severe cases, however, in
which both the stomach and cesophagus are deeply corroded,
the sensibility seems to be blunted, and but little pain is
complained of. This probably results from extreme shock to
the system. The patient expectorates and vomits either
dark-coloured fluid or a frothy secretion containing blood and
shreds of membrane. The vomiting may continue for two
or three days, but occasionally, in the most severe cases, it
ceases altogether after three or four hours, and notwithstand-
ing this apparently favourable turn the patient may succumb
within a short time. If the larynx is implicated, there is
extreme difficulty of breathing, together with troublesome
cough. There is usually very great prostration, the pulse being
quick and small, and the skin bathed in perspiration. Some-
times, however, there is active vascular excitement, the skin
is hot and dry, the pulse hard and quick, and as the result of
cerebral irritation, or possibly of some form of intoxication
produced by the poison, the patient is very restless, or even
delirious. Most patients suffer from distressing thirst,
and if they survive there is nearly always obstinate coji-
stipation.

In less severe cases, when the mineral poisons have been
taken in a diluted form, the symptoms are comparatively
slight, and resemble those described under "Acute CEsopha-
gitis" (pp. 28, 29) — that is to say, there are inability to
swallow and constant expectoration of glairy fluid. The charac-
teristic anxious expression is also present in the countenance.

1 I am indebted to the editor of the " Birmingham Medical
Review" (Oct. 1880) for calling my attention to these omissions, and
also for a very kind and critical review containing other valuable
suggestions.

TRAUMATIC (ESOPHAGITIS. 43

The patient complains of a burning acid, or of an acrid
alkaline taste, according to the chemical nature of the
poison. In these apparently mild cases, however, the dan-
gerous symptom of progressive dysphagia may show itself at
a later stage.

Patholoijy. — The morbid changes, of course, depend on the
nature and degree of concentration of the poison. In severe
cases the gullet as a whole may be gangrenous, its walls here
and there being even completely perforated by deep ulcers.
In these instances the tongue, pharynx, and larynx are almost
always extensively implicated in the destructive process.
According to Casper,1 in cases of poisoning by corrosive or
irritant substances, " the oesophagus is only in the rarest
instances carbonized like the stomach ; generally it is only
hard to cut as if tanned, and of a grey colour, and the vascular
injection of its mucous membrane may still be recognized."
The tissues of the gullet are in fact quite firm, the mucous
membrane is grey, and has an acid reaction. In poisoning
by corrosive sublimate, the mucous membrane of the mouth,
pharynx, and oesophagus generally has a violet tint, but
sometimes it is whitish.

When the corrosive action has been less violent, the lining
membrane of the oesophagus is of a brownish or ashen
colour, whilst its longitudinal ridges are partially corroded,
and more or less detached.

In the milder cases the mucous membrane is extremely
hypenemic and highly succulent, whilst there is abundant
cell-proliferation ; but it is only in cases where the injury
kills through the severity of the gastric affection, whilst the
(jesophagus remains comparatively unscathed, that these slight
pathological changes can be studied.

It is worthy of note that in some instances the stomach
may be seriously injured, whilst the oesophagus altogether
escapes the corrosive action of the poison.2

Diagnosis. — It .s very seldom that any difficulty in dia-
gnosis can arise, the immediate occurrence of the symptoms
on swallowing the poison leaving no doubt as to the nature
of the affection. Casper,3 however, points out that in infants
it is very important to distinguish between the state of the
tongue in poisoning by sulphuric acid and that occurring
in thrush.

It is necessary to ascertain, if possible, the nature of the

1 Op. cit. vol. ii. p. 57. 2 "Lancet," Nov. 6, 1880.

3 Op. eit. vol. ii. p. 57.

44 DISEASES OF THE THROAT AND XOSE.

poison that has been taken. If the patirnt is insnisil.1.-
\vl ii-ii the surgeon arrives, and the character of the poison is
unknown, the bottles, vials, and vessels in the room should
be examined, with the view of discovering some remains
of the acrid fluid. If this does not supply tin- ilrsirrd
information the vomited matters should be tested. Should
it happen, however, that the patient has not been si«-k,
emetics should be administered. The use of the stomach-
pump, though constantly recommended by surgical wri*
is in these cases attended with great risk, as the point of tin-
instrument is extremely likely to be pushed through the
walls of the oesophagus.

It is only in dealing with the sequelce of the accident that
there can be any doubt as to the nature of the original
lesion. Thus, a patient suffering from a stricture brought
about by a corrosive poison taken with suicidal intent, is
sometimes ashamed to confess the origin of the condition ;
and in these cases the question of diagnosis between cica-
tricial stricture and malignant disease may arise. This sub-
ject will be fully considered in the article on " Cicatricial
Stricture of the (Esophagus."

Prognosis. — The prognosis must depend on the amount and
degree of concentration of the corrosive poison that has been
swallowed, and also on the extent to which adjacent parts are
implicated. In severe cases the absence of pain must be
looked upon as a very unfavourable sign. Vomiting of dark-
brown fluid and of membranous shreds, and extreme pros-
tration are generally indications of an early death ; but even
in less severe cases it must not be forgotten that stricture
is exceedingly likely to supervene. It may be added that
though this may be cured for the time, it is almost certain to
recur, and that patients who have once suffered from trau-
matic stricture are afflicted with an infirmity which will
probably exist all the rest of their life.

Treatment. — Acids should always be neutralized by the
administration of alkalies largely diluted in water, barley-
water, or milk. Carbonate of soda, potash, and magnesia are
the best remedies, but any alkali that can be obtained, such
as chalk, whiting, or even the scrapings from a whitewashed
ceiling, should be at once administered. Sal volatil<
generally at hand and can be given freely diluted.

In the case of poisoning by phosphorus, carbonate of mag-
nesia should be given in drachm doses every fifteen minutes
till the breath ceases to be phosphorescent.

TRAUMATIC (ESOPHAGITIS.

If the poison has been an alkali, acids should not be used,
as they increase the inflammation, but oil or melted butter
should be given. Hot poultices should be applied over
the lower part of the neck and to the back along the
course of the gullet. The thirst must be assuaged by iced
drinks. Very little food, and that only of the blandest
character, should be allowed to be taken by the mouth, but
the patient should be fed from the very outset by nutritive
enemata, and anodynes should be given subcutaneously.
Should the patient recover from the immediate effects of the
injury, prompt and persevering measures must be adopted to
prevent the obliteration of the canal by cicatricial contraction.

As cases of corrosive poisoning are so common, and nearly
every pathological museum in London contains specimens of
the accident, I do not think it necessary to append any
examples.

It may not be out of place to mention that traumatic oeso-
phagitis occasionally arises from the stings of insects accident-
ally swallowed. In these cases the inflammation develops sud-
denly ; there is extreme odynphagia, as well as a burning pain
at the seat of the sting. The patient is generally very pros-
trate and alarmed. If able to swallow at all he should be
induced to take a weak alkaline solution, which generally
gives immediate relief. Should the pain be severe, morphia
must be administered hypodermically. In a case related by
Ranse 1 the sting was quickly followed by a swelling in
the neck corresponding to the supposed site of the sting
in the gullet, just below the thyroid gland on the right side,
and by an urticaria-like eruption which affected the body
generally, but was most marked on the side of the neck
near the same point. The following case occurred in my own
practice : —

In August, 1877, a gentleman, aged fifty-four, whilst drinking some
beer suddenly felt a very sharp pain in the gullet at a point cor-
responding to the episternal notch. This was followed by repeated
severe paroxysms of coughing, and at length by vomiting. It was
not till the contents of the stomach were brought up and a wasp
seen that the nature of the injury was guessed. I saw the patient
about three hours after he was stung, and he was then very anxious
and rather faint, and complained of something lodging in the throat
just above the level of the sternum. The pharynx and orifice of
the larynx were seen to be free from congestion. I endeavoured to

1 "Gaz. Med. de Paris." Sept. 1875.

46 DISEASES OF THE THROAT AND NOSE.

administer a weak solution of ammonia, hut the patient could not
swallow it. I then gave morphia hypodermically. In the evening
the patient felt pretty well, but still could not swallow. Th- next
day ne could take liquids but not solids, and deglutition was not
fully re-established till nine days after the sting.

CHRONIC (ESOPHAGITIS.

Latin Eq. — (Esophagitis chronica.

French Eq. — (Esophagite chronique.

German Eq. — Chronische Entziindung der Speiserohre.

Italian Eq. — Esofagite cronica.

DEFINITION. — Chronic inflammation of the fining mem-
brane of the oesophagus, giving rise to dygphagia and occa-
sionally leading to ulceration.

Etiology. — The observations with regard to the comparative
rarity of acute inflammation of the oesophagus (see page 27),
apply also to the chronic form of the disease. Many cases of
chronic cesophagitis are probably often regarded as examples
of gastric irritation, and treated as dyspepsia, which, as will
be hereafter shown, occasionally causes, and frequently f< ill< AVS.
slight cesophageal inflammation. It is extremely probable,
and the point has been insisted on by several writers, that the
long-continued abuse of ardent spirits is a frequent source of
chronic cesophageal inflammation. Daily experience proves
that excessive indulgence in the stronger forms of alcohol
irritates and inflames both the pharynx and the stomach ;
and though the oesophagus possesses greater powers of res St-
ance than either of these parts, it is not likely that it enjoys
absolute immunity. The complaint has been attributed to
chewing tobacco, but there is no positive evidence on the
subject.

Habitual vomiting may sometimes produce the affection,
and according to Cornil and Ranvier,1 it is occasionally
brought about by pyrosis. The disease probably sometimes
commences in a slight accidental injury such as may be
caused by swallowing a hard or pointed substance, or it
may arise from taking food either too hot, or of too pungent
a character.

It is generally asserted that the disease often follows the
acute form of inflammation of the oesophagus, and from the

1 " Manuel d'Histologie Pathologique." Paris, 1869, p. 769.

CHRONIC CESOPHAGITIS. 47

analogy of most disorders of inflammatory nature such a
sequence might reasonably be looked for,. There is not,
however, a single case on record which supports this view,
and my own experience, which, though very limited as regards
this complaint, is large in relation to the number of published
cases,, is altogether opposed to the theory that the chronic
affection often originates in an acute attack. I have met
with one instance in which the disease followed an attack
of pleurisy, the pleural inflammation being very localized, and
affecting the base of the left lung near the posterior medias-
tinum. In this case, as the pleura got well the oesophagus
became affected, a slight degree of inflammation being set up
which lasted for nearly three months. Though acute oeso-
phagitis is comparatively common in infants, the chronic form
of the disease appears to be confined to adults. I have never
met with it under twenty-five years of age, and most of my
patients have been over forty.

As a secondary phenomenon the condition is occasionally
seen in phthisis, and when syphilitic ulceration of the
gullet occurs, there is no doubt always some associated
inflammatory action. In stricture of the oesophagus like-
wise, whether arising from cancer, syphilis, or injury, chronic
inflammation is always present. This is brought about by
the irritation of food (often undergoing fermentative changes),
which lodges above the stricture, and sometimes probably
by the passage of bougies.

Symptoms. — The symptoms of the affection are obscure
when the disease is slight, and it is only in rather severe
and protracted cases that it can be distinctly recognized.
The most marked symptom is discomfort or even pain
in swallowing. Solids sometimes cannot be taken at all,
whilst liquids cause considerable inconvenience. The act
of swallowing is always performed very slowly. In most
of the cases that have come under my notice the inflamma-
tion appeared to be at the upper part of the gullet, but I
have met with one in which it was in the lower third. There
is generally a good deal of expectoration of viscid mucus,
but sometimes the sputa are frothy and closely resemble
ordinary saliva. There is never such an abundant flow as
is met with in acute oesophagitis. '

Pyrosis and hiccough are described by most writers as
being present, but I have not observed them in any of the
uncomplicated cases which have come under my notice.
Occasionally chronic oesophagitis follows chronic gastric

48 DISEASES OF THE THROAT AXD NOSE.

catarrh, and the two diseases may coexist for a long time.
Again, as the existence of chronic cesophagitis compels
patients to subsist for a long time almost cntin-ly mi liquids,
dyspepsia not infrequently follows. Whether the irritation
of the stomach be primary or secondary, when once it is
established, pyrosis is nearly sure to ensue, and in my
opinion must be looked upon as a gastric symptom. In
these cases, in addition to the purely oesophageal troubles,
gastric pain, flatulent distension of the abdomen and costive-
ness are present, whilst headache and depression of spirits;
are also complained of.

On auscultating the oesophagus, the descent of the alimen-
tary bolus can generally be perceived to be delayed, whilst
if the surface of the mucous membrane be roughened, a loud
harsh noise may be heard accompanying each act of degluti-
tion. When there is much obstruction, air-bubbles, and
sometimes perhaps the "morsel" itself, can be heard to ascend.
Exploration with the bougie should on no account be
attempted, as this is likely to aggravate the mischief.

The disease undergoes a good deal of variation, getting
better and worse without any assignable cause; but a marked
tendency to recurrence after any degree of improvement is
one of its most characteristic features.

Pathology. — The morbid changes that take place have
not hitherto been investigated, for the disease of itself,
though causing much inconvenience, never terminates fatally.
It is only in cases of cancerous obstruction and stricture,
that the pathological changes of chronic inflammation of
the oesophagus can be studied. In these cases, at a con-
siderable distance from the morbid growth, the vessels are
seen to be enlarged and tortuous, whilst the mucous mem-
brane is irregularly thickened, and often presents numerous
ulcers which vary greatly both in size and depth. They are
very frequently of a narrow oval form, and as the oasopha-
geal glandulae are arranged in short longitudinal rows, it is
probable that many of these ulcers are of follicular origin.
There is often considerable proliferation of the areolar tissue
beneath and around the ulcerated surface.

Diagnosis. — The disease with which this complaint is
most Irkely to be confounded is spasm of the oesophagus,
in which aft'ection there is, probably, always considerable
hypersemia of the mucous membrane. In chronic inflamma-
tion, however, the difficulty of swallowing is co7intant, whilst
in spasm it varies to some extent from day to day, and

CHRONIC (ESOPHAGITIS. 49"

from meal to meal. The most important point of dis-
tinction, however, between these two affections is that whilst
in spasm solids or semi-solids can often be swallowed with
comparative ease, in simple chronic inflammation liquids
pass down much more readily.

Chronic oesophagitis may be confounded with laryngeal
disease in which implication of the epiglottis or arytenoid
cartilages has given rise to dysphagia. In these cases the
laryngoscope furnishes a means of diagnosis, but it must
always be remembered that the two affections may coexist —
the oasophageal malady being generally secondary.

The symptoms of incipient cancer are very like those of
inflammation, but the former affection is mostly a disease
incidental to the decline of life ; in persons of middle age the
progress of the case can alone enable the surgeon to dis-
tinguish between the two conditions.

Prognosis. — There does not appear to be any danger to
life from this disease, but it is extremely apt to recur, and
any attack may be of long duration.

Treatment. — The most important feature in treatment is
the avoidance of anything that can irritate the mucous mem-
brane. The diet must be confined to soft or liquid food.
A bismuth pastil (Throat Hosp. Phar.) taken every half -hour
or hour, often seems to soothe the mucous membrane ; and
when the disease is beginning to pass away, lozenges of rha-
tany, kino, or tannin are now and then of use. Swallowing
small particles of ice sometimes gives relief, but occasionally
warm mucilaginous drinks are more soothing. There are
cases, however, in which all remedies appear to act preju-
dicially, the most important indication seeming to be the
maintenance of the oesophagus as far as possible in a state
of rest. If anodynes are required, they should, as a rule,
be administered hypodermically. In some cases I have found
counter-irritation by means of mustard poultices, blisters,
or croton oil of considerable use. Hot foot-baths, as recom-
mended in acute oesophagitis, sometimes act beneficially.

CASES ILLUSTRATING CHRONIC (ESOPHAGITIS.

Case 1. — C. S., a butcher, aged forty-seven, applied at the Throat
Hospital on January 14, 1874, complaining of difficulty of swallowing,
and pain over the episternal notch. He stated that up to that time
he had enjoyed good health, although he had been accustomed to
drink rather freely. He had latterly noticed a slightly increased
flow of saliva. The laryngoscope showed the upper part of the
throat to be healthy ; on auscultation, great slowness in the act of

VOL. II. E

50 DISEASES OF THE THROAT AND NOSE.

deglutition was perceived, but there was no special roughness nor
apparent obstruction at any one spot. A bougie could not be passed
beyond the upper third of the oesophagus. The patient compl-iim-d
very much of the use of the instrument, and spat up about a tea-
spoonful of blood immediately after it was withdrawn. The next
day difficulty in swallowing had slightly increased. He was put
upon iodide of potassium, and no food but milk and beef-tea was
allowed. A week later he had slightly improved, but alleged that
the iodide of potassium caused such a constant disagreeable taste
in his mouth that he was unable to take food. The medicine was
accordingly discontinued. In a few days the patient appeared a
little better, the pain in the neck being less, and he stated that he had
eaten some bread and milk. The probable inflammatory nature of
the disease was now first recognized, and the patient was prrsu;ideil
to become a "teetotaller." He was given bismuth mixture, and
ordered to discontinue crying out the price of food, inviting cus-
tomers, &c., after the manner of butchers in the poorer quarters
of London. At the end of March the man was quite cured, and was
able to eat and drink anything without difficulty. In February,
1876, this patient had a second attack, which, however, was of milder
character, and entirely passed off in three weeks.

Case 2. — Mr. T. S., a farmer, aged twenty-nine, consulted me on
November 11, 1876, on account of difficulty of swallowing. He
stated that until recently he had been a strong healthy man, and had
always been temperate. In addition to the dysphagia there was
slight odynphagia, besides an increased flow of saliva and pain
between the shoulders. The affection had come on gradually about
three months previously ; the patient had neither pyrosis, sickness,
nor any other symptom of indigestion. Examination with the
laryngoscope showed the larynx and pharynx to be healthy. On
auscultation of the gullet, slowness in swallowing and decided
obstruction opposite the fifth dorsal vertebra were plainly perceived.
An attempt to pass a bougie failed, the point of arrest appearing to
be at the orifice of the oesophagus — much higher than auscultation
had indicated. [The difficulty was probably caused by spasm, but
the patient refused to permit an examination under an anaesthetic.]
On November 12, the day following the attempt to pass the bougie,
the patient was unable to swallow at all, and he became very much
alarmed. A hypodermic injection of morphia was given at 8 p.m.,
and after a good night he was able to swallow nearly as well as on
the llth. In the course of a few weeks he quite recovered.

VARICOSE VEINS OF THE GULLET.

Latin Eq. — Varices oesophagi.
French Eq. — Varices cesophagiennes.
German Eq. — Varicositaten der Speiserohre.
Italian Eq. — Vene varicose del esofago.

DEFINITION. — Enlarged veins at the lower part ami occa-
sionally at the middle third of the osmphagus, <j<-n<-ralbj

VARICOSE VEINS OF THE GULLET.

resulting from some obstruction of the portal circulation,
occasionally rupturing and giving rise to hcematemesis.

History. — Haemorrhage from the gullet was recognized by Galen,1
but after his time there is no allusion to the subject till the early
years of the present century, when a varicose condition of the ceso-
phageal veins was mentioned by Portal 2 as sometimes giving rise to
haemoptysis. It was not till 1820, however, that Peter Frank,3
pointed out the connection existing between gastric haemorrhage and
obstruction of the portal circulation, and thus paved the way for the
elucidation of cesophageal bleeding. In 1840, Rokitansky4 published
an instance of fatal haemorrhage from enlarged cesophageal veins.
In 1853, Gubler,6 in comparing the loss of blood from enlarged
haemorrhoidal vessels with some forms of haematemesis, called
attention to the analogy in the distribution of the veins at each
end of the digestive tract, and described the peculiar arrangement
of the veins at the lower part of the gullet. In 1858, Fauvel's8
case (which had been observed in 1837 and referred to by Gubler
in the work just cited) was published together with one by Ledi-
berder. In the following year Bristowe' related a case, and in
1874 an example was published by Ebstein.8 Since then, Audibert9
and Dusaussay 10 have treated the subject in short monographs, and
Duret n has given a clear account of the anatomical conditions lead-
ing to the development of the affection. Zenker 12 has devoted to it
a few pages of his valuable article on the oesophagus, and quite
recently Eberth w and Hadden 14 have described instances of the
complaint.

De locis affectis," lib. v. cap. iv.

Cours d'Anat. M<5d." Paris an xli. (1803) t. iv. p. 539.

Trait6 de M6d. Prat." t. iii. p. 245.

Med. Jahrb. d. OEsterr. Staates." 1840, Bd. xxi. p. 230.

De la Cirrhose." Paris, 1853, p. 62.

Kecueil des Travaux de la Soc. Med. d'Observ." 1858, fasc. iii. p. 257.

Trans. Path. Soc." London, 1859.

Schmidt's Jahrb." 1874, clxiv. p. 160.

Des Varices (Esophagiennes." These de Paris, 1874.

Etude sur les Varices de I'CEsophage." These de Paris, 1877.

Progres Medical," t. v. 1877, p. 304.

Ziemssen's Cyclopaedia," vol. viii. p. 130, et seq.

Deutsches Archiv. fur Klin. Med." 1880, vol. xxvii. p. 566.

Trans. Path. Soc." London, 1882, vol. xxxiii. p. 190.

Etiology. — According to Galen,1 haemorrhage may take
place from the oesophagus, " ob solam sanguinis plenitu-
dinem," but this theory is not likely to meet with accept-
ance in the present day. Cirrhosis of the liver has generally
been considered to be the cause of this affection, but any
hepatic disease which obstructs the portal circulation is apt
to produce it, and it would appear from Zenker's 2 statistics
that the affection occurs with relatively greater frequency in
senile atrophy than in cirrhosis. Thus, in 178 cases in which
there was advanced chronic (especially senile) atrophy of the
liver, oesophageal varices were found forty-three times or in

1 " De locis affectis," lib. v. cap. iv. sub fin.

2 Op. cit. vol. viii. p. 132.

52 DISEASES OF THE THROAT AND NOSE.

•_M per cent., whilst the varicose condition was present
only once, i.e., 5£ per cent., in 18 cases of cirrhosis. In
Bristowe's case there was considerable enlargement of the
spleen, but the liver was normal. The cuntlitiuii »( tin- portal
vein, however, is not described. It must nut be forgot te: .
Zenker very properly points out, that senile atrophy <>f tin-
liver is a disease of old age, a period of life at which v.n
are most apt to occur, and hence that the dilated Mate . ,f
the cesophageal veins must not be regarded as necessarily
due to hepatic obstmction. Zenker unfortunately doea ii"t
nientinii tu what extent . varices were present in other part-
of the body in his 178 cases. Klebs l has met with instance.-
in which the affection was due to syphilitic disease of the
liver, and Konig 2 states that he has also seen a case in
which "fatal haemorrhage took place from a varix in the
neighbourhood of the cardia in a patient suffering fruin
syphilitic hepatitis." As Gubler and Monneret3 have in-
dicated, there is a tendency to loss of blood from various
parts when the liver is diseased. Indeed, even as far back as
the time of Hippocrates epistaxis in adults has been considered
to be a frequent concomitant of chronic hepatic disease. This
no doubt depends on some morbid alteration in the condition
of the blood. In the gullet, however, the peculiar relation of
the veins at its lower part to the general circulation on the
one hand and to the portal system on the other, favours the
development of the affection. For, as Gubler remarks, there
is towards the cardiac orifice of the stomach a neutral
territory, in which two sets of veins meet each other — one set
being radicles of the vena azygos, and thus communicating
with the general circulation, whilst the others end in the
portal vein through the coronary branch of the stomach.
This arrangement probably tends to cause obstruction to the
circulation where the two currents meet ; and Gubler 4 points
out that at the lower part of the rectum, where there is an
analogous communication between the systemic and portal
veins, haemorrhoids , are very common as the result of
obstruction.

An additional factor in the causation of these varices is,
according to Duret,5 the relatively large capacity of the

1 " Hand, der pathol. Anat." 1868, Bd. i. p. 162.

2 " Deutsche Chirurgie " v. Billroth u. Liicke. — " Krankheitcn <l>'s
Pharynx und (Esophagus," p. 30.

3 Gubler : Op. cit. p. 69.

4 Op. cit. p. 62.

5 " Progres Medical." 1877, t. v. p. 306.

VAKICOSE VEIXS OF THE GULLET. o3

cesophageal plexuses as compared with the size of the tho-
racic veins with which they communicate. Hence, if any-
thing prevents the former from emptying themselves into
the coronary veins of the stomach, the blood is necessarily
driven back, and the outflow into the bronchial, azygos, and
phrenic vessels not being sufficiently free, retardation of the
current is produced, the cesophageal plexuses become dis-
tended, and, if the cause continues, varix results. Paul,
Bert l has shown that each act of inspiration tends to increase
the quantity of blood in the thoracic veins ; it can, therefore,
easily be understood that when, owing to the conditions
which have just been described, these vessels are already over
full, bodily effort or any other influence causing increased
frequency of breathing favours the production of varix, or
even rupture.

'It is possible, also, that, owing to the vertical position of
the gullet, gravitation may play some part in the production
of varicose veins, in the same way as it does in the legs.

Symptoms. — Occasional heematemesis occurring in elderly
people in whom there is reason to suspect disease of the
liver, kidney, or spleen, is suggestive of the existence of
varicose veins of the gullet. It is seldom, however, that
the disease can be recognized with certainty during life
except by the aid of the cesophagoscope, and even with this
instrument it is often impossible to detect the enlarged veins,
which may be altogether at the lower part of the gullet. In
one of the two cases I have met with, however, I succeeded
in seeing the dilated veins during life. In both cases the
patients complained of an uneasy sensation in the throat,
and in one of them constant hiccough was a marked feature ;
but as the patient was a confirmed drunkard, this symptom
has no special significance as regards the complaint now
under consideration. In some of the recorded instances
pain has been complained of in the region of the stomach.
The evacuations are sometimes distinctly bloody, but more
often tarry in appearance. More rarely the stools are of
natural appearance.

Diaf/nosis. — It is extremely difficult to determine with
certainty during life that the disease exists, except in the
rare cases in which the desired information can be got by
O3sophagoscopy. Even in these cases it is not unlikely that
the veins of the stomach may also be affected in a similar
manner, and that the source of the bleeding may be there.
1 Quoted, by Duret : Loc. cit.

54 DISEASES OF THE THROAT AND NOSE.

Haemorrhage caused by the rupture of varicose veins has
likewise to be distinguished from that arising from other
local conditions. Although none of these has any abso-
lutely characteristic feature by which it can be identified,
some special points may be indicated by which the cause of
the bleeding may sometimes be recognized. Thus the haemor-
rhage from perforation by an aneurism is excessively profuse,
, whilst in bleeding due to the pressure of a solid tumour or
to ulceration, whether malignant or specific, there is a his-
tory of pre-existent severe dysphagia. In the case of for
bodies, the occurrence of the accident is usually known.

Pathology. — The general pathology of the disease has
already been described in dealing with the etiology, and it
only remains to make some remarks on the local condition.
It is probable that the cesophageal veins are more frequently
dilated than is generally supposed, for out of eighteen gullets
taken altogether at random, in seven I found more or less
dilatation of the submucous veins, whilst there was distinct,
although slight, varix in two cases. In four instances the
enlargement was above the middle of the tube, in three it was
at the lower end, and in one both the upper and lower portions
of the gullet were affected, the intervening surface, to the ex-
tent of four inches, being normal in appearance. In all the
cases the enlargement was most conspicuous on the front wall
of the gullet, and varied in degree from well-marked arbores-
cence of engorged venules to black, bead-like prominences,
connected with vessels of about the size of the angular vein
of the face. Although they were not examined microscopi-
cally, it seems certain that these naevoid points were true
vascular expansions and not ecchymotic patches, for they
could neither be washed nor scraped off. It may be re-
marked that the mucous membrane itself was perfectly free
from redness, although until it was stripped off it appeared
coloured by the enlarged underlying vessels. It may be
added that, so far as was known, none of the subjects from
whom the specimens were taken had shown any sign of
cesophageal trouble during life.

InEberth's1 case there was chronic catarrh of the intestinal
mucous membrane, and he thought that this condition had
led to general phlebectasis of the chylopoietic viscera. Not
only was the rectum the seat of large haemorrhoids, but the
vessels of the liver were in many parts much dilated, and at
one spot formed a true erectile tumour. The coats of the
1 Loc. cit.

VARICOSE VEINS OF THE GULLET. 55

collapsed oesophageal vein, from which the bleeding had
taken place, were extremely attenuated, and the vessel itself
was so superficial in situation that to the naked eye it
appeared to be lying quite bare of any mucous covering.

Treatment. — There is but little to be done in the way
of cure, though the haemorrhage can generally be arrested
by making the patient swallow a strong styptic. Among
remedies of this kind the mixture of tannic and gallic acids
contained in the Throat Hospital Pharmacopoeia, under the
name of Gargarisma Acidi Tannici fort., is probably the most
effectual. Treatment is of little avail as regards the varicose
condition of the vessels, and it is seldom that the hepatic
disease upon which it depends can be relieved.

CASES ILLUSTRATING VARICOSE VEINS OF THE
GULLET.

Case 1. — Mr. H. B., aged fifty-nine, consulted me in January, 1875,
on account of a constant uneasy sensation in the throat, and occasional
attacks of spitting of blood. The patient was an exceedingly stout
man, of dull grey complexion, and of a generally unhealthy appear-
ance. Though seldom drinking to intoxication he had freely
partaken of spirits for the last forty years. He stated that he
had been quite well till two years before, when he had had slight
jaundice. Since then he had attacks at intervals, but they had
generally not lasted more than a few days. Since the commencement
of his illness he had occasionally had rather severe feverish colds,
accompanied by pain over the liver. Six months after he first
became ill he had severe bleeding from the nose, which broke out
at intervals during a week, and was at last arrested only with the
greatest difficulty. On physical examination, owing to the extreme
obesity of the patient, it was very difficult to make out the limits
of the liver. The heart sounds seemed very feeble, but no murmur
or other evidence of disease could be detected. Examination of
the throat showed that the pharynx was much relaxed, the uvula
elongated, and the mucous membrane of the larynx slightly congested.
On February 7 I was summoned to see Mr. B. on account of
what was called "spitting of blood," but on arriving I found that
the haemorrhage occurred in a gush with slight retching, and was
clearly of the nature of hsematemesis. There had been three gushes
of blood, amounting in the aggregate to eleven and a half ounces.
I directed the patient to swallow a small quantity of the Garg.
Acid. Tanuic. fort, of the Throat Hospital Pharmacopoeia, and no
more haemorrhage occurred on that occasion. The patient, how-
ever, was greatly weakened by the loss of blood, and a few days
later had a severe attack of diarrhoea. Two subsequent bleedings
from the throat took place in March and April, and at the beginning
of May the patient was attacked with bronchitis and died in a few
days. The following are the notes of the autopsy which was made
by Mr. Poyntz Wright thirty-six hours after death. Rigor mortis
not perceptible ; subcutaneous tissue loaded with fat ; lungs very
cedematous in the lower third, especially at posterior part ; mucous

.""><'> DISEASES OF THE THROAT AND NOSE.

membrane of lirom -liial tubes bright rc.l and covered with frothy
iinirus ; left lobe of liver much reduced in si/c, right lobe slightly
smaller than normal ; surface hob-nailed ; substance hard and dry
on section. Numerous ecchymotie spots were seen hcni-ath the
lining membrane of the stomach, one being as large as a penny,
but most of them ninrh smaller. On opening the o-sophagus the
veins at its lower part were seen to be enormously enlarged. Six-
large veins with free anastomoses ascended fur about two im-hes.
whilst two of these reached considerably above the middle third
of the tube. Three small hard whitish vertical eieatrit-es \\vi>
three-quarters of an inch above the cardia, and one larger ami redder
cicatrix three inches from that point.

Case 2. — Mr. M., a hotel keeper, aged fifty-one, was sent t«> me in
October, 1880, by Dr. Robert Cross, of Craven Street. The patient.
who hail been a free liver, complained of a disagreeable sensation in
the throat, with a constant feeling of sickness and frequent hiccough.
Examination of the throat showed great relaxation of the mucous
membrane of the pharynx and larynx, and elongation of the
uvula. A portion of it was subsequently removed, with consider-
able relief to the symptoms. After about two months, however,
the patient began to experience slight difficulty in swallowing.
On examination with the cesophagoscope a dark round tumour
about the size of a pea, with a black streak passing into it .both
above and below, was seen, rather below the middle of the oesophagus,
and I had little doubt but that this object was an enlarged vein.
As the examination was exceedingly disagreeable, the patient would
not submit to a second exploration. Nevertheless, I felt justified in
writing to Dr. Cross, expressing my opinion that the patient had
varicose veins of the gullet, and that haemorrhage was likely to occur.
Up to this time it must be observed there hail not been the slightest
sign of haemorrhage. A month later my prediction was verified, for
a sudden attack of hsematemesis came on. This was repeated on
several occasions, but though a large quantity of blood was brought
up, the stools had only once a tarry character. This fact mak
almost certain that the bleeding came from the gullet and not from
the stomach. In August, 1881, after a severe outburst of hemor-
rhage, a fatal attack of delirium tremens supervened. No post-mortem
examination was allowed.

PERI-CESOPHAGEAL ABSCESS.1

{SYNONYMS : POST-CESOPHAGEAL ABSCESS. RETRO-CESOPHA-

GEAL ABSCESS.)

Latin Eq. — Abscessus peri-oesophageus.
l-'ri'in-li Eq. — Abc&s peri-oesophagien.
Ci-nnan Eq. — Penoesopliageal&bsceapi
Italian Eq. — Ascesso peii-eaofagea

DEFINITION. — An it\fl(tmmatory wijlliinj r<>>/f(i/tti>/>/ ////>•,
iji'in rul/n (iriijiiidtiinj in tin' /i///i/J/(ifir ijldinl* <i>//i>/>///itf tin'

1 Although the term " pat-jffutrjfngeal abscess" is an appropriate
'one, as abscesses frequently form behind. the back wall of the pharynx.

PERI-CESOPHAGEAL ABSCESS. 57

Oesophagus, but sometimes commencing in the areolar tissiie,
and more rarely induced by caries of the vertebrce. In
a<l nit* the abscess occasionally penetrates the muscular coat,
and gives rise to diffuse suppurative inflammation of the
xiilii/mcous areolar tissue, and as a still rarer sequel, a
cicatricial diverticidum of the oesopliacfus may result.

History. — It has been already pointed out that it is useless to
attempt to separate into two classes abscesses which are formed in
the neighbourhood of the pharynx, and those developed in immediate
proximity to 'the gullet. The older writers made no such distinction,
and accordingly in an historical retrospect it will be convenient
to treat the whole subject together. The first notice of abscess in
the pharyngo-cesophageal region dates as far back as in the second
century of the Christian era, when Galen J related a case which had
occurred in his own experience, and which terminated in spontaneous
rupture. From his manner of alluding to the case it would appear
that he had seen several examples of the same kind, most of which had
cmlcd fatally. No mention of the complaint was made by any other
writer, so far as I am aware, till the middle of the 18th century, when
we meet with Morgagni's 2 careful description of a case in which an
abscess pressing on the oesophagus and trachea caused the patient's
death by opening into the latter tube. In 1785 Bleuland3 mentioned
that his master, Van Doeveren, had seen a fatal instance of the disease
at Groningen. In 1819 Abercrombie4 reported three cases of retro-
pharyngeal abscess which he had met with in young children, and he
seems to have been the first physician who recognized the idiopathic
character of the affection. He was under the impression that the
disease had never before been described, and he mistook his first case
for croup. Sir Astley Cooper 5 refers to two examples which he had
seen in adults, the dissection of the first leading him to the diagnosis
and successful treatment of the second. In 1839 Petrunti6 published
a case which he cured by making an incision into the oesophagus.
In 1840 Fleming7 described the affection with considerable detail

De locis affect," lib. v. cap. iv.
De sedibus et causis morb." torn. ii. lib. xv. art. xv.
3 ' Observ. anat. med. de sana et morbosft oesophagi struct." Lugd. Batav.
1785

' Edin. lied, and Surg. Journal," vol. xv. p. 259, et seq.

' Princ. and Pract of Surgery." Ed. by A. Lee. 1836, voL i. p. 79.

' Gazette Me'dicale," 2e se'rie, t. vii. p. 122.

' Dublin Journ. of Med. Science," vol. xvii. p. 41, et seq.

the expression " post-cesophageal abscess " is less accurate, inasmuch
as purulent collections in proximity to the oesophagus are quite as
often at the side of the tube, or even in front of it, as behind it.
It is true that for practical purposes there is no difference between an
abscess behind the Imcer part of the pharynx and one behind the upper
part of the (esophagus ; but there is a veiy wide difference between an
abscess on a level with the hyoid bone, and another occurring some
inches below the level of the cricoid cartilage. In point of fact, the
pharynx is so broad, and extends laterally so far into the neck, that
an abscess situated at one side of it practically becomes a cervical
abscess, and is generally very properly treated as such.

58 DISEASES OF THE THROAT AND NOSE.

as it occurs in the upper part of the neck, reporting three cases which
h:nl come under hia own notice, and giving a drawing of an instrument
devised by himself for the safe opening of such abscesses. In 1841
Ballot ' described a case of abscess in close relation to the gullet.
Mondiere* followed in 1842 with a collection of cases gathered from
many sources, and a year later Duparcque3 made some interesting*
observations on the subject. More recently Caulet,4 Gillette,5 and
Gautier,8 have contributed to the literature of the disease.

1 • Arch. G4n. de Me"d." 3e st^rie, t. xii. p. 257, et seq.

-• ' L'Expe'rience." Jan. and Feb. 1842.

3 ' Gaz. cles Hdpitaux." 1843, p. 105.

* ' De la Peri-oesophagite." Paris, 1864.
•"' ' Des Abces pharyngiens." Paris, 1867.

* ' Des Abces rttropharyngiens." Geneve et Bale, 1869.

Etiology. — Peri-oesophageal abscess, regarded as a distinct
disease, probably nearly always commences in the glands in
the neighbourhood of the gullet, though, in some instances,
it may possibly originate in the areolar tissue. In some
rare cases it appears to have its starting point in a distinct
tubercular deposit.1 As an occasional feature accompany-
ing caries of the vertebrae, it is also sometimes met with,
but this form of abscess need only be referred to in
connection with diagnosis, its treatment coming within
the province of the orthopaedist or general surgeon. The
glandular inflammation may be either jiriniari/ or seconifuri/
— that is to say, it may occur in a child previously appa-
rently healthy, or it may be developed in the course of
an eruptive fever. The special predisposition to glandular
inflammation in young subjects is too well known to require
comment. It has been suggested that the irritation of the
glands in these cases takes its rise from difficult dentition,2
and I have no doubt that it is sometimes also connected with
post-nasal disease, e.g., chronic catarrh, or adenoid vegeta-
tions. According to Barthez and Rilliet,3 abscesses in con-
nection with the upper part- of the food-tract are most fre-
quently met with in the four earliest years of life, especially
in the first. The cause of the disease is, however, often
obscure, and in one of Petninti's 4 cases the origin was attri-
buted to "catching cold." Though the affection is often
met with in infants, early life as compared with adult age
does not exhibit that preponderating frequency which is
seen in the case of the similar abscesses involving the
pharynx. Occasionally the malady is distinctly pyaMnie in

1 Laboulbene: "Anat. Pathol." Paris, 1879, p. 89.

2 Fleming : Loc. cit. p. 41.

5 "Maladies des Enfauts." Paris, 1853, 2nd ed. t. i. p. 243.
4 Loc. cit.

PERI-CESOPHAGEAL ABSCESS.

character. Thus there is a case in Guy's Hospital Museum
in which purulent inflammation following amputation of the
arm extended through the axilla to the root of the neck,
and gave rise to a peri-ossophageal abscess which ultimately
involved all the tissues of the gullet. A case described by
Ziesner1 appears to have had a similar origin. The patient
had suffered from puerperal fever and from abscesses in the
ovary and kidney ; a collection of pus was formed between
the vertebral column and the gullet, finally bursting into the
latter.

Symptoms. — These depend on the size, seat, and stage of
development of the abscess. Its size varies, as a rule, from
a hazel-nut to a hen's egg, but in some cases the sac attains
enormous dimensions. The space corresponding to the
interval between the fourth and seventh cervical vertebrae
is a common seat of the affection ; but a purulent collection
may form in connection with any part of the ossophagus.
Follin and Duplay2 state that an abscess at the upper part
of the food-tract is more often situated laterally than in a
central position. Whatever may be its original site, however,
the abscess, especially if chronic, as it increases frequently
gives rise to a swelling on the side of the neck.3 Hocken*
has reported a case in which a fluctuating tumour of this
nature reached as high as the mastoid process. Even if the
abscess itself is at a considerable depth from the surface
it may cause extensive oedema of the cervical region. In
two cases related by Petrunti,5 the thyroid cartilage was
pushed forwards ; lateral displacement may also occur,
though this is probably very rare. In the early stage of the
complaint the local symptoms are vague, there being usually
nothing more than a feeling of dryness and swelling within
the throat, accompanied, perhaps, by some slight tenderness
in the neck if it be the upper part of the* food-channel that
is affected. Pain in swallowing is generally present from
the outset ; it is at first localized in some particular part of
the canal, but soon begins to radiate — usually in an upward
direction — and may be referred to the entire length of the
gullet. Any movement of the neck is also extremely
painful, but even when the parts are at rest there is a

1 " Rams oesophagi morbus. " See "Disputat. Hallerii." Lausannfe,
1760, vol. vii. p. 629.

"Traite Elem. de Pathol. externe." Paris, 1877, t. v. p. 252.

3 Mondiere : " L' Experience." 1842.

4 "Journ. des Connaiss. Med.-Chir." Juillet, 1843.

5 "Gazette Medicale." 1839, 2e serie, t. vii. p. 122.

constant throbbing ])ain, if the disease is acute. As tin-
abscess develops dysphagia begins to 1»- felt, deglutition
gradually becoming all luit impossible, not only from actual
obstruction to the passage of food, but also from the inability
of the patient to make the required muscular eflbrt. A- a
rule, however, a bougie can be passed, and in t\vo in>tances
mentioned by Caulet,1 this circumstance led to tin- erroneous
inference that there was no compression of tin- d-sopha^-al
canal. If the abscess presses on the windpipe there •
course, some dyspnoea — which is generally more marked
during the act of swallowing, the food in its passage do\\ n
the gullet narrowing still further the tracheal lumen. Tin-
voice is generally altered, and occasionally, according to
Duparcque,2 it has a very peculiar character, resembling the
"quack of a duck." Cough is not a constant symptom, and
when present, is too slight to be troublesome. The head is
in most cases kept rigidly upright; occasionally, however,
when the abscess is situated high up, the neck is thrown
backwards almost as in opisthotonos, whilst, if the disease is
at a lower point, the patient's chin may be drawn down
towards his sternum.

The malady usually runs an acute course, and it is
probably only when it originates in vertebral caries that it
has a chronic character. It may end in spontaneous rupture
of the sac, the contents being discharged into the gullet, from
which they are at once expectorated. If the abscess, however,
is large, its sudden evacuation in this manner is attended with
considerable danger, for the matter may h'nd its way into
the larynx, and cause suffocation. On the other hand, the
pus may penetrate the muscular coat, and burrow rapidly
in the submucous tissiie, giving rise to true phlegmonous
cesophagitis or supjmrative inflammation of tin ,//////•/. This
complication, however (see "Pathology"), is most uncommon,
and when it does occur, there is little change in the symptoms.
In some cases the inflammation becomes gangrenous, when
death quickly ensues, with the usual typhoid symptoms.
Gautier8 has collected six instances in which this sequel was
observed, the abscess in all of them being connected with
the upper part of the food-tract.

The symptoms differ to some extent in children and in
adults. In the former the abscess is, in the majority of

1 "Dela Peri-oesophagite." Paris, 1864, p. 32.

- " Annales d'Obstetrique, " t. ii. p. 21.

3 " DCS Abces retropharyngiens. " Geneve et Bale, 1869

PERI-<ESOPHAGEAL ABSCESS.

cases, at the upper part of the neck, and, according to
Barthez and Kllliet,1 one of the earliest signs of the disease
is a peculiar form of dry coryza, which shows itself within
the first few days of the invasion. In children, moreover,
the constitutional disturbance is generally very great ; there
is a considerable degree of fever at the onset of the malady,
and rigors ensue as suppuration becomes established. Brain
symptoms, such as convulsions and coma, are not unfre-
quent ; they are more likely to occur when the abscess,
being situated laterally, impedes the circulation through the
large vessels, or presses on the vagus or spinal accessory
nerve. In a case reported by Fleming,2 the child, which was
comatose when lying on its back, recovered consciousness
when placed in a sitting posture.

In adults the onset of the complaint is not, as a , rule,
so sudden as it is in children, nor are the constitutional
symptoms so severe. Kausea and vomiting may occur, and
fever sets in with frequent rigors as the disease develops.
The patient often exhibits an extraordinary anxiety of
countenance, even at an early period of the complaint.

The above description must be understood to refer to
simple abscess produced by ' inflammation of the peri-oaso-
phageal areolar tissue or of the lymphatic glands contained in
it. Where the disease owes its origin to caries of the vertebrae,
the development of the abscess is slow and unattended with
febrile disorder, and it consequently acquires considerable
bulk before attention is drawn to it. In such cases, more-
over, previous, symptoms of spinal mischief are sure to have
shown themselves. Even if there be no curvature, tenderness
over the affected part and diminished mobility of the ver-
tebral column can be detected 011 careful examination.

Diagnosis. — The disease may be mistaken for croup, such
careful observers as Abercrombie3 and Carmichael4 having
fallen into this error. The dysphagia and stiffness of the
neck which are present in peri-cosophageal abscess are,
however, essential points of distinction. In true croup,
moreover, the pharynx generaDy presents some traces of
false membrane, whilst shreds can almost always be found
in the sputa. The continued severity of the symptoms in
peri-oesophageal abscess also serves to distinguish the disease

1 Op. cit. p. 420.

2 "Dublin Journ. of Med. Science." 1840, vol. xvii. p. 43.

3 Loc. cit.

4 "Trans, of King ami Queen's Coll. of Phys. in . Ireland, " vol. iii.

62 DISEASES OF THE THROAT AND NOSE.

from croup, which either terminates fatally or ends in
recovery in a few days. AVhere the laryngoscope can be
used it furnishes a ready means of differentiation.

The disease can scarcely be confused with oesophagi t is, in
which a constant flow of saliva and extreme odyn]>ha.uria
are always present. Pericarditis with great effusion may
simulate the affection, but physical exploration of the pne-
cordial region will at once reveal the real nature of the case.
Peri-oesophageal abscess may occasionally present a likeness
to hydrophobia, in that liquids cannot be swallowed, but tin-
characteristic terror is absent, and, moreover, the difficulty is
still greater as regards solid food.

Pathology. — When the abscess is formed at the upper part
of the throat, it is almost always situated behind the food-tract.
In thirty-eight autopsies Gautier1 found it in this position
in every case. The abscess occasionally pierces the muscular
coat of the oesophagus, and whilst remaining beneath tin-
mucous membrane rapidly sets up suppurative i ?//«/// //"///<///
of the whole circumference of the phaiyngo-GMOphage*]
canal. The inflammation may be limited to a small section
of the canal, or may involve its entire length, the exten-
sion being favoured by the arrangement of the lymphatics
in a single layer. (See "Anatomy," p. 6.) According to
Zenker,2 who has greatly elucidated this rare affection, the
stibmucosa under these circumstances soon becomes con-
verted into a cavity filled with pus, amongst which bundles
of areolar tissue may still be found. In favourable cases
the pus bursts through the mucous membrane at several
points, and produces cribriform ulcers, which may ultimately
heal, leaving small saccular depressions lined with epithe-
lium as permanent evidences of the disease. Occasionally
these minute cavities, wherein papillae may sometimes be
found, are bridged across by little bands, which further
reduce their orifices. In less favourable cases the uinx-
cularis becomes involved, the pus disorganizes the fibrillae,
and fatty degeneration of the structure occurs. When
the abscess is circumscribed, and has emptied itself into
the oesophageal canal, the sac may gradually contract, and
in course of healing may draw a small portion of the mucous
membrane outwards, giving rise to " traction-diverticula "
(see "Dilatations of the Gullet"). In another class of
cases the abscess approaches the integument at the root

1 Op. cit p. 20. 2 "Zicmssen's Cyclopaedia," vol. viiL p. 147

PERMESOPHAGEAL .ABSCESS. 63

of the neck, and comes within easy reach of the surgeon's
inife.

Prognosis. — This is always grave, though many patients
recover. The least favourable cases are those dependent on
vertebral caries. Peri-oesophageal abscesses are less fatal
than similar abscesses in immediate relation to the pharynx.

Treatment. — According to Barthez and Ellliet1 neither
antiphlogistic nor mercurial treatment can arrest the disease,
even at its commencement. When once the case has been
diagnosed, the neck should be constantly fomented ; and if
there be any distinct fulness, poultices should be applied
over the part. It is generally desirable to feed with the
cesophageal tube, but if the tender age of the patient renders
this method impossible, recourse must be had to nutritive
enemata. A fear of establishing an cesophageal fistula or
even a diverticulum has sometimes prevented surgeons from
making a prompt incision into the abscess ; but this danger
is comparatively slight, penetration of food into the tissues
being only likely to occur in cases of a decidedly gangrenous
character. Where practicable the abscess should be opened ;
but otherwise, when there is reason to believe that sup-
puration has taken place, emetics may be given, in the hope
that during vomiting the sac may burst. Sometimes the
surgeon can cut down through the neck, and reach the
abscess. A remarkable illustration of this procedure has
been published by Petrunti,2 who made an incision along
the anterior border of the sterno-mastoid one inch and
a half in length, and dissected carefully down till the
oesophagus was exposed, and the situation of the abscess
could be clearly made out. On opening the sac,' twelve
ounces of pus escaped, to the immediate relief of the patient.
Drainage was kept up by means of a strip of lint, and the
cure was complete in a month. After incision or accidental
bursting of the sac the case must be watched, as the opening
is very likely to heal up prematurely. When the abscess
has been opened, or has burst, deglutition greatly assists in
emptying the sac, by causing pressure on its walls.

Tracheotomy is sometimes called for, but as might be
expected, does not always relieve the symptoms. This was
shown in a case reported by Ballot,3 in which, however, the
disease was mistaken for oedema of the glottis.

1 Op. cit. p. 243. 2 Loc. cit 3 Loc. cit. p. 258.

64 DISEASES OF THE THROAT AND NOSE.

THRUSH OF THE GULLET.1
(SYNONYM : APHTHA.2)

Latin E(j. — Aphthse oesophagi.
French Eq. — Muguet de 1'cesophage.
German Eq. — Soor der Speiserohre.
Italian Eq. — Mughetto del eaofago.

DEFINITION. — Inflammation of the <E<toplta<jti* ">•'•//, •/•//nj
in infants, generally accompanying a ximifar disease of tin'
Iniccal mucous membrane, characterized IHJ an exudat/»>t
creamy in colour and consistence, which usually coiit'
large quantities of the parasitic fungus knoicn as ouUmn
albicans.

1 Tlie fact that aphthae attack the oesophagus more frequently
than the pharynx has led me to treat the subject in greater detail
in this section than in the first volume.

2 The Greek writers used the. word afyOa (derived from aTrro), "I
set on fire") for ulcerated spots in the month. The English word
thrush is supposed to be allied to thrust, signifying a "breaking
out," its earliest occurrence, .so far as I am aware, being in
Arbuthnot's "Practical Rules of Diet," London, 1732 (chap. iii.
p. 355), where he defines thrush as "small round superficial ul«-er-
ations which appear first in the mouth." At present, English
writers apply the word thrush to any aphthous affection occur-
ring in the mouths of infants ; in the words of our great medical
classic, "Children in arms who exhibit aphthae are said to have
the thrash." (Sir T. Watson: "Lectures on the Principles and
Practice of Physic." 1857, 4th ed. vol. i. p. 119.) The French,
on the other hand, make a great distinction between aphthe and
muguet, the latter being a name derived from the resemblance of
the vegetation to the white blossom of the may-flower. Thus the
term muguet is strictly limited to the parasitic affection in which
the (tidium albicans is found, whilst aphthe is employed to de-
scribe a non-parasitic pseudo-membranous exudation. [The above
was in type before the French translation of the first volume
of this work appeared. My distinguished friends, Drs. Moure and
Bertier, have added a long note in order to "establish a line of
demarcation between aphtha and muguet, confounded together by the
author " (myself). Whilst there is much to be said in favour of the
French view, the presence or absence of the minute fungus has not
hitherto been accepted by English writers as a sufficient ground of
distinction. The difficulty of the subject is not diminished by the
admission of Drs. Moure and Bertier that muguet rather frequently
complicates aphtha (see also "Diet. Encyclop. des Sciences Mexli-
cales," t. v. p. 668).] The German writers (see Niemeyer : "Lehr-
buch d. Speciellen Pathologic uud Therapie," 7th Auflage. Berlin,
1868, Bd. i. p. 472 and p. 483) use the words Soor and Schwdmmchen,
as the French employ muguet for the parasitic affection, whilst they
apply the term aphthai to simple exudative inflammation of the
mucous membrane of the mouth.

THRUSH OF THE GULLET.

History. — In dealing with the history of this disorder, it may be
remarked that the buccal affection has been recognized from the
earliest periods, whilst the cesophageal form has only been described
in modern times. Hippocrates1 mentions the fact of newly-born
children being liable to aphthae. Celsus2 also treats of the subject
in some detail, but from his expressions I am inclined to believe that
he is speaking of some more serious disease than thrush. Indeed,
all the earlier writers seem to have included under the general name
of apMhce every form of ulceration affecting the mouth. An
approach to a more correct knowledge of thrush was made by Boer-
haave,3 who described it as a papular or vesicular eruption on the
mucous membrane of the mouth. Particular attention was attracted
to the affection by a very severe epidemic which occurred at the
Children's Hospital in Paris in 1766, and some years later a prize of
1,200 livres, offered by the Academic de M^decine for the discovery
of the cause of the disease, was divided among four competitors, who
all agreed in regarding "muguet" as consisting essentially in a
creamy exudation from the inflamed mucous membrane. In 1785 Bleu-
land4 related a most remarkable case, in which the oesophagus of an old
woman who died from inanition was found filled with " aphthae albae,"
a condition which, in his opinion, gave rise to the fatal aphagia.
Baillie5 gives some drawings of the disease, in one of which the vegeta-
tion is seen to occupy nearly the entire length of the gullet. After the
publication of Bretonneau's researches on diphtheria in 1821, thrush
was classed among false membranes, and treated of from that point of
view by Lelut,6 Ve"ron,7 and Blache.8 The latter writer also pointed
out the occurrence of the vegetation in adults suffering from wasting
diseases, such as cancer and phthisis, and insisted on it as a sure
sign of impending death under these circumstances. Billard 9 gives
some remarkable examples of the cesophageal form of the disease,
which is also noticed by Andral.10 Valleix11 studied the malady with
much attention, and was familiar with the fact of its occurrence in
the gullet. Cruveilhier12 in his great work gives three plates portraying
thrush in the o?sophagus. Finally, in 1842 Berg,13 of Stockholm, was
able, by microscopic examination, to establish that the disease is gene-
rally of parasitic nature, and owes its existence to a cryptogamic
fungus, to which he gave the name wdium, albicans. The life-history
of this parasite was very completely worked out by Robin14 in 1853.
Two years later Seux15 published the results of an extensive clinical
experience, and whilst accepting the view as to the parasitic
origin of thrush, he endeavours to show that it is essentially a con-
stitutional disorder, the exudation on the mucous membrane being

i ' Epidem." lib. iii.

! ' De medicina," lib. vi. cap. xi.

3 Van Swieten : " Comment, in H. Boerhaave aphorismos," t. iii. p. 197.

! ' De sanft et morb. cesoph. structura." Leidse, p. 71.

' ' Engravings of Morbid Anatomy." London, 1813, tab. ii. fasc. iii.

! ' De la fausse Membrane dans le Muguet." — " Arch. Ge"n. de Me'd." Ixiii.
" ' Observ. sur les Maladies des Enfants." Paris, 1825.

8 Art. " Muguet," Diet, en xxx. vol.

9 " Maladies des Enfants nouveau-ne's." Paris, 1828, p. 283, et seq. See also>
the " Atlas d'Anat. Pathol." which accompanies that work, pi. i. and ii.

1 " Precis d'Anat. Pathol." Paris, 1829, p. 161.

1 " Clinique des Maladies des Enfants nouveau-ne's." Paris, 1838, p. 237, et seq.

2 "Anatomic Pathologique." Paris, 1835-42, livr. xv. pi. v.

13 Quoted by J. Muller, " Arch. f. Anat. u. Physiol." 1842, p. 291.
" Hist. Naturelle des V6g6taux Parasites, &c." Paris, 1853.
' " Recherches sur les Maladies des Enfants nouveau-n6s." Paris, 1855
VOL. II. P

66 DISEASES OP THE THROAT AND NOSE.

of the nature of an exanthem. Quite recently, M. Parrot * has
described the minute characters of the disease with the greatest
accuracy, concluding that it is a local expression of general mal-
nutrition.

1 " Clinique <les nouveau-ne'g." Paris, 1877, p. 213, et Beq.

Etiology. — The origin of the disease is not clear, the exact
bearing of the fungus which is commonly present being as
yet undetermined. It is also often impossible to tell what
relation the local affection bears to the extensive visceral
disease which frequently accompanies it. Thrush is usually
supposed to be more commonly met with in the cold northern
countries than in the south, but this view is not absolutely
correct. It appears to be much more frequently seen in
Paris than in London,1 and according to Seux2 it is more
common in Marseilles than in Paris. This physician, how-
ever, observed that in the capital the disease is more severe
than in the southern city, a circumstance which he attributed
to causes connected with the nutrition of the little patients.
Thus he found that in Paris, on the appearance of the
slightest symptom of the affection, the nurses, fearing that
the disease might be communicated to their nipples, at once
weaned the children, whereas at Marseilles the infants were
suckled during the whole course of the malady.

Thrush often invades the oesophagus after it has attacked
the mouth and pharynx, but it not unfrequently passes
by the pharynx altogether and involves the gullet. In-
deed, thrush of the bucco-cesophageal mucous membranes
is more common than the coexistence of the affection in the
pharynx and mouth. It is, however, extremely rare for the
disease to be limited to the oesophagus. Steffen3 did not
meet with a single example of this circumscribed form of
the malady in forty-four autopsies on infants who had
died from cesophageal disease. Indeed, as far as I am

1 In comparing the diseases of infancy in London and Paris, it must
not be forgotten that whilst in Paris infantile affections are carefully
studied from birth at the Hospice des Enfants-Trouves by thoroughly
trained internes, in London children are not admitted into the Chil-
dren's Hospitals under the age of two years.

2 Op. cit. p. 197.

8 "Jahrb. fur Kinderheilk." 1869, Bd. ii. p. 142. It is worthy
of note, however, that among these forty-four cases, Steffen has
recorded not less than fifteen instances of cesophageal diphtheria (!), a
disease which, according to the experience of all other physicia :
extremely rare. It is highly probable that some of Steffen's cases
(notably Nos. 12, 13, 15, 19, 26, and 31) of supposed diphtheria were,
in fact, examples of thrush.

THRUSH OP THE GULLET.

aware, there are but three cases on record1 in which thrush
was found to be confined to the gullet. Unlike the pharyn-
geal form, of this affection, which frequently attacks adults
in the last stages of chronic disease, oesophageal thrush is
scarcely ever met with except in infants.

Symptoms. — If a child is suffering from aphtha of the
mouth, and suddenly shows signs of difficulty in swallowing,
it may be suspected that the disease has passed down to the
gullet ; but if spots can actually be seen in the pharynx, the
oesophageal affection will generally soon come on, for when
* the disease reaches the pharyngeal mucous membrane it
almost always extends downwards. Whilst the affection
is confined to the pharynx it seldom gives rise to any dys-
phagia, but this symptom immediately occurs when the
oesophagus is involved. The local phenomena are generally
complicated by serious disease of the internal organs. In
the three uncomplicated cases above referred to, the most
prominent symptoms were inability to swallow and obsti-
nate vomiting ; death took place from marasmus. Wherever
situated, thrush is often associated with erythema of the
buttocks and enteritis ; indeed, Valleix2 asserts that in new-
born children intestinal inflammation hardly ever occurs
without thrush.

Pathology. — The disease is found in the oesophagus in
three forms — First, as minute adherent, slightly elevated,
greyish-white specks, varying from a pin's head to a lentil in
size, resembling little drops of tallow, or morsels of curd;
secondly, in patches mostly elliptical in shape, the long axis
of which corresponds with that of the oesophagus; thirdly,
in zones of varying width, covering from one-third to two-
thirds of the circumference of the gullet. These zones,
according to Parrot,3 are not generally uniform in elevation,
but are alternately raised and depressed ; they vary in hue
from pale white to greyish-yellow, the white zones being
usually wider than the others.

According to Seux4 the oesophagus ranks next to the
mouth as regards frequency of invasion by thrush, the
lower portion of the tube being the part most prone to the

1 Valleix, op. cit. p. 89 (for a full account of this case, see p. 239,
et seq., of the same work): Andral, op. cit. p. 161 ; Bleuland, op. cit.
p. 71.

2 Op. cit. p. 481.

3 Op. cit. p. 214
Op. cit. p. 113.

68 DISEASES OF THE THROAT AND NOSE.

disease, which, however, very seldom extends farther down
than to within a centimetre of the cardia. In some ran- in-
stances, however, the thrush extends beyond the oesophagus,
Steffen1 having reported two cases in which not only tin-
whole of the oesophagus, but the stomach and small intes-
tines were implicated in the morbid process. Taking twenty-
six of Seux's cases, and twenty-two of Valleix's — together
forty-eight examples — the pharynx was involved in twenty-
three, and the oesophagus in thirty-two. In two of 1 In-
latter the gullet alone was affected, but in no case was
the pharynx the sole seat of disease. As a rule, however,
thrush does not involve the gullet except when the mouth is
very severely affected.

Although the colour of the vegetation, when first formed,
is probably always yellowish-white, it is often found after
death to be grey, green, or even black, the hue probably
depending on the nature of the food and medicine taken,
or the matters vomited, and in some cases on degenerative
changes of the materies morbi itself. The mucous mem-
brane underneath may show only slight injection, or there
may be extensive ulceration, or even, as in one of Seux's
cases, the walls of the oesophagus may be totally destroyed
by gangrene.

The consistency of the exudation varies from that of cream
to stout blotting-paper which has been wetted, and it gene-
rally adheres to the underlying epithelium with sufficient
tenacity to resist slight attempts to tear or scrape it off.

Even the softer kind, which can be washed off, leaves
behind a sort of thin foundation layer which requires
some degree of force to separate it from the surface of tin-
mucous membrane. The granular specks are usually much
more intimately attached than the patches. On digesting
the morbid material in liquor potassae, and submitting it
to microscopical examination, it is generally seen to consist
of the spores and filaments of the dulium albicans, with fat-
globules, epithelial cells, and granular debris. Zenker has
also found pus-cells in the epithelium. The fungus itself
consists of cylindrical highly-refracting filaments, composed
of long cells connected together, which contain granules ami
terminate in spores and spore-cells; the latter are round or
oval, generally adherent to each other, and, like the fila-
ments, often contain granules.

1 Loc. cit.

DIPHTHERIA OF THE GULLET.

The cesophageal fungus, according to Wagner l is at first
situated on the level surface of the epithelium; this, how-
ever, soon becomes depressed by the penetration of the fila-
ments, which sometimes strike so deeply as to drive in the
walls of the blood-vessels of the submucosa. Parrot2 states
that in some instances the fungus nearly reaches the muscular
coat. The rough pathological distinction between the false
membrane of diphtheria and thrush consists in the fact that
the former frequently attains a dense cohesion, thick wash-
leather-like tissue being produced, whilst the thrush-exuda-
tion, though sometimes thick enough to narrow materially
the lumen of the ossophagus, is merely a pulpy mass of aggre-
gated particles. The microscopic characters of diphtheria
have already been described (Vol. i. p. 150, et seq.).

Diagnosis. — It is impossible to diagnose the disease with
certainty during life, but where there is evident difficulty
in swallowing, and the vomited matters contain outturn
albicans, there can be little doubt that thrush is present
in the oasophagus.

Prognosis. — If it can be ascertained that the gullet is
extensively involved, the prospects of the patient must be
regarded as extremely unfavourable. In doubtful cases, if
the thrush in the mouth becomes of a dark colour, if the
food be regurgitated, if there be much vomiting or diarrhosa,
and if there be marked general wasting, an unfavourable
opinion must be given. The presence or absence of enteritis
is, however, probably the most important factor in prognosis.
Few cases of thrush recover if there be inflammation of the
bowels, whilst, on the other hand, in the absence of this
complication, thrush is seldom a serious disorder.

Treatment. — The rules already laid down under pharyngeal
thrush (Vol. i. p. 1 1 9) should be carried out with even more
assiduity.

DIPHTHERIA OF THE GULLET.

Diphtheria of the gullet is extremely rare, and when
present has no special clinical significance. After death, how-
ever, the false membrane is sometimes found to have involved
the ossophagus. Amongst the few writers who have published

1 "Manual of General Pathology." Transl. by Van Duyn and
Seguin. London, 1876, p. 99.
a Op. cit.

70 DISEASES OF THE THROAT AND NOSE.

cases are — Bretonneau,1 Ferrand,2 Espagne,3 West,4 Seitz,
Steffen,6 Ziemssen,7 Trendelenburg,8 and Laboulbene.9 Green-
how10 appears to have heard of cases occurring in the prac-
tice of others, but to have met with no examples himself.
Squire11 mentions the occurrence of the oesophageal anVrt i' >n in
two instances out of a tabulated list12 of seventy-four cases of
general diphtheria, but this probably represents an unusually
large proportion. In their more important works neither
Trousseau nor Oertel gives any example of oesophageal
diphtheria, whilst Empis points out that its non-occurrence
in the oesophagus is one of the essential points of distinction
between diphtheria and thrush, which so often attacks the
gullet. In two of Bretonneau's cases the disease extended to
the gullet. In the first, which occurred in a weakly boy, aged
fifteen, it reached, in the form of long bands, to the cardiac
extremity of the tube, leaving the intervening portions of the
mucous membrane healthy ; whilst in the second, in which
the patient was an infant eight months old, the exudation
formed a continuous loosely-adherent coating. Ferrand has
reported two cases in which the disease was secondary to
scarlatina. The false" membrane extended deeply into the
air-passages, and the upper part of the oesophagus was
invaded. Laboulbene states that he has met with three
cases. In one of them the membrane, which appeared to
have extended from the pharynx, was of slight consistence,
and did not lie on an ulcerated surface. Seitz has reported
one instance in which a thin membranous exudation, covered
with pus, extended four centimetres down the oesophagus.
Steffen13 has reported no less than fifteen examples, nearly all
of which were complicated with one or more of the follow-
ing conditions, viz., pneumonia, tubercle, chronic peritonitis,

1 "Memoirs on Diphtheria." Syd. Soc.Transl. 1859, pp. 17, 18, 77, &c.

2 " De 1' Angine Membraneuse. " Paris, 1827, pp. I/, 20.
"De la Diphtherite." Montpellier, 1860, p. 107.

4 "Diseases of Infancy and Childhood." London, 1874, 6th ed.
p. 426.
8 " Diphtheric und Croup," von Dr. F. Seitz. Berlin, 1877, p. 349.

"Jahrb. fur Kinderheilk. " 1869, Bd. ii. p. 143.

" Cyclopaedia, " vol. viii. p. 145.

8 First published in Petit's "Traite de la Gastrostomie." Paris,
1879, p. 261, et sea.

9 "Nouveaux Elem. d'Anat. Pathol." Paris, 1879, p. 85.

10 "Diphtheria." London, 1860, p. 184.

11 "Reynolds' System of Medicine. . 1866, vol. i. p. 399.

12 This list is given in the "Brit. Med. Journ." 1859, p. 305, et seq.

13 Loc. cit. See page 66, note 3, respecting these cases.

CANCER OF THE GULLET. 71

intestinal catarrh, follicular enteritis, caseation of the
bronchial glands. In one instance there was a splenic
abscess. Of the four cases in which the diphtheritic mem-
brane was confined to the oesophagus, in one there were also
extensive noma and chronic miliary tubercle of the lungs ; in
another there were chronic peritonitis, circumscribed pneu-
monia, and splenic abscess ; in a third there were cedema of
the lungs and intestinal catarrh ; and in the fourth there were
pneumonia, catarrhal inflammation of the epiglottis, and an
ulcer at the lower part of the gullet.

I have myself seen two cases of diphtheria of the gullet,
one in a child aged three, in which the upper third of the
oesophagus was covered with a thick adherent membrane,
a similar deposit being present in the pharynx. My other
case was that of a boy, aged six, whose pharynx, posterior
nares, larynx, and trachea were covered with false membrane,
whilst the whole of the oesophagus to within an inch of the
cardia was similarly coated.

The nature and treatment of diphtheria have already
(Vol. i. pp. 119 to 186) been so fully discussed that they
need not be again referred to here.

MALIGNANT TUMOURS OF THE GULLET.

Under this head are included (1) Carcinomata and
(2) Sarcomata.

CANCER OF THE GULLET.

Latin Eq. — Carcinoma oesophagi.
French Eq. — Cancer de 1'oesophage.
German Eq. — Krebs der Speiserbhre.
Italian Eq. — Cancro del esofago.

DEFINITION. — Cancerous growth in the walls of the gullet,
generally undergoing ulceration, but giving rise at the same
time to great narroicing of the canal, often to perforation of
the trachea or bronchi, and in rare instances to penetration
of one of the large blood-vessels. In nearly all cases extreme
dtjsphagia and marasmus are present.

History. — From the fact that the earlier writers did not attempt to
separate malignant from non-malignant growths there is consider-
able difficulty in giving an accurate historical sketch of cancer of
the oesophagus. Inasmuch, however, as benign growths are exceed-
ingly rare in this situation, in doubtful cases it has been assumed that
the writers have referred to malignant tumours.

72 DISEASES OP THE THROAT AND NOSE.

In the second century Galen l speaks of fleshy growths completely
or partially obstructing the (esophagus. In tne tenth century
Avicenna,- in describing the various conditions giving rise to
dysphagia, mentions tumours as a frequent cause. Kernel, :i wlm
flourished in the sixteenth century, relates the case of a woman who
died in consequence of her gullet being blocked up, close to its cardiac
extremity, by a large hard mass, which prevented any food passing into
her stomach for two months before her death. Goiter,4 wlm lived some-
what later, mentions an interesting case of a woman who died alter
having suffered from dysphagia for eight years. After death a " scir-
rhous tumour of the size of a man'sfist was found obstructing the lower
end of the gullet." In Bonnet's8 large collection of post-mortem
records there are several cases of growths connected with the oeso-
phagus, which had destroyed the patient by rendering swallowing
impossible. An excellent account of various forms of cesophageal
obstruction was given by Beutel.6 Boerhaave and his pupil and
commentator, Van Swieten,7 were familiar with cancer of the gullet,
and to the latter is due a remarkably vivid description of the sufferings
endured by the victims of this disease. The subject did not escape
the attention of Morgagni,8 who, besides commenting on the cases
of Bonnet and others, mentions one or two occurring in his own
experience. Lieutaud a gives several examples, chiefly collected from
the writings of other observers. Sir Everard Home10 relates many
cases of cesophageal stricture, some of them undoubtedly malignant.
Baillie11 referred to the subject in his work on pathology, giving
also some excellent engravings12 of oesophageal tumours, and soon
afterwards Honro tertius*3 published some additional cases. Sub-
sequently Bell,14 Howship,15 and Mondiere 16 recorded examples of the
disease, and described its features in some detail. Since then, nume-
rous cases have been published in the medical journals, and in the
transactions of the various medical societies, whilst the subject has
been more or less fully treated bvWalshe,17 Lebert,18 Follin,19 Behier,20
Zenker and Ziemssen,21 Luton,2* Konig,23 and Butlin.24

1 " De symptomatum causis," lib. iii. c. li.
1 " Canon," lib. iii. feu 13, tract, i. cap. iv. et v.

3 " De morbis univers. et particular. Libri quatuor posteriores pathologies."
Lib. vi. cap. i. p. 125. "Trajecti ad Rhenum," 1656.
* " Observ. Anatom. Chir." p. 121.

1 " Sepulchretum." Geneva, 1700, lib. iii. sect. iv. obs. ii.
" De strunia oesophagi." Tubingen, 1742.

7 "Comment, in H. Boerhaave aphorisniog." Lugdun. Batavorum, 1745,
t. ii. § 797, p. 644, et seq.

8 " Epist. anat. med. de sedibus et causis morborum." Lugdun. Batavorum,
1767, ep. xxviii. sect. 14, 15, 16, t. iii. p. 12, et seq.

» " Hist. Anat. Med." Parisiis, 1767, t. ii. p. 805, et seq.

10 " Pract. Observ. on the Treatment of Strictures in the Urethra and the
(Esophagus." 1805, 3rd ed. vol. i. p. 537, et seq.

" Pathological Anatomy." London, 1802.
i- " Engravings to illustrate Morbid Anatomy." London, 1872, tab. ii. fasc. iii.

' Morbid Anatomy of the Human Gullet, <fec." Edinburgh, 1811.
!•» ' Surgical Observations." London, 1817, vol. i. p. 76, et seq.
is ' Practical Remarks upon Indigestion, Ac." London, 1825, p. 161, et seq.
i« ' Arch. Gen. de Med. ' 1833, 2 stSrie, t. iii.

17 'On the Nature of Cancer." London, 1846.

18 • Trait6 des Maladies Oance' reuses." Paris, 1851, p. 442, et seq.

19 • Sur les Relre'cissenients de l'(Esophage." Paris, 1853, p. 49, et seq.

20 'Conferences de Clinique Medicate." Paris, 1864, p. 57, et seq.

-'i ' Cyclopaxlia of Pract. Medicine." London, 1877, vol. viii. p. 172, et seq.
^•uveau Diet, de M6d. et de Chir. Paris, 1877, t. xxiv. p. 384, et seq.
M " Deutsche Chirurgie,' von Billroth und Liicke. " Krankheiten des Pharynx
und Oesophagus." Stuttgart, 1880, p. 68, et seq.
24 " Sarcoma and Carcinoma." London, 1882, p. 159, et seq.

CANCER OF THE GULLET.

Etiology. — Though cancer of the gullet may be regarded
as the typical disease of that organ — the affection with which
most practitioners are best acquainted — it is not relatively
common. According to Zenker and Ziemssen,1 in 5,079
autopsies, primary cancer of the gullet was present only
thirteen times. Concerning the relative liability to cancer
of the oasophagus as compared with other organs, there is
less positive evidence. Dr. Walshe2 states that 13 out of
8,289 deaths from malignant disease in Paris were ascribed
to cancer of the oesophagus. In a table of 471 cases, the
accuracy of which is vouched for by Lebert,3 the gullet was
the seat of the disease in 8 instances. The difference in
the last two series is so great that at present the question
must remain undecided. The same causes which predispose
to or excite cancer in other parts of the body lead to its
development in the oesophagus. Amongst the former are
heredity, age, and sex ; amongst the latter, continued local
irritation, accidental injury, and chronic inflammation may
probably be reckoned. Heredity appears to have considerable
influence, for among sixty cases which I have examined with
reference to this circumstance, some member of the patient's
family had died from malignant disease in eleven instances,
whilst among ten cases observed by Richardson,4 there was
in no instance wanting a history of some malignant affection
amongst the relatives. Age greatly influences the outbreak
of the disease, which is extremely rare under forty. The
greatest number of cases are met with between fifty and
sixty, although the decennia immediately before and after
that period furnish almost as many cases. In my 100 fatal
cases the incidence of the disease in relation to age was as
follows5 : —

1 "Cyclopedia," vol. viii. p. 173.

2 Op. cit. p. 270.

3 Op. cit. p. 441.

"Trans. St. Andrew's Med. Grad. Assoc." 1872-73, vol. vi. p. 184.
5 Of these 100 cases, 60 of the patients were under my own care,
23 having been treated by me in private practice, 28 at the Throat
Hospital, and 9 at the London Hospital ; 25 were treated by my
colleagues at the Throat Hospital, and 15 by my colleagues at the
London Hospital. These cases all occurred before the year 1875,
when I published some lectures on the subject in the " Medical Times
and Gazette." My clinical experience is based on a far larger number
of cases, but patients suffering from cancer of the gullet seek a great
variety of medical advice, and cases which have been treated up to
within a few weeks of their death are often finally lost sight of. My
published statistics being based on 100 cases, I have not thought it
worth while to introduce fresh figures by adding those I have met
with since 1875.

74 DISEASES OF THE THROAT AND NOSE.

TABLE 1. — AUTHOR'S CASES.

Age. No. of cases.

From 30 to 40 8

„ 40 to 50 28

,, 50 to 60 34

„ 60 to 70 24

„ 70 to 80 6

Total 100

The following table is an analysis of thirty cases occurring
in the "Transactions of the Pathological Society."1 It will
be seen that £he results closely correspond with my own
cases : —

TABLE 2. — CASES FROM "TRANS. PATH. Soc."

Age. Vo. of cases. Percentage.

From 30 to 40

.. 6-66

,, 40 to 50

.. 20-

„ 50 to 60

.. 36-66

,, 60 to 70

.. 26-66

,, 70 to 80

.. 6-66

Over 80 ..

3-33

Total 30

The following is an analysis of forty-three cases observed
by Bchier,2 but it is right to remark that in three of the
cases occurring between twenty and forty the diagnosis was
doubtful : —

TABLE 3. — BEHIER'S CASES.
Age. No. of cases.

From 20 to 30 3

30 to 40 4

40 to 50 10

50 to 60 11

60 to 70 10

70 to 80 3

At 82 1

„ 86 J.

Total 43

1 There are in all forty nominal cases reported in the " Trans-
actions" up to the end of the session, 1874-75, but some of them do
not appear to have been true cases of cancer, others are incomplete,
and a few, having been reported by myself or my colleagues, are included
in my own series.

3 " Conferences de Cliuique Medicale." .Paris, 1864, p. 119, et seq.

No. of cases.
8

Total ..

CANCER OF THE GULLET. 75

The following table gives the result of fifty-eight cases
collected by Mr. Butlin1 : —

TABLE 4. — BUTLIN'S CASES.
Age.

From 30 to 40
„ 40 to 50
„ 50 to 60
„ 60 to 70
„ 70 to 80
Over 80

It may be remarked, however, that if the various tables
were corrected in accordance with the number of people
living at each decennial period, they would show a con-
stantly increasing mortality from the disease as age advances.

Men are much more liable to the disease than women, a
fact which is very distinctly borne out by my own series of
100 cases, of which 71 were of the male, and only 29 of
the female sex. Habershon 2 gives a table of " 85 cases
collected from ' Guy's Hospital Post-mortem Records,' the
' Pathological Society's Transactions,' and other sources,"
of which 59 were men and 26 women. In Petri's3 cases
examined at the Pathological Institute at Berlin, the liabi-
lity of the male sex to the disease is even more remarkable,
for out of 44 cases, in only 3 were women the subjects of
the disease. Ziemssen4 reports 18 cases, among which there
was but 1 female, but the diagnosis was not verified in
every instance. Zenker5 met with 15 cases of the disease,
of which 1 1 were men and 4 women. Whilst, however, men
are more frequently attacked than women, the latter suffer
at an earlier age. Thus, in Table 1, all the patients under 40
years of age were women, three of them having been 34,
and the rest older. The average age of the men in my
series was 52*43, and that of the women 44 '5, whilst in
Habershon's cases the average age of the men was 55£, and
that of the women 44|, the latter average tallying exactly
with mine. The greater predisposition of the male sex to

1 Mr. Butlin gives a list comprising fifty-nine cases, but in one of
these the age of the patient is not stated.

"On Diseases of the Abdomen." 1878, 3rd ed. p. 84.

3 "Ueber44 im Pathologischen Institut in Berlin in der Zeit von
1859 bis zum Marz 1868 vorgekommene Falle von Krebs der
Speiserb'hre. " Berlin, 1868.

4 Ziemssen's "Cyclopaedia," vol. viii. p. 193.
8 Ibid. vol. viii. p. 186.

76 DISEASES OF THE THROAT AND NOSE.

cancer of the oesophagus is remarkable when it is recollected
that more than twice as many women as men die of malig-
nant disease, and that cancer of the contiguous viscus — the
stomach — which in its liability to irritation is exposed to
the same conditions as the gullet, is equally common in both

The tubercular diathesis, which is ordinarily regard" ••! as
antagonistic to cancer in general, has been thought, on the
contrary, by Lebert,2 Hamburger,3 and Fritsche4 to predispose
to that disease in the gullet. Lebert observed the coexistence
of pulmonary tubercle with cancer of the oesophagus in seven
out of nine cases, whilst Behier5 insists on the frequent
coincidence of the two affections. The general experience
of the profession points to an opposite conclusion, and con-
sidering the frequency of tubercle, the two diseases cannot
be said to coexist frequently. Petri6 found only 4 examples
in his 44 cases, whilst out of 100 examples I only met
with 3, in all of which the pulmonary disease showed sip is
of retrograde change.

Amongst local causes, the abuse of spirits has, since the
time of Gyser,7 been looked upon as an important factor in
the production of cesophageal cancer, and the greater pre-
valence of the disease among men as compared with woim-n
has been attributed to this cause. Out of my own 60 cases
only 5 acknowledged to have been free drinkers, and 6 others
were publicans by occupation. It is quite possible that the
abuse of spirits may predispose in several ways to the
development of cancer in the gullet. Thus, by lowering the
tone of the nervous system and causing degeneration of
tissue, it may render all the organs less capable of resisting
the constitutional taint. There does not, however, exist any
decisive evidence on this point. Again, alcohol may directly
irritate the mucous membrane or indirectly produce a similar
result by causing eructations and vomiting. Further, when
people are half intoxicated, they are apt to be careless as to

1 Excluding cancer of the sexual organs, which is disproportionately
frequent in woman, malignant disease aifects both si-xrs in an almost
equal ratio. This makes the greatly more common occurrence of
cancer of the gullet in men all the more remarkable.

2 Op. cit. p. 445.

8 " Klinik d. (Esophaguskrankheiten." Erlangen, 1871.

4 "Ueberd. Krebs d. "Speiseriihre. " Berlin, 187-!.

5 Op. cit. 6 Loc. fit.

7 "De fame lethali ex callosa oesophagi angustia." Argentorati,
1770, sect. vi.

CANCER OF THE GULLET.

what and how they eat, and under these circumstances pieces
of meat or foreign bodies accidentally introduced into the food
are more likely to be swallowed, and thus to set up irritation.
My own impression, on the whole, is that the effect of
excessive indulgence in alcohol has been overrated in con-
sidering the etiology of ossophageal cancer.

The accidents which arise from taking too large or too
hot morsels of food deserve a passing notice. Nearly a
century and a half ago Van Swieten l was disposed to
attribute the origin of the disease to swallowing very hot
fluids, especially coffee, which at that time was coming into
general use. This view, however, was no doubt erroneous,
and was strongly opposed by Morgagni.2 It is only when
an excessively hot morsel has been swallowed that it can
give rise to active symptoms. It is possible, also, that hot
liquids may in some cases have caused an ulcer which has
subsequently contracted in healing, and that the disease after-
wards met with, though mistaken for cancer, was not really
of a malignant character.3

Sometimes the supposed cause, such as a foreign body
sticking in the throat, is only the first symptom of the
malady, but there appear to be other cases, such as those of
Henoch4 and Fritsche,5 in which the swallowing of a very
hot morsel of food seems to have determined the site of
the growth.

In addition to other causes of oesophageal cancer the
irritation set up by indigestion, with its attendant troubles,
eructations and vomiting, must be mentioned. These have
been already referred to as resulting from the abuse of
alcohol ; but of course they may arise from other causes.

In three cases that have come under my notice the
patients suffered from vomiting for many years before any
dysphagia was observed, and it is quite possible that in
these instances the retching excited the development of
cancer in the gullet. It is worthy of note that none of
these patients were addicted to the use of alcohol.

Cancer may supervene on simple stenosis, as in a case

1 Op. cit t. ii. pp. 647, 648.

2 Op. cit. § 797, ep. xxviii. art. 15, t. iii. p. 15.

3 As in a case reported by Leroux, "Cours sur les generalites de
la Medecine Pratique." Paris, 1825, t. i. p. 315.

4 Casper's " Wochenschr. f. d. gesammte Heilk." 1847, No. 39.

5 Op. cit. p. 74. These cases are quoted by Zenker and Ziemssen,
who also refer to another case by Deininger, which, however, does
not appear to me to be so conclusive.

78 DISEASES OF THE THROAT AND NOSE.

reported by Dr. Hilton Fagge;1 and I have met with
several instances in which slight chronic inflammation having
existed for many years, cancer ultimately showed itself.
The following is a good illustration, but others equally
remarkable have come under my observation. A ]"><>r
woman, aged forty-five, consulted me in 1863, on account
of dysphagia. A bougie could be passed with ease, and
as the patient was of very nervous temperament I treated
her with valcrianate of zinc and similar remedies. Sin-
frequently consulted me, and for some years I reganlcd her
case as " functional ; " judged of, however, by the light of
others which I have since met with, I feel sure that the
symptoms were due to chronic inflammation of the ceso-
phagus. In the early part of 1874 a cancerous growth was
seen with the mirror protruding from the orifice of the
oasophagus, and by the end of the year the patient died from
extensive epithelioma of the gullet. It appears more pro-
bable that the cancer originated as a spot chronically inflamed
than that malignant disease existed all the time, but was
completely masked, and progressed so slowly that it did not
terminate fatally for ten years.

The frequency with which cancerous growths originate in
cicatrices in other parts of the body makes it probable that
they sometimes have a similar starting-point in the oeso-
phagus. Neumann 2 has recorded what appears to be an
example of this mode of origin, and Ziemssen 3 has met with
another which might bear a like interpretation. From the
analogy of the tongue, where it is a matter of common
observation that syphilitic ulceration is prone to take on a
carcinomatous character, it may justly be inferred that scars
left by old venereal mischief in the gullet may become tin-
site of malignant disease.

Symptoms. — The most constant, striking, and important
phenomenon is difficulty in swallowing. It is this which
usually first attracts and then rivets the sufferer's attention.
The train of symptoms is generally somewhat as follows : —
The patient first experiences an occasional obstruction to the
descent of food, if he takes a large mouthful, or if the food
is of a dry nature. In a short time this difficulty becomes
habitual, and the patient complains that food lodges some-
where— usually at the same point — when he tries to swalli >w.

1 "Guy's Hospital Reports," series 3, vol. xvii.

2 " Virchow's Arehiv," ]M. xx. p. 142.

3 " Cyclopaedia of Medicine," voL viii. p. 188.

CANCER OF THE GULLET 79

He now often begins to be troubled with cough, especially
when deglutition is attempted, and as the disease progresses
he is obliged to wash down every mouthful with a draught of
liquid, and he soon finds that he cannot take solids at all,
except after prolonged mastication and with the aid of fluids.
Then he is no longer able to swallow solid food in any form,
his diet is restricted to liquids, and he loses flesh rapidly.
As time goes on in some cases the stricture becomes so narrow
that even liquids cannot be got down, or a fistulous opening
being formed between the oasophagus and trachea, the swal-
lowed liquids pass into the windpipe and are immediately
ejected by a violent and painful attack of coughing. As soon
as the gullet becomes much contracted the patient begins to spit
up a frothy fluid, which is at first clear, and closely resembles
saliva, but which soon becomes viscid or muco-purulent, and
is not unfrequently streaked with blood. Sometimes small
particles are voided, which, on microscopic examination, are
found to be of cancerous nature. Emaciation rapidly ad-
vances, and the patient soon becomes greatly wasted, and
so weak that he is unable to take any exercise, or indeed to
perform any act requiring muscular effort. The cancerous
cachexia is often absent, the patient dying of starvation
before the constitution becomes markedly perverted.

On analysing the symptoms it will be found that there is
not one which may not be occasionally absent, and that the
mode of their occurrence varies in particular cases. Dysphagia
is the most constant symptom, but there is at least one case
on record l where it was not present. The patient generally
states that the food is arrested at the upper part of the gullet,
even in those cases where subsequent post-mortem evidence
shows that the stricture was situated quite low down, a cir-
cumstance probably to be explained by the occurrence of
reflex spasm. Though the dysphagia generally comes on
gradually, it sometimes arises quite suddenly. I do not refer
here to those cases in which the patient having swallowed
too large or too hot a mouthful, the symptoms have deve-
loped from that date, but to those rare instances of which
the following, recently under my notice, may be taken as an
illustration : —

E. Y., aged fifty-six, was in perfect health, as far as he was aware,
until a certain day when at dinner. After eating a few mouthfuls a
piece of meat stuck in his throat, and he had to leave the table and

1 "Trans. Path. Soc." vol. vii. p. 188.

80 DISEASES OF THE THROAT AND NOSE.

eject it. He returned to his dinner, but could not swallow any food,
though he was able to drink beer. In the evening he tried -<>im
supper, but found he could not swallow solids ; and from that day till
his death, seven mouths afterwards, he was never able to take ;i im>i»-l
of solid food.

As has been already shown, dysphagia begins with ;i diffi-
culty in swallowing solids, and the patient is soon obliged i»
depend entirely on liquids. In swallowing these lie makes
a loud gurgling noise, which is audible to himself, and even
to those standing near. At first he drinks easily, but a ft IT
a little time he finds that the fluids will only pass very
slowly down the gullet, and if he is not very careful, the
drink will be suddenly and violently ejected through tin-
mouth and nose. Occasionally a portion of the drink or
semi-solid substance may be retained for a few minutes and
then vomited, but the alkaline character of the ejecta shows
that they come from the oesophagus and not from the stomach.

Patients in extremis, previously almost unable to swallow
liquids, may suddenly regain their power of taking semi-solid
food for a short time before death, but such improvements
are illusory, and may probably be explained by the sloughing
away of a portion of the growth, or by diminution of spasm
from increasing muscular debility. The act of deglutition is
very seldom painful, but there is sometimes a dull aching sen-
sation, which, if present, is generally aggravated on swallowing.
The pain is occasionally referred to a definite spot, which
corresponds with the point where the food seems to lodge.
At other times it is felt between the shoulders, behind the
sternum, at the epigastrium, or more rarely in one of tin-
ears. The pain is often slight, amounting to little more
than uneasiness, and it is only in rare cases that it is
described as sharp, cutting, or burning. The suffering is,
as a rule, more keenly felt at night, and sometimes it is
sufficiently severe to keep the patient from sleeping.

Here it may be mentioned as a curious circumstance that
a darting pain between the shoulders — occurring indepen-
dently of deglutition, and not increased by that act — is
occasionally the first symptom of cancer of the gullet. I
have met with two instances in which this symptom preceded
dysphagia by more than three months.1

1 Odynphagia preceded dysphagia in a case of malignant disease of
the cesophagus reported by Cooper Forster ("Guy's Hosp. Rep"
1858, 3rd series, voL iv. p. 1., et. seq.), and in another by Sydney Jones
("Trans. Path. Soc." 1860, vol. ix. p. 101).

CANCER OF THE GULLET. 81

The digestion becomes greatly impaired. Milk or eggs
sometimes remain in the stomach for four or five hours
without undergoing any appreciable change. Positive evi-
dence of this can often be obtained on examination of
the vomit of patients after the passage of bougies for the
purpose of dilatation. In order to lessen the chance of
inducing sickness I always direct the patient to abstain from
food for some hours before the instrument is to be used,
but in spite of this precaution, the contents of the stomach
are occasionally brought up, and I have not unfrequently
remarked that they have scarcely been acted on by the
gastric juice. Independently of the use of instruments,
however, real gastric vomiting occasionally takes place,
and when the disease is advanced, this is a very distressing
symptom. For the stricture appears to become tightened at
the moment of vomiting, and entirely prevents the ejection
of matters from the stomach, whilst repeated fruitless con-
tractions of the latter viscus often give rise to a feeling of
weight and sometimes to a dull heavy pain in the epigastrium.
The patient is also further tormented in some instances by
the impossibility of ridding himself by eructation of the gas
which is formed in large quantities. As might be expected, the
excretions become much diminished in quantity. The bowels
frequently do not act for a week or ten days together, and the
faeces are very hard ; as a rule, very little urine is passed.

Hunger is sometimes complained of when the patient begins
to be unable to swallow solids, but this soon passes off, and
in an advanced stage of the disease the very thought of food
is generally loathsome. When the canal is nearly closed
xip the patient's sufferings are aggravated by dryness of the
throat and intense thirst, which generally persist till within
a few hours of death. Should there be much \ilceration (and
especially when the disease affects the upper part of the
throat) the breath has often a faint or fetid odour, whilst if
gangrene comes on the smell is horribly offensive.

Cough is of frequent occurrence, and is generally due to
slight chronic laryngitis, which commonly accompanies stric-
ture of the oesophagus. The affection of the windpipe may
occur as an extension of the cancer, or it may be caused by
the passage of food or the overflow of saliva into the larynx.
If a fistulous communication has been established between
the ossophagus and the trachea or bronchi, the coughing is of
a very violent kind, and is called forth whenever swallowing
is attempted. Dysphonia is not unfrequent. It may be caused

VOL. II. O

82 M>K.\H-:> '<>!•• TIII: TMI«I.\T AM» N

by slight inflammation of the larynx, or by ]iaraly>is of a
voeal rord from implication of one of tin- recurrent in-rvrs in
the di.-ease. For nlivious anatomical reason.- (see \'"1. i.
Fig. '.'") the left nerve is much more frequently affected than
the right. When the latter is paralysed it usually indicates
that the eaiieer is situated in the upper part of the throat.
Tin-re may even be some dyspnoea or stridor, when, as gen-
rally happens in the early stage of nerve-pressure, it is the
alxluctor muscle which is mainly affected. The laryngeal
symptoms are of course greatly intensified when lioth ahduc-
tors are involved (see Vol. i. p. 443, Case 3).

In an advanced stage of the malady, the growth may pre>>
directly on the windpipe posteriorly, and thus give rise t<-
severe dyspnoea. There are seldom any external signs of the
disease, hut when the upper third of the gullet is affected.
careful examination will sometimes detect a slight thickening
in the neck, some distance below the surface, and in rare
cases the deep cervical glands can be perceived to be enlarged.
Still less frequently the superficial glands are enlarged and
tender. On introducing the cesophagoscope, the sitiiation
and character of the disease can sometimes be made out, but
its extent cannot be ascertained.

On auscultating the gullet the site of the disease can
generally be determined. At the commencement of the affec-
tion, the "bolus" may be merely delayed, or irregularly forced
down, but temporary arrest in its descent can generally be
observed at a very early period. As the disorder gains ground
the acoustic signs become more marked. Instead of the
sound of a small fluid body rapidly passing beneath the
stethoscope, a prolonged and confused gurgling noise is heard
over the diseased spot, and a little above it. Below this
point deglutition is scarcely audible.

The bougie, as anile, furnishes very precise information if
it be carefully used while the patient is fully under the
influence of an anaesthetic. On the other hand, the know-
ledge obtained by means of this instrument whilst the patient
retains consciousness is generally incomplete and often mis-
leading Chloroform is the best agent for the purpose, ether
having an irritating effect in these cases, and nitrous oxide
being too transient in its action. On attempting to pass a
bougie, it will be found that the progress of the instrument
is completely arrested at a certain spot, or that it can only be
passed with difficulty through a constricted opening. Some-
times after the bougie has penetrated one stricture it encoun-

CANCER OF THE GULLET. 83

ters a second, the two obstructions generally corresponding to
the upper and lower edges of a single ulcer, but in rare cases
being caused by two separate growths.1 However gently the
instrument may be used, its point will sometimes be found to be
smeared with blood, and the patient may spit up a few drops,
or even a drachm or two, of blood directly after the operation.

The local phenomena and physical signs of the disease
having been discussed in some detail, it is necessary to make
a few further remarks on the general symptoms exhibited
by the patient. These are progressive emaciation, extreme
muscular debility, and intense faintness.

The weight of the patient gradually but steadily dimi-
nishes. Thus, one of my patients was reduced from twelve
to five and a half stone in less than three months, and
in another case five stone were lost in seven weeks.

But whilst emaciation almost invariably accompanies the
malady, patients occasionally die from asthenia, while the
nutrition is still almost unimpaired. As an example I may
mention that in one of my patients on whom Mr. Heath
performed gastrostomy after nine days' total privation of
food, the fat in the abdominal walls was an inch in thick-
ness, whilst the omentum was a mass of adipose tissue.
In another case on which I recently made a post-mortem
examination, though the disease had run an unusually
long course, there was not a trace of wasting in any part
of the body. All patients, however, experience a dreadful
sense of faintness. Whilst revising these pages I have
received a letter from a patient in a very advanced stage of
the complaint, in which the following passage occurs: — "I do
not think anything has passed down during the last forty-
eight hours ! My weakness rapidly increases, and I suffer
from a terrible faintness. My flesh decreases daily, and my
body has gone hollow." Except in very warm weather there
is often a feeling of cold, not only in the extremities, but in
the body generally.

Although the sufferings are very severe until within a day
or two of the fatal termination, the last hours are generally
quite placid, the patient retaining his faculties till very near the
end, and passing away in a state of gradually deepening coma.

1 See the cases of Sedillot ("Gaz. Med. de Strasbourg," 1853,
p. 69); Poinsot (reported by Bidau, " De 1'CEsophagotomie. "
Bordeaux, 1881, p. 79); Golding Bird (" Trans. Clin. Soc." 18Stf,
vol. xv. p. 36); and Annandale ("Liverpool Med.-Chir. Journ.'
July, 1881, p. 14)

84 DISEASES OF THE THROAT AND NOSE.

Death usually takes place from exhaustion, unles-
complication should arise from tin- extension <>f the disease
to neighbouring organs. The most common form of this is
perforation into the air- passages. In my 100 cases drat I:
suited from exhaustion in 78, from pneumonia in 17, from amte
pleurisy in 3, and from gangrene of the lungs in ii instau

The modifications in the symptoms, which are caused
by the spread of the cancer in different directions, require a
brief notice. As just remarked, the most common inten-
sion is into the air-passages, between which and the
phagus a communication or perforation1 is often established,
but in rare cases a large vessel may be laid open by the
ulcerative process. As the result of the invasion of neighbour-
ing parts by the growth, inflammation of many adjacent
organs and tissues may occur, pericarditis, pleurisy, pneumonia,
or even peritonitis being occasionally met with, whilst t\vo
cases are on record2 in which paralysis of the lower extre-
mities ensued from the disease at last reaching the >pjnal
cord.

The signs of perforation of tin- ijnUi-t dej>end on the
nature of the communication which is set up with the food-
tract. Thus, simple perforation into tin- ^H>ri-<e.tonliaiji-al Con-
nective tissue leads to abscess, sloughing, and gangrene, but
the symptoms are often so slight that they are not r»
nized during life. On the other hand, />< rfomtion into f/f>-
air-passa<je$ produces such a characteristic train of symptoms
that it is generally easily discovered. This is the most com-
mon form of perforation, and is especially to be feared in those
cases in which there is frequent but not severe spitting of
blood. Violent coughing and considerable dyspnoea when the
patient attempts to swallow are the symptoms which show
that the air-passage has been j>enetrated.3

1 By some authors perforations of the yiillet, from whatever eau«'
arising, and whatever the nature of the communication establish i-<l.
are classified together and treated in a separate article, though tin-
utility of such an arrangement is not obvious. The perforations
produced by a malignant growth, an aneurism, or a foreign body, .in-
totally different in their mode of development, in the symptoms tlu-y
cause, and in their ultimate termination. Again, the widest diU'rn -n< •••
exists, according as the perforation takes place into the air-passages,
into a large vessel, or into the peri-oesophageal tissue. It is diftinilr,
therefore, to discover what advantage can be derived from bringing
together a set of accidents disagreeing in almost every particular.

*Mondiere, "Arch. Ge"n. de Me*d." t. xxx. p. 515, and Znik.r,
" Ziemssen's Cyclopaedia," vol. viii. p. 180.

3 According to Lebert (op. cit p. 445), perforation of the aii-

CANCER OF THE GULLET. 85

Perforation of a large vessel is a rare termination of the
disease, and did not occur once in my 100 cases. Although
there are numerous instances recorded in medical literature,
it must not be forgotten that these cases are generally pub-
lished on account of their comparative rarity, and that they
exemplify the exception rather than the rule. If a large
vessel be ruptured, violent haemorrhage comes on, to which
the patient may succumb in a few seconds, or the bleeding
may stop for some hours — but only to break out anew with
a fatal result. The subject of perforation will be again referred
to in dealing with the pathology.

Pathology. — There has been a growing tendency for some
years past to consider that a very large proportion of cancers
of the O3sophagus are of epitheliomatous nature, and Zenker
and Ziemssen1 go so far as to state that this is the only form
which is met with in this situation. This statement, how-
ever, is too absolute, for in the elaborate collection of cases
of malignant disease made by Mr. Butlin,'2 three were un-
doubtedly scirrhous in character, whilst one certainly be-
longed to the medullary, and another to the colloid variety
of carcinomata. The three instances of hard growth showed
a well-marked alveolar structure, and their course was much
more chronic than that of the epitheliomatous cases. The
nature of the medullary tumour was determined by so high
an authority as Dr. Joseph Coats,3 of Glasgow, whilst the
case of colloid cancer was reported on by the committee of
the Pathological Society,4 and may therefore be a6cepted as
undoubtedly genuine. It presented a honey-combed struc-
ture, and contained a viscid material. The opinion, however,
seems to be now pretty generally entertained by pathologists
that the appearances which sometimes resemble scirrhous or
encephaloid cancer depend on the varying degrees of density
in the structure of the stroma, or on degenerative changes
which may have taken place in the morbid tissues them-
selves. The disease is usually supposed to commence in the

passages does not always give rise to these symptoms, and it some-
times happens that the lesion is not suspected until the autopsy is
made. Ihis observation can only apply to very small perforations,
or to those which have taken place only a short time before
death.

1 " Cyclopaedia of Medicine," vol. viii. p. 173.

• "Sarcoma and Carcinoma." London, 1882, pp. 177, 178. See
also Tables, pp. 185—187.

3 " Glasgow Med. Journ." 1872, 2nd series, vol. iv. p. 402.

4 "Trans. Path. Soc." 1868, vol. xix. p. 228.

£6 DISEASKS OF THE THItoAT AM) NOSE.

deeper layers of the nnn-nxn, hut in some cases it appears to
he developed from the epithelial lining of the follicle-;.

If the cesophagus could lie exposed to view at a very
early date the disease would pnil lahly present itself in the
form of one or more small isolated patches ; hut hy the time

FIG. 13. — MAI.H;XAST DISEASE OF THE GULLET.

At the narrowest part only the fine glass rod, shown in the cut, could be
passed through the stricture.

(From a Specimen in the Museiun of the Throat Hospital.)

death takes place, it has generally involved the whole <-ir-
cumference of the gullet, and extended for three or four
inches in the vertical direction. Sometimes, however, even
when the patient has died from dysphagia, it is found after
death that the growth occupies only one side of the CB8O-
phageal canal. The surface of the tumour is more or le>>
irregular, and is generally extensively and deeply ulcerated.

CANCER OF THE GULLET. 87

Among Butlin's fifty-three cases ulceration had taken place in
forty-nine. The ulcer has, as a rale, a foul sanious base and
a raised thickened everted edge. It can generally be per-
ceived that the stricture which has existed during life has
lici-n caused by masses of growth projecting into the canal,
or by general thickening of the walls, or by the out-turned
edges of the ulcer diminishing the cesophageal lumen.
This last cause is principally in operation at the upper
and lower borders of an ulcerated surface, and hence ob-
servers have sometimes been led to imagine that there
were two growths, each causing a stricture in the canal,
when, in point of fact, there was only one tumour.1 When
the mass is cut into, the section is of a greyish-white or occa-
sionally of a brownish-red colour, and when squeezed, yields
a milky juice. On microscopic examination this fluid is found
to consist of aggregated and distinct epithelial cells, and the
growth is seen to be made up of a stroma of fibrillated
tissue, arranged so as to form alveoli of various shapes and
sizes, within which flat epithelial cells are found. Some of
these bodies are grouped together so as to produce concen-
tric globes, which on being cut through present the well-
known form of nested cells. The epithelial elements may be
seen making their way into the tissues around the ulcer, and
beyond these again will be found an infiltration of small
round corpuscles (indifferent cells).

There is considerable difference of opinion as regards the
part of the gullet most frequently attacked. Sir Everard
Home2 says : " There is this one spot immediately behind
the cricoid cartilage where the fauces may be said to ter-
minate and the oesophagus to begin, in which such a con-
traction is so often met with, that I must consider it as
more liable to become diseased than the rest of the canal."
Rokitansky3 affirms that the upper half of the gullet is most
often the seat of the disease, and Habershon's experience
and my own point to the same conclusion. Klebs4 and
Rindfleisch5 find the middle portion most frequently affected,
whilst Petri,6 and Zenker and Ziemssen" have observed that

1 See a ease reported by Motta, " Gazette Medicale." 1873.

2 Op. cit. vol. ii. p. 395.

"CEsterr. inedicin. Jahrb." 1840, Bd. xxi. p. 225.
4 " Handbuch d. pathol. Auatomie." 1868.

" Tathol. Histology." Syd. Soc. Transl. 1872, p. 457.

6 Loc. cit.

7 Op. cit. p. 176.

DISEASES OF THE THKOAT AXI>

the lower third furnishes the greatest number of cases.
f»lli>\viiiLr tallies show these various results: —

HABKI:-HHN.

Uniwr part

Middl.- ,,

Lower ,

MACKENZIE.

Upper third
Middle „

44
... 28

Lower ,,

... 22

Lower half

100

PETUI.

Upper third

... 2

Middle ,,

... 13

Lower ,,
Upper and middle thirds

18
... 1

Middle and lower ,,

... 8

Whole canal

The

33
30
10

/KNKEK.

Upper third

Middle „

Lower ,,

Upper and middle thirds
Lower and middle „
Whole canal ..

1
6
2
3
1

Mr. Butlin1 states that in his series of fifty-nine cases,
" in by far the larger number of instances, the disease
occurred in the upper than in the middle or lower thirds."
but " the point of junction of the middle and lower thirds
was three times more often attacked than that between the
two upper thirds ; so that if the canal lie divided into halves
instead of thirds, the number of cases affecting each half is
very nearly equal."

As the result of rfinicaf examination, Ziemssen2 has found
the disease situated in the lower third of the gullet in
thirteen cases out of eighteen. The great discrepancy between
the different tables may, perhaps, be explained by the fact of
some pathologists having excluded cases of cancer of the
upper part of the oesophagus in which the pharynx was also
implicated. As has already been pointed out (Vol. ii. p. 1),
the line of demarcation between the pharynx and the gullet
is arbitrary, some anatomists fixing the linn-r l«,r<li-,- <,f t/f
cric-oi'l aiiiilmji' as the point of separation, whilst others take
the cricoi'/ <j<>)t''r<tlli/ as the boundary line. As cancer of the
food-tract behind the cricoid is relatively very common, it
makes a great difference whether this situation be included in
the pharynx and excluded from the oesophagus in statistical
tables. Further, as Mr. Butlin3 observes, when the dis-
ease is wide-spread, the difficulty of determining its primary

1 " Sarcoma and Carcinoma. " London, 1882, p. 162.

2 Op. fit. p. 193.

3 Op. cit. p. 163.

CANCER OP THE GULLET. 89

point of invasion impairs the accuracy of all calculation as
regards the part of the oesophagus most frequently affected.

As Kb'nig1 has remarked, the situation of cancer of the
oesophagus is a matter of some practical importance, for if
the growth is at the lower part, gastrostomy is the only
palliative operation that is justifiable.

Cancer of the oesophagus is sometimes confined to that
tube, but observation shows that it spreads both by con-
tinuous extension and by secondary deposit. In my 100
cases the deep cervical glands were alone attacked in fourteen
cases (in conjunction with other glands in three other cases,
and in conjunction with other organs in four cases) ; in two
cases one lung was involved, in one case the liver, and in one
the liver and one lung were implicated, whilst the left kidney,
stomach, and tongue were each once affected. Out of forty-
four cases of cancer in the upper third, in twelve the disease
at the same time involved the pharynx above the level of the
arytenoid cartilages, and in one case the thyroid gland, whilst
of thirty cases at the lower part of the oesophagus, in only one
the disease reached the stomach. In thirty-six cases in which
there was a broncho-cesophageal fistula, the tissues surround-
ing the opening were thickened in every instance, whilst in
thirteen there was distinct disease within the trachea. In
seven other cases in which perforation had not taken place,
there were nodular elevations of the lining membrane of the
tracheo-bronchial canal. In the whole series of 100 cases
perforation of the air-passages took place thirty-six times, the
trachea being perforated twenty times, the right bronchus
seven and the left bronchus four times, the base of the lungs
in two instances, and the pleural cavity in one, whilst twice
the perforation took place into the peri-oesophageal tissues.
In my 100 autopsies the left recurrent nerve was found to
be involved nine times, the right recurrent once, and in one
instance both nerves were affected. It should, however, be
remarked that all these eleven observations occurred among
my own sixty patients (see Foot-note 5, p. 73), and it may
be presumed that if this matter had been carefully looked
into in the other forty cases, nerve-lesion would have been
frequently met with. *

Perforation of blood-vessels, according to Lebert,2 is rare,

1 " Deutsche Chirurgie " von Billroth und Liicke. " Kraukheiten
des Pharynx und (Esophagus," von. Prof. Kbnig. Stuttgart, 1880,
p. 69.

3 Op. eit. p. 444.

90 I'l-KASES OF THE THROAT AMI M>sK.

whilst Kokitansky ' in expressing a somewhat similar opinion,
asserts that the amlii and right pulmonary artery are the
vessels which most frequently yield. In addition t«> tln->e
vev-els, the carotid,- subclavian,-'1 vertebral.' n-sophageid,'1 and
superior intercostal1' arteries may lie mentioned as having
been thus perforated.

1 have met with two cases (Specimens 101 and 200,
Throat Hospital Museum) in which abscess was developed
in connection with the diseased mass in the gullet, and a
further example of a similar complication has lately been
reported by Dr. Semon."

lUdtjitoxi*. — Although under ordinary circumstances the
recognition of cancer of the oesophagus is easy, cases <>t
doubtful nature occasionally present themselves. It is im-
portant, therefore, to determine at once whether the dysphagia
lie (hie to an extrinsic or an intrinsic cause. Laryngoscopie
examination enables the observer to discard disease either
of the pharynx or larynx as a possible factor, whilst tin-
absence of swelling or tenderness in the neck will serve to
eliminate most of the morbid conditions in that region which
could give rise to compression of the gullet. When this is
produced by deeply -seated tumours or abscesses, a bougie
can be passed in most cases, but the pressure on the canal
resulting from great enlargement, whether cancerous or fibroid,
of the thyroid body, or from malignant deposit in the media-
stinum, is sometimes sufficient to prevent the introduction
of the finest instrument. In such instances, however, the
external evidences and physical signs of the radical disease
.are generally obvious.

In aneurism of the aorta and in other affections of tin-
circulatory system, there is seldom any difficulty in passing
the oesophageal bougie, though force should on no account
be used ; the physical signs of aneurism are also generally
discernible by auscultation and percussion. When it has
been established that the disease is intrinsic, it must next be
decided whether the dysphagia be organic or functional.

Si'Mamo'I/i' xfricture is far more common in women than in
men, and usually occurs under the age of forty. The symp-

1 "Pathological Anatomy." Syd. Soc. Transl. Lomloii, 1854, vol.
ii. p. 11.

- "Lancet," February 14, 1860.

3 "Trans. Path. Soc." vol. xxii. p. 134.

4 Ibid. vol. ix. p. 194 ; vol. xii. p. 108.

* Ibid. vol. xiv. p. 167. 8 Ibid. vol. viii. p. 210.
7 "Archives of Laryngology." 1882, vol. iii. p. 125.

CANCER OF THE GULLET. 91

toms are suddenly, not progressively, developed as in cancer.
There is 110 pain or regurgitation of frothy fluid, though
the mouthful of solid or liquid food may be immediately
and forcibly ejected. A bougie can always be passed, though
sometimes this can only be effected under the influence of an
anaesthetic. There is seldom any considerable wasting, but
on the contrary, the patient, though weak, is often plump.
Collateral evidence, such as a markedly emotional disposition,
may assist in the diagnosis.

Paralysis of the wsoplwfjus generally occurs in the old and
feeble — that is, in people whose muscular system is weak,
or in cases of chronic wasting disease. The dysphagia is
seldom extreme, and the easy passage of a bougie at once
shows the absence of true stricture.

Passing to organic lesions in syphilitic disease there may
be a clear history of infection or the acknowledgment of
former symptoms, such as a skin eruption, falling of the
hair, nocturnal pains in the shin-bones or the scars of
former xilceration, either on the skin or mucous membrane ;
or coexistent disease of an undoubtedly syphilitic character
may remove all doubt as to whether the system has been
infected. Of course, cancer may occur in syphilitic indi
viduals ; but the curative effects of iodide of potassium in
truly syphilitic cases, and the fact of its being virtually
inoperative when cancer has been engrafted on syphilitic
ulceration, will eliminate this source of difficulty. Xarrow-
ing of the canal, caused by tubercular deposit, being extra-
ordinarily rare, and always secondary, requires only to be
mentioned.

In traumatic stricture the history of the case explains its
origin, but it may be added as a negative sign that in this class
of cases the recurrent nerves are very seldom involved. In
<-li run i<- oesophagitis the dysphagia is also much less marked
than it is in carcinoma, and the inflammatory affection is not
progressive. The food can, indeed, generally be swallowed,
though with uneasiness, or even pain. On the other hand,
the odynphagia is much more marked in chronic inflamma-
tion, and a bougie usually causes so much pain that it can
only be passed under the influence of an anaesthetic.

In simple ililatation frequent regurgitation of unaltered
food after a meal is a prominent symptom, and although
there may be difficulty in passing a bougie, this can generally
be overcome with perseverance.

( 'ancer of the pyloric orifice of the stomach is occasionally

92 M.-KASE8 OF THE THROAT ANI> .\c»K.

mistaken liy the inexperienced for malignant disease of the
o-sophugus; hut in the former complaint the fno.l i> ^em-rally
retained for an lioiir or two, and, when brought up, has a
decidedly acid reaction. Lastly, the diagnosis may lie a— i-ted
by a careful consideration of the symptoms, , which, taken to-
gether, HO characteristic of cancer of the cjesoplm-u- : these are
y//v»//v.W/v dysphagia, expiation of a fluid, at first frothy, hut
afterwards thick, muco-purulent, and sometimes tinned with
blood, obstruction to the passage of a Ixmgie, frequent para-
lysis of one, and occasional paralysis of hoth ahductors of
the vocal cords, with progressive emaciation and debility
occurring in a person over forty years of age.

/'rni/Hiixi*. — The course of the disease tends steadily
towards a fatal issue, the opinion of Rokitansky,1 based on
the frequent appearance of certain cicatrices in the oesophagus.
that cancer in this situation is often cured, being opposed to
all other experience. In my 100 cases, the average duration
of life after undoubted symptoms were developed was only
eight months — the maximum being sixteen months, and the
minimum five weeks. Each case, however, must of course be
judged on its own merits. \Ve must take into consideration
the age of the patient, his previous health, and especially
his temperament — persons of nervous organization gene-
rally resisting the slow starvation much longer than the
phlegmatic. The duration of life is, however, dependent
on such purely accidental conditions that it is never safe to
give an opinion as to how long it may be extended. Tin-
gullet, which has remained partially pervious for months,
may be suddenly completely blocked, or a perforation may
occur without any warning.

When a perforation into the air-passages takes place, the
patient seldom survives more than three or four weeks —
unless he can be fed with a tube, when life may still occa-
sionally be prolonged for a few months. If a considerable
haemorrhage occurs, and is arrested, its speedy recurrence
must lie looked for.

Apparent improvements are only of the most temporary
character, and the recovery of the power of swallowing at a
late period of the disease must not be regarded as a favour-
able symptom, but rather the reverse, indicating, as it usually
does, sloughing of the growth or the mere giving way of
>pasm from increasing weakness.

Ti->atiiii'ii1.- In dealing with cancer of the oesophagus, we
1 "Lehrbudi d. path. Auatoiu." 1855, Bd. i. p. 278.

CANCER OF THE GULLET. 93

have no satisfactory task, hut something may he clone to
prolong life and more to assuage suffering. Local treatment
is rarely of any use, but when the disease is situated at the
orifice of the gullet, the growth may sometimes be in part
destroyed by electric cautery, or removed with cutting
forceps. I have also seen benefit from insufflations of a
powder composed of one part of persulphate of iron to three
parts of starch. This astringent application causes some
shrinking of the growth, and thereby widens the canal.
This effect, however, is, of course, only mechanical and
temporary. Directly there is a suspicion of malignant
disease the food should be most carefully selected. Milk,
on account of its highly nutritive and unirritating cha-
racter, should be regarded as the staple article of diet, but
beef-tea, mutton broth (free, of course, from pepper or salt),
eggs, arrowroot, or thin, soft farinaceous food may be
given; stimulants should, if possible, be avoided, as they
irritate the diseased surface. It is important to determine
the circumstances which jiistify the use of bougies, and
also to appreciate the conditions under which the feeding
tube may be employed with advantage. In the first place,
it must be distinctly stated that as long as the patients can
swallow liquids easily, bougies should not be passed. When,
however, fluid nourishment can only be got down with diffi-
culty, and when that difficulty is steadily increasing, the
time for instrumental interference has arrived, and the ques-
tion arises whether an attempt shall be made merely to keep
the oesophagus open, or whether the surgeon shall endeavour to
enlarge the narrowing canal. At this period it will generally
be found that only a No. 3, or at most a No. 4 (Author's scale,
Vol. ii. Fig. 2, p. 11) can be passed, but sometimes a No. 5
or No. 6 can be got through. As a rule, the mere passage of
a bougie from time to time is of little use, for it is found
tli at progressively smaller sizes have to be employed, and
that at the end of a few weeks no instrument will pass.
Hence it is almost always desirable to attempt some dilata-
tion. This should be done twice a week, and the surgeon
must be satisfied if he can dilate to the extent of No. 8.
If the passage of a bougie causes bleeding, instrumental
treatment should be discontinued for a time. In any case,
however, when dilatation has been practised for a few weeks,
it is almost certain on one occasion or another to give rise to
some inflammatory action within the gullet, and the patient
may find that after the use of the instrument he is unable

94 HI-I:A>I:> »i mi; THROAT AM> \

tu swallow fur many hours. After a few days' rest,
liquids again ]iass, and nieehanieal treatment can !»• resumed.
In certain cases it may lie possible {<> remove projecting
portions of the growth, and so open a way for an irsuphageal
tulie. By means of tin- OBBOphagoecope I was al>le on one
occasion to carry out the line of treatment here sn^xested.
The following are the details of the case : —

Mrs. B., aged sixty-two, was sent to me by Mr. Yate, of Godal-
iiiiug, on June 28, 1880, on account of difficulty of swallowing,
which had commenced two years previously. She was able to take
liquids easily, but could not swallow solids. The dvspliagin
gradually increased, and at the beginning of August, Mrs. I'., could
take liquids only with the greatest difficulty. At last, even liquids
could not be swallowed. With the oesophagoscope a ragged project-
ing mass was seen about three inches below the lower bonier of tin-
cricoid cartilage. On August 18, in the presence of Mr. Yate, Mr.
Hovell, 'and Mr. Bailey (who administered chloroform), I succeeded
in removing with the cesophageal forceps a piece of growth about tin-
size of a cherry. The effect of the operation was most satisfactory.
The patient felt some pain for two or three days, but a week after
the operation she was able to swallow semi-solids with ease. Micro-
scopic examination showed that the tumour was an epithelioma.
Mrs. B. lived rather more than half a year after the operation,
which may fairly be considered to have prolonged life for four or
five months.

The cesophageal feeding tube (Vol. ii. Fig. 11, p. 24) may
be used under two conditions : First, when the disease
is complicated by spasm ; and secondly, when there is a
broncho-o3sophageal fistula. In cases of spasm it is only
when the muscular contraction is of a very enduring
character — that is, when it lasts for the greater part of the
day — that the feeding tube is required. Under these cir-
cumstances the patient should be placed fully under the
influence of chloroform, and a pint of strong nutriment
administered at least once in the twenty-four hours. When
this process has been repeated for a few days the spasm often
passes off, and the artificial feeding can then be discontinued.

It is, however, when a tracheo-cesopnageal fistula has
been established that the feeding tube is of special ,-erviee.
The train of symptoms by which the existence of the fistula
can be recognized has already been described (p. 84). If
the opening between the two tubes is small, although liquids
when swallowed will pass through the aperture and give rise
to violent coughing and choking, the point of the instrument
will often glide over the orifice of the fistula, and thus allow
the patient to be fed. When, however, the opening of
the fistula is large, there is a risk of the feeding tube passing

CANCER OF THE GULLET. 95

through it into the windpipe. Hence it is very important not
to use force in introducing the tube, and the operator should
be quite certain that the feeding tube has not found its way
into a false passage before he injects any food. If the instru-
ment has penetrated the windpipe some spasm is nearly sure to
be set up, and the patient on coughing will force air through
the tube, and thus demonstrate its position. In most cases
of fistula, the feeding tube should be used as long as the
patient survives, but sometimes the tracheo-oesophageal open-
ing increases in size after a few weeks, and the tube can no
longer be passed with safety. When the patient is quite
unable to swallow, either from complete closure of the gullet,
or from the establishment of a large fistula, the time for
using nutritive enemata commences. It is a mistake to begin
this method of feeding as long as the patient can get down
any considerable quantity of liquid food, as it may irritate
the bowel prematurely, and thus prevent rectal alimentation,
when it might remain as a last resource. The patient should
be fed with Leube's pancreatized meat (the formula for
which I have slightly modified)1 twice in the twenty-four
hours. Should there be a difficulty in retaining the enemata
(though the solid kind just mentioned causes far less irritation
than the liquid injections, such as beef -tea or eggs beaten up
in milk, which are commonly used), or should the food be
returned without having undergone any digestive change, the
permanent oasophageal tube (Vol. ii. Fig. 10, p. 22) may be
introduced. It should be explained to the patient or his
friends that the use of this instrument is attended with some
danger, but that it may be the means of prolonging life for
a few days — occasionally for a week or two, or even longer.

If thirst be greatly complained of in the last days, tepid
footbaths of milk often comfort and refresh the patient, and
possibly afford some slight nourishment.

The question of a cutting operation has been deferred to
this late stage of the subject for the sake of clearness, but in
actual practice it must be entertained directly the diagnosis of
the disease is accurately established. Surgical measures, which
at an early period may be attended Avith the happiest results,
if postponed till the patient is worn out with disease, can
only end in failure, and add to his sufferings. The point
which has first to be considered is whether excision of
the growth is practicable, the alternative operations being
(Ksopliayostomy and yastrostomy.

1 See Vol. i. p. 580.

96 DISEASES i'K I UK THROAT AND \..>K.

The idea nf excising a portion of the gullet appears to have
originated with Hill roth,1 who in 1S7- published a short
account of two experiments made on dogs. In '-ach <-.i><- a part
of the oesophagus was cut out; one dog died tivc days after-
wards from the result of an accident, but the other recovered
completely, and lived for several months, when he was killed,
in order that the parts might !»• examined. The tirst sur-
geon, however, so far as I am aware, who attempted t<>
carry out this proceeding in the human subject was Kap-
peler,2 who in 1875 endeavoured to excise a portion of the
gullet in a man, aged forty -two, who had suffered from
dysphagia for about eight months. The operator, however,
was baffled by the extent and connections of the diseased
mass, which also prevented him from opening the tul>e
below the stricture. He had, therefore, to content himself
with introducing a catheter into the oesophagus above the
seat of disease, and trying to force a passage downwards.
The patient died on the following morning. Resection
of the oesophagus was again attempted by Kappeler* in
1876, but with no better result. The patient was a man,
aged sixty-five, who had felt difficulty in swallowing
for three years and a half. The main features of this
case were almost identical with the one just related, as far
as the operative procedures are concerned, and the result
was equally unsatisfactory, as the patient died on the second
day. A year or two later Prof. Czerny4 was more fortunate.
The patient in this instance was a woman, aged fifty-one,
who had suffered from dysphagia for some months. Czerny
made an incision from the level of the hyoid bone down
to the sternum along the anterior edge of the gterno-mastoid
on the left side; the omo-hyoid muscle was divided, tin-
thyroid body was pushed upwards and inwards- and the
oesophageal tumour, which could then be felt with the finger,
was carefully dissected out. A segment of the gullet, in-
volving the upper six centimetres of the canal, was removed,
and the upper orifice of the lower section of the divided tube
was stitched to the edges of the skin-wound. A catheter,
through which the patient could be fed, was then pa— ed
into the oesophagus through the wound, and the lips of the
superficial incision were brought together. By the fourth

1 " Langenbeck's Archiv. fur klin. Chir." 1872, Bd. xiii. p.

2 "Deutsche Zeitschr. fur Chirurgie." 1877, Bd. vii. p. 379.
8 Ibid.

4 "Beitriige z. operat. Chir." Stuttgart, 1878, p. 41.

66.

SARCOMATA.

day all the sutures were removed, and the catheter was
replaced by a large hollow bougie, which at first was left per-
manently in situ, but in a short time was taken out, and only
introduced when nourishment had to be given. The patient
learnt to feed herself in this manner, and five months after
the date of the operation she was still in perfect health, with-
out any trace of recurrence. She continued to use the sound
for the purpose of taking food. On examination a partition
about half a centimetre in thickness was found closing the
lower aperture of the 'pharynx, thus cutting off all communi-
cation between the upper and lower parts of the pharyngo-
cesophageal canal. In this instance the disease was epithelio-
matous in character, and the mass encircled the gullet, but
no perforation of the tube or extension of the growth beyond
its walls had taken place, and there were no enlarged glands.
Whilst, therefore, Prof. Czerny must be congratulated on the
highly successful issue of his bold procedure,1 the case itself
was an exceptionally favourable one for the operation.

The fact, however, that malignant disease of the gullet
spreads to contiguous organs at an early period is likely to
prevent the operation of resection being frequently applicable.

The surgeon has in the next place to take into considera-
tion the chances offered to his patient by cesophagostomy or
gastrostomy. The advantages and disadvantages of these
procedures will be fully considered under the head of <{ Cica-
tricial Stricture of the Gullet," a condition which is much
more favourable for such operations than where the narrow-
ing is due to malignant disease.

SAKCOMATA.

Sarcomata are occasionally met with in the oesophagus.
Kosenbach 2 has reported a case in which a growth about the
size of a common fowl's egg was attached to the right side of the
gullet just below its junction with the pharynx. The tumour
was soft, slightly lobulated, and almost transparent, closely
resembling an ordinary nasal polypus. On microscopic exami-

1 Whilst these sheets are passing through the press I learn from
Prof. Czerny that the woman died rather more than a year after the
operation described in the text. Recurrence of the disease took
place to an extent which rendered tracheotomy necessary, and the
patient succumbed some weeks afterwards (Private letter, dated
July 22, 1882).

3 " Berlin, klin. Wochenschrift," September 20 and 27, 1875.

VOL. II. H

98 DISEASES OF THE THROAT AND NOSE.

tuition, however, it was found to be a round-celled san-oma.
Tracheotomy having been first i>erfonm-<l tin- growth \v;is
removed by subhyoid phaiyngotomy. In another
reported by Chapman,1 several tumours, partially connected,
varying from one and a half to two inches in diameter, \\.-iv
found occupying the upper orifice of the oesophagus.

Cases of calcification, cartilaginous strictun-, and even
ossification of the oesophagus are referred to by sum.' ..f tin-
older authors, such as Sampson,- Morgagni.:: (lyser,4 and
Desgranges.5 It is not improbable that calcification some-
times occurs in this situation,6 but I know of no authentic
instance of such a transformation recorded in modern
literature.

1 "Amer. Jour. Med. Sci." October, 1877, vol. cxlviii. p. 433.

2 "Miscell. Curios." 1613, p. 170.

3 "De sedibus et causis uiorb." Ep. xxviii. art. 15, ed.
Patavii, 1765, t. ii. p. 10.

4 "De fame lethali ex callosa cesoph. angustia." Argentorati,
1770, p. 16.

8 "Journ. <Ie Corvisart." 1801, t. iv. p. 203.

6 Both enehondromata and osteomata have been found in tin-
mucous membrane of the trachea, and though the normal pn-srinv
of cartilage in the windpipe renders it a more likely locality for the.
development of these growths, it is quite possible that they may also
occur iu the gullet.

NON-MALIGNANT TUMOURS OF THE GULLET.

(SYNONYMS : BENIGN GROWTHS OF THE GULLET. POLYPI m-
THE GULLET.)

Latin Eq. — Tumores non maligni oesophagi.
French Eq. — Tumeurs non malignes de 1'u'sophage.
Gentian Eq. — Gutartige Geselnviilste der Speiseroluv.
Italian E<I. — Tiunori non maligni del esofago.

DEFINITION. — (Iroirthtt of Ix^iiijn <'ltara<-f<-i;

or fibr&MluCOUS in xfritrfin'r, ijiritnj /•/.*• f» im

to pain, <><-ca$i»nallii t<> tf ;/.•</ wi-a, ami //•>'</>/i-nf/t/
t» i>.rtr< in*-

History. — In 1717 Schmieder ' published an example of jiolypus
of the oesophagus, but I know no particulars of tin- case beyond

i "Dissert, de polypo oesophagi verniifonni rarissimo e pulveris steniutatmii
Hispaiii abusu progeuito." Italic, 1717.

XOX-M ALIGN AXT TUMOURS OF THE GULLET. 99

those contained in the title-page of his essay.1 In 1750 Vater-
reported the case of a man who had suffered from dysphagia for
some time. This improved after he had vomited a ' ' fleshy mass
about the size and thickness of a finger ; " subsequently, how-
ever, the difficulty of swallowing recurred, and the patient sank from
inanition. After death the walls of the oesophagus above the cardiac
orifice were found thickened, the lumen of the tube being much nar-
rowed. There was the appearance of a cicatrix on the ossophageal wall
at this part. This seems to have been an example of simple polypus,
which, as in Coats's case (see below) gave rise to chronic inflammation,
and probably ulceration of the mucous membrane. The inflammatory
changes were presumably too far advanced to permit the recovery
of the patient after the spontaneous separation of the growth. In
1763 Dallas3 met with a remarkable instance, in which the polypus
had so long a stalk that on making the patient retch it was projected
into the mouth as far as the front teeth. In 1764 De Graef 4 reported
the case of a patient who died from inanition, in whose oesophagus
was found a small cone-shaped growth, with its apex towards the
cardiac opening. In 1776 Macquart5 published an account of a
tumour in the gullet, which does not seem to have been malignant.
In 1784 Schneider 6 gave a description of a case in which three polypi
were found in the gullet after death. Baillie,7 in 1802, stated that
he had seen a fibrous growth springing from the inner coat of the
gullet. In 1806 Vimont8 placed on record two examples of cesopha-
geal polypi, both occurring in women who had long suffered from
goitre. Dubois,9 in 1818, related an instance in which an cesophageal
polypus had been ligatured, and the patient was suffocated from the
tumour coming away in his sleep and finding its way into the air-
passage. Rokitansky 10 related a case in which a very large polypus in
the gullet caused little or no dysphagia. In 1847 Arrowsmith11 de-
scribed a pedunculated and freely movable polypus growing at the
upper part of the gullet, and admitting of easy removal if the affec-
tion had been recognized. In 1857 Middeldorpf12 having met with a
remarkable example of the disease, and having collected a few pre-
viously published cases, wrote a monograph of considerable value on

I In a list of examples of oesophageal polypi given by Middeldorpf at the end
of his essay (" De polypis oesophagi," Vratislaviae, 1857, pp. 22, 23) cases are cited
from Pringle, Gilbert, Waugh, and Lesueur. These, however, have not been
included in the above history, as they were not true benign polypi. Pringle's
case("Med. Essays and Observations by a Society in Edinburgh." Edinburgh,-
1737, 2nd ed. vol. ii. pp. 324, 325) was probably malignant ; Waugh's (Ibid. vol. i.
p. 274) was clearly an example of oosophageal abscess terminating in complete
recovery after spontaneous rupture of the sac ; whilst the growth in Lesueur's
case (" .Revue Med.-Chir. de Paris," 1850, t. viii. p. 360) is distinctly stated by the .
reporter to have been encephaloid cancer.

"Dissert, inauguralis de deglutitione difficili et impedita." Vitembergse.

3 " Edin. Literary and Phys. Essays," vol. iii. p. 525. This case is associated
with the name of Monro, who saw the patient in consultation with Dallas, and
suggested the ligature. It is related at length in Monro's " Morbid Anatomy of
the Gullet," &c. 1830, 3rd ed. p. 426.

•* " Diss. illustrans hist, de callos. excrescent, oesoph. obstruente." Altorfli, 1704.

5 "Obs. sur une Tumeur dans 1'ffisophage." Hist, et Mem. de la Soc. R. de
\U d. 1776, Hist. p. 280.

6 " Chirurg. Geschichte." Chemnitz, 1784, Bd. x.
" Pathological Anatomy," p. 102.

8 " Annales de la Soc. de Med. Prat, de Montpellier," t. viii. p. 69.
» " Propos. sur 1'Art de Guerir." These de Paris, 1818, No. 104.
10 "(Ksterr. medicin. Jahrb." 1840, Bd. xxi.

II " Mi'd.-Chir. Trans." 1847, vol. xxx. p. 229.
i- " De polypis ossophaid." VnUislavise, 1857.

100 DISEASES OF THE THROAT AND NOSE.

the subject. Since then examples of mvomatous polpyi in the oeso-
phagus have been published by Eberth/ Coats,4 Fagge,3 and Tonoli,4
whilst Wyss,8 Ziemssen,8 and Sappey,7 have recorded the occurri-nn-
"I small cystic tumours in the same situation. I have myself im-t
with three examples .of non-malignant growth in the gullet

1 Virchow's Archiv." 1868, Bd. xliii. p. 187.
'Glasgow Med. Journ." Feb. 1872.
'Trans. Path. Soc." London, 1875, vol. xxvi. p. 94.
Oazetta Medica Ital. Lombard." 1880, Serie viii. t. 11. No. 49, p. 479.

Virchow's Archiv." 1870, Bd. 11. p. 144.

Cyclopedia of Pract. Med." vol. vlil. p. 161.

Trait6 d'Anatomie Descriptive." Paris, 1879, 3me ed. t. iv. p. 155.

Etiology. — These growths are very rare, and probably
originate in most instances in chronic inflammation. As far
as the recorded cases go, it would appear that oesophageal
polypi are more common amongst men than amongst women.
In De Graef's case the patient had been a free drinker, and
had frequently suffered from inflammation of the throat and
tonsils, but none of the others show a similar history. As
regards myomata, it was to be expected, a priori, that they
would be occasionally met with in a muscular canal like the
oesophagus.

Symptoms. — The most frequent symptom is slowly increas-
ing dysphagia. The disease, however, may exist for many
years, as in Rokitansky's case, even when the growth is
very large, without interfering with deglutition, until an ad-
vanced period of its development. Sometimes no symptom
whatever has been observed, and the tumour has only been
discovered after death.1 In other cases the dysphagia has
Ijeen attributed to cancer.2 These growths are often pedun-
culated, and the stalk may be so long that, as in Dallas's
patient, the polypus, in retching, may be projected into the
mouth. Sometimes it may be seen with the laryngoscope,
at the lower part of the pharynx ; and in one instance,
hereafter reported, I was able, by means of the oesophap >-
scope, to obtain a view of a growth situated about one
inch below the cricoid cartilage. A bougie can occasionally
be passed and withdrawn without difficulty, although the
operation may cause severe pain, as in Coats's case. On the
• >t her hand, in some instances, an obstruction may be per-
< rived in using the instrument, or it may be impossible to
pass it at all. In Tonoli's case a movable tumour could In-
distinctly felt with the bougie. Sometimes the tumour has
lieen known to give rise to dyspnoea and indistinctness of
utterance,3 and in one instance great pain was experienced;
but in this case (Coats's) the pressure of the growth had
1 Schmieder ; Fagge. s Coats. * Dallas.

NON-MALIGNANT TUMOURS OF THE GULLET. 101

induced extensive ulceration of the oesophageal walls, and
the pain was probably due to this condition. Middeldorpf s
patient complained of severe pain in the fauces and in the
back.

In one case (Vater's) the growth separated spontaneously,
and was ejected by the mouth ;. but even in this instance, as
already remarked, the patient died from inanition, apparently
owing to the chronic inflammation which had been set up by
the growth.

Pathology. — The most common kinds of non-malignant
growths met with in the oesophagus are those of a simple
warty or papillary structure. " They are sometimes single,
at other times in large numbers, scattered over the whole
length of the tube." x Small cysts, containing a clear colour-
less viscid fluid, are occasionally found ; 2 they probably
originate from obstructive distension of the mucous follicles.
Wyss 3 has described a case in which a cyst was situated
on the posterior Avail of the oesophagus one and a half
centimetres from the cardia. It was of the size of an apple,
and was filled with liquid, which was found, on microscopic
examination, to contain globules of free mucus and ciliated
epithelium. Sappey 4 states that he has on several occasions
seen cysts in the gullet, and he describes one case in which
there were about twenty small cysts, varying from ten to
twelve millimetres in length. Fibromata are also met with,
and often attain a much larger size than the growths already
described. They are usually single, but occasionally multiple.
In Schneider's case, as already remarked, three polypi were
found after death. These tumours vary in size from a currant
to a hazel nut, but sometimes attain much larger proportions.
In Eokitansky's case the polypus measured seven and a half
inches in length, and its broadest part was two and a half
inches in thickness. The mucous membrane covering the
growth is generally smooth, but sometimes it is rough, and
covered with papilla. In Baillie's case the surface of the
growth was considerably ulcerated. In the well-known
instance reported by Middeldorpf the exact origin of the
growth was not ascertained. It may have grown from one
of the ary-epiglottic folds or from the posterior part of the
cricoid cartilage, or from the upper part of the oesophagus.

1 "Ziemssen's Cyclopaedia," vol. viii. p. 168.

2 Ibid. Also Fagge : Loc. cit.

3 Loc. cit.

4 Op. cit. t. iv. p. 155. Foot-note.

102 DISEASES or i in: TIMIOAT AMI NOSK.

On making the patient vomit, a large purple body, which at
lirst appeared t<> lie the tongue, was thrown forwards against
the teeth. The tumour, wliich was ligatured, and then
removed, was three inches long, and half an inch wide ; it
was smooth and glistening, somewhat uneven ;md warty at
the lower part, and superficially ulcerated. It had a covering
of pavement epithelium, beneath which were conical papilla-,
and under these again was embryonic connective tissue. In
Tonoli's case the growth was oblong in shape, and was
attached by a short stalk to the left side of the gullet at the
lower part of its middle third.

Weigert1 has reported a case of adenoma 2>"t !//>"*""< about
the size of a hazel nut, which grew from the anterior wall of
the lower third of the oesophagus. It contained numerous
hollow spaces, lined with cylindrical epithelium, and sur-
rounded by a stroma of connective tissue. Zenker and
Ziemssen,2 in commenting on this case, remark that it
probably originated in the mucous follicles.

Lipomata are stated by Laboulbene3 to be occasionally
found in the oesophagus, but he does not refer to any actual
cases.

As already stated, examples of mytnnata have been
recorded by Eberth, Arrowsmith, Coats, and Hilton F.
In the Last-mentioned case the patient, who was under tin-
care of Mr. Bryant, died from the effects of an injury to the
knee-joint, and there was no mention of dysphagia in the
clinical history. The tumour grew from the anterior wall of
the oesophagus just below the level of the bifurcation
of the trachea. It was about two inches in length, one and
a quarter in width, and one inch in thickness. In Coats'*
case the patient was a man, aged sixty -one, and the growth
was elongated and irregularly oval in shape. It was attached
to the posterior wall of the oesophagus six inches and three-
quarters below the level of the glottis by a thin fibrous
pedicle, one inch and three-quarters long, which was inserted
into the body of the tumour two inches below its upper end.
The polypus measured four inches and three-quarters from
above down, two from side to side, one to one and a quarter
from before backwards. The surface was irregularly lobu-
lated, generally greyish in colour, but of dark brown tint at
the upper part. The body of the tumour was horizontally

1 "Virchow's Archiv." 1876, Bd. IxiriL pp. 516, .117.

2 " Cyclopaedia, " vol. viii. p. 169.

3 "Xouv. filem. d'Anat. Pathol." Paris, 1879, p. 91.

XOX-M ALIGN AXT TUMOURS OF THE GULLET. 103

constricted, the upper part being larger than the lower.
Portions of the surface had an appearance of sloughing. On
section the growth was tough, but not very dense. The
"•sophagus was dilated near the seat of implantation of the
polypus, and its surface was of a slaty colour, and ulcerated
in several parts, two of the ulcers having eaten through the
mucous coat, and one through the entire thickness of the
gullet-wall.

Diagnosis. — There is considerable difficulty in diagnosing
these tumours, for as has been observed, they sometimes give
rise to no symptoms at all, whilst in other instances they
produce almost the same symptoms as malignant growths.
As compared, however, with cancer, the dysphagia, as a rule,
progresses much more slowly, and it may be years before it
gives rise to serious inanition. When the growth has a long
pedicle it may be occasionally protruded into the mouth,
and in other cases it may be seen with the laryngeal
mirror or with the oesophagoscope. Careful examination of
the neck and chest will eliminate cervical and mediastinal
tumours.

Prognosis. — The prospects of the patient must depend on
the situation of the growth, on its size, and on the rapidity
of its increase. Small warty growths need give rise to no
anxiety, but if the polypus be large it must be looked upon
as a serious disease, which at any moment may so much
interfere with deglutition as to bring the patient's life into
immediate danger.

Tr«dmmt. — When the tumour is projected into the
mouth it may be ligatured and cut off. This course, as
already mentioned, was pursued by Middeldorpf, whilst in
the earlier case of Dallas a ligature was applied, the polypus
was again swallowed, and allowed to come away per anum.
In this instance, owing to the dyspnoea that was produced
when the polypus was vomited into the mouth, it was neces-
sary to perform tracheotomy as a preliminary measure.
When a ligature has been applied it is highly desirable
that the patient should remain under close observation, as
in one case in which separation occurred during sleep, the
growth became impacted in the pharynx and caused fatal
apiKwi.1 In two cases that came under my own care some
years ago, in which I had not diagnosed the growth, polypi
wen- removed with the parasol-probang, which was used
the patients were under the impression that they had
1 Dubois : Loc. cit.

104 DISEASES OF THE THROAT AND

foreign bodies in their throats. In a more recent instance I
was fortunately able, by means of an cesophagoscope, to
diagnose a small polypus situated about one inch below the
upper orifice of the oesophagus, and to remove it with forceps.
Should a growth, which cannot be removed per vias
fifit !n rales, occupy the upper part of the gullet, recourse
should be had to cesophagotomy, whilst if the tumour be in
the lower part of the tube, gastrostomy offers a prospect of
permanent relief.

CASES OF NON-MALIGNANT GROWTH IN THE GULLET.

Case 1. — Mrs. M., aged thirty-seven, was sent to me by Mr.
Symonds, of Oxford, in March, 1874. She had felt some difficulty in
swallowing for eleven months ; but during the eight weeks previous
to her coming under my observation, the dysphagia had become inten-
sified to such a degree that she could take only liquid nourishment.
The patient stated that she had lost flesh, and she was afflicted with
a troublesome cough. Laryngoscopic examination showed that her
larynx was health)', and no sign of disease could be found in the lungs.
From the fact that she had first noticed a difficulty in swallowing
whilst eating hashed pheasant, Mrs. M. was under the impression
that a bone had stuck in her throat. A bougie (No. 10 English mea-
sure) was passed with some trouble, a hitch having been felt in the
upper third of the gullet. Two days later I introduced a parasol -
probang, and on withdrawing it with a little difficulty, a round
smooth growth of about the size of a marble, with a pedicle half an
inch in length was brought up with the instrument. The patient
spat up two or three drachms of blood, and next day was unable to
swallow even liquids. On the second day, however, the dysphagia
had abated, and by the end of a week it had quite passed oft'. I saw
this lady again in 1875, and she had experienced no further difficulty
in deglutition. On microscopic examination the growth proved to be
of true fibrous structure, the fibrillae being arranged concentrically
round a white nuclear portion, and the whole being covered with
squamous epithelium.

Case 2. — The Rev. P. E., aged forty -seven, consulted me in June,
1875, on account of difficulty of swallowing. This symptom was
first noticed two years and a half previously, after eating some fish,
and the patient attributed the trouble to the lodgment of a bone.
The difficulty in swallowing had increased by slow but not regular
degrees. At first it was slight, and only came on occasionally,
whilst at other times the food went down perfectly well. During
the first six months of 1874 the dysphagia passed off, but in the
beginning of July of that year it suddenly returned, and since then
there had always been some trouble. The patient stated that he
had consulted several practitioners, and on two occasions attempts
had been made to pass a bougie, but he was under the impression
that the instrument had been stopped in the upper part of the throat.
These measures had not given him any relief. At the patient's
urgent solicitation, rather than with the idea of meeting with any
foreign body, I passed a parasol- bougie. Though it went down
easily, I had some difficulty in pulling it up, and was about

SYPHILIS OF THE GULLET.

105

to release the web of the bougie, when the obstruction suddenly
yielded, and on withdrawing the instrument a small pedunculated
tumour, about the size of a bantam's egg, fell from the patient's
mouth. He subsequently brought up about a teacupful of blood.
I forbad the patient taking any solid food, but this injunction was
scarcely necessary, as for several days he experienced considerable
pain even in swallowing liquids. There was no return of the bleeding.
The patient ultimately made a good recovery, and I heard in January,
1878, that he was perfectly well. The tumour was of somewhat oval
shape, though one side was very much flattened, and the surface
ulcerated. On microscopical examination made by Dr. Stephen
Mackenzie, it was found to be of fibrous structure, but covered,
except at the ulcerated point, by pavement epithelium.

Case 3. — Miss P., aged twenty-seven, consulted me in August, 1880,
on account of difficulty of swallowing, which had existed more or
less for six or seven years. Examination with the ossophagoscope
revealed an oval, semi-transparent polypus, situated on the right of
the gullet, one inch below the cricoid cartilage. On August 28, in
the presence of Mr. C. L. Taylor, I removed a growth about the size
of a white currant. The patient felt some slight pain for twenty-
four hours after the operation ; but at the end of a week she was able
to swallow perfectly, and has not since had any recurrence of the
symptoms. The following is the report of Dr. Stephen Mackenzie
on the specimen : — " The surface of the growth is covered with squa-
mous epithelium, beneath which is a very lax .cedematous and highly
vascular mass with numerous lymphoid cells (leucocytes) infiltrated
into the tissue. It appears, in fact, to be a polypus arising from
chronic inflammation of the cesophageal mucous membrane."

SYPHILIS OF THE GULLET.

Latin Eq. — Syphilis oesophagi.
French .fi^.— Syphilis de 1'oesophage.
German Eq. — Syphilis cler Speiserbhre.
Italian Eq.— Sifilide del esofago.

DEFINITION. — Constitutional syphilis manifesting itself
a- i Hi in the gullet by the usual secondary or tertiary lesions,
or more rarely occurring in the congenital form, causing
dysphagia and occasionally leading to death by marasmus.

History. — Severinus,1 who lived in the latter part of the sixteenth
and the first half of the seventeenth centuries, appears to have been
the first writer who called attention to this disease, and his con-
temporary, Rhodius,2 recorded the case of a patient suffering from
syphilis, in whom a growth was found originating from cicatricial
thickening at the lower end of the oesophagus. Ruysch,3 who
flourished somewhat later, gave an account of a case treated by him-
self and Boerhaave, in which very severe dysphagia, due apparently
to some obstruction at the level of the fifth or sixth dorsal vertebra,

1 Quoted by Lieutaud : " Hist. Anat. Med." Parisiis, 1767, t. ii. lib. iv. obs. 105.

' " Obs. Anat. Med." Patavii, 1657, Cent. ii. obs. 46.

3 " Advers. Anat. Med.-Chir." Amstelodami, 1717. Decad. i. obs. x. p. 24, et seq.

106 DISEASES OF THE THROAT AM) NUSK.

yielded to a short course of mercurial baths.1 In 1820 Palletta3
dcM-rilicd ;iu example of dysphagia occurring in a patient who had
previously suffered from syphilis ; the difficulty of swallowing came
on on t\v<> occasions, and eadi time readily yielded to mercurial treat-
ment. The first mention of congenital syphilis in the (esophagus
was made hy liillard," who found ulcers which he •• msidered to In of
specific character, in the gullet of a girl six days old. In recent years
a few additional examples of ccsophageal syphilis have been observed.
In 1860, West,4 of Birmingham, published two cases whieh settled
the question as to the occurrence of syphilis in the oesophagus, lie
also quoted three other supposed examples of the same disease,
two from Cannichael, and one from Turner. From a earet'ul perusal
of the notes, however, it appears that in all these instances the di>
was situated in the pharynx. West 'soon afterwards related a third
example occurring within his own experience, in whieh a woman,
suffering from rupia and ulceration on the face and legs, died (nun
marasmus, consequent on inability to swallow. Follin 6 refers to two
cases which had come under his notice. In one there was palmar
psoriasis and dysphagia ; the latter symptom disappeared without in-
strumental treatment. In the other the lesion was probably more
severe, and only a partial cure was effected. Virchow7 states that he
has in his possession two specimens illustrating the disease. In one
of them he describes a softened gumma closely connected with a con-
tracting cicatrix in the oesophagus. In the other case the preparation
shows a flat ulcer withfa "fatty indurated base." Wilks and Moxon8
affirm that they have seen in a st/philitic subject two yellowish gum-
matous patches in the oesophagus, and in another instance they
describe the gullet as having been penetrated by a large soft syphilitic-
deposit originally outside it. The same authors also allude to a
specimen showing a contracted cicatrix in the oesophagus, which they
consider to be probably due to syphilitic lesion. Knott* has added two
cases. One of them — a specimen of ulceratiou of the oesophagus —
was brought before the Pathological Society of Dublin in 1839 by
Cusack. In another case that had come under Knott's own notice,
severe cesophageal dysphagia occurred in a patient suffering from
tertiary syphilis who quickly recovered the power of swallowing
under the use of iodide of potassium. In 1868 Stetfen 10 recorded
two cases of ulcers of the oesophagus found in children suffering from
congenital syphilis. In 1870 a case was published by Maury,11 of
Philadelphia, in which syphilitic stenosis of the gullet rendered
gastrostomy necessary. In 1873 Podrazki 12 described a case in which

1 Haller has been quoted (Follin, " B^trtcissements <le I'CEsophage." Paris,
1853, p. 30) as describing a case of syphilitic stricture of the gullet which was
cured by the use of mercurial pills. On reference to the original report, however,
("Opuscula Pathologies, " obs. Ixxviii. in Haller's "Opuscula Mlnonu" LMMUUMB,
1768, t. iii. pp. 380, 381), I can find no evidence whatever, either that the disease
was venereal or that Haller considered it to be so.

••^ ' Exercit. Pathol." Mediolani, 1820, p. 226, et seq.

3 ' Trait6 des Maladies des Enfants nouveau-neV Paris, 1883, p. 807.

4 ' Dublin Quarterly Journ. of Med. Science." Feb. 1860, No. 57, p. 86, et seq.
8 Pjid. Aug, 1860, vol. xxx. p. 29, et seq.

« 'Trait4 Elein. de Pathologic externe." Paris, 1861, t. i. p. 696.

7 ' Die Krankhaften Geschwiilste." Berlin, 1864-65, Bd. ii. p. 415.

8 ' Pathological Anatomy." London, 1875, 2nd ed. pp. 365, 366.

9 ' Pathology of the (Esophagus." Dublin, 1878, p. 161.

10 ' Jahrb. fiir Kinderheilk." vol. ii. p. 144.

11 ' Amer. Journ. Med. Sci." April, 1870, p. 856.

12 ' Wien. Med. Wochenschr." 1S73, Xos. 33, 35, 30.

SYPHILIS OF THE GULLET. 107

a man who had suffered from severe tertiary syphilis experienced
difficulty in swallowing during more than two years ; gradual dila-
tation was tried without success, but great benefit was afforded by
mercurial inunction. After death a cancerous stricture was found,
but from the long duration of the symptoms, and the temporary good
effect of the anti-syphilitic remedy, it is probable that the affection
was venereal at least in the earlier part of its course. In 1874 J I
recorded a case of probable syphilitic ulceration of the resophagus
which had caused dysphagia on previous occasions, and which was re-
lieved by iodide of potassium. In the following year an example of
02sophageal syphilis was related by Godou.a The patient, a man aged
twenty-four, recovered rapidly under the use of iodide of potassium
and ice. In 1876 Reimer3 published a case of congenital syphilis
occurring in a boy of twelve ; besides many other lesions, there
was a sinus opening on the surface of the neck and leading into
the resophagus. The tissues of the gullet for some way round
the ulcer were diseased. In 1877 Bryant 4 related an instance of
cesophageal stenosis occurring in a tubercular subject, which "he con-
siders to have been due to syphilitic ulceration. The dysphagia was
so severe that gastrostomy was judged necessary. In the same year
Lutou5 gave a brief account of a case in which a man aged forty,
suffering from syphilitic disease of the gullet which had resisted
treatment by mechanical dilatation, was speedily and permanently
cured by iodide of potassium. A case has been reported by Billroth 6
in which serious difficulty of swallowing was caused by syphilitic
deposit behind the cricoid cartilage. The patient, a man aged fifty-
five, had condylomata in the mouth and on the tongue. The dys-
phagia yielded promptly and permanently to anti-venereal remedies
combined with mechanical dilatation.

' Lancet," May 30, 1874.

' Archives of Dermatology." 1875, vol. i. p. 276.

' Jahrb. f. Kinderheilk." vol. x. p. 98. •» " Lancet." 1877, vol. ii. p. 9.

' Nouy. Diet, de M<§d." Paris, 1877, t. xxiv. pp. 403, 404.

'Clinical Surgery." Syd. Soc. Transl. London, 1881, p. 128.

Etiology. — When the system has become infected with
the venereal poison, local manifestations may take place in
any part of the body. The oesophagus, however, shows
'comparatively little proclivity to syphilitic affections, and is
probably attacked only when previous disease or injury has
produced a locus minoris resistenticu at some point in the
canal. Hereditary syphilis probably shows itself but seldom
in the gullet ; indeed, I know of no cases but those of
Billard, Steffen, and Reimer, above referred to, in which this
form of the affection has been actually observed.1

Symptoms. — The chief of these is dysphagia, which, in its

1 It was formerly believed that congenital syphilis of the larynx
was extremely rare, but the recent researches of Dr. John Mackenzie,
of Baltimore ("Amer. Journ. Med. Sci." October, 1880), have proved
this condition to be of more frequent occurrence than was previously
supposed, and if the gullet could be thoroughly examined during
life in patients suffering from congenital syphilis, this canal also
would probably be found to be affected much more often than is
generally suspected.

108

DISEASES OF THE THROAT ANI>

mode of development, greatly resembles that due to swallow-
ing an irritant or mild corrosive poison. Thus, difficulty <>f
deglutition occurs at the time the ulcer forms, disappears as it
heals, and recurs when the cicatricial tissue begins to shrink.
Patholoijy. — The morbid changes closely resemble those
met with in the pharynx :md
larynx — that is to say, simple.
ulceration of the mucous iin-in-
brane may take place ; or gum-
mata may be formed in the
submucous tissue, which slowly
break down, ulcerate, and give
rise to rigid contracting cica-
trices. * In my first case there was
a single raised cicatricial band
just below the cricoid cartilage.
It was nearly half an inch in
width, and ran round the _tube
for three-fourths of its circum-
ference, reducing the canal to
the size of a Xo. 3 oesophageal
bougie (old English scale). In
my second case (Fig. 14) slightly
raised transverse ridges occupied
the anterior wall of the gullet
one inch and a half below the
cricoid cartilage, the upper and
lower bands giving off short
vertical spurs. There was very
little thickening of the walls of
the gullet except immediately
beneath the cicatricial bands.
In one of West's -cases the
oesophagus was constricted four
inches below its upper orifice
for about two inches and a half,
and the narrowed portion, owing
to thickening of the mucous
membrane, and fibrous de-
posits in the form of bands and
ridges, presented very much the
appearance of an old stricture

FIG. 14.
SYPHILITIC CICATRICES IN

THE (ESOPHAGI'S.
(SEEN FKOM BEHIND.)
a and a', anterior wall of gullet ;
b, sides of the gullet thrown out-
wards ; e, situation of transverse
ridges of cicatricial tissue (above
and below them vertical ridges are
seen) ; d, posterior surface of cricoid
cartilage (between d and a a por-
tion of the posterior wall of the
trachea is visible) ; e, left, and /,
right bronchus ; g, edge of trachea.

right bronchus ;?; edge of trachea, appearance ol an old stricture

1 Berkeley Hill: "Syphilis and Local Contagious Disorders."
1868, p. 127.

SYPHILIS OF THE GULLET. 109

of the urethra. In another case reported by West the
oesophagus presented reddish livid erosions for about two
inches above the cardiac orifice, and there was a consider-
able amount of fibrous deposit in the submucous tissue.
Laboulbene1 found in the gullet of a man, aged thirty, who
had died of acute oedema of the larynx caused by an ulcerated
growth in that situation, scars of old ulcers and interstitial
deposits of a hard whitish fibroid material which infiltrated
the mucous membrane. All who saw it agreed that it was of
gummatous nature.

Diagnosis. — The diagnosis of syphilitic disease of the
gullet is extremely difficult, and under the most favourable
conditions can never amount to anything more than con-
jecture. The affection presents no pathognomonic feature,
and the surgeon can only come to a probable conclusion by
a consideration of all the circumstances of the case. The
history of the patient must always be carefully investigated.
Inquiries should be made as to the previous occurrence
of skin eruptions, loss of hair, miscarriages, nocturnal pains
in the shin-bones, and the various other symptoms in-
dicative of constitutional syphilis. The skin, tongue,
pharynx, and larynx should be carefully examined to see
if there are any old scars or patches of induration ; nodes
should be sought for on the front of the tibia, and the con-
dition of the sub-occipital glands should be ascertained.
The duration of dysphagia for some time, its apparent
complete cure by anti-venereal remedies, and its subsequent
recurrence, are the salient features of the malady.

It is not to be wondered at, however, that in a matter
so beset with difficulties, observers are often led astray.
It is likely that in many instances syphilis of the gullet has
been mistaken for cancer, and, on the other hand, erroneous
conclusions may be arrived at even when the history and
course of the complaint seem most clearly to indicate a
specific origin. Thus, in a case of dysphagia which came
under my own notice, I supposed the symptom to be one of
syphilitic lesion at the upper part of the oesophagus. This
was rendered more probable by the fact that the patient
was suffering from a well-marked venereal affection of the

1 "Nouv. £lem. d'Anat. Pathol." Paris, 1879, p. 96. The same
writer also states that lie had met with an example of stricture of the
gullet in which a woman suffering from tertiary syphilis was cured
by iodide of potassium, and refers to two similar cases related to him
by Fournier.

110 DISEASES OF THE THROAT AND NOSE.

pharynx. After death, however, absolutely no trace of
disease could be seen in the gullet, and the difficulty of
swallowing was found to have been due to great enlarge-
ment of the posterior part of the cricoid cartilage.

I'rniiitnxiii. — This is very unfavourable, for though when
the lesion only amounts to superficial ulci-ration the patient
can generally be relieved by treatment, there is a great
probability of permanent stricture resulting fn>iii subsequent
cicatricial contraction. Although this may be sometimes
combated for a time by the use of bougies, it very often
happens that as soon as the patient feels a slight improve-
ment in his condition he will discontinue his attendance, and
when he again presents himself it may be impossible to pass
an instrument. When a large gumma forms, or when tin-
walls of the gullet become much thickened, the prospects of
the patient are still more gloomy.

Treatment. — The constitutional remedies which are suitable
in other forms of tertiary syphilis may be employed here.
When the presence of gummata or specific ulcers is suspected,
iodide of potassium, in doses of ten grains three times a day,
will probably quickly relieve all the symptoms. Ammonia,
which is so useful in combination with this drug, should not
be given in these cases, as it is apt to irritate the gullet.
Should frequent relapses take place, bichloride of mercury
(one-sixteenth of a grain) twice or three times a day, or tin-
cyanide of mercury (one-eighth of a grain) may be found
beneficial.

The proper treatment of the actual constriction of the
oesophagus will be considered under " Cicatricial Stricture
of the Gullet."

The first two of the following cases were undoubtedly
examples of syphilitic disease of the oesophagus, and the
last one probably belongs to the same category : —

Case 1. — Sarah H., a married woman, aged forty -one, applied ;it
the Throat Hospital in June, 1874, on account of difficulty in
swallowing. She stated that she had had three miscarriages. There
was a large rupial eruption over the right shin-bone. Careful
examination of the pharynx and larynx gave negative results ; hut
on attempting to explore the gullet it was found imi>ossible to pass
the bougie beyond the upper orifice of the canal, even when tin-
patient was under chloroform. Iodide of potassium was given,
liquid diet of highly nutritious quality was obtained for her, and
she was directed to wean an infant which she was suckling. In a
few weeks Sarah H. had so far recovered as to be able to swallow
semi-solid food. She thereupon discontinued her attendance. In
February, 1875, however, word was brought to the hospital that she

SYPHILIS OF THE GULLET. Ill

was dying. Mr. Poyntz Wright saw her several times, but in spite
of every effort to overcome the obstruction, her oesophagus was found
impermeable, and she soon died from exhaustion. After death the
canal, about an inch below the cricoid cartilage, was found so much
narrowed that a No. 3 bougie (old English scale) could with
difficulty be passed into it. The contracted portion extended down-
wards for less than half an inch in a vertical direction, and consisted
of a raised ridge, occupying three-fourths of the circumference of
the tube. Two whitish nodules, presenting all the appearance of
syphilitic gummata, one about the size of a filbert, and the other
somewhat smaller, were found in the liver.

Case 2. — John W., aged sixty-five, came to me at the Throat
Hospital in July, 1876, on account of dysphagia. He had suffered
from primary syphilis seven years previously, and his palate had
been perforated by an ulcer in 1874. The patient was much
emaciated, and very feeble ; he had also paresis of the left arm.
Examination of the pharynx showed no signs of the disease, and the
larynx was healthy, with the exception of slightly impaired mobility
of the left vocal cord. The patient could not swallow solids at all ;
but liquids went down pretty easily. On auscultation of the gullet
prolonged gurgling noises were heard over the sixth and seventh
vertebrae, whilst below that point the oesophageal sounds were
scarcely audible. An attempt to pass a No. 6 bougie (old English
scale) altogether failed, owing to obstruction just below the cricoid.
Stricture was diagnosed, and it was thought that the disease might
be syphilitic. No improvement, however, was produced by iodide of
potassium ; the dysphagia gradually got worse, and the patient died in
January, 1877. Post-mortem examination showed fine, slightly raised,
almost transverse ridges on the anterior wall of the gullet (Fig. 14).
The uppermost ridge was about an inch and a half below the lower
border of the cricoid cartilage, and from it two spurs passed upwards.
The lowest transverse ridge also sent a prolongation downwards.
These ridges were darker in colour than the rest of the mucous mem-
brane, and presented an uneven surface. The walls of the gullet
were very little thickened, except just beneath the ridges.

Case 3. — A man, aged sixty-one, came under my care in June, 1873.
He had suffered since the foregoing February from dysphagia, which
had gradually become worse, till, when I saw him, he could only swal-
low fluids. He had had venereal disease eighteen years before, and
had on two different occasions since then suffered ffom difficulty of
swallowing. One of these attacks had occurred eleven and the other
four years previously. There was neither cough nor expectoration,
and the pharynx appeared healthy, with the exception of a slight
cicatricial puckering on the right anterior pillar of the fauces. The
larynx was normal. On auscultation of the gullet, however, the
"morsel" was found to be arrested at a point opposite the sixth
dorsal vertebra, and on exploration with the bougie a tight stricture
was recognized about the junction of the lower with the two upper
thirds of the gullet. Iodide of potassium was given, and in ten days
the patient had recovered his power of swallowing.

Although the evidence in this case amounts to no more than
probability, I think it may be accepted as a genuine example of
syphilitic stenosis. The previous history of the patient, and espe-
cially his rapid recovery under iodide of potassium, point clearly to
such a conclusion.

112 DISEASES OF THE THROAT AND XOSE.

TUBERCULAR DISPOSE OF THE GULL I. T.

This affection is characterized by the secondary deposit,
in the mucous membrane of the oesophagus, of tubercles,
which break down in the ordinary* way and end in nleeration.
It is only in comparatively recent times that this disease has
been recognized. The first mention of it appears to have
been made by Andral,1 who speaks of finding tubercles
beneath the oesophageal mucous membrane. Some years
later a case was reported,2 in which tubercles were found at
the upper part of the gullet. In 1851 Oppolzer3 referred t<i
tubercle of the oesophagus as a. pathological curiosity. An
instance of the affection -was recorded by \Villigk,4 in 1854,
and ten years later Maisonneuve5 related an example of
stricture of the upper part of the gullet, caused by tuber-
cular infiltration. In 1868 a conclusive case was published
by Chvostek,6 and a doubtful one by Paulicki.7 Zenkei
and Ziemssen8 briefly allude to two cases which "they
believe could be called tubercular." One of these, how-
ever, appears to have been merely an example of caseous
peri-oesophageal glands perforating the gullet. The account
of the other case is so meagre that it is impossible to arrive
at any independent opinion as to its nature. In both
instances the microscopic examination gave only negative
results. Knott9 quotes a case which was reported to the
Pathological Society of Dublin by Professor R. W. Smith.
Laboulbene10 states that he has met with two instances of
the disease, of which he had unfortunately neglected to keep
notes. The etiology of the disease is obscure, the well-known
tendency of Jubercle to become developed in various organs
after its primary deposit in the lungs being manifested only
to a very slight extent in the oesophagus. No satisfactory
evidence of the primary occurrence of tubercle in this

1 'Precis d'Anat. Pathol." Paris, 1829, t. ii. p. 274.

2 ' Wiirtemberg Med. Corresp. Blatt." 1844, Bd. xxiii.

3 'Wien. Med. Wochenschrift." 1851, Nos. 2, 5, and 12.

4 'Prag. Vierteljahrschr. " 1854, Ix. 4.

8 'Clinique Chirurgicale. " Paris, 1864, t. ii. p. 410.

6 '(Esterr. Zeitschr. fiir prakt. Heilk." 1868, xiv. 17 and 18.

? 'Virchow's Archiv." 1868, Bd. xliv. pp. 373-375.

8 ' Cyclopedia of Pract. Med." vol. viii. p. 191.

8 'Pathology of the (Esophagus." Dublin, 1878, p. 215.

10 'Xouv. Ek'm. d'Anat. Pathol." Paris, 1879, p. !O.

TUBERCULAR DISEASE OF THE GULLET. .113

situation has yet been produced, though in the case quoted
by Knott the dysphagia was present some months before
there was any evidence of pulmonary mischief. I have
myself never seen an example of the disease. It is probable,
however, that it is more common than the small number of
recorded cases would lead us to suppose, and I have little
doubt that examples of it will be more frequently met with as
the pathology of the gullet comes to be more closely studied.

From the few cases on record this affection would appear
generally to occur in middle life or old age, and it has not
hitherto been met with in children. The only symptoms are
dysphagia and odynphagia, the former being generally the
more marked. In Chvostek's case the patient, a man aged
forty-three, was attacked by acute pulmonary tuberculosis in
April, 1865 ; pain and difficulty in swallowing came on in
January, 1866, and the patient died a week or two later.
Paulicki's patient began to suffer from dysphagia two months
after the first signs of lung disease showed themselves, and
death was very gradual.

The pathological changes vary greatly in different cases.
In that of Chvostek pleurisy, pulmonary tubercle, and enlarge-
ment of the liver were found, but there was no intestinal
ulceration. The mucous membrane of the gullet was smooth
and unbroken at the upper part, but downwards from the level
of the third dorsal vertebra there were numerous ulcers of
various shapes with sharp-cut edges. In some instances the
ulcers had a smooth, in others a villous, base of dark grey
colour. Over their surface were scattered whitish-yellow
nodules, from some of which a thick yellowish purulent
fluid could be squeezed out. The character of the ulcers in this
instance was established microscopically by Professor Engel,
whilst in Paulicki's case the tubercular origin of the cesopha-
geal lesions was rendered probable by the history of the disease
although microscopic examination failed to prove it. Here,
together with signs of old pleurisy, a suppurating cavity was
found in the left, and some caseous deposits in the right apex.
In the gullet, at the level of the cricoid cartilage, there was a
stricture ; and on the posterior wall were two ulcers, one of
them being half an inch in length and reaching through the
entire depth of the mucous membrane, which was congested
for some distance round.

The diagnosis of this affection from cancer of the oeso-
phagus must rest chiefly on the fact that the dysphagia is
not regularly progressive ; there is probably, too, in most

VOL. II. I

1 1 4 DISEASES OF THE THROAT AND XO8E.

- abundant evidence of tubercular deposit in the lungs.
The fact that malignant disease of the gullet occasionally
coexists with tubercle of the lungs must not, however. b«-
forgotten, and hence, even when there is undoubted evid<-m •••
of pulmonary phthisis, it cannot be absolutely determined
that the u'sophageal disorder is of similar nature.

As the disease has not hitherto been detected during life,
nothing can be said as regards />rnt/H<Hn#. The all'ectioii can
only be fri-atnl syniptoniatically ; if there he much pain
in swallowing, hypodermic injections of morphia should be
given.

DILATATIONS OF THE GULLET.
(SYNONYMS : DIVERTICULA. POUCHES.)

Latin Eq. — Dilatationes oesophagi.
French Eq. — Dilatations de 1'oesophage.
Gem/an Eq. — Erweiterungen der Speiserohre.
Italian AV/.— Dilatazioni del esofago.

DEFINITION. — Sacciilateff protrusion* from tin-
ranal, or uniform expansion of it* u-all*, >//'•/>«/ /•/>•'• t<>
thjsphayia and reyurf/itation of tlie inyesta.

History. — Blasius1 described, under the name of "double stomach"
what, from his own report, and the rough drawing which acioiu-
lianies it, was undoubtedly an instance of dilatation of the lower jwrt
of the gullet. A case of oesophageal pouch was referred to by Mi>r-
gagni2 in 1765 as having been described by (imslmis lung before,
jind two years later Ludlow3 reported his remarkable case. Isolated
examples of the affection have, since then, been placed on record by
(Hauella,4 Bell,5 Purton,6 Worthington,7 Mayo,8 and others. In 1840,
Kokitansky" described an instance in which part of the O3sophageal
wall had been drawn outwards in the course of cicatrization of a
diseased lymphatic gland — a class of cases to which Zenker and
Ziemssen subsequently gave the name of " traction -diverticula." In

i "Obs. nied. anat. rarior." pars iv. obs. ix. Lugdun. Batav. 1711, p. 53, and
1 ';<!>. vi. ng. v., Ibid. p. 113.

- " l)e sed. et caus. morb." epist. xxviil. art. 18, ed. secund. Patavii, 1785, t. ii.
p. 11.

:l "Med. Observ. and Inquiries, by a Society of Physicians in London."
l..iiiiloii. 1767, vul. iii. p. 85, et seq. Ludlow's letter describing the case is
dated Sept. 9, 1764.

* Borsieri : " Istituz. di Med. Prat." cap. xxxix. § mccxix. Firenze, 1837, t. ii.
p. 998, foot-note 4. The case was observed in 17---J.

s ' Surgical Observations." London, 1817, vol. i. p. 64, et seq.

« ' London Med. and Phys. Journ." 1821, xlvi. p. 541.

" 'Med.-Chir. Trans." London, 1847, vol. xxx. p. 199, et seq.

» -Outlines of Pathology." London, 1835, p. 285.

» ' (Esterr. Jahrb." 1840, Bd. xxi. p. 219.

DILATATIONS OF THE GULLET. 115

1861 Rokitansky1 described systematically the various kinds of dilata-
tions which are found in the pharyugo-cesophageal canal. In 18(57
an inaugural dissertation on the subject of cesophageal pouches was
published by Fridberg.2 In recent years, Zenker3 has collected a
large amount of pathological material bearing especially on the
question of tractiou-diverticula, and the whole subject has been
treated with remarkable completeness by Zenker and Ziemssen.4

1 " Lehrbuch d. pat hoi. Anat." vol. iii. p. 127.

2 " Diss. de oesophagi diverticulis." Giessen.

3 " Cyclopaedia of Pract. Med." vol. viii. p. 68.

4 Ibid.

3."% Dilatations differ so widely as regards their mode of
origin, situation, symptoms, course and termination, that in
dealing with them it will be found more convenient to depart
from the regular plan adopted in this work, and to describe
separately each form of the disease.

SIMPLE DILATATIONS.

These dilatations may be either primary or secondary —
the former occurring without any obvious cause, and the
latter being the result of a stricture of the cesophageal
canal at a lower level.

PRIMARY DILATATIONS.

These are cylindrical or fusiform in shape, generally affect-
ing the whole length and circumference of the oesophagus, and
usually attaining their maximum girth in the thoracic region
about the middle of the gullet. The fact of the widest ex-
pansion occurring in this situation is probably to be explained
by the greater freedom of the tube at this point from immediate
pressure by the neighbouring parts. In the case, however,
described and figured by Blasius,1 the dilatation was just
above the diaphragm, and affected only the lower three
inches of the gullet. Judging from the drawing, the dilata-
tion must have been spheroidal hi shape, measuring about
four and a half inches from side to side.

This form of dilatation is rare, and the cause of it i*
general weakness, congenital or acquired, of the
wall in its whole circumference. In most of the
recorded examples the symptoms appear to have commenced
between the ages of fifteen and twenty, but it is probable
that in many of these cases the predisposing local weakness
had existed since birth. One example of feeble development

1 Op. cit. See also von Ammon, "Die angeborenen
Krankheiten des Menschen." Berlin, 1842, p. 37, and Taf. viii.

Fig. 15.

116 UISKA>i:s ol 1IIK THHOAT AND NOSE.

has been observed by Zenker,1 in which simple dilatation of
the gullet occurred in a seven months' child which died on
the seventh day after birth. Klebs2 has reported a case
of dilatation which he supposed to be due to atony of the
ualls of the tube. Spengler3 has recorded an example in
which the first symptoms came on after swallowing a very
hot dumpling which was temporarily arrested in the gullet.
Purton4 has reported a case in which the affection developed
after a blow on the chest, and a similar instance is related
by Hannay.6 An example of the disease is mentioned )>y
Oppolzer,6 in which the patient had taken large quantities
of warm water to relieve gout. Although it is not at all
impossible that in this case mechanical dilatation may have
been effected in the manner described, it is much more likely,
as Knott" suggests, that a gouty condition of the muscles of
the oesophagus diminished their power of resistance, and
thereby favoured dilatation.

The most prominent symptom exhibited by patients
labouring under this affection is the regurgitation of food
some hours after it has been swallowed. The matters thus
returned are alkaline or neutral in reaction, and if starchy
food has been taken, they have a sweetish taste. They
present no digestive alteration, however long they may have
been retained ; thus in a case reported by Delle Chiaje,8
coffee was thrown up four or five days after it had been
swallowed without having undergone any change whatever.
There is generally a greatly increased secretion of saliva,
which the patient has continually to spit out. In Worthing-
ton's case a pint and a half of fluid was frequently voided
from the mouth in the course of twenty-four hours. There
is usually also some dysphagia.

The patient's breath is in most cases fetid, owing to the de-
composition of the food which remains in the gullet. Some-
times there is an agonizing feeling of distension, from which
relief can only be obtained by vomiting. Occasionally then- is
a sensation of heat or burning throughout the gullet. When

1 Op. cit. p. 51.

2 Quoted by Zenker : "Ziemssen's Cyclopaedia of Pract. M"l."
English Transl. vol. viii. p. 47.

3 "Wien. Med. Wochenschr. " 1853, No. 25.

4 "London Med. and Phys. Journ." 1821, xlvi.
s "Edin. Med. and Surg. Journ." July, 1833.

6 "Wien. Med. Wocherischr." 1851, NOB. 2, 5, 12.

7 Op. cit. p. 21.

8 " II Progresso." Napoli, 1840.

DILATATIONS OP THE GULLET. 117

the dilatation affects the thoracic portion of the tube, the
distended oesophagus may, by pressure on the heart, give
rise to fainting and to symptoms similar to those of angina
pectoris. In Davy's1 case there was a pulsation resembling
that of an aneurism, together with considerable pain and
tenderness on pressure. There was also marked dulness on
percussion. This patient was only able to swallow in a
semi-recumbent position, with his right arm over the back
of a chair ; in any other posture deglutition was impossible,
and the attempt was accompanied by a sense of suffocation
which gave rise to violent attacks of coughing.

A bougie can be passed only in certain cases, the possibility
of doing so probably depending on whether the oesophagus
remains of normal length, or whether, becoming stretched, it
is doubled upon itself.

The progress of the disease is generally slow, lasting from
five to ten years or even more. Indeed, in some cases
sufficient food always reaches the stomach, and there is no
wasting. A very remarkable case, however, has been
recorded by Dr. Ogle,2 in which great emaciation resulted,
not only from the difficulty of swallowing, but more especially
from the pressure of the dilated portion of the gullet on the
thoracic duct.

In the cases now under consideration, after death the
calibre of the oesophagus is found to be greatly enlarged,
the dilatation being generally somewhat spindle-shaped. In
Luschka's 3 case (Fig. 15) the O3sophagus was forty-six centi-
metres in length and thirty centimetres in circumference at
the widest part. From the extreme length of the organ in
this instance, it is clear that during life it must have been
doubled upon itself. In these cases the muscular fibres over
the affected part are greatly hypertrophied, the submucous
tissue and the mucous membrane being thickened, whilst
the latter is almost invariably congested, and frequently
presents patches of ulceration. Occasionally, hsemorrhagic
spots are seen, and the papillae are often much enlarged.

The diagnosis of this condition may be assisted by the
exclusion of the various other causes of dysphagia, but can
only be arrived at with certainty when, whilst unaltered
food is regurgitated some hours after it has been swallowed,
a large bougie can be easily passed down the gullet.

1 "Med. Press and Circular. " May 5, 1875.

2 "Trans. Path. Soc." London, 1866, vol. xvii. p. 142.

3 •' Virehow's Archiv." 1868, Bd. xliii. p. 473, et seq.

118

<>K THE THROAT AND NOSE.

'I'lu- iirn<iw»<ix as regards cure is exceedingly unfavourable,
hut by selection of suitable food tin- patient'* life may !>»•
for many years.

FKJ. 15. — LVM-HKA'S CASE OF DILATED (EsopHA<;r>

(AFTER COHEN).

A, the thyroid cartilage; B, the thyroid body; c, the trachea; P, the
uasophagus; E, the stomach.

DILATATIONS OF THE GULLET. 119

The treatment must consist in the use of bland liquid food
taken at frequent intervals and in small quantities. If
alcohol be indicated by the weak condition of the patient, it
should be given in a very dilute form.

SECONDARY DILATATIONS.

These are always the remit of obstruction.

Although writers on stricture of the gullet frequently
describe dilatation as existing above the narrowed part,
this condition is, in fact, extremely rare. Among the very
large number of cases of cancer of the gullet which I have
examined, I have not met with a single example of secondary
dilatation. Wilks and Moxon l state that they have not
seen much of the condition, and suggest as reasons for the
rarity of its occurrence that in such cases little or no food is
taken, and that if the disease is malignant, its course is usually
too rapid for a dilatation to have time to form. A few well-
marked instances of secondary dilatation have, however, been
recorded. Monro2 speaks of having found it in cases where
the gullet had been for a long time obstructed by an im-
pacted foreign body, or " by any other cause." Cruveilhier^
has given a drawing of a case in which the gullet was narrowed
at its lower part and dilated above. Lindau4 has described an
example which he met with in a man aged thirty, who was
suddenly seized with difficulty in swallowing ; after a time
the food began to be regurgitated, and the patient died of
exhaustion rather more than a year after the onset of the
complaint. The gullet was found dilated in its whole length,
but chiefly at its middle part, where it measured eleven
centimetres across. Around the cardiac orifice was a rigid
band, the exact structure of which is not described ; this
ring narrowed the opening, but had not prevented the
passage into the stomach of a sponge probang during life.
In the dilated portion was found one kilogramme (24 Ibs.)
of pultaceous fluid, acid in reaction, and horribly foetid, com-
p< >sed of mucus, coagulated albumen, and altered blood. The
mucous membrane was almost completely stripped off. The
muscular coats were greatly stretched over the expanded
portion, the longitudinal and circular fibres being separated

1 "Morbid Anatomy of the Human Gullet, &c." Edinburgh,
1811, p. 12.

2 "Lectures on Pathological Anatomy." London, 1875, 2nd ed.
p. 364.

3 "Anatomic Pathologique." Paris, 1835-42, livraison 38, pi. 6.

4 " Casper's Wochenschr. fur die gesammte Heilkuude." 1840, p. 356.

120 DISEASES OF THE THROAT AND NOSE.

so as to give them the appearance of forming a wide-mesh ( <1
network. Watson1 refers to a preparation showing dilata-
tion of the gullet above a cancerous stricture of the cardiac
orifice of the gullet. Gradenwitz '2 has related a remarkable
instance in which the oesophagus of a man who had suffered
from difficulty in swallowing for forty -three years was found
thickened and contracted at the lower part, and dilated a1x>\ <•.
He had been in the habit of making the food, which accumu-
lated above the narrowed part, pass into the stomach by
stretching himself, when it could be heard to go down with
a loxul gurgling noise. In a case of syphilitic stricture
described by West3 the constricted portion occupied t\v<>
inches and a half of the oesophagus about its middle, and was
so narrow as barely to allow a No. 4 catheter to go through ;
above this point the gullet was much dilated. In 1877 a
case was reported by Nicoladoni4 in which the patient, a girl
aged four, hail swallowed lye two years before she came
under notice. (Esophagostomy was done with a fatal result,
and after death the gullet was found narrowed for about eight
centimetres at its middle. Above the point of stricture
the tube was irregularly dilated for two and a half centi-
metres, the bulging being greatest towards the front and
the left side. In 1878 Gouguenheim5 described a case of
oasophageal stricture, probably malignant in character, in
which the gullet Avas dilated above the seat of disease, the
\valls of the expanded portion being greatly thinned. S<M.U
afterwards a good example of secondary dilatation was
published by Brazier.6 The patient was a woman, aged
ninety-six, who died of cancer of the stomach. The gullet
was found greatly constricted for six or seven centimetres
at its lower end ; above this narrowed portion was a dila-
tation extending some way upwards, and measuring " some
centimetres" across. The mucous membrane lining this
pouch was sodden and pulpy, owing probably to the pro-
longed sojourn of food at this part. The oesophageal wall
at the point of stricture was found to consist entirely of

1 "Principles and Practice of Physic." London, 1857, 4th ed.
vol. ii. p. 372.

2 'Schmidt's Jahrb." 1859, vol. ci. p. 298.

3 'Dublin Quart. Jouru. of Med. Science." No. 57. FeK 1860,
p. 86, et seq.

4 'Wien. Med. Wochenschr." 1877, No. 25.

5 ' Gazette des Hftpitaux." 1878, p. 446.

8 'Contribution k 1'Etude de I'CEsophagisme." These de Paris,
1879, pp. 89, 90.

DILATATIOXS OF THE GULLET.

121

bundles of muscular fibres, so rigid as almost to suggest the
idea of contraction. A case has recently been recorded by
Marchand l in which the gullet was expanded above the
situation of an epitheliomatous growth ; this being the only
instance among thirty autopsies collected by that writer in
which such a condition was found.

A case of a different kind has been reported by Wilks,2 in
which there was a supposed congenital stricture of the cardiac
end of the gullet with great dilatation of the entire organ
above the point of constriction (Fig. 16), but whether the
dilatation was congenital or
secondary to the stricture can-
not be determined. In cases
of stricture of the gullet, un-
complicated by dilatation, the
food, on reaching the narrow
part of the canal, is usually at
once returned ; but should there
be a dilatation above the con-
tracted portion of the tube, the
food would probably be re-
tained for a time and after-
wards thrown up unchanged.

This form of dilatation may
be distinguished from that last
described by the fact that in
the case of simple pouches, as
already explained, there may
be a difficulty in passing a
bougie at one time and not
at another, whilst if a stricture
be present, the obstruction is
persistent ; the prognosis de-
pends on the original cause of
the affection, and the treatment
must be directed to the stricture.

(See " Cicatricial Stricture.")
SACCIFORM DILATATIONS.

FIG. 16.

WILKS'S CASE OF SUPPOSED
CONGENITAL STRICTURE AND
DILATATION OF THE (ESOPHA-
GUS (AFTER KNOTT).

These depend on weakness
of a small portion, generally of
the muscular structure, of the wall of the gullet.

They have

"Neoplasies de 1'CEsophage. " These <le Paris, 1880, p. 50.
"Guy's Hosp. Rep." 1871-2, vol. xvii.

}'2'2 IUSK.VSKS ill' TIIK THKOAT AND

been called " prcssure-diverticula " (" PuIsions-I >ivcrtikel ")
by /iemssen, owing to the. fact that they are formed by
y</<x.w//v of the o-sophageal wall outwards.

They vary in si/c from a slight bulging to a sac five?
inches or i' veil more in length. They arc rare, rind arc. in
the majority of instances, situated in the posterior wall of the
•MfftiagUB, nt its junction witli the pharynx, and pass down
lietween the food-tract and the vertebral column. They
are, in fact, phaiyngeal rather than <esophageal pouches.
Most writers believe that these pouches originate in con-
genital weakness of a limited portion of the cesophageal wall.
Although the protrusion is very slight, and perhaps inappre-
ciable in early life, it is probable that the oesophagus gives
way under some trifling pressure at a later period. Hitherto,
no example of this condition has been observed in a new-
born infant, or even in a child, but a case has recently been
published by Fer^,1 which furnishes a possible explanation
of the mode of formation of some cesophageal pouches.
Although in this instance the deficiency of tissue was not in
the situation where a pouch is usually formed, but at a
spot precisely in the middle of the anterior wall of the
gullet, the case has a direct bearing on the point \mder
consideration. The muscular coat was found to be want-
ing over a space one millimetre square, and about one
centimetre below the upper end of the oesophagus. Even
with the microscope no trace of muscular covering could
lie seen in this place. The borders of the space were
thickened, and the interval was filled up by areolar tissue
mingled with some elastic fibres. The congenital absence of
the muscular covering at any point would, it need scarcely
be remarked, greatly favour the development of a jxnich.
lUllroth,'2 however, who had recorded an instance in which a
pouch on the left side of the gullet was covered, not only
by the mucous membrane, biit by the proper muscular
investment of the tube, suggests that such diverticula have
their origin in a branchial fissure, the internal orifice . .f
which remains patent, whilst the external outlet has become
obliterated in the normal way. Cases are more often met
with in men than in women. In twenty-nine cases collected
by Zcnker and Ziemsscn :i in which the sex is stated, there

1 "Progres Medical." 1879, vii. p. 227.

2 "Clinical Surgery." Syd. Soc. Transl. London, 1881, p. 130.

; •• /H-iiisseu's Cyclopaedia of Pract. Med." English Trausl. vol.
viii. p. 64.

DILATATIONS OF THE GULLET. 123

were but two women, and in both of them the origin of the
affection was apparently traumatic. According to the same
authors,1 the disease most commonly begins after the fortieth
year, and they explain the special predisposition of males, and
the age at which the disease occurs, by the ossification of the
cricoid cartilage, which, it is well known, is much more fre-
quent, and comes on at an earlier age in men than in women.
Zenker and Ziemssen2- point oat that the muscular invest-
ment of the pharynx is weaker near its junction with
the gullet than at any other part of the pharyngo-
oesophageal canal, for where the lower fibres of the inferior
constrictor muscle become continuous with the upper circular
fibres of the oesophagus there is a triangular space left
covered only by the transverse fibres of the constrictor.
< hving to the narrowness of the tube just below this, and the
comparatively unyielding wall formed in front by the back
of the cricoid cartilage, a hard morsel of food or a foreign
body is likely to be driven against the posterior wall. A
depression thus made is liable to be constantly enlarged
by the pressure of descending food, and the pouch, which
mainly consists of mucous membrane protruded between the
muscular fibres, has no power of emptying itself by con-
traction on its contents. As it becomes larger it pushes
the corresponding part of the oesophagus slightly forwards,
and subsequently the food, in descending, tends to pass
into the diverticulum, instead of going clown the normal
canal. Further, as the pouch becomes full, resistance to its
distension in a backward direction is offered by the vertebral
column, and consequently the sac presses anteriorly on the
oesophagus, and sometimes closes it completely. A good
illustration of this form of compression is shown in the
annexed drawing of a case (Fig. 17) reported by Dr. Ogle.;-
For many years the patient had suffered from extreme
dysphagia, which was sxipposed to be due to stricture of the
tube. Cases originating in the manner above described have
been published by Ludlow,4 Dendy,5 and Kiihne.6 Gassner "
records an instance of the affection in which an officer
received a severe injury to his neck in a fall from horse-back,

1 Op. cit. p. 65. 2 Ibid. p. 59.

* "Trans. Path. Soc." London, 1866, vol. xvii. p. 141.

4 Loc. cit.

"Lancet." June, 1848.

" Froriep : " Chirnrgische Kupfertafeln. " Weimar, 1820 — 1847.
Taf. 392.
7 Fridberg : " Diss. de o?sophagi diverticulis." Giessen, 1867.

124

DISEASES OF THE THROAT AND N"-K.

which gradually resulted in the formation of an oesophageal
punch, which ultimately caused his death. In a case reported
by Waldenburg 1 tin; patient ascribed the origin of the con-
dition to his having been throttled, whilst in another de-
scril)fd by Klose12 the supposed cause was the inipactinn

FIG. 17. — OGLE'S CASE OF SACCIFORM DILATATION OF THE
(ESOPHAGUS (AFTEU KSOTT).

of a fishbone. Biicking3 has related an example (which,
however, was not verified by post-mortem examination), in
which the affection was ascribed to wearing too tight a
necktie. I have recently met with a case (see " Cicatricial
Stricture") in which a small pouch two and a half cen-
timetres in length and four millimetres in diameter re-
sulted from the swallowing of a strong alkaline solution.

1 " Berlin Med. Wochenschr." 1870, No. 48, p. 578.

- "Giinsburg's Zeitschr. fur klin. Med." 1850, Bd. i. p. 344.

3 "Baldinger's Neues Magazin fur Aerzte." 1781, Bd. iii. ]>. Jl'J.

DILATATIONS OF THE GULLET. 125

The sac was situated about seven centimetres above the
cartlia. Half of it was really a fistulous passage between
the muscular coats, but the lower portion, which projected
obliquely downwards and was covered with muscle, was
a true pouch. .The sac communicated with the ossophagus
by means of three small openings (see Fig. 20, d). It
probably became developed in the following manner : — The
caustic solution caused an ulcer in which particles of food
lodged ; further swallowing drove the first particles — pos-
sibly some gritty substance — more deeply into the wall
of the gullet, which finally was itself pushed out.

The symptoms are at first so slight as not to attract
much notice. They consist chiefly in the temporary
retention of small fragments of food. It is only when
the diverticulum enlarges and begins to press on the gullet
that medical advice is sought. Owing to the situation of
the pouch, when it attains any size, it is always visible in
the neck at the side of the larynx. The swelling may
be unilateral or bilateral. It is often impossible to pass a
bougie, but it sometimes happens that it can be pushed down
one day and not the next, the possibility of introducing the
instrument depending on the fulness or emptiness of the sac.
As a rule, when this is full, the ossophageal canal is pressed
upon, and the bougie cannot be passed, but sometimes when
the sac is of moderate dimensions, its temporary distension
by food prevents the sound entering the abnormal cavity,
and permits it to traverse the normal canal. In an instance
reported by Belz1 a loud splashing sound could be heard on
pressing over the episternal notch. As the sac increases in
size a considerable quantity of food lodges in it, and this
is from time to time regurgitated in a manner somewhat
resembling rumination. After a time the patient may
gradually waste, and actually perish from inanition. In
many cases, however, death has not taken place till an
advanced age.

The pathology of these cases is very simple. The pouch,
as already remarked, almost invariably forms at the junc-
tion of the pharynx with the ossophagus, and as it increases
in size it usually becomes pyriform in shape. The
lining membrane of the sac generally shows signs of
chronic inflammation. The mucous membrane and the
tubmucoea are, very much thickened, the surface of the
former being sometimes covered Avith papillary growths.
1 " Schmidt's Jahrb." 1873, Bd. clx. p. 183.

126 DISEASES UK Tin; THROAT AND XOSE.

Zenker and Ziemssen J maintain tliat tlv sac ha* i/»
i-nlar rnri'i-imj t'.n-/-/,f at it* w/v/r, but in Worthington'l
ease it is stated that "nearly the upper two-thirds wen-
covered witli muscular fasciculi derived from the pharyngeal
constrictors, the fibres of which wen- unusually developed,"
and in Billroth'.s case, as already pointed out, the sac had
a complete muscular covering. The disease does not seriously
shorten life, for out of nineteen cases collected by Zenker
and Ziemssen,2 in which the age is given, death took place as
follows : —

Deaths.
Between the ages of 40 and 50 . .. ..2

50 „ 60

60 „ 70

70 , , 80

At the age of 80

These authors further point out that the progress of the
disease is generally very slow, and that in many cases it is
reported to have lasted from twenty to thirty years, and in
one instance for forty-nine years.

The brief remarks made under " Simple Dilatation " as
to diet and treatment apply here.

TRACTION-DIVERTICULA.

The peculiarity of these diverticula is that the ca
tin in i* alt'xji'tluT <'.i-f/'i-)ta/ to tJif cesoplMyeal mill.

This form of dilatation is relatively common, and is
generally found on the anterior wall of the oesophagus, most
frequently at a point either opposite or very near to the bifur-
cation of the trachea. These diverticula are generally, but
not invariably, conical in shape, the broad base correspond inn;
to the oasophageal wall, and the apex directed horizontally
forwards or even upwards. The disease probably begins in
childhood, and it seems to affect both sexes in nearly equal
proportion. Out of fifty -four cases collected by Zenker ami
Ziemssen,3 twenty-nine occurred in men, and twenty-five in
women. The sacs vary in size from two to eight millimetres,
but occasionally they measure as much as twelve millimetre!
from the base to the apex ; indeed, in the case reported by
KridlM-rg,4 the {K>uch was one and a half inches long.

Traction-divert icula appear to originate most commonly

1 Op. cit. p. 57. - Op. cit. p. 64.

3 Ibid. 4 Op. cit.

DILATATIONS OF THE GULLET. 127

in scrofulous disease of the lymphatic glands, which are
so abundant about the bifurcation of the windpipe. The
inflammation spreads from the gland to the peri-ossophageal
areolar tissue, and sometimes reaches even the muscular
coat : subsequently, fibroid or calcareous degeneration of
the gland takes place, followed by cicatricial contraction,
and it is by the latter process that the Avail of the gullet
is drawn out and a sac formed. In some instances the
suppuration of a scrofulous gland appears to have produced
direct ulceration of the oesophageal wall, and in such cases
the altered gland-structure forms the outer covering of the
diverticulum. It is probable that these are the cases in
which the conical form is not preserved. Vertebral caries has
sometimes led to the formation of pouches.1 The disease
occasionally seems to originate in the trachea from the
inhalation of gritty particles, which by setting up disease
in the respiratory passages may ultimately lead to peri-
ossophageal contraction.

As far as I am aware, this form of diverticulum never
gives rise to any symptoms during life. It is just possible
that in some cases the orifice of the sac might be seen on the
anterior wall with the cesophagoscope. The opening is
generally exceedingly black, and the mucous membrane
around it puckered, and if it came within the range of the
mirror it could not be mistaken.

The form and size of traction-diverticula have already
been described, and it now only remains to be observed, that
in those cases in which the fundus of the diverticulum has
ulcerated, disease of adjacent organs is often noticed after
death. In such instances a dark-coloured fluid and occa-
sionally portions of food are found within the sac ; and
Rokitansky 2 has reported a case in which a small flat piece
of bone was met with, which was supposed to have given
rise to a perforation at the distal end of the diverticulum.
In such cases a fistulous tract may even extend to the
pericardium, the pleural cavity, or the apex of one of
the lungs, where it is sometimes in communication witli
a previously existing vomica. The most frequent course
of the fistula, however, is into one of the bronchi. The
passage of small particles of food or portions of ichorous
matter into the bronchial tubes may give rise to bronchitis,
pneumonia, or even gangrene. The fistula may cause instant

1 Zenker and Ziemssen : Op. cit. p. 75, foot-note 1.
3 "Lehrb. d. pathol. Anat." Wien, 1861, p. 38.

128

I'I.-I;.\SE8 OF THE THROAT AM'

death by perforation of the aorta, as in a case observed by
< ;. Merkel,1 but this is a very rare phenomenon.

As the disease has not hitherto been recognized during
life, the question of prognosis does not come within the
domain of practical medicine. No treatment is likely to be
of any avail, and should the complaint be suspected, all that
the physician can do is to recommend a soft and non-irri-
tating diet.

The following is a good illustration of traction-divertieulum
which recently came under my notice : —

In the gullet of a man, aged fifty-three, a pouch was found, of
which the annexed woodcuts give a good representation (Figs. 18 and

19). It was situated at the junction of the anterior and left walls,
the opening being vertical in direction, and irregular from puckeriiu:
of the mucous membrane. The aperture was from four to five milli-
metres wide and nineteen in length, its upper end being rather mole

1 " Ziemssen's Cy< l<>p;e<li;i." vol. viii. j>. M.

CICATRICIAL STRICTURE OF THE GULLET. 129

than nine centimetres below the lower rim of the cricoid cartilage.
The diverticulum was large enough to admit the tip of the little linger,
and extended inwards for eleven millimetres at the deepest part.
The lining membrane was perfectly healthy but much puckered.
The direction of the pouch was horizontally forwards to the trachea,
into which the fibres were inserted by a quasi-aponeurotic band of
thickened areolar tissue. The attachment was about a quarter of an
inch in breadth, and joined the posterior wall of the trachea to the left
of the middle line — that is to say, altogether on the cartilaginous part
of the air-tube ; the insertion of the pouch was more or less vertical
in direction, corresponding to flie intra-cesophageal opening, but
with a distinct inclination downwards and inwards. External to
the pouch were some enlarged glands, and it was surrounded,
especially near the tracheal extremity, by a good deal of thickened
tissue. No symptoms traceable to this condition had been noticed
during life. The patient died from cancer of the gullet, but the
malignant disease was at the upper part of the tube, and did
not approach nearer than from two to three centimetres to the
pouch. No connection could be discovered between the two affec-
tions, and, as far as could be judged from the appearance of the
surrounding tissues, the diverticulum was long antecedent to the
carcinomatous growth.

CICATRICIAL STRICTURE OF THE GULLET.

Latin Eq. — Coarctatio oesophagi a cicatrice.
French Eq. — R^tre'cissement cicatriciel de 1'oesophage.
German Eq. — Narbige Strictur tier Speiserbhre.
Italian Eq. — Strettura cicatriciale del esofago.

DEFINITION. — Diminution of tlie lumen of the oesophagus
caused by contraction of the cicatrix of a previously existing
nli-iT or wound, giving rise to severe dysphagia, and often to
death by starvation.

History. — The ancient physicians had probably no acquaintance
with traumatic stricture of the gullet, for in those days the strong
acids and the weak alkaline solutions, now so largely used in the arts
and for household purposes, were confined to the alchemist's labo-
ratory. (Esophageal stricture, however, arising from the healing
of syphilitic or variolous ulcers1 did not escape the notice of the
earlier writers. (See "Syphilis of the Gullet.") Cicatricial con-
traction was distinctly recognized by Beutel2 as a possible cause of

i Two cases have been related (Brechfeld : "Ephem. Natur. Curios." 1671,
p. 182. Lanzoni : Ibid. Ann. ii. Obs. ix. t. xlv. p. 80) in which obstruction appears
to have been due to the agglutination of the opposite sides of the gullet from
ulceration consequent on variolous pustules. The affection, however, is so ex-
tremely rare, that it has not been thought necessary to treat of it in a separate-
article.

- " De struma oesophagi." Tubingen, 1742.

130 DISEASES OF THE THROAT AND NOSE.

narrowing of the cesophageal canal, and it was also mentioned by
Morgagiii.1 At a later period cases of injury to the oesophagus from
corrosive solutions, followed by stricture of its channel, were related l>y
Charles Bell,2 Cumin,8 Dewar,4 Syme,8 Gendron,8 Bayle and Cayol,7
Wolff,8 and Behier.9 In 1862 Keller10 reported a number of cases
•>ccurring in young children, whilst quite recently Wolzendorf u has
published ninety-one examples of the affection collected from various
sources.

1 ' De sed. et causis morb." ed. secunda. Patavii, 1765, ep. xxviii.

2 ' Surgical Observations." 1817, vol. i. p. 80.

8 ' Trans. Edin. Med.-Chir. Soc." 1827, vol. ill. p. 600, Ac.

* ' Edin. Med. and Surg. Journ." vol. xxx. p. 310, &c.
5 ' Edin. Aled. and Surg. Journ." October, 1836.

* ' Journ. des Connaissances Me'd.-Chir." 1837.

7 ' Diet, en 60 volumes," t. Hi. 'p. 615.

8 ' Archiv. G6n." 1853, t. ii. p. 490.

9 ' Conferences de Clinkiue Medicale." Paris, 1864, pp. 113-117.

10 ' CEsterr. Zeitung fur prakt. Heilk." 1862, Xos. 45-47. Keller's cases have
already been referred to under " Traumatic ffisophagitis."

« " Deutsche Militar&rztl. Zeitschr." 1880, p. 477.

Etiolof/y. — Cicatricial stricture of the gullet may result
from any disease or injury in which ulceration is followed
by healing. The most common cause of these contractions is
probably to be found in the swallowing of weak alkaline solu-
tions, especially soap-lees, but occasionally they are due to the
action of concentrated poisons (see " Traumatic CEsophagitis ").
Most of the patients in this country are adults, but abroad the
accident appears to be not unfrequent among children and even
infants, Keller having reported no fewer than forty-five cases
met with in children between twelve and fifteen months old.
Contraction also sometimes arises from the temporary impac-
tion of a foreign body producing an ulcer, which ultimately
cicatrizes. Leroux l mentions a case in which the narrowing
followed the swallowing of very hot liquid containing a piece
of leek. A most interesting case has lately been related by
Dr. Kendal Franks,2 in which gradually increasing dys-
phagia had followed the impaction of a hard piece of bread-
crust. When the patient, a girl, aged twenty, was first seen
by Dr. Franks, the affection had existed for four years and a
half, and she was much emaciated. There was no evidence
of hysteria, and I think there can be no doubt that the stric-
ture was due to cicatricial thickening at the place where the
gullet had been injured by the rugged edge of the crust at
the time of the accident.

Symptoms. — The characteristic symptom of cicatricial stric-
ture of the oesophagus is dysphagia, which in general terms

1 " Cours sur les Generalites de la Medecine pratique." Paris,
1825, t. i. p. 315.
3 " Med. Press and Circular." April 19, 1882, p. 335.

CICATRICIAL STRICTURE OF THE GULLET. 131

may be said to vary in degree according to the amount of
narrowing of the canal. Sometimes, however, though the
actual organic obstruction may be slight, deglutition is
rendered difficult by superinduced spasm. Where the con-
traction results from the swallowing of a weak caustic or
irritant solution, there is generally, at the commencement, an
inflammatory period, during which there is great dysphagia
and often odynphagia ; these symptoms persist as long as the
ulceration continues, but when the ulcer heals, the patient
can usually swallow with ease, and for some time may con-
sider himself cured. At the end of a few months, however,
owing to the contraction of the tissue forming the cicatrix,
difficulty in swallowing is again experienced. From this
period the dysphagia generally grows steadily worse, and if
not relieved is extremely likely to prove fatal. In cases where
the poison has been a strong caustic, the dysphagia does not
pass off at all, or only subsides for a few days, and soon again
becomes urgent. Thus in a case reported by Fugier,1 after
the expulsion of a large mass of membrane, liquids passed
easily, but this improvement only lasted for twelve days,
when it became impossible for the patient to swallow nourish-
ment of any kind. The course of cicatricial stricture result-
ing from disease is very similar to that arising from accidental
injury, for the dysphagia from which the patient suffers whilst
the ulcer is open, passes off as the surface heals, and again
causes trouble after cicatrization.

The position of the stricture may be ascertained by auscul-
tation, or by the passage of a bougie. On listening over the
course of the oesophagus posteriorly it will be noticed that
fluids pass at the ordinary rate and give rise to the normal
sound till they reach the upper part of the stricture, when
the fluid is partially arrested, and a gurgling or trickling
noise is perceived below the point of obstruction. The latter
phenomenon may be observed to continue for three, four,
or even five minutes after a mouthful of fluid has been
swallowed. On using the bougie, the instrument is either
arrested at the point of obstruction, or is passed beyond it
with difficulty. Sometimes a second stricture may be found2
lower down, whilst occasionally even three strictures are
present.3

1 " Des Retrecissements de l'(Esophage." Th&se de Paris, 1877
p. 20.

" Bull, de la Soc. Anat." 1841, p. 170.
3 Basham : " Med.-Chir. Trans." vols. xxxiiL and xlv.

132 DISEASES OF THE THROAT AND NOSE.

i*. — As a rule, in the traumatic cases, the
presents no difficulty, the history of an irritant poison having
been swallowed at once removing all doubt. It is only
in very rare instances — where, for example, the temporary
lodgment of a foreign body, or the fact of an irritant having
been swallowed in early life has been forgotten, or where
a caustic poison having been taken suicidally the patient
is unwilling to confess the circumstance, or where an insane
person is the subject of the stricture — that any question
can arise. Under such exceptional circumstances it will In-
necessary — first, to determine whether the difficulty of swal-
lowing be due to stricture or to compression of the oesopha-
gus ; and, secondly, in the event of the affection being intra-
cesophageal, to eliminate the various other diseases of the
gullet. In cases of compression, the difficulty of swallowing,
though considerable, is seldom so marked as in cicatri«-ial
stricture, except in certain rare instances of fibrous or can-
cerous enlargement of the thyroid gland, or of tumour in
the posterior mediastinum. In aneurism of the arch of
the aorta, and enlargement of the cervical or bronchial
glands, as well as in peri-cesophageal abscess, the difficulty
in swallowing is seldom so extreme or so constant. The
morbid conditions, moreover, which cause dysphagia by com-
pression are in most cases sufficiently obvious to be at once
recognized. They will be again referred to in the article »n
"Compression of the Gullet."

The only diseases of the oesophagus itself which require
to be differentiated from cicatricial contraction are cancer
and simple stenosis. Malignant disease may be recognized
by its usual occurrence in persons over forty years of age, and
by its progressive character, the dysphagia generally attain-
ing its full intensity in the course of a few months. The
special, though not invariable, characteristic of true cicatricial
stricture, on the other hand, is the peculiar character of the
dysphagia — that is to say, its primary occurrence, its disap-
pearance, and its subsequent return in a more severe and
intractable form. In cases of simple stenosis there is a his-
tory of difficulty in swallowing from an early period of life,
and the symptom is not progressive. Where cicatricial stric-
ture results from the healing of an ulcer caused by disease,
a clear history of the previous existence of the constitutional
complaint can alone establish the diagnosis.

Pathology. — The stricture in traumatic cases nearly always
occupies two or three inches of the gullet, and may occasion-

CICATRICIAL STRICTURE OF THE GULLET. 133

ally involve its entire length. In a case reported by Czerny,1
cicatricial tissue replaced the normal structures throughout the
lower third of the tube. In one of my cases (Sarah C.), here-
after reported, the stricture extended from within half an inch
of the cricoid cartilage to within an inch of the cardia. In
nearly every instance the walls of the ossophagus are con-
siderably thickened. The lumen of the canal is generally
very much narrowed, and sometimes, as in a case related by
Horsey,2 absolutely obliterated, the gullet being represented
by a dense fibrous cord. The lining membrane presents con-
siderable variety of appearance, for sometimes long vertical
folds are met with, which during life, no doubt, meet in the
centre of the canal, or even interlock in such a way as
completely to occlude the passage. Sometimes there are
transverse bands, and not unfrequently a rough reticular
structure is found formed by short fibrous ridges running in
every direction, whilst occasionally a quasi-cribriform appear-
ance is produced by the presence of a great number of small,
deep excavations. In nearly all cases there are some smooth
indurated patches where the mucous membrane has been
replaced by cicatricial tissue. Although dilatation of the
oasophagus above the seat of stricture is not generally observed
in cases of cicatricial contraction, still it has been occasionally
met with.3

I'i'dtjnosis. — The prospects of the patient depend a good
deal on the strength of the irritant solution which has
been swallowed. For this reason, in suicidal cases where
strong mineral acids are usually taken, extensive and intract-
able cicatrices are much more likely to be present than
where patients have accidentally swallowed solutions of
soap-lees. It may, however, be laid down as a general rule
that cicatricial stricture is always attended with considerable
danger, for not only is it often exceedingly difficult to effect
dilatation, but even in cases where some degree of expansion
has been produced, subsequent contraction is likely to take
place unless the use of bougies is regularly persevered with.
.Many instances of cure, however, have been reported. The
most successful series is that of Keller's 4 thirty-five cases,
of which twenty-three were cured, three benefited, five died
(one of them from gangrene of the lungs), and four remained

" Beitriige zur Operativen Chirurgie." 1878, p. 70.
"Amer. Journ. Med. Sci." 1876, New Series, Ixxii. p. 114

3 See " Dilatations of the Gullet."

4 Loc. cit.

134 DISEASES OF THE THROAT AND NOSE.

under treatment at the time of the report.1 "When it is
remembered that in all these instances the patients were
infants under two years of age, the success of the treatment
is all the more remarkable, and must indeed be regarded as
quite exceptional. It is probable that in many of these cases
the obstruction was due rather to inflammatory thickening
and induration than to actual cicatrization. Out of seventy-
five cases of which details are given by Wolzendorf,2 twenty-
three proved fatal.

Treatment. — Medical treatment is of little use, but, as is
shown by the above figures, surgery claims many cures.
More often, however, all that can be done is to prolong
life. The following are the various methods of combat-
ing the local condition : — 1, gentle dilatation ; 2, forcible
dilatation ; 3, internal cesophagotomy ; 4, oesophagostomy ;
and 5, gastrostomy.

Gentle dilatation is the method by which the largest
number of cases have been cured, but it is obvious that its
success is likely to be greatest where the disease is slight
and recent, and more especially in those cases which, though
originating in the same way as true cicatricial stricture, and
scarcely to be distinguished therefrom in their clinical history,
strictly belong to the class of indurations. Dilatation is best
effected by passing bougies of gradually increasing diameter.
The mode of using these instruments has already been de-
scribed (pp. 11 and 12). "Where there is obvious difficulty in
swallowing, a No. 6 (Author's scale) should first be tried, and
if this will not pass, a smaller instrument must be employed.
As the passage of the bougie often provokes coughing and
a considerable flow of saliva and mucus, the patient should
be made to bend forwards in order that the secretion
may fall easily into a hand-basin. The bougie should,
if possible, be left in position on the first occasion for five
minutes, and as the patient gets accustomed to its use, he
may be able to tolerate it for ten or twenty minutes or even
for half an hour at a time. The operation may be repeated
twice a week, and in some cases on alternate days. Very few
patients can bear the daily passage of the instrument. The
same size of bougie should be passed on at least two occasions,
and generally it is better to use it three or four times before

1 Keller reports forty-six cases of traumatic cesophagitis caused
by swallowing soap-lees, but eight of these were slight cases, in
which 110 stricture resulted, and three died soon after the accident.

2 Loc. cit.

CICATRICIAL STRICTURE OF THE GULLET. 135

a larger one is employed. Some surgeons, after withdrawing
a bougie, immediately try to pass a larger one, under the im-
pression that an instrument of greater size can by this means be
more easily made to traverse the stricture. I have not found
this to be the case, but on the contrary it has appeared to
me that the passage of one bougie generally gives rise
to a slight amount of congestion, which renders it difficult
to introduce a second one at the same sitting. In adults it
is unnecessary to dilate the oesophagus beyond the size of
No. 15 (Author's scale), whilst for children under twelve,
bougies larger than No. 8 should not be used, and for those
between twelve and sixteen years of age, the maximum size
should be No. 12.

I formerly attempted to dilate cicatricial strictures by means
of oversliding catheters — that is to say, by first passing a
whalebone bougie, and then running over it a catheter finely
tipped with metal ; but though I tried a great variety of
instruments, I found that owing to the relaxed condition of
the walls of the oesophagus, the catheter was so often caught
in the folds of the mucous membrane, that I was obliged to
give up this method.

Forcible Dilatation. — My experience of forcible dilatation
has not been satisfactory. In 1862 and the following year I
had several instruments made,1 and I had an opportunity of
using them in four cases of cicatricial stricture, but though I
did not meet with any accident, I found it extremely difficult
to apply the dilating force at exactly the right spot, and also
to regulate the degree of expansion. Some of these cases
which appeared to be cured 2 at the time relapsed after a
few months, and I ultimately abandoned the method alto-
gether. Quite recently, however, Dr. Kendal Franks3 has
been more fortunate, and in the case already alluded to nnder
" Etiology," he succeeded in effecting the cure of a fibrous
stricture by rapid stretching with Otis's dilating urethrotome
followed by the regular passage of bougies.

Of the remaining operations, internal oesophagotomy,
oesophagostomy, and gastrostomy, the two latter have been
performed much more frequently for cancerous than for
cicatricial stricture, not because the results in the former

1 By Krohne and Sesemann.

* See a report of one of these cases in the "Transactions of the
Clinical Society," 1870, vol. iii. pp. 181, 182, where also a description
of the instrument which I used may be found.

3 Loc. cit. p. 335.

136 DISEASES OF THE THROAT AND NOSE.

condition promised to he more favourable, but because cancer
of the gullet gives rise to. obstruction much more often than
any other affection. It has therefore been thought desirable
to consider these two operations irrespectively of the special
lesion for which they have been undertaken.

Internal (Eupkagatom/y. — Strictures may sometimes In-
cut through by means of an instrument introduced through
the narrowed portion of the gullet.

History of the Operation. — To Maisonneuve l belongs the credit of
first attempting to relieve cieatricial stricture of the gullet by internal
incision. He operated on three cases, of which two died and one
recovered. In the two fatal cases the patients wen- women, and
succumbed to peritonitis, which Maisonneuve believed to have l»-rii
set up by the operation in consequence of a special sympathy which
he assumed to exist between the gullet and the peritoneum. In ;i
fourth case in which the same surgeon attempted internal oesophago-
tomy the patient's death was due to a false passage which was
made into the posterior mediastinum. Lanelongue2 soon afterwards
operated successfully. Dolbeau 3 performed the operation on two
patients, both of whom appeared to be cured as long as they continued
under observation. Trelat4 had a good result from the procedure
ill spite of severe primary and secondary haemorrhage. Tillaux,5
Studsgaard,6 and Schilz,7 have each reported a successful case. The
last-named surgeon was less fortunate in a second instance, in which
the patient died from profuse haemorrhage.8 Czerny9 performed the
operation on a child who died from peri-oesophageal cellulitis
complicated by diphtheria. Recently cases have been treated after
this method by myself and by Dr. Roe,10 of Rochester, U.S., the
particulars of which will be found below. Dr. Elsberg,11 of IS'ew
York, has also operated successfully in two cases.

Clinique Chirurgicale." Paris, 1864, t. ii. p. 409.

Mem. de la Soc. de Chir. de Paris." 1865, t. vi. p. 547.

Gazette des H6pitaux." 1870.

Bull. Gen. de Therap." 1870, t. Ixxviii. p. 252.

Bull, de Therap." 1872, t. Ixxxiv. p. 14.

Canstatt's Jahresb." 1873, Bd. ii. p. 487 ; and 1875, Bd. ii. Abtheil. ii. p. 297.

7 ' Correspondenz-Blatt. d. arztl. Vereins in Rheinland." April, 1877, No. 19,
p. 19.

8 Ibid.

' Beitrage zur Operat. Chirurg." 1878, p. 70.
' New York Med. Record." Nov. 11, 1882.
11 ' Arch, of Laryngol." Jan. 1883, vol. iv. No. 1, p. 56, et seq.

The stricture has sometimes been divided from above
downwards,1 but this method is extremely dangerous, and
should never be attempted. The incisions should always
be made from below upwards. The use of the cesopha-
gotome (Fig. 9, p. 21) is perfectly simple. It is introduced
with the blade concealed, and when the portion of the
instrument containing the knife is felt to be below the
stricture, the blade is to be made to project, and by a rapid

1 By Maisonneuve, Lanelongue and Studsgaard.

CICATRICIAL STRICTURE OF THE GULLET. 137

upward movement of the instrument the obstructing band
should be cut through. If necessary two or three incisions
may be made. A week after the operation a medium-sized
bougie should be passed to counteract the tendency of the
divided tissues to shrink in healing, and instruments of
gradually increasing size should be used from time to time.

From an examination of the results of the published
cases (see " History ") internal oesophagotomy does not appear
to be a very satisfactory operation. Of the seventeen cases
in which it has been practised, four died, i.e., 23'5 per cent.
This estimate includes only cases which proved fatal within
fifteen days of the operation ; the mortality would doubtless
appear much higher if all the cases were counted in which
death, though directly traceable to the operation, did not
occur within the above-mentioned period. Thus, in my own
case the patient died three months after the oesophageal
stricture was divided, but the pulmonary inflammation, to
which he ultimately succumbed, came on so soon after the
operation that it is most probable there was a causal relation
between the two events.

On analysing the statistics more closely it will be found
that the operation has been done eleven times for the relief
of cicatricial stricture, twice for ossophageal stenosis of an
indefinite nature, once for malignant, and once for tubercular
disease. Of the remaining two cases I have no details
beyond the fact recorded by the operator that they were
successful. Of the cicatricial cases three, i.e., 27 '28 per
cent., died. This average, however, would be considerably
reduced if each individual act of oesophagotomy were to be
counted as a separate case, for the operation was performed
six times on one of the patients, three times on another, and
twice on a third. This would raise the total mimber of
operations to nineteen, with a mortality of only 15 '7 per
cent. In the case of malignant disease intra-oesophageal
section was practised five times, on each occasion with
definite, though transient, benefit, and the patient finally
died of phthisis. The patient with tubercular stricture died
of peritonitis four days after the operation.

The advantat/es of internal oesophagotomy are : —

1st. That it is attended witli an inconsiderable amount of
shock.

2ndly. That if the stricture can be thoroughly divided,
gradual dilatation can be carried out and a cure thereby be
effected.

138 DISEASES OF THE THROAT AND XO8E.

3rdly. That the procedure involves no external wniind re-
quiring constant attention and giving rise to disfigurement.

The tlixd'ti'dufdi/i'x of internal oesophagotomy are : —

1st. That it can only be safely performed in cases where
it is still possible to get a bougie through the stricture.

•_'mlly. That owing to the formation of tin-si- strictures,
which often extend far down the gullet, it is difficult to get
beyond all the points of obstruction. ( It may be added that
in many cases of cicatricial narrowing the obstructing ri
are vertical in direction, and therefore cannot be divided by
any instrument [see Fig. 20, a].)

3rdly. That in many cases the walls of the oesophagus are
so much thickened that limited longitudinal incision cannot
relieve the obstruction.

4thly. That the actual danger attending the performance
of the operation is far from inconsiderable. (Indeed, the
thinness of the oasophageal walls, the close proximity of
many vital organs, and the fact that in disease the gullet is
often intimately adherent to the surrounding parts, constitute
dangers which cannot be ignored. In one of the fatal cases
death was due to haemorrhage, and in one of the successful
operations bleeding occurred to an alarming extent.)

The following case illustrates cicatricial stricture : —

Henry A. drank a solution of potash on September 17, 1880, and
in spite of immediate treatment at the London Hospital, his gullet
became so much narrowed that thirteen weeks elapsed before he was
able to swallow fish. The stricture was treated by gradual dila-
tation until February, 1881, when, owing to an attack of small-pox,
the patient discontinued his attendance for four weeks. When
seen again he could swallow nothing but jelly. He was admitted
into the Hospital for Diseases of the Throat, under my care, on
April 7, 1881, being by that time in an extremely weak condition.
The stricture was found to begin just below the level of the cricoid
cartilage, the canal of the oesophagus at the affected part being very
tortuous and deviating to the left side. Gradual dilatation rendered
it possible to pass a No. 8 bougie by June 2 ; but more than a month
later an advance of only one size had been made. On July 121 per-
formed internal cesophagotomy, dividing the stricture in the middle
line behind from below upwards. A No. 14 bougie could then be
passed without difficulty. The pain of the operation was slight, but
in a few hours the patient began to feel some discomfort over the
base of the right lung, and unmistakable signs of pneumonia soon
afterwards showed themselves. Dilatation with bougies was resumed
after a few days, and in August No. 15 could be passed easily. The
patient was shown to the members of the International Congress on
August 4, and at that time, whilst still suffering from some pulmonary
trouble, his general condition was fairly satisfactory, He passed
from my care a day or two afterwards, as the Throat Hospital had to
be closed for the purpose of being rebuilt. He soon afterwards re-

CICATBICIAL STRICTURE OF THE GULLET. 139

entered the London Hospital, and died in that institution about the
middle of October, 1881. At the autopsy both lungs showed patches
of pneumonia, and there was some purulent effusion in the right
pleura. The gullet was found thickened to such an extent as to
narrow considerably the calibre of the tube for three inches down-
wards from the level of the cricoid cartilage. The strictured portion
was found to have been divided posteriorly for about an inch at the
lower part.

Dr. Roe, of Rochester, U.S., has lately reported two cases1
in which he has successfully used my oasophagotome. One
was that of a lady, aged twenty-four, on whom he twice
operated for stricture of the gullet, making on the first
occasion one posterior incision, and on the second two lateral
cuts, after which dilatation with bougies could be satisfac-
torily carried out.

The patient in the other case was a boy, aged eight years,
whose oesophagus was narrowed at its lower part through the
action of a caustic fluid, to such a degree that even milk
could scarcely be swallowed. Dr. Roe divided the stricture
in six different places at intervals of a few days, and then
practised dilatation with success.

(Esophagostomy. — The gullet may sometimes be opened
either at the seat of stricture, or below it. This is an opera-
tion which, in a few cases, has proved highly successful.

History of the Operation. — The establishment of a fistulous opening
in the neck for the relief of stricture of the oesophagus appears to have
been first suggested by Stoffel.2 The first recorded instance, however,
in which the operation was performed is one briefly alluded to by
Tarenget3 in 1786. The operator's name has not been preserved, but
the case was more successful than any of those which have been done
since. The patient was a woman suffering from what would seem
to have been cancer of the gullet, and in spite of the fact that the
cervical and submaxillary glands were already enlarged at the time of
the operation, she is stated to have survived for a period of sixteen
months, during which she was fed entirely through the fistula. More
than half a century later, Watson4 published a case of what he calls
tubercular stricture, in which he opened the gullet. The disease, how-
ever, was possibly malignant, as there were no signs of tubercle in the
lungs. The patient — a young man, aged twenty-four — lived two
months after the operation, and died of redema of the glottis, and for
which tracheotomy had to be done. The thyroid body was greatly
enlarged, but does not appear to have pressed upon the gullet. Soon
afterwards Lavacherie5 operated on a man, aged sixty-eight, suffering
from what was probably a cancerous stricture of the oesophagus.

1 " New York Med. Record." Nov. 11, 1882, pp. 536, 538.

2 Quoted by Bonet: " Sepulchretum," Lugduni, 1700, lib. lii. sect. iv. Obs. xx
p. 35.

3 " Journ. de M«5d., Chir. et Phar." 1786, t. Ixviii. p. 250.

* " Dublin Journ. of the Med. Sciences." 1845, vol. xxvii. p. 260.
<s "Bull, de 1'Acad. de MM. Koyale de Belgique." 1845, t. iv. p. 758.

140 DISEASES OF THE THROAT AND NOSE.

This case is of somewhat doubtful character, as the cutting operation
appears to have been undertaken mainly, if not solely, for the extrac-
tion of an ivory tube which had been passed into the stricture and
could not be withdrawn. The gullet was opened, and the patient was
fed through a tube, but it is not clear whether this was introduced
through the wound or through the mouth. Death took place on tin-
fifteenth day. (Esophagostomy was successfully performed by Monod1
on a woman suffering from cancerous stricture of the upper part of
the food-channel. She survived the operation three months, and died
from the inevitable progress of the disease. In 1853 Follin- published
a monograph on stricture of the gullet, wherein he advocated ceso-
phagostomy in suitable cases. Richet3 states that he perform i-d
the operation for impermeable narrowing of the gullet opposite the
second dorsal vertebra ; the canal was opened, and a sound passed
through the stricture and left in situ. Unfortunately, no further
details are given, either as to the result of the case or the nature of
the disease. In 1859 Brims4 reported the case of a man, aged thirty-
eight, suffering from dysphagia, on whom he operated. The patient
lived ten days, and, after death, the cause of the complaint was found
to be compression of the oesophagus by an enlarged thyroid. A some-
what similar case was related by the same surgeon* a few years later.
The patient was a man, aged thirty-seven, who had been afflicted
with difficulty of swallowing for a year ; cesophagostomy was done,
and the man died in five weeks. In this case, as in Watson's
above related, death was due to pulmonary disease and to oedema
of the larynx, which made tracheotomy necessary. The thyroid
was found to be somewhat enlarged, and a vast abscess with
gangrenous walls was seen encircling the upper part of the gullet.
Three years afterwards, Willett6 performed the operation on a
woman, aged forty -seven, suffering from ccsophageal carcinoma ; the
patient had begun to regain her strength when she refused to be
fed, and died of exhaustion eighteen days after the establishment
of the fistula. In 1868 Cheever, 7 in an interesting report of two
cases of external cesophagotomy for foreign bodies, took occasion
to make some remarks on the same proceeding when practised for
stricture of the gullet, and two years later the whole subject was
fully discussed by Terrier 8 in an elaborate and valuable monograph.
In 1870 the operation was performed by Menzel9 on a man, aged
forty-four, a patient of Billroth's, who was suffering from cancerous
stricture ; death took place on the following day. Three years sub-
sequently, Podrazki10 performed cesophagostomy on a man, aged
forty, who had suffered from well-marked syphilis ; the patient died
two days afterwards, and his disease, which, during life, had been
supposed to be of venereal origin, was found to be purely carcino-
matous. In 1875 Poinsot11 operated on a woman, aged fifty-five,
whose cesophagus was obstructed by malignant growths ; the patient

' Quoted by Follin : " Rltr&issements tie 1'CEsophage." Paris, 1853, p. 116.

2 Ibid.

S 'Trait£ Prat. d'Anat., MM. Chir." 1860, 2e 6d. p. 508.

4 ' Deutsche Klinik." 1859.

8 Ibid. 1865, p. 37.

« ' St. Earth. Hosp. Rep." 1863, vol. iv. p. 204.

7 ' Two Cases of (Esophagotoniy.*" Boston, 1868, p. 61.

8 ' De 1'OEsophagotomie Externe." These de Paris, 1870.

» ' Wien. Med. \Vochenschr." 1870, No. 56, p. 1350, et seq.
10 Ibid. 1873, Nos. 33, 35, 30.
» Reported by Bidau : " De 1'CEsophagotomie." Bordeaux, 1881, p. 19.

CICATRICIAL STRICTURE OF THE GULLET. 141

expired twenty hours after the operation. In 1876 l I recorded a
case in which oesophagostomy had been performed by Evans, nine years
previously, on a woman, aged forty-three. The disease was malignant,
and the patient died of collapse fifty hours after the operation. In
the same year a case was related by Horsey,2 in which he operated on
a boy, aged five, who had swallowed some caustic fluid ; the gullet
was unintentionally opened above the stricture, which was found to
be quite impervious. The wound was therefore closed, and the little
patient died of shock within twenty-two hours. In 1877 Kappeler3
related two cases of cesophageal cancer, in which he made an open-
ing into the gullet through the neck. In each instance the operation
had been undertaken with a view to actual removal of the disease by
excision, and it was only when this was found impracticable, owing
to the extent and situation of the morbid mass, that, as a desperate
measure, cesophagostomy was tried. The first patient, a man, aged
forty-two, died five days after the operation ; whilst the other, a
man of sixty -five, survived only forty-four hours. In the same year,
Bryk 4 published a case in which he had performed cesophagostoniy
for the relief of cicatricial stricture ; the patient was alive seven
weeks after the operation, but the ultimate result is not stated.
Nicoladoni5 also recorded a case in which he had recourse to
cesophagostomy. The patient was a girl, aged four, who was
suffering from cicatricial stricture of two years' standing ; the gullet
was incised above the point of nan-owing, when it was found that
the tube was expanded into a pouch at its upper part. The little
patient died in six days. An instance is related by Zenker,6 where
the operation was done on a boy, aged three years and a half, for
cicatricial stricture. Death occurred within twenty-four hours.
Sinion is referred to by Konig 7 as having opened the oesophagus in
a case of cancer, but no detail is given beyond the fact that the
patient survived only thirty-four hours. Hadlich 8 operated in 1880
on a man, aged sixty, who was unable to swallow from some cause,
the nature of which was not clearly made out. The patient died
thirteen months after the operation, but no autopsy was per-
mitted. In the same year Studsgaard 9 performed cesophagostomy
on a woman, fifty-two years of age, suffering from cancerous stric-
ture ; she improved considerably after the operation, and died five
months later from the natural progress of the disease. The same
surgeon10 operated quite recently on a girl, aged nine, who had
swallowed nitric acid. Death took place eight days afterwards,
owing to "haemorrhage from the internal jugular vein caused by
septic ulceration." In 1880 cesophagostomy was also performed by
Holmer,11 of Copenhagen, on a man, aged fifty -seven, for cancer of
the right tonsil and pharynx ; the patient lived two months. In
1881 Annandale 12 related three cases in which he had performed the

1 ' Med. Times and Gaz." 1876, vol. ii. p. 137.

2 ' Amer. Journ. of Med. Sci." New Series, 1876, vol. Ixxii. p. 114.

3 ' Deutsche Zeitschr. f. Chir." 1877, vol. vii. p. 381, et seq.

4 ' Wien. Med. Wochenschr." 1877, Nos. 41 and 45.
8 Ibid. 1877, No. 25.

6 ' Ziemssen's Cyclopaedia," vol. viii. p. 28.

7 ' Krankheiten des Pharynx nnd (Esophagus." Stuttgart, 1880, p. 122.

8 ' Deutsche Zeitschr. f. Chir." 1882, Bd. xvii. p. 138, et seq.

» ' Hospitals Tidende." 2 R. vii. No. 43. Copenhagen, Oct. 27, 1880.

10 Private letter from Dr. Studigaard to the Author, dated Dec. 21, 1882.

11 ' Hospitals Tidende." Copenhagen, 1882, No. 1.

12 ' Liverpool Med. -Chir. Journ." No. 1, July, 1881, p. 14, et. seq.

142 DISEASES OF THE THROAT AND NOSE.

operation for cancerous stricture. In the first the patient, a woman
aged forty-two, survived three months, and finally died of sej>ti-
oemia ; in another the patient, also a woman, aged fifty-three, aUd
in ten days. Unfortunately, no details are given of the third case,
which is the more to be regretted as it was one of exceptional
interest, a second stricture having been encountered when the gullet
had been opened below the first, and gastrostomy having, therefore,
been found necessary. The operation has lately been practised by
Timothy Holmes. 1 The patient was a man, about fifty years of age,
who suffered from malignant stricture of the oesophagus ; he died
about three days after the operation. Reeves * has also recently per-
formed cesophagostomy on a man, aged sixty-three, who died on the
eighth day. To these cases should be added one in which Butlin 3
states that he witnessed an attempt at a-sophagostomy which had to
be abandoned owing to the wide extent of the disease, and another
reported by Maydl,* in which it was found impossible to open the
gullet in a case of cicatricial contraction, because of the extreme
hardness of the walls.8

1 " Med. Times and Qaz." July 29, 1882, p. 117.

2 Private letter from Mr. Reeves to the Author, dated July 20, 1882.
s " Sarcoma and Carcinoma." London, 1882, p. 184.

* " Wien. Med. Blatter." 1882, No. 17, p. 623.

s Gross (" System of Surgery," 6th ed. 1882, vol. ii. p. 495) refers to cases in
which resophagostomy has been practised by Packard and Cohen. As I am
unable to find any published details of either of these cases, they have not been
included in the above summary.

The mode of performing oesophagostomy is as follows : —
The patient should be placed on his back with his shoulders
somewhat raised, and his head turned towards the right side.
An anaesthetic having been given, the surgeon, standing
behind the patient's head, should make an incision through
the skin on the left side from just above the sterno-clavicular
articulation to about the level of the hyoid bone. The
platysma should be cut through, and if a vein of any six.r,
such as the external or anterior jugular, is met with, it
should be divided between two ligatures and turned aside.
The superficial fascia should next be slit up on a groovt-d
director along the line of the original incision, and the
anterior edge of the sterno-mastoid laid bare. The patient's
head should then be slightly raised so as to relax the tissues
of the neck, and an assistant should draw aside the sterno-
mastoid with a retractor. The omohyoid (which can be
recognized by its direction inwards and upwards) having
thus been brought into view, should be divided as near to
its hyoid insertion as possible. The carotid sheath is now to
be held aside together with the sterno-mastoid, whilst the
trachea is drawn inwards by a second assistant. The con-
nective tissue having been torn through with the handle of
the knife, the left lobe of the thyroid body should be raised
and pushed towards the middle line, when the trachea will

CICATRICIAL STRICTURE OF THE GULLET. 143

be fully exposed, together with the oesophagus behind it.
It may sometimes be difficult to identify the latter tube, and
it may therefore be necessary to pursue the dissection down
to the prevertebral muscles. At this stage a sound1 should,
if possible, be passed from the mouth through or into the
stricture. By this the operator will be guided to the situation
of the gullet, which should be opened by a vertical incision
2| to 5 centimetres long, through its lateral wall. In cases
of cancerous stricture the opening should be made as far
below the seat of disease as possible, whilst in cicatricial
stenosis the knife may be carried through the contracted
tissues. When the tube has been opened a silk ligature
should be passed through each edge of the oesophageal
wound, and again through the corresponding lip of the
cutaneous incision, and the gullet should be gently drawn
towards the surface and loosely attached to the outer
wound. A curved tube, measuring about three inches in
length below and one inch above the bend, with a suitable
shield at its upper extremity, should be introduced into the
oesophagus through the wound, and fixed in position by
means of tapes round the -neck. Sutures may be used to
bring the edges of the skin-wound together above and below
the feeding tube, should this appear desirable.

The food should, of course, be liquid, and in order to
prevent it from soaking into the tissues of the neck, when
the patient is to be fed, it is better to pass a second long
inner tube some way down the gullet, through the shorter
tube which is constantly worn. The nutritive fluid may
either be injected with a syringe, or poured in through a
glass funnel.

CEsophagostomy should never be performed unless there be
good reason to believe that it will be possible to introduce a
tube into the gullet below the seat of stricture.

On analysing the recorded cases of oesophagostomy,
it will be found that out of twenty-six cases in which
the operation was performed, sixteen, i.e., 61*5 per cent.,
died within a fortnight, whilst death from shock occurred

1 A special instrument was devised for this purpose by Vacca
Berlinghieri ("Delia Esofagotomia, " Pisa, 1820), consisting of a curved
hollow sound containing a stylet, which projects two inches beyond
the distal extremity of the tube. The sound ends at its lower part
in a staff grooved at one side. On pushing down the stylet, its
point is protruded and thrusts the wall of the gullet outwards. An
ordinary flexible bougie tipped with a metal knob will, however, be
found to answer just as well.

144 DISEASES OF THE THROAT AND NOSE.

within forty-eight hours in seven, or26'9 per cent. Q
phagostomy has been performed seventeen times for tin • relief
of cancerous stricture, four times for cicatricial contraction,
three times for dysphagia caused by compression of tin-
gullet from without, and twice for stenosis of somewhat
doubtful character.1 The longest duration of life after tin-
operation in any of these cases was sixteen months, tin-
shortest eighteen hours.

In the malignant cases the average duration of life after
the operation was rather more than fifty-two days. If,
however, Tarenget's case, in which the patient lived sixteen
months, be omitted from consideration as too vaguely
reported and of too ancient date to be qxiite trustworthy,
the average term of survival in the remaining fifteen
instances was twenty-four days. In seven cases of oesopha-
gostomy for cancer, in which sufficiently full details .in-
given for an estimate to be made, the average duration
of the symptoms before the operation was six months,
the longest being eleven months, and the shortest three
months.

In the four cases in which oesophagostomy was done for
cicatricial contraction, the average duration of life after tin-
operation was nearly seven weeks. In three of the four,
however, the patients were children, and in them the average
was little more than two days and a half. This high mor-
tality of the operation in the case of children iitterly in
tives the opinion that the shock caused by oesophagostomy
is inconsiderable.

In the three instances of dysphagia from compression the
average period of survival was five months, whilst in tin-
two cases of doubtful nature it was nearly two months.

Death from the immediate shock of the operation took
place in four of the cases of malignant obstruction
and in two of the cases of cicatricial contraction. The
statistics of this operation do not show the steadily
progressive improvement which is seen in the case of
gastrostomy.

The great advantages that are claimed2 for oesophagostomy
are : —

1 Richet's case is too lacking in detail to be taken into account.

2 Whilst Follin ( " Retrecissements de 1'CEsophage," Paris, 1853,
pp. 125, 126), Terrier ("De 1'CEsophagotomie Externe," Paris, 1870,
p. 62, et seq.), Annandale (" Liverpool Med. -Chir. Journ." No. 1, July,
1881, p. 13), Bidau ("De 1'CEsopnagotomie," Bordeaux, 1881, p. 38,
et seq.), and T. Holmes ("Med. Times and Gaz." July 29, 1882, p.

CICATRICIAL STRICTURE OF THE GULLET. 145

1st. That it is attended with comparatively little systemic
shock.

2ndly. That it facilitates subsequent dilatation of the stric-
ture ; in other words, it is so far curative that it may enable
the patient's existence to be indefinitely prolonged.

The supposed absence of shock, however, is not borne out
by the actual facts, seeing that in five cases l death occurred
within twenty-four hours after the operation, whilst in a
sixth,2 the attempt to open the gullet had to be given up,
owing to the collapsed condition of the patient. As regards
the second alleged advantage, it does not appear that there
is any case on record in which an oesophageal stricture has
been successfully dilated through an opening in the neck.

The disadvantages of the operation are : —

1st. That owing to the depth from the surface at which
the gullet is situated, and the fact that when diseased it is
often fixed to the surrounding parts, the operation is a
very difficult one. (To this should be added, in cases of
cicatricial stenosis, that the walls of the organ may be so
tough as to make it difficult, or even impossible,3 to cut
through them.)

2ndly. That great danger inevitably attends a cutting opera-
tion carried out in immediate proximity to such important
structures as the large blood-vessels and nerves of the neck,
and the thyroid gland, which is not unfrequently enlarged
in cases of cesophageal stenosis.

3rdly. That there is great uncertainty in any given case
whether the opening in the oesophagus can be made below
the stricture. (Even when its upper limit can be made out
with tolerable accuracy, the extent of the disease cannot
even be guessed at, and if in an exceptionally favourable
case the lower margin could be approximately ascertained, a
second stricture may exist lower down.)

4thly. That a discharging fistula in the neck is a conspi-
cuous disfigurement.

Gastrostomy. — This has been the most frequently practised,
and will probably be proved to be the most valuable of all
the operations for the relief of ossophageal stricture.

118) give a moderate support to the operation, Mr. Reeves ("Trans.
Clin. Soc." vol. xv. 1882, p. 29, et seq.) has come forward as an
uncompromising champion of it.

1 Menzel, Poinsot, Kappeler, Horsey, Zenker.

2 Maydl : Loc. cit.
8 Maydl : Ibid.

VOL. II. L

146 DISEASES OF THE THHOAT AND NOSE.

History of the Operation. — Gastrotoniy, for the extraction of foreign
bodies, has been practised since the sixteenth century, but gastro-stom y .
or the establishment of a "mouth" in the stomach, for the purpose of
fooling a patient who is unable to swallow, was first proposed, ami
fully described by Egeberg,1 a Norwegian sur^.-nn. in 1837. It
however, actually earned out for the first time in France, by Sedillot,-
in 1849. After him it was performed by Fenger, Cooper F<M
Sydney Jones, Curling, Bryant, Van Thadeu, myself, Troii|>,
Durham, Fox, Maury, Low, MacCormac, Jouon, Smith, Clark.
Mason, Jackson, Rose, Miiller, Jacobi, Hjort, Kiister, Tay. Ht-itli.
Vemeuil, Callender, Schbnborn, Lanelongue, Courvoisiu. Trendctm-
burg, Le Dentu, Riesel, Messenger Bradley, Studsgaard, Langenbudi,
and Langton. The details of all the operations performed by
these surgeons may be found in an elaborate treatise published
by H. Petit 3 in 1879. Since the appearance of that work cases
have been reported by Littlewood,^ Milner Moore,8 McCarthy."
Escher,7 Liicke,8 Elias,9 Pye-Smith,10 Buchanan," Moi:
McGill,13 Gritti,14 Kronlein,18 Bryant,18 Langton,17 Golding-Bird.1"
Reeves,19 Kappeler,20 Anders,21 Fowler,22 Bugantz,23 Maydl,24 and
Hume.25 Several cases have been operated on by Howse and Davii >-
Colley, but the details have not been published.

1 Memoir read before the Med. Soc. of Christiania, May 8, 1837.

2 " Gazette MMicale de Strasbourg." 1849, p. 366.

3 ' Traits de la Gastro-stomie." Paris, 1879.

4 ' Lancet." 1879, vol. i. p. 475.
s Ibid. 1879, vol. ii. p. 425.

e bid. 1879, vol. ii. p. 466.

' Centralblatt f. Chirurgie." Leipzig. 1880, vii. p. 625.

' Med. Times and Gazette." 1880, vol. ii. p. 187.

' Deutsche Med. Wochenschr." Berlin, 1880, vi. pp. 329-333.

Trans. Intern. Med. Cong." 1881, vol. ii. p. 456, et seq.

Lancet." 1881, vol. i. p. 7.
12 Ibid. 1881, vol. ii. p. 873.
is bid. 1881, vol. ii. p. 942.

Gazzetta Med. Ital. Lombardia." 1881, serie viii. t. iii. p. 3.
' Centralblatt f. Chirurgie." 1881, p. 16.
' Lancet." 1881, vol. i. p. 572.
' Brit. Med. Journ." July 15, 1882.
' Trans. Clin. Soc." 1882, vol. xv. p. 33, et seq.

17
18

20 ' Deutsche Zeitschrift f. Chirurgie." 1882, Bd. xvii. Heft 1 and 2.

21 ' St. Petersburg Med. Wochenschr." 1882. xvii. p. 185, et seq.

22 ' Ann. Anat. and Surg." Brooklyn, Xew York, 1882, vi. p. 27, et seq.

23 Quoted by Maydl : "Wien. Med. Blatter." 1882, No. 22, p. 682

M "Wien. Med. Blatter." 1882, Nos. 15, 16, 17, 18, 19, 21, 22, 23, and 24. Twelve
cases are here reported by Maydl, but the actual operator in six of them was
Albert.

25 «« Lancet." Dec. 23, 1882, p. 1074.

The following is the best mode of operative procedure : —
The patient having been placed on his back, and an anes-
thetic having been administered, the surgeon should first
try to map out by careful percussion the situation of tin-
stomach. The area of stomach-resonance varies somewhat in
different individuals, and also in the same person according
to the condition of the viscus itself. In those who have been
suffering for some time from partial starvation, the organ
is apt to be retracted so as to be altogether covered by the

CICATRICIAL STRICTURE OF THE GULLET. 147

inferior margin of the thorax. To obviate any difficulty from
this source the stomach has sometimes been successfully
inflated with air before the operation, or ether has been
pumped into the viscus from the mouth, or gas has been
generated within the organ itself, by the administration, first
of hydrochloric or tartaric acid, and shortly afterwards of
bicarbonate of soda.1 When the stricture is not impermeable,
any of these plans may be of service, but none of them is
necessary.

Gastrostomy should always be done with the strictest
antiseptic precautions. There are three stages in the opera-
tion : 1, to open the abdominal parietes ; 2, to transfix the
stomach and secure it to the edges of the wound in the
abdomen, and to the integument ; and, 3, to open the
stomach. Between the second and third stages it is most
important that some days should elapse.

1st Stage. — An incision should be made through the
skin for a distance of two or three inches in a direction
parallel to the left costal margins, and about one finger's
breadth to their inner side ; the centre of the incision
being made to fall about three-quarters of an inch internal
to the outer edge of the rectus abdominis muscle.2 The

1 Schonborn ("von Langenbeck's Archiv." vol. xxii. p. 500) fitted
an india-rubber ball to the end of a fine hollow sound, which he
passed down the gullet. When the ball was in the stomach it was
inflated by blowing down the tube. Felizet ("Lancet," Oct. 7,
1882), in a case in which he had lately to open the stomach for the
removal of a foreign body, passed a small india-rubber tube through
one of the patient's nostrils into the stomach. The proximal ex-
tremity of the tube was bifurcated, a funnel being connected with
one branch, and the other communicating, by means of a piece of
tubing, with a recipient containing ether. The stomach was first
washed out with a solution of sodium bicarbonate poured in through
the funnel, and made to flow out again by depressing the tube
below the level of the viscus, so as to make the former act as fc syphon.
When the patient was fully under chloroform the ether-holder was
plunged into a vessel of water, at a temperature of 60° Centigrade,
when the stomach at once became distended by the vapour. It is
obvious that neither this nor Schonborn's plan could be pursued if
the 'gullet was much narrowed. Jacobi ("New York Med. Journ."
1874, vol. xx. p. 142) passed a fine catheter into the stomach, and
injected a solution of bicarbonate of soda, and shortly afterwards a
solution of tartaric acid. Fowler ("Annals of Anat. and Surgery,"
Brooklyn 1882, vol. vi. p. 27), injected thirty drops of dilute hydro-
chloric acid, mixed with an ounce of water, followed, after an interval
of from two to three minutes, by an ounce of a saturated solution
of bicarbonate of soda.

2 Some surgeons prefer to make a vertical incision along the outer
margin of the left linea semilunaris, commencing immediately below

148 DISEASES OF THE THROAT AND NOSE.

lips of the skin-wound should then be held asund« -r, ami
tin- fibres of the rectus should be divided in a vertical
direction for about an inch, all haemorrhage being at nun-
checked by torsion of the vessels, or ligature with fine
carbolized catgut. When the parietal peritoneum is readied
it should be gently picked up with forceps, and a minute
opening should be made in it with the knife. Through
this aperture a grooved director should be introduced, <in
which the membrane is to be slit up in the axis of the incision
through the rectus. The peritoneal sac being thus laid open,
the stomach will in most cases be at once visible, but some-
times instead of it the omentum, or even the colon, comes
into view. The former is not likely to mislead the operator,
but as it has actually happened that the colon has been opened
instead of the stomach, it is well to be on guard against such
an accident. The longitudinal bands, together with the
appendices epiploicm, and the thinness of the walls will serve
to identify the colon, which should be gently pushed down-
wards out of the way. Should the omentum present itself
in the wound, gentle traction should be made on it until the
stomach is brought down so as to bulge out of the wound
somewhat like a hernia.

2nd Stage. — To keep the stomach in a proper position and
prevent its falling back into the abdominal cavity during the
remaining steps of the operation, the base of the projecting
portion should be transfixed in a direction parallel to tin-
surface of the belly by two long needles, the extremities
of which should reach considerably beyond the edges of
the wound on either side.1 The stomach is thus held fast
between two transverse supports resting on the surface
of the body. The viscus should now be stitched to the
abdominal wall either by a single or a double series of
sutures.* Verneuil uses one set of stitches, the sutures, which
are of silver wire, being passed first through the skin close
to the edge of the wound, next through the parietal peri-
toneum, lastly through the peritoneal and muscular coats of

the edge of the thorax, and continued downwards for three or four
inches. The incision through the rectus, as recommended above,
was first practised by Mr. Howse, to whom the greater success of
gastrostomy in this country in recent years is largely due. The
straight fibres of the rectus form a sphincter round the gastric
wound, and the dribbling of the contents of the stomach so prone to
occur during coughing is thereby prevented.

1 This plan was first recommended by Verneuil (" Bull, de 1'Acad.
de Med." 1876, p. 1025).

CICATRICIAL STRICTURE OF THE GULLET. 149

the stomach, and out again ; the ends are then threaded
through a perforated plate, and afterwards through shot
drilled for the purpose, when they are fixed by crushing
the leaden ball over them with pincers. Howse, on the
other hand, prefers a double circle of stitches ; the outer,
which consists of carbolized silk sutures, passes through the
serous and muscular tunics of the stomach, and afterwards
through the skin about three-quarters of an inch beyond the
lip of the wound, and is here tied over pieces of quill ; the
inner circle is made with ordinary sutures of fine wire or
carbolized silk, and unites the serous coat of the viscus to
the skin close to the edge of the incision. The object of
the two circles of stitches is to provide a greater area for
adhesion, the whole of the zone between the two rings
being likely to unite with the abdominal parietes.

3rd Staije. — As already remarked, it is most important to
delay this till adhesions have been produced between the
corresponding peritoneal surfaces round the wound, and the
stomach thereby securely fixed to the abdominal wall. Mr.
Howse's method is to defe/ the third step of the operation
till the fifth or sixth day, and by some surgeons1 an interval
of a week or even a fortnight is allowed to elapse between
the preliminary part and the completion of gastrostomy. The
stomacn may be opened by puncturing the centre of the
exposed portion with a fine-pointed bistoury. As considerable
haemorrhage has followed this apparently simple proceeding
on more than one occasion, the surgeon should be prepared
for such a contingency, the occurrence of which is probably
favoured by the congested condition of the islet of stomach-
wall included within the ring of sutures. Pressure will pro-
bably suffice to stop the bleeding, or the risk may perhaps be
altogether obviated by opening the stomach with a thermo-
cautery point, after the manner of Albert. An india-rubber
tube, provided with a plug, may be left in the wound,
and kept in situ by means of a silver suture, passing through
it and the skin on each side, or, as is Mr. Howse's prac-
tice, the fistulous opening, which is at first made only large
enough to take a No. 6 catheter, may be gradually dilated to
the size of a Xo. 32 instrument (French scale). In either
case the wound should be dressed with a pad of lint steeped
in carbolized oil (1 in 60), over which may be put an addi-
tional pad of boracic lint, the whole being kept in place

1 Maydl (Loc. cit. No. 15) gives two cases where the interval was
fourteen days.

150 DISEASES OP THE THROAT AND NOSE.

by means of a body-bandage. The sutures should not be
removed for about ten days.

In the interval between the second and third stages of
gastrostomy the patient's strength should, if possible, !»•
maintained by rectal alimentation. If, however, aphagia
has existed for more than two or three days it may be
necessary to do the entire operation in one act.

A few words must be added regarding the manner of feed-
ing the patient after the completion of gastrostomy, as the
success of the operation greatly depends on this. Nourish-
ment should be administered in small quantities and at v« -in-
frequent intervals, and during the first few hours it should
be given cold or even iced, in order to check vomiting.
The act of feeding should, as far as possible, be an imi-
tation of the natural mode of taking food — that is to say,
nourishment should be given in small spoonfuls, about
half a minute being allowed to intervene between the
helpings. The cause of failure after gastrostomy has un-
doubtedly sometimes been the unphysiological mode in which
the food has been administered. *At first the diet should
be confined to milk, beef-tea, and a little stimulant ; later
on, when the stomach has become more accustomed to the
novel conditions under which it has to work, light puddings,
of tapioca or arrowroot, hot milk sweetened with sugar, eggs
boiled very soft, beef-tea, and chicken broth may be allowed.
Pounded meat or panada may be given when the power of
digestion has become established. Trendelenburg1 advises
that the patient should, if possible, masticate the food, and
should then blow it through an elastic tube passing from his
mouth to the permanent tube in the gastric fistula. The
patient has thus the enjoyment of eating, and the digestive
process has the advantage of the salivary function.

Many operators have noticed that after gastrostomy the
oesophageal stricture yields a little ; this is probably due to
relaxation of the muscular spasm, and subsidence of the
inflammation which almost invariably affects the mucous
membrane near the seat of disease. Hence a day or two after
the establishment of the gastric fistula, a little liquid food can
often be swallowed. In this way the feeding through the
stomach may be minimized at first, and that organ gradually
habituated to the abnormal method of receiving nutriment.

Gastrostomy has been done sixty-seven times for cancer of
the gullet, twelve times for cicatricial stricture, and twice for
1 "Von Langenbeek's Archiv." 1878, vol. xxii. p. 227.

CICATRICJAL STRICTURE OF THE GULLET. 151

syphilitic stenosis. On examining the records of seventy-six
examples of the operation concerning which I have been able
to obtain sufficient details, it appears that the total number
of deaths occurring within a fortnight was fifty-five, i.e.,
72 '4 per cent.

In the cases of malignant disease the average duration of
life after the stomach was opened was rather more than
twenty days, the longest period of survival having been six
months, and the shortest twelve hours. On looking more
closely into the matter, however, it is plain that the results
of this operation are progressively growing more favourable.
Thus, in thirty-five cases collected by Petit, and extending
over a period of thirty years, the average survival of the
patient after gastrostomy for oesophageal cancer was slightly
more than fourteen days and a half, whilst in thirty-two cases
in which the operation has been done for the relief of the
same disease within the last three years, the average subse-
quent duration of life has been more than thirty days. This
estimate does not include Howse's cases, which have been
alluded to by several surgeons as amongst the most success-
ful operations of the kind that have yet been performed.
It should be added that in fifty-seven cases of which a
sufficiently detailed account is given, the average duration
of the symptoms at the time of the operation was about
six months and a half, the longest being three years, and
the shortest six weeks.

In twelve cases in which gastrostomy has been done for
cicatricial stricture the average of after-life has been more
than five months and a half, not including a case of Bryant's,
where the result is simply indicated as " cure," without
further details. In these cases the average duration of
symptoms at the time of the operation had been rather more
than five months, the longest period having been one year,
and the shortest four weeks.

Lastly, in two cases in which this operation has been done
for syphilitic stenosis, the average survival has been slightly
over three days, whilst the average duration of the symptoms
had been seven months and a half.

In a total number of eighty-one gastrostomies death from
occurred within forty-eight hours in twenty, i.e., in
24 '6 per cent.

The advantages of gastrostomy are : —

1st. That it can be carried out with comparative ease.

2ndly. That there is very little risk in the steps of the

152 DISEASES OF THE THROAT AND N<»K.

operation itself, especially if done in two acts separated l.y
a proper interval of tinn-.

•"•nlly. That there is almost entire certainty1 of being able
to effect the ohjeet aimed at, which is the establishment of
an alimentary fistula alt".ur|ither beyond the seat of strietnre.

4thly. That the fistula is hidden from sight.

The only •Uxmli-uittaw, on the other hand, is that gas-
trostomy, with every aid of antiseptic precautions in tin-
actual performance of it, and the improved after-treatment
which is now adopted, still yields a high percentage nf di-aths.

Comparing gastrostomy and oesophagostomy together, it
may be affirmed — 1st, that gastrostomy is both i-axii-r and
safi'i- to perform, the risk of haemorrhage and other surgical
complications being much less ; and 2ndly, that gastrostomy
always meets the difficulty to be overcome — that is to say,
the obstruction to the passage of food into the stomach —
except in those comparatively rare cases in which the
stomach itself is also diseased. The effect of either procedure
in relieving the patient's immediate sufferings, notably from
thirst, and occasionally, in a less degree, from hunger, is often
very marked, and it may be expected that the malady will
make less rapid progress when the gullet is no longer ex-
posed to irritation by persistent endeavours to swallow. It
can hardly be denied, however, that the benefit of these
operations has often been shown more in the euthanasia
which they have brought about, than in any appreciable
prolongation of the patient's life. In fact, judging from
statistics alone, operative interference would seem to be
attended with less satisfactory results than the milder
palliative measures generally adopted. Thus, whilst the
average duration of life in my series of 100 cases2 of
malignant stricture of the gullet in which no operation was
attempted was eir/ht months, the average extent of life after
the first manifestation of distinct symptoms till death in
fifty-three cases in which gastrostomy was performed was
seven months.3 The records of oesophagostomy for cancer

1 See, however, two cases reported by Maydl (Loc. cit.), in one of
which the operator was foiled by finding a large growth in the
stomach itself, whilst in another there was a cancerous condition
of the fundus and anterior wall of that organ in addition to the
oesophageal disease.

2 See page 73.

3 It is right to state, however, that the recent records of this opera-
tion, taken alone, show much better results. Thus, in twenty cases
reported since 1879, the average duration of life from the first onset

CICATRICIAL STRICTURE OF THE GULLET.

153

seem at first sight more favourable than either of the above
estimates, for in eight cases of which sufficient details are'
given to form the basis of such a calculation, the average
period from the first appearance of dysphagia till death was
tun months. This result is largely due to Podrazki's case
being included. It may be pointed out, however, that the
long duration of antecedent dysphagia in this case furnishes
no very certain measure of the length of time during which
the cancer had existed, the patient having suffered severely
from syphilis, and the difficulty of swallowing having at
first yielded to anti-venereal treatment. Moreover, as the
patient survived the operation only two days, it is obvious
that the weight which the case apparently throws into the
scale in favour of oesophagostomy is altogether illusory.
Podrazki's case may therefore be disregarded as being
merely a disturbing element in the present calculation. The
remaining seven cases of oesophagostomy for malignant
disease show an average duration of life of only seven
months after the first appearance of symptoms.

On reviewing the whole subject, gastrostomy may be said
to have now taken its place among the procedures of every-
day surgery, and a hope may legitimately be cherished that
as the increasing resources of science render earlier recogni-
tion of oesophageal disease possible, the results of the opera-
tion will be still more satisfactory in the future. The fatality
of gastrostomy has been in a great measure due to the fact that
it has often been performed only at the eleventh hour, when
the patient was almost moribund — "a species of refined
cruelty reflecting no credit on surgery," to use the words of
Professor Gross. l (Esophagostomy has a much narrower range
of usefulness ; it is always more or less a " leap in the dark,"
and though its effect may occasionally be brilliant, it is, after
all, an operation more likely to find favour with the adven-
turous surgeon than with the careful practitioner. In cases
of syphilitic origin, however, where the stricture is at the

of the disease was seven and a half months, notwithstanding that in
one case the period of survival is only reckoned as four months, and
in another as ten days, though the patients in each instance were still
alive, and likely to live for some time at the date of the report. If the
Albert-Maydl cases alone are considered, a still more favourable
result will be found. The total average in seven cases was eleven
and a half months, notwithstanding that one of the patients still
living at the date of report is only counted as surviving the operation
six weeks.

1 "System of Surgery." 1882, 6th ed. vol. ii. p. 495.

154 DISEASES OF THE THROAT AND NOSE.

upper part of the gullet, O3sophagostomy offers a very gin id
prospect of success, as the disease is much more likely to be
limited in extent than either cancer or the lesion produced
by corrosive fluid. As regards internal oesophagotomy,
increased experience will probably show that, though its
immediate results are not so frequently fatal, its ultimate
effects even when successful are less beneficial to the patient
than those of either gastrostomy or cesophagostoniv.

The following is an interesting example of cicatricial
stenosis of the gullet in which gastrostomy was }>erformed : —

Sarah C., aged twenty -six, swallowed hydrochloric acid oil
February 16, 1879. She was taken to Guy's Hospital, where the
immediate symptoms were treated, but the dysphagia increased so
much that on April 24 gastrostomy was performed l>y Mr. Howse.
The patient was fed entirely through the artificial opening for nearly a
year, when dilatation of the oesophagus with bougies, which had been
found impracticable at an earlier period, owing to the tightness of the
stricture, was again attempted. By this means the patient recovered
the power of swallowing to such a degree that Mr. Howse allowed the
fistulous opening to close, warning her at the same time that it would
be necessary to pass a bougie occasionally. She left Guy's Hospital
in August, 1880, by her own desire. On September 6 in the same year
she came under my care at the Throat Hospital. A No. 2 bougie was
passed, and the stricture was gradually dilated till it was large
enough to admit a No. 9, and the patient's condition improved con-
siderably. In February, 1881, however, the dysphagia had again
become so severe that she had to be taken into the Throat Hospital,
where for three months she was confined to bed, suffering from con-
stant pain between the shoulders, which was increased when she
tried to swallow. During all this time her temperature was always
above the normal point, being often as high as 102° Fahr. in the
evening. No cause, however, could be discovered for the pyrexia.
After this illness the patient steadily improved for some time, not-
withstanding occasional relapses. In the autumn of 1882 her gullet
again became almost blocked up, in spite of constant attempts at
dilatation, and she gradually lost strength till the early part of
November, when she died.

The following are the notes of the post-mortem examination. The
body showed little sign of wasting, there being full}' an inch of fat
on the abdominal walls. Both lungs were adherent to the chest
walls. The oesophagus was bound to the prevertebral muscles by
bands of dense fibrous tissue, rendering its separation from the .sur-
rounding parts very difficult. Barely half an inch below the cricoid
cartilage the stricture commenced, and extended downwards to within
two centimetres and a half of the cardia. The walls of the gullet
throughout the whole of the strictured portion were enormously
thickened, the cut edge in some places being an eighth of an inch
in width, and very tough. The narrowest part of the stricture cor-
responded to the upper inch and a half of the gullet (Fig. 20, a), and
consisted of four longitudinal ridges, mainly situated on the anterior
wall, but partly on the sides of the gullet. These ridges almost

CICATRICIAL STRICTURE OP THE GULLET.

155

blocked up the lumen of the oesophagus, which was still further
narrowed below by a transverse cicatricial band connecting the

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longitudinal folds together. Lower down the stricture was made up
of a meshwork of bands, most of which had a transverse direction.

156 DISEASES OF THE THROAT AND NOSE.

Seven centimetres above the canlia there were three openings, admit-
ting a large probe, surrounded by some cicatricial bands. These
openings communicated with a canal, which ran for two centimetres
and ii half downward*, and slightly to the right between the muscular
fibres, and terminated in a pouch covered with muscular fibres, half
an inch long, external to the gullet. Higher up, at a point rather
below the middle of the oesophagus, there was a minute perforation,
leading into the trachea through iN posterior wall. The stomach was
6J inches in its smaller curvature, and 12A in its larger curvature. Its
anterior surface measured 3£ inches iu its widest part, and 2 inches in
its narrowest part.

There was a cicatrix 1\ inches long in the abdominal wall, and on
opening the stomach a depressed cicatrix, with radiating ridges, was
seen about an inch and a half from the greater curvature, and rather
nearer the pylorus than the cardia. The stomach was united to the
anterior wall of the abdomen by a dense fibrous tissue.

SIMPLE STENOSIS OF THE GULLET.

Latin Eq. — Stricture oesophagi.

French Eq. — R<$trecissement de 1'cesophage.
German Eq. — Verengung der Speiserbhre.
Italian Eq. — Stenosi del esofago.

DEFINITION. — Abnormal narrowness of a limited
of the (esophagus without any morbid change in any of its
component tissues at the seat of stricture.

History. — The earliest recorded example of this affection is that
of Blasius.1 More than a century later, Sir E. Home2 related some
instances in which the oesophagus presented a uniform circular con-
traction behind the cricoid cartilage. Cassan3 described a case in
which the gullet was contracted for a length of eight millimetres.
There was not the least change in the mucous membrane at the seat
of narrowing, but the pharynx above was increased to double its
usual width. Cruveilhier4 has placed on record a case of simple
narrowness of the cesophageal channel at its lower part, while there
was a dilated portion above, the inner surface of which was covered
with large polypoid vegetations. Wilks,5 in 1866, and Hilton Fagge,6
in 1872, have each recorded an example of stenosis at the lower
part of the tube, whilst Zenker7 has lately described a case in which

1 'Observ. Anat." 1674, p. 170.

'-' ' Pract. Obs. on the Treatment of Strictures in the Urethra and (Esophagus."
London, 1803, vol. ii. p. 414.

3 'Arch. Gen." 1826, t. x. p. 79.

4 ' Anatomie Pathologique." Paris, 1835-1842, livr. 38, pi. 6.

5 'Trans. Path. Soc." 1866.

« ' Guy s Hospital Reports." 1872, p. 413.

" '£iemssen's Cyclopaedia of Pract. Med." English Transl. vol. viii. p. 19.

SIMPLE STENOSIS OP THE GULLET. 157

the oesophagus was greatly contracted at its upper part, the mucous
membrane in that situation being pale, thin, and loosely attached to
the submucosa, but presenting no anatomical change. At the lower
part the tube was of normal calibre, but the mucous membrane was
unnaturally pale.

Etiolocjy. — The origin of this condition is exceedingly
obscure. In most of the cases it is stated that the patient
had a " small swallow " since childhood, but every practi-
tioner must be aware that this phrase is used in a very vague
way, and by numberless people who have no real narrowing
of the oesophagus. Although it is highly probable that the
condition is a congenital abnormality, I am not aware that
there is any instance on record in which its existence in
early life has been proved by post-mortem examination. It
is possible that the smallness of a portion of the gullet may
be simply due to an arrest of growth in infancy or early
childhood, or it may result from partial paralysis of a portion
of the longitudinal fibres of the oesophagus in infant-life, the
frequency of other paralytic affections at that period being
an established fact. In cases where the narrowing is at the
lower part, there is occasionally some degree of dilatation
above, and it may be, under these circumstances, that the
original formative material constituting the oesophageal walls
has been unequally distributed. Dr. Wilks was strongly of
opinion that the dilatation in his case, as well as the stricture,
was congenital, but it is scarcely necessary to point out that
a congenital stricture is extremely likely to give rise to
dilatation higher up.

Symptoms. — In all the cases that have been recorded,
although there has been more or less difficulty of swallowing
from an early period of life, the dysphagia has remained
stationary till not long before death, when, in some instances,
disease has developed above the seat of stricture. In
Fagge's case, during twenty years the patient had at in-
vervals suffered from complete occlusion of the oesophagus,
which on one occasion lasted for a period of eight days.

Regurgitation appears to occur chiefly in those cases in
which there is a pouch above the stricture. The patients
can generally swallow liquids with ease, but solids have to
be washed down with drink. Evidence as to the nature of
the affection can be obtained by the bougie and by aus-
cultation, for an instrument of medium size is arrested at
the seat of stricture, whilst on listening over the oesophagus,
the food can be perceived to reach the point of constriction

158 DISEASES OF THE THROAT AND NOSE.

at the ordinary rate, whilst below this only a trickling or
dropping sound can be heard.

Pathofof/y. — In nearly all the cases that have been ob-
served, it is stated that the tissues had undergone n<> patho-
logical change ; but it does not appear that the muscles
and nerves of the oesophagus have ever been submitted
to microscopical examination in these cases. Disease is
likely to be found in the part of the gullet a//»rr the
stricture. Thus, in Cassan's case there were signs of general
inflammation, whilst Cruveilhier's, as already remarked, pre-
sented polypoid vegetations on the mucous membrane of tin-
dilated sac, and in Fagge's, cancer had become developed in
the wall of the pouch.

Diagnosis. — The absence of any traumatic cause of stric-
ture, the continuous existence from early childhood of
dysphagia, and the non-progressive character of this symp-
tom, serve to distinguish this class of cases.

Prognosis. — In two instances the patients lived to the age
of seventy-four years, and the prognosis is not very unfavour-
able if great care be taken in the selection of diet. The
predisposition to secondary disease above the stenosis, how-
ever, must not be forgotten.

Treatment. — It is extremely important in these cases that
the patient should take only liquid or semi liquid food of a
non-irritating character, whilst stimulants must, as a rule,
be avoided. The patient should be enjoined to eat with
care and deliberation. Dilatation should not be attempted,
as it could only give rise to rupture of one or more of the
oesophageal tunics. There remains, therefore, only resopha-
gostomy or gastrostomy. Considering, however, the non-
progressive character of the stricture, these operations an-
not likely to be called for unless some complication should
arise.

COMPRESSION OF THE GULLET.

Compression of the gullet may be effected by any of the
organs in its immediate neighbourhood. It is seldom, how-
ever, that severe compression is produced, except in the case
of constricting or cancerous bronchocele, enlargement of the
deep lymphatic glands near the tube, or tumours of malig-
nant character in the neck or in the posterior medias-
tinum. Neither aneurisms nor dilated heart, as a rule, gives
rise to extreme dysphagia. The condition most frequently

COMPRESSION OF THE GULLET.

causing compression is constricting goitre. Twice I have
known this to cause death by inanition ; one of these will
be recorded and illustrated under the head of " Goitre." I
have seen several examples of cancer of the thyroid gland
pressing so much on the gullet as to hurry on the fatal termi-
nation. In several patients suffering from lymphoma, whom
I have been called on to treat, dysphagia has been a trouble-
some symptom. Cases have been recorded in which com-
pression was produced by thickening of the posterior plate of
the cricoid cartilage,1 and one instance (Specimen No. 132,
Throat Hospital Museum) has come under my own notice in
which this part measured one centimetre in thickness, and
caused death by starvation. In other instances, dysphagia
has been attributed to abnormal length of the styloid pro-
cess,2 to ossification of the stylo-hyoid ligaments,3 and to
lordosis of the spinal column.4 Sir Astley Cooper 5 related
a case in which great difficiilty of swallowing was caused by
the sternal end of a dislocated clavicle pressing on the gullet.
The dysphagia was at once relieved on the inner end of the
bone being sawn off. Morgagni 6 refers to a case in which a
soldier, suffering from opisthotonos, was unable to swallow,
which he attributes to the over-extension of the gullet,
caused by the arching backwards of the neck. It is obviously
possible, however, that the ossophageal muscles may have been
in a state of tetanic contraction. Some illustrations of com-
pression caused by aneurism have been collected by Knott.7
In general, however, as already stated, aneurisms of the
aorta, even when they impinge on the gullet, do not seriously
obstruct the passage of food. Out of fourteen marked cases of
aortic aneurism pressing on the oesophagus, brought together
by Mondiere,8 in twelve there had been no dysphagia. Perfo-
ration, however, not unfrequently takes place in such cases ;

1 Travers : "Med.-Chir. Trans." vol. vii. ; Gibb : Diseases of
the Throat," 1864, 2nd ed. p. 378; Wernher : "Chirarg. Central-
blatt," 1875, No. 30; Hadlich : "Deutsche Zeitschrift f. Chirurgie."
1882, Bd. xvii. p. 138, et seq.

"Wien. Med. Wochenschr." No. 5, 1882.

3 Emnringhaus : " Deutsches Archiv. f. klin. Med." Bd. xi. p. 304.

4 Sommerbrodt : " Berlin, klin. Wochenschr." 1875, p. 334 ; Hey-
mann : Ibid. 1877, p. 763; Lennox Browne : "The Throat and
its Diseases." London, 1878, p. 119.

5 "Lectures on Surgery." London, 1827, vol. iii. pp. 296, 297.

8 " De sedibus et causis morb." Epist. xxviii. art. 14. Lugd.
Batav. 1767, t. iii. p. 13.

7 " Pathology of the (Esophagus." Dublin, 1878, p. 217, et seq.

8 "Arch. Gen." 1833, 2e serie, t. iii. p. 51.

160 DISEASES OP THE THROAT AND NOSE.

and among one hundred and twenty examples of perfora-
tion of the gullet, rupture of the aorta occiirred in eighteen,
whilst the pulmonary, carotid, subclavian, inferior thyroid,
and superior intercostal arteries each furnished one instance.
Hypertrophy of the heart, and especially fluid effused into
the pericardium,1 sometimes occasions considerable difficulty
in swallowing, but the pressure of an enlarged heart sonic-
times has a totally different effect, and may give rise to
hypertrophy of the oesophageal walls. Thus \Vilks and
Moxon 2 have found " the muscle of the oesophagus thrice
its normal thickness " from this cause.

The means of distinguishing between compression of the
O3sophagus and cancerous stricture, have been pointed out in
dealing with the latter subject (p. 90), and as regards the
treatment, it is obvious that all remedial measures must be
directed against the essential disease. A feeding tube can
be introduced in some cases when the normal descent is
interfered with, and by this means life may occasionally
be prolonged ; but it must not be forgotten, that when an
aneurism is the cause of the compression, there is some
danger in using such an instrument. (Esophagostomy, or
gastrostomy, remains as a last resource, and the relative
merits of the two methods should be considered, not only
qua operation (see " Cicatricial Stricture of the Gullet"), but
more especially in relation to the nature and situation of the
compression.

RUPTURE OF THE GULLET.

Latin Eq. — Diruptio guise.
French Eq. — Rupture de 1'cesophage.
German Eq. — Ruptur der Speiserohre.
Italian Eq. — Rottura del esofago.

DEFINITION. — Sudden bursting of the gullet durin</
longed and violent vomiting, giving rise to acute pain in the
course of the tube, to extreme dyspnoea, and sometimes even
to orthnpnoea, to subcutaneous emphysema, and to collapse
generally quickly ending in death.

1 Several interesting cases of dysphagia due to this cause may be
found in a short treatise by Bourceret, " De la Dysphagie dans la
Pericardite." Paris, 1877.

* "Pathology." London, 1875, 2nd ed. p. 364.

RUPTURE OF THE GULLET. 161

History.1 — The earliest case on record is that related by Boerhaave,2
in 1724, as an injury of which there was no previous example in
medical literature. An abstract of this interesting case will be found
at the end of this article. In 1788 a case was reported by Drydeu,3
a military surgeon serving in Jamaica, in which, as in Boerhaave's
patient, the gullet had given way under the strain of vomiting. In
1811 Monro4 stated that he had in his possession the gullet of a child
in whom this lesion had taken place, adding that an example of a
similar occurrence had been related to him by Carmichael Smyth.5
Both these cases, however, must be regarded with suspicion for the
reason hereafter stated in the short article on ' ' Post-mortem Solution
of the Gullet;" a remark which also applies to the following case,
but in a less degree, owing to the symptoms observed during life.
In 1812 an account was published by Guersant6 of a rupture of the
oasophagus which took place in a little girl, aged seven, during an
attack of fever in which there had been much nausea and vomiting.
In 1837 a case was related by Heyfelder7 in which a drunkard died
in convulsions, and after death his gullet was found ruptured at its
lowest part. This, however, seems to me a very doubtful example
of the accident now under consideration. In 1843 Wilkinson King8
described as an instance of post-mortem digestion of the gullet, a case
in which there appears every reason to believe that the tube had been
ruptured during life. In 1848 C. J. B. Williams9 published a case
in which not only the oesophagus but the diaphragm had given way
under the strain of violent and prolonged vomiting. Examples of
this rare injury have also been recorded by Oppolzer,10 Meyer,11
Graininatzki,12 Griffin,13 Charles,14 Bailey,15 Fitz,16 Adams,17 and
Taendler.18 (All the unequivocal cases of rupture which have been
published, amongst which several, though referred to in the above
short historical summary, cannot be included, are placed in a table
at the end of this article. )

1 Several cases of so-called rapture have been omitted in this place as being
too doubtful in themselves or too incompletely described to be of much value.
Such cases are those of Kade (" De morbis ventric." Hate, 1798, p. 17, et seq.) ;
Thilow (" Baldinger's Magazin f. Aerzte." 1790, vol. xii. p. 114); Bouillaud
(" Arch. G6n. de He'd." 1823, t. i. p. 531) and Le Ray (Roumegoux, " Essai sur
les Plaies et les Ruptures de I'CEsophage." These de Paris, 1878, No. 369, pp. 34,
35). Two interesting but doubtful cases recently reported by Mr. Stanley Boyd
("Trans. Path. Soc." 1882, vol. xxxiii. p. 123, et seq.) do not seem quite to
come within the terms of the above "definition."

2 " Atrocis nee descripti prius morbi historia." Lugduni Batavorum, 1724.
" Medical Commentaries." Edinburgh, 1788, Dec. ii. vol. iii. p. 308.

•» " Morbid Anatomy of the Gullet, Stomach, and Intestines." Edinburgh.
1811, 1st ed. p. 311.

5 Dr. Carmichael Smyth was a man of considerable distinction in his profes-
sion, and Physician to the King in Scotland towards the close of last century.

" Bull, de la Fac. de M6d. de Paris." 1812, t. i. p. 73.

7 " Sanitatsbericht liber das Fuerstenthum Hohenzollern-Sigmaringen wahrend
des Jahres 1837."

1 " Guy's Hospital Reports." 1843, 2nd series, vol. i. p. 113.
» " Trans. Path. Soc. " London, 1848, vol. i. p. 151.
10 "Wien. Med. Wochenschr." 1851, p. 65.

" Med. Vereinszeitung v. Preussen." 1858, Nos. 39, 40, 41.
" Veber die Rupturen der Speiserohre." Konigsberg, 1867.
13 " Lancet." 1869, vol. ii. p. 337.
» " Dublin Jouni. Med. Sci." 1870, vol. i. p. 311.

" New Y,,rk Med. Journ." May, 1873.

16 " Amer. Journ. Med. Sci." January, 1877, p. 17. The case is narrated by
Dr. Fitz, who made the autopsy, but the patient had been under the professional
care of Dr. Allen.

" Trans. Path. Soc." London, 1878, vol. xxix. p. 113.

" Deutsche Zeitschr. f. prakt. Med." 1878, No. 52.

VOL. II. M

162 DISEASES OF THE THROAT AND NOSE.

Hjt/. — The immediate cause appears always to In-
violent retching, in most cases following a heavy meal. In
some instances the vomiting was brought on voluntarily with
the help of emetics, whilst in others it followed a drunken
debauch, or came on in the course of a severe febrile com-
plaint. In two cases, however, the accident seems to have
originated in forcible efforts to dislodge a foreign body from
the gullet. In one1 of these the action was retlex — that is
to say, it consisted in vomiting; but in the other-' there
was violent voluntary straininy to expel the impacted sub-
stance. In both instances some bleeding took place at tin-
time of the accident, and it is highly probable that a wound
was made in the oesophageal wall. It is likely that vomit-
ing only causes rupture when the contents of the stomach
cannot be expelled through the gullet at the same rate that
they leave the viscus. This want of relation between expul-
sion and transmission may be due to the abnormal quantity
of fluid in the stomach, or to obstruction of the oesophageal
canal. It is obvious also that any disease or injury causing
softening or atony of the walls of the gullet, or any morbid
condition of the tissues surrounding the tube which restrains
its normal expansion at any part, would favour rupture.

Analysing these causes of mpture, it may be remarked
that in nearly every case of which details on the subject have
been published, the stomach was sufficiently full at the time
of the accident to have its contents expelled with some
force. But it is probable that some temporary obstruction
near the upper end of the gullet, preventing the flow of
fluid matters from the stomach, is the essential factor in
the rupture. To determine the cause of this obstruction is
not always possible. In two cases, as already remarked, a
foreign body was impacted in the oesophagus, but these were
exceptions. In all the others the obstruction, if present,
must have been due to something inherent in the tube
itself. This is probably to be found in strong contraction
of the circular fibres of the gullet at the upper part of the
oesophagus. In two cases — those of Fitz and Wilkinson
King — there was tetanic spasm, affecting in the one the flexor
muscles of the limbs, and in the other the abdominal muscles;
and it need scarcely be pointed out that if such a condition
existed at the same time in the muscular walls of the gullet,
rupture would be likely to take place. In other cases it is
probable that the spasm was limited to the oesophageal
1 Meyer. 2 Fitz.

RUPTURE OP THE GULLET. 163

muscles. Absolute obstruction, however, is not necessary ;
if the contents of the stomach pass into the gullet more
quickly than they can escape a rupture may occur. It must
be borne in mind that the upper two-thirds of the cesopliageal
canal are covered by striped muscular fibres, whilst the lower
third has only unstriped fibres ; and that whilst electrical
shocks throw the former into violent contraction, the latter
only take on gentle peristaltic action.1 The lower portion of
the tube would, therefore, be less capable of resisting pressure
from within, and more likely to rupture. It is possible,
however, that in some cases the obstruction is not caused by
muscular contraction, but is due to the unyielding character
of the pharyngeal orifice of the gullet, protected anteriorly
by the cricoid cartilage, and behind by the vertebral column.
Supposing, then, an obstruction to exist at the upper end
of the tube, it becomes interesting to ascertain what strain its
walls will withstand when the contents of the stomach are
thrown violently into the canal. In order to determine the
bursting-point of the gullet, I made the following experiments
with the assistance of Mr. Charles L. Taylor : — The upper
end of a healthy oesophagus, removed from the body shortly
after death, having been tied, water was thrown in at the
opposite orifice by means of a forcing-pump provided with a
pressure-gauge. The average pressure at which the tube gave
way was rather over seven pounds, the highest being eleven
and the lowest five and three-quarters. Among the subjects
from whom the gullets were taken there were eight males
and four females ; their average age was between thirty-
eight and thirty-nine years, the oldest being sixty-six and
the youngest seventeen. In three of the twelve cases the
rupture occurred about an inch above the ligature, i.e.,
speaking roughly, about two inches above the cardia ; in
eight, the rent took place at a point one to two inches
higher, whilst in one case the gullet burst just above the
junction of the lower and middle thirds. In every instance
the solution of continuity was vertical in direction, and varied
from a third of an inch to nearly two inches in length.
These experiments imitated, as far as possible, the ex-
pulsion of the contents of the stomach through the gullet
in violent vomiting, and produced a condition exactly
like rapture, as it occurs during life — that is to say, a
vertical rent with clean-cut edges at the lower part of the

1 Tcxld anil Bowman : " Physiological Anatomy." London, 1859,
vol. ii. p. 189.

164 DISEASES OP THE THROAT AND NOSE.

gullet. Thinking it possible that the occurrence of the rent
in the lower portion of the gullet might have been due to
the injection having been made near that part, tin- experi-
ment was reversed, and the cardia having been tied, the
injection was made from above. In five out of six trials1
the rupture occurred within three inches of the cardia, ami
only once higher up.

The conclusions to be drawn from these experiments are :
1st, that rupture by direct pressure applied within the
gullet always takes place in a longitudinal direction ; 2ndly,
that the rent never occurs in the upper half of the tube, ami
in most cases is confined to the lower third ; 3rdly, that the
mucous membrane offers greater resistance to strain than
the muscular covering. As regards the actual production of
the rent, the following seemed to be the sequence of events :
as the water was pumped in, the tube became distended,
especially at the lower part, where the muscular coat became
gradually blanched from stretching ; next, in eleven of the
eighteen cases, the muscle and the mucous membrane gave way
together, the former presenting a somewhat irregular fissure
with ragged edges, and often with nerve-fibres stretching
unbroken across it, whilst the mucous membrane showed ;i
clean straight slit, as if it had been cut with a knife. In the
remaining seven cases the rupture took place gradually, the
muscular bundles first separating at one place, and leaving an
interval through which the mucous membrane bulged out in
a hernia-like sac, which was stretched to an extreme degree
of tenuity before giving way. In all the eighteen cases the
laceration of the mucous membrane was from a quarter to
half an inch shorter than the fissure in the muse ill ar coat.

There is no difficulty in showing that the walls of the tube
have, in several of the published cases of oesophageal rup-
ture, been in an abnormal condition. In one2 of them there

1 In the six cases in which the injection was made from above, the
average bursting-point was a trifle over six pounds, the maximum
being eight, and the lowest just under five. The subjects were all
of the male sex, and their ages averaged nearly forty-nine years, the
oldest being fifty-nine, and the youngest twenty-six. The direction
of the rent was vertical in every case, and its situation was from one
to three inches above the point of ligature in five of the cases, whilst
in the remaining one the (esophagus gave way exactly midway
between the cricoid cartilage and the diaphragm. The rupture
occurred four times in the posterior wall, once in tlie middle' line in
front, and once on the left side of the tube, the length of the rent
varying from three-quarters of an inch to an inch and a half.

2 Meyer.

RUPTURE OP THE GULLET. 165

was slight cicatricial stricture of the gullet near the cardia ;
whilst in another l it is stated that the patient had had occa-
sional difficulty in deglutition since infancy ; and in a third 2
that the food could only be taken in small morsels and
slowly for some years before the accident. In the two cases
in which foreign bodies had been impacted, it is extremely
probable that some injury was done to the wall of the gullet
which lessened its power of resistance. Although in most
of the other examples the mucous membrane is said to
have been perfectly healthy, except as regards digestive
solution, it may be pointed out that all the patients were
men, and that most of them had been accustomed to the
free use of ardent spirits, and had suffered from habitual
vomiting — circumstances which would have been very likely
to lead to slight, though perhaps not apparent, changes in
the textural firmness of the lining tunic of the gullet. In one
of the most recent examples 3 of this accident a small, white,
stellate cicatrix was found beside the lower part of the rent,
and further down there was another smaller scar, showing
that ulceration had previously existed. It is highly probable,
therefore, that the texture of the lining membrane of the
gullet was somewhat weakened, and that the canal itself
was slightly dilated. In certain instances there may likewise
have been some change in the muscular coats of the ceso-
phagus or some impairment of innervation — conditions which
wovdd, doubtless, diminish the power of resistance to strain.
From the previous habits of life of those who have suffered
from rupture of the oesophagus, it is likely enough that
some of them were the victims of gout. As regards one
patient 4 it is expressly mentioned that this was the case.

Although it is not stated in any of the accounts that the
oesophagus was bound down externally at any point, yet it is
quite possible that in some cases there may have been small
unobserved cicatrices in the peri-cesophageal tissue, which
would have deprived the tube of the natural mobility which no
doubt helps it to bear the strain occurring during vomiting.

It remains now to consider the various other views which
have been put forward as to the etiology of rupture.

Boerhaave, arguing from his unique observation, attributed
the rupture to direct traction on the gullet in the act of
v< uniting, the lower end of the tube being drawn down by
the weight of the overloaded stomach, aided by the rigid
contraction of the diaphragm, whilst the superior extremity
1 Charles. - Fit/:. 3 Adams : Loc. cit. * Boerhaave.

166 DISEASES OF THE THROAT AND NOSE.

was forcibly stretched above by the straining efforts induced
by tickling the fauces. As in Boerhaave's case there was a
transverse rupture, it is highly probable that his explanation
is correct. It does not, however, meet the other cases, in all
of which the rent was vertical.

Zenker and Ziemssen1 consider that the accident results
chiefly from " intra-mortem cesophageal malaria," or softening
of the coats from peptic solution in the last hours of life.
With a view of testing the trwit<>n-i>»n-*'i- of the gullet,
Ziemssen'2 suspended an oesophagus, freshly removed from
the body of a powerful man, aged fifty-five, and attached
weights to the lower end. It was found that, although the
muscular coat gave way under a weight equal to five kilo-
grammes, the mucous membrane remained uninjured under
a weight of twelve and a half kilogrammes. Ziemssen
argues from this, that no amount of strain that could be
applied within the body would cause ruptxire of the gullet
when its tissues are in a healthy condition, or, in other
words, until softening has been produced by the digestive
action of the gastric juice. I have repeated this experiment
in four cases with the following results : — In the first the
gullet (taken from a man aged sixty-four) began to stretch
at a weight of six kilogrammes, and the muscular coat
gave way close to the upper end on the addition of one
kilogramme. At this time the tube had lengthened fully
two inches ; after a weight of eight kilogrammes had been
attached to it the gullet continued to stretch for a feu-
seconds, when it ruptured close to the upper cud. In the
second case the oesophagus was taken from a woman a-* ••!
sixty ; the tube stretched a little, but without rupture, as
weights were gradually added, up to nine kilogrammes, when
both the muscular and the mucous coats gave way with a
sudden snap close to the lower extremity. The third experi-
ment was made on an oesophagus taken from the body of a
woman aged thirty ; the tube began to stretch under a weight
of seven kilogrammes, and finally gave way at the upper end
under a total weight of eleven kilogrammes. The fourth
experiment was made with the gullet of a woman aged fifty-
four, which was torn asunder suddenly close to its lower end
when a weight of six kilogrammes had been attached to it.

The average point of rupture under tension, therefore, in
these four cases was eight and a half kilogrammes, i.e., about

1 "Cyclopaedia of Medicine," vol. viii. p. 100.

2 Op. cit. vol. viii. p. 96.

RUPTURE OF THE GULLET. 167

ei: n'h teen pounds, the greatest resistance being eleven, and the
least being six kilogrammes. The average age of the subjects
was fifty-two. Hence it is probable that in Ziemssen's case
the resistance was somewhat exceptional, and the varying
results show, as was probable a priori, that there is a
considerable difference in the strength of the human gullet.
If, however, we accept the highest power of traction, viz.,
twelve and a half kilogrammes, I do not think it at all
impossible that it will be found to be exceeded by the
combined expulsive power of the diaphragm and the strong
abdominal muscles. Moreover, it must not be forgotten that
in these experiments just described the force was gradual,
and was applied in a totally different way to that which
occurs during life, when fluid is dashed violently and sud-
denly against the inner walls of the oesophagus.

The foregoing experiments, which merely show the traction-
power of the gullet, though of value in relation to Boerhaave's
case, in Avhich the solution of continuity was horizontal in
direction, have no bearing on any of the other recorded cases,
in all 1 of which the rent was vertical.

Zenker and Ziemssen2 further call attention to the occa-
sional tearing of the pleura which, they consider, " forces
them" to accept the theory of oesophagomalacia. They
think that the repeated efforts at vomiting cause the re-
gurgitated food and gastric juice to remain in the gullet
.sufficiently long to give rise to digestive softening of its walls,
and that the faint condition of the patient produces "spastic
ischsemia," a condition commonly expressed by the blanched
face of a person who is vomiting. This explanation appears
to me somewhat far-fetched, for vomiting, with its accom-
paniment of so-called spastic ischaemia, is a very common
occtirrence, while rupture of the gullet is one of the rarest
of accidents. It is further negatived by the fact that the
lesion generally takes place when the stomach is loaded with
food or drink, and therefore when the gastric juice is ex-
tremely diluted. The suddenness of the event, and the fact
that the lesion has usually been produced when the patient
was in the upright position (in which case the gastric juice
could not remain in the gullet), render it highly improbable
that ante-mortem peptic softening can be the cause of the
injury. Further, were the rupture caused by digestive solu-
tion, whether before or after death, it if probable that the

1 In Wilkinson King's case the direction of the rent is not stated.
J Op. cit. p. 97.

168 DISEASES OF THE THROAT AND NOSE.

opening would be more or less irregular, the edges of Un-
wound being "ragged and fringed with flocculent shreds of
half-dissolved tissue" (see "Post-mortem Digestion "), and
not a longitudinal rent with sharj>ly-(-nt edg'-s, sneh as almost
invariably occurs when the accident results from vomiting.

An attempt was make by Wilkinson King l to prove that
no such lesion as rupture of the oesophagus during life ever
occurs, the supposed symptoms of such an accident being,
according to him, due to other conditions, and the rent found
after death resulting from post-mortem softening. This theory
was based mainly on the following case, to which I have
alluded in the historical summary as an undoubted example
of rupture during life : —

A cabinet-maker, aged twenty-four, who had been very intempe-
rate for years, Juid complained for many months of severe epigastric pain
and sickness, and had also been troubled by loss of appetite and flatu-
lence. While at a public supper, at about 9 o'clock in the evening,
he felt sick, and soon afterwards left the table. He vomited slightly,
and had to be assisted home. Castor oil was then administered.
When first seen by a medical man (at 3 a.m.) the patient complained
of great pain at the pit of the stomach, the abdominal muscles were
rigidly contracted, he could only breathe when sitting up in bed
and leaning forwards on his hands, whilst his countenance expressed
the greatest anxiety. Emetics (antimony and ipecacuanha) were
given without effect. At 7.30 the pain was less severe, but the
dyspnoea was much worse, and there was emphysema of the face,
throat, and chest ; another emetic was given, and an enema was
administered, both without effect. The stomach-pump was used at
10 o'clock without result ; death took place at noon — that is to say,
fifteen hours after the patient had sat down to supper.

Post-mortem. — "A large rent was found in the gullet as it passes
through the diaphragm, filled with ingesta from the stomach (sic).
There was food in the posterior portion 'of the chest."2 The left
end of the stomach was softened by digestion. The lungs on both
sides seemed congested, the left being ' ' contracted ; " there was
some dark offensive fluid with castor oil floating on it in the left side
of the chest. A small quantity of plastic lymph was found inside
the pericardium, but the heart was healthy.

1 " Guy's Hospital Reports." 1842, p. 139, and 1843, p. 113.

2 The ipifumina verba are given, as the passage is somewhat involved, but the
author probably meant that a space, i.e., the pleural cavity, communicating with
the rent (not the rent itself), was filled with ingesta.

Wilkinson King himself admits the imperfection of the
report of the case, observing that it was compiled from
" the Iin4ij Jiott't of Mr. Condey." It is conceded that the
patient died very suddenly, i.e.', in fourteen hours after the
first marked symptom, that he vomited, and that a rent was
found in his gullet after death, yet King thinks it more
reasonable to attribute the death to " sudden inflammatory

RUPTURE OP THE GULLET. 169

tumefaction of the larynx," of which there is not any evi-
dence whatever in his published record of the autopsy. The
extensive emphysema is in like manner ascribed to a " rupture
of the air-tube," of which again there is no mention in the
account of the post-mortem examination. Xo attempt is made
to explain the other features in the case, such as the inability
to vomit and the acute pain in the epigastrium.

My own view is that the vomiting was much more
severe than it is said to have been in the " hasty notes "
of the case, or that the epigastric pain, from which the
patient had suffered for some months, was due to ulceration
of the (Esophar/us, and that therefore its walls gave way
under much less strain than in the other instances. If tin's
latter explanation be correct, the case would closely resemble
that reported by Mr. Adams.

The almost universal occurrence in these cases of subcu-
taneous emphysema closely following the patient's own sense
of some grave accident having befallen him, is a strong argu-
ment against the theory of post-mortem digestion. It is well
known that even in ordinary respiration some air is drawn into
the gullet, and when dyspnoea is present (as in most cases
of cesophageal rupture) the quantity of air thus swallowed
is probably considerable. Hence, should a rent occur in the
tube, it is clear that subcutaneous emphysema woxild be
almost sure to take place. In the cases in which the bowels
were distended with flatus (as in those of Boerhaave, Meyer,
Wilkinson King, and Charles) it is not improbable that the
gas was formed in the intestinal canal. Instead of accepting
these obvious sources, Wilkinson King remarks that the
pericarditis began before the dyspnoea, and says, " I impute
to the latter the production of emphysema, though by no
means definitely. We know that violent efforts of respiration
rupturing the air-tube do cause the extravasation of air into
the cellular tissue as well as the fracture of the rib" (sic). This
passage is somewhat involved, but I gather from it that
King attributes the emphysema to a rent in the trachea,
although, as already remarked, there is not the slightest
allusion to any such lesion in the account of the post-mortem
examination. It will be seen that the views of King do
not deserve serioiis consideration, and they have only been
refuted because they have so often been referred to by medical
writers, who have evidently not read the original article.

It need scarcely be pointed out that the presence of the
contents in the mediastinum or pleura! cavity, does

170 DISEASES OF THE THROAT AM> tlOSM

not in any way militate against the theory i>f nijiturc from
violent contraction, nor support that of /x<>7-///«/7r/// or
tntm-rifd/n digestion of the cesojihageal walls, for if the
vomiting continue after a rent has taken place, the gastric
juice and the contents of the stomach will !»• forced through
the aperture, and may l>e found after death in the medias-
tinum, or in one or both jileiu-.il cavities.

Si/iitptontx. — As already remarked, the accident usually
occurs during vomiting after a full meal or a drunken
carousal. The patient suddenly feels as if something had
given way, his face becomes blanched, and expresses extreme
anxiety; cold sweat breaks out over the body, and tin-re
may even be syncope. Excruciating pain is often felt along
the course of the oesophagus or in the ejiigastric region, or
occasionally shooting through from the ensifonn cartilage
to the back. This last symptom, however, is not invariably
present at the time of the accident ; but, as in Fitz's case,
may be deferred for some hours, probably showing that the
actual rupture did not take j>lace at the h'rst onset of the
symptoms. The patient, who has previously been retching,
suddenly becomes unable to empty his stomach, or can only
with the greatest difficulty bring uj> a small quantity of the
liquid that has been swallowed.1 In three cases- it is men-
tioned that the patient could endure his suffering only when
suj)j)orted in a half upright position, with the body bent
slightly forwards. The least movement generally aggravates
the pain. In nearly every instance subcutaneous emjihysema
has been observed, usually beginning at the root of the neck
anteriorly, and extending more or less over the body. In
Meyer's case, however, this was first noticed on the right side
of the face. Sometimes the patient complains of thirst, and
he can generally swallow with ease, although the greater part
of the fluid probably passes into the mediastinum.

I'utlinliHiij. — The rent in the gullet has, in every recorded
case, been at the lower end of the tube, and in all but one3
it has been longitudinal in direction. The exception occurred
in the memorable instance related by Boerhaave,4 an abstract
of which is given further on. In this case the two ends of
the tube seem to have been drawn apart. In the other c
the rent varied from two to five centimetres in length. In most
of them the gullet was torn only at one place, but in that

1 For exceptions see Foot-note 1, p. 172.

2 Boerhaave, Meyer, Grammatzki.

3 See Foot-note 1, p. 167. 4 Loo. cit.

RUPTURE OP THE GULLET. 171

observed by Grammatzki1 a second longitudinal fissure was
found on the opposite side of the tube, involving, however, only
the mucous membrane. Externally to the opening there is
usually a cavity in the mediastinum, containing a discoloured
fluid, and in some instances fragments of food. Often this
space, in its Jurn, communicates with one or both pleural
cavities, which also frequently contain a large quantity of the
fluid drunk during the last hours of life, but discoloured with
blood and softened tissue. In Boerhaave's case no less than
104 ounces of this fluid were removed from the thoracic cavity.
In the examples reported by Wilkinson King2 and Charles,3
the greater curvature of the stomach was very much softened.

FIG. 21. — CHARLES'S CASE; OF RUPTURE OF THE (ESOPHAGUS
(AFTER KNOTT).

A, the lower part of the wsophageal canal ; B, the external wall of the gullet ;
C, stomach ; a, longitudinal fissure reaching through all the coats of the
oasophagus ; 6, small aperture communicating with left pleura ; c, large irre-
gular aperture, probably accidental ; d, fundus of stomach, mucous membrane
very soft and dark ; e, pylorus, near which the mucous membrane is red ; /,
very prominent ruga?.

Diagnosis. — Boerhaave4 remarks that from the description
of his case any future accident of the kind could be recog-
nized. This, however, has not proved to be the fact, for in
no single instance, except that of Meyer, has the nature
of the lesion been recognized during life. The diagnosis
has been laid down somewhat dogmatically by Oppolzer,5

1 Loc. cit. 2 Loc. cit. 3 Loc. cit. 4 Op. cit. p. 60.

5 " Vorlesungen iiber speciclle Pathologic u. Therapie." Erlangen,
1872, Bd. ii. Lieferung i. p. 151.

172 DISEASES OP THE THROAT AXD NOSE.

who states that rupture of the gullet may be conjectural t»
have taken place when previous signs (if an atleetion of the
oesophagus having been present, there suddenly occurs violent
pain along the course of that organ, with expuition of blend,
great shock, and inability to vomit.1 The "previous si-ns
of an affection of the oesophagus" have not, Ijowever, in the
recorded cases been sufficiently obvious to attract attention.
Hamburger2 suggests that auscultation may be of use, but it
is extremely doubtful whether any trustworthy information
can be gained by this method in such cases.

Prognosis. — All the reported cases have ended fatally, the
patients generally dying within a few hours of the rupture,
though in one case life was prolonged for some days. In one
instance3 the patient died in four hours, in two4 in seven
hours, in two others5 in twelve hours; in other cases death
took place in thirteen,6 fourteen," seventeen,8 eighteen and a
half,9 and twenty-four10 hours respectively. In one case,
however, the patient did not succumb till fifty hours11 after
the accident, and in another,12 in which the rent was pro-
bably very small at first, and afterwards extended, life was
protracted for nearly eight days, during which the sufferer
passed through a sharp attack of delirium tremens.

Treatment. — Directly the rent occurs it might be worth
while to introduce the permanent oesophageal tube (Vol. ii.
Fig. 10, p. 22). It must be admitted, however, that the instru-
ment woidd be not unlikely to pass through the rent into the
mediastinum ; and that should this accident be avoided, the
introduction of the tube would probably give rise to attempts
at vomiting. But if the instrument can be tolerated, it is
within the range of possibility that a small and extremely
narrow rent might heal. If, however, the patient be unable
to bear the tube, it will be necessary to feed him entirely by
nutrient enemata. The fact that Allen's patient lived for
more than seven days shows that sometimes, at least, there is
time for the employment of therapeutical measures, amongst
which the administration of anodynes must be considered
the most important.

1 Baron de Wassenaer was slightly sick several times after the
accident, and in the case of Bailey's patient, efforts at vomiting
continued till death. Allen's patient also vomited the contents of his
stomach frequently after surgical emphysema had occurred.

- " Kliuik der QEsophaguskrankheiten." Erlangen, 1871, p. 189.

3 Taendler. 4 Charles and Adams. 6 Dryden and Grammatxki.

6 Williams. 7 Wilkinson King. 8 Gritiin. " Boerhaavc.

10 Bailey. n Meyer. 12 Fitz.

RUPTURE OF THE GULLET. 173

ABSTRACT OF THE CASE OF RUPTURE OF THE
(ESOPHAGUS OBSERVED BY BOERHAAVE.

(The original occupies seventy closely-printed pages.)

The subject of this accident was Baron de "Wassenaer, a man
over fifty years of age, and of powerful frame, whose appearance
betokened perfect health. In his youth he had frequently suffered
from "angina," and for many years during the winter he had
been subject to gout, attributed by himself to over-eating and want
of exercise. After a full meal he always felt a sensation of great
weight at the pit of the stomach, and to relieve this he was in the
habit of taking ipecacuanha in a copious infusion of blessed-thistle,1
though he sometimes used the latter beverage alone.

At the time of the accident which caused his death, Baron de
Wassenaer was atoning by low diet for an excess at table committed
three days before, and a glance at his last meal — an early dinner — may
give some idea of the character and amount of his food when he was
not stinting his appetite. It has long been supposed that the Baron
was a gross feeder, but after a careful perusal of the case, so eminent
an authority as Professor von Ziemssen does not think this opinion
warranted by the facts. .An examination of the following list, which
does not represent the bill of fare, but only that portion of it which
was partaken of by the Baron, will enable the reader to determine for
himself a matter which has an important etiological bearing on the
case : —

DINNER.

Veal Soup, with Herbs.

Boiled Lamb and Cabbage.

Fried Sweetbread and Spinach.

Duck.

Two Larks.

Compote of Apples.

DESSERT.
Pears, Grapes, Sweetmeats.

Beer and Moselle.

In justice to Baron de Wassenaer it must be stated that he does
not seem to have eaten largely of any of these viands, except perhaps
of the duck, of which he took a leg and breast. In the afternoon
he went out riding, and returned in his usual health. No supper
was taken, but about half-past ten in the evening, he began to
complain of the old disagreeable feeling about the stomach, and he
swallowed three tumberfuls of a hot infusion of thistle. As this
did not act with its usual efficacy, he took four more glasses of the
same infusion, but still without effect. Much surprised at this, the
Baron ordered another dose to be prepared, and in the meantime
strove to excite vomiting by tickling his fauces. Whilst straining
violently he suddenly felt a horrible pain, and gave such a cry of

, * Carduus or Cnicu* Bene.dictus. This herb was once much used as a febrifuge
and tonic and as a mild diaphoretic. The infusion is said to induce vomiting,
or rather to assist the action of emetics, but probably it has much the same
effect as warm water.

174 DISEASES OF THE THROAT AND NOSE.

anguish that his servants hastened to liis assistance. He exclaim. -.1
that something had burst or been violently di>plai •<•<! near the pit <>f
the stomach, and that he was sure he must die immediately. He was
put to bed in a state of utter prostration, being pale, bathed in col.l
sweat, and pulseless. Half an hour after the seizure he swallow.-,!
four ounces of olive oil, and with the help of his finger succeeded in
vomiting some of the oil together with a certain quantity <>f the
thistle-infusion. Two ounces more of olive oil, however, produced
neither nausea nor vomiting, and the pain increased. Shortly after-
wards the Baron drank about six ounces of warm spruce-beer.

On his arrival Boerhaave found the Baron sitting in bed, with liis
body bent forwards almost double. Three servants supported him
in this attitude, as every other posture, especially sitting or standing
upright, caused excruciating agony. On examining his patient,
Boerhaave found that there was nothing to be seen in the th
there was no nausea, scarcely any eructation, the breath was not
offensive, there was neither pain nor difficulty in swallowing, there
was no thirst, and the feeling of weight about the stomach was no
longer present.

No swelling or hardness could be detected in the chest or abdomen.
The urine was natural, and could be passed without difficulty. The
patient's body seemed to be of normal temperature, the pulse quick
and full, but regular, the breathing and sound of the voice natural.
There was frequent deep sighing, but no cough. The colour of the
Baron's face was natural, his mind was quite clear, and there was no
paralysis. In short, the only sign of disease was the agonizing pain
felt by the patient, and an indefinable sense of some change in the
situation of parts within the chest. The pain was situated at first in
the epigastric region, and was described by the patient himself as a
feeling of some sensitive membrane having been torn ; it never
ceased, and hardly abated for an instant. Later on, the pain,
without leaving its original seat, extended backwards, then along
the sides, and finally over the whole inner wall of the chest. The
patient stated that flatulence caused extreme suffering, the gas
apparently not finding its way up ; he could feel it leave the
stomach, and then almost immediately experienced an excruciating
pain in the chest. The physician in vain sought for a satisfactory
explanation of the phenomena, the possibilities of " internal inflam-
mation," thoracic tumour, displacement of parts, poison, and gout
being successively considered and dismissed.

Boerhaave was inclined to give a hopeful prognosis from the
absence of any symptom of disease except pain, which, in spite of its
atrocious severity, he did not think would be sufficient to cause
death. With the view of diminishing his agony the patient was bled
almost to syncope, but this measure failed to give the slightest
relief. Poultices, applied near the stomach, made his sufferings
worse. Anodyne draughts were administered, but the use of nar-
cotics was avoided, as tending to lessen excretion. The bowels wen-
emptied by enemata. The voiding of urine was diminished to a
few drops, passed with great straining and a sensation of scalding.
The urine was thick, red, and strong-smelling, these characters
proving to Boerhaave's mind that none of the abundant quantity i if
fluid which the Baron had swallowed could have reached the kidneys.
The heart now (sixteen and a half hours after the seizure) beganto
fail, the face grew pale, the extremities cold, the breathing became

RUPTURE OF THE GULLET. 175

hurried, and though the patient's mind continued clear, death seemed
imminent from mere exhaustion. As a last resource, thinking that
possibly the cardiac orifice of the stomach was obstructed by un-
digested food, Boerhaave ordered two ounces of sweet almond oil, to
be followed by seven ounces of warm water, and directed that the
action of the remedy should be assisted by tickling the fauces with a
feather dipped in oil. As the result of this, a little dark liquid was
thrown up, but none of the oil returned, and no relief was obtained.
Here it may be mentioned that there had been no hiccough during
the whole course of the affection. Boerhaave was still inclined to
believe that the upper orifice of the stomach was blocked up ; on
reckoning up the large quantity of drink taken by the patient, and
the small amount vomited up or passed as urine, it seemed clear that
the fluid could not have reached the stomach. A swelling was now
observed in the epigastrium, which seemed to confirm this view.
Shortly after the administration of the last emetic, eighteen and a
half hours from the beginning of his cruel suffering, the Baron
showed signs of collapse, and, rather to the surprise of his physician,
suddenly expired.

Autopsy twenty-four hours after death. — A large livid stain was
seen on each side of the thorax, with blac'k patches here and
there. There was emphysema all over the front and sides of the
chest. The abdomen was inflated and extremely tense. On opening
it, the peritoneum, intestines and stomach were all found enormously
distended with air, but to Boerhaave's extreme amazement, the
latter viscus contained only a few drops of reddish-brown fluid.
The bladder was empty and contracted. On opening the chest cavity
Boerhaave, who at the time knew nothing of the nature of the
patient's last meal, remarked a strong smell of roast duck. The
pleural sacs were found distended with gas, the lungs collapsed and
almost bloodless. In each side of the chest there was a large
quantity of fluid resembling that previously seen in the stomach,
mixed with some of the thistle-infusion. Floating on this was the
almond oil ordered by Boerhaave, but, on careful examination, not
a drop of blood or pus could be seen. The fluid collected from both
sides of the chest measured 104 ounces (Amsterdam measure). On
the part of the pleura covering the left side of the oesophagus, at a
distance of two inches from the diaphragm, there was a discoloured
patch about three inches in diameter, in the middle of which a fissure
was perceived half an inch in length, and three lines in breadth.
This fissure was found to communicate with a space in the medias-
tinum, from which the retracted ends of the ruptured oesophagus had
been drawn asunder in opposite directions. The most minute inspec-
tion failed to show the least sign of ulcer or other disease in the oeso-
phagus ; Boerhaave emphatically states that thoiigh he searched in
the expectation of finding some pre-existing lesion of the gullet-
walls to explain so unprecedented an accident, the more he looked
at the edges of the rent and the surface of the oesophagus near
thorn, the more perfectly healthy they seemed to be. The stomach
was also quite free from disease.

176 DISEASES OF THE THROAT AND N"-K.

ABSTRACT OF DR. FITZ'S CASE OF RUPTURE OF THK
GULLET.

The patient was a man aged thirty-one, whose constitution was
much impaired by the abuse of alcohol. For several years he had
cut his food into small pieces and eaten it very slowly, but he had
experienced neither pain nor difficulty in swallowing. About a year
previous to the accident he had suffered from delirium //>//«///>. fol-
lowed by very obstinate gastritis, from which, however, he recovered,
but a few weeks before his death he had another attark <>t inflamma-
tion of the stomach. On both occasions the vomiting was distressing,
and was accompanied by haematemesis.

At supper one evening he was suddenly "partially strangled" by
a piece of food which lodged in his throat. There was intense dis-
comfort, but no cyanosis or dyspnoea. About an hour after the
occurrence, by straining with his whole strength, he succeeded in
dislodging the impacted substance, which was .shot out with con-
siderable noise, as if discharged from a popgun. It proved to be a
piece of gristly meat one inch in length, and rather more than half an
inch in diameter. The patient then fell back exhausted, and spat up
some liquid and clotted blood. A sAvelling (emphysema) was soon
afterwards observed at the angle of the jaw on the left side, and a
little later a similar swelling appeared on the right side, the two soon
extending and meeting across the front of the neck. The patient was
thirsty, and could swallow fluids easily. He did not complain of
pain, but his face had an expression of great anxiety. There was
some tenderness on the left of the trachea just over the clavicle.
There was slight nausea, and the patient had vomited about an hour
after the accident, there being no blood in the matters brought up.
He was drowsy, but could not sleep. During the night pain came
on in the left side of the chest, and also in a less degree on the
right side, and at the upper part of the back ; the swelling of the
neck extended down the arms to the fingers and over the front of
the chest, the skin being tense, hard, and dark, and having the
appearance of erysipelatous inflammation. There was tenderm >- »\\
both sides of the trachea, and ropy mucus mingled with blood was
constantly expectorated. Thf. contents of the stomach //•••,•, • frri^i, uttii
vomited, sometimes mixed with blood.

The treatment consisted of hypodermic injections of morphia
together with bismuth internally, and a mustard poultice over the
stomach. Ice was given to assuage the burning thirst, cooling lotions
were applied to the swollen skin, and the patient was fed with milk
and beef-tea. During the next two days there was little change in
his condition ; the emphysema had spread over nearly all the sub-
cutaneous tissue of the body. The bowels and kidneys acted regularly.
The patient was very weak and restless, but Hoffmann's anodyne
seemed to give him relief. During the fourth, fifth, and sixth
days he passed through an ordinary attack of //«•///•/<//// /,••
falling into a deep stertorous sleep on the evening of the sixth day.
He could retain the food and stimulants given to him. On tin-
seventh day he passed three bloody stools, and had three fits of
"cramp," each lasting for half an hour. They began with trem-
bling of the limbs, which was followed by rigid and painful contrac-
tion of the flexor muscles. There was excruciating pain over the

RUPTURE OF THE GULLET. 177

heart and stomach, together with apparent dyspnoea ; the counte-
nance expressed great terror, but there was no loss of consciousness.
After each fit there was profuse cold sweating. On the eighth day,
after a quiet sleep, the patient woke up quite rational. He took
some nourishment and a little stimulant, but became more and more
prostrate, and died quietly just seven and a half days after the begin-
ning of his illness.

Autopsy by Dr. Fitz forty-eight hours after death. — The anterior
mediastinum was emphysematous. The right lung was partly ad-
herent to the chest-wall by recent fibrinous exudation. There was a
cheesy nodule in the apex of the right lung, and a similar deposit
iu the upper lobe of the left lung.

In front and to the right, from the level of the bifurcation of the
trachea downwards, the oesophagus presented a longitudinal rent
two inches in length, reaching completely through all its coats.
The edges were clean-cut, and there was no evidence, even on micro-
scopic examination, of pre-existing ulceration or degeneration. The
wound opened into a cavity in the right side of the posterior medias-
tinum, extending between the gullet and the trachea in all direc-
tions, and also partly behind the former. This space might have
contained a small lemon, and was crossed by fibrous trabeculse, the
intervals between them being filled with clotted blood. The walls of
the cavity were of greenish hue, and the vagus nerve could be seen
behind, thickened and red. The internal surface of the gullet, from
the tracheal bifurcation down to the cardiac orifice of the stomach, was
greenish in colour, the epithelial layer was flocculent, and here and
there somewhat thickened, but it was entirely wanting over a space
about an inch in diameter below the rent. The cesophageal walls
were of normal consistence. The stomach showed the usual appear-
ance of chronic catarrhal gastritis ; there was no trace of post-mortem
softening. Some black grumous material, probably altered blood,
was found in the intestines, the spleen was enlarged and softened ;
there was "cloudy swelling" of both kidneys, and fatty infiltration of
the liver. The heart presented signs of fatty degeneration.

VOL II.

178

DISEASES OF THE THROAT AND NOSE.

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DISEASES OF THE THROAT AND XOSE.

WOUNDS OF THE GULLET.1

Latin E<]. — Vulnera oesophagi.
French E<j. — Plaies de 1'oesophage.
German Eq. — Wunden der Speiserohro.
Italian Eq. — Ferite del esofago.

DEFINITION. — Wound* of the iBSophagus of an zW /.»•"/,
punctured, or contused character, caused Ity sharp
penetrating the walls of the tube either from within or
without, always (jiving rise to dt/sphagia.

History. — Wounds of the oesophagus have hitherto attracted com-
paratively little notice, owing to the fact that this organ is seldom
injured alone. Its deep situation, indeed, protects it to a very
great extent from external wounds. When the gullet is wounded
the windpipe and the large vessels of the neck are generally implicated
in the injury, and from the urgency of the immediate symptoms they
absorb the attention of the surgeon.

Ambroise Pare 2 appears to have been familiar with wounds of the
gullet, and he directs that they should be treated with sutures when
jwssible to apply them. He placed on record3 an extraordinary case
in which the windpipe and gullet were both completely divided. Pare
succeeded in uniting the divided trachea sufficiently to allow of the

Eatient recovering the power of speech so far as to be able to name
is assailant, but all his efforts to bring the retracted ends of the
oesophagus together in the same way failed, and death took place on
the fourth day.

Isolated cases were reported by Larrey,4 Boyer,5 and Dupuytren,"
but the subject was first systematically treated by Horceloup.7 More
recently several additional cases have been brought together by
Durham8 and Knott.9

1 Extensive wounds in which the gullet is only one of several important
structures involved will be considered in a separate article under the head of
" Cut-throat."

2 See the chapter, " Des Plaies de 1'CEsophague."— CEuvres (Malgaipne's
edition, Paris, 1840), vol. ii. p. 90.

3 CEuvres, liv. x. ch. 31.

« ' Clinique Chirurgicale." Paris, 1829, t. ii. p. 158.

8 ' Traits des Maladies Chirurgicales," t. vii. p. 279.

fi ' Blessures par Armes de Guerre," t. ii. p. 334.

^ ' Plaies du Larynx, de la Trachee, <fec." Paris, 1869.

* ' Holmes's System of Surgery." London, 1870, 2nd ed. vol. ii. pp. 445 and
457.

» " Pathology of the CEsophagus." Dublin, 1878, pp. 151-154.

Etiology. — Wounds produced by the perforation of small
sharp substances that have been swallowed will be referral
to under "Foreign Bodies," and it therefore only remains to
consider wounds arising from the introduction of cutting
weapons, such as swords and foils, and those caused by
external injury. Accidents belonging to the former category
are extremely rare, but a case is recorded by Levillain,1 in
1 "Journ. Univ. de Med." 1820, p. 238.

WOUXDS OF THE GULLET. 183

which an officer whilst fencing received a wound from a foil
as In- was stooping. The point of the foil entered his mouth,
lacerating the soft palate, and ran through the posterior
wall of the oesophagus at the level of the fourth or fifth
dorsal vertebra. A remarkable accident was related by Dr.
Parkes1 in which a sword-swallower pushed his weapon
through the anterior wall of his gullet five and a half inches
below the pharynx. The pericardium was pierced, most
acute inflammation of the membrane ensued within an hour,
and the patient died on the second day. Xo other injury
was found after death. A peculiar feature in this case is
that whilst one of the immediate symptoms caused by the
wound was violent vomiting, the matters thrown up con-
sisted solely of the contents of the stomach without a drop
of blood. An extraordinary case was reported by Guise,'2
of Charenton, in which a lunatic thrust the handle of a fire-
shovel into his throat with such force that it tore through
the gullet, and fractured the fourth rib at the costo-vertebral
ligament.

In illustration of injury from without there are several
examples. Boyer3 has described the case of a young man,
who received a bayonet-thrust at the anterior and upper part
of the chest, causing a wound four lines from the sternum
between the third and fourth ribs, from which there was
a violent escape of air. Three days later food and drink
appeared through the wound, but the patient ultimately
recovered. Larrey4 has reported an example of this accident
which proved fatal. The patient, who had received a sword-
thrust at the upper part of the chest, between the first
and second ribs, at first improved under treatment, but was
ultimately suffocated in trying to swallow some large pieces
of bread. In another instance,5 the patient, having received
a wound between the fifth and sixth ribs, died at the end of
thirty-six hours, all fluids that were drunk passing through
the wound. There is also a case on record6 in which
a soldier was wounded by a bullet which traversed the
oesophagus at its upper part. Drink passed through the
wound, but the patient ultimately made a good recovery.

1 "Trans. Path. Soc." London, 1848-9, p. 40.

2 Quoted by Horteloup : Op. cit. p. 24.

"Traite des Maladies Chirurgicales," t. vii. p. 279.

"Clinique Chirurgicale." Paris, 1829, t. ii. p. 158.
5 M. C. Etienne : " Consid. gener. sur les causes qui genent ou
finjit'chent la deglutition." These de Paris, 1806, p. 8.
B Horteloup : Op. cit. p. 61.

184 DISEASES OF THE THROAT AND No.-K.

In Dupuytren's1 case, the patient, a woman, was stabbed just
above the clavicle on the left side. She died on the seventh
day, the fact that the gullet was wounded not having been
recognized during life.

Symptoms. — The characteristic symptom of wounds in
the oesophagus is the escape of food from the opening. It
must not he forgotten, however, that when the trachea or
larynx is injured from without, and especially if the pneunio-
gastric or superior laryngeal nerve has been divided, the
food may pass into the windpipe, and, as in wounds of the
gullet, may come out through an opening in the neck. In
most of the reported cases, violent hiccough and intense thirst
have been present. There is often difficulty in breathing,
but this appears to be due to complications arising from
injury of the lungs or trachea.

Diagnosis. — The history of the case, taken in connection
with the objective signs, generally renders the diagnosis easy.
It is only in rare instances, such as that of Dupuytren, where
a wound was inflicted on the oesophagus through the neck,
and fluids subsequently swallowed did not escape, that the
nature of the accident is likely to be overlooked. Possibly
some cases of this kind occur which are never suspected, for,
as Horteloup2 points out, stabs with a knife or dagger as a
rule cause only minute punctured wounds.

Prognosis. — For many years it was supposed that com-
plete transverse division of this tube always proved fatal,
and this was strongly supported by the experiments of
Jobert.3 This view, however, has been proved to be
fallacious. When the wound is in the cervical portion of
the gullet, and is limited to that organ, the case almost
invariably does well ; but of course, if the air-passages are
injured at the same time, the prognosis is much more serious.
Wounds in the thoracic portion are extremely fatal.

Treatment. — If the wound be large the edges should, if
possible, be stitched together. The patient should be entirely
fed by nutrient enemata (Vol. i. p. 580). If, however, this
mode of administering nutriment does not seem sufficient
to sustain the patient, he should be fed by the oesophageal
feeding tube (Vol. ii. Fig. 11, p. 24) passed an inch or two
beyond the wound ; and if there be any difficulty in carrying
out this treatment, an anaesthetic should be administered each
time that the patient is fed. In some cases, however, owing

1 Loc. cit. 2 Op. cit. p. 19.

3 Boulin : " Plaies de I'CEsophage." These de Paris, 1828, p. 20.

FOREIGN BODIES IN THE GULLET. 185

to the irritation caused by the passage of the instrument, or to
the impossibility of striking the orifice of the lower segment of
the cesophagus when it has been completely cut across, it may
be necessary to allow the patient to swallow bland liquids.
Although, under these circumstances, most of the food will
<-scape by the wound, a small quantity will trickle down the
gullet. "When the necessities of nature require nourish-
ment to be taken by the mouth," as Heister1 remarks, the
wound should constantly be diligently cleaned afterwards,
lest any part of what was taken should stick by the way and
putrefy, which would bring on very bad symptoms." It is
only when there does not appear to be the slightest chance
of the wound healing that the patient should be nourished
by means of an instrument passed through the neck.

As a rule, a very nutritious and stimulating diet is neces-
sary, and, in most cases, anodynes are required.

1 " General System of Surgery." English Transl. 1743, vol. i. p. 77.

FOREIGN BODIES IX THE GULLET.

Latin Eq. — Corpora adventitia in oesophago.
French Eq. — Corps etrangers dans 1'oesophage.
German Eq. — Fremde Kbrper in der Speiserbhre.
Italian Eq. — Corpi stranieri nel esofago.

DEFINITION. — Foreign bodies lodged in the gullet, most
rniiDiionly gaining access to tliat canal by the mouth, but
<><• rationally passing up from the stomach, and more rarely
xfi/l fitter i-n g through the neck, giving rise to dysphagia,
.«niii'tiinK8 to dyspnoea, and often causing death.
^

History. — The literature relating to the impaction of foreign bodies
may he said to begin with the elaborate memoir on the subject presented
by Heviu1 in the middle of last century to the French Academy of
Surgery. In this essay the author collected nearly all the instances of
this accident scattered throughout the medical records of former times,
and discussed the best methods of dealing with such cases. His work
remains to this day the most complete account of foreign substances
lodged in the cesophagus, and subsequent writers have added little to
it, except descriptions of more convenient instruments for exploration
of the canal and the extraction of bodies impacted in it. Bordenave2
soon afterwards published a short memoir on " Foreign Bodies in
the Gullet," and a work by Eckhold3 on the same subject appeared
in 1799, in which the instrument now known as Griife's coin-catcher

1 " Mftnpires de 1'Acatlftnie R. de Chir." 1761, vol. i. p. 444, et seq.

" Thesis de corporibus extraneis intra cesophagum latentibus." Parisiis, 1763.
3 " Ueber das ausziehen fremder Korper aus dera Speisekanal. ' Leipzig, 1799.

I Sb DISEASES OF THE THROAT AND NOSE.

is described and figured. This author, however, does not claim t<>
have invented it, but says that he had first seen it used in Loinlon.
In 1830 Mondiere1 devoted one of his papers on the oBsophagus t.i
foreign bodies in that canal. Several years later essays were written
by Simon, a Haken,3 Boumeria,4 Pawlikowski, s and Gebser, ' and
in 1867 Adelmann7 published a collection of 314 cases of fon-i.^n
bodies in the gullet and pharynx.8 In 1868 a thesis on " Foreign
Bodies in the Gullet" was written by Martin,9 and in 1876 vmi
Langenbeck10 published the mature results of a very large experience
of such accidents. In 1879 Nevot11 brought together several in-
teresting cases in which foreign bodies had perforated the gullet and
laid open neighbouring blood-vessels.

1 " Arch. G&i." 1830, Ire soi-ie, t. xxiv. p. 388, et seq.

- " Des Corps Etrangers dans I'CEsophage." Strasbourg, 1858.

s " De corppribus alienis oesophago illatis" Dorpati Livonorum, 1859.

» " Des Accidents produits par leg Corps Etrangers arretes dans I'fEsophage."
Strasbourg, 1860.

•' " !»<• corporibus alienis in resophago." Vratislavirc, 1860.

8 " t'eber fremde Korper im (Esophagus und Pharynx." Leipzig, 1865.
" Prager Vierteljahrsehrift f. prakt. Heilkunde," vol. xcvi. p. 66, et seq.

8 This unfortunate mingling of cases diminishes the value of the paper. General
conclusions drawn from such statistics are fallacious, inasmuch as the impac-tinn
of foreign bodies in the pharynx is ceteris paribut far less dangerous than when
they -are lodged in the gullet.

» " Des Corps Etrangers de 1'OEsophage." These de Paris, 1868, No. 117.

10 " Berlin klin. Wochenschr." Dec. 17 and 24, 1876..

11 " Perforation des Oros Vaisseaux par les Corps Etrangers de IXEsophage."
These de Paris, 1879, No. 81.

Etiology. — The most common cause of accidents of this
kind, is the lodgment in the gullet of substances such as
fragments of bone, gristle, fruit-stones, or even pieces of
wood swallowed with the food, or the impaction of largt-
nnmasticated morsels in hurried or gluttonous eating.1 Such
foreign bodies as pins and needles,2 knives,3 forks,4 spoons,5
buckles,6 rings,7 keys,8 coins, singly or in rouleaus,'-'

1 See Pare, Le Dran, Fabricius Hildanus, Wierus, Rhodius, Houillier,
all in Hevin, loc. cit. pp. 446, 447, 448, and 455.

2 See particularly "Lond. Med. Gazette," February, 1844, where
a case is related by Bell in which death resulted from perforation of the
right common carotid, and Schmidt's " Jahrbuch," vol. xxxix. p. 334,
where an instance is recorded in which death occurred from gastritis
more than two years after the foreign bodies had been swallowed.

3 Hevin : Loc. cit. pp. 471, 515, and 595.

4 Ibid. p. 518. Henocque : "Gazette Hebdom." 1874, p. 229.

5 Fournier : "Diet, des Sciences Med." — Art. "Cas raivs."
Baraffio : " Progres Medical." 1876, p. 70.

8 Harrison : Dublin Journal of Meti. Sci." vol. viii. Fournier :
Loc. cit.

7 Hevin : Loc. cit. p. 449.

8 " Edinburgh Med. and Surg. Journ." 1843, vol. Ix. p. 1P.">.
The French poet Gilbert died in the Hdtel-Dieu in 1780, having
swallowed the key of his room five weeks before, whilst delirious
from the effect of an injury to his head.

9 Hevin : Loc. cit. pp. 449, 452, 455, 459. Gay : " Boston Med. and
Surg. Journ." 1879, p. 356. Mignot : " Gazette Hebd." Oct. 30, 1874.

FOREIGN BODIES IN THE GULLET. 187

seals,1 beads,2 nails, 3 and stones4 have found their way into the
oesophagus by accident, or have been deliberately swallowed
by insane people, or out of mere bravado by persons con-
sidered sane. Sometimes jewels or money have also been
swallowed for the purpose of concealment. An extraordinary
instance is on record5 of a blacksmith who was killed by
a fragment of a red-hot key which he was in the act of
forging. The key broke, and a bit of the metal flew down
the man's throat and lodged in his gullet. False teeth and
palate-obturators have sometimes slipped down into the
gullet, and this mischance is especially likely to happen during
sleep or unconsciousness, if such objects are not removed
from the mouth. A curious case has been reported by von
Langenbeck,6 in which a woman who had suffered from
syphilis was for some time in a critical condition from the
greater part of the bony framework of her nose having
become detached by necrosis, and fallen into her gullet while
she was asleep. Many accidents have occurred from the well-
known propensity of infants to put into their mouths anything
which they can lay their hands on. Older children have
sometimes swallowed playthings which they have had in
their mouths on going to sleep. There are also cases on
record in which children have introduced most dangerous
foreign bodies into other peoples' throats. In two instances
of this nature, fish-hooks have been fixed in the oesophagus,
apparently through a precocious love of sport. In one case,"
a little boy, finding his mother asleep with her mouth
open, ingeniously introduced a fish-hook attached to a line.
The mother suddenly awaking, involuntarily swallowed the
hook, which, after passing several inches down, penetrated the
walls of the gullet. In another case,8 a boatman's children,
aged five and four years respectively, agreed to " play at fish-
ing," the elder persuading the younger to take the part of
" fish." The hook was baited with a tempting morsel, and
the younger boy, having played round it for some time after

1 Billroth : " Archiv. f. klin. Chir." 1872, vol. xiii.

2 Monti : "Jahrb. f. Kinderheilk." 1875, vol. ix.

3 Harrison : " Dublin Journ. of Med. Sci." vol. viii. Hevin :
Loc. cit. p. 471.

4 Castresana " Espana Medica," Aug. 18, 1859. Holmer : "Med.

Times and Gaz.
5 Bierfreund

Jan. 13, 1883, p. 47.
"Med. ZeitungRussl." 46, 1848.

" Memorabilien Jahrg." Bd. xxii. Heft 1.

7 Leroy : " Revue Med.-Chir. de Paris." 1847, t. ii. p. 110.

8 Baud : Ibid. 1848, t. iii. p. 44.

188 DISEASES OF THE THROAT AXD XO8E.

the manner of fishes, seized it with his mouth ami swallowed
it. The youthful angler at once dexterously jerked the line,
ami hooked the " iish " near the lower end of the gullet.
In both these remarkable cases, the hooks were removed l>y
an ingenious device to be presently described.

There are several instances in which ears of rye are stated l
to have been taken into the oesophagus with serious and even
fatal results, but a careful study of these cases shows that
in nearly all of them the foreign body had really been drawn
into the trachea, and not into the gullet.

Frogs,2 small live fish,3 eels,4 and even snakes"' have in
various manners found their way into the oesophagus, and
there are a considerable number of cases in which severe
symptoms have been caused by the presence of a leech'1 in
the gullet. All the recorded examples of the latter accident
have occurred in soldiers, which is accounted for by tin-
fact that during campaigns, brackish water has often to be
hurriedly drunk out of wayside pools.

Undigested substances thrown up from the stomach have
not unfrequently become impacted in the gullet.7 Parasitic,
worms have been vomited through the, mouth after having
caused obstruction of the oesophagus.8

One of the most complicated cases of foreign body in the
gullet is related by Adelmann,9 in which a man swallowed a
piece of mutton with some of the bone. Attempts at extrac-
tion with forceps, and at propulsion with the Bponge-proittBg
having failed, Grafe's coin-catcher was tried. This instrument
was passed below the foreign body, but became so tightly
wedged in that it could not be withdrawn. The unfortunate
patient remained with this additional foreign body in his gullet
for more than two days. The coin-catcher was finally loosened

1 Hevin: Loc. cit. p. 553. Desgranges : " Journ. de .Mi'-dcrim-,"
t. xxxviii. No. 1359.

2 "Allgem. Repert." 1838, ix. p. 109.

a "Union Medicale." 1863, p. 568. " Archiv. f. klin. Chir." 8,
p. 481. Norman Chevers : "Manual of Med. Jurispr." Calcutta,
1870, p. 619.

4 "Allgem. Repert." 1838, xi. p. 90.

5 Ibid. 1838, xi. p. 89.

" "Journ. Univ. des Sciences Medicales," January, 1828. Hai/cau :
"Gazette Medicale de Paris." 1863.

7 Hevin : Loc. cit. p. 455. Boulard : "Archives Gen." t. xxiii.
p. 528.

8 Laprade : " Compte rendu des Travaux de la Societe de M^In-hir
<1>' Lyon." 1821, p. 62. Meplain : "Journ. Com plem." t. xvii. p. :;7mJ.

9 Loc. cit. p. 66, et seq.

FOREIGN BODIES IN THE GULLET. 189

by means of a gum-elastic catheter, which was threaded over
it, and when the impacted instrument had been got out, the
original foreign body was pushed into the stomach. The
patient succumbed about a fortnight after the first accident,
but it does not seem that the fatal result was in any way
caused or accelerated by the surgical mishap. A similar
accident occurred quite recently to Dr. Holmer, of Copen-
hagen, whilst attempting to pull out a stone impacted in the
gullet of a lunatic who had swallowed it with suicidal purpose.
External oesophagotomy was at once performed, and both
the foreign bodies were removed, the patient making a good
recovery. The stone was five centimetres long, and five
broad at its widest part.1

Symptoms. — Foreign bodies which are at all large are
especially liable to be arrested either at the upper orifice of the
oesophagus, or at the middle third where the left bronchus
crosses the gullet. Small sharp bodies, such as pins and fish-
bones, may stick into the oesophageal wall at any level. The
.symptoms depend mainly on the consistence, dimensions, and
form of the foreign body. Thus, bodies of soft structure,
such as pieces of food, even when large, though temporarily
obstructing the oesophagus, generally soon become sufficiently
macerated to pass downwards. Large hard bodies give rise
to the most urgent symptoms, such as extreme dysphagia,
intense dyspnoea, acute pain, and profound oppression and
anxiety. If, as is commonly the case, such a body becomes
lodged in the cervical part of the gullet, it may give rise to
a swelling in the neck. If the body be not large enough
to cause immediate danger, the inflammation which is set
up causes considerable fever, and the patient usually wastes
rapidly. Small liard bodies, if rough or angular, generally
give rise to slight dysphagia and a constant feeling of irrita-
tion. In some cases, however, there is rather severe spasm
of the gullet, so that great difficulty in swallowing is ex-
perienced. In other instances, the symptoms, though slight
at the time, may ultimately become serious. The following
is a case 2 of this kind : — A girl, whilst eating some soup,
accidentally swallowed a fragment of bone. The first symp-
toms soon passed off, but after a time her voice became
reduced to a whisper. She became feverish, lost flesh, and
had a troublesome cough with thick blood-stained expecto-
ration. At the end of fourteen years, this patient was seen by

1 "Med. Times and Gazette," Jan. 13, 1883.

2 "Jouru. de la Soc. de He'd, de Paris," t. xxiv. p. 13.

190 DISEASES OF THE THROAT AND NOSE.

(iauthier de Claubry, who at first believed her to be in tin-
last stage of phthisis. On pressing her neck, however, In-
found marked tenderness above the left clavicle. This
examination caused an inclination to vomit, and the patient
brought up the piece of bone, feeling at the same time a
"tearing" pain in the nqck. Her health was subsequently
completely restored.

Sometimes, however, foreign bodies produce very little
irritation, and I may remark that I know of an instance
where a halfpenny was retained in the oesophagus for many
years without giving rise to much inconvenience. From the
symptoms it appeared that the coin was pressed laterally
against the sides of the oesophagus, in which position it was
probably retained by bands of fibrous tissue. A still more
remarkable case has been reported by Larrey1 in which a five-
franc piece became impacted in a man's gullet. Propulsion
was tried and was thought, both by the surgeon and t In-
patient, to have been successful. The patient, however,
suffered afterwards from convulsions, and died two months
later from meningitis. After death the coin was found fixed
perpendicularly about an inch above the cardiac orifice, the
rim pressing on the wall of the gullet on each side. The
coats of the tube were much thickened at this part, and the
pneumogastric nerves were stretched over the edges of the
coin. There was spindle-shaped swelling with great red-
ness of both nervous cords, especially of the right one. It is
remarkable, however, that the mucous membrane presented
scarcely any trace of inflammation.

Analysing the symptoms in greater detail, the dysphagia,
as already indicated, varies to a considerable extent, being
sometimes so extreme that even the saliva cannot be swal-
lowed, whilst in other instances, solids can be taken without
much pain. Dyspnoea likewise may be either present or
absent, its occurrence being generally due to the large size or
singular form of the foreign body. In the former case the
interferenee with respiration may result from direct pres-
sure on the back of the trachea, in the latter from reflex
spasm of the glottis. If the dyspnoea be intermittent, it
may be inferred that it is of reflex origin. The oppression
and anxiety which are caused by the presence of a foreign
body in the gullet are characteristic of nearly all acute
affections of the oesophagus, and they are sometimes ac-
companied by cold sweats and syncope. The voice is often
1 "Clinique Chirurgicale. " Paris, 1829, t. ii. p. 165.

FOREIGN BODIES IN THE GULLET. 191

greatly modified, and sometimes altogether extinguished. The
pain is sometimes described as being of a " bursting " cha-
racter, and frequently gives rise to straining and unsuccessful
efforts at vomiting. In some cases convulsions and even
lockjaw l have followed the impaction of a foreign body in
the gullet. These various symptoms often abate for a few
hours, to come on again with additional violence. On the
other hand, small smooth foreign bodies may be occasionally
lodged in the oesophagus for a considerable time without
giving rise to any active symptoms, and it is only when
inflammation is set up that they attract attention.

The exact position of a foreign body can often be ascer-
tained by physical exploration. Sometimes it may be
possible to use the cesophagoscope, and when this instru-
ment is employed to detect an impacted body, it is better
to administer an anaesthetic. In other cases useful informa-
tion may be obtained by means of the bougie. The sensation
caused by the contact of a foreign body with the instrument
may be greatly intensified by using Duplay's resonator
(Vol. ii. Fig. 5, p. 18). By auscultation of the oesophagus in
the ordinary way during the act of deglutition, fluid may be
heard to strike against the foreign body, whilst below this
point there is either no distinct sound, or only a slight
trickling noise can be perceived.

If the foreign body be allowed to remain and the patient
survive, a variety of secondary symptoms may arise. In many
cases inflammation is set up, and the tissues imprisoning
the foreign substance being destroyed by ulceration, it is set
free and may be vomited up, or may fall into the stomach.
Whether the offending body be extruded or not, however,
perforation of the oesophagus is a frequent consequence of the
accident. Sometimes extensive ulceration takes place in
the areolar tissue surrounding the gullet, and a large cavity
is formed in the mediastinum. Occasionally the ulceration
may extend to the trachea, bronchi, or pericardium, giving
rise to acute inflammation of any of these organs. In a case
reported by Walshe,2 the point of a knife had perforated the
[ii'iicardium and set up pericarditis; and, in a somewhat
>hnilar instance,3 the entrance of air and particles of food
into the pericardial sac through the wound in the gullet,
had caused the pericardial inflammation to be of a purulent

1 Godinet : " Annales de Montpellier," t. iii. p. 230.

- "Diseases of the Heart and Great Vessels." 1873, 4th ed.
jijj. 42 and 273.

* Ibid. p. 218.

192 DISEASES OF THE THROAT AM) X<>-K.

character. Occasionally vessels are laid open, and death
ensues from haemorrhage. A circumscribed abscess is SOUM--
times formed, and this may point in the neck. Two cases '
are on record in which the temporary impaction of a foreign
body led to rupture of the oesophagus. In one instance2
a fish-bone, perforating the gullet in the neighbourhood of
the heart, pierced the pericardium and fixed itself in the
middle of the septum after wounding the right coronary
vein. When the foreign body penetrates by ulceration into
one of the pleural cavities, it generally soon gives rise to
1'inpyema, and the offending substance has sometimes been
removed by paracentesis. In a case which I saw some years
ago with Dr. Turtle, of Woodford, a very careful examina-
tion failed to discover a fish-bone which had accidentally
found its way into an infant's throat. The baby gradually
wasted away, and when it died, at the end of some months,
it was found that the fish-bone had passed through the
intervertebral substance and wounded the cord. In some
instances the foreign body reaches the stomach, or it may
pass into the intestines, and cause fatal ulceration in any
part of its course ; or perforating into the areolar tissue of
the groin or lumbar region, it may give rise to an artificial
anus. If, however, the body be small and smooth, it will
often pass through the whole intestinal tract, and be got rid
of per rectum without doing any harm.

Pathology.— Any of the various pathological conditions
which have been referred to under the head of " Symptoms,"
such as inflammation, abscess, gangrene, or perforation involv-
ing either the oesophagus alone, the surrounding areolar tissue,
or any of the adjoining organs, may be present. Abscesses
are especially likely to be formed even a considerable length
of time subsequent to the impaction of the foreign body.
The interval in Adelmann's3 cases ranged from a week to
fifteen months. In the same series,4 perforation of the aorta
occurred foxirteen times, and of the common carotid six
times, whilst the right subclavian and the pulmonary artery
were each wounded once.

Diagnosis. — In most cases this is easily arrived at from the
history, and, as a rule, it is only when the patients are insane

1 Meyer: " Canstatt's Jahresb." 1858, vol. iii. p. 334. Allen:
"Amer. Journ. Med. Sci." January, 1877, p. 17.
- Andrew: "Lancet," 1860, p. 186.

3 Loc. cit. p. 99.

4 Loc. cit. p. 103.

FOREIGN BODIES IN THE GULLET. 193

persons or children that any doubt can arise. Under such
circumstances the sudden establishment of dysphagia will
lead to an examination of the oesophagus, and one of the
methods of exploration already described will, in most cases,
clear up all doubts. The following example will show the
advantage of oesophagoscopy in facilitating the detection and
removal of foreign bodies that might otherwise baffle the
practitioner's efforts : —

Mrs. B., aged fifty-one, was sent to me by Dr. Spitta, of Clapham,
in February, 1881. She complained of great difficulty of swallowing
and a feeling of something sticking in her throat. The symptoms
had commenced suddenly whilst she was taking a meal, a fortnight
previously. At the first examination with the cesophagoscope, the
interior of the gullet was seen to be highly inflamed, but no foreign
body could be perceived. At a second sitting, however, a few days
later, a flat lamella of bone, about four millimetres square, was
detected on the anterior wall of the oesophagus, about two inches
below the cricoid cartilage. The bone, together with a small piece
of decayed meat, which was adherent to it, was easily removed with
forceps. Mrs. B. felt some slight inconvenience for three or four
weeks after the foreign body had been taken out, but when last seen
she was able to swallow without any difficulty.

Prognosis. — This depends, in the first place, on whether
the foreign body is removed or remains fixed in the oeso-
phagus. In the latter case, if the substance be of any con-
siderable size, the prospects of the patient are extremely
unfavourable.

Even if the foreign body be quickly ejected, however,
inflammation may have been set up which may subsequently
give rise to very dangerous complications. Further, when
the body has remained long enough in situ to cause slough-
ing, it must not be forgotten that, though relief may be
obtained for a time by the expulsion of the offending sub-
stance, the patient's life may be brought into jeopardy in
the progress of subsequent cicatrization.

Treatment. — In all cases an attempt should be made, in the
first instance, to withdraw the foreign body from above per
mas naturales. This may be accomplished — either with the
parasol-probang, with Grafe's coin-catcher, or with forceps.
The first-mentioned instrument is by far the most service-
able for small bodies ; Grafe's snare answers well when a coin
is lodged in the gullet ; whilst the use of forceps is indicated
where the body is large and firmly imbedded. The reader
is referred to the description of these instruments and the
mode of using them already given (Vol. ii. pp. 19, 20).
Where instrumental treatment has to be adopted, it is often

VOL. II O

194 DISEASES OF THE THROAT AND NOSE.

very desirable to administer an anaesthetic. This is especially
the case if the foreign body be large, if there be much spasm,
or if the patient be nervous or of tender years. Kxceptimial
bodies require exceptional instruments for their removal.
In the cases where fish-hooks were swallowed,1 they were
both removed by a very similar procedure, which suggested
itself quite independently to two different surgeons, Baud
and Leroy, both practising in the Low Countries. Baud
did not record his case, which appears to have occurred
somo time previously to that of Leroy, until the latter
surgeon had published an almost identical example of the
accident. The mode in which the fish-hooks reached the
gullet has already been described under the head of
"Etiology." In both instances a leaden bullet pierced
through the centre was threaded along the fishing line, and
allowed to fall by its own weight down the oesophagus till
it reached the hook. The further descent of the bullet
dragged the hook downwards, and thus disengaged it, and its
barb having come in contact with the lead, both were drawn
up together. Baud employed a ball which had a diameter
double that of the hook, whilst Leroy used a smaller bullet,
with a hollow reed attached — an arrangement which he
considers assisted in disengaging the hook from the flesh.
On the whole, however, Baud's method appears the more
simple and efficacious. In another case, reported quite
recently by Laurent,2 a fish-hook was removed from the
gullet of a boy who had accidentally swattowed it, by the
following plan : — A full-sized hollow ossophageal bougie was
threaded along the line attached to the hook till it readied
the bend of the latter. Gentle pressure with the instalment
set the hook free, when the line was tightened, and the
bougie withdrawn together with the foreign body.

Formerly emetics were often administered, with the view
of effecting the expulsion of foreign bodies, and this measure
has often proved successful. I do not recommend this treat-
ment, but there are occasions when it may be desirable to
try it. As the patient is unable to swallow, the best
mode of producing vomiting is by the subcutaneous injection
of hydrochlorate of apomorphia, -^th to y^th of a grain.
One grain may be dissolved in 50 minims of distilled water,
but as the solution is very unstable it should always be
freshly prepared for hypodermic use. Enemata of tobacco

1 Loroy : Loc. fit. Baud : Loc. cit.
a "Laucet." 1882, vol. ii. p. 745.

FOREIGN BODIES IN THE GULLET. 195

have also been used for the same purpose, and, in some
instances, with success. In a few cases, intravenous injec-
tion of tartar emetic has proved effectual, but this is a
dangerous plan. Treatment by emetics has sometimes been
attended with success, even in cases where the foreign body
has remained in the gullet for a considerable period, but,
as a general rule, it cannot be relied upon. Other plans have
occasionally been tried. Thus, an instance1 is on record in
which a large soft substance was thought to have been digested
in the gullet by the administration of pepsine sixty-eight
hours after the accident. Inversion, as already described in
detail (Vol. i. p. 570), may be useful when the body to be
dislodged is smooth and heavy. The first recorded instance2
of inversion for the extraction of a foreign body impacted
in the gullet, which I have been able to find, is in the case
of a patient who had swallowed a knife. At his own sug-
gestion, he was several times hung up by the heels in the hope
that the knife might fall out by its own weight. His per-
severing efforts were, however, unavailing, and the knife was
removed by gastrotomy. In a case in which the patient was
threatened with asphyxia through the impaction of several
large pieces of potato in the oesophagus, Dupuytren3 managed
to pinch the gullet with his fingers through the neck, so as
to crush the potato and thereby enable it to be swallowed.
Langenbeck 4 was on two occasions able, by the same
method, to alter the shape of a tough piece of meat suffi-
ciently to allow the impacted morsel in one instance to
descend into the stomach, and in the other to be removed
through the mouth with forceps. In a case reported by
Atherton,5 the patient herself, an old woman, had attempted,
and partly succeeded, in forcing an impacted bone downwards
by external manipulation.

If it be found impossible to draw up the foreign body, it
must either be left in situ, pushed into the stomach, or
if situated in the cervical portion of the gullet, removed by
oesophagotomy. If the patient is able to swallow liquids,
it is better, when the foreign body cannot be removed, to
leave it alone, in the hope that as soon as the spasm gives
way, or the inflammation subsides, the substance may be

1 "Deutsche Klinik." 1861, p. 109.
1 Hevin : Loc. cit. p. 595.

3 Quoted by Luton : " Nouveau Diet, de Med. ot do Cliir."
Paris, 1877, t. xxiv. p. 356.

4 Loc. cit.

5 " Boston Med. and Surg. Journal." 1870.

196 DISEASES OF THE THROAT AND NOSE.

vomited up. Sucking small particles of ice is sometime!
of use in these cases. Large angular bodies, such as false
teeth or pieces of bone, should be pushed into the stomach
only as a last resource, and when they are impacted in
the lower part of the oesophagus. Such bodies cannot
remain long in that situation without causing death, and it
is therefore better, under the circumstances, to thrust them
down, even if some degree of force has to be employed.
Propulsion may be most readily effected by means of tin-
ordinary sponge-probang. Injection of water into the gullet
and dilatation of the canal by means of an air-pessary passed
down to the foreign body have also been used with sun •< ^
for the same purpose. In the former case the force is applied
directly to the foreign body, whilst in the latter, where an
india-rubber bag is inflated with air, the impacted body is
probably set free by the forcible expansion of the cesophageal
Avails. If the body be inconsiderable in size, such as a fish-
bone, or a small fragment of the bone of any animal, or even
a coin, it is best, if a careful attempt at propulsion has failed,
to leave the offending substance undisturbed, provided the
patient can swallow sufficient nutriment.

CEsophagotomy is indicated in all cases where, the foreign
body being situated in the cervical or the upper part of tin-
dorsal region of the gullet, deglutition is impossible, or then-
is dangerous pressure on the trachea.

EXTERNAL (ESOPHAGOTOMY.

History. — This operation appears to have been first suggested by
Verduc * towards the end of tne seventeenth century. About lit'ty
years later Guattani 2 read a paper before the Academy of Surgery
of Paris, in which he strongly maintained the practicability of the
operation, and gave an account of some experiments on the dead
body made with the view of determining the best method of carrying
it out, and of some vivisections on dogs undertaken to test the result
of such a procedure. External oesophagotomy, however, hail at that
time been already carried out in actual practice, although the
had not been published. One operation of the kind had been done
for the removal of a foreign body ; whilst another is merely mm
tinned without any detail.3 In 1781 a thesis was sustained on tin
subject by Sue,4 at Paris, in which he gave the results of some
experiments on dogs which had been forced to swallow fragments <>t
hone of such large size that they became impacted in the oesophagus.

i " Traite des Operations de Chirurgie." Amsterdam. 1739, t. ii. pp. 3M
(The original edition was published in Paris in 1693.)

\1rni. del'Acad. Royale de Chir." 1747, t. Hi. p. 351.

3 Both these cases are mentioned in the " Mini, de 1'Acad. de Chirurgie."
1757, t. iii. p. 14.

* " Programme de (Ksnphagotoiiiia." Paris, 1781.

FOREIGN BODIES IN THE GULLET. 197

A few years later Eckholdt J proposed to open the gullet between
the heads of the sterno-mastoid, a plan which would enable the
surgeon to reach the tube quite at the lower part of the neck. This
ilitticult operation has never, I believe, been tried on the living
subject. In 1820 Vacca Berlinghieri 2 published an essay, in which
he advocated cutting into the cesophagus on a sound previously
jussed through the mouth as a guide. In 1832 a valuable paper on
external oesophagotomy was written by Begin,3 who was the first
to describe in detail all the steps necessary for opening the gullet
with the least possible danger to the many important neighbouring
structures. Since that time the operation has become a recognized
surgical procedure. A full histoiy of external resophagotomy, with a
detailed account of most of the cases recorded in medical literature,
was published in 1870 by Terrier * in his valuable monograph on
the subject.

i " Ueber das Ausziehen fremder Korper ans dem Speisecanal." Leipzig, 1799.

- " Delia Esofagotomia." Pisa, 1820. The instrument has already been de-
scril>ed in speaking of oesophagostomy (see Foot-note, p. 143), for which opera-
tion it is more useful than for the removal of a foreign body.

« Mem. de Med. de Chir. et de Phann. Milit." 1832, t. xxxiii. p. 241.

< " De I'CEsophagotomie Externe." Paris, 1870.

It would appear from Terrier's l statistics that the success
of the operation depends in great measure on its early per-
formance, for out of six operations done before the sixtli
day only one death occurred, while of five cases where it
was carried out from the eighth to the thirty-sixth day
three proved fatal. The mode of performing the operation,
is as follows : —

Exte)-nal GEsophagotomy. — The preliminary steps of the.
operation are similar to those already described under the
head of " CEsophagostomy " (see p. 142). The incision need
not, however, be so long as is there recommended, but should
be made so that the middle part of it shall correspond to
the supposed point of impaction of the foreign body. A
special difficulty is likely, according to von Langenbeck,2
to be encountered in cases where a large foreign body has
been impacted behind the cricoid cartilage for several days.
Under these circumstances the thyroid body is exceedingly
apt to be so much swollen by venous congestion as almost
entirely to cover the gullet. To expose that tube, therefore,
the thyroid must be carefully raised from it, and for this
purpose the capsule of the gland must be incised. When
the gullet has been laid bare the foreign body will in most
cases be seen or felt projecting through the wall, which
should be nicked with the knife, just sufficiently to permit
the impacted substance to be drawn out with forceps. Should
it, however, be too small to be felt, a bougie with a metallic
1 Op. cit. pp. 116, 117. 2 Loc. cit.

198 I'isKASBS OF THE THROAT AND NOSE.

or ivory knob should he passed into tin- gullet l>y the
mouth, or Vacca iWlinghieri's sound may be used. Upon
the extremity of one of these instruments an incision should
be made in the oesophagus for about half an inch in the
direction of the long axis of the tube, care being taken to
open it as far back from the trachea as possible, in order
to avoid wounding the recurrent nerve. The fact that the
gullet has been opened will be rendered apparent by the
e-.-a])e of a considerable quantity of mucus from the wound.
If the impacted substance has not already been discovered,
it should now be searched for and removed. The edges
of the O3sophageal wound should afterwards be brought
together with catgut sutures, the ends of which should be
cut off short. If possible, the patient should receive nourish-
ment only by enemata for the first M'eek or ten days, but
if this means of sustaining life prove inadequate, a gum-
elastic tube must be passed down the gullet beyond tin-
seat of the wound, and food administered through it.

[NEUROSES OF THE GULLET.]
PARALYSIS OF THE GULLET.

Latin Eq. — Imbecillitas gulae.
French Eq. — Paralysie de 1'oesophage.
German Eq. — Lahmung der Speiserohre.
Italian Eq. — Paralisi del esofago.

DEFINITION. — Loss of pmcer of tf/> nmx<->ilar til/n't of the,
wsopliaipi*, i-ansing food to lodge in the canal, or t<> /<•
viral 'fenced with difficulty.

History. — Galen1 was acquainted with this disease, which he
referred to as " iiubecillitas guise," carefully distinguishing between
difficulty of swallowing from this cause, and that due to narrow-
ing of the canal itself, or to the pressure of a tumour on its walls.
The affection was mentioned by Altius8 in the sixth century, hut
the complaint was not generally recognized till after the middle
of the seventeenth century, when our own celebrated physician,
Willis,3 published a remarkable case in which he had kept a jmtient
alive for nearly twenty years by teaching him to push his food down
with a sponge-probang. The subject was treated of by Stalpaert

1 " De locis affectis," lib. ii. cap. v.

2 " Tetrabiblos," ii. Senno ii. c. 33.

3 " Pharui. Rat." part i. sect. 2, cap. i. Oxonii, 1674.

PARALYSIS OF THE GULLET. 199

van tier Wiel l in 1682, and by Spies 2 in 1727, whilst Hoffmann,3 in
1734, described the case of a patient who was obliged to wash down
every mouthful of food with water. Some years later van Swieten4
gave a clear account of the affection, and in 1757 Wepfer 5 recorded
several instances in which palsy of the gullet had followed an attack
of apoplexy. The subject was discussed, with somewhat less than
his usual thoroughness, by Morgagni,8 and in the early part of the
present century Monro 7 published many interesting examples of the
complaint. Esquirol,8 in 1829, described paralysis of the oesophagus
as a condition somewhat frequently occurring in lunatics, and occa-
sionally proving the direct cause of their death. In 1833 Mondiere 8
treated the subject with his usual erudition, and since then the
disease has been more or less fully described in nearly every text-
book of medicine.

l ' Obs. med. rarior, centur. post." 1682, p. i. obs. xxvii.
' De deglutitione Isesa." Helmsted, 1727.

1 ' Consult, et respons. cent." t. i. p. 304.

4 ' Comment, in H. Boerhaave Aphorismos." Lugd. Batav. 1745, t. ii. p. 701.

> 'Historia Apoplect." Venetiis, 1757, p. 376.

6 ' De sedibus et eausis rnorb." Ed. secunda, Patavii, 1765, epist. xxviii.
art. 14.

7 ' Morbid Anatomy of the Human Gullet, <fec." Edinburgh, 1811, p. 290, et seq.

8 ' Annales d'Hygiene Publique." 1829, No. 1, p. 141.
» 'Areb.iv.G6n." 1833, t. iii.

Etiology. — The affection is met with under three forms —
viz., first, where it is due to central disease ; secondly, where
it results from nerve-pressure ; and thirdly, where it arises
from muscular iceakness. It is obvious, however, that all
these conditions, or any two of them, may coexist. As
examples of central diseases giving rise to loss of power in
the oesophagus may be mentioned haemorrhage into the pons
Varolii, or the medulla oblongata, or the development of a
tumour in either of these situations, bulbar paralysis, multiple
sclerosis, progressive locomotor ataxy, or cerebral atrophy as
it occurs in general paralysis of the insane ; in short, any
condition affecting the " centre of deglutition " may be the
cause of the paralytic phenomena. Wepfer x has recorded
several cases in which the immediate cause of death in
persons suffering from apoplexy was inability to swallow, and
a very remarkable example of the central origin of oesopha-
geal paralysis has been related by Flaudin 2 in which a
patient suddenly lost the power of deglutition whilst at
table, the seizure being followed within a few hours by
facial paralysis. Larrey 3 published an interesting case in
which a lance thrust through the posterior lobe of the left
hemisphere of the brain was supposed to have penetrated
to the fourth ventricle. The wounded man recovered with

1 Op. cit. p. 376.

2 "Journ. Hebdom." 1831, No. 4.

3 " Becueil de Mem. de Chir." 1821. •

200 DISEASES OF THE THROAT AND NOSE.

the loss of most of his special senses, and with complete
paralysis of the pharynx and oesophagus. Esquirol l observes
that palsy of the gullet is very common in the insane, and
that in such patients asphyxia often results from food arcu-
mulated in the oesophagus pressing on the trachea. A case
is related at the end of this article which well illustrates
the effect of pressure by a small clot, probably in the vicinity
of the fourth ventricle. Montaut 2 mentions an instance in
which oesophageal paralysis was caused by a hydatid cyst at
the base of the brain.

As regards peripheral lesions it is doubtful whether
paralysis of one pneumogastric nerve would seriously inter-
fere with the function of the gullet, and the conditions are
very rare in which both nerves are diseased or pressed upon
by diseased structures. As far as I am aware there an-
no illustrations in recent medical literature of oesophageal
palsy resulting from nerve-pressure, but Kohler 3 relates an
instance of paralysis in which tubercular infiltration of the
bronchial lymphatic glands compressed the pneumogastric
nerves, and Wilson 4 met with a case in which the nerves were
injured by a syphilitic enlargement of the cervical vertebrae.
The exostosis having disappeared under anti-venereal treat-
ment, the power of swallowing was at once recovered.

In these various examples of central and peripheral paraly-
sis, it must be borne in mind that the imperfect action of
the muscular fibres of the oesophagus may be due either to a
direct derangement of the motor function or to impair in' itt
of the sensibility of the mucous membrane, which accordingly
fails to convey the necessary stimulus for reflex action. It is
probable, however, that in most instances both the motor
and sensory nuclei of the vagus are at fault.

In approaching dissolution the function of the nerve-
centre controlling the act of deglutition is extinguished some
time before circulation and respiration cease.

In simple weakness the disease is probably in great measure
myopathic, but in some cases the muscles may become feeble
from impaired innervation. This is the most common form
of paralytic dysphagia, and it is met with in persons broken
down by ill-health or old age ; it is much more frequently
found in men than in women.

1 " Annales d'Hygiene Publique." 1829, No. 1, p. 141.

2 Quoted by Mondi&re : "Arch. Gen." 2e serie, t. iii. p. 43.

3 Ibid. p. 42.
« Ibid. p. 46.

PARALYSIS OF THE GULLET. 201

In addition to these special causes of paralysis of the
oesophagus, there are certain general conditions of the system
with which it is often associated, and in which it is hard to
determine how far the affection is myopathic or neuropathic
in origin. Thus in many of the acute fevers there is difficulty
of swallowing, apparently from the imperfect action of the
pharynx and oasophagus, but whether this depends on loss of
sensibility, derangement of the motor apparatus, or diminishd
excitability of the "centre of deglutition," it is not easy to
tell. It is not improbable, indeed, that the dysphagia in
these cases is sometimes mainly mechanical— that is to say,
that it arises from mere dryness of the mucous membrane.
In diphtheria the affection is generally a neurosis,1 whilst
syphilis may affect either the medulla, or the nerves in some
part of their course. In palsy of the gullet arising from
lead poisoning, of which I have met with two examples, the
muscular structure is probably most implicated. This variety
of poisoning is also said to have occurred through the use of.
lead gargles.2

Ollenroth3 many years ago described a form of oasopha-
geal paralysis which on three occasions he had observed in
nurslings. The onset of the affection was in each case
preceded by aphthous eruptions about the corners of the
mouth and round the anus. This was followed by rigors
and high fever, with vomiting and profuse alvine discharge
of a milky-looking fluid without any smell. The whole
pharyngo-oesophageal canal next appeared to be stricken with
paralysis, and death qiiickly ensued from collapse. The post-
mortem appearances were not recorded, and it is highly pro*
bable that these cases were not really examples of paralysis,
but of thrush of the gullet (See Vol. ii. p. 64).

Though hysteria so frequently gives rise to paralysis
of other muscles, it very seldom affects the oesophagus in
this way, generally, on the contrary, causing spasm of the
tube.

Symptoms. — In all cases of paralysis of the gullet the
essential symptom is dysphagia, its sudden or gradual
development, and the degree it attains being dependent
on the fundamental cause of the malady. The difficulty

1 See " Diphtheria, its Nature and Treatment." By the Author.
London, 1879, pp. 56, 57.

1 "Hufeland's Journal." 1797, Bd. Hi. p. 698. It should be
observed that in this case the paralysis was preceded by sharp
spasrn.

» "Schmidt's Jahrb." 1837, Bd. xvi. pp. 50—52.

202 DISEASES OF THE THROAT AND NOSE.

of swallowing, though considerable, probably never reaches
to the extent of complete aphagia, unless the i)harynx i.- at
the same time paralysed.

As bilateral paralysis of the nerves is extivinely rare, ami
would produce nearly the same oesophageal symptoms as
cerebro-spinal disease, two divisions are sufficient for clinical
purposes : these are central and local paralysis.

In central, disease the mode of development depends on the
special nature of the medullary lesion; thus in ha-mnrrh
the symptom occurs suddenly, and at once attains its maximum
intensity. In cases of cerebral tumour the dysphagia becomes
gradually developed, whilst in bulbar paralysis, multiple
sclerosis and locomotor ataxy, oesophageal palsy is a very
rare symptom, and, if present, comes on, as a rule, only at
an advanced stage of the disease. In general paralysis of
the insane dysphagia is more common and occurs at an
earlier period. In almost all cases of central origin signs
of impaired innervation of the larynx, such as an;i stln -ia
of the mucous membrane or paralysis of the abductor
filaments of the recurrent nerve accompany the oesophageal
symptoms. The patient is almost always feeble and de-
pressed, but emaciation is not usually a marked symptom.

In local paralysis, the development of the dysphagia is
very gradual. I have seen several instances in which the
disease has lasted from ten to twenty years. It apparently
leads, after a time, to some stenosis of the gullet, and in
long-standing cases the isthmm faucium, and even the mouth,
is often much contracted. In 1875 I had a patient under
my care whose mouth had become so reduced in size that it
only measured one inch and an eighth across, whilst the
distance between the lips, when parted to the utmost extent,
was no more than a quarter of an inch. This patient had
suffered from dysphagia for sixteen years, and for the last.
five years had lived entirely on cornflour and tea, with a
little beef-tea once a week. In this form of oesophageal
paralysis, owing to the longer duration of life, emaciation is
a much more marked symptom than when the loss of power
is due to central disease.

In both varieties important information may be obtained
by the employment of the bougie and by auscultation.
Certain features are common to both kinds of nervous
dysphagia. Thus a bougie can usually be passed easily,
and the employment of the instrument does not give rise
to so much nausea and retching, as in health. Occasionally,

PARALYSIS OF THE GULLET. 203

however, when the disease has existed for many years,
the habitual use of liquids appears to lead to general
narrowing of the canal, so that there may be considerable
difficulty in passing an instrument. On auscultation the
normal oasophageal sound is found to be greatly altered
or altogether lost, and the act of deglutition is observed to
l)e markedly prolonged. Hamburger points out that the
" morsel " seems to lose its resemblance to the form of an
inverted egg, and to assume the shape of a funnel, but I
have never been able to verify this refinement of diagnosis.
In extreme cases there is no longer any sound like that of a
defined body of fluid passing downwards, and all that is
heard is a thin stream trickling down drop by drop.

There is seldom any regurgitation in paralysis, but in slight
cases, where semi-solids can be taken, patients often com-
plain of the food lodging in the gullet.

Pathology. — The various lesions of the nerve-centres which
may be met with after death have already been referred to
under the head of " Etiology." My own experience in this
affection is entirely clinical, and I have never had an oppor-
tunity of making an autopsy in a case of either central
or local paralysis of the gullet. In most instances there is
probably more or less degeneration of the muscular tunic
of the oesophagus, and possibly some structural lesion of the
nerves themselves.

Diagnosis. — It is important to distinguish paralysis both
from spasm and from malignant disease.

In spasm the dysphagia is intermittent, the patient being
sometimes able to swallow quite well, whilst at other times
he cannot get down a morsel of food. On the other hand,
in paralysis the dysphagia undergoes little, if any, variation.
In spasm it is often quite impossible to pass a bougie,
whilst, as already remarked, in paralysis there is seldom any
difficulty in using that instrument. In the latter affection
there is no regurgitation, but in spasm this is often very
marked. The acoustic signs are also quite different ; for
whilst in paralysis only a confused gurgling noise is heard,
in spasm a sharp click can be perceived, sometimes in one
part and sometimes in another. Again, whilst paralysis
more frequently affects the old and feeble, spasm is more
often met with in the young and hysterical.

Cancer, like paralysis, is a disease which occurs in the
decline of life, but the comparatively rapid progress of
malignant disease soon sets the question of diagnosis at rest.

204 DISEASES OF THE THROAT AXD NOSE.

Moreover, in cancer there is always obstruction to tin-
passage of a bougie.

Although the diagnosis of oesophageal paralysis is gi-m1-
rally very easy, there are some cases where the affection jin>-
bably altogether escapes observation, owing to the pharynx -;il
contraction forcing the food through the gullet. Km- tin-
experiments of Chauveau1 clearly show that even in com-
plete paralysis of the oesophagus from section of its motor
nerves vigorous contraction of the pharynx can impel tin-
food into the stomach. Although Chauveau's observations
wen- made on the horse, it seems reasonable to infer that
the almost vertical position of the canal in man would render
the passage of food still easier.

Prognosis. — This, of course, depends on whether the
disease be local or central. In the simple local paralysis due
to muscular weakness, the prognosis is always favourable.
Long-standing cases can generally be benefited, and those of
shorter duration can be cured. In cases of diphtheria and
lead poisoning the prognosis is very favourable, but when the
oesophageal paralysis is due to the coarser forms of nerve-
disease, the prospect must always be most grave.

Treatment. — In the more severe forms of paralysis, little
can be done in the way of treatment, but in the simple
local cases a cure can often be effected. In all cases treat-
ment must be directed to the fons et origo mali. In the
milder local form of paralysis attention must be paid to
the general health, and tonics, such as strychnia, iron ami
ergotine, are often of advantage. The patient require- n
nourishing and stimulating diet, and a glass of wine taken
at the commencement of a meal acts beneficially both as a
local and a general stimulant. Condiments should always
l)e freely taken, and the patient should be encouraged as far
as possible to eat solids. Pungent viands are more likely to
stimulate the constrictors to reflex action than soft insipid
food. In the way of local treatment topical stimulants,
such as a benzoic acid lozenge of the Throat Hospital Phar-
macopoeia, taken five minutes before eating, will often prove
most serviceable. The value of electricity was recognized
at an early date, Monro2 having reported several cases in
which the external use of it was followed by marked improve-
ment, and in some by cure.

The best method of applying electricity, however, is by

1 " Journ. de Physiologic de Brown-Sequard," t. v. p. 327.

4 "Morbid Anatomy of Gullet, &c." Edin. 1830, 2nd efl. p. 290.

PARALYSIS OF THE GULLET. 205

internal faradism. The positive pole being placed, by means
of the necklet, in contact with the spinous processes of the
upper cervical vertebrae, the negative pole is applied to the
interior of the gullet by means of the oesophageal electrode
(Vol. ii. p. 17). This instrument should be used at least
daily, and if possible, several times in the day. The best
time for it is before meals. On each occasion the electrode
should be introduced three or four times, and retained in situ
for a few seconds whilst a succession of shocks are passed.
The treatment generally requires to be continued for several
weeks, but after the first week or two the application need
not be made so often. By this method I every year cure
a large number of patients.

Palliative measures must be adopted when those of a more
radical character fail, and in connection with this point some
hints may perhaps be obtained from cases like that of Willis,1
already referred to (see " History " ). Baster 2 has also sup-
plied a somewhat similar illustration where a girl, who for
fourteen months had fed herself by pushing her food down
with a probang, ultimately recovered her power of swallowing.
Desault 3 claims to have cured a man by feeding him with a
tube, and Sedillot 4 mentions an instance of a young woman
whose power of swallowing was completely restored by
blisters to the neck, ammonia liniment, and gargling and
swallowing mustard-and-water.

The following is a remarkable illustration of oesophageal
palsy dependent on a central cause : —

Master W. B. C., aged sixteen, of Utica, New York, U.S.A., was
brought to me5 on June 18th, 1880. Besides the usual ailments of
childhood, he had suffered at various times from "croupy" attacks,
but for the three or four years preceding the onset of the complaint
for which my advice was sought, he had enjoyed uninterrupted good
health. In May, 1879, whilst playing at base-ball, he noticed that
whenever he threw the ball a sharp pain seemed to shoot through the
region of the larynx. This pain was of only momentary duration, but
for several days afterwards he had frequent tingling, shooting sensa-
tions down the left arm from the shoulder to the wrist. He continued,
however, to play ball daily, and on one occasion, about a fortnight
after the occurrence of the laryngeal pain mentioned above, he

1 " Pharmaceutice Rationalis, " part i. sect. 2. cap i.

2 Referred to by Stalpaert van der Wiel : "Observ. Med. rarior,"
cent. 2, part i. obs. xxvii.

"(Euvres Chirurg." Paris, 1801. t. ii. p. 291.

4 " Recueil Periodiqne," t. xl. p. 81.

5 The patient had previously been seen by Dr. Elsberg, to whom I
am indebted for some information respecting the beginning of the
malady.

206 DISEASES OF THE THROAT AND NOSE.

became conscious, whilst greatly excited in the middle of a game,
that he hail some difficulty in swallowing.1 That evening it rost
him some effort to eat his supper, and on the following day tin;
dysphagia had become so great that he could only swallow liquids,
which, however, were occasionally thrown back through the nose.
About the same time Master C. was attacked with almost constant
hiccough, and his voice acquired a nasal twang. Dr. Gray, of
Utica, was called in, and found it necessary to feed him with the
help of a stomach-tube during three weeks. The patient then some-
what recovered his power of swallowing. In July, 1879, he had
a tit of dyspnoea, followed by several similar paroxysms during
the autumn. The difficulty of breathing gradually grew more JMM -
sistent, and in January, 1880, the number of respirations had fallen
to six per minute. Tracheotomy was performed about this time by
Dr. Hutchinson, of Utica, and Master C.'s breathing was relieved, but
his dysphagia did not improve. He gained weight, however, and his
general condition was fairly satisfactory, but his left arm remained
weak and somewhat numb, and he became partly deaf in the left ear.

When I saw Master C. I found him wearing a tracheotomy tube,
but he was able to breath fairly well when its orifice was closed with
a cork. His voice was rather feeble and slightly nasal (from ini]>er-
fect action of the uvula). His left arm and left leg were weak, and
his power of grasp with the left hand was decidedly less than normal.
He walked in a somewhat unsteady way, and when his eyes wen-
closed his movements resembled those of a patient suffering from
locomotor ataxy. On the left side he could not hear a watch tick at
a greater distance than nine inches from the ear. On the right M< li-
the hearing was perfect.

On inspecting the pharynx, the uvula was found to possess
diminished sensibility, but was not drawn to either side. On
laryngoscopic examination the vocal cords appeared to act imperfectly
as regards abduction, adduction, and tension. The abductors, how-
ever, were chiefly affected, the utmost separation of the vocal eonl>
in forced inspiration affording an opening only about one-third of
the normal size. There was also diminished sensibility of the mucous
membrane of the larynx. On directing the patient to swallow some
water, the act of deglutition was seen to be very slowly and imperfectly
performed.

Having treated several somewhat similar cases in conjunction with
Dr. Hughlings Jackson,,! requested him to see the patient with me,
and the following is his report — "Discs normal, retinal veins strik-
ingly irregular, patellar-tendon reflex quite absent." Dr. Hughlings
Jackson thought that there was a small tumour pressing on the
medulla. I venture to suggest that rupture of a small artery in
the medulla took place during the violent exercise in which the
boy was engaged, and that the subsequent development of the
symptoms was due to sclerotic changes in the clot.

It need scarcely be said that I was unable to recommend the re-
moval of the tracheotomy tube in this case, but whilst pointing out
that no very remarkable results could be anticipated from treatment,
I suggested that local farad ism and galvanism might be tried on
alternate days. This treatment was carried out by Dr. Ford, of

1 A few days previously he had taken a large quantity of ice water whilst
heated, anil had eaten some ice creani, but this does not seem to have hail any
causal relation with his malady.

SPASM OF THE (ESOPHAGUS. 207

Utica, who forwarded the following report in October, 1880, after
he had pursued the treatment for a short time — " I have applied
electricity as you suggested, and observe that the parts are vastly
more sensitive to electricity, but there is as yet no appreciable
increase of motion." Dr. Hutchinson, of Utica, was good enough
to send me, quite recently (December 5th, 1882), some notes which
bring the case almost down to the present time. " I saw the patient
yesterday, " he says, ' ' and found him quite strong and in apparent
good health. He still wears the tube, although he can breathe for
some time with it closed. As he inspires the nose contracts and
becomes pinched, and he breathes with some effort. He has still
difficulty in swallowing, and does not like to be seen at the table by
strangers. He is still uncertain with his left arm and leg, and has
fallen from his horse because he could not keep his left foot in the
stirrup."

SPASM OF THE (ESOPHAGUS.

(SYNONYM : (ESOPHAGISM.)

Latin Eq. — Spasmus oesophagi.
French Eq. — Spasme de Fcesophage.
German Eq. — Krampf der Speiserbhre.
Italian Eq. — Spasmo del esofago.

DEFINITION. — Rigid approximation of the trails of a
.^'i/nifmt of the oesophagus through contraction of the circular
fibres of its muscular coat, giving rise to dysphagia, varying
in intensity and duration.

History. — The affection was referred to by Hippocrates,1 but only
in a casual manner, and no other ancient writer seems to have been
acquainted with it. In more modern times van Helmont2 pointed
' out that difficulty of swallowing sometimes occurs in hysterical
women, but he was under the impression that the symptom was due
to an actual rising of the womb to the throat, which he thought
caused temporary obliteration ot the cesophageal canal. It was
not till the early part of the eighteenth century that the disease
was really made the subject of rational investigation by Hoffmann,3
and little has been added since his time to the clinical knowledge
of the affection. A short essay on ' ' Spasmodic Disease of the
Gullet" was published by Courant4 in 1778, and a few years later
Bleuland 5 briefly discussed the malady in the little treatise which
has been already several times referred to, and in particular
pointed out that spasm of the gullet is sometimes produced by the

i " De Morbis." Littre's edition, 1. iii. c. xii. vol. vii. p. 133.

* " Ignot. Act. Kegim." § 43. Joannis Baptists: van helmont, " Opera Omnia."
Krancofurti, 1707, p 322 ; also " Asthma et Tussis," § 31. Ibid. p. 292, where he
relates a case in which a woman had hardly swallowed anything for three
n.onths. He adds, "I came, recognized the d.gease, and immediately the Lord
cured her," but van Helmont unfortunate y omits to state how.

3"De morbis itsophagi spasm odicis " in F. Uuttii.anm, "Op. Omn. Phys.
J;ed." GenevfC, 1740, t. iii. p. 132.

4 " De normullis morbis eonvu.swis rcsophagi." Montpellier, 1778

8 " De sana et morbobit U'Soph. stnu-tu a." I A- idee, 1786, p. 50.

208 DISEASES OF THE THROAT AND NOSE.

irritation of a neighbouring inflamed part, e.g., by gastriti*.1
Several interesting examples of the disease were related by Monro.-
and the subject also was treated of by Mondiere.8 A very full account
of spasm of the gullet was given by Follin,4 and more recently
Hamburger8 published an accurate account of the affection. A paper
containing some important hints as to the diagnosis of the affection
was written by Roux6 in 1873, whilst soon afterwards some ^oo<l
examples of the complaint were reported by Foot,7 and an important
clinical lecture on the subject was published by the late Maurice
Raynaud.8 More recently the disease has been discussed in some
detail by Zenker9 and by Brazier,10 whilst it has also been fully
dealt with in recent volumes of the " Nouveati Dictionnaire il>
Medecine et de Chirurgie,"11 and the "Dictionnaire Encyclopedique
des Sciences Medicales." la

1 Ibid. p. 62.

2 " Morbid Anatomy of the Human Gullet," Ac. Edinburgh, 1811, p. 223 ; and
2nd ed. 1830, p. 268, et seq.

3 ' (Esophagisme "— " Archiv. Gen." 1833, t. i. p. 465.

•« ' Rtftrecissements de 1'CEsophage." Paris, 1853, p. 154, et seq.

• ' Klinik der OEsophaguskrankheiten." Erlangen, 1871, art. iv. p. 94, et seq.

6 ' Diagnostic des lU-trecissemeuts Spasmodiques de 1'OSsophage." These de
Paris, 1873.

7 ' Dublin Journ. of Med. Sci." April, 1874.

8 ' Annales des Maladies de 1'Oreille et du Larynx." 1877.

9 ' Ziemssen's Cyclopedia of Pract. Med." 1878, vol. viii. p. 204.

10 ' Contribution a 1'Etude de I'CEsophagisme." These de Paris, 1879.

11 Paris, 1877, t. xxiv. p. 359.

12 Paris, 1880, 2e partie, t. xiv. p. 529.

Etiology. — Spasm of the oesophagus occurs more com-
monly, in the female than in the male sex. It is most
frequent in young women between the ages of eighteen and
thirty, but it is often met with later in life, and sometimes
though very rarely, it occurs in childhood. I have twice-
seen it in patients under ten years of age. The affection,
or at any rate, the nervous constitution which predisposes to
it, is occasionally hereditary. In May, 1875, I succeeded in
curing a patient whose mother and grandmother had both
suffered from the same complaint. A case has also been
reported by Stevenson,1 in which he successfully treated a
mother and her daughter for spasm of the gullet, the former
having suffered from the complaint for twenty years, and the
latter, aged twenty, all her life. When men are the subjects
of oesophagism they are always of a highly emotional tem-
perament, and are generally victims of hypochondriasis.

Spasm of the oesophagus may be (1) a mere psychical or
hysterical phenomenon, or (2) it may occur in the course
of certain nervous disorders, such as chorea, epilepsy, and
especially hydrophobia ; or (3) it may be due to some reflex
irritation, the cause of which may be either in the gullet
itself, or at a distance from that part ; or (4) it may result
1 "Med. and Phys. Journ." vol. viii. p. 35.

SPASM OP THE (ESOPHAGUS. 209

from the strain of violent retching. Of the psychical
causation of this malady, the most striking example is to
be seen in the case of patients who imagine that they
are suffering from hydrophobia. A remarkable instance 1
of this is the case of a man who, on returning to France
after an absence of twenty years, was told that his brother
had died from the effects of the bite of a dog by which
he had himself been bitten. Shortly after hearing this
news of his brother, he was seized with oesophageal spasm,
which quite prevented him swallowing and ultimately proved
fatal. A case is also related 2 of a man who was bitten by
a favourite dog, which soon afterwards ran away. The
master showed all the signs of hydrophobia until the dog
returned, perfectly well, nine days after, when the man
instantly recovered. Another remarkable example is related
by Dr. Dolan,3 on the authority of Trousseau, in which a
man showed the characteristic signs of hydrophobia after a
rabid dog had tried to bite him. The symptoms had come
on after a feast, and vanished on his being made to vomit.

In the severe nervous diseases to which reference has been
made, such as tetanus and epilepsy, the oesophagus sometimes
participates in the spasm which affects so many of the other
muscles of the body. In chorea, spasm of the gullet is less
frequent, but I have seen two examples of this complication,
In true hydrophobia, the muscles of the pharynx and
oesophagus are specially involved.

Setting aside foreign bodies, the most frequent topical
source of reflex irritation of the gullet is probably to be
found in a gouty condition of the blood. Brinton,4 who
first called attention to this source of irritation, was of opi-
nion that in lithsemia the acid condition of the blood causes
spasm of the oesophagus, in the same manner that it pro-
duces cramp in the legs, or numbness and formication in
various parts of the body. The immediate cause of the
oesophageal spasm in these gouty cases often appears to be
the eructation of acid matters. Amongst the reflex causes
acting at a distance, diseases of the stomach, and affections
of the uterus, may be mentioned. Of the former, Howship5

1 " Bibliotheque Med." t. xxxix. p. 234.

2 "Diet. Encyclop. des Sci. Med." t. xiv. p. 530.

3 Quoted, with many other illustrations, by Dr. Dolan in his
admirable "Report on Rabies or Hydrophobia" (pp. 82, 83), as Com-
missioner for the "Medical Press and Circular," 1878.

4 "Lancet." 1866, pp. 2 and 253.

5 "Practical Remarks on Indigestion." London, 1825.

VOL. II. P

210 DISEASES OF THE THROAT AND NOSE.

has recorded two remarkable examples. One of these was
that of a man who had been treated with bougies for four
months on account of stricture of the middle third of tin-
oesophagus. After death no stricture was found, hut the
stomach was in a state of " fungous ulceration for a hand's
breadth." In another case, a lady, aged sixty-nine, suffered
from spasmodic stricture of the upper part of the gullet, which
was relieved by the passage of bougies. The patient, how-
ever, still continued to vomit a glairy fluid, and ultimately
sank from exhaustion. At the post-mortem the stomach
was found to be a mass of scirrhus, whilst the oesophagus
Was perfectly healthy. A similar case has been reported by
Munro.1 Another instance was related by John Shaw,- in
which he had treated a patient for organic stricture of the
oesophagus. After death the dysphagia was found to have
been caused by ulceration of the larynx. The affection has
been known to be caused by metritis, and to disappear on
the cure of that disease.3 I have myself met with two
patients who always suffered from ossophageal spasm when
pregnant, but were relieved immediately after parturition.
As an analogous case, I may mention that I formerly treated
a lady in whom the spasm came on whilst she was suckling.
This recurred to such an extent at the birth of each child
that she was never able to nurse. The case reported by
Bettali,4 in which the presence of a tapeworm in the in-
testinal canal gave rise to spasm of the oesophagus, and that
referred to by Bouteille,5 in which the Affection was caused
by the existence of worms in the ear, may be mentioned
as other examples of reflex action. There are two cases on
record in which the spasm is said to have resulted from
vomiting. One is related by Sir Everard Home,6 in which
a lady, after severe sea-sickness, was quite unable to swallow
owing to spasmodic contraction of the gullet. From the
description of the symptoms, however, I am disposed to
believe that this was really a case of acute inflammation.
The other, which is mentioned by Can-on,7 is more to tin-
purpose. Here, intense spasm followed sickness induced by
the use of emetics. An extraordinary case of an opposite

1 Op. cit. p. 266.

- "Loud. Med. and Phys. Journ." vol. xlviii. p. 185.

3 " Archiv. Gen." t. xxxi. p. 474.

4 Quoted by Mondiere : "Arch. Gen." 1833, vol. i.
» Ibid.

8 Op. t-it. p. 549.

' "Recueil Periodique," t. xl. p. 58.

SPASM OF THE (ESOPHAGUS. 211

character is mentioned by Home,1 of a young man in whom
difficulty of swallowing, apparently spasmodic in character,
which had existed since childhood, was relieved for weeks at
a time after violent retching.

As regards the actual mechanism of spasm, Dr. Andrew
Smith2 has advanced the following ingenious hypothesis :—
"In normal deglutition," he observes, "the contact of
the bolus with the mucous membrane of the gullet produces
an impression which is reflected to the muscular coat
at a point above the mass which is being swallowed,
and thus the resulting wave of contraction follows imme-
diately after the bolus and forces it downward. But in-
spasm of the oesophagus, it would seem that the excitation
is reflected to a point below instead of above the bolus, so
that the resulting contraction presents an effectual obstacle to
the passage of the alimentary mass, or even forces it upward."

Symptoms. — Dysphagia is always complained of. It
varies in intensity from a slight feeling of difficulty in
performing the act of deglutition, which can be overcome by
an effort of the will, to an almost total inability to swallow.
In slight and recent cases, solids or semi-solids are swal-
lowed more easily than liquids, but as the disease becomes
more established fluids pass the more readily, and warm
drinks can be taken with less trouble than cold ones. The
dysphagia is also, as a rule, more or less paroxysmal, occasion-
ally coming on in the middle of a meal, but sometimes it
lasts, with slight intermissions, for months, or even years.

Seney 3 relates a case in which the morsel of food was
seized in the oesophagus and could neither be swallowed
nor rejected, the most severe cramp being felt at the same
time in the throat. This is a rare symptom, and, so far as I
am aware, it has not been mentioned by any other writer.
I have myself never met with an example of this kind of
spasm.

In cases of spasm the patient not only cannot swallow,
but generally has very little inclination for food. Regurgita-
tion is sometimes present, and when it does occur, it comes
on instantaneously after swallowing, there being no appre-
ciable interval as in organic stricture. The food, under
ihi-se circumstances, is sometimes rejected with so much force
that it is thrown quite out of the mouth. Slight odynphagia

1 Op. cit. p. 550.

2 "Virginia Med. Monthly." 1877, vol. Hi. No. 34, p. 743.

3 " CEsophagisme Chronique." These de Paris, 1873.

'212 DISEASES OF THE THROAT AND NOSE.

may be complained of, and an uneasy sensation, or even a
little pain may occasionally be felt between meals. Some-
timt's the sufferer experiences the well-known feeling »>f a
"ball rising in the throat." Hamburger1 indeed believes
that " globus hystericus " consists in a wave of spasm
affecting successive segments of the gullet from below up-
wards. He observes that if a patient can be examined
with the stethoscope at the moment she experiences the
sensation of "the ball" rising, a sudden contraction of
the oesophagus and the ascent of a bxibble of air will be
heard. On the other hand, Rosenthal'^ found in two cases
that galvanisation of the hypoglossal nerve immediately
inhibited the spasm of the oesophagus ; and he considers that
the fact that the patient can swallow whilst the "globus
hystericus" is felt, proves that the phenomenon cannot In-
due to cramp of the cesophageal muscles. A case, however,
has recently come under my notice which directly contro-
verts the last statement. The patient, a lady, aged sixty-
two, whom I saw in consultation with Mr. Buee, of Slough,
had been suffering on and off for several months from
spasm of the gullet. She often went several days without
swallowing a particle of food or drinking a drop of liquid.
[ saw her make the attempt, but violent coughing at once
came on from the drink jessing into the windpipe. When
the spasm relaxed, however, the patient was able to swallow
easily. She stated of her own accord that the sensation in
the throat was like a ball — in fact, like " hysteria," as she had
experienced it when a girl. Tlie patient also assured me,
,,1-npno motu, that as long as this sensation lasted nothing
would go down the throat.

Emaciation is often altogether wanting, and never bears
any proportion to the duration and apparent severity of the
obstruction ; often, indeed, well-nourished women are met
with who declare that they cannot swallow at all. Expia-
tion only occurs when the spasm is very severe, both as
regards intensity and duration. There is seldom any altera-
tion of the voice or cough, except when the spasm of the
gullet is reflected from the larynx.

Auscultation of the oesophagus often affords valuable infor-
mation. Thus the point of obstruction may be Ix-anl to rar;i

1 " Klinik der (Esophaguskrankheiten." Erlangen, 1871, 4 art.
p. 94.

- "Handbuch der Diagnostik und Therapie der Xervenknink-
bciten," p. 245.

SPASM OF THE (ESOPHAGUS. 213

in situation. The first morsel may be arrested or retarded at
the upper part of the oesophagus, whilst the second or third
morsel is stopped two or three inches lower down ; or whilst
the act of deglutition is arrested or delayed one moment,
it may be performed perfectly the next. This is an absolute
proof of the spasmodic character of the affection. Again,
the morsel may be heard to be arrested or forced upwards
for a second and then to pass down the gullet. There is
generally not nearly so much of the bubbling or gurgling
sound as is met with in organic stricture or cesophageal
diverticula. On passing a bougie, an obstruction will gene-
rally be felt in the region prone to be contracted, which is
usually near the upper or lower orifice of the gullet, but
much more frequently the former. The obstruction can
often be overcome by moderate force, but sometimes the
spasm is so tight that it will not yield to anything short
of violence. In such cases repeated attempts should be
made on different occasions to pass the instrument. Some-
times a rapid attempt to introduce it will succeed when
a slower one fails, but more often the spasm gives way
before steady pressure. If the patient be placed fully under
the influence of an anaesthetic, all difficulty in using the
instrument will disappear. It may be remarked here that
in some cases the passage of the bougie causes great pain,
a phenomenon probably dependent on the existence of ex-
treme congestion of the lining membrane.

Diagnosis. — The age, sex, and nervous temperament of the
patient are of help in arriving at an accurate diagnosis. The
abrupt commencement and intermittent character of the
dysphagia, the suddenness of regurgitation (when it occurs),
the fact that in most cases the obstruction can be overcome
with the bougie, and the absence of emaciation are the salient
features. In paralysis of the gullet, the dysphagia is constant,
and in malignant disease it is nearly always progressive.1

Pathology. — The affection consists essentially of a spastic
contraction of the circular fibres of the muscular coat of the

1 It might be extremely difficult to distinguish true spasm from
the condition known as dysphagia hisoria. This is generally said to
arise from the compression to which the gullet is subjected by the
right subclavian artery when, as an abnormality, it springs from
the arch of the aorta. In its course from the left to the right side of
the chest, the vessel must of necessity pass either in front of, or behind
the gullet, which may thus be pressed on. More or less intermittent
dysphagia will in this manner be produced. The existence of this
form of dysphagia is, however, altogether denied by some writers.

214 DISEASES OF THE THROAT AND NOSE.

oesophagus. Its more frequent occurrence at the extremities
of the tube is explained by the greater alnindam-e and higher
development of the circular fibres in those situations.

A perverted or unstable condition of the nervous centres
is doubtless necessary for the production of the affection, and
hence the complaint occurs in connection with hysterical and
other nervous disorders.

Although it is highly probable that whenever muscles
are repeatedly thrown into a state of spasmodic contrac-
tion, both myopathic and neuropathic changes ensue, yet
such morbid alterations of structure have not hitherto
been observed. Even in hydrophobia, there is seldom
any appreciable change to be seen in the condition of
the cesophageal canal. In tetanus, Larrey ] found the
oesophagus and pharynx tightly contracted after death.

I'fitf/nosis. — The prognosis is generally favourable in re-
cent cases, but where the disease is of very long standing,
like many other nervous affections it becomes intractabla
It is apt to lead to narrowing of the oesophagus, and may
sometimes predispose to cancer or determine the site of its
development. Even when the disease is of only mode-
rately long duration the cure is often protracted, and
relapses are apt to occur.

Cases have been reported which have resulted in death,
though no disease could be found in the oesophagus. Mr.
Power2 has related a remarkable instance which was seen
by several eminent members of the profession, in which the
spasm was sufficiently severe to destroy the patient, a
man aged forty-eight, by inanition, and yet after death no
organic lesions whatever, in or around the gullet, could be
found to account for the symptoms. A case has also been
recorded by McKibben,3 in which death occurred in five
days, spasm of the gullet, with absolute aphagia, and
profound prostration of the nervous system being the
only marked symptoms. There was no obstruction, and a
stomach-tube could be easily passed, but the utmost elt'orts
of the patient to swallow were quite unsuccessful. Tin-
case, however, is very incompletely rejwrted, and no autopsy
was made. It seems highly probable that paralysis rather
than spasm was the cause of the dysphagia.

1 "Mem. de Med. Chir. et Pharm. Milit." t. xiv. p. 175.

"Lancet." 1866, vol. i. p. 252.

3 " Amer. Journ. Med. Sci." Oct. 1859. Quoted by Andrew
Smith : Loc. cit.

SPASM OF THE (ESOPHAGUS. 215

Treatment. — When the affection depends on serious disease
of the general nervous system, the attention of the prac-
titioner must be directed to the fundamental lesion. Thus,
in hysteria the patient must be braced up by moral, as well
as by hygienic and medicinal agencies. His mind should,
if possible, be kept employed by regular and interesting
occupation, or by change of scene and travel. By passing a
bougie, and assuring the patient that there is no obstruction,
such persons may sometimes be made aware of the ground-
lessness of their sensations. If the disease is believed to be of
reflex origin, the cause must be sought out and if possible re-
moved. Where the affection results from a gouty condition,
an alkaline draught containing bicarbonate of potash and
aromatic spirits of ammonia, will often at once give relief.
Other drugs are sometimes of great service. I have employed
bromide of potassium with marked benefit in several cases,
and it has also been found useful by Gubler1 and Amory,'2
but valerianate of zinc in combination with assafoetida has
proved even more effectual. In many cases the passage of
bougies lessens the irritability of the canal and speedily
brings about a cure, and it may be remarked that, as a rule,
the ivory-knobbed bougies answer better for the purpose
than the ordinary gum-elastic instrument. The bougie,
which must be wanned, should either be kept in situ for
a minute or two, or it should be slowly moved up and down
the gullet ; but it should not be used when there is hyper-
sesthesia of the mucous membrane. Under such circum-
stances it is better to treat the case at first with injections.
Various mineral astringents, such as chloride of zinc or
porchloride of iron, may be used, but a weak solution of
nitrate of silver (gr. v. or gr. x. ad §j.) answers best. The
solution should be warmed, and about half a drachm injected
into the gullet with the " oesophageal injector " (Vol. ii.
Fig. 4, p. 17) as nearly as possible at the seat of spasm.
Three or four injections made on alternate days will often
effect a cure, or they will relieve the irritability so much that
bougies can subsequently be employed. Broca 3 cured a
patient by forcibly opening the stricture with a dilator, but
I believe that his case would have yielded to bougies. If,
however, mechanical measures do not succeed, galvanism will
almost invariably conquer the disease. Indeed, this remedy

1 " Bull. Gen. de The>ap." 1864, t. 67, pp. 10, 11.

2 "Diet. Encyclop." vol. xiv. p. 538.

8 "Gazette des Hdpitaux." Aug. 7, 1869.

216 DISEASES OP THE THROAT AND NOSE.

is so certain, that, if ordinary medication fails, I at once have
recourse to it. A ten or twelve-celled battery should !><•
used. The cesophageal electrode should be introduced into
the gullet at least once a day, and kept in position for a
minute or two or longer if the patient can bear it. The
application should be made at such a time that a consider-
able interval may elapse between the treatment and the next
meal. After a week or ten days, the application should In-
made on alternate days for a fortnight, when the cure will
generally be complete.

The dietary in these cases is of the greatest importance. If
the spasm is very severe, thickened liquids should be given,
and it is well to bear in mind the fact, which has been
already pointed out, that warm drinks are much less apt
to bring on spasm than cold ones. It is remarkable, too,
than in nine cases out of ten if the drink be sweetened
it is better borne. Gradually the food may be thickened,
and panada1 may be allowed. If the case progresses favour-
ably, the patient will be able to return by degrees to ordinary
diet. Stimulants should not, as a rnle, be given, and all
pungent food should be prohibited. It is the greatest mis-
take to force these patients to take solid food before the cure
is complete. They may sometimes be tricked out of their
malady when it is slight and recent, but rough measures
always fail.

MALFORMATIONS OF THE GULLET.

Latin Eg. — Deformitates ingenitse oesophagi.
French Eq. — Vices de conformation de I'eesophage.
German Eq. — Missbildungen der Speiserb'hre.
Italian Eq. — Vizi di conformazione del esofago.

DEFINITION'. — Congenital irregularities in the formation
of the oesophagus, resulting in an excess, a deficiency, or
an imperforate condition of that tube. The first-named
anomaly is exceedingly rare, and is only met with in
disomatous monsters. Deficiency of a part of the oeso-
/ >/i ague, generally affecting the middle third, together icith art
abnormal communication between the gullet and the tradu-a
or one of tlie bronchi, is the most common deformity, ami
though met with in monsters and still-born children, is most

1 See Vol. i. p. 580.

MALFORMATIONS OF THE GULLET. 217

in infants icho are born alive, but survive only a
/'•//• days. The other deformities are too rare to requi re-
definition.

History. — In all probability, malformations of the oesophagus are
of rare occurrence. All the recorded cases which I have succeeded
in collecting amount to no more than sixty-two, and I am able to add
only one from my own observation. These facts are especially
significant when we remember that the condition, in viable infants
at least, is attended by such striking symptoms, that it is hardly
possible for them to escape notice, whilst the inevitably fatal result
always affords an opportunity of investigating their cause. At the
same time, it must not be forgotten that Hirschsprung himself per-
sonally observed four examples of the condition in less than seven
months in a town of only 180,000 inhabitants, and that within
three weeks Ilott met with two cases in a country district near
London. It is, indeed, possible that if still-born infants, and especi-
ally monsters, were more uniformly submitted to careful dissection,
malformations of the oesophagus w-ould be found more frequently
than the small number of published cases would lead us to suppose.
The earliest recorded instance of cesophageal deformity appeal's to be
that related by Durston in 1670.1 Two cases were published by
Blasius2 in 1674, in one of which the tube bifurcated and again
united, whilst in the other there was saccular dilatation of the gullet
at its lower end. In 1791 an instance was recorded by Tenon,3 in
which there was membranous obstruction of the gullet in its upper
part. In 1810 Brodie4 reported a case in which there was blind
termination of the tube, and a few years later Lozach3 published an
example of complete absence of the organ. In 1821 Martin8 published
an example of deficiency of a portion of the oesophagus, with inter-
communication between the alimentary and respiratory tracts. It was
not, however, till 1861 that the literature of the subject was collected.
In that year, Hirschsprung, 7 in a small work of considerable merit,
brought together ten cases of the affection, and further elucidated it by
lour examples which had come under his own notice. Since then,
several fresh cases have been placed on record, whilst many others
have been discovered in the annals of medical literature, and the
following synopsis, I think, represents with a fair degree of complete-
ness the facts published up to the present date.

Of complete deficiency there are five cases on record, viz., those
of Lozach,8 Sonderlaud,9 Mellor, 10 Heath,11 and a specimen in the
Museum of the Army Medical Department at Netley.12

1 " Collect. Academ." Partie etrangere. 1670, t. ii. p. 288.

2 " Observ. med. rarior." Leidsc, 1674, tab. vi. flg. 5.

:! Fourcroy : " La McVieciue eclairee par les Sciences." 1791, t. i. p. 301.

* For the scanty particulars of this case the reader is referred to the French
" Biblioth. Mdd." 1810, t. xxx. p. 381, as I have been unable to find the original
article.

s " Journ. Univ." 1816, t. iii. p. 187.

« " Expose'' des Tray, de la Soc. Roy. de Mdd. de Marseille." 1821, p. 44.
" Den Medfodte Tillukning af Spiseroret." Copenhagen, 1861.

i " Journ. Univ." 1816, t. iii. p. 187.

» " Uufeland's Journal," August, 1820.
N> " Lond. Med. Gaz." June 26, 1840, vol. xxvi. p. 542.

11 Ibid. (Mellor's case is given in detail, but Heath's is only briefly referred to.

12 " Catalogue of the Museum Army Med. Dept." 1845, p. 3aS.

218 DISEASES OF THE THROAT AND NOSK.

Of blind termination there are nine examples, viz., those of Durston.'
Brodie,2 Rocderer,3 Miirrigues,4 Lallemaiul,8 Van Cruyck,8 Pagni-
sterhcr,7 Warner,8 ant I Pinard."

Of cases in which there was an intercommunication between the
ii-suphagus and air- passages, with deficiency of a portion of the fornn'i-,
or, as they have been r-illed, "inosculating" cases, there are 43,
the communication being with the trachea in 40, and with <>in- nf tin-
bronchi in three. The former category includes the cases of Martin.1"
Houston,11 Padieu,1- Schiiller,13 Davis,14 Tilanus,18 Levy,1" (Jrrnet.17
Luschka,18 Cruveilhier, 19 Ayres,20 Ogle," Ward,22 Willigk," Steenbt-rg,-'
Hirschsprung25(three cases), Maschka^Bendz,37 Boucher, ^Annandale,2*
Luschka,30 Porro,31 Sundewall,32 Perier,33 Polaillon,34 Ilott38 (two cases),
Lehmann,38 Westbrook,37 and Mackenzie,38 together with specimens in
the. museums of the Royal College of Surgeons of Ireland,39 of tip
Boston Society of Medical Improvement40 (two cases), of the Army
Medical Department at Washington,41 and of the Royal College of
Surgeons of England42 (three cases).

The three cases in which there was a communication with one of

1 " Collect Acadera." Part, etrang. 1670, t. ii. p. 288.
» "Bibl. Mod." 1810, t. xxx. p. 381.

3 Meckel : " Handbuch d. pathol. Anatomie." Leipzig, 1812, Bd. i. p. 494.

4 riiid.

5 "Observations pathologiques proprea k eclairer plusieurs points de physi-
ologic." Paris, 1816.

« " Bull, de la Soc. MC-d. d'Emu'ation de Paris." 1824, p. 251.

7 v. Siebold's " Jounial f. Geburtshiilfe," &c. 1830, Bd. ix. p. 112.

8 " Lancet," 1839, vol. ii.

» " Bulletin de la Soc. Anat." 1873.

10 Loc. cit.

11 " Dublin Hosp. Rep." 1830, vol. v. p. 311.

12 " Bulletin de la Soc. Anat." 1835, t. x. p. 35.

13 " Neue Zeitschrift f. Geburtskunde." Berlin, 1838, vol. vi. p. 2.

14 " Lond. Med. Gaz." Jan. 13, 1848. vol. xxxi. p. 543.

is " Verh. van het Genootschap d. Genees en Heelk. te Amsterdam." 1£44.
18 " Neue Zeitschrift f. Geburtskunde." Berlin, 1845, vol. xviii. p. 436.

17 Oppenheim's " Zeitschrift." 1847, p. 378.

18 " Virchow's Archiv." 1848, vol. xlvii. p. 178.

18 " Trait^ d'Anat. Patho'. goner." Paris, 1849, t. ii. p. 232.

2" " Trans. Path. Soc." 1852, vol. iii. p. 91.

31 Ibid. 1856, vol. vii. p. 52.

21 Ibid. 1857, vol. viii. p. 173.

2» " Prager Vierteljahrschr." Aug. 13, 1856, p. 34.

24 Hirsehsprung : Op. cit. p. 37.

2» Ibid. pp. 39-50.

28 " Allg. Wiener Med. Ztg." 1862, No. 9, p. 78.

27 " ligeskrift for Lager." 1867.

28 " Bulletin de la Soc. Anat." 1868.

29 " Edin. Med. Journ." Jan. 1869, vol. xiv. p. 598.
3° " Virchow'g Archiv." 1869.

31 " Annali Universal! di Medicina." Milan, 1871, t. ccxvi'. p. 4"1.

32 " Upsala Lakaref6r-mings Tdrhandlinger," 5te Bandel, 5te Haftet.
S3 " Union Medicale." 1873, No. 145, p. 894.

34 " Gaz. des H6pitaux." July 17, 1875.

38 " Trans. Path. Soc. Lond." vol. xxvii. p. 149.

3« " Schmidt's Jahrb." Bd. cxlviii. p. 269.

" Annals of the Anat. and Surg. Soc. of Brooklyn." 1879, vol. i. pp. 98, 99.

:w Published in detail at the end of tbis article.

s» " Catalogue Roy. Coll. Surg. Ireland." " Anatomy," vol. i. p. 15-_'. Dublin.
lx<4. Spec. Oa. 58.

*' " Catalogue Boston Soc. of Medical Improvement." Specs. Nos. 456 and 457,
p. 128.

•" " Catalogue Mus. Washington," D.C. 1867.

*2 " Catalogue Mus. Roy. Coll. Surg. Eng." " Teratological series." London,
1872. Specs. 394, 395, 396.

MALFORMATIONS OF THE GULLET. 219

the bronchi are those of Levy,1 Hirschsprung,2 and an example in the
Dupuytren Museum at Paris.*

Of intercommunication between the oesophagus and trachea (the
cesophagus being otherwise normal) there are two cases, viz., those
of Lamb4 and Pinard.3

Of membranous obstruction there are two cases in which the
rt'sophageal canal was completely blocked up, viz., those of Rossi8 and
Tenon ;7 and one in which a valve-like opening allowed food to pass
with difficulty. In the case of Rossi the obstruction was just above
the cardia, and the infant died on the third day ; Tenon's case was
similar, but the obstruction was in the upper part of the oesophagus.
In the remaining case it is highly probable, although not absolutely
certain, that the malformation was congenital.

The following are the paiticulars :8— An old woman had manifested
great difficulty in swallowing from, early infancy. (Esophageal vomit-
ing came on when she attempted to take food otherwise than in very
small morsels. After death a dilatation of the gullet was found.
About six fingers' breadths below the pharynx there was a completely
circular valve, with an opening about one centimetre in diameter.
This valve seemed formed by a folding inwards transversely of the
mucous membrane, involving the whole circumference of the tube,
the free edge of the valve being strengthened by firm tendinous fibres
running round it.

Of congenital pouch there is perhaps one example, viz., that of
Blasius,9 but the case is not given in sufficient detail to show whether
the malformation was congenital or acquired.

Of longitudinal division of the cesophagus there also exists one
example, related by the same author.10

i Loc. cit. 2 Op. cit. s Specimen No. 51.

* " Philadelphia Med. Times." 1873, p. 705.

5 " Bulletin de la Soc. Anat." 1873.

6 " Memorie dell'Academia delle Scienze di Torino." 1826, vol. xxx. serie t«,
pp. 15ft-170.

~ Fourcroy : " La Mecl. eclairge par les Sciences Phys." t. i. p. 301.

" Bolletino delle Scienze Mediche," t. xix. p. 267, 1851.

9 Loc. cit. Many cases of oasophageal pouch have been recorded, but as far aa
I am aware, in every instance the subject has been an adult.
10 Ibid. Fig. 2.

Etiology. — The essential cause of congenital malformation
of the oesophagus is involved in the same obscurity that
hangs over the whole subject of teratology. It is obvious,
however, that the deformity must arise from some abnormal
conditions, either in the spermatozoon, in the ovum before
impregnation, or in the embryo. That the first cause is suffi-
cient to produce malformation is proved by the fact that the
same male occasionally produces a similar deformity in the
offspring of different women.1 With reference to the second
i a use, it is well known that unimpregnated ova are not
unfrequently diseased, and it is possible that such ova, if
fertilized, would in some cases produce a malformed foetus.

1 Meckel : " Handbuch d. pathol. Anatomic." Leipzig, 1812,
vol. i.

220 DISEASES OF THE THROAT AND NOSE.

At the same time, so far as I am aware, no observations
have been made in connection with the female element in
reproduction analogous to that mentioned above in refer-
ring to the male element — that is to say, there is no instance
on record in which the same female has by different males
given birth to infants with a similar deformity. It is pro-
bable, however, that it is the third cause which is the most
potent, and that by far the larger number of malformations
of the oesophagus are due to disease of an embryo previously
well formed, or to a displacement of formative material at a
very early period of embryonic life ; the main argument in
support of this view being that even in cases where the
gullet is partly absent, there are almost always traces of
the obliterated portion. The most generally accepted view
as to the immediate cause of cesophageal malformations
is that they depend on "arrested development."1 This
view is probably correct so far as it goes, but it does not
explain the cause of the arrested development. Schbller 2
considers that if the deformity were entirely due to im-
perfect evolution it would be more frequently met with,
and Luschka3 suggests that both influences, viz., disease
and irregular development, are at work, and that in those
cases in which the oesophagus and trachea intercommuni-
cate, the sequence of events is somewhat as follows : First,
the canal of the oesophagus becomes obstructed, then
hypertrophy of the portion of it above the point of
obliteration takes place, and the formative matter, being
exhausted by the excessive development of the pouch, is
not sufficient to close up the opening between the two
canals. Hirschsprung4 considers that the entire absence of
anything in the least degree resembling a cicatrix refutes
the idea of destructive ulceration, but it is probable that
the effects of inflammation and ulceration occurring in the
earliest period of foetal life would be entirely obliterated
at the time of birth. The frequent coexistence of other
deformities with malformation of the oesophagus has been
regarded as evidence that the latter depends on imperfect
evolution, and not on disease. This is merely begging
the question : the facts sustain equally well the theory
that in such cases the embryo is extensively diseased.
If a glance be taken at the normal development of the

1 Meckel : Loc. cit. Bischoff : " Beitrage zur Lehre von den
Eyliiillen des Menschlicheii Fotus." Bonn, 1834.
- Loc. cit. 3 Loc. cit. 4 Op. cit.

MALFORMATIONS OF THE GULLET. 221

oesophagus and trachea, as recently described by Kolliker,1
it will facilitate the comprehension of the mode in which the
malformation may arise through some slight morbid deflec-
tion of the normal process.

The whole intestinal canal, from the month to the anus, is formed
of three segments, i.e., a middle portion and two extremities. The
former is called "the primitive intestine," the latter are the
"cephalic" and the "pelvic" portions.

The primitive intestine is formed in mammals by the separation of
the hypoblast and a layer of the mesoblast from the germinal vesicle.
At first it consists of a groove or "semi-canal," but soon becomes
transformed into a complete tube. Like the whole intestinal canal,
this primitive intestine is also divided into three portions, an anterior,
middle, and posterior. It is from the anterior portion that the
pharynx, oesophagus, larynx, trachea, and lungs are developed. The
opening of the primitive lung into the anterior portion of the primi-
tive intestine is situated in mammals at the junction of the pharynx
and oesophagus. In rabbits, on the tenth day, the anterior portion
becomes differentiated into a ventral and a dorsal division. The
ventral part is the germ for the lungs, larynx, and trachea, whilst
the dorsal portion is the nucleus of the pharynx and oesophagus.
The lower part of the ventral division becomes expanded to form the
lung, which at that time consists of a semi-canal terminating in two
vertical grooves, and freely communicating on its dorsal side with
the oesophagus by means of a linear fissure, somewhat wider at its
lower end. A separation of the two organs takes place on the
eleventh day, the anterior portion of the primitive intestine being
thus differentiated into an anterior or tracheal segment, and a
posterior or cesophageal segment. The separation proceeds from
behind forwards up to the level of the laryngeal orifice in the
pharynx, and gradually becomes more and more complete. Above
the laryngeal aperture no demarcation takes place between the air-
passages and the digestive canals. The process just described occurs
in the human fetus in exactly the same manner. Kolliker saw an
embryo of four weeks in which the two tubes were almost completely
separated, only a thin membrane intervening between them. The
sac-shaped lungs constituted at that time a prominence at the lower
end of the oesophagus, covering it on each side like a saddle.
Whether at that time a fissure-like communication still existed
between the tracheal and cesophageal tubes is not clear from Kb'l-
liker's description. In any case, however, it is probable that, by the
beginning of the second month, the entire separation of the two tubes
is an accomplished fact.

The cephalic portion of the intestine originates from the epiblast.
It grows backwards to meet the pharyngeai extremity of the anterior
part of the primitive intestine, until they are separated only by a thin
membrane (the pharyngeai membrane of Remak).2 The membrane
tlii-n disappears, and its residue forms the arcus palati and uvula.

1 " Entwickelungsgeschichte ties Menschen." Leipzig, 1879, p. 810, Ac.

- In the two cases of " obliteration " of the oesophagus referred to, ai 1
probably in some of the examples of "blind termination," the malformatio
was probably due to non-obliteration of this normal embryonic membrane, ai 1
it miirht have been expected that obstruction of the pharynx itself would som
times result from the same arrest of development. I am not aware, however,

222 DISEASES OF THE THROAT AND NOSE.

Symptoms. — The phenomena of congenital mal format inn
of the oesophagus are so characteristic, that when present
they will at once be recognized. The infant may appear
healthy whilst at rest, but the moment it attempts to swallow
the most distressing attacks of suffocation supervene, and
there is great danger of one of these proving fatal. In
Porro's case, actual suffocation appears to have taken place
through a large quantity of milk passing into the air-
passages, but as a rule the infant becomes gradually weaker,
and expires at the end of a few days from exhaustion. When
the malformation affects the upper portion of the tube, it
can sometimes be felt on passing the finger down the pharynx
of the infant. At other times, the use of a bougie will reveal
the condition of the canal, the instrument being arrested at
the end of the oesophageal pouch. Although in most cases no
instrument reaches the stomach, meconiurn is often passed.

Pathology. — The appearances after death vary according
to the nature of the deformity. Where the oesophagus is
absent, the pharynx ends in a cid-de-sac, and the stomach is
generally adherent to the diaphragm. Of the five instances
of this kind one was an anencephalous monster ; in another
the pharynx, larynx, and trachea were wanting ; and in two
the condition of the other organs is not stated. In cases of
blind termination the gullet may terminate quite high up, as
in Roederer's case, or may reach nearly to the stomach, as in
that of Warner. In the records of this class of cases, the
other organs — especially the intestinal canal — generally show
a wide departure from the normal form : thus, in one instance l
the stomach was deficient, the intestinal canal consisting of
two parts, one comprising the colon and rectum, the other
the small intestine ; the latter terminated at both ends in a
blind sac, and the upper portion of the larger bowel was closed
in a similar manner. In another case,2 the intestinal canal was
divided into four parts, each terminating at both ends in a blind
extremity, whilst the anus was imperforate. In a third ex-
ample,3 the fundus of the stomach was wanting, but in its place
was a wide round opening, the edges of which were formed of
muscular tissue. In a fourth instance,4 the brain was imper-

1 Roederer : Loc. cit. - Marrigiies : Loc. cit.

8 Pagenstecher : Loc. cit. 4 Lallemand : Loc. cit.

the existence of any case supporting this view. It may be added that coniiii»n
as are pouches of the pharynx there do not appear to be any proved examples of
congenital defonnity on record.

MALFORMATION'S OF THE GULLET. 223

fectly developed, and the upper part of the oesophagus com-
municated through the vertebral canal with the mouth. In a
fifth case the subject was an anencephalous monster.1 In
other examples of this variety of malformation the condition of
the other viscera is not stated. The cases, however, in which
there is deficiency of a greater or less amount of the middle
third of the oesophagus, with inosculation between it and the
air-passages, are the most common, and the most interesting
to the pathologist. Here the upper part of the gullet
usually terminates in a dilated pouch about half an inch
above the bifurcation of the trachea, whilst the lower portion
generally originates from the windpipe still closer to the
bifurcation, and passing downwards enters the stomach in the
ordinary way. The portion of the oesophagus immediately
at its origin from the trachea is generally very narrow, but as
it descends it acquires its normal size. The upper portion,
or pouch, is always much dilated, and its walls considerably
thickened. Sometimes the pouch-like expansion is limited
to the gullet (as in my case), whilst in others (as in those
of Ilott) the enlargement involves the pharynx also. The
two separate portions are generally connected by a small
band of muscular or tendinous fibres. In my own case
(see Vol. ii. Fig. 22 B) the lower extremity of the pouch (a')
actually overlapped the lower segment of the oesophagus (b')
where it proceeded from the trachea. On laying open
the gullet, the lining membrane is almost invariably seen
to be perfectly free from disease. In only one 2 out of all
the recorded cases is there any mention of ulceration of
the mucous membrane, and in that instance the lesion
was superficial, and was no doubt caused by the retch-
ing and straining which occurred on attempting degluti-
tion. On dividing the trachea, the opening of the oeso-
phagus may generally be seen as a small aperture situated
in its posterior wall and directed downwards. Sometimes
the opening is described as oval and sometimes as round
in shape, but in my specimen (Fig. 22 C b") the aper-
ture is distinctly crescentic — the concavity being directed
downwards. In this specimen (Fig. 22 C a") the hyper-
trophied pouch of the oesophagus forms a projection on
the posterior wall of the trachea, which considerably
diminishes its lumen. In one of Hirschsprung's cases,3 more

1 Pinard's second case : Loc. cit. - Scholler : Loc. cit.

3 Op. cit. case 7, p. 35.

224 DISEASES OF THE THROAT AND NOSE.

or less complete cartilaginous rings were found at the hum-
end of tlie cesf»phaf/U8.

As regards the associated deformities, in one instanec '
there were spina bitida, absence of anus, and a single
horse-shoe kidney placed over the spine. In two •
there was trifurcation of the trachea,2 and in two others
there was atelectasis pulmonum.3 In another rase, tin-
stomach and intestines were contracted.4 The other deform-
ities associated in different cases with oesophageal inoscula-
tion were: malformation of the uterus;5 combination of
the male and female genital organs ; 6 imperforate amis with
a communication between the intestine and bladder and
deformity of the pelvis ; " absence of right lung and atresia
ani ; 8 imperforate anus with intercommunication between
bladder and rectum, deficiency of the radius in each arm, and
clubbed hands ; 9 imperforate anus with intercommunication
between rectum and urethra and right auriculo-ventricular
opening almost blocked up by membranous diaphragm.10

In only three instances is it expressly stated that there was
no other deformity ; whilst in nineteen cases there is either
no mention of the condition of the other organs, or it is
formally stated they were not examined.

J}/iii/no»is. — There is no disease for which this malforma-
tion can be mistaken. The absolute inability to swallow,
which cannot fail to be observed from the first time the
infant attempts to suck, is characteristic ; whilst, if a
measured quantity of milk be administered with a teaspoon,
and the ejected fluid collected, it will be found that it is
all returned. The diagnosis can be further verified by the
passage of a catheter. In new-born children the minimum
diameter of the oesophagus is four millimetres, whilst the
distance from the border of the gums anteriorly to the cardiac
orifice of the stomach is seventeen centimetres.11 If, there-
fore, a catheter of suitable size cannot be passed for this
distance, it may be presumed that there is a congenital
obstruction.

]'ru<inosis. — As already stated, infants born with a malfor-
mation of the oesophagus generally succumb in a few days, the
duration of life probably depending more upon the vigour of

I Davis : Loc. cit. ' 2 Hirschsprung : Loc. cit.

8 Ibid. 4 Padieu : Loc. (it.
Spec. 457, Boston Museum. 6 Levy : Loc. cit.

7 Hirsrhsprung: Op. cit. 8 Maschka : Loc. cit.

9 Pinard's first case : Loc. cit. 10 Polaillon : Loc. ''it.

II Mouton : " Du Calibre de 1'CEsopbage." Paris, 1874, p. 61.

MALFORMATIONS OF THE GULLET.

225

the child when born, than on the exact nature of the malfor-
mation. Thus, in five cases of complete deficiency of the
oesophagus, one infant lived seven days, another eight days,
a third " a few days," whilst in the two others no informa-
tion is given on this point, though, from the context, it is
possible that the infants were both born dead. In eight cases
of blind termination, three infants lived to the third, fourth,
and fifth day respectively, whilst in five cases the duration
of life is not stated. In thirty-seven cases, in which there
was inosculation between the oesophagus and air-passages,
the duration of life was as follows : —

Date of death.
Two hours after birth
Second day .
Third day
Fourth day .
Fifth day
Sixth day
Seventh day .
Ninth day
Eleventh day
Twelfth day .
A few days .
Not stated

Cases.
1
8
4
6
4
1
1
1
2
1
1

In one of the cases in which the gullet and trachea
intercommunicated, whilst the former was otherwise' normal,
the patient lived seven weeks. The cause of this com-
paratively long existence will be understood from the
following description : —

" In the median line, nearly half an inch below the lower
border of the cricoid cartilage, was a fistulous communication
between the two tubes, having a longitudinal diameter of
three lines, and a transverse diameter of one line. The
direction of the fistula was downwards and backwards, the
opening in the oesophagus being at a lower level than in the
trachea ; the edges were smooth and rounded, and the mucous
membrane normal. The danger of passage of the contents
of the oesophagus into the trachea appears to have been
guarded against to some extent by the close apposition of the
walls of the fistula." 1

In one of the two cases of membranous obstruction of the
oesophagus, the patient lived till the third day ; in the other
the duration of life is not stated.

Treatment. — In none of the recorded instances was any
attempt made to preserve the life of the infant by any

1 Lamb : Loc. cit.
VOL. II. Q

226 DISEASES OF THE THROAT AND NOSE.

surgical procedure, and it is obvious that but little hope
can be entertained of relief by art, as the opening into the
air-passages, which is so often present, would probably inter-
fere with the maintenance of life even if the oesophageal canal
were patent throughout. Mr. Holmes1 thinks that where
no tracheal communication can be made out an operation
might be attempted. "The object," he observes, "would In-
to cut down upon the point of a catheter passed down to
the pharynx, and then to attempt to trace the obliterated
oesophagus down the front of the spine, until its lower
dilated portion is found. A gum catheter would then In-
passed through an opening made in the upper portion, and
so into the stomach through the lower portion. If the two
portions are near enough to be connected by silver sutures
over the catheter, and if the latter can be retained until they
have united permanently, success might possibly be main-
tained." Such an operation would evidently be extremely
hazardous and difficult, if not impracticable. Gastrostoiny
has been recommended by Sedillot, who remarks : " In all
cases where the oesophagus is simply obliterated, atrophied,
or interrupted, gastrostomy would give the hope of saving the
infant, without any accident except that of the operation
itself. If there exists a communication between the lower
•end of the oesophagus and the trachea, there is a risk that
food received into the stomach would be regurgitated into
the air-passages ; but the narrowing of the abnormal
opening, and its natural tendency to close, would afford
.some security against such an inconvenience." Whilst
•quoting the views of this eminent surgeon, I cannot endorse
them, as I consider that section of the stomach and the
subsequent artificial alimentation of a newly-born infant
•could not be attended with satisfactory results. The
following case illustrates the malformation : —

In September, 1879, I was consulted (on the advice of Dr.
Walker, of Putney) by the father of a male infant, eight days old.
'The history of the case, as supplied to me by Dr. Walker, was as
follows : —

Mrs. S., a primipara, gave birth to a male infant in September,
1879. At birth the child was feeble and badly nourished, and had
difficulty both in breathing and crying; there was also a constant.
rattling noise in the throat, which continued in spite of all efforts to
remove the mucus. On the following day milk and water was given,
but it was at once rejected through the mouth and nostrils ; later

1 "The Surgical Treatment of the Diseases of Infancy." London,
1869, 2nd ed.

MALFORMATIONS OF THE GULLET. 227

ill the day the breathing became more troubled. Dr. Walker
administered a measured quantity of milk and water, and having
taken steps to receive all that was ejected from the mouth and nose,
found that nearly all the ingesta were returned. Next day the child
was able to keep down a very small quantity of milk, but he hail
become extremely emaciated, and appeared to be sinking. Enemata
of milk and lime-water were given, and a small quantity of brandy
and water was occasionally administered by the mouth. On the
fourth day Dr. Feun, of Richmond, saw the child with Dr. "Walker,
and on passing a gum-elastic catheter down the pharynx, they
found its course completely arrested about two inches below the
cricoid cartilage. During the next few days the child seemed to
improve, the breathing became easier, and crying and coughing
much stronger. Drs. Walker and Fenn having arrived at the
conclusion that the case was one of obstruction of the oesophagus,
consulted me as to whether I was prepared to perform any operation
with a view of overcoming the difficulty. I did not, however, feel
myself justified in recommending any operative procedure, and the
child died from exhaustion on the eleventh day after birth.

The father of the infant stated that a former wife had given birth
to a child which died after nineteen days with exactly the same
symptoms, as those recorded in this instance. No other child of his
had any malformation.

A post-mortem examination, limited to the throat, was made by Dr.
Walker and Mr. Hovell, with the following results : — The infant was
of ordinary size and well formed, but much emaciated. There was
no malformation of the lips or palate. The pharynx was of normal
configuration, but slightly constricted at its junction with the ceso-
phagus, which consisted of two portions — an upper part, which com-
municated with the pharynx, and a lower portion, which, originating
from the stomach, passed upwards and terminated in the trachea.

The upper portion of the oesophagus terminated in a blind
extremity two centimetres and a half below its origin. The whole
of this portion of the gullet was hypcrtrophied, so that it measured
three centimetres in circumference.*

Ascending from the stomach, the lower end of the oesophagus
passed upwards in the usual manner, but three and a half centi-
metres above the diaphragm its muscular fibres suddenly became
thinner and paler, and the tube becoming smaller, terminated in the
trachea immediately beneath the lower end of the upper division of
the gullet. The connection between the two parts of the oesophagus
was maintained by a narrow muscular fasciculus, which passed from
the upper extremity of the inferior portion to the under surface of
the upper part, and by a thin membranous expansion, which inter-
vened between the two portions. On dividing the trachea vertically
in front, the lower part of the upper portion of the oesophagus was
seen to form a distinct projection on the posterior wall of the trachea,
considerably diminishing the antero-posterior diameter of the latter
tube. Situated transversely on the posterior wall of the trachea, at
a point just below the level of the lower end of the upper section
of the oesophagus, was a minute crescentic opening, directed down-
wards and backwards, which led into the lower portion of the
oesophagus. The rectum was normal.

1 The ordinary circumference of the oesophagus at birth is from one and a.
half to two centimetres, but it seldom exceeds eighteen millimetres.

228

DISEASES OF THE THROAT AND RO6B.

t',,n,j,-jiltnl Dilatations and Stenoses. — As, in C(.MSC(|UCIICC
of symptoms not manifesting themselves till lati-r in life, it

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is often impossible to determine whether certain dilatations
or stenoses are congenital or acquired, it has been thought

POST-MORTEM SOFTENING OF THE GULLET. 229

better to treat those conditions as diseases rather than mal-
formations. The dilatations which probably depend on
some- congenital weakness have been considered at page
115, and stenoses of probably congenital origin at page 156.

POST-MOETEM SOFTENING OF THE GULLET.

Just as softening, and even perforation, of the stomach
sometimes occurs as a result of the action of the gastric juice,
so likewise a similar process occasionally takes place in the
gullet after death. This is much more rare, however, in the
oesophagus than in the stomach, as the former is but seldom
exposed to the action of the solvent. It has long been a
moot question whether the softening takes place during the
last hours of life or only after death ; and, in spite of the
patient consideration which has been given to this point by
Budd,1 Canton,2 Ziemssen,3 and others, the problem is not
yet absolutely decided.

The chief factors in post-mortem solution of the giillet are,
first, the presence within its channel for a considerable time
of gastric juice which retains its normal acidity ; secondly, a
proper degree of temperature (90° to 100° Fahr.) ; thirdly, the
absence of resistance in the tissues themselves to the digestive
power of the fluid — a resistance attributed by Hunter to the
influence of the " vital principle," and by modern authorities,
with some probability, to the neutralization of the acid of
the gastric juice by the presence in the living tissues of a
large quantity of alkaline blood. In the majority of cases
where softening of the gullet has been observed the stomach
has also been more or less destroyed. Post-mortem solution
is much more common in the bodies of young children than
in the case of adults, but I am not aware that any explana-
tion of this fact has been offered. The degree of macera-
tion of the tissues varies |rom mere erosion of the epithelial
layer, either in small patches or in longitudinal strips cor-
responding to the folds of the lining membrane of the tiibe,
to complete perforation of the entire thickness of the gullet
wall over a greater or lesser area. Intermediate stages of the

1 "Croonian Lect." — "London Med. Gazette." 1847, vol. xxxix.
p. 896, et seq.

2 "Lancet," October, 1859.

3 "Cyclopaedia of the Practice of Medicine," vqj. viii. p. 89, ct *«\.

230 DISEASES OF THE THROAT AND NOSE.

process have been noted where, in addition to the stripping
oft of tin- epithelium, the denuded mucous membrane had a
whitish sodden look, as if it had been steeped in spirit, All
these derives <>f digestive solution may sometimes be observed
in the same specimen. When perforation has taken place the
o -.-••phageal wall may present one or more irregular rent.-. <>r
it may be fissured in a longitudinal direction ; the etL
the apertures in either case being ragged, and fringed with
floceulent shreds of half-dissolved tissue. In some instances
the oesophagus is destroyed throughout its whole circum-
ference, but usually the digestive action is confined to t la-
posterior wall. The reason of this is no doubt to be found
in the fact that the body has been lying in the su pi im-
position. In no recorded case, so far as I am aware, has the
action been seen to have extended above the lower half of
the gullet. The wall of the oesophagus in the neighbourhood
of the softened parts is generally quite normal in appearance,
but the vessels of the contiguous mucous membrane are
sometimes congested, and even patches of ecchyniosis have
been observed. In two cases reported by Hoffmann1
the mucous membrane of the gullet was saturated with
extravasated blood.

AVhere the wall of the gullet has been eaten through,
the solvent action of the gastric juice is found to have
extended to the neighbouring parts. One or both pleural
cavities are seen to have been laid open by the destruc-
tion of the portion of the parietal layer of the membrane
lying nearest to the point of perforation in the oeso-
phagus ; and gastric juice with shreds of undigested food,
mixed, in some instances, with blood-stained fluid from
maceration of the adjacent lower lobe of the lung, may be
found in the thorax. There is generally, moreover, some
emphysema tons distension of the areolar tissue in the
posterior mediastinum. It will not unfrequently be found
that only one pleural cavity has been opened, and in such
cases it is almost invariably the le£t that communicates with
the hole in the gullet.2 The cause of this will be apparent,
when it is remembered that the lower end of the oesophagus
lies to the left of the vertebral column, and therefore in
closer proximity to the left pleural sac than to its fellow.

1 "Yirchow's Aivhiv." Bel. xliv. p. 352. Ibid. Bd. xlvi. j.. 124.

2 A case, however, has lately been reported by Quincke ("Deutschcs
Arcliiv fiir klin. Med." 1879, vol. xxiv. p. 72), in which the right
pleural sac alone wa$ perforated.

POST-MORTEM SOFTENING OP THE GULLET. 231

It is probable that similar changes may take place in the
gullet when life is at its lowest ebb, especially when the
approach of death is very slow and gradual, as in persons
enfeebled by long wasting maladies. In such cases the
conditions already described as necessary for the process of
what may be called " self-digestion," come into play. Long
continuance in the horizontal position and atony of the
muscular walls of the gullet are likely to favour regurgitation
of the acid contents of the stomach beyond the cardiac
orifice, whilst the feeble circulation of impoverished blood
leaves the tissues exposed to the digestive power of the
gastric juice. Although this theory is very plausible, no
positive proof of its soundness can be given ; nor is this a
matter of any practical importance, for the recognition of
digestive solution of the oesophagus, when the patient is
in articulo mortis, can lead to no result.

From statistics given by Ziemssen,1 there seems to be some
connection between softening of the gullet and certain diseases
of the brain. He affirms that in 2,587 autopsies made at the
Pathological Institute at Erlangen, from 1862 to 1876, soften-
ing and perforation of the gullet were found in nine cases.
In one of these the head was not examined, but in each one
of the other eight cases there was (in addition to pathological
changes elsewhere) some lesion of the brain. In four of them
there was inflammation of the membranes at the base of
the brain, together with acute hydrocephalus ; in one there
was an enormous congenital hydrocephalus ; in one there
was a cicatrix in the striate body, with slight chronic
hydrocephalus ; in one great congestion of the brain, with
slight hydrocephalus, and in one moderate congestion,
together with some osdema of the brain. The ages of these
patients ranged from three months to fifty-eight years.
Whether wider observation would confirm these statistics it
is of course impossible to say, but the simultaneous presence
of pressure on the cerebral substance and digestive solution
of the gullet in all the cases examined, certainly seems to
suggest a relation of cause and effect between the two
conditions.

1 Op. cit. p. 104.

232 DISEASES OF THE THROAT AND NOSE.

SECTION V.— THE NOSE.

ANATOMY OF THE NASAL FOSSAE.

THKSE intricate cavities are bounded above by the undrr surface of
the anterior third of the base of the skull, below by the upper surface
of the hard palate, externally by the wall of the orbit and by the
superior maxillary bone, whilst iiiternally the two nasal chambers are
separated from each other by a perpendicular septum, in part bony
and in part cartilaginous. In front the nasal fossae open into the
cavities of the nostrils or vestibula nasi (hereafter described, p. 243)
by two oval apertures — the anterior nares — placed in the vertical
plane, and inclined very nearly at right angles to the external ori-
fices of the nostrils. Posteriorly they communicate with the upper
part of the pharynx by the posterior nares or choancc, two quadri-
lateral openings looking backwards and somewhat downwards. Kadi
nasal cavity may be described as an irregular four-sided passage, of
somewhat pyramidal form. Of this passage the upj>er wall or roof is
horizontal in its middle third, but inclines abruptly downwards both
in front and behind ; the lower wall or floor is almost horizontal,
having only a slight inclination downwards and backwards, whilst
the external and internal walls are, roughly speaking, vertical and
parallel to each other.

The roof is formed, in its horizontal portion, by the cribriform plate
of the ethmoid bone, and constitutes, for a limited space, the immediate
floor of the brain. In its anterior portion it is made up of the nasal
process of the frontal and the nasal bone proper, its downward incli-
nation gradually increasing from behind forwards. The posterior
third of the roof, which is inclined almost at right angles to the
horizontal portion, is formed by the body of the sphenoid bone, being
continuous behind with the basilar process of the occipital.

The floor of each nasal cavity is composed anteriorly of the palatine
process of the superior maxilla, and posteriorly of the horizontal
plate of the palate bone. It is slightly hollowed out from side to
side, and presents anteriorly the orifice of the nasal canal.

The internal or median wall, constituting the septum narii/m. is
roughly quadrilateral in outline, and after the seventh year is
generally inclined to one side or the other, thus slightly enlarging
one cavity at the expense of its neighbour. In many cases, however,
this lateral deflection of the nasal partition is sufficiently pronounced
to cause serious obstruction in one of the nasal passages, a deformity
which will be subsequently considered under the nead of " Deviations
of the Septum."

The septum of the nose is formed behind by the vomer and perpen-
dicular plate of the ethmoid, and in front by a vertical cartilaginous
plate received into the angle of junction between these bones. The
inner edge of the palatal process of the superior maxillary bone and
of the palate bone itself rises on the upper aspect into a crest which

ANATOMY OF THE XASAL FOSSA'. 233

forms a slight bony ridge along the middle line of the floor of the
nose when the bones of both sides are in apposition. This ridge is
the base of the nasal septum.

The external wall of each cavity is placed almost vertically, but
with a slight inclination downwards and outwards. In its upper
part it is formed by the frontal process of the superior maxilla, the
lachrymal bone, and the orbital plate of the ethmoid ; in its lower
part by the inner surface of the body of the superior maxilla, the
perpendicular plate of the palate bone, and the internal pterygoid
plate of the sphenoid. The surface of the outer wall is, however,
rendered uneven by the turbinated bones which form projections
in the nasal cavity, leaving intervening spaces between them which
are called rneatuses.

There are always three turbinated bones, and frequently a fourth.
Each one is formed of a thin lamina, somewhat triangular in
shape, perforated by numberless minute openings, and so curved
upon itself as to present a convexity upwards, inwards, and slightly
forwards. The three turbinated bones spring from the lateral
walls of the nasal cavity, at about equal distances from each
other, their margins of attachment being horizontal and nearly
parallel, while their free incurved margins are convex, so that each
bone is widest at its centre. The posterior extremities of their
attachments are placed nearly in the same vertical line, and as
each bone is longer than the one above it the anterior extremity
of the inferior bone approaches nearer to the anterior nares than
that of the middle bone, and this, again, is very considerably in
advance of the anterior extremity of the upper bone. Examining
the turbinated or spongy bones more in detail, it will be seen that
the inferior one is the most developed and the most compact in struc-
ture, and that it is the only one which is an independent bone. It
varies in length from twenty -five to fifty millimetres, and in breadth
from five to fifteen. It articulates with the superior maxilla, its
anterior pointed extremity coming into relation with the anterior
portion of the nasal process of that bone, while its posterior rounded
extremity extends to the internal pterygoid process. The middle and
superior bones are merely processes of the ethmoid, and though
separated behind they are united together in front. The middle
spongy bone is more rolled round at its centre than at its extremities.
Near its anterior free end a small projection — the agger nasi1 — is
directed inwards, and on the corresponding level of the septum there
is a slight bulge. These two minute protuberances make a faint
line of demarcation between the olfactory region above and the
respiratory passage below. Above the middle spongy bone is the
superior one, and this, again, by a horizontal slit in its posterior
edge, is often divided, so that there is, in fact, a fourth turbinated
bone, which is still shorter than the one below it. The existence of
the fourth bone was first pointed out by Santorini, ~ and, according
to Zuckerkandl,3 it is present in more than one-third of all cases.

By the projection of the turbinated bones each nasal cavity is
broken up into three passages or meatuses, communicating internally
with that remaining narrow portion of the fossa where nothing is
intri-posed between the roof and the floor. The uppermost of these
yes, the superior meatus, is limited by the upper and middle
1 H. Meyer: " Lehrb. d. phys. Anat." Leipzig, 1856.
- "Observ. Anatom." Venetiis, 1724, cap. v. p. 801
3 " Anatomie der Nasenhtihle." Wien, 1882, p 31.

234 DISEASES OF THE THROAT AND NOSE.

turbinated bones aiul by that portion of the external wall included
between them ; it communicates by means of a foramen with tin-
posterior ethmoidal cells, and through them with the sinusrs in tin-
body of the sphenoid. When there is a fourth spongy bone, then-
is also a fourth meatus. The middle meatus is situated between the
middle and inferior turbinated bones. It communicates above with
the anterior ethmoidal cells, and on its outer wall is a creseentic
opening — the hiatus semilunaris, or ethmoidal fissure — about two
centimetres in length, the convexity of the crescent being directed
forwards and downwards. The curve of the uncifonn process of the
ethmoid bone forms the lower boundary of the hiatus scmilunaris. tin-
upper edge being constituted by the lower surface of the ethmoidal
cells. One of the ethmoidal cells bulges outwards opposite the middle
of the uncifonn process, giving rise to a prominem-e whieh has been
called by Zuckerkandl 1 the biilla ethnwidalis. The hiatus semilunaris
leads to a funnel-shaped cavity — the infundibulum — whieh communi-
cates at its upper and anterior part with the frontal cells, and at its
lower and posterior part by the ostium maxillare with the antrum of
Highmore. Immediately behind the hiatus semilunaris there is
also often a small additional opening into the antrum2 — the ostium
maxillare acccssorium. The inferior meatus runs between the lower
turbinated bone and the floor of the nasal cavity. In the anterior
part of the meatus, at the articulation of the turbinated bone with
the nasal process of the superior maxilla, is situated the orifice of
the lachrymal duct.

Each nasal fossa is, as already remarked, continuous in front with
the cavities of the nostril, or vestibula na-si. Here, however, the
bony framework gives place to cartilaginous plates. These, though
subject to variations in form and number, consist in their simplest
development, of three distinct cartilages, one median and two lateral.
The former, by means of its rhomboidal perpendicular plate, helps
to complete the septum narium, and supports the bridge of the nose
below the nasal bones. The portion of its anterior border which
serves the latter purpose is broad and grooved, while the part above
it is applied to the suture between the nasal bones, and that below
it is bent abruptly backwards to terminate at the anterior nasal spine.
Attached at an acute angle to the broad and grooved portion are two
lateral plates which, together with the lateral cartilages proper, serve
to support the outer walls of the cavities of the nostrils. Each of
these lateral plates is triangular in form, and is attached above to the
sharp margin of the nasal bone, whilst its lower margin is free
and somewhat incurved, so as to make a slight projection inside the
nostril. The lateral cartilages proper support the outer and a small
part of the inner walls of the nostrils. Tney consist of two segments
united together at an acute angle. The larger portions, roughly
triangular in shape, slightly overlap the lateral plates of the median
cartilage and form the framework of the alee nasi. The smaller por-
tions give support to the septum between the nostrils, filling up
the space left by the retreating border of the perpendicular plate.

The interior of the nasal cavities is lined throughout by mucous
membrane, which is continuous in front with the skin of the face and
posteriorly with the mucous lining of the pharynx. It varies con-
siderably in character in different parts, but in its general arrange

1 Op. cit. p. 36.

2 According to Zuckerkandl (op. cit. p. 22) this accessory foramen was found
in every ninth or tenth cranium which he examined.

ANATOMY OF THE NASAL FOSSAE. 235

incut it follows pretty closely the ramifications of the bony frame-
work. It consists of two layers, a deep fibrous, and a superficial
mucous stratum which is covered by epithelium. The deep layer
forms the immediate covering of the skeleton of the nose, having the
functions of periosteum over the bones, and of perichondrium over
the cartilaginous parts. It is somewhat loosely attached to the
cartilages, but in other parts is firmly adherent. This membrane
has been shown by Panas1 to be much thicker and more fibrous
at the upper and posterior part of the septum and the immediately
adjoining space on the base of the skull than at any other part. The
superficial layer of the mucous membrane may be roughly divided,
according to its histological character and physiological functions,
into two portions — a superior, or olfactory, and an inferior, or
respiratory, tract. In the former the membrane is thin and closely
adherent to its deep layer or periosteum ; it is not very vascular, but
is of a palish brown colour from the presence of pigment in the
epithelium and the glands. The epithelium is of the columnar
variety, but without cilia, and lying amongst the columnse are the
peculiar rod-shaped bodies known as the olfactorial cells of Schulze.
The blood-supply of the olfactory region comes principally from the
anterior ethmoidal and the nasal branches of the posterior ethmoidal
arteries, whilst the nerves are the terminal twigs of the olfactory
itself, which, after passing through the aperture in the cribriform
plate of the ethmoid, is distributed to the roof and to the inner and
outer wall of the nasal cavity in the upper third. In the respiratory
tract the deep is separated from the superficial layer of the mucous
membrane by some connective tissue which gives support to the
numerous vessels and capillaries supplied to this part. Anteriorly the
latter approximates in character to the external skin, its epithelium
being tesselated and disposed in layers, while just within the nostrils
it is provided with hair-sacs and sebaceous follicles. The tesselated
epithelium not only covers the whole of the mucous membrane which
has a cartilaginous framework, but extends as far back as the
anterior extremity of the lower turbinated bone. The remainder of
the respiratory tract is furnished with columnar ciliated epithelium,
the cilia of which vibrate towards the posterior nares. The nervous
supply of this portion of the nasal passage is mainly derived from
offshoots of Meckel's ganglion. In the neighbourhood of the fora-
mina, by means of which the nasal cavities communicate with the
adjacent sinuses, the mucous membrane does not exactly follow the
contour of the bony framework, but presents folds, which deserve
a brief mention. Thus, in front of the chink-like opening by which
the anterior ethmoidal cells open into the middle meatus, the mucous
membrane is raised into a fold to form a groove, which corresponds
to the fissure in the bony skeleton, already described as the hiatus
semilunaris, and considerably increases the depth of that cavity.
The mucous membrane of the antrum is also occasionally continuous
with that of the middle meatus by means of a small circular accessory
opening placed just above the attachment of the inferior turbinated
bone, near the posterior extremity of the hiatus semilunaris. In
the inferior meatus the shape of the outlet of the lachrymal duct is
considerably modified by the disposition of the mucous membrane
around it. In the recent state this orifice is sometimes circular in
form and sometimes elongated, either in a vertical or transverse direc-
tion, whilst the mucous membrane is occasionally arranged so as to
1 " Bull, lie la Soc. de Chir." July 9, 1873.

236 |.]>K.\M-:s c.l- TIIK TlllioAT ANH M>SK.

make a groove below the opening. On the floor of the nasal cavities
the mucous membrane dips down into the uaso-palatiue foramiiiii,
whirl, are situated one on each side of the septum at about half an
inch from the anterior nares, being sometimes continuous through
these openings with the mucous covering of the hard palate.

The mucous membrane covering the turbinated bones is crowded
with glands, the openings of which may be readily seen upon its
surface, though the glands themselves are deeply imbedded in the
sub-epithelial structures. On the other hand, the glands in the
membrane covering the septum are small in size and few in numlier.

The arterial supply of the nasal fossre is derived from two sources,
viz., the posterior nasal branch of the internal maxillary, and the
anterior ethmoidal branch of the ophthalmic. The former enters at
the spheno-palatine foramen and divides into two branches : a lateral,
passing off behind the turbinated bones and supplying the adjacent
structures, and a median branch supplying the septum and forming
an anastomosis with the septal branches of the anterior ethmoidal.
The latter artery, besides supplying the anterior portion of the septum,
also sends branches to the lateral portions of the fossae. All the
above arteries contribute to form a dense capillary network, which is
most developed beneath the mucous lining of the respiratory tract.
The veins of the nasal cavities, as a rule, accompany the arteries, but
are larger and more numerous. They communicate chiefly with the
facial and ophthalmic veins, but also pass through the cribriform
plate of the ethmoid, and in young subjects send branches through
the foramen ccecum, the superior longitudinal sinus, a few twigs not
unfrequently, indeed, terminating in the coronary sinus. The veins
over the turbinated bones, between the periosteum and the mucous
membrane, were first shown by Kohlrausch1 to form a "cavernous
network," and soon afterwards a more detailed description of this
structure, with highly artistic illustrations, was given by Bigelow,-
who demonstrated the truly erectile character of the structure.
Voltolini3 pointed out that each turbinated bone, in spite of its
extremely delicate structure, can, after maceration, be seen to be
perforated by countless minute holes. Through these openings small
vessels pass, and they perforate the bone in such abundance that in
a space of three square millimetres ten patent vessels have been
counted. The soft parts are closely adherent to the elevations and
depressions of the periosteum, covering the bone, as Voltoliui says,
just as a sponge does the hard coral beneath it. The cavernous net-
work, with its bony support and investing mucous membrane, consti-
tutes the " turbinated bodies."

The lymphatics form a very superficial network, and terminate in
two trunks which pass close to the openings of the Eustachian tubes
to join glands in the lateral wall of the pharynx.

The nerves are of two kinds — those of general and those of special
sensation. The former consists of the spheno-palatine branch of the
second division of the fifth, and of the vidian nerve which supplies
the upper and back part of the septum ; of the nasal branch of the
ophthalmic which ramifies on the upper and interior part of the
septum and the upper portion of the external wall ; of the naso-pala-
tine nerve which supplies the middle part of the septum ; and of the
anterior palatine nerve which is distributed to the middle and inferior

i " Muller's Archiv." 1853. p. 149.

- "Boston Metl. and Surg. Journ." April 29, 1875.

3 " Monatsschrift fiir Ohrenheilkunde." 1877, No. 44.

RHINOSCOPY. 237

turbinated bodies. The nerve of special sense is the olfactory, the
filaments of which, after passing through the foramina in the cribri-
form plate of the ethmoid, are distributed to the upper third of the
septum, and to the superior and middle turbinated bodies. Some
filaments of the sympathetic can also be traced in the nasal mucous
membrane.

RHINOSCOPY.

The nose can be examined by three methods. Thus, 1st,
a speculum may be passed into the nares, and a large portion
of the anterior part of the nasal cavity thereby brought into
view ; 2ndly, the upper and central parts of the nose can be
sometimes inspected by means of a small mirror introduced
along the floor, with its reflecting surface directed obliquely
upwards ; and 3rdly, the hinder portion of the nose and the
posterior nares themselves can be seen by placing a mirror at a
suitable angle behind the uvula. Hence anterior rhinosnrpy,
median rhinoscopy, and posterior rhinosca^y may be practised.

ANTERIOR RHINOSCOPY.

History. — From a very early period in the history of medicine
attempts were no doubt made to inspect the interior of the nasal
fossse by throwing back the patient's head, and tilting the tip of the
nose upwards with the finger. A nasal speculum was described and
figured by Dionis1 at the beginning of last century ; it was simply
a dilating instrument, and was recommended by the inventor chiefly
as part of the apparatus required for the removal of polypi. In
modern times Markusovzsky seems to have been the first to attempt a
regular examination of the nasal cavity by means of a speculum, and
in 1859, whilst-.pn a visit to Pesth, I had an opportunity of seeing his
instrument, 'which appeared to be a modification of Kramer's ear
speculum. 'In 1860 Czermak2 expressed his appreciation of it. Soon
afterwards Voltolini3 stated that he was able to see the Eustachian
cushion by passing an ear speculum into the nose. Subsequently he
showed4 that by dilating the nasal passages in a good light the
pharyngeal wall could be easily seen, and that this was particularly
the case in ozsena, when there was atrophy of the turbinated bodies.
In 1868 Thudichum5 described a speculum for examining the anterior
nares, whilst in the same year Duplay6 devised an excellent instru-
ment for the inspection from the front of the deeper parts of the nose ;
to this method he gave the name of anterior rhinoscopy. In 1872
Friinkel7 published an account of his admirable speculum, hereafter
described. In 1873 Michel8 stated that he was often able, by means
of Duplay's speculum, to see the posterior half of the Eustachian

' Cours d'0p6ration3 de Chirurgie." Paris, 1714, 2e &1. p. 483, and Fig. 37 K.
'Wien. med. Wochenschrift." 1860, No. 17.

' Die Rhinoscopie und Pharyngoscopie." Festschrift zur 50 jahrigen Jubel-
feiei der Universitat Breslau zum 3 August, 1861.
* ' Monatsschr. fur Ohrenheilkunde," No. 3, 1868.
Lancet." 1868, vol. ii. pp. 243, 244.
Bull, de la Soc. de Chir." 1868, 2e s£rie, t. ix. p. 446.
Berlin, klin. Wochenschrift." 1872, No. 6. 8 Ibid. 1873, No. 34.

238

DISEASES OF THE THROAT AND NOSE.

orifice, and the whole of its cushion, and that he could perceive the
movements of the tube in phonation and swallowing.

A new departure was given to rhinoscopy, carried out from the
front, by Zaufal,1 who, in 1875, first recommended the use of a funnel-
shaped speculum, long enough to pass completely through the na^il
cavity. Notwithstanding that the merit of this met hod has ln-en
contested by Weber-Liel, Gruber, Schrotter, and Yoltolini, it is
undoubtedly of value, and Habermann,- a pupil of /aiil'al's, has
recorded a very large number of cases in which the funnel-specu-
lum has been employed with much advantage.

i " Aerztliches Correspondenz-Blatt aus Btthmen," 1875. See also " Archiv fiir
Ohrenheilkunde, " Band xii. Viertes Heft, 1877.
- " Wien. med. Presse." 1881, Nos. 23, 24, and 25.

Nasal Specida. — For ordinary examination of the .front
part of the cavities Frankel's speculum will be found most
serviceable. This instrument consists, as may be seen in
the annexed woodcut (Fig. 23), of two fenestrated blades,

FIG. 23.— DR. FKANKEL'S NASAL SPECULUM.

made of German silver wire, two and a half centimetres in
length, and somewhat resembling miniature obstetric forceps,
but with shanks about five centimetres in length. The proxi-
mal extremities of the shanks are connected by a horizontal
bar, through which there is a central screw acting on both
blades. Frankel recommends that one blade of the instru-
ment should be introduced into each nostril, but mentions
that both blades may be passed into a single nostril, and
I prefer this plan. By turning the screw the blades are
gradually separated, and a good view of the interior of
the nose is obtained. When the blades are sufficiently
opened to press slightly on the nasal alse, the instrument
becomes self-retaining, and the lower part of the speculum
falling in front of the lip causes no obstruction to the sight.
The great advantage of this instrument consists in its afford-
ing an excellent view, whilst causing no pain, and scarcely
any inconvenience to the patient.

Von Trb'ltsch1 has taken the screw arrangements of Frankel's
instrument, and replaced the wires by two solid blades,
1 "Lehrbuch der Ohrenheilkunde." Leipzig, 1877, p. 317.

RHINOSCOPY.

239

each three centimetres in length, but I have not found
this speculum so convenient as Frankel's.

Another speculum, the blades of which somewhat re-
semble those of Frankel's, has been recently invented by
Goodwillie,1 of New York. The instrument is kept open by
the elasticity of the wire which connects the two blades.
With it, however, it is impossible to regulate the separation
of the blades so accurately as with Frankel's, and hence no
fewer than five specula are needed to suit the varying sizes
of the nasal orifices. Creswell Baber,2 of Brighton, uses
a speculum (Fig. 24), which consists of two little curved

FIG. 24. — DR. CRESWELL BABER'S NASAL SPECULTTM.

wires, kept in position by a band passing round the head.
Spencer Watson3 employs a modification of Noyes's eye
speculum attached to a frontal band worn by the patient.
I do not think, however, that either of these instruments
is so convenient as Frankel's. Thudichum's speculum
(Fig. 25) consists of two flat blades united together, and
at the same time kept apart by means of a piece of elastic

FIG. 25. — DR. THUDICHUM'S NASAL SPECULUM.

wire. The objections already mentioned in speaking of
Good willie's instrument apply to that of Thudichum; be-
sides which, it so often hurts the patient that I have 'now
quite given up its use.

1 Bosworth : "Diseases of the Throat and Nose." New York,
1881, p. 23.

2 " Brit. Med. Journ." 1881, vol. i. p. 55. The instrument is made
by Messrs. Wright, of 108, New Bond-street.

3 "London Specialist." 1880, vol. i. No. 1.

240

M>I-:.\SK>

THI-: mn".\r AM> M>SI:

For examining the deeper parts of the nose Dujilay's
speculum, which is a hollow cone-shaped l.ivahv instru-
ment (Fig. 26 A), is of the greatest service. The two

blades of the instrument are slightly flattened, so that
the distal end is somewhat beak-shaped, but the inner

RHINOSCOPY.

241

blade (intended to be applied against the septum) is more
flattened than its fellow. The outer blade is movable in
the distal four-fifths of its length, and when pulled open
is fixed in position by means of a running screw (Fig. 26 A,
e and e'). Its full size is shown in Fig. 26 A, and no larger
instrument is ever required, and can seldom be tolerated.
It will be seen that the blades open very widely.

Schuster, of Aix-la-Chapelle, has modified Duplay's
speculum by employing a fixed instead of a running screw
(Fig. 26 B). The instrument is rather too large, and yet
does not open so widely as Duplay's ; but the blades can be
opened more gradually, and are thus less likely to hurt the
patient. Voltolini (Fig. 26 c) has also modified Duplay's
arrangement for opening the speculum, by adapting a rack
movement to it, but I have not found tliis at all convenient,
and the instrument is apt to cause a good deal of pain.
Massei l again has varied Duplay's speculum, by fenestrating
one of the blades, and under some circumstances this instru-
ment is very useful.

Elsberg has invented a trivalve speculum (Fig. 27) by

FIG. 27. — DR. ELSBERG'S TIUVALVE NASAL SPECULUM.
A, the instrument closed ready for introduction. B, the instrument expanded.

means of which the interior of the nose can be thoroughly
inspected. The three blades are separated by closing the
handles, or may be more gradually separated by means of a
screw in the shank of the instrument. This speculum
however, has the disadvantage of not being self-retaining,

1 "Malattie del tratto respiratorio." Napoli, 1882, p. 178. The
instrument was described and figured in a paper read before the
Royal Med.-Chir. Society of Naples on the 30th May, 1875.

VOL. II. R

242

DISEASES OF THE THROAT AXD XOSE.

and though I occasionally use it, I much more frequently
employ one of those previously descrilxjd Schnitzk-r *
recommends Roth's modification of Kramer's aural instru-
ment further altered by the fenestration
Qof each blade.
For examining the posterior wall of the
l)narynx an(l ^ne neighbourhood of the
Eustachian tube Zaufal's funnel (Fig. L'^)
is very useful. The instrument is well de-
i scribed by its name, as it is nothing more
than a perfectly cylindrical metallic tube,
widening at its proximal end into a funnel-
shaped mouth. The length of the cylin-
drical portion of the speculum is from six to
eight centimetres, that of the funnel is three
centimetres, and total length of the instru-
ment being therefore from nine to eleven
centimetres. The diameter of the proxi-
mal end is about two centimetres. The
instrument is made in five different sizes,
the smallest one (called No. 3) having a
diameter of three millimetres at its distal
extremity, the next (No. 4) a diameter
of four millimetres, and the others hav-
ing diameters of five, six, and seven mil-
limetres respectively. There is no canula
with a diameter of either one or two mil-
limetres, as the lumen of such instruments
would be too small to permit of satis-
factory observation. -The range is there-
fore from No. 3 to No. 7, lx»th numbers
inclusive, and of these Zaufal himself
most frequently employs Nos. 6, 5, and 4.
The interior of the funnel-shaped mouth
is blackened, whilst the cylindrical portion
of the instrument has a polished inner
surface. Zaufal at first used a pilot sound
ZAUFAL'S FUNNEL, for passing the speculum through the nose,
6 shows the size most but has now discarded this. It may be
frequently used ;« and atided that he employs the instrument

c are sections of tubes « •« -,• • i

of smaller and larger not only for diagnostic, but also for ope-
rative, purposes. In the latter case he
chooses, if possible, the largest tube, which serves, in fact,
1 " Laryngoscopie und Rliinoscopie." Wien, 1879, p. 59.

RHINOSCOPY. 243

as a canula through which he introduces tube-forceps or
snares. I have used Zaufal's funnels in a good many in-
stances, but more for the purpose of experiment than with
a clinical object. I have, however, fully convinced myseli
of the possibility of making observations in a considerable
proportion of cases. Voltolini,1 though strongly objecting to
Zaufal's instruments, has latterly made use of short funnels
varying in length from four to seven and a half centimetres
with a lumen of from five to eight millimetres. In connec-
tion with these he employs Brunton's otoscope.2

Illumination. — For anterior rhinoscopy a good light is
required. Sunlight may be employed if it is available, but
as this is unfortunately rarely the case in this country, it is
better to have some artificial means of illumination. Any
of the arrangements for this purpose, which have been already
described (see Vol. i. pp. 218 — 224), may be used.

THE APPLICATION OF ANTERIOR EHINOSCOPY.

The operator should wear a perforated concave reflector
supported by a spectacle frame or frontal band (Vol. i.
p. 218), whilst the patient should sit upright opposite
him. A good lamp being fixed near the patient's head or
the same side as that on which the surgeon wears the
reflector, and the nose being tilted up, the vestibule comes
into view. This is an irregularly oblong cavity, the outer
wall of which (corresponding to the lower two-thirds of the
lateral cartilage) extends farther back than the inner, which
is formed by the inner returning portion of the lateral car-
tilage. This space is lined with common integument, and
on it grow numerous short coarse hairs, which protect the
entrance of the nose. At the upper end of the vestibule is
the opening of the anterior nares, the inner, upper, and
outer borders of which are sharply defined. On introducing
a speculum and separating its blades, the interior of the
nostrils comes into view, together with the anterior extre-
mity of the inferior turbinated body and a part of the
cartilaginous portion of the septum. If the patient's head
be very slightly bent forwards, the observer can trace the

1 "Rhinoscopie und Pharyngoscopie." Erste Halfte, p. 81.

- This instrument consists of a metallic tube provided with an eye-
piece. Into this tube a funnel opens at right angles, through which
the light is made to fall on a perforated reflector, which throws the
rays through the distal part of the cylinder into an ordinary ear
speculum.

244 DISEASES OP THE THROAT AND NOSE.

inferior turbinated body backwards, its outer convex surfare
ami lower border being often visible throughout. Between
the free edge of this body and the floor of the nose is the
inferior meatus, the height of which is rather less than tin-
distance between the upper and lower borders of the inferior
turbinated body. A ray of light can generally be projected
into the anterior half of the inferior meatus, but seldom
beyond this point ; and not unfrequently, owing to a slight
twist inwards of the front part of the turbinated body,
especially at the point where its anterior and inferior borders
meet, only the anterior fourth of the lower meatus is visible.
On inclining the patient's head backwards, the lower border
and the inferior portion of the inner convex surface of the
middle turbinated body come into view, whilst a small por-
tion of its outer concave part can sometimes be seen. The
superior turbinated body can occasionally be observed quite
at the back and near the vault of the nose, but this is the
exception. I have never been able to distinguish the superior
meatus from the front. If the patient throws his head very
much forwards, the floor of the nose can often be followed to
the posterior extremity. It is almost always uneven, and
frequently presents small irregularly rounded eminences.

The septum can generally be seen, except its upper sixth
and posterior eighth. The partition, as already stated (see
Anatomy) is seldom quite symmetrical, being often slightly
convex on one side, and correspondingly concave on the other.
Even when the septum is straight, irregular projections
are often seen, especially at the lower and back part of the
vomer. Small exostoses can also often be perceived at the
angle where the perpendicular plate of the ethmoid, the
vomer, and the cartilage of the septum meet one another.

The colour of the lining membrane of the nose varies in
different situations. The anterior border of the inferior
turbinated body is, as a rule, bright red, and its inferior
convex border is mostly of the same hue. The lower border
of the middle turbinated body is generally quite pale, and is
indeed less vascular than any other portion of the lining
membrane of the nose. The floor of the nasal fossa is of a
dull red colour, whilst the surface of the mucous membrane
covering the septum is pale red.

On looking directly through the nose whilst the patient's
head is inclined slightly forwards, the posterior wall of the
pharynx can sometimes be seen ; and on directing him to
swallow, the cushion of the Eustachian orifice may l»e

RHINOSCOPY.

245

observed to move upwards. A better view, however, of the
posterior wall and Eustachian orifice can be obtained with
Zaufal's funnel.

FIG. 29. — THE EUSTACHIAN ORIFICE AS SEEN FROM THE FRONT
(AFTER ZAUFAL).

A, the orifice at rest. B, the orifice as seen in deglutition and in certain acts
of articulation. So, Eustachian orifice. EC, Eustachian cushion. R/, Bosen-
miiller's fossa.

MEDIAN RHINOSCOPY.

Wertheim1 first suggested the idea of passing into the
nose a small tube provided with a steel mirror directed
upwards, and a corresponding fenestra at its end, like Avery's
laryngoscope, and to this instrument he gave the name of
" conchoscope." In order to prevent the mirror from becoming
soiled by mucus on its introduction into the nose, Voltolini
provided the fenestra with a small shield which could be
drawn back by means of a thread when the instrument was
in position. Voltolini also substituted glass for steel in the
mirrors.

The illumination recommended for anterior rhinoscopy is
equally applicable to the median method, but the mode of
examination itself is seldom of any practical advantage. I
may mention, however, that by this plan I once succeeded
in obtaining a view of a small polypus situated just above
the anterior extremity of the middle turbinated body, which
could not be brought into view by any dilating speculum.

1 " Ueber eiu Verfahren zum Zwecke cler Besichtigung des vorderen
und mittleren Drittheiles der Nasenhohle." " Wien. med. Wochen-
schrift." 1869, Nrs. 18, 19, 20.

POSTERIOR RHINOSCOPY.

History. — The idea of examining the posterior nares by placing a
mirror at the back of the mouth, with its reflecting surface directed
obliquely upwards, appears to have occurred to Bozzini,1 Baumes,2

1 " Der Lichtleiter, oder Beschreibung einer einfachen Vorrichtung, und ihrer
Anwendung zur Erleuehtung innerer Hohlen, und Zwischenraume des lebenden
Hiiinialischen Korpers." Weimar, 1807.

^ " Compte-remlu des Travaux de la Soc. de Med. de Lyon." 1836-38, p. 62.

246 DISEASES OF THE THROAT AND NOSE.

and others ; but the practical application of the method is un-
doubtedly due to Czermak,1 and the art of rhinoscopv dates from a
•paper published by him in "August, 1859. In the following
Semeleder2 made some remarks on the subject, and later on* he
brought out a small work which contained many useful dircctinns tor
rhinoscopy, a number of very interesting cases, and some beautiful
coloured illustrations. Soon after the ap]>earance of Semeleder's first
paper, articles were published by Stoerk,^ Tiirck,5 and Voltolini.6 T<-
the last-named writer, however, is due the credit of systematically
working at the subject for many years, and of having produced
the most valuable treatise7 on rhinoscopy that has yet appeared.

' Wien. med. Wochenschrift," Aug. 6, 1859.

't'eber die I'ntersiichuiigen des Nasenrachenraumes." "Zeitschr. d.
Oesellsch. d. Aerzte zu Wien." I860.

' Die Rhinoscopie imd ihr Werth fur die Srztliche Praxis." Leipzig, 1862.

' Rhinoscopie." " Zeitschr. d. Geaellsch. d. Aerzte zu Wien." I860. \r. 26.

'Beitrage zur Laryngoscopie und Rhinoscopie." "Zeitschr. d. Gesellsch. if.
Aerzte zu Wien." 1860, Xr. 21.

6 " Die Besichtigung der Tuba Enstachii und der Ubrigen Theile des Cavum
pharyngonasale mittelst des Schlundkopfspiegels." " Deutsche Klinik," 1860,
Nr. 21.

7 " Rhinoscopie und Pharyngoscopie." Brealau, 1879.

The Rhiiud Mirror. — A small laryngeal mirror answ-rs
the purpose very well. Its reflecting surface should not In-
more than 1^ centimetre (|-mch) in diameter. An excellent
rhinoecopio mirror has been invented by "W. C. Jarvis, of

FIG. 30. — DR. JAUVIS'S COMBINED TONGUE DEPRES.SOK AND
POST-NASAL MIRROR.

a, the shank of the mirror ; 6, screw by which the shank is fixed to handle ;
e, descending anu of shank ; d, spring-joint at which the mirror can be fixed
at any angle desired. The handle of the instrument can either be continued
in the same line of the shank by fixing at a, or it can be secured at an angle by
screwing it to c, as in the woodcut. The expanded portion of the shank acts aa a
tongue-depressor.

New York (Fig. 30), which combines a mirror and tongue-
spatula in the most simple and convenient manner. Frankel

RHINOSCOPY. 247

has devised an instrument in which the mirror is hinged
on to the shank, and this again is fixed at nearly a right
angle to a wooden handle (Fig. 31). By pushing forward

FIG. 31. — FRANKEL'S POST-RHINAL MIRROR.
a, the hinge ; b, the running bar.

a little bar acting on the hinge the angle of the mirror can
be changed after its introduction. Michel1 has also invented
a rotating mirror, in which the movement of the glass is
rapidly effected by a spring in the handle of the instru-
ment. The disadvantage of this arrangement is that the
mirror has to be kept in the desired position by the con-
stant pressure of the thumb on the spring. I may repeat,
moreover, in connection with these various rhinoscopes, tliat
I find the ordinary small-sized laryngeal mirror answer every
purpose.

Palate Hooks, — The uvula, often causes an impediment to
posterior rhinoscopy, and various devices have been suggested
for the temporary removal of this obstruction. The first
instrument invented for this purpose was the palate hook
of Czennak. This instrument2 (Fig. 32 c) consisted of a

1 "Die Krankheiten der Nasenhohle. " Berlin, 1876, p. 9.

2 "Der Kehlkopfspiegel and seine Yerwerthung fiir Physiologic
und Medizin." Leipzig, 1860.

248

DISEASES OK THE THROAT AND XO8E.

metal rod about four inches in length, one end of which was
fixed into a wooden handle, whilst the other was widened
towards the distal extremity and terminated in a short blunt
right-angled hook a quarter of an inch in length. C/ermak
remarks that the size and curve of the hook must vary accord-
ing to the proportion of the pails. The vali f an instru-
ment of this kind is strongly insisted on by Voltolini,1 who
uses a much larger hook provided with two small wings
attached to the distal extremity of the shank, just lief on- the
bend (Fig. 32 A). The object of these wings apiiears t" be to

FIG. 32. — PALATE HOOKS.
A, Voltolini's palate hook ; B, Fraukel's palate hook ; c, Czenuak's palate hook.

form a kind of spoon-shaped cavity which supports the uvula
in the middle line, thus keeping it from obstructing the view.
An instrument of intermediate size and fenestrated at the up-
turned part of the blade is used by Frankel (Fig. 32 B), who
also occasionally employs an instrument combining a gag. a
tongue-depressor, and a groove to hold his palate-hook. But
it is very seldom that such instruments, however ingi-nious,
can be successfully employed, and I may remark that I
rarely use even a simple hook.

Voltolini,2 who, as already remarked, is a strong advocate
of the palate hook, attaches great importance to his mode
of using it, which he describes in the following terms : —
" With the index finger of the left hand the patient's tongue
should be strongly depressed, and then, without any cere-
mony or preparation, the hook having been boldly and

1 "Rhinoscopic uml Pharyngoscopie."

2 Op. cit. pp. 17, 18.

1879, p. 17.

RH1NOSCOPY.

249

quickly passed high up behind the uvula, even to the pos-
terior nares, should be drawn forcibly forwards." J Vol-
tolini states that he has never met with a patient who
could not bear the application of the hook in this way,
and he affirms that the uvula yields better to a "forcible
grasp than to tender or timid handling." He then proceeds
to quote Lb'wenberg, Monro, Michel, and myself, to show
that we all teach that the hook should be used gently, and
that we consequently fail to appreciate its value. Voltolini
maintains that most practitioners have overlooked the physio-
logical law that a slight irritation causes more reflex action
than strong pressure ; and he also urges that when his hook
is used the soft palate has less power of resistance, the
muscles, as it were, losing their point of leverage.

Fio. 33.

VfJLTOLINl'S UVULA-NOOSE.

Fio. 34.
THE AUTHOR'S UVULA-SWITCH.

OtluT Instruments for Drawing the Uvula Forwards. —
Instead of using a hook, Turck 2 suggested that the uvula

1 Op. cit. p. 17.

2 " Prakt. Anleitung zu Laryngoscopie. " Wien, 1860, p. 65.

250 DISEASES OF THE THHOAT AND M •<!•;.

should be held with miniature calculus-forceps. He
devised for the same purpose a running noov. <•<. nesting
of a piece of string passed through a tube. Y<>lt<>lini '
modified this somewhat by fixing one end of the string
inside the tube (Fig. 33). I have always, however, found
it exceedingly ditticult to apply this apparatus, but have
occasionally employed a "twitch" (Fig. 34), consisting of
a small piece of string threaded through the end of a
rod four or five inches in length. With this the uvula
can be readily caught, and a few twists of the shank
will enable the operator to hold the part in any position
that he may desire, without crushing or pulling it with
undue violence. Dr. Lori, of Buda-Pesth, has invented an
instrument, resembling a paper-clip, which has been further
improved by Voltolini.2 It is rather more than three centi-
metres in length, and to its handles threads are attached,
the ends of which pass through the patient's mouth,
and can be fastened round one of the ears. Stoerk 3 pro-
posed to pull the uvula forwards by means of a silk ribbon
passed through the nose, and brought out through the mouth.
The nasal and buccal ends are then tied together, and given
to the patient, who, by gently pulling, endeavours to draw
the velum forwards and upwards. This plan is open to the
obvious objection that the soft palate, instead of being
drawn directly forwards, is tilted sideways. Surgeon-General
Wales,4 of the American Navy, improved this method by
suggesting the use of an elastic tractor, consisting of an
india-rubber cord, about two millimetres in diameter. This
should be not less than eighteen inches in length, and one
end should be carried through each nostril into the pharynx
with the help of Bellocq's sound or a gum-elastic catheter.
Each end, as it appears below the soft palate, should !»•
seized with the finger or with forceps, and drawn out

1 Op. cit. p. 10. 2 Op. cit. p. 12.

3 Oj>. cit. p. 95. It may be mentioned that Desgranges ("Gaz.
Hebdom." 1854, p. 647) proposed a similar method of eiuarginj; tin-
lower opening of the naso-pharynx, and Palasciano actually put it
into practice a few years later ("Bericht der Naturforscherversanmi-
lung in Carlsruhe im Jahre 1858 "), but in each of these cases the
object was to open a wider way for digital examination of naso-
pharyngcal growths. Stoerk was, so far as I know, the first who had
recourse to such a means of controlling the velum for rhinoscopic
purposes.

4 "New Method of Rhinoscopic Exploration." Washington,
1877, p. 7.

RHIXOSCOPY. 251

through the mouth. The middle part of the cord is thus
fixed by the lower part of the septum in front, and by
pulling gently on the free ends which pass through the
mouth it will be found that the velum can be drawn for-
wards to any extent that may be desired. The ends may
be held by an assistant, or may be tied round the patient's
head. I have tried this method of enlarging the naso-
pharyngeal space for the purpose of rhinoscopy with some
success, but the passage of the cords through the nose into
the pharynx is highly disagreeable to the patient, and their
contact with the mucous membrane often increases the
natural irritability of the parts. Indeed, in addition to
the " gagging " which is thus caused, a flow of secretion
is sometimes excited, which seriously interferes with the
examination. Jarvis, of New York, uses two elastic cords,
which are passed through the nose and drawn out by the
mouth in the manner just described, but they are fixed
over the upper lip by means of clips provided with a small
upright plate grooved on the upper edge so as to serve as a
support for the stem of a snare or other instrument which it
is desired to use within the nose.

In order to set free one of the operator's hands, the mirror
and palate hook have been combined together by Stoerk,1
Baxt,2 and Duplay.3 I cannot say, however, that I have
found any advantage from this combination.

Tongue Spatidas. — I seldom employ any instrument for
depressing the tongue, but occasionally a spatula may be
required. Under these circumstances the instruments of
Tiirck or Frankel, in which the ordinary tongue-spatula is
fitted to a long vertical handle, to be held by the patient
well out of the way of the operator, will be found the most
convenient.

THE APPLICATION OF POSTERIOR KHINOSCOPY.

The examination should be conducted as follows : —

The operator should place himself opposite the patient,

who must be seated in an upright attitude, with his head erect

or bent slightly forwards, the lamp being in the same position

as in laryngoscopy. The patient should be directed to open

1 " Zur Laryngoscopie." Wien, 1859, p. 20.

a " Berlin, klin. \Vochenschrift." 1870, No. 28.

3 "Traite Elem. de pathol. externe." Paris, 1877, t. iii. p. 752.

252

DISEASES OF THE THROAT AND NOSE.

his mouth widely, and the light should he made to fall rather
lower in the fauces than when it is desired to examine the
larynx. The rhinal mirror should then be carried to the
back of the throat, its upper border being a little below the
curtain of the palate, and its face directed upwards, so as to
form an angle of about 135° with the horizon. If the uvula
happens to be drawn upwards and backwards, as is often tin-
case, the patient should be told to expire gently, or to pro-
duce some nasal sound, such as hany. Straining and forced
inspiration must be especially avoided. It is sometimes
necessary to depress the tongue with a spatula, but the shank
of a rhinal mirror generally answers sufficiently well.

It is a good plan to pass the small mirror between the
anterior pillar and the uvula on one side first, and then
to withdraw it and introduce it again in the same manner on
the opposite side. By slanting the mirror a little laterally

FIG. 35. — POST-RHIXAL IMAGE.

». superior turbinated body ; m. middle turbinated body ; f. inferior tur-
binated body ; e.e. Eustachian cushion ; e.o. Eustachian orifice ; tt.r. uvula-
cushion ; u. uvula ; s.ph.j'. salpingo-pharyngeal fold ; s.pj. salpingo-palatine
fold.

the posterior comers of the naso-pharynx with the orifice of
the Eustachian tubes and the folds which bound them come
into view ; the vault of the pharynx is seen when the mirror
is nearly horizontal. When the glass is held in a nearly per-
pendicular position, the upper part of the arching posterior
wall of the pharynx can be perceived, but the laws of per-
spective reduce this view to the narrowest limits. To inspect
even one side of the naso-pharynx thoroughly, however, it
is often necessary to introduce the mirror several times, and
to turn its reflecting surface in different directions ; hence
the post-rhinal image (Fig. 35) is a compound picture made
up of many limited views. In the middle the septum is

RHINOSCOPY. 253

seen forming a thin projecting partition between the choanse,
slightly thicker above and below than in its central por-
tion. The most conspicuous objects are the middle tur-
binated bodies, which appear as two pale oblong tumours
extending downwards and inwards from the outer walls
towards the septum, and occupying the middle third of the
choanae. Above the middle turbinated bodies the superior
ones are seen as small, greyish, horn-shaped projections
running in the same direction as those just below them but
not extending so far inwards. At the bottom of the nasal
fossae the inferior turbinated bodies appear as two pale,
rounded, solid-looking prominences, redder in colour than
the middle turbinated body, and somewhat nearer the
septum. The meatuses, as might be expected by those
acquainted with the anatomy of the parts, are not very
distinct. The superior meatus, though actually the smallest
and most shallow, sometimes appears, owing to the upper
turbinated body being so little developed, as the largest.
The middle meatus can generally be made out, but the
lower one is either not visible at all or appears only as
a narrow slit below the turbinated body and close to the
septum. On the outer wall of the naso-pharynx the yellow
orifice of the Eustachian tube can be seen, bounded by
the salpingo-palatine fold on its inner, and the salpingo-
pharyngeal fold on its outer side ; the base of the opening
being formed by a projection, described by Zaufal as the
" leva tor-cushion." External to the salpingo-pharyngeal fold
is Rosenmuller's fossa. Beneath the septum the base of the
uvula containing the azygos muscle forms a slight projec-
tion, called the " uvula-cushion." When the mirror is held
obliquely so that its reflecting surface approaches the hori-
zontal position, the vault of the pharynx comes into view,
and at its anterior part a number of pale pink elevations
and depressions are seen together, constituting a small irregu-
lar body of adenoid tissue, known as Luschka's tonsil (see
Anatomy, Vol. i. p. 2). Quite in the centre of this there
is often an opening, which has been called the mouth of
this gland, but is really a small spot free from gland tissue.
Behind this tonsil the smooth greyish surface of the vault
of the pharynx with its median raphe is sometimes visible.

-"'1 DISEASES OF THE THROAT AND NOSE.

POSTERIOR RHINOSCOPY BY DOUBLE REFLECTION.

Voltolini l has suggested the use of two mirrors for posterior
rhinoscopy, more especially with the object of obtain!;
good view of the Eustachian orifice. One mirror with a
long curved shank bent at a right or even a slightly acute
angle is passed well up into the naso-pharynx, close to its
posterior wall, in such a way that the reflecting surface is a
little above the level of the choanae ; whilst a second mirror
is introduced in the usual manner, but its reflecting surface is
kept in a somewhat more horizontal position, so that instead
of directly receiving the image of the posterior nares it
receives a secondary image, first formed in the upper mirror.
In employing these mirrors the uvula has to be held forwards
by some of the special arrangements already described.
This method is so complicated and so rarely capable of
application that it requires only a passing notice. Voltoliai
has, however, reported one case 2 in which, by using two
mirrors, he was able to see the Eustachian orifice, into which
a catheter had been previously introduced.

Auto-Rhinoscopy, Magnifying Mirrors, fyc, — The obser-
vations which have been already made upon the kindred
subject of Auto-laryngoscopy (see Vol. i. pp. 224 and 237)
apply equally here.

NASAL INSTRUMENTS.

Nasal Probes. — Useful information as to the condition
of the mucous membrane, the attachment relations and
density of growths, the presence of exposed surfaces of bone
and various other matters can often be obtained by examining
the interior of the nose with small probes. These instru-
ments may be either straight or slightly hooked at the end,
the curved portion being somewhat broad and flat, and, of
course, blunt at the edge. Nasal probes, in fact, resemble
those recommended for the larynx (Vol. i. Fig. 26, p. 243),
as regards the distal extremity, but the stem is straight, and
is fitted into a handle, at an angle of about 135°.

Nasal Bougies. — These are useful, both for purposes of
diagnosis and of treatment. They are made of gum-elastic
or vulcanite, and are from three to four inches in length.
They may be round, or slightly flattened from side to side

1 "Die Rhinoscopie, &c." 1879. 2 Op. cit. p. 179.

NASAL INSTRUMENTS.

255

like the cesophageal bougies (see p. 11), and I generally find
six sizes sufficient, viz., from three to eight millimetres
in the short transverse diameter, i.e., from one flattened sur-
face to the other. It greatly facilitates the use of these
instruments if they are probe-pointed. In introducing the
bougie the flattened sides are, of course, directed towards the
septum and the outer wall of the nasal fossae respectively.

Shields. — In applying strong caustics, or in using the
electric cautery within the nose, shields are sometimes
required to protect the healthy parts from injury. Shurly,1
of Detroit, has invented two instruments for this purpose.
One of them (Fig. 36) is a modification of the nasal dilator,

FIG. 36. — Dn. SHURLY'S NASAL SHIELD.

At the points x and z the blade and plate can be reversed. The instrument can
thus be made applicable for either nasal passage. As a rule it is for the purpose
of protecting the septum whilst the operator is making applications to growths
on the turbinated bone, that the ivory plate is required.

or speculum, one blade being replaced by an ivory plate.
The other instrument consists of an ivory plate, which is
passed into the nasal fossa, and a wire spring attached to it,
which is applied to the ala of the nose externally. Both
these instruments are occasionally useful, but if it be possible
to dispense with them it is desirable to do so, as any shield,
however well made, impedes the view and diminishes the
space available for manipulation.

Insufflators. — For the application of remedies in the form
of powder, the tube-insufflator (Vol. i. Fig. 39, p. 251) may
1 " St. Louis Mecl. and Surg. Journ." Jan. 5, 1880.

256

DISEASES OF THE THROAT AND NOSE.

1)C used, or the patient can apply the powder himself, by

of Bryant's auto-insufflator.1 This consists of a bent tube,

provided at one part with a corked opening for receiving the-

Fio. 37. — MR. BRYANT'S AUTO-INSUFFLATOI:.

powder. The instrument having been charged, the patient
puts one end of the pipe in his mouth and the other up
his nose, when, by gently blowing, the powder is driven
into the nasal fossa. Andrew Smith has constructed an
insufflator on the model of the hand-ball spray-producer,
which can be used either for the anterior or the posterior

FIG. 38. — DK. ANDREW SMITH'S INSI-FKLATOU.
A shows the nozzle required for the posterior nares ; B, that for the anterior.

nares. It consists of a glass bottle, with an india-rubber
stopper which is perforated to allow the passage of two
tubes. One of these reaches but a short way into the
bottle, and is connected outside with an ordinary elastic
hand-ball, by means of a piece of flexible tubing, the other
almost touches the bottom of the bottle, whilst its free
portion is straight, and somewhat bulbous at the end, or
when intended for post-nasal use, longer, and curved upwards
and slightly backwards, as shown in the cut (Fig. 38 A).
The receptacle being partially filled with powder the ball
is squeezed once or twice, when a small quantity of the

1 "Practice of Surgery." London, 1872, 1st ed. p. 124.

NASAL INSTRUMENTS. 257

contents of the bottle will be forced out through the nozzle.
Clinton Wagner has lately brought under my notice a still
more simple and handy apparatus, in which a test-tube takes
the place of the bottle above described.

Brushes. — For the application of remedies to particular
spots in the front part of the nasal passages a fine brush
tixed to a handle at a suitable curve is often serviceable.

FICJ. 39.— NASAL BRUSH.

This instrument shows the angle at which all nasal
instruments should be bent.

For the posterior nares and naso-pharynx the laryngeal
brushes Nos. 1 and 2 (Vol. i. p. 244) answer every purpose.
Caustic Holders. — Some caustics can be applied with the
brush just described, and nitrate of silver may be conveniently
used by simply fusing it on a metal rod (Vol. i. p. 252) ;
but various instruments have been invented with the view
of protecting the contiguous parts from the action of the
caustic. A very useful instrument for the application of

FIG. 40. — PROF. SCHROTTER'S PORTE-CAUSTIQUE
(AFTER BEVERLEY ROBINSON).

the solid nitrate of silver has been devised by Schrbtter.
It consists of a long grooved probe, provided with a turning
shield, which covers the groove, into which the nitrate of
silver is fused. The instrument should be introduced closed
to the part which it is desired to cauterize, when the shield
is turned aside, and the caustic brought into contact with
the tissue to be destroyed.

For applying strong nitric acid and similar escharotics

VOL. II. 8

•_'.">* DISEASES OF THE THROAT AND NOSE.

Andrew Smith's instrument, which has been somewhat
modified and improved by Beverley Robinson (Fig. 41), is
very useful. It consists of a grooved director, mad'
vulcanite, and bent at a suitable angle. Into the groove
a slender steel wire, armed with cotton-wool, is introduced
a short way, and a few drops of acid are placed on the
exposed surface of the wadding. The. whole instrument,
after being oiled, is then passed into the nasal fossa, and the
wire rod carried along the groove as far back as may be
desired. On withdrawal of the wire any excessive action of

FIG. 41. — DR. ANDREW SMITH'S MODIFIED CAUSTIC HOLDEI:.

the caustic is neutralized by the passage of a similar wire,
the wadding of which has been steeped in a solution of
bicarbonate of soda. A more simple method is that recom-
mended by Harrison Allen,1 who employs a tapering rod
of soft iron, slightly roughened at the distal end, for the
more secure attachment of a pledget of cotton-wool, whirh
is wound round it. The proximal extremity of the rod is
fitted into a wooden handle. The rod may be bent to any
shape that may be wished, and the cotton-wool can be soaked
with any solution that is thought desirable ; the instrument
should be introduced into the nose through a speculum.

Hand Washes. — These require no apparatus, the medicated
liquid being drawn up into the nose from the hollow of the
hand. A small quantity of tepid water, in which chlm-ide
of sodium, carbonate of soda, or some other medicament ha-
been dissolved, is used in the manner described, and when it
comes into the mouth is spit out. Rumbold,2 of St. Louis,
has shown that the direction which fluids take in passing
through the nose depends on the position of the patient's
head. In order, therefore, that the wash may reach all
parts of the nasal cavity the patient, whilst sucking up tin-

1 " Amer. Journ. Med. Sci." New Series. No. clvii. 1880, p. 62, ft
- " Hygiene and Treatment of Catarrh." St Louis, 1880, part i.

NASAL INSTRUMENTS.

259

fluid through the nose, should be enjoined first to bend his
head forwards and downwards, then to keep it in a nearly
erect position, and finally to throw it as far back as he is
able whilst drawing up the medicated liquid.

Douches. — The douche, or irrigator, was introduced by
Thudichum,1 who first applied Weber's 2 discovery that the
nasal channels act as two arms of a syphon, when the
mouth is kept open. Thudichum's original instrument con-
sisted of a piece of india-rubber tubing, about four feet in
length, provided at one end with a perforated weight, and at

FIG. 42. — NASAL DOUCHE.

Elastic tubing terminating at a in a hollow metal weight, and at c in a nozzle,
whilst at & is a metal or vulcanite shoulder, fitting loosely, so that it can be run
along the tubing, a, the metal piping is placed at the bottom of a bottle or jug
containing tepid saline water ; 6 rests on the edge of the vessel ; and c passes
into the nose of the patient. In order to start the current, suction must first be
made at the nozzle.

the other with an appropriate nozzle for passing into the
nostril. The weighted end of the tubing is put into a vessel!
containing the medicated liquid, and the latter is placed on
a shelf a little above the patient's head. On starting the
flow by suction at the nozzle, and placing the instrument in
the nose, the fluid will run in a continuous stream until it
is exhausted. This instrument has since been somewhat
improved (Fig. 42) by the addition of an arm of vulcanite
or metal, to cover the tube where it passes over the edge of
the vessel, an arrangement which prevents the tubing from
being pressed upon, and dispenses with the necessity of a
weight.

The Parson's douche is a still more perfect instrument,

1 " Lancet," Nov. 24, 1864.

2 " Miiller's Archiv." 1847, pp. 351-354.

260

DISEASES OF THE THROAT AND NOSE.

being provided with an elastic ball, by means of wlm-h tin-
flow can be started, and a tap by which the stream can l»c ;it
once shut off.

FIG. 43. — THE PARSON'S NASAL DOUCHE.
a, elastic hand-ball ; 6, tap ; <•. nozzle.

About a pint of water at a temperature of 90° Fahr. should
be used, one drachm of chloride of sodium or carbonate of
soda having been first dissolved in it. A few years ago irri-
gators were tried on a very extensive scale, but the observa-
tions of Koosa,1 of New York, and others, showed that fluids
introduced through the nose occasionally pass into the Kus-
tachian tube, and excite severe inflammation of the middle
ear. The accident is most likely to occur from the fluid brin.^
driven through the nose with too great force, or from the
patient swallowing whilst using the instrument Comin»n
salt is ordinarily employed for the purposes of irrigation, but
Weber-Liel2 has found that carbonate of soda is less likely
to produce a serious result, should any fluid find its way
into the middle ear. Solis Cohen,3 who strongly insists on
the value of this method of treatment, has noticed that the

1 "Arch, of Ophthal. aiid Otology," vols. i. ii. and iii.

2 "Deutsche Zeitschr. f. prakt. Med." 1877, No. 30.

3 "Diseases of the Throat, &c." 2nd ed. p. 360.

NASAL INSTRUMENTS. 261

accident generally occurs when cold, instead of warm water,
is used ; and he calls attention to the fact that Cassels has
tried it in 1,500 cases, without ever having seen or heard
of an untoward result. I do not employ irrigation nearly so
frequently as formerly ; not because I have noticed any
injurious effects from it, but because I have obtained equally
good results from sprays, which, as a ride, are much less
disagreeable to the patient.

Spi'ay Producers. — There are a great variety of these in-
struments, most of those already described in connection
with laryngeal disease (Vol. i. pp. 246, 247) being also service-
able in affections of the nose. As a rule, however, it is

FIG. 44. — ANTERIOR NASAL SPRAY PRODUCER.

Though a reserve ball for continuous spray is shown in the cut, one ball is
quite sufficient.

best to use an apparatus, the nozzle of which can be passed
some distance into the nasal fossa. Two kinds of spray-
pxoducers are required, viz., the anterior and the posterior.

The ordinary anterior nasal spray-producer (Fig. 44)
consists of a silver pipe about three inches long, terminating
in a fine perforated point, and provided with a piece of
tubing and an elastic hand-ball.

262

I'l.-I'A-KS OK TIIK THROAT AND N<>sK.

The same apparatus can be used for the posterior
but the tube carrying the medicated liquid should pass in a

FIG. 45. — POSTERIOR NASAL SPRAY- PRODUCER.

nearly horizontal direction from the bottle, and its extremity
should be directed upwards and slightly backwards (Fig.
45). Lefferts prefers a conical nozzle (Fig. 46) which
accurately fits into the nostril, and thus prevents any

FIG. 46.

DR. LEFFERTS'S NASAL SPRAY-PRODUCER WITH CONICAL NOZZLE
(AFTER BEVERLEY ROBINSON).

return of the medicated fluid. Owing to the prevalence of
catarrh of the naso-pharynx in America, and the necessity
of thoroughly cleansing that cavity when diseased, great
attention has been given by physicians in the United States
to the subject of spray-producers, and both the air-pump and
water-power have been brought into requisition to give force
and steadiness to the spray. The most convenient pneumatic
spray-producer is that of Livingston (Fig. 47). It consists of
an outer cylindrical chamber resting on a broad iron stand,
and provided with an air-pump and pressure-gauge, the tube
of which can be shut off from the air-chamber when desired.

NASAL INSTRUMENTS.

263

264 DISEASES OP THE THROAT AND NOSE.

To the top of the receiver is fitted a long piece of elastic
tubing, provided with a turn-tap at its point of f-xit, which
communicates at its further end with the horizontal and per-
pendicular tubes of a spray-producer. In immediate con-
nection with these tubes, and intervening between them
and the elastic pipe of the pneumatic machine, is a little
piece of metal tube bent at a right angle, and provided with
a springe- valve which controls the communication with the
air-chamber. The perpendicular tube of the spray-apparatus
passes into a common test-tube which contains the medicated
fluid, and the operator, whilst holding the test-tube with his
fingers, can manage the valve with his thumb. The tubes
of the spray-apparatus are modifications in metal of Sass's
glass tubes, and their adaptation to the air-pump permits
the spray to be projected in any direction with an amount
of force which can be accurately regulated.

In place of the air-pump, a hydraulic arrangement can
be employed, a cistern at the top of the house supplying the
pressure. A number of test-tubes containing different medi-
cated fluids are all in communication with an air-chamber,
kept constantly full of condensed ak by the aid of the
water-pressure derived from the cistern, and the operator, at
a moment's notice, can make any spray-application desired. I
recently saw an excellent form of this ingenious arrangement
in working operation in the consulting-rooms of Dr. Cheetham,
of Louisville, Kentucky, and it seemed to me to constitute
the best method of employing sprays hitherto invented.

Inhalations. — Medicated steam inhalations used through
the nose are sometimes serviceable, although seldom so bene-
ficial as in the case of inflammation of the throat. Most of
the inhalers already described (see VoL L pp. 248, 249), un-
provided with a special nozzle adapted for nasal inhalation,
but the best instrument for the purpose is one lately devised
by Dr. Whistler.1 This consists of a vulcanite mould of the
tip and alse of the nose, from the upper surface of which
project two hollow conical pieces for insertion into the
nostrils, whilst to the under part is attached a cylindrical
chamber which, by means of india-rubber tubing, can be
made to communicate with an inhaler. The patient can,
however, use this form of medication without any apparatus
whatever, by inhaling through the mouth and forcing tin-
vapour back through the posterior nares, as is often done
by tobacco smokers.

1 "Med. Times ami Gaz." 1882, vol. ii. p. 737.

NASAL INSTRUMENTS.

265

Syringes. — For the injection of fluid through the anterior
nares an ordinary straight glass or vulcanite syringe will
serve perfectly, but for cleansing the posterior nares Solis
Cohen's instrument, which has a suitably curved nozzle (Fig.
48), will be found most useful. The point is perforated with

FIG. 48.— DR. Sons COHEN'S POST-NASAL SYRINGE.

many small holes like a rose, so that the fluid is thrown out
in all directions.

Cuttinr/ Instruments, Forceps, fyc. — For cutting away
vegetations or removing polypi, forceps or snares may be
employed. The old-fashioned forceps still commonly used
by general surgeons for the evulsion of polypi are shown
in the annexed woodcut (Fig. 49). The blades are serrated

FIG. 49. — ORDINARY POLYPUS FORCEPS.

for about half their length, and are slightly curved. This
forceps can often be employed successfully, but it is some-
what large, and the handle being in a line with the blades,
both the instrument and the operator's hand obstruct the
view of the growth.

FIG. 50. — MR. GANT'S VINE-SCISSOR FORCEPS.

Mr. Gant has invented a scissor-forceps (Fig. 50) on the
principle of the vine or flower-scissors, one edge of either

266 DISEASES OF THE THROAT AND NOSE.

blade being like that of an ordinary scissors, and the other
broad and rasped, so as to ensure firmness of grasp, and to
retain the growth after it has been divided. This instrument
may be useful when the growth is unusually hard, but it
is open to the objection already urged against the common
forceps, viz., that it obstructs the view.

The instrument which I generally use, and which in my
hands has proved thoroughly satisfactory, is my "puin-h-
forceps" (Fig. 51). The handles are placed at sue li an

FIG. 51. — THE AUTHOR'S Puxcn-FoRCEPs.1

a, small ridge or " punch," fitting, when the blades are approximated, into b, a
fenestra in the corresponding portion of the other blade ; d and e, joints where
the male and female blades can be removed and their positions reversed, or, if
desired, different kinds of blades may be substituted.

angle as to be altogether below the level of the blades, so
that the surgeon's hand in no way impedes his sight when
operating. The blades themselves are slender and open in
the vertical direction, so as to be well adapted for working
in a narrow space. The special feature of the forceps,
however, is that the lower blade carries on its surface a
small projecting bar or punch of metal, corresponding to a
fenestrated portion in the upper blade. A growth seized

1 This instrument, as well as the various others which have been
invented by the author, is made by Messrs. Mayer & Meltzer, Great
Portland-street.

NASAL INSTRUMENTS.

267

with these blades is generally cut through at once, but, if
not, the forceps can of course be used for evulsion in
the ordinary way ; or if it be desired, the blades can be
changed and blunt ones substituted.

For the removal of very small growths situated in the
upper part of the nose, the axial forceps, constructed on the
principle of Burge's cesophageal instrument, in which, whilst
the blades themselves open widely, their shanks scarcely
move, will be found useful (Fig. 52).

FIG. 52. — THE AXIAL POLYPUS FORCEPS.

Beverley Robinson has modified the ordinary polypus
forceps by making the point longer and more slender, and
providing the handles with a lock (Fig. 53). The inner

FIG. 53. — Du. BEVERLEY ROBINSON'S TOOTHED AND LOCKING FORCEPS.

a, lock by which the handles can be fixed together ; 6, separate view of on
blade showing the grooved centre and the serrated edges.

surface of the blades, moreover, has a groove along the
middle, whilst the edges on each side are deeply serrated.
This feature, combined with the locking of the handles,
gives the instrument a powerful grip, and according to
Robinson renders it very suitable for the evulsion of
hypertrophied mucous membrane.

A rotatory forceps for the extraction of polypi has been
invented by my colleague Dr. George Stoker, whereby, after
the pedicle of the growth has been seized between the
blades of the instrument, these can be fastened together
by means of a spring catch, and then twisted on their
own axis by turning a small handle. The annexed cut

268

DISEASES OF THE THROAT AND NOSE.

(Fig. 54) shows the mode of action of the instrument with
sufficient clearness.

FIG. 54. — DR. GEORGE STOKER'S ROTATORY POLYPUS FORCKI-S.

A shows the instrument open ; a, the spring catch ; b, slit through which a
passes when the blades are brought together ; c, double cog-screw, allowing the
stem of the instrument to be twisted round independently of the handle. B shows
the blades locked and partly turned round.

FIG. 55. — THE AUTHOR'S XASAL BONE-FORCEPS.

a, central pivot, through the perforated extremity of which slides 6, connected
with the handle, / ; c, upper, and d, lower blade of the forceps ; e, rest for the
operator's right forefinger.

NASAL INSTRUMENTS.

269

For the removal of portions of the turbinatecl bones and
nasal exostoses, I have had an instrument made which com-
bines the grasping power of ordinary forceps with a cutting
blade. The instrument (Fig. 55) consists of deeply grooved
blades, somewhat flattened from side to side, opening verti-
cally, and constituting a tube when closed. Each blade, in
point of fact, is a half tube, and has therefore an inner and
an outer edge. .The inner edges of each blade (those which,
when the instrument has been introduced, are nearest the
septum) are slightly serrated to enable the operator to seize
the turbinated bone securely. Within the tube formed by
the closed blades, a third blade, bevelled at its anterior
extremity to a sharp edge, like a chisel, can be projected
forwards when the instrument is in position. The forceps
is introduced with the chisel drawn back, and the tissue in
be removed having been firmly grasped with the forceps, the
cutting point is driven home with the operator's free hand.

Snares and Ecraseurs. — Snares have been used for many
years for the removal of polypi. The best known instru-
ment of this sort is that of Hilton 1 (Fig. 56), which
consist* of a quadrangular shank, terminating at one end

FIG. 56. — HILTON'S IMPROVED SNARE.

( This instrument has nmo only an historical interest, having been
superseded by snares of simpler and more convenient construction. )

in a ring for the thumb of the operator, and at the other in
a tapering nasal portion. A cross-bar to which the ends of
the wire are secured slides on the quadrangular part of the
shank. The distal end of the nasal part is bulbous, and is
perforated in the longitudinal direction with two holes,
through which the wires pass to form a loop beyond the
point of the instrument. This instrument has been im-

1 For information concerning the origin of this instrument, see
the History of " Non -malignant Tumours of the Nose."

270 DISEASES OF THE THROAT AND NOSE.

proved in recent years by Clarence Blake, of Boston,
Zaufal, and myself. The straight shank was first bent at
a suitable angle by Blake, an arrangement permitting an
uninterrupted view of the entire operation of evulsion. In
Zaufal '.s instrument the wire at its distal extremity rests
on two little rods, and the loop is only formed when the
rods are thrust forwards. The loop, therefore, is not bent
or pushed on one side, as is apt to be the case during its
introduction into the nose, and the wire is only " paid out "
when the tip of the instrument is close to the polypus.

My own improvements consist in slight modifications of
Blake's instrument, by which it can be more easily held, and
the wire more readily pulled home. In my snare (Fig. 57)

FIG. 57.— THE AUTHOR'S POLYPUS SNA UK.

a, the wire ; b, tube along which the wire Is passed ; c, centre-piece of the
cross-bar ; e, finger-rest ; rf, centre-piece to which e and / are fixed ; /, thumb-rest ;
g, ring for thumb.

the thumb of the practitioner, after passing through a ring on
the upper surface of the handle, is received into a slightly
concave metallic rest, which can be slid along the handle and
fixed at any point which suits the hand of the operator.
Below this rest a tapering trigger-shaped crutch projects,
upon which the tip of the ring-finger is placed.

The great attention which has recently been given to hyper-
trophy of the turbinated bodies, has led to the invention of
several instruments for the removal of the redundant tissue.
Among these must be especially mentioned a very delicate
and, at the same time, highly practical form of snare which
has been devised by Jarvis, of New York.1

1 The value of the principle of this instrument may be gathered
from the fact that within six months of its description having born
published, no less than seven modifications or so-called ' ' improve-
ments " were brought out in America and England.

NASAL INSTRUMENTS.

271

The instrument (Fig. 58) consists of a straight nickel
canula, seven inches in length and one-sixteenth of an inch in
diameter. Its outer surface is smooth for four
inches from the distal end ; but for the rest
of its length it is wormed. Over this portion
is fitted a second canula somewhat larger in
bore ; this is smooth exteriorly, but grooved
on its inner surface to prevent any rota-
tion. Over the screw-thread runs a small
wheel, half an inch in diameter and three-
sixteenths of an inch thick, roughened on
the outer edge, and so arranged as, when it
is turned, to push before it the movable
canula. At the proximal extremity of this
outer tube are two small pins, round which
the ends of the wire may be secured after
being drawn through the whole length of
the inner canula. The loop of wire that
projects from the distal extremity of the
canula may, of course, be of any size that
is required. The advantages of the instru-
ment are that it can be easily worked, and
that the loop of wire may be tightened,
either sloiclij by turning the wheel and
thus gradually pushing down the outer tube
on which the wire is fixed, or quickly by
pulling back the outer tube itself. It is
obvious that this little instrument is well
adapted for removing mucous polypi as well
as hypertrophied mucous membrane.

My former assistant, Jefferson Bettman,
now of Chicago, has modified Jarvis's
instrument by having the end of the tube
flattened, so that the point of exit of the
wire can be placed in closer apposition to the
surface on which it is desired to operate.
The modified snare, moreover, is made in
several parts, and tubes of various calibre,
length, and shape, can be substituted for the FIG. 58.
original straight one. By this means the DR. JARVIS'S NASAL
snare can be used for the posterior nares. ECRASEUR (AFTER
Another advantageous feature in Bettman's BOSWORTH).
snare is that instead of having to be twisted round
pegs, the free ends of the Avires are fixed by means of

272 DISEASES OP THE THROAT AND NOSE.

a damp screw, which can be tightened or slackened at
pleasure.

An excellent modification of Jarvis's snare has lately
made by Bosworth,1 who has had it bent at the pmper
for nasal instruments.

!•'.•• mneurs. — For the removal of the denser varieties nf
polypus, I have found the 6craseur represented in the aee.,m-
panying woodcut (Fig. 59) very useful. In this instrument

FIG. 59. — THE AUTHOR'S NASAL ECRASEUR.

a, the wire passing from the end of the barrel to the two reels b ; e, cog-
wheel ; d, stop-spring, which, by pressing on the button /, is released, allowing
the reels to be unwound ; e, tooth controlled by the spring g, which in its turn
is acted on by lever h ; i, spiral spring raising lever after use ; j, short cylindrical
portion of shaft in which the proximal end of the barrel is contained.

the wires are threaded through a barrel and wound round
two reels by means of a lever, which works a cogwheel The
barrel is about nine centimetres in length, and is flattened
for about twenty millimetres at the distal end to allow uf
more easy insertion into a narrow channel.

Electric Cautery. — The electric cautery is extremely useful
for the destruction of polypi, of hypertrophied mucous mem-
brane, and cartilaginous out-growths. For application within

1 "Philadelphia Sled. News," Feb. 24, 1883, p. 230.

NASAL INSTRUMENTS.

273

the nose any of the electrodes already described (Vol. i. p. 508)
can be employed, the wires, however, being previously suit-
ably bent. For the last four years I have employed Schech's
admirable electrodes,1 which enable the operator to treat
almost any case. For the application of cautery to the cen-
tral portion of the nasal fossa Lowenberg's instrument (Fig. 60)

FIG. 60. — DR. LOWENBERG'S NASAL ELECTRODE.

has, however, the great advantage that it can be readily
used without a shield ; for the incandescent point, instead
of being placed at the distal extremity of the electrode, is
situated at the side on one of the wires, so that when in
the nose the other wire protects the healthy parts.

FIG. 61.
Dn. LINCOLN'S POST-NASAL ELECTRODE (AFTER BEVERLEY ROBINSON).

A, the complete electrode showing 6, spiral spring and c, shield ; B, portion of
electrode showing the disk d uncovered ; c, disk surrounded by shield.

For applying the electric cautery to the vault .of the
pharynx, Lincoln has invented an ingenious apparatus (Fig.
61). It consists of an electrode, around which is fixed
1 Made by Albrecht, of Tubingen, at a very moderate cost.

VOL. II. T

274 DISEASES OF THE THROAT AND NOSE.

a spiral spring, ending in a bell-shaped shield of bone, which
projects beyond the electrode and conceals a platina disk
which terminates the electrode. When the instrument is
pressed against the tissue to be destroyed, the shield is
forced Lack on the spring, and the electrode is thus allowed
to come into contact with the affected part.

Poft-NasaJ Forceps. — For removing growths from the vault
of the pharynx, and from the neighbourhood of the posterior
nares, Lowenberg's curved forceps and my own sliding forceps

FIG. 62. — DR. LOWENBERG'S POST-NASAL FORCEPS.
are both of service. The former (Fig. 62) is an instru-
ment with long slender curved handles and very short
blades turned upwards from the rivet at an obtuse angle.
The blades are scooped out on their inner surfaces, and each
ends in a sharp, somewhat overhanging edge, which comes
into apposition with the corresponding part of its fellow
when the handles are closed. My colleague, Dr. Woakes,1
recommends that the cutting edges should be carried further
round the blades than was the case in Lowenberg's earlier
instruments.

My own instrument (Fig. 63) consists of a male and a
female portion. The latter is a straight cylindrical tube
open on the upper aspect throughout its whole length,
nud ending in a sharp, spoon-shaped blade at the distal
extremity ; the male portion is composed of a solid shank
playing backwards and forwards in the cylindrical part
of the other limb of the instrument, and terminating in
a blade of similar shape to the other, directed so that
when the two are brought together the cutting edges corre-
spond. The handle is fixed to the under surface of the
proximal end of the female portion, the rivet being
close to the body of the instrument, and the limbs placed
one behind the other. The anterior one is fixed, and to

1 " Trans. Intern. Med. Congress." London, 1881, vol. iii. pp.
295, 296.

NASAL INSTRUMENTS. 275

the posterior, which can be moved backwards and forwards,
is attached a lever which traverses a slit in the anterior limb
to the under surface of the cylinder, where it is fixed to a
pin connected with the shank of the male portion. The
opening along the top of the cylinder allows the upturned

FIG. 63. — THE AUTHOR'S SLIDING POST-NASAL FORCEPS.

blade of the male portion to be pulled back as far as the
limbs of the handle can be opened. The instrument is
better adapted for the removal of growths from the sides
of the pharynx, whilst Lowenberg's is more suited for
operating on those on the vault and posterior wall.

Michael,1 of Hamburg, has invented an instrument for
the removal of adenoid vegetations, which he states that
he has used for the last three years. He calls it a double
chisel, but it is, more strictly speaking, a cutting forceps.
The blades are turned up at a right angle from the stem, the
angle, however, being well rounded, and the cutting edge
extending three centimetres beyond that point. It differs
from other forceps of an analogous character in the circum-
stance that the principal cutting part of this instrument is at
the angle and not at the point, as in Lowenberg's and my
own. I may add that I have not found Michael's instru-
ment at all convenient.

In removing post-nasal vegetations, Meyer, of Copen-
hagen, prefers to use his own " ring-knife." This " con-
sists, first, of a little ring of a transverse oval shape, its
axes being 1*4 and 1 centimetre respectively, and its breadth
1'5 millimetre, having one edge sharp, although not abso-
lutely cutting, and the other one rounded off ; and secondly,
of a slender, stiff, but at the same time flexible stem ten
centimetres long, bearing the ring at one extremity, fixed

1 "Berlin, klin. Wochenschrift." 1881, No. 5.

276

DISEASES OF THE THROAT AND NOSE.

into a roughened liamlli- at tlie other."1 Meyer's plan
of operating is to introduce this instrument through the
patient's nose into the nasopharynx with the right hand,
whilst the left index finger is passed into the mouth behind
th'- velum, where it is made to press the vegetations against
the edge of the ring-knife, which must at the same time be
drawn downwards, so as to scrape away the cxrivsn-nre.
The st«-m being flexible, the knife can be bent towards c. in-
side or the other, as may be necessary.

Stoerk has had a special loop (Fig. 64) adapted t» his
laryngeal guillotine (Fig. 48, Vol. i. p. 259) for the re-

FIG. 64.— PKOF. STOERK'S POST-NASAL SNAKE.

moral of post-nasal growths. By means of this instrument
I have several times taken away vegetations frcnn the vault of
the pharynx.

For the removal of small post-nasal vegetations Capaii

Fro. 65. — Dit. CAPART'S FINGER SHEATH WITH CUTTING SPOON.

A, the position of the hand and finger in holding the spoon ; a, lateral view
of the cutting spoon. B, enlarged view of the two parts of the metal sheath ;
"' , cutting spoon.

has suggested the use of a sharp spoon (Fig. 65) which

can be fastened on the index finger by means of a metallic

1 " Med.-Chir. Trans." London, 1870, vol. liii. pp. 211, 212.

NASAL INSTRUMENTS.

277

sheath composed of two rings, held together at each side
by rivets, so that sufficient play is allowed for them to be
moved when the finger is bent. On the palmar surface of
the distal ring is the spoon. The little instrument thus
serves to carry the blade, and to protect the operator's
finger whilst it is in the patient's mouth. Many surgeons,
however, prefer the natural cutting edge provided by a sharp
forefinger nail.

For the purpose of removing small sequestra of bone or
other broken-down tissue, or of " vitalizing " the borders

FIG. 66. — NASAL CURETTES OR SHARP SPOONS.

a, spring catch ; b, articulation of the stem with the handle, which ends in a
ring to receive it ; the catch a is shown in position in the upper woodcut.

of an indolent ulcer within the nasal cavity, Volkmann's
cutting spoons are very useful. I have had curettes of
various sizes fitted to a handle at the proper " nasal angle "
(Fig. 66.)

Haemostatic Instruments. — For arresting haemorrhage from
the nose, plugging the nostrils anteriorly is often found
insufficient, and it then becomes necessary either to close
the posterior nares, or to apply pressure within the
nose. Hence there are post-nasal plugs and intra-nasal
plugs.

Of the former kind of instrument Bellocq's well-known
sound (Fig. 67) is the best. It consists of a piece of watch-
spring, attached to a stylet contained in a canula. The
watch-spring is fixed by a screw to the proximal end of the
stylet, so that the point holding the string projects beyond
the canula. After the instrument has been introduced
through the nose, the screw is turned round, so that the
Watch-spring runs down the stylet and becomes attached
to its lower end, while its free extremity projects into the

DISEASES OF THE THROAT AND

])li;iryiix near the base of tin- tongue, allowing tin- string
to be readily seized with tin- tingei-s m- forceps. A firm
pledget of lint, sufficiently large to cover both ehoana-
completely should be tied to the string, which is then
drawn back through the nose and fastened round the
The string should be further secured to the face by strip.-*

FIG. 67. — BELLOCQ'S SOUND.

A, the instrument with the stylet x armed with a thread and ready for use ;
B, the same after introduction through the nares, the stylet x appearing at the
back of the mouth.

of plaster. This instrument, however, is very seldom at
hand when wanted, and an ordinary flexible catheter will
be found quite as useful. The most efficient post-nasal plug,
however, is that of St. Ange1 (Fig. 68). This instrument,
which bears the formidable name of " rhinobyon," consists
of three parts, viz., a small syringe ; a tube opening at its
distal end into an india-rubber bag ; and a small pilot sound.
The pilot is introduced into the tube, and the hag is thus
passed through the nose into the naso-pharynx, when the
pilot is withdrawn, and the nozzle of the syringe being fitted
to the mouth of the tube, air is injected and the hag dis-
tended to such an extent as to cover the choana. A little

1 Lapeyroux : " Method e pour arreter les he'morrhagies nasales."
" These de Paris." 1836, No. 314. In the original instrument there
is a tap in the india-rubber tube instead of the little clip above-
mentioned. Kiichenmeister subsequently invented an instrument
which he called a "rhineurynter," closely resembling the one here
described.

NASAL INSTRUMENTS.

279

clip attached to the tube keeps it closed when the syringe-
is withdrawn.

Of intra-nasal plugs J. P. Frank1 appears to have been
the inventor, for he was the first to devise a special instru-
ment (if such it can be called) to bring pressure to bear
directly on the walls of the nasal fossa?. He introduced into

FIG. 68. — ST. AXGE'S RHINOBYON, OR POST-NASAL PLUG.

A, syringe for injecting air or water ; B, india-rubber tube or bag ; C, pilot
for bag. After the bag has been introduced, the point x of the syringe fits into
the orifice z.

the nose a piece of dried hog's intestine, tied at the distal
end, and then injected water into the open end projecting
from the nostril, tying up the gut as he withdrew the syringe.
The best form of instrument, however, for this purpose, is
that invented by Dr. Cooper Kose (Fig. 69). It consists of
a thin india-rubber bag connected with a tube, provided with

1 "De curandis hominum morbis." Mannhemii, 1807, lib. v.
pars ii. p. 144.

280

TIIK THII"AT AMI N<>SK.

a stopcock. The bag is introduced empty into the nose ;iinl
passed almi^ the fossa, when it is inflated by blowing through

FIG. 69. — DR. COOPER ROSE'S INTKA-XASAL Pi.n.1
(AFTER SPENCER WATSON).

A, the instrument as ready for introduction into the noae ; B, the same expanded
with air.

the tube. The tap should then be turned off and the instru-
ment left in situ as long as may seem desirable.

Instruments for the Removal of Foreign Bodies from tin'
Nasal Cavities. — Gross's instruments, shown in the anno:. •<!

1 This instrument is made by Messrs. Coxeter, Grafton-street East.

NASAL INSTRUMENTS.

281

woodcxit (Fig. 70), may be found useful. They consist of
little scoops, cork-screw points and booklets. For the extrac-

FIG. 70. — PROF. GROSS'S NASAL SPUDS (AFTER SOLIS COHEN).

tion of small nasal calculi, slender forceps (Fig. 71) have
been recommended. The blades, which are scissor-shaped,
and terminate in roughened bulbous ends, articulate only

FIG. 71. — FORCEP.S FOR REMOVING SMALL FOREIGN BODIES
(AFTER SPENCER WATSON).

after they have been passed separately into the nose.
Instruments bent at the proper angle (Figs. 39 and 51)
will, however, generally be found more convenient, as they
do not obstruct the view of the operator.

Other Instruments. — For the remedy of deformities of the
nose, arising from congenital deviation or badly set frac-

FIG. 72. — MR. ADAMS'S FORCEPS FOR BREAKING

DOWN THE SEPTUM.
ture of the septum, Adams1 employs a pair of powerful
forceps (Fig. 72), with smooth flat blades which can be

1 "Med. Soc. Proceedings," April 26th, 1875. London, 1874-5,
vol. ii. pp. 99, 100.

282 DISEASES OF THE THROAT AND

easily introduced into the nasal fossa- ami made to grn>p
the partition between them. With this instnunrnt it is •
either to separate the cartilaginous from tin; bony part of
the septum, or to fracture the former, if desired. The t
iiH'iit.-; ;uv rctaincil in their new position by means of two
little splints made either of ivory or steel, one being placed
in eacli nostril, and the two fastened together outside with
strings. These splints, however, cannot be kept in appo-
sition without a truss to make pressure on the upper frag-
ment, and an ingenious arrangement for this purpose has
been devised by Adams.1

Jurasz2 of Heidelberg, was led to improve upon this plan
on finding that the septum regained its wrong position when
he withdrew the forceps, before there was time to adjust the
splint. He therefore modified Adams's instrument by having
the blades and shanks of the forceps separate, though screwed
together. The instrument is introduced, the septum broken,
the shanks unscrewed, whilst the blades, locked together on
the principle of the ordinary midwifery forceps, remain in
the nose to act as splints.

For plugging the nasal fossse in cases of oza?na, Gottstein's
cotton wool tampon (Fig. 73) is extremely useful. All that

FIG. 73. — DK. GOTTSTEIN'S COTTON WOOL TAMPON.
A, screw armed with wadding-tampon ; B, the naked screw.

is required is a screw about fourteen millimetres long, ter-
minating in a shank fixed to a handle. Round this screw
a small piece of wadding is twisted. The instrument is then
inserted into the nasal channel, when the screw is reversed
and withdrawn, leaving the cotton-wool accurately in position.
Ti'iiijinrai-i/ Sponge-Tampon for the Poxfn-i<>,- Xan'*. — In
the case of infants and very young children sprays should

1 " Brit. Mecl. Journ." 1875, vol. ii. pp. 421, 422. The instrument
lias been considerably modified by Mr. Adams, since he first published
a description of it. It is sold by Mr. Gustav Ernst, Charlotte-street,
Fitzroy-square.

2 " Berlin, klin. Wochenschrift." 1882, No. 4.

ACUTE NASAL CATARRH.

283

not be used through the anterior nares without care being
first taken to prevent the fluid from running through the pos-
terior nares into the larynx. These openings should, there-
fore, be temporarily plugged. This can be most conveniently
effected by passing a small sponge into the naso-pharynx by
means of the instrument shown in the annexed woodcut
(Fig. 74). This consists of a short metallic stem fitted to a

FIG. 74.

THE AUTHOR'S TEMPORARY SPONGE-TAMPON
FOR THE POSTERIOR NARES.

a, stem ; 6, handle ; c, holes through which the
pad can be stitched to the tip ; d, sponge.

wooden handle at the proper "nasal angle," and curved
upwards at its distal end into a bulbous perforated point.
A piece of sponge is stitched to the point of the instrument.

ACUTE XASAL CATARRH.
(SYNONYMS: CORYZA; COLD IN THE HEAD.)

Latin Eq. — Gravedo : Catarrhus narium.
French Eq, — Catarrhe nasal.
German Eq, — -Schnupfen.
Italian Eq. — Corizza.

DEFINITION. — Acute catarrlial inflammation of the
Sclnit'itlcrian membrane, causing sneeziny, more or less
obstruction of the nasal 2mssa'Jesi an(l lujper-secretion of
an irritatiny serous or sero-mucotis fluid.

History. — Until the seventeenth century it was the belief of
physicians that covyza was a flux of serous fluid from the cere-
bral ventricles, and a "cold in the head" was looked upon as a

284 DISEASES OF THE THROAT AM) NOSE.

" purging of the brain." This idea prevailed till Schneider1 gave a
more correct account of the anatomy of the nose, anil in particular of
the function of the membrane that bears his name. Within the
succeeding century several works were published on catarrh by
Wedel,2 r. Frank,3 Camerarius,4 Stoll,8 and others, but no tYe,ii
light was thrown on the subject till J. P. Frank,8 towards the •
of the last century, gave a very full account of the complaint.
Several years afterwards Rayer7 published a short monograph, in
which he showed how dangerous the affection is to sucklings. In
the elaborate treatise on the nose by Cloquet,8 a chapter is devoted
to coryza, which is equally remarkable for antiquarian lore ami
practical wisdom. In 1837 Billard9 followed up the clinical investi-
gations of Rayer in relation to infantile catarrh. In the same year
the subject was discussed by Anglada I0 at some length, but with
no novelty of view as regards either the nature or the treatment
of the malady. Since then the writings of Bouchut,11 Kussmaul,12
and Kohts13 have elucidated the affection, especially as regards
infants. Vauquelin 14 appears to have made the earliest investi-
gations on coryza from the chemical point of view, but Bonders u
was the first to publish a detailed analysis of the secretion.
Friedreich 16 made some experiments on the inoculability of the dis-
ease, and to Ranvier 17 we owe an elaborate account of coryza from
the purely pathological standpoint.

1 " De catarrhis." Wittenbergse, 1664.

2 " Casus laborantis coryzft." Jense, 1673.

3 "Dissert, de coryza." Heidelberg, 1689.
* " De coryza." 1689.

» " Ratio Medendi," t. iii. p. 44.

" De curand. homin. morbis." Mannhemii, 1794, lib. v. p. 102, et seq.
7 " Sur le Coryza des Eufants k la Mamelle." Paris, 1820.
> "Osphrteiologie." Paris, 1821.
» "Maladies des Nouveau-n*%." Paris, 1837, 3me ed. p. 502, et seq.

10 " Sur le Coryza simple." These de Paris, 1837.

11 "Trait^ pratique des Maladies des Nouveau-nes." Paris, 1867.

12 " Zeitschrift fur rationelle Medicin." 1865.

is "Krankheiten d. Nase," in Gerhardt's "Handbuch d. Kinderkrankheiten.'
Dritter Bd. Zweite Halfte. Tubingen, 1878.
1* Quoted by Anglada. Op. cit. p. 16.

" Nederlandsch. Lancet." 1849-50, 2 series, v. p. 312.

16 " Virchow's Handb. d. Pathol. und Therapie." Erlangen, 1865, Bd. v.
Abtheil I. p. 398.

17 " Soc. de Biologic de Paris." Summary in " Lancet." 1874, vol. i. p. 687.

Etiology. — The causes of catarrh in general have already
been discussed in previous sections (Vol. i. pp. 15 and 265),
and only a few remarks need be made here concerning the
etiology of nasal catarrh. As in most other diseases, there
are pn'<lixi>n*in<i and exciting causes. Among the former
youth is one of the chief, children being particularly subject
to coryza. The comparative immunity of the aged \\as
recognized as far back as the time of Hippocrates.1 Certain
constitutional conditions seem to render the mucous mem-
brane more susceptible to catarrh, and this is especially

1 "Aphorism." Paris, 1844, ii. 40, Littr^'s ed. t. iv. p. 483.

ACUTE NASAL CATARRH. 285

seen in the stnimous diathesis. In these cases there is not
unfrequently at the same time chronic enlargement of the
tonsils, and sometimes catarrh of the naso-pharynx with
obstruction of the Eustachian tubes. The nasal disease may
be the cause or the consequence of these conditions, or, in
some cases, all the phenomena may depend on a general
dyscrasia. People of rheumatic constitution, and those
in whom the sweat-glands act feebly, are also prone to
nasal catarrh. Alibert1 maintains that persons of decidedly
nervous temperament are especially liable to the complaint,
and he states that he has seen extremely acute forms of
nasal catarrh, with very profuse secretion, occur in women
after convulsions. Asthmatic people are particularly liable
to the affection, and hay fever may be regarded as a con-
necting link between these two disorders.

Exposure to cold, under certain circumstances, is very apt
to cause catarrh, but the exact mode of its operation is
uncertain. Cold currents of air on the head are familiarly
recognized as a cause of the disorder, and the bald are
in this respect, of course, peculiarly vulnerable. Cloquet'2
was of opinion that the frequent occurrence of coryza after
getting the feet wet or cold, was to be explained by some
special sympathy between the feet and the pituitary mem-
brane, a connection which he attempts to support by an
isolated case, in which nasal catarrh was always a con-
comitant of gout in the toe.3 The truth seems to be that
catarrh so frequently results from wet feet, simply because
those extremities are exposed to wet and cold more often,
and for longer periods than any other covered portion of the
body.

The influence of heat in producing catarrh is less generally
recognized, and its mode of action is very imperfectly under-
stood. Its effects are seen under two conditions : first, where
the disease results from exposure to the sun ; secondly,
where it follows confinement in hot rooms. The catarrhal
symptoms, arising from exposure to the sun, may be due
to direct irritation by the solar rays, or it may be of reflex
character, i.e., dependent upon the impression on the retina.
Coryza resulting from confinement in a hot room is generally
observed in persons of enervated constitution, whose mucous
membrane has been relaxed by previous attacks.

1 "Obs. sur les Affections Catarrhales en G&ieVal." Paris, 1813.

2 Op. cit. p. 602.

3 Compare Stoll : " Ratio Medendi," v. p. 436.

286 DISEASES OF T1IK TIIKuAT AM) NOSE.

The influence of irritating vapours, or solid particles
suspended in the air, in producing inflammation of the
pituitary memlirane, will IH> considered under "Traumatic
Rhinitis," and the effects of the pollen of certain grasses will
be treated of under "Hay Fever." In connection with the
action of local irritants, it may be observed that the sensi-
bility of the nasal mucous membrane becomes 1 limited in the
case of the habitual snuff-taker, in whom also the liability to
catarrh is diminished.1

Occasionally coryza appears to be due to epidemic
influences, and several persons in the same house, the
dwellers in a particular street, or even the inhabitants of a
whole town, may be observed to suffer simultaneously.
The supposed epidemic described by Anglada,2 in which
an entire army became suddenly affected with catarrh, is
however, probably, only an illustration of the ordinary mode
in which cold is caught. The French troops, after spending
the greater part of a very hot and dry summer in Anda-
lusia, were caught in a violent storm after a long and
fatiguing march. This was immediately followed by an
almost universal catarrh.3 In short, coryza can only be
said to occur epidemically, in so far as a sudden lowering
in the temperature, with increased humidity of the air, may
cause the malady to be widespread.

Although there is a belief among the laity that a cold
can be " caught " from a person labouring under the dis-
order, there is no evidence that coryza is infectious, and
it is very doubtful whether it is ever spread by contagion.
Immediate contact,4 especially in kissing, is, however,

1 Plugging the nose with tobacco was formerly thought a good
protective against "catching cold." Sir William Temple is said to
have kept a leaf of tobacco up each nostril for an hour every morn-
ing, in order to drain the secretion from the eyes and head. In
this way he fancied that his sight was preserved, at the same time
that liability to coryza was diminished. (Sigmond : "Lectures on
Materia Medica at Windmill-street") "Lancet," 1836-37, voL ii.
p. 157.

2 Op. cit. p. 16.

3 Cloquet has alluded to an epidemic of coryza among dogs
(Stoll : " Ratio Medendi," t. iii. p. 44), and his observations have
been repeatedly quoted by subsequent writers. On referring to the
original text of Stoll, however, it is clear that the epidemic was one
of distemper : ' ' tussis laboriosa, spontanese vomitiones, putrilago
vomitibus refusa, extrema macies, et tandem veluti quorundain
artuum semi-paralysis, et more. "

4 The belief in the contagious nature of coryza appears to have
existed for several centuries. Thus, more than two hundred and

ACUTE NASAL CATARRH. 287

thought by many to be a common mode of spreading the
complaint. Frankel l states that he has seen several cases
which appeared to originate in this way. But the only
attempt at direct inoculation with which I am acquainted is
that of Friedreich,2 who endeavoured to generate the disorder
in his own person, by applying the secretion taken from
persons in various stages of coryza to his nasal mucous
membrane. The results of this experiment, however, were
entirely negative.

The suppression of habitual discharges is sometimes
followed by the development of coryza. Cloquet 3 mentions
that the disorder may follow the cure of chronic ophthalmia,
the stoppage of bleeding from piles, the cessation of the
menstrual flow, or even the disappearance of a rash. I have
myself frequently noticed an increased susceptibility to nasal
catarrh in delicate women during or immediately after the
catamenial period, but I am inclined to consider the occur-
rence of catarrh under these circumstances to be due to the
temporarily lowered vitality which affects the whole system.
I have also several times seen coryza follow the cure of
chronic otitis.

Nasal catarrh frequently complicates the exanthemata,
especially measles, small-pox, scarlatina, and typhus ; it also
accompanies facial erysipelas, and it is nearly always one of
the earliest and most marked symptoms of influenza.4 In
measles there can be little doubt that the congested appear-
ance of the nasal mucous membrane is, in fact, the eruption
itself, whilst in scarlatina the coryza seems usually to be
caused by an extension of the inflammatory process from the
throat. In typhus, the pituitary membrane merely shares in
the general catarrhal affection of the mucous tracts.

Nasal catarrh, as a symptom of iodism, is a familiar fact of
medical experience.5

seventy years ago Crato spoke of " coryzse halitu etiam contagiosae.
Id cum vulgus in Gerinania sciat, non facile ex eodem poculo, e quo
coryza laborans potum hausit, bibit." (Johannes Crato in " Epist.
Philosoph. Med.' Hanoviae. MDCX. Ep. cvi. p. 188.)

1 "Ziemssen's Cyclopaedia," vol. iv. p. 117.

2 Loc. cit.

3 Op. cit. p. 602.

4 At the commencement of nasal diphtheria, coryza is occasionally
present, but, as has been already remarked (Vol. i. p. 185), the
actual membrane nearly always forms first in tlie pharynx, and from
thence extends into the nares.

5 In accordance with the germ theory so much in vogue at the
present day, it has been suggested that nasal catarrh may be caused

•JS,S DISEASES OF THE THKOAT AXI> X<»K.

Symptoms. — A cold in the head is of such every-day
occurrence that a very brief description of the >yni]>t"iii>
will suffice. Like other disorders of an inflammatory nature,
the first indications are those of pyrexia, viz., lassitude,
chilliness, and occasionally, but very rarely, a slight rigor.
The first sensation, however, which points distinctly to the
nature of the attack, is a feeling of fulness and sometiin
throbbing or pain in the frontal region, and this symptom
is soon succeeded by paroxysms of sneezing of greater or
less severity. In a short time the nares become blocked up
from swelling of the mucous membrane, and after a few
hours the characteristic state of hyper-secretion is established.
The local phenomena relating to the discharge from the nasal
mucous membrane are seen in four stages : The lining mem-
brane of the nose is first slightly swollen, then an abundant
irritating icatwy secretion takes place, afterwards this lie-
comes thick and muco-purulent and loses its irritating
quality, and finally the discharge gets thin again, without
recovering its irritating properties, and gradually ceases
altogether. The time occupied by these various stages differs,
some catarrhs passing off in three or four days, whilst others
last as many weeks. The duration of the attack principally
depends on the length of time which the third and fourth
stages occupy ; for the dryness of the mucous membrane
rarely continues more than a few hours, and the abundant
irritating secretion seldom causes trouble for more than one
or two days.

The watery fluid of the second stage is decidedly saline,
and from its irritating quality it often causes excoriation of
the skin about the margin of the nostrils. Together with
these symptoms there is usually more or less impai ment of
the sense of smell. When the anterior nares are completely
obstructed, the voice has a nasal twang in all its tones, whilst
when the stoppage is confined to the ponti-rior nares, the
general character of the voice is normal, but the articulation

by a specific germ. Indeed, Salisbury (" Haller's Zeitschrift," Jena,
January, 1873, p. 7) has described and figured this germ under tin-
name of Asthmatos Ciliaris. It lias also been seen by Ephraini
Cutter and P. F. Reinsch ("Virginia Med. Monthly," November,
1878), and, on one occasion, by Daykin, a pupil of Salisbury, who
remarks that he had "had a nice time looking at the animal" (see
Coomes : " Pharyngeal Catarrh," Louisville, 1880, p. 134). Notwith-
standing this confirmation, minute organisms are so common even
in healthy secretions that further observations are necessary before
the view can be accepted.

ACUTE NASAL CATARRH. 289

is defective, m becoming b, and n being sounded as d. Of
course, if the obstruction affects the whole nasal passage, both
the general and the special defects are present. These points
have been explained in connection with post-nasal growths
by Lbwenberg1; and Seiler2 has recently shown that the
peculiar tone of the voice caused by obstruction of the
anterior nares is due to the fact that the nasal cavities can
no longer act as a reverberating chamber, whilst post-nasal
obstruction simply interferes with that free passage of air
which is necessary for the articulation of the letters m and n.

The course of a simple attack of acute nasal catarrh just
described in detail is, however, often arrested or modified,
and almost any of the symptoms, except the discharge, may
be entirely absent.

On the other hand, when the bony cavities communicating
with the nose are involved in the catarrhal process, the
symptoms are sometimes more troublesome. If the antrum
of Highmore becomes affected, there will be severe pain in
the cheek, whilst extension to the frontal sinuses causes a
dull pain in the forehead, and if the ethmoidal and sphenoidal
cells become implicated, the headache becomes intensified.
Ringing in the ears and deafness point to temporary blocking
up of the Eustachian tube, and the occurrence of epiphora
shows that the lachrymal duct is obstructed. Slight but
painful abrasion of the nasal mucous membrane near the
margin of the nostrils a"nd herpes labialis are often trouble-
some concomitants. In infants coryza sometimes produces
such dangerous symptoms that it will be more convenient
to deal with them separately (see p. 293).

Diagnosis. — An ordinary catarrh can scarcely be mistaken
for any other affection, but it must be remembered that it
is sometimes a premonitory symptom of some acute specific
disease, and when there is much conjunctival inflammation
the likelihood of the development of measles should be
borne in mind. Still more rarely nasal catarrh may simulate
disease of the bones. Thus Peter3 relates a case in which
there was such severe pain in the brow at the outset that
the complaint was regarded as one of " acute caries " of the
frontal bone, but on the application of a poultice to the

1 " Tumeurs adenoides du Pharynx nasal." Paris, 1879, p. 26.

2 " Archives of Laryngology." January, 1882, vol. iii. No. 1,
p. 24.

8 Quoted in the article on "Coryza" in the "Diet. Encyelop.
des Sci. Med." Paris, 1878, t. xxi. p. 3.

VOL. n. tr

290 DISEASES OF THE THROAT AKD XOBB.

root of the nose a profuse discharge was establish! •<!, which
almost instantly relieved the pain and proved the case to be
one of coryza.

Proynonis. — In the great majority of cases complete re-
covery takes place, and it is only in old j><-<>i>lr and MTV
young children that coryza is attended with any danger :
but it may terminate in chronic catarrh with much thicken-
ing of the mucous membrane, or it may lead to the develop-
ment of polypi.

Patholotjy. — The process is essentially one of active con-
gestion of the pituitary membrane followed by serous
exudation. The fluid is stated by Cornil and Ranvier1 to
contain lymph-corpuscles from the outset, and epithelial cells
are found in increasing numbers as the catarrhal condition
advances, the discharge being thus rendered at first cloudy
and afterwards opaque. The mucous membrane is red and
tumid, and numerous small tortuous vessels are often visible ;
whilst here and there dark brown stains, caused probably by
submucous ecchymosis, may sometimes be seen with occa-
sional abrasion or slight ulceration of the imicous membrane.

Treatnwmt. — Though from an early period -it has been a
constant reproach to medical practitioners that they are
unable to cure a " common cold," the blame really rests with
the patient more than with the physician. For as a rule,
persons suffering from catarrh feel so little inconvenience
that they are unwilling to submit to the restraint and regimen
which are necessary to ensure rapid recovery. The disorder
may be treated by stimulants, by derivatives, or by one of
the many remedies, the action of which is too obscure to
permit of classification. Of all stimulants opium is the most
trustworthy. The older physicians recognized its value in
stopping a catarrh, and generally gave it in the form of
Dover's powder at bedtime, but the effect of the drug is
much greater if administered in small doses during the day.
Laudanum is better than any other preparation, and five or
seven drops taken at the commencement of an attack will
often cure it at once. The remedy acts more quickly and
more certainly if taken on an empty stomach, and if one
dose is not sufficient it may be repeated twice in the day at
intervals of six or eight hours. If at the end of two days
the catarrh still persists it is useless to try to cut it short.
( )pium may also be administered in the form of a snuff
containing morphia and bismuth as first recommended by
1 "Manuel d'Histologie pathol." Paris, 1869, pp. 653, 654.

ACUTE \ASAL CATARRH. 291

Ferrier1 (see Appendix). The patient ought to commence
taking the snuff as soon as the symptoms of coryza begin
to show themselves, and at first it should be employed
frequently so as to keep the interior of the nostrils well
coated. Each time the nose is cleared another pinch should
be taken. This powder may also be administered by blow-
ing it into the nasal cavities with Bryant's auto-insufflator.
(Fig. 37, p. 256).

Camphor has long been held in high esteem by the public
as a " certain cure " for incipient catarrh, and many persons
find that ten drops of spirits of camphor taken on a piece of
sugar at once arrests a cold.

Instead of employing medicines which control secretion by
acting through the nervous system, local stimulants may be
prescribed in the form of inhalations. In Germany a pre-
paration known as Hager-Brand's " Anti-catarrhal Kemedy," 2
and consisting of ammonia and carbolic acid, is largely used
as a household remedy (see Appendix). The vapour of a few
drops of this nostrum, poured into a small cone of blotting-
paper, should be inhaled till the liquid is evaporated, and this
may be done every two or three hours until relief is obtained,
or the inefficacy of the remedy proved. " Alkaram," so ex-
tensively advertised in this country, appears to contain the
same ingredients. I have often seen great benefit result
from smelling strong ammonia salts without the addition of
carbolic acid. These " olfactories " should only be employed
at the moment when a disposition to sneeze is felt, for at
other times they will often increase the catarrh by provok-
ing an attack of sneezing. In some porsons the inhalation of
iodine vapour acts favourably, and will cut short a catarrh
in a few hours. "The inhalation of chloroform to the induc-
tion of anaesthesia administered after the patient has been
put to bed will often be found adequate," says Solis Cohen,3
" to abort a cold by its relaxing influence upon the structures
which are in a state of tension." Although I do not in the
least doubt the efficacy of this plan, it is obviously too risky
to be adopted, unless under very exceptional circumstances.

Derivative treatment may be carried out by the adminis-
tration of diaphoretics, diuretics, or purgatives. James's
powder, of which the pulvis antimonialis of the British

1 "Lancet," Aprils, 1876.

"Wien. med. Wochenschrift," June 5, 1872.
3 "

" Diseases of the Throat and Nasal Passages." New York,
1879, 2nd ed. p. 336.

292 DISEASES OF THE THKOAT AND XO8E.

Pharmacopoeia is an imitation, was once a very popular
remedy in England. If used, two grains should be given
every three or four hours until diaphoresis is established. A
mixture, consisting of five grains of nitrate of potash, twenty
drops of spiritus setheris nitrosi, and two drachms of liquor
ammoniae acetatis is a time-honoured remedy. If such
medicaments are administered the patient should at the same
time use the familiar adjuvant of a hot foot-bath. It need
scarcely be added that if this form of treatment be adopted
the patient should be confined to the house, or even kept
in bed. His diet should be light, and alcoholic stimulants
should be avoided, the only exception being a glass of hot
spirits and water at bed-time. Diaphoresis may be carried
out in a more energetic way by means of Turkish baths,
a method which has the advantage of not preventing the
patient from pursuing his ordinary avocations.

The late Addington Symonds, of Clifton, widely known
as a most accomplished and experienced physician, strongly
recommended 1 the following pill and draught as a means
of preventing nasal catarrh from miming into bronchitis :
R. Extr. Hyoscyami, Pulv. Conii, aa. gr. iv. ; Calomel,
Pulv. Ipecac., aa. gr. j. M. ft. pil. ii. vespere sumendae.
This was followed by a draught in the morning consisting of
Rochelle salts (tartrate of soda) and senna, and the patient
was kept in bed half the following day.

Small doses of aconite have been recommended for catarrh,
but I have frequently tried this remedy in cases where the
coryza was accompanied by high temperature, and have
never been able to satisfy myself that it produced any
appreciable effect in cutting short an attack.

In conclusion it may be mentioned that total abstinence
from liquids, as was pointed out by Richard Lower,2 and
more recently by C. J. B. Williams 3 will generally quickly
check catarrh. The coryza begins to diminish in about
twelve hours, and a cure is usually effected in two days.
"Williams allows, without recommending, a tablespoonful of
milk or tea twice in the day, and a wine-glass of water at
bed-time. The system should be put in force at the very
outset of a catarrh.

1 "Ranking's Abstracts." 1868, vol. i. p. 55.

2 "Dissert, de Origine Catarrhi." Ed. quinta, Lugduni Bata-
vorum, 1708, cap. vi. p. 258.

3 "Cyclopaedia of Pract. Med." London, 1833, vol. i. p. 484.

ACUTE CORYZA IN INFANTS. 293

ACUTE CORYZA IN INFANTS.

It is a matter of familiar observation that the nose is
relatively smaller than the other features in newly-born
children, but it is only recently that the peculiar anatomical
condition of the nasal fossae in infants has been distinctly
described. To Kohts and Lorent 1 we are indebted for
showing that in these young subjects the meatuses are
exceedingly narrow, the free extremity of the inferior tur-
binated bone being, as compared with that in the adult,
longer and curved further round, so that scarcely any room
is left for a passage at all. The relative smallness of the
passages, however, is most marked in the middle meatus,
its direction being quite horizontal, and its anterior orifice
being only an exceedingly minute circular opening. During
adolescence this round aperture enlarges anteriorly and at
the upper part, resulting in a kind of crook-shaped curve,
which greatly increases its size. Now it appears from
the observations of Kussmaul 2 that the mouth in newly-
born children is almost always closed during sleep, that
the tongue is brought into contact with the hard palate,
and that thus even in those rare cases where the lips are
open no air passes through the mouth. Bearing in mind the
anatomical conditions of the nose in infants which have just
been described, it can easily be understood that a very slight
swelling of the pituitary membrane is likely to be attended
with considerable difficulty in breathing, a circumstance
which J. P. Frank 3 was the first to recognize. No sooner
does the child suffering from severe catarrh fall asleep than
it is apt to be attacked by a paroxysm of dyspnoea, and
the attempts to inspire under these circumstances may lead
to extreme pulmonary engorgement. The difficulty of breath-
ing is, according to Bouchut,4 sometimes greatly intensified
by the tongue being drawn down and blocking up the
laryngeal orifice in the same manner as it does occasion-
ally under the influence of an anaesthetic. These attacks

J " Handb. d. Kinderkrankheiten," von Prof. Gerhardt. 1878.
Dritter Band, Zweite Halfte, p. 4, et seq.

"Zeitschrift f. rationelle Medicin." 1865, p. 225.

3 "De curandis hominum morbis." Mannhemii, 1794, lib. v. pars
i. p. 107.

* Quoted by Frankel, " Ziemssen's Cyclopaedia," vol. iv. p. 106.
On this interesting subject see also Henoch (" Beitnige z. Kinder-
heilk. Berlin, 1868, p. 124) and Manner (" Jahrb. f. Kimlerheilk."
1862, vol. v. p. 73).

'294 DISEASES OF THE THROAT AXD XOSE.

frequently resemble laryngismus stridulus, or may even be
mistaken for laryngitis. But there is another danger, viz.,
that of starvation, for the child may be unable to surk
without risk of suffocation on account of the obstructed state.
of its nasal passages. Although, however, infants are liaUi-
to these perils it must be admitted that they are very rarely
encountered in practice.

Most of the remedies recommended for adults may In-
used in reduced doses, but opiates should never be adminis-
tered. A small open tube put through the nose will soiin--
times enable the child to suck easily ; but should this plan
not answer, the infant must be taken from the breast ami fed
with its mother's milk by means of a spoon, and as a last
resource a short oesophageal tube (Fig. 11, p. 24) must bo
used.

PURULENT NASAL CATARRH.

Purulent inflammation of the nasal mucous membrane, in
exceedingly rare cases, may be simply an aggravation of an
ordinary acute catarrh. It may likewise result from injuries
or from the prolonged presence of foreign bodies ; but in
this article it will be briefly referred to as an acute affection
in which the formation of pus is the distinguishing feature
from the outset. Purulent nasal catarrh may be met with
both in newly-born children and in adults. In the former
case it is generally thought that the inflammation results
from infection of the mucous membrane of the nose with
the leucorrhoeal discharge which frequently occurs in the last
months of pregnancy, or in some still rarer instances from
gonorrhoea, from which the mother may have been suffer-
ing at the time of parturition. It is extremely doubtful,
however, whether such catarrhs are really the result of
maternal infection — the sudden exposure at birth of the
delicate mucous membrane to the irritating influence <>f tho
atmosphere, or the entrance of soap into the nostrils in
careless washing, being sufficient to account for the occa-
sional occurrence of the complaint. It may be added that
the influence of vaginal discharges upon the mucous mem-
brane of the eyes and nose of infants in the act of birth
has yet to be investigated on a large scale. If sufficient
statistical evidence can be obtained to show that the chil-
dren of women suffering from such discharges are often

PURULENT NASAL CATARRH. 295

affected with purulent ophthalmia or rhinitis, Whilst the
infants of women free from leucorrhoea show no signs of
such inflammations, the question will be settled. At present
the weight of opinion is no doubt in favour of the theory
of contagion at the time of birth ; but this view rests
more on a priori grounds than on statistical evidence.
Hermann Weber,1 however, ha»s reported a case in which it is
probable that direct contagion occurred. The mother had
suffered during the last weeks of gestation from an abundant
yellowish discharge from the vagina, and the child, which
had not been washed for three hours after birth, was subse-
quently attacked with purulent inflammation of the left
eye and of the nostrils, the nose being swollen and stuffed
up with crusts. The nasal discharge varied somewhat in
character, being sometimes watery, sometimes thick and
yellow, and sometimes mingled with blood.

There are very few cases on record in which purulent
nasal catarrh has resulted from gonorrhoeal infection in
adults. The only instances which I have been able to find
in medical literature are the three following : Boerhaave2
relates that a patient of his own, after squeezing some matter
out of his urethra for the inspection of the surgeon,
thoughtlessly put his fingers immediately afterwards into his
nose. Very severe rhinitis ensued, followed by extensive
ulceration. Another case is related by Edwards3 in which
an elderly woman consulted him for inflammation of the
nose with purulent discharge which had excoriated the
upper lip. The patient suffered so much pain and was so
emaciated and ill that the disease was suspected to be
malignant ulceration of the nasal cavity. Edwards, however,
on inquiring into the history of the case, ascertained that
about six months previously the woman had wiped her nose
with a handkerchief which had been employed as a suspen-
sory bandage by her son, who was suffering from gonorrhoea
at the time. Five days after this occurrence the patient's
nose became violently inflamed. She was treated with iron
and quinine internally, and the nasal fossae were washed
out with tepid water, after which a mildly detergent lotion
was used. Edwards, in commenting on the case, affirms
that he has known several instances where patients suffering

" Med.-Chir. Trans." 1860, vol. xliii. p. 177.
" Tractatio med. pract. de lue veuered." Lug'

Lugd. Batavorum, 1751,
41.
3 "Lancet," April 4, 1857.

296 DISEASES OF THE THROAT AND NOSE.

from gonorrhoea had infected their own nostrils by caiv-
lessly touching them with their fingers, but this \vas tin-
first case in his experience in which another individual had
been so inoculated.1 A revolting example of direct infi-r-
tion of the nasal mucous membrane has been ivjx»rtcd by
Sigmimd,2 in which a man contracted purulent rhinitis from
introducing his nose into the vagina of a prostitute suffering
from gonorrhoea.

An attack of purulent inflammation of the nose is usually
ushered in by some degree of systemic disorder, such as
shivering and general febrile symptoms. In Edwards's case,
quoted above, these were very severe. Excoriation and
ulceration are almost always produced by the discharge,
especially at the edges of the nostrils, and on the upper lip.
The inflammatory process is also apt to invade the eyes, if
indeed the conjunctiva is not simultaneously infected. In
infants the nose may be so plugged up by thickened secretion
that respiration by that channel is rendered impossible, and
thus the troublesome consequences described in the last
article are likely to follow.

The treatment should consist in cleansing the parts
with a tepid alkaline spray or collunarium (see Appendix).
Afterwards the nasal cavities should be syringed out with
some mildly astringent injection such as alum (gr. v. ad 53.),
sulphate of zinc (gr. ij. ad §j.), sulphate of copper (gr. ij. ad 5j.),
or nitrate of silver (gr. j. ad §j.). In the case of infants the
injections into the nose often give rise to violent attacks of
coughing, owing to some of the fluid getting into the larynx.
Under these circumstances it will be found convenient
to use the "Temporary Sponge-Tampon" (p. 283) whilst
douching or syringing is being carried out. Where there
is difficulty of sucking from stoppage of the nose, the
little patient should be fed in the manner recommended
under "Acute Coryza in Infants" (p. 294).

TRAUMATIC RHINITIS.

Irritating vapours, or solid particles suspended in the
atmosphere, frequently produce catarrh, and no doubt many

1 Cheliua ("System of Surgery." Eng. Transl. London, 1847,
vol. i. p. 177) mentions purulent rhinitis as an occasional concomitant
of gonorrhoea, and his translator, South (Ibid, note to paragraph
168), quotes two examples of such an occurrence from Benjamin Bell.

a " Wien. nied. Wochenschrift." 1852, p. 572.

PURULENT NASAL CATARRH. 297

otherwise inexplicable cases of coryza are due to this cause.
It can be readily understood that the vapours of chlorine,
ammonia, and iodine are extremely likely to set up irri-
tation of the nasal mucous membrane. The influence of
more palpable irritants is seen in the case of millers, ivory-
turners, sawyers, brush-makers, and persons engaged in
kindred employments. It is remarkable, however, that the
nasal mucous membrane does not generally seem to suffer in
the same way as the pharynx from exposure to hot steam or
smoke (Vol. i. p. 101).

In addition to casual sources of irritation there are certain
sxibstances which when present in the atmosphere, produce
a specific effect on the lining membrane of the nose, and
amongst these bichromate of potash, arsenic, and mercury
may be particularly mentioned ; whilst osmic acid is stated
by Seiler1 to be an irritant of such strength as to be capable
of producing coryza within one or two hours. Attention was
first drawn to the influence of bichromate of potash by
Becourt and Chevallier,2 who noticed that certain effects
were produced on the workmen exposed to the steam from
the boilers in which that substance is made. The subject
was afterwards taken up and investigated by Delpech and
Hillairet,3 who found that similar effects were produced on
persons exposed to the dust of the yellow chromate, although
they were manifested less rapidly, and in a much slighter
degree than in the case of the bichromate vapour.

The first symptoms produced by the bichromate are a tick-
ling sensation in the nose, violent sneezing, and an abundant
discharge, which at the commencement is watery in charac-
ter, but soon becomes thick and green. At a later period
the discharge contains crusts, and even flakes of sloughing
mucous membrane, but it is never offensive. Epistaxis not
unfrequently occurs, and ultimately portions of cartilage are
expelled. Perforation always takes place at a level of one
and a half, or at most two centimetres above the lower edge
of the septum. At first the aperture is round, and very
small, but as it increases in area it becomes oval in shape.
It may thus extend to the junction of the cartilage with the
vomer and the perpendicular plate of the ethmoid. As the
lower and anterior part of the cartilage always remains
intact, the bridge of the nose never falls in. Ulcers occa-

1 " Diseases of the Throat." Philadelphia, 1883, 2nd ed. p. 204.

2 " Annales d'Hygiene," Juillet, 1863, t. xx. p. 83.

3 Ibid. I860, t. xxxi.

298 DISEASES OF THE THROAT AND NOSE.

sionally form on the turbinated bodies, but they are not
nearly so severe as on the septum.

Casabianca1 points out that the reason why the septum
particularly suffers, is that, owing to the shape of the
nostrils, the columns of inspired air, on entering tin- nose,
first strike against that part ; whilst the mucous membrane
in that situation being much less rich in glandulae than that
of the external wall, is not so well protected by secretion.
The rapidity with which perforation occurs is due to the
thinness of the mucous covering, which leads to its ajH-edy
destruction by uleeration, coupled with the fact that tin-
cartilage itself receives its vascular supply solely from this
source, and therefore necessarily loses its vitality as soon
as the membrane is destroyed.

Snuff-takers seem to be exempt from the disease, and those
who have once suffered from it afterwards enjoy immunity
from common catarrh.

Delpech and Hillairet2 have reported four cases of an
analogous nature, in which perforation of the septum
occurred in individuals exposed to arsenical dust, principally
those who worked with " Schweinfurth green." The same
thing has been noticed among makers of artificial flowers and
wall papers, liberations of the nasal mucous membijme
have also been observed3 among those who use bichlorMe
of mercury in dyeing feathers and silvering mirrors.

The poisonous effect of these materials in such cases is
no doubt purely local, and is not the result of constitutional
absorption.

All persons employed in trades which cause the nasal
mucous membrane to be exposed to deleterious matters
should wear plugs of cotton-wool in their nostrils. Although
when perforation has once taken place it is difficult to pre-
vent the formation of a tolerably large hole in the septum,
the morbid action is strictly confined to a small area, be-
yond which its ravages never extend. The use of simple
sj trays will soon restore the surrounding mucous membrane
to a fairly healthy condition.

1 "Des Affections de la Cloison des Fosses nasales." Paris, 1876,
p. 42.

2 Loo. cit.

3 Casabianca : Op. cit.

HAY FEVER. 299

HAY FEVER.

(SYNONYMS : HAY ASTHMA. SUMMER CATARRH. ROSE
CATARRH.)

Latin Eq. — Catarrhus aestivus.
French Eq. — Catarrhe d'ete. Catarrhe de foin.
German Eq. — Friihsommer-Catarrh. Heu- Asthma.
Italian Eq. — Asma dei mietitori.

DEFINITION. — A peculiar affection of the mucous membrane
of the nose, eyes, and air-passages, giving rise to catarrh and
asthma, almost invariably caused by tlie action of the pollen
of grasses and flowers, and therefore prevalent only when they
are in blossom.

History. — The first detailed account of hay fever was given by
Bostock,1 who, in 1819, described a "periodical affection of the eyes
and chest," from which he was himself a sufferer. In 1828 2 this
physician published some further observations of the complaint,
under the name of " summer catarrh." A short paper on hay
asthma, by Gordon,3 appeared in 1829, and in 1831 Elliotson 4 gave
a brief description of the complaint. A few years later the same
physician5 discussed the subject more fully, and with characteristic
sagacity pointed to pollen as the probable cause of the affection.

A systematic inquiry into all the circumstances of the disease was
made in 1862 by Phoebus,8 of Giessen, whose own personal observa-
tion of the disease was, however, confined to a single case. Unlike
most of the other writers upon the subject, moreover, he did not
himself suffer from the complaint. His method consisted in issuing
circulars and advertisements inviting medical men all over the world
to send him answers to a series of questions so framed as to embrace
every possible kind of information about the causes, symptoms, and
progress of the disorder ; its periods of prevalence, geographical and
ethnological distribution ; and its prevention and treatment. In this
manner a vast quantity of facts and observations was collected, and
from these Phoebus endeavoured to extract a complete theory of
the disease. During the ensuing ten years pamphlets on hay fever
were published by Abbott Smith,7 Pirrie,8 and Moore,9 dealing with

i "Med.-Chir. Trans." London, 1819, vol. x. Pt. i. p. 161, et seq.
'•« Ibid. vol. xiv. pt. il. p. 437, et seq.

3 " London Med. Gazette." 1829, vol. iv. p. 266.

4 Ibid. 1831, vol. viii. p. 411, et seq.

8 " Lectures on the Theory and Practice of Medicine." London, 1839, pp.
516—527.

6 " Der typische Friihsommer-Katarrh." Giessen, 1862.
' " Observations on Hay Fever." London, 1865, 2nd ed.
8 "Hay- Asthma." London, 1867.
» " Hay-Fever." London, 1869.

300 DISEASES OF THE THROAT AND NOSE.

the disorder from various points of view, but all, more or less, show-
ing a disposition to limit the cause of its development to emanations
from plants.

In 1869 a theory of hay fever was propounded by Helmholtx,1
who was himself a sufferer from the complaint. He held that the
symptoms were produced by vibrios, which, although existing in the
nasal fossse and sinuses at other times, were excited to activity by
summer heat. He professed to have found a ready means of relict'
and even of prevention in the injection of quinine, which Bin/, had
shortly before shown to be poisonous to infusoria. Subsequent
experience has not confirmed Helmholtz's conclusions. In the follow-
ing year a short practical paper was published by Roberts,- in which
he claimed to have been the first to observe that excessive coldness
of the tip of the nose is " the pathognomonic " symptom of hay fever,
and desired to have due credit awarded for the discovery. In 1872
Morrill Wyman 3 discussed the disease as it prevails in America, and
tried to establish that two distinct forms of the complaint exist in
that country — one occurring in May and June, and corresponding
to English hay fever, and a later variety peculiar to America, which
he called " Autumnal Catarrh." In 1873 Blackley,4 of Man-
chester, published a work which is a model of scientific investigation.
By a most ingenious and carefully conducted series of experiments he
proved that in his own person at least the pollen of grasses and flowers
was the sole cause of hay fever, and that in the case of two other
patients the severity of the disease bore a direct relation to the amount
of pollen in the air. His subsequent observations make it extremely
probable, indeed almost certain, that though transient irritation of
the mucous membrane may occasionally be caused by simple dust,
pollen is in fact the true matcries morbi of summer catarrh. In 1876
a short treatise was published by Beard,5 of Xew York, in which
he dealt with the complaint as it is met with in the United States.
His information was collected chiefly by circulars after the manner
of Phojbus, but more fortunate than that observer, Beard had himself
seen and treated many cases. He received replies from over two hun-
dred patients, and on these data he came to the conclusion that the
immediate exciting causes are more than thirty in number, and that
further investigations may extend the number of secondary causes to
fifty or even a hundred. Beard showed clearly from his statistics
that a large proportion of the sufferers are of nervous temperament,
and that nerve-tonics are of considerable value in the treatment
of the affection. In 1877 an essay was published by Marsh,8 in
which he completely accepts the pollen theory. The influence of a
morbid condition of the nasal mucous membrane in favouring the
development of hay fever has been recently insisted on by Daly,7
Roe,8 and Hack.9

1 Binz: " Virchow's Archiv." February, 1809.

2 ' New York Med. Gaz," Oct. 8, 1870.

3 'Autumnal Catarrh." New York, 1872.

* ' Hay-Fever." London, 1873, and 2nd edit. 1880.

s ' Hay-Fever, or Summer Catarrh." New York, 1876.

« 'Hay-Fever, or Pollen-poisoning." Read before the New Jersey
Medical Society, 1877.

7 ' Archives of Laryngology." 1882, vol. iii. p. 157.

8 ' New York Med. Journ." May 12, 1883.
» ' Wien. Med. Wochenschrift." 1882-83.

HAY FEVER. 301

Etiology. — In accordance with the usual method, the
causes of hay fever may be conveniently divided into (a)
predisposing and (&) exciting.

a. The predisposing cause of the complaint is the pos-
session of a peculiar idiosyncrasy, but on what that idiosyn-
crasy 1 depends is quite unknown. Whether it is due to
some local abnormality affecting the structure of the mucous
membrane, the capillaries, or the periphery .of the nerves,
but of too delicate a nature to admit of detection by avail-
able methods of research, cannot be determined. The fact,
however, remains, that whilst millions of people are ex-
posed to the cause of the affection very few suffer from it.
The idiosyncrasy is generally suddenly developed without
apparent reason. Once acquired, however, it is seldom lost,
the predisposition seeming rather to increase with each re-
curring summer. The circumstances which are supposed to
influence this idiosyncrasy are race, temperament, occupation,
education, mode of life, sex, heredity, and aye. These various
points may, with advantage, be considered in detail.

The influence of race is seen in the fact that it is the
English and Americans who are almost the only sufferers
from the complaint. In the north of Europe — that is, in
Norway, Sweden, and Denmark — it is scarcely ever seen,
and it rarely affects the natives of France, Germany, Russia,
Italy, or Spain. In Asia and Africa, also, it is only the
English who suffer. As far as I have been able to ascertain,
the complaint is more common in the south of England than
in the north ; whilst in the north of Scotland it is very
rare. In America it occurs in nearly every State, though
diminishing in frequency towards the south. I think it
extremely likely that the disorder will be found in Aus-
tralia and New Zealand, but I am not aware that any cases
have yet been reported from those countries. In support
of the view that race has an important influence, Beard
mentions that Dr. Jacobi, whose practice in New York lies

1 In this respect the idiosyncrasy is like idiosyncrasies in general.
The existence of these personal peculiarities is too well known to
require much comment. Many people cannot eat crabs, lobsters, or
strawberries without being attacked with urticaria. Others, again,
cannot eat mutton or white of egg without being sick. One of the
most interesting cases of idiosyncrasy, and peculiarly appropriate
to the present subject, inasmuch as it was brought into operation
through the nasal mucous membrane, was that of Schiller, to whom
the smell of rotten apples was so beneficial that he could not "live
or work without it" (Lewes: "Life of Goethe." London, 1864,
2nd ed. p. 381).

302 DISEASES OF THE THROAT AND NOSE.

largely among Germans, has never met with a case of hay
fever in a patient of that nationality, and that Dr. Chavcau,
of the same city, has never observed the complaint amonir
his French compatriots residing there. Beard himself n»-vr
heard of a case amongst Indians or negroes, except the
instance related by Wyman, in which an Indian child was
the subject of the disease.

TJie nervousr temperament has undoubtedly a certain in-
fluence in predisposing to hay fever. This, of course, d<if-s
not mean that all the patients are highly nervous people ;
some are of nervo-bilious, others of nerve-sanguineous tem-
perament, but nearly all belong to the active, energetic class
of so-called nervous organization.

One of the most singular features of this complaint is,
that it is almost exclusively confined to persons of some
education, and generally to those of fair social position.
Whilst I have notes of sixty-one cases of hay fever from
my private practice,1 and have seen many others of which
I have kept no record, I have not met with one amongst
my hospital patients. Of forty-eight cases which came more
or less directly under the notice of Blackley, every one
belonged to the educated classes ; whilst out of fifty- five
cases reported by Wyman, in forty-nine the patients were
educated people. The influence of the mode of life is
shown in the fact that the rustic is much less subject to the
affection than the citizen. Thus farmers and agricultural
labourers, who of all people are most exposed to the disease,
very rarely suffer from it, there having been only seven
cases among the two hundred reports collected by Beard.
It is not possible to tell whether the villager owes his
exemption to the vigorous health maintained by an out-
door life, or whether habitual exposure to the cause of the
complaint begets tolerance ; but the fact remains, that
dwellers in towns are much more prone to the affection
than those who live in the country.

Sex has a distinct influence, many more men than women
suffering from the disease. Out of a grand total of 433
cases cited by Phoebus, Wyman, and Beard, only 142, or
about a third, were females. Against these statistics it may
be urged that the information on which they are based was
collected by circulars, to which, perhaps, women would be
less likely to reply than men. This objection, however,

1 This was written in 1879.

HAY FEVER. 303

floes not apply to my own cases, amongst which I met with
thirty-eight belonging to the male and only twenty-three to
the female sex.

Heredity has likewise a powerful influence. This has been
abundantly proved by Wyman and Beard, and it is supported
by my own observations. In Wyman's experience there was
heredity in 20 per cent, and in Beard's in 33 per cent. Out
of my sixty-one cases, in twenty-seven one or more near
relatives had suffered in the previous generation. I have also
several times treated father and children at the same time.

Aye to some extent governs the disorder. In the great
majority of cases the liability to hay fever appears before
the age of forty; but several instances have been reported
of the first occurrence of the malady in patients as old as
sixty. It is somewhat rare for this affection to show itself
in very young children, but I have seen it in one patient
at two years of age, and in another at three. In these cases,
as in all those of very young patients that have come under
my notice, the little sufferers were the 'children of parents
who had themselves been victims to the complaint. Had
not the parents been subject to the affection, it is most likely
that the true import of the symptoms would not have been
recognized in the children, but would have been attributed
to a common cold.

b. Exciting Causes. — A great variety of agencies have been
looked upon as the direct causes of this disease, but there
can now be little doubt that pollen is the essential factor
in the case of those who possess the peculiar predisposition.
Before, however, proceeding to show that pollen is the real
cause of the affection, it may be well to pass in review some
of the other sources to which its origin has been attri-
buted. The most important of these are heat, light, dust,
benzoic acid, coumarin, excess of ozone, and over-exertion, or
several of these influences in combination.

Heat. — Popular observation had already associated hay fever with
effluvia from grass or hay, at the time when Bostock, from his own
personal experience, put forth the view that the affection was due
to the influence of solar heat. The obvious difficulties in the way
of this theory led Phoebus to attribute the affection to " the first
heat of summer" which, he observed, "is a stronger cause than all
the grass emanations put together." Later on, however, Phcebua
remarked that " the first heat of summer only acts in an indirect
manner as an exciting cause ; " and he admitted that hay and the
blossom of rye cause exacerbations. Heat alone will not, however,
produce the disease. It is not met with in the plains of India when
the heat is greatest, though occasionally it is seen in the cooler

304 DISEASES OF THE THROAT AND NOSE.

months before the vegetation is burnt up. Hay fever is also found
in the milder climate of the Indian hills, when the grasses and ct/n-als
are in blossom. The intense heat of the desert does not prodm-i- tin-
disease, nor does it occur at sea in the sultry equatorial regions, though
the heat when vessels are becalmed, is sometimes almost beyond
endurance. In America, hay fever is much more common in autumn
than in the tropical summer of that country.

Light. — The observations as regards heat apply equally to light.
Phcebus thought that the longer days, which produce a more con-
tinuous action of light, are perhaps to blame; but where the light is
strongest and lasts longest, indeed in the land of "the midnight
sun," hay fever is almost unknown. At sea, when the sun is bright,
it is well known that nothing can exceed the glare ; yet a sea-voyage
is the best safeguard for the sufferer from hay fever. Persons with
a sensitive mucous membrane, especially those subject to hay fever,
are no doubt sometimes liable to attacks of sneezing from sun-light,
and incautious observers might mistake these symptoms for true hay
fever. Some of Beard's patients even attributed the affection to
gas-light, but gas-light is used much more in winter when hay fever
is absent, than in the English summer and American autumn, when
the affection prevails.

Dust. — This is a more difficult subject to dispose of. Most writers
who accept dust as a cause of summer catarrh, speak of " common
dust," but as Blackley remarks, there is no such thing as common
dust. The constitution of dust depends upon the geological character
of the soil , upon the vegetation which it supports , and on the
season of the year, as well as on "the number and kind of germs
and other organic bodies " present in the atmosphere. Beard's
statistics, if accepted without consideration, strongly point to dust as
the most common cause of hay fever, for out of 198 patients no less
than 104 attributed the affection to dust. Of these 198 cases, how-
ever, 142 occurred between May and September ; and it may well be
asked : How was it that dust did not affect these patients in the
winter months ? Does this not clearly point to the presence in the dust
of some special irritant during the summer and autumn months,
which does not exist at other times ? In England, in the months of
February, March, and April, when strong east winds often blow
clouds of dust against the face, symptoms of hay fever do not appear,
whilst in June and July, when there is comparatively little dust, hay
fever attacks its victims. It is true that in many of Beard's cases,
collected by circulars, the patients attributed the affection to ' ' indoor
dust," and some even to "cinders." But as people stay in the house
more in winter than in the autumn and summer, and use fires at
that time, these agencies, if of any real power, would produce their
greatest effect in winter. Directly the opposite, however, occurs.
Is it not highly probable, therefore, that these patients were misled as
to the real cause of the malady ? We all know how easy it is for the
trained physician to make erroneous observations and to overlook
important physical signs, and how much more likely is the untutored
patient to make a mistake in the obscure and highly complicated
problems of etiology !

Ozone, Benzoic Add, fyc, — An excess of ozone in the atmosphere was
suggested by Phoebus as a possible cause of hay fever, but Blackley
purposely breathed air highly charged with this substance for five or
six nours without effect. He, moreover, inhaled artificially prepared

HAY FEVER. 305

ozone, in quantities far exceeding what is ever found in the same
volume of atmospheric air, without feeling any inconvenience. The
same physician also studied the effects on his own person of benzoic
acid,1 coumarin (the odorous principle of many flowering grasses),
and of the volatile oils which impart to many plants, such as pepper-
mint, juniper, rosemary, and lavender, their characteristic perfume.
The results were in all these cases entirely negative.

Over -exertion, or prolonged exercise in the open air, never has any
effect in cold weather, or indeed at any other time except when grass
is in flower. Its influence, however, in aggravating hay fever, in the
hay season, is very great, and will presently be considered.

Combined Causes of Hay Fever. — Several writers have contended
that although any one of the above causes may not alone be
sufficient to produce hay fever, several of them acting together may
l)e able to do so. Such theories are the last resource of those who
are unable to discover the true etiology, and there is not a tittle of
evidence in their support.

Having shown what does not generate hay fever, its real mode of
origin must now be demonstrated.

1 This substance has been shown by Vogel to be contained in anthoxanthum
odoratuin and holcus odoratiu, the two species of flowering grasses to which the
causation of hay fever has been in a special manner attributed.

Blackley's observations leave no doubt that the cause of
hay fever is the acti<m of pollen on the mucous membrane*
His experiments were framed on a most comprehensive plan,
and carried out in a rigorously scientific spirit. By well-
devised tests he succeeded in proving — 1st, that in his own
person the inhalation of pollen always produced the cha-
racteristic symptoms of hay fever ; 2ndly, that in his own
case, and in that of two other persons, there was a direct
relation between the intensity of the symptoms and the
amount of pollen floating in the air ; and 3rdly, as already
shown, that none of the other agents referred to, such as heat,
light, dust, odours, or ozone, can of themselves cause the
complaint.

Blackley's experiments were made with pollen of various
grasses and cereals, and with that of plants belonging to-
thirty-five other natural orders.

The grasses which, as already stated, were at one time
considered to be especially active are the anthoxanthum
odoi-atum and the holcus odoratus, but this idea no doubt
originated in the extremely fragrant odour of these plants,
and there is no reason to suppose that their pollen is more
active than that of the alopecurus pratensis, and the various-
poce and lolice. The pollen of rye is, however, more potent
than some of these, and that of wheat, oats, and barley is
also very active. The careful observations of Blackley show

VOL. II. X

30G DISEASES <>!•• TIIK TH1«>.\T AM) N«>sK.

tliat in England, during the season of hay fever, ninety-live
per cent, of tlie pollen contained in the atmosphere belongs
to the i/ninii/Kif/'ii;. This order generally comes into full
blossom between tlie end of May ami the latter part of «/"/>/,
and that is precisely the period of the year when hay fever
prevails. If the season be wet and cold the disease usually
sets in rather later, and is milder in character than when
the weather is fine, and the vegetation luxuriant.

There are persons in whom the presence of roses will give
rise to an attack, and in America the affection is sometimes
called "rose fever." No doubt it is the pollen of the rose
which is the active agent. The celebrated Broussais1 appears
to have been impeded in his botanical studies by this idiosyn-
crasy, whilst the case related by Hiinerswolff2 of a man in
whom the perfume of roses invariably produced an attack of
coryza, has been often cited by modern writers. I have
myself met with a similar case. A lady living in Devonshire
consulted me in 1864, on account of constant severe coryxa,
which came on whenever she smelt a rose. All treatment
proved futile, and she was ultimately obliged to banish these
flowers from her garden.

In America the pollen of the Roman wormwood (ambrosia
artemisictifolia) appears to be the most common cause of
hay fever. This plant (which belongs to the genus ambro-
siacew, order compositor) is not met with in Europe, but is
extremely common in nearly every part of the United
States. Wyman 3 found that when a parcel containing
this plant was opened at White Mountain Glen, where he
had retired in order to avoid hay fever, he and his son
were immediately attacked with all the symptoms of the
malady. Tlie plant blossoms in Atujuat and Septa////' •/•, awl
it is tlien that luiy fever most prevails in America. Several
varieties of the artemisice, a closely-allied genus, are met
with in England, and I think it not improbable that some
cases of hay fever which have occurred at the seaside in
this country may have been due to the pollen of the
artemisia maritima, or its variety, arf<'///ixia ijaUica. It is
curious that, except in the case of Indian corn, the pollen of
ill-Haw* appears to have but slight effect in America, though
u mild form of hay fever is met with in that country from
May to August.

1 Anglada : "Du Coryza simple." These de Paris, 1837, p. 14.

2 " Epheni. Nat. Curios," dec. ii. ami. v. obs. xxii.

3 Op. cit. p. 101.

HAY FEVER. 307

There are certain supposed fallacies in the pollen theory
Avhich must be referred to. Thus a case is mentioned by
AValshe,1 in which the patient retained the symptoms of hay
fever during a passage across the Atlantic, and another has
been reported by Abbott Smith,2 in which the disease came
on at a distance of nine miles from land. These are, I
believe, the only authenticated instances in which hay fever
has continued to exist, or has originated at sea, and they are
open to various explanations. It has been distinctly shown
1 iv I Uackley that pollen may be retained in an article of dress
for many weeks, and in Smith's case, the patient, who was
yachting, experienced the symptoms after assisting " to hoist
the sails." The attack came on on the 13th of June, and it
is not unlikely that when the sails were unfurled a large
quantity of pollen collected in their folds was set free. In
Walshe's case, the symptoms may have been kept up by
some other irritant to which the patient may have had a
peculiar susceptibility, or the case may not have been a true
example of hay fever, but of ordinary asthma, complicated
with catarrh. It is not altogether impossible, however, that
pollen may be deposited on a ship miles away from land.
Darwin3 has shown that dust is sometimes thus deposited
far out in the Atlantic. " The dust," he observes, " falls in
such quantity as to dirty everything on board and to hurt
people's eyes ; vessels have even run on shore owing to the
obscurity of the atmosphere." Again, in speaking of the
distribution of pollen, Darwin reminds us that the ground
near St. Louis, in Missouri, has been seen covered with pollen
as if it had been sprinkled with sulphur, and there is good
reason to believe that this had been transported from the
pine forests at least 400 miles to the south.4 A shower
of yellow pollen was wafted to Philadelphia 5 from some
distant pine forest so recently as the 16th of March (1883).
It caused such a thick deposit as to lead ignorant people to
take it for brimstone. These facts are sufficient to show
that the influence of pollen may be experienced under
circumstances where it would not generally be looked for.

1 " A Practical Treatise on Diseases of the Lungs." London, 1871,
4th ed. p. 228.

" On Hay Fever." London, 1866, 4th. ed.

"Journal of Researches, &c." London, 1845, 2nd ed. p. 5.

4 "The Effects of Cross and Self- Fertilization in the Vegetable
Kingdom." London, 1876, p. 405.

5 " Philadelphia Med. News," April 7th, 1883.

308 IUSKASBS OF Tin: TIIUOAT AND NOSE.

"WhiUt userting that pollen is the universal cause of the

peculiar form <>f catarrh known as hay fever, I do nut mean
to deny that other irritating particles might produce a similar
complaint if persistently brought in contact -with the mucous
membrane. Thus, it is well known that powdered ipecacuanha
will in some persons cause a peculiar form of asthma duM-Iv
resembling hay asthma, and with many people the fnnp
burning sulphur have the same effect. I have frequently
observed slight attacks resembling hay fever produced by the
insufflation into the larynx of powdered lycopodium, and,
indeed, I have for this reason been compelled to give up tin-
use of this drug as a diluent for medicinal powders. Some
people experience symptoms somewhat analogous to those . .f
hay fever from smelling certain fruits, whilst others are
troubled in the same way by the presence of cats, rabbits,
and guinea-pigs, and Bastian l suffered from an affection
closely resembling hay fever in dissecting the awn-i* nn><ialn-
n'jiJia/a, a parasite which infests the horse. If the specific
exciting influence is kept in operation on a person sxibject to
an idiosyncrasy of this kind, a complaint almost precisely
similar to hay fever is produced ; but as a rule, the conditions
leading to its manifestation are exactly known by the patient,
and can therefore be avoided. The etiological peculiarity <>f
hay fever consists partly in the fact that the idiosyncrasy as
regards pollen is more common than other individual suscep-
tibilities, but chiefly in the circumstance that at certain
seasons pollen exercises its influence over wide areas, and
can be excluded only with great difficulty.

In a recently published article, Daly,2 of Pittsburg, has
endeavoured to show that in a large proportion of cases
there is an intimate relation between hay asthma and chronic
nasal catarrh, and that except when disease of the nasal
mucous membrane exists the alleged exciting cause of sum
mer catarrh is inoperative. He rejx>rts two cases of thicken
ing of the turbinated bodies, and one of polypus, in which,
after the cure of the local condition, the patients lost their
susceptibility to hay fever. These ]>ersons had suffered from
summer catarrh for twenty-one, fifteen, and six years respec-
tively. Roe3 and Hack4 have since enunciated similar views
to those propounded by Daly. It is not at all unlikely that
au unhealthy state of the mucous membrane of the nasal

1 "Philosophical Transactions." 1866, vol. c-vi.

'-' " Archives of Laryngology." 1882, vol. iii. No. 2.

3 Lor dt ' 4 Loc. cit.

HAY FEVER. 309

fossa may predispose to hay fever, hut I may remark that
I have repeatedly examined the interior of the nose in cases
of hay fever without finding anything more than general
congestion.

Symptoms. — The disease shows itself under two well-
marked types, the catarrhal and the asthmatic. In the former
the onset is very sudden, the patient becoming conscious of
an itching, smarting sensation in the nose and eyes, and
sometimes in the fauces and roof of the mouth. Not un-
frequently the attack commences with a feeling of extreme
irritation at the inner canthi. Paroxysms of sneezing, often
of extreme violence, quickly ensue, fallowed by an abundant
thin discharge from the nose. The mucous membrane of
the nasal fossae swells so as to block up the passages and
make respiration through them impossible. At the same
time there is profuse lachrymation with much pricking and
stinging of the conjunctiva! surfaces and sometimes photo-
phobia. There is often a certain amount of chemosis,
and occasionally the eyelids become puffed so as almost to
close the eyes. The discharge from both nose and eyes
gradually grows thicker, and sometimes becomes even semi-
purulent in character. There may be severe neuralgic pain
in the eyeballs and over the back of the head. Now and
then there is some degree of pyrexia, but this is by no
means the rule. The disorder often varies considerably in
intensity, even in the same person within short intervals of
time, so as almost to give an intermittent character to the
complaint. This is due to the varying quantity of pollen
present in the atmosphere, the severity of the disease being,
as a rule, in direct proportion to the abundance of the
iitafi-rifx moi'bi. An attack lasts from a few hours to several
days, or even longer, finally ceasing almost as suddenly as it
set in, and leaving little or no trace of its presence either in
local lesion or systemic disturbance. In some patients hay
fever is accompanied by nettle rash.

The asthmatic form of the complaint may be superadded
to the disorder just described, or may constitute the entire
affection. It generally comes on in the day-time, and the
paroxysm may pass off in a few hours, the patient first
expectorating a little ropy mucus and later an abundant
frothy secretion, or there may be only a slight remission,
the dyspnoea continuing as long as the sufferer is exposed
to the influence of pollen. The attacks seldom produce any
emphysema, and the patient sooner or later entirely recovers

310 DISEASES <>K T1IK THKoAT AND NOSE.

fitt. — From the resemblance of hay fever to
catarrh on the one haiul, and to spasmodic asthma <m the
other, mistakes in diagnosis were formerly very common ;
hut tin- disea-e is no\v so well known that errors an- not likely
to occur. The first attack might perhaps he confounded
with ordinary coryza ; hut the suddenness of the onset, the
characteristic oedematous pufiiness of the eyelids, toother
with the alisence of constitutional symptoms, will speedily
lead to a truer diagnosis. People who are prone to catarrli
are very apt to catch cold in the changeable weather of
the spring and early summer of this country, and these cases
are sometimes mistaken for hay fever ; but the readiness
with which they yield to anti-catarrhal treatment at once
shows their real nature.

The asthmatic form of hay fever may, in some instances,
be less easy to recognize ; but the history of the case will
generally guide the practitioner to a correct opinion. The
fact that hay fever often comes on in the day-time, out of
doors, and in the summer, whilst paroxysms of true asthma
most frequently occur in the evening or night, indoors, and
in one of the other seasons of the year, may help to differ-
entiate the two complaints.

Proynn#i#. — This is in all cases favourable as regards the
termination of each attack ; o-.^ajitf ran*", f>-.<--t(t ^/fi-tit*.
"When the season of flowering grass is past the complaint
will certainly depart ; but it will almost as surely reappear
whenever the patient is again exposed to the action of
pollen.

Patholoyy. — Hay fever leaves no permanent structural
lesion behind it. Blackley thinks that pollen has a peculiar
and specific effect in causing dilatation of the capillaries and
exudation of serum from them ; but it appears to me highly
doubtful whether this is anything more than the reaction
which follows the application of an irritant.

Treatment. — In no disease is the old adage, that " preven-
tion is better than cure," more truly applicable than in the
case of hay fever. If the poison be continually introduced
into the system, the antidote, if one exists, can have but
little chance of effecting a cure. The first measure, there-
fore, must be to remove the patient from a district in which
there is much flowering grass. A sea-voyage is probably
the most perfectly satisfactory step that can be taken.
Patients who are unable to go to sea should endeavour to
reside at the seaside, when- they will generally be free from

HAY FEVER. 311

their troublesome complaint, except when land-breezes blow.
Dwellers in towns should avoid the country, and those who
reside in the country should make a temporary stay in the
centre of a large town. It often happens, however, that such
:. change of abode is not practicable, and, under such circum-
stances, if the complaint is very severe, the patient should, if
possible, remain indoors during the whole of the hay season.
Many persons, of course, cannot keep to the house during the
month or six weeks of the hay fever period ; and those who
can, are apt to find such detention not only exceedingly
irksome, but very injurious to the health. If, therefore, a
patient is obliged to go out of doors he should plug his
nostrils with cotton-wool or wadding by means of Gottstein's
screw (Fig. 73, p. 282), and should defend his eyes by wear-
ing spectacles with large frames, accurately adapted to the
circumference of the orbits.1 Protected in this way, many
people predisposed to hay fever escape altogether, whilst
others contract the affection in a very mild form.

As the disease most commonly occurs in persons of
nervous temperament, nerve-tonics and other constitutional
remedies have been used for the purpose of warding off
hay fever, or controlling the violence of its attacks.
Amongst these, quinine, arsenic, opium, and belladonna
have been employed, but I have found valerianate of zinc,
in combination with assafcetida, more valuable than any
other drug. I usually give the remedy in the form of pills
containing one grain of valerianate of zinc and two grains
of the compound assafcetida pill. I direct my patients to
begin taking these pills as the hay season approaches, and
under the use of this remedy, persons who formerly suffered
most severely from hay fever have in many cases ceased to
be troubled with it.

When the disease is established, tincture of opium is of
great benefit in controlling hay asthma, reducing the secre-
tion, diminishing the sneezing, and at the same time bracing
up the nervous system. It should be given in the manner
recommended for acute catarrh (p. 290), but continued for a
longer time. Belladonna has been recommended, but I have
had no experience of its use in this complaint.

I trust very little to local measures in the treatment of
hay fever, but when there is profuse secretion with an ex-
cessive tendency to sneeze, the inhalation of strong ammonia

1 Both the screw and the spectacles are sold by Messrs. Mayer and
Meltzer, Great Portland Street.

312 DISEASES OF THE THROAT AND NOSE.

salts often gives great relief. I have not found injections
of quinine, as recommended by Helmholtz, at all useful.
Though in a few cases benefit was derived, in mo.-t in-
stances no effect was produced, whilst some patients were
actually made worse. The Vapor Uen/.oini of the Throat
Hospital Pharmacopoeia has occasionally produced a soothing
effect, and I have also seen good results from insufflations into
the nose of a powder consisting of one-sixteenth of a grain of
morphia and one grain of bismuth. This should be upplie.1
several times a day. Fender's snuff (see Appendix) may lv
substituted for the above formula, but it should be applied
by insufflation.

In a few cases I have seen some benefit from the use
of medicated bougies, such as the bisnmth, and acetate of
lead Buginaria of the Throat Hospital Pharmacopoeia (see
Appendix), bxit, like quinine, they occasionally aggravate the
mischief they are meant to cure.

The upper lip and the margins of the nostrils should
be smeared over with benzoated zinc ointment two or three
times a day.

For the relief of the irritation of the eyes, frequent bathing
with very cold water is sometimes useful, though Rolwrts l
appears to have found more benefit from warm and slightly
salt water. Sulphate of copper (gr. ij. ad jy.) or sulphate of
zinc (gr. ij. ad §j.) may sometimes do good, but I have found
a lotion containing two grains of acetate of lead with two
drops of dilute acetic acid in an ounce of water, the most
soothing application.

Asthmatic patients often derive benefit from inhaling the
fumes of nitrated blotting paper (see Appendix, Vol. i. p.
576), the good effect of which is further increased by steep-
ing the paper in a solution of stramonium, datura tat u la,
belladonna, or lobelia.

CHRONIC NASAL CATARRH.

Latin J%j. — Catarrhus longus.
Fri'itrli Eq. — Coryza chronique.
ti'i-nian Eq. — Chronischer Nasencatarrh.
Italian E<I. — Corizza cronica.

DEFINITION. — Chronic inflammation of tin- linim/ nt>-,,i-
brane of the nasal fossa; cliaractcrized Iry sicdlinrj of the
1 "New York Med. Gaz." Oct. 8, 1870.

CHRONIC NASAL CATARRH. 313

mucous membrane, by increase in the natural secretion, by
more or less obstruction of the nasal passages, nasal voice,
and impairment or loss of smell. The affection sometimes
causes a watery flux, and when neglected may give rise to
great hypertrophy of the turbinated bodies.

History. — Since the issue, many years ago, of Cazenave's1 two
papers, little attention was directed to the complaint until it began to
be studied by American physicians. Excellent practical articles
have recently been published by Solis Cohen,2 Beverley Robinson,3
and Bosworth ; 4 whilst Rum bold 5 has given his views on the disease
at great length. In Europe the subject has been treated by Michel,6
TilTot,7 Liiwenberg,8 and Bresgen.9

1 "Sur le Coryza chronique." Paris, 1835; another article, 1848. This
physician practised at Bordeaux, and must not be confounded with his cele-
brated namesake of Paris.

2 " Diseases of the Throat and Nasal Passages." New York, 1879, 2nd ed.
p. 346, et seq.

3 "Practical Treatise on Nasal Catarrh." New York, 1880, p. 69, et seq.

•4 " Manual of Diseases of the Throat and Nose." New York, 1881, p. 179, et seq.

5 " Hygiene and Treatment of Catarrh." St. Louis, 1880.

6 " Krankheiten der Nasenhbhle." Berlin, 1876.

7 " Annales des Maladies de 1' Oreille, etc." 1879.

8 " Union Medicate." July 28, 1881.

9 " Der chronische Nasen und Rachen-Katarrh." Wien und Leipzig, 1883.

Etiology. — The commonest cause of chronic catarrh is
the previous occurrence of acute attacks. The most obsti-
nate cases are generally supposed to depend on the strumous
diathesis, or to occur in persons who have suffered from
constitutional syphilis ; but I have sometimes found the
complaint very intractable when there was not the slightest
evidence of any constitutional taint. The disease may com-
mence at any period of life, but is most common in child-
hood, when it is occasionally caused by the presence of
adenoid vegetations in the naso-pharynx. In the aged it
often assumes the character of a mild flux, producing the
" bead ". at the end of the nose, made so familiar by cari-
caturists. Chronic catarrh may be induced by any of the
various causes referred to in connection with acute catarrh,
such as the inhalation of irritating vapours, or of solid
particles suspended in the atmosphere. Snuff-takers and
spirit-drinkers are generally subject to chronic catarrh of
the nose, and whilst the affection is occasionally the cause,
it is often the consequence of a polypus in the nasal cavity.

Symptoms. — An increased secretion of mucus is the most
common symptom of chronic nasal catarrh, but the patient
almost always experiences a feeling of " stuffiness " in the
nose. There is often sufficient obstruction to interfere with
nasal respiration, and the well-known alteration in the

314 DISEASES OF THE THKOAT AXD NOSE.

character of tin- voice, already described in dealing with
acute catarrh (pp. 288, 289), is produced. The patient in such
a coiitlitiim is popularly said to speak " through his n
though as a matter of fact tin- peculiarity is due t«> obstrue-
tion of the nasal passages. The affection sometimes extends
to the naso-pharynx, and may even spread up the Kustachian
tube, and give rise to catarrh of the middle ear and serious
deafness.1 In severe cases the tear-duct is often obstructed,
and, as Bresgen2 has pointed out, even when the complaint
is slight the skin of the nose, especially near its tip, is
generally red.

Occasionally, on the other hand, the complaint eonsi.-ts
of a constant running of watery fluid from the nose, con-
stituting a veritable rltinnrrlm'a, the secretion be ing sometimes
so abundant as to cause the greatest inconvenience. I have
treated several cases in which the patient has been obliged
to use fifteen or twenty pocket-handkerchiefs in a single day,
and one in which from thirty-two to thirty-five were required
daily for a fortnight. A good example of the affection is
related by Morgagni,3 in which a woman suffered from a
discharge of " watery fluid " from the left nostril (after the
other symptoms of an ordinary catarrh had left her) for
several months. About half an ounce passed every hour, and
the patient, who had been fat and florid, wasted away. < Mi
the stoppage of the rhinorrhoea she recovered weight. The
same writer quotes from Bidloo an instance, apparently "f
traumatic origin, in which twenty-five ounces of pale fluid
were discharged from the right nostril in twenty-five hours.
A still more remarkable case is related by Elliotson,4 where

1 Dr. Rumbold, whose work on catarrh has already been referred
to, states (Pt. ii. pp. 239, 240) that in the course of eighteen years
of practice he has " had many patients, amounting to several hun-
dred, whose mental condition has been more or less affected by this
inflammation extending from the nasal j>assages to the membranes

of the brain Uncontrollable melancholia and dissatisfaction,

inability to think consecutively, to recollect the common matters of
life, to add up a column of figures, to remember immediate relations'
names," are some of the distressing symptoms exhibited by Dr.
Rumbold's patients. Others forget even their own names, whilst
one unfortunate gentleman, whose nose was no doubt in an excep-
tionally morbid state, "experienced the sensation, while walking.
that he was sinking into the pavement up to his knees." Such
complications of catarrh, however, are fortunately not met with in
this country.

2 Op. cit. p. 70.

3 " De sedibus et causis morboruni," epist. xiv. sec. 21.

4 " Med. Times and Gaz." Sept. 19, 1857.

CHRONIC NASAL CATARRH. 315

a lady on two different occasions suffered from profuse dis-
charge of watery fluid from the left nostril, the first attack
having lasted eighteen months, and the second twenty-three.
It was estimated that during the first attack she passed one
hundred and ninety-three gallons of fluid in all, whilst during
the second, three quarts were discharged in a single day. On
the first occasion the affection ceased suddenly without any
apparent cause ; on the second it stopped gradually under
the internal and local use of sulphate of zinc prescribed by
Sir Benjamin Brodie,1 but as no amelioration Avhatever took
place during the first three weeks of this treatment, Elliotson
doubts whether the remedy really had any effect in con-
trolling the disease.

It will be understood from the above description of the
very varying character of the secretion that the condition of
the mucous membrane itself must differ greatly in individual
cases. On examining the nose in ordinary cases of chronic
catarrh the mucous membrane is seen to be red and succu-
lent, and covered here and there with patches of thick, moist,
yellow secretion, or Avith a few thin flakes of dried mucus.
In rhinorrhoea, on the other hand, the lining membrane is
usually pale and sodden. If the disease exists for any
length of time, some of the morbid changes described in the
next article may be seen. In all cases of chronic inflamma-
tion, abrasions of surface are apt to occur, and these some-
times give rise to small ulcers, causing great annoyance by
exciting a sensation of tingling and heat in the nose, which
often leads the patient (especially if a child) to pick off the
scabs and thus increase the irritation. The ulcers most
frequently form in the mucous membrane covering the carti-
laginous septum just inside the nose, and in neglected cases
perforation may take place, and a permanent aperture result.

Diaf/nosis. — If a complete examination can be made, and
it can be ascertained that neither polypi, polypoid tumours,
nor post-nasal adenoid growths are present, there will be no
difficulty in determining the nature of the affection, which,
indeed, is generally quite obvious. It is only in cases of
severe rhinorrhoea that any doubt can arise, and in these
it must not be forgotten that excessive discharge of a watery
fluid from the nose may be caused by a polypus in the
antrum,2 or may be of reflex character arid result from disease

1 Quoted by Elliotson, loc. cit.

a Paget: "Trans. Clin. Soo." 1879, vol. xii. p. 43, ct se(j.

316 DISEASES OP THE THROAT AND NOSE.

«>r injury of the fifth nerve,1 from optic neuritis,2 and pro-
bably from even more remote sources of irritation.

/'/•«<//'"•"•'•-•• -With ordinary care a favourable n-sult may
always l>e predicted, but there is a great tendency t<> recur-
rence in the old, the very young, and in persons of debili-
tated constitution. It is most important, however, to cure
every case as quickly as possible, esjM-cially in young children,
lest the disorder should lead to hypertrophy, or possibly to
atrophy and ozaena.

PathnJfHjy. — Little is known as to the local condition
in ordinary chronic catarrh of the nose, but it is likely that
the usual phenomena characterizing chronic inflammation
in mucous membranes are exhibited in such cases. Infiltra-
tion of the sab-epithelial connective layer, with consequent
thickening and induration of the membrane and atrophy of
the glandulse owing to the pressure exercised on them by
the tissues in which they are imbedded, probably constitute
the sum of the morbid changes to which chronic catarrh
gives rise within the nose, though the troublesome sequehe
detailed in the next article are not unlikely to occur in
protracted cases.

Tri'dtmi'iit. — Astringent washes, douches, and sprays are
generally the best remedies, but it is very important to re-
member that the mucous membrane of the nose will not bear
nearly such strong medicaments as the pharynx or larynx.
Simple alkaline solutions, such as bicarbonate of soda (gr. x.
a'l 5J-)> often answer perfectly well, but the remedy which
I have found most effectual is the " compound alkivline
wash " (see Appendix, Nasal Washes). Several of the collu-
naria contained in the Throat Hospital Pharmacopoeia are
sometimes of service, especially the coll. acidi tannici, and
the coll. aluminis. If washes and douches cause pain, sprays
may be employed, and they are likely to be most useful
when the secretion is thin and abundant. In such cases I
have known a spray of tannic acid (gr. iij. ad 33.), or
alum (gr. iv. ad sj.), rapidly effect a cure in cases that
have been going on for months and even years. If solu-
tions do not succeed, some of the astringent or sedative
powders, the formula? for which will lie found in the
Appendix, may be blown into the nose once or twice
daily by the patient with Bryant's auto-insufflator, or the

1 Althaus: "Brit. Med. Journ." 1868, vol. ii. p. 647, et sea.
- Xettleship : " Ophthalmic Review." Jan. 1883, vol. ii. No. 15,
p. 1, et seq. Priestley Smith : Ibid. p. 4, et seq.

HYPERTROPHY OF THE NASAL MUCOUS MEMBRANE. 317

same class of remedies may be employed as snuff. Porter,1 of
St. Louis, has found the frequent use of a snuff composed of
camphor, tannic and salicylic acid very advantageous. In
long-standing cases medicated bougies, as first recommended
by Catti,2 are often of great service, the Buginarium bismuthi,
and the B. plumbi acetatis (Tliroat Hospital Phar.) being
especially efficacious. Should there be much swelling of the
mucous membrane a gum-elastic bougie (p. 254) should be
passed into the nose every day, and at first allowed to remain
in situ for a few minutes. This period may be gradually
extended to half an hour, a larger instrument being used as
the passage widens.

In some cases, however, every kind of local treatment
seems only to irritate, whilst a cure can be quickly effected
by keeping the mucous membrane at rest. With this view
it is very important that the patient should be directed not
to blow his nose, the forcible removal of the mucus causing
an increased flow of blood to the part, and consequently a
more copious secretion. If the patient will submit to the
slight inconvenience occasioned by the collection of mucus,
and merely wipe, the nose from time to time, the secretion will
diminish, and will soon cease to be troublesome. Sneezing
should, if possible, be prevented in the manner already recom-
mended (p. 291). Should hypertrophy of the mucous mem-
brane take place, the case will probably require to be treated
by some of the various measures described in the next article.

In obstinate cases, and especially when old persons are the
subjects of the complaint, constitutional treatment of an
analeptic and tonic character should be carried out, and
above all things, such patients should be enjoined to seek,
if possible, a warm and dry climate. Where the complaint
is of a secondary character, the original malady must be
removed before a cure can be looked for.

HYPERTROPHY OF THE MUCOUS MEMBRANE
OF THE NOSE.

When chronic catarrh of the nose has existed for some
years, and, indeed, in children of scrofulous type, when it
has troubled the patient for only a few months, great

1 "St. Louis Med. and Surg. Journ." Dec. 1875.

2 " Zur Therap. d. Nasenkrankheiteii." — "Wien. ined. Zeitschr."

1876.

318

i> <>K I UK THKOAT AM

thickening "f the mucous membrane sometimes takes place,
This hypertrophy may involve either the front or liaek portion
of the nasal passages. The colour of tlie swollen mucous
membrane is generally bright red in front, but of a duller
red or purple tint in the posterior portions of the D
Tlie anterior extremity and the whole lower border of tin-
inferior turbinated body is perhaps the most common site of
the hypertrophy, which in the latter situation is occasionally
so considerable as completely to block up the inferior meatus.
Less frequently the middle turbinated bodies are the seat of
hypertrophy. When the thickening affects the posterior
part of the lower turbinated bodies, instead of producing
a more or less uniform swelling of the tissues, it more
often leads to the development of numerous dark red or
purple polypoid vegetations, giving the turbinated body a
somewhat mulberry-like appearance (Fig. 75). Sometimes

FIG. 75. — HYPERTROPHY OF BOTH TURBINATED BODIES.
(SEEN FROM BEHIND.)

FIG. 76. — SHOWING THE PALE VARIETY OF HYPERTROPHIED Tissi K.
(SEEN FROM BEHIND.)

the growths are pale, and appear to hang down from the
choanae towards the uvula (Fig. 76). These excrescences

HYl'SRTROPHY OF THE NASAL MUCOUS MEMBRANE. 319

bleed readily, though only slightly, when touched. Whether
the hypertrophy involves the anterior or the posterior por-
tion of the turbinated bodies, if at all considerable, the
swelling is almost always bilateral, and generally symmetri-
cal. Occasionally the septum is greatly thickened, the hyper-
trophy usually occurring at the lower and back part.

The symptoms are the same as those of ordinary chronic
catarrh, but intensified, the patient being often quite
unable to blow his nose, and being obliged to breathe
entirely through the mouth. The voice is persistently
nasal, and the patient, if a child, always keeps the mouth
open, presenting the well-known stupid appearance which
has already been described in connection with the subject of
enlarged tonsils (Vol. i. p. 62). It has recently been noticed
by several physicians that obstruction of the nasal passages
is apt to give rise to very troublesome reflex phenomena, such
as asthma, cough, and even epilepsy, complications which
will be considered in dealing with polypus of the nose (see
p. 360, et seq.). These phenomena, however, are not nearly
so frequent in cases of simple hypertrophy as in polypus, the
probable reason being, as suggested by Hack,1 that the morbid
alteration of structure destroys the cavernous tissue, dimi-
nishes sensibility, and thereby lessens reflex excitability.

The diagnosis is easy, for a careful examination with the
speculum and rhinoscope will usually reveal the nature of
the case. Those, however, who are not practised in the
examination of the interior of the nose sometimes mistake
a thickened condition of the mucous membrane covering
the lower spongy bone for a polypus. It is only necessary,
however, to bear in mind the fact that hypertrophy is nearly
always bilateral, and in most cases symmetrical, a circumstance
which generally serves to differentiate the affection from
polypus. Moreover, catarrhal thickening chiefly affects the
lower turbinated bodies, whilst true polypi, as a rule, spring
from the mucous membrane covering the middle and upper
bones or the corresponding meatuses. Cases not unfrequently
occur, however, in which polypi and hypertrophy coexist,
and occasionally one of these conditions conceals the other.
Gottstein2 has pointed out that it is not always possible at
first to distinguish between the swelling produced by chronic
perichondritis and that due to simple hypertrophy. In a
very instructive case related by that observer, the appearance

1 "Neue Beitrage zur Rhinochirurgie. " Wien, 1883.

2 "Berlin, klin. Wochenschrift, " 1881, No. 4.

320

IHSKASKS (>F TIIK THUoAT AM> MiSK.

was entirely that of hypertrophic catarrh ; but after an
absence of two months the patient, who meanwhile hail
remarked m> change in his symptoms, returned with ex-
tensive destruction of the septum, due to the perichondritii
which had doubtless existed all al<

The /Hif/ni/tit/i'i-df <-lini«ii'* which sometimes result from
chronic nasal catarrh are no doubt largely due to the peculi-
arly vascular and cavernous structure of the turbinated bodies
(see Anatomy, p. 236). The hypertrophy occasionally pro-
duces an appearance somewhat resembling in form faejtoceulut
of the cerebellum, but of a bright pink or deep red colour.
This is well shown in the annexed cut (Fig. 77),' copied

Fl(J. 77. — HYPERTROPHY OF THE POSTERIOR THREE-FOURTHS OF 1 III:

LOWER TURBINATED BODY. FROM SPECIMEN No. 2201c ix THI:
ROYAL COLLEGE OF SURGEONS' MUSEUM.

(The outline of the nose has been added by the artist.)

from a specimen in the Museum of the Royal College of
Surgeons. The morbid process has been carefully studied
and well described by Bosworth1 and Seiler.2 From the
investigations of these observers, it would seem that the

1 "Trans. Intern. Meil. Congress." London, 1881, vol. iii. p. 327,
et sen. ; and " The (New York) Medical Record," June 10, 1882.

2 Philadelphia "Med. Times," Jan. 14, 1882. See also the report
of a case by Thierfelder ("Atlas der path. Histol." Lief. 1) referred to
by Seiler.

HYPERTROPHY OF THE NASAL MUCOUS MEMBRAXE. 321

changes which take place are similar to those commonly ob-
served in chronic inflammation of mucous membranes. Thus
the epithelial cells are increased in number, and though show-
ing no marked tendency to desquamation, are seen here and
there to be undergoing fatty degeneration ; the basement mem-
brane is thickened, the mucosa densely infiltrated with small
cells ; the glands and their ducts are filled with proliferating
epithelium, the blood-vessels increased, both in size and in
number, and the trabeculae and sinuses greatly enlarged.

There is no doubt a close connection between thickening
of the nasal membrane and genuine polypus. The two
conditions are frequently found associated, and a good illus-
tration of this is afforded by a specimen in the Museum of
the College of Surgeons, a woodcut of which will be found
further oil (see Fig. 79, p. 365). Some cases classified as
hypertrophy of the nasal mucous membrane are also pro-
}>ably of papillomatous nature (see "Papilloma of the Nose").

The prognosis is favourable, for almost every case can
be cured by suitable treatment.

The treatment frequently needs to be of a vigorous cha-
racter, but at an early stage the mildest measures are some-
times sufficient, the daily use of gum-elastic bougies often
effecting a cure. The smallest size of instrument should, as
a rule, be used at first, and at the beginning of the treat-
ment the bougie should be left in the nose for no longer than
five minutes at a time ; after a few da}rs, however, it may
remain in situ from ten minutes to a quarter of an hour, and
at the end of a week it can be easily tolerated for half an
hour. Larger bougies should afterwards be employed, but
force must be carefully avoided. Mild alkaline sprays or
hand-washes are often of great service if the treatment is
perseveringly carried out. Sneezing must be checked by
smelling strong ammonia or acetic ether.

Should this plan not succeed more active steps must be
taken ; but a word of caution is perhaps necessary in con-
nection with this point. For, though the introduction of the
electric cautery and the wire ^craseur permits some relaxa-
tion of the rule under which surgeons were taught " to cut
through everything soft, to saw through everything hard,
and to tie everything that bleeds," the spirit of this simple
instruction has, I fear, in recent years, sometimes influenced
the young practitioner, and the nasal passages have occa-
sionally been " cleared " with a zeal and energy worthy of the
industrious backwoodsman. In several cases that have come

VOL. II. Y

:'.-!'J DISEASES OF THK TIIKOAT AM) KO

under my own can-, in which severe measures had previously
been urgently advised by others, I have succeeded in t-H'-rt-
ing a cure by the simple removal of all causes of irritation
and the persevering use of gentle dilatation. I would al-o
warn some of my younger <•«////>•/>•>• that as the appearance
of the interior of the nose varies iniinensely in hi-althy
persons, it is unnecessary, where no inconvenience is felt,
to restore geometrical symmetry to the turhinated lilies, or
to invest the lining membrane of the nose with artist it-
merit. But whilst deprecating unnecessary aggression in this
•tender region, I do not deny that there are many cases which
can only be cured by active treatment.

Should the hypertrophy resist the measures already recom-
mended, the redundant tissue must be destroyed or removed.
Destruction with electric cautery will be found the most
simple and efficacious method. If the thickening is in tin-
anterior part of the nose, the nostrils should be well dilated
with a speculum, and the exuberant tissue carefully destroyed
with the porcelain knob electrode, or removed with the hot
loop (see Vol. i. p. 508, Fig. 101, c and d), or a number of
slight lines may be burnt with the spatula-like points (Vol i.
Fig. 101, a). If the thickening affects the central portions of
the turbinated bodies Lb'wenberg's electrode (p. 273) answers
well, and when the posterior part of the middle turbinated
bodies is involved, Lincoln's instrument (Fig. 61, p. 273)
will be found very serviceable. In applying electro-cautery, as
already remarked, I endeavour to avoid employing a protect-
ive shield, the loss of space and contracted field of vision
involved in the use of such an instrument often more than
neutralizing any advantage which it may possess. Some-
times, however, when the swelling is very great, a shield
is required, and in these cases I find Shurly's instrument
(see p. 255) the best. Instead of electric cautery Paquelin's
thenno-cautery, as modified by Goodwillie,1 can be tried :
but as this instrument has to be introduced red hot, it is
more likely to cause accidental injury than electric cautery,
and it can seldom be used except when the patient is under
chloroform. Those who have neither this instrument nor
any convenient electric apparatus at hand, can destroy the
redundant tissue by means of London paste (Thr. Hosp. Ph.),
nitrate of silver, or glacial acetic acid. The two first-named
caustics can be readily applied with the pharyngeal spatula

1 Bcvorley Robinson: "Practical Treatise on Nasal Catarrh."
New York, "1880, p. 111.

HYPERTROPHY OF THE NASAL MUCOUS MEMBRAXE. 323

(Vol. i. p. 9), whilst nitrate of silver can be brought into
contact with the hypertrophied tissue either with Schrbtter's
(Fig. 40, p. 257) or Andrew Smith's instrument (Fig. 41,
p. 258), or with Allen's wires (p. 258). Bosworth1 has found
glacial acetic acid of greater value than any other caustic,
and Sajous2 has also strongly recommended this remedy.

Instead of destroying the hypertrophied tissue, however,
it may be removed by a cutting operation. For this pur-
pose either a snare or sharp forceps may be employed.
Jarvis's3 ecraseur (p. 271) is an excellent instrument, whilst
my own (p. 272) will be found very convenient. When the
anterior part of one of the turbinated bodies is enlarged
it should first be transfixed with a needle mounted in a
light handle, the loop of the ecraseur being then passed over
the needle, and gradually drawn round the hypertrophied
membrane. If the posterior extremity of the turbinated
body be the part affected, such a bend should be given to the
loop before it is pushed through the nose that it will pass
over the mass in the naso-pharynx. Two or three turns of
.Jarvis's screw, or a few touches of the lever of my instrument,
will suffice to secure the growth, which, if haemorrhage is
anticipated, should be cut through very slowly, the operation
being interrupted from time to time, and not completed for
half an hour or even an hour. In these cases it will be
found much more easy to remove the swollen tissue with the
ecraseur passed through the nose than to destroy it through
the naso-pharynx. Beverley Robinson 4 has successfully
removed hypertrophied tissue from the turbinated bodies by
means of his strongly-toothed forceps (p. 267), but this
treatment appears to be much more severe than either the
electric cautery or the wire ecraseur.

1 "Diseases of the Throat and Nose," New York, 1881 ; and " New
York Medical Record," June 10, 1882.

- "Med. and Surg. Reporter." Dec. 31, 1881.
3 " New York Medical Record." 1881.

* Op. cit. p. 114.

'._' I DISEASES OF THE THHOAT AND NOSE.

DKY1 CATARRH OFTEN LEADING TO OZ.KNA.-

K<I. — Catarrhus siccus abiens stepe in ozaenam.
French Eq. — Coryza sec <;<>nduis;tnt souvent a I'ozt'-in'.
ili'i-nutit /v/. -Trockener Katarrh oft in Ozaena ubergehend
Italian Eq. — Catarro secco producendo spesso 1'ozena.

DEFINITION. — Chronic inflammation oft/if I hint;/
of the nose, in which a thin secretion, instead, o
away, dries on the surface, giving rise to a/fl/> rrnt //?•<///•//
in- green flakes or crusty masses of dried mucus, «•///<•// «r>
ajit to undergo decomposition and cause a disgusting ami
chetracteru&ic stench Jmoicn under the name <>f </:.•" i«i. Tin n
in often atrophy of the turbinated bodies ami <>f tin- subjacent
In my structures, whilst the nasal passages and meat uses a/->
proportionately increased in capacity.

History. — The relation of dry catarrh to ozsena has only been recog-
nized in quite modern times, but the term ozcena is one of the oldest
in medicine. As used by the Greek and Latin technical writers, it
signified not simply a stench, but, more concretely, a foul-smelling
ulcer in the interior of the nose. Pliny * mentions the treatment of
I'-.irniK (ulcers) of the nose, and Celsus2 quotes the Greek surgeons as
applying the term to fetid sores covered with crusts. The etymo-
logical meaning of the word, however, was soon forgotten, and a
i-riitury and a half after the time of Celsus we find Galen3 speaking
of two kinds of ozeena — one being simply an ulcer difficult to cure.
and another where the ulcer is accompanied by a disagreeable odour.
Paul of ^gina4 defines ozsena as a "carious and putrid ulcer,
produced by saturation (of the nares) with acrid humours." .ffitius*
lefers to ozrena as being of the nature of an nicer, and advisr>
treatment by remedies applied by insufflation through a reed, or
by means of medicated tents inserted in the nostrils. Alexander

'Hist. Nat." 25, 13, 102.

' De Medicina," lib. vi. cap. 8.

' De compos, pharniacorum sec locos," lib. iii. c. 3.

' Opera,'1 lib. iii. c. 24.

' Tetrabiblos," ii. scrino. ii. cap. 90.

1 Notwithstanding the recent strictures of Virchow ("Address
delivered before the Berlin Medical Society, January 24, 1883."
" Med. Press and Circ." April 11, 1883, p. 312), principally based on
etymological considerations, to the term "dry catarrh," its conve-
nience is so great that it cannot well be dispensed with. Dry catarrh
means a catarrh in which the secretion is prevented from " flowin-;
nway " through its rapidly drying property. In other words tin-
t> nn avoids the use of a long explanatory paraphrase.

"*O£i;, a stench. Forcellini (sub voce) states that the term in its
medical sense is derived from ozcena, a fish, " ex polyporum gein-re.
'..|iut habens gravissimi odoris;" but it seems more probable thai
the li-b and the disease take their name from the same word.

DRY CATARRH. 32o

Trallianus,1 in the sixth century, mentions the disease, merely, how-
ever, repeating the words of Galen. In the twelfth century,
Actuarius- gives a clear description of the condition as arising from
decomposed secretions, without mentioning ulceration as a n'ecessary
feature of the complaint. Ambroise Pare"3 contents himself with
transcribing the words of Galen, merely adding a suggestion for a
remedy of which uritw, asini appears to have been the chief ingredient.
In the beginning of the seventeenth century, Johannes Crato4
anticipated in a remarkable manner the most modern doctrine as
regards the nature of ozaena. His words are: " Imo in catarrhosis
pituitam putrescere, et putridum quiddam eos expirare indicio sunt
coryzse halitu etiam contagiosae. " Fabricius ab Acquapendente5
seems to have been familiar with the affection, which he looked
upon as an ulceration of the interior of the nose, often connected
with syphilis, but not at all necessarily dependent thereon. Sir
Thomas Mayern6 mentions several remedies for the disease which he
also considered as being most frequently due to venereal disorder, but
iu some cases proceeding "ab humoribus acribus et salsis. " At the
close of the seventeenth century, Vieussens7 taught that/cetor nariwm
— i.e., ozsena in its modern sense — arises from the fermentative putre-
faction which the mucous secretion is apt to undergo if it be retained
too long within the nose or the adjoining sinuses. Some years later
Reininger8 maintained that the decomposition of mucus within the
tthmoidal, sphenoidal, and frontal sinuses, and the antrum of High-
more, produced almost incurable ozaena. Giinz9 published some
valuable observations, chiefly of cases where the odour was due to dis-
ease of the sinuses opening into the nose. This subject, like every-
thing else in connection wuh the nose, is treated of with his usual
erudition by Cloquet in the work10 already frequently referred to.
Cazenave,11 of Bordeaux, studied the complaint from a scientific point
of view, as far as could be done with the imperfect means of diagnosis
at his command. Trousseau,12 whilst refusing to commit himself to
any theory as to the origin of ozsena, described its clinical features
with remarkable clearness, and his instructions for treatment were
marked by his usual sound sense. A great step in advance was
made by Otto Weber,13 who pointed out that ozsena is merely a
symptom, and that it would be better either to lay this term alto-
gether aside, as only serving to conceal an incomplete diagnosis,
or to retain it for those cases in which there is no trace of ulceration.
In recent years, improved methods and appliances for the examina-
tion of the nose have led to a more active interest in its diseases,
and a number of valuable monographs and papers have appeared on

1 " De art* medica," lib. iii. cap. viii.

" De methodo medeudi," lib. ii. c. viii.
3 " Cliimrgie," liv. ii. chap. xv.

* " Epist. Philos. Medic." Hanoviae, 1610, epist. cvi. p. 188.
' "Opera chirurgica." Lugd. Batavorum, 1723, p. 444, et seq.

6 " Praxeos Mayernianse Syntagma." Londitii, 1690, vol. i. cap. xvi. p. 89 ;
also vol. ii. p. 261, et seq.

7 " De cerebro," cap. xvi. ; in Leclerc and Mangel's " Bibliotheca Anatomica."
Geneva;, 1699, t. ii. p. 159.

" Dissert, inaugur. de cavitatibus oggium capitis.'' Altorf, 1722, £ xxxix. p. 31.
" " Obs. ad ozocnam maxillarum." Lipsuc, 1753, p. viii.

10 "Osphresiologie." Paris, 1821.

11 " De 1'Ozene non-vene'rieune." Paris, 1801.

12 " Clinical Medicine." Syd. Soc. Traiml. 1870, vol. iii. p. 59, et seq.

> :< " Von Pitha u. Billroth ; Chirurgie.' Bd. iii. i. Abtheil. 2 Heft, Erlangeu,
ISBfi, p. 187.

320 DISEASES OF THE THROAT AND NOSE.

tin' subject of n/irna. Of these I need only mention tli- contribution*
«.f Schrottpr,1 Zaufal,'- Tillot,:l Michel.4 15. rV.inkel.-"1 Koii^e," (Jottstcin.7
('ox/olinn,11 K. Frankel,11 Beveiley Robinson." Stoerk," Franks, 1-
Srliull'er, >:1 Miirtin,14 Krause,1* and Massei.1" Tin- vie-.1
these iiutliors will In- referred to in detail in the' l»ody of tin- article,
but I think it desirable to remark here that the theory of Cnito and
Yieussens, and the more precise statements of otto Weber, attracted
little or no notice ; and it was not till Kninkel, of Kerlin, insisteii on
the view that the term oxa-na, if retained at all, should be confined to
c.-ises of dry catarrh, in which the decomposition of the retained •
tions gives rise to an offensive smell, that a new era was established.
Tliis mode of regarding ozsena lias since been followed by Hcverley
Robinson and (Jottstein, l>oth of whom have also made valuable sug-
gestions as to the treatment of the complaint.

1 ' Jahresbericht der Kliiiik fiir Laryngoscopie." Wien, 1871 ; Il>id. 1873-75.

- ' Aerzt. Correspondenzblatt." 1874, No. 33 ; Ibid. 1877, No. 24.

s ' Annales ties Maladies de 1'Oreille, <tc." 1875, t. i. p. 112, et seq.

< 'Krankheiten der Nasenhohle." Berlin, 1870.

B ' Ziemssen s Cyclopaxlia." 1876, vol. iv. p. 136, et »eq.

6 ' Compte-rendus et M£m. du Congrfes des Sci. Medicales de Geneve." 1S77.

~ 'Breslau. Aerztliche Zeitschrift." Sept. 27, 1879.

' Ozena, e pseudo-ozeni," Napoli, 1879. See also " Ozena e sue forme cliniche. '
i. 1881, by the same author.
' Virchow's Archiv." Bd. Ixxv. 1 Heft, 1879.
i" ' Nasal Catarrh." New York, 1880, p. 74, et set],
'i ' Laryngoscopie und Rhinoscopie." Wien, 1880.
i- ' Dublin Journ. of Med. Science." June, 1881.
i» ' Monatsschrift fiir Ohrenheilkunde." 1881, No. 4.
14 ' De 1'Orene." These de Paris, 1881.

n 'Virchow's Archiv." 1881 ; and " Trans. Intern. Med. Congress." London,
1881, vol. Hi.
is " Giornale Internaz. delle Scienze Mediche." Anno iv. Napoli, 1882.

Minlngy. — Dry catarrh is pretty common up to the jwriod
of middle life, but it rarely gives rise to ozaena in the case of
adults ; indeed, in upwards of twenty years' experience I can
only recall five cases in which ozsena commenced after thirty.
One of the patients was a lady fifty -three years old, and
another a man aged fifty-seven. The other three patients
were between thirty and forty. On the other hand, in the
case of children and young persons, especially at the age
of puberty, dry catarrh so rapidly passes into ozaena that
the parched condition of the mucous membrane is often not
observed till the foetor calls attention to it.

Ozsena is generally thought to be a complaint of rfnixtiin-
tional origin, and those who use more precise language call it
either nt)~um0u8 or mjphilttic. Schaffer, who employs the term
ozaana in a somewhat comprehensive manner, has pointed
out that the countless acinous glands of the Schneiderian
membrane, which are so abundantly supplied with blood
through the rich cavernous structure of the spongy bodies,
afford a peculiarly favourable ground for the manifestation
of a dyscrasia, and he considers the complaint as always due
to struraa or syphilis, hereditary or acquired. He states that

DRY CATARRH. 327

in 119 cases1 lie found ninety-nine of strum ous and twenty
of syphilitic origin. In two cases the complaint was distinctly
due to hereditary syphilis. In one of them the patient died
at the age of four months, presenting pemphigus on the soles ,
of the feet, and ulcers at the margins of the nose together
with a fetid discharge. In a second case, the symptoms com-
menced when the child was between five and six weeks
old, and were relieved by mercurial treatment and carefully
applied local remedies, which had been used without success
in the other instance. Schrotter and Stoerk employ the
word ozsena in its ancient vague sense, and their recorded
experience must therefore be received subject to certain
qualifications. Of seventy-seven cases reported by Schrotter,
syphilis was the supposed cause in thirty -four, and scrofula
in ten ; whilst in the remaining cases the etiology could not
be determined, except in two, which were of traumatic
origin. Stoerk thinks that ozaena is always syphilitic, but
that when it develops some time after birth, it is often
difficult to prove its hereditary origin, and that under these
circumstances, physicians fall back on the theory of scrofula.
Of twelve cases examined by Gottstein, there were only two
in which it appeared probable that there was any scrofulous
taint, whilst in none was there the slightest trace of syphilis.

I do not myself consider that the disease is constitutional
in the true sense of the word. Though scrofula probably
produces a certain disposition to catarrh, and renders the
affection more intractable when it does occur, it cannot, in
my opinion, be said to cause ozaena. In adults dry catarrh
shows no special disposition to affect the stnimous.

I have met with only three cases in which there was any
evidence of hereditary syphilis, and I only know of three
in which ozaena, without ulceratwn, has followed acquired
syphilis. As, however, the disease frequently arfces in
persons otherwise apparently healthy, it is obvious that it
may occur also in those who have had syphilis. Ozaena
often affects several children of the same family, but it
is not contagious. I have had several negative proofs of
this statement, especially in the case of nurses suffering
from ozaena who have lived in the same family for years
without the children under their charge becoming affected.

1 Schaffer actually reports 123 cases, but as in four of these there
was " independent disease of bone," they do not come within my
<lotinition of ozaena. In Schaffer's cases the female sex was affected
nearly half as frequently again as the male.

326 I'lH-lASKS (IK THK THKOAT AND V

The immediately exciting cause of dry catarrh is some-
times, no doubt, the entrance of irritating particles from
the surrounding atmosphere. Any condition of tin nasal
orifices, such a.s unusual size, patency, forward direction,
or absence of vibrissae, which favours the entrance of
irritating particles, predisposes to dry catarrh. On the
other hand, anything which prevents the expulsion of
morbid secretions from the nose tends to produce the
disease ; especially any peculiarity of shape in the nasal
chambers which hinders the free blast of air through them.
Thus bony or cartilaginous outgrowths,1 or a deviated
septum, may mechanically interfere with efficient blowing
of the nose. A hole in the septum, by lessening the blast
of air through each passage, also favours the retention of
mucus. It will be readily understood that there must be a
certain relation of size between the nasal passages and their
external orifices, and that if the interior of the nose is too
capacious, the blast of air may not be sufficient to clear all
the parts of it. A relatively small size of the tnrbinated
bodies may be the special disturbing influence, and Zaufal
considers that ozaena is actually due to insufficient size of
the spongy bones. His views will be again referred to in
dealing with the pathology of this disease.

The precise conditions which cause the secretion to dry
and become adherent to the mucous membrane are unknown ;
but the process is probably due to some chemical change in
the liquid itself. It has been shown by Kanvier2 that in
acute coryza the ciliated epithelial cells are shed very
abundantly, and it is possible, as suggested by Solis Cohen, ::
that the deficiency of the ciliary element in the nasal
passages thus brought about may lead to the stagnation of
the secretion upon the membrane, and consequently to the
formation of dry crusts upon its surface. Friinkel4 considers
that the drying of the secretion is due to its richness in cells
and comparative deficiency in water, and that the desic-
cation is further promoted by the patient failing to dear his
nose sufficiently. He suggests, moreover, that in these <

1 Those hard tumours which give rise to ulccration introduce an
f ntirely new element into the subject, and take the case out of the
category of true ozxena. Soft growths, such as polypi, generally
cause an increase of secretion, which, as the irritation is constant,
does not become dry.

2 " Lancet." 1874, vol. i. p. 687.

3 " iled. News and Library," October, 1879.

4 "Zicmsseu's Cyclopedia," vol. iv. p. 138.

DRY CATARRH. 329

there may be diminished reflex irritability, and possibly im-
pairment of the activity of the cilia.

How it is that in some cases the retained secretions give
rise to ozsena and not in others has not yet been determined.
It may be that in some instances the mucus, though dry,
does not remain long enough in situ to decompose, or the
stench may, as first suggested by Vieussens, and subsequently
by Frankel, depend on some fermentative change which occurs
in certain cases and not in others. In his more recent con-
tribution to this subject, Frankel appears to have given up
this idea, and attributes the smell entirely to decomposition.
I am still, however, inclined to accept his earlier explanation,
for the smell seems to me to be produced too quickly to be
the result of simple putrefaction. Thus, if a person suffering
from ozaena has the nares thoroughly cleansed by a detergent
spray the stench often only ceases for a few hours, returning
within so short a period that though fermentation might
have occurred, there would not have been time for true
decomposition. Franks and Krause are of opinion that
the smell is due to a fatty degeneration of the mucous
cells, the fatty material subsequently becoming acid (see
Pathology).

It has been thought by some that the peculiar smell is
not developed unless there be real atrophy of the minute
glands of the submucous tissues lining the nasal cavities.
That atrophy commonly exists cannot be denied, but it is
not a universal law ; at least I may say that I iiave seen
several cases of ozaena in which no atrophy could be
detected. Gottstein,1 who has generally found atrophy,
has also reported one case in which ozsena occurred with
hypertrophy ; but it must be borne in mind that limited
atrophy might easily have coexisted in some situation not
accessible to view, both in this case and in those observed
by myself.

Michel, arriving independently at the same opinion as
Reininger, contends that the complaint is due to chronic
suppurative inflammation of the sphenoidal and ethmoidal
cells, and that the discharge from these cavities reaching the
mucous membrane of the nose forms' the characteristic crusts.
Though in some rare cases this may occur, it is no doubt
very uncommon, and has not been found to exist in the post-
mortem examinations which have been made by Hartmann,2

1 " BresJaii. aerzt. Zeitschrift, " September, 1879.

2 "Deutsche med. Wochenschrift." 1878, No. 13.

.'O DISEASES ()K TIIK THROAT AND XOSE.

Krause,1 and Gottstein (see Pathology). Massei believes thai
the peculiar odour depends ni\ some specific transformation of
the products of secretion, and that this alteration, probably
due to some chemical change in the inucin, only takes place
at the moment that the mucus passes through the epithelium.
This view is, to say the least of it, somewhat speculative.

Whilst it has appeared desirable to refer t" the theorie-
"f some of the recent workers in rhinology, much difficulty
still surrounds the, subject, owing to the fact that the term
ozsena continues to be applied to totally different affections.
I Mseased bone, fetid ulcers, decomposed secretion, all give
rise to a stinking odour, but there can be little advantage
in bringing together such a variety of affections merely
because they have one symptom in common. Moreover, and
particularly as showing the inconvenience of thus classifying
these conditions together, it may be mentioned that the
stench in each of these cases is quite different. The smell of
diseased bone in the nose is the same as that generated by
dead bone elsewhere, bxit in the former situation it appears
somewhat stronger, because its source is generally nearer to
the bystander, and also because it is constantly diffused by
eipiration; but it is difficult to discover any advantage in
describing the odour of dead bone in the nose by the name
of ozsena. I entirely agree with Frankel,2 therefore, that
if the term be retained, its application should be limited
to those cases in which, in the absence of ulceration and
diseased bone, the odour depends on changes in the retained
secretions.

Symptoms. — The subjective symptoms of dry catarrh vary
according to the site and intensity of the disorder. When
the affection is limited to the anterior portion of the nasal
channels, as a rule it causes but little inconvenience, the
patient merely feeling a slight itching sensation, and a desire
to blow the nose. In bad cases, however, the irritation is so
great that the patient cannot restrain himself from scratching
and picking the mucous membrane, the annoyance being
chiefly felt over the septum. Under these circumstances the
patient will often pick the nose to such an extent as to
produce ulcers, and several cases have come under my notice
iu which perforation of the septum has been produced in
this way.

1 "Trans. Intern. Med. Congress." London, 18S1, vol. iii. p. 311,
ot seq.

• " Ziemssen's Cyclopaedia," vol. iv. p. 138.

DRY CATARRH. 331

On examining the nose from the front, the ohserver is
generally struck by the extreme roominess of its interior,
and by the small size of the turbinated bodies. Indeed,
in old cases the nasal canal is so large that on simply ex-
panding the alae with a speculum, not only the posterior
wall of the pharynx, but even the orifice of the Eustachian
tube, may be visible. Crusts of yellowish-grey or brown
mucus may be noticed adhering to the septum and turbi-
nated bodies. On cleansing the nose with a detergent spray,
the mucous membrane is seen to be considerably congested,
but if the part be examined twenty minutes or half an
hour later, the membrane, though swollen, is generally pale.
Sometimes the membrane bleeds slightly when the crusts
are removed, and occasionally, though very rarely, the dried
mucus adheres to the siirface of superficial ulcers. It is
important, however, to bear in mind that ulceration is a
purely accidental complication, and in no way essential to
the complaint.

The symptoms of ozcena are the same as those which have
just been described as belonging to dry catarrh, but there
is, in addition, a peculiar foster. In the ordinary form of
ozsena the thin flakes of dried secretion already described
are met with, but in some cases round or oval lumps from
two to three centimetres .in length, and from one to two
centimetres in width, are slowly formed and expelled at
intervals of a week or ten days. These masses are generally
of a dirty white or green colour, but they may be brown or
even black, their colour depending on the length of time the
secretion has been retained, and on accidental circumstances,
such as discoloration by carbon in the air, or by slight acci-
dental bleeding.1 They are of somewhat dense structure,
moist externally, but dry arid very compact in the centre.
When they attain a certain size, it would seem that by
pressing on the mucous membrane, they excite a liquid
secretion, which facilitates their expulsion. These masses,
when they form in the nose, generally collect in its vault
in the neighbourhood of the superior turbinated body, but
they sometimes accumulate in the naso-pharynx.

1 An extraordinary case is related by Gallway ("Lancet," October
15, 1859), in which a lady occasionally blew out of her nose a black
sooty powder, dry, and insoluble in water. This occurred five times
in the course of nine months, and was not accompanied by pain or
uneasiness of any kind. The patient had not used charcoal in any
way. It may be stated that she was a woman of nervous tempera-
ment, from thirty-five to forty years of age.

332 DISEASES OF THE THROAT A\D XOSE.

It would be no doubt desirable, if possible, to di>s<-rilie
tin- stench of ozsena, but I know of no way in which an
odour can be described except by comparing it with soiii'-
other smell, and in this instance there is no stench \«
which it bears the faintest resemblance.1

Diaynoiiis. — It is very important to distinguish true o/;t>na
— i.e., dry catarrh with fetid secretions — from cases in which
there is ulceration of the mucous membrane or disease of the
bones. Careful examination with the speculum will usually
enable the observer to detect any morbid alteration in the
skeleton, but Eugene Frankel has shown that in some <
the necrosis may be so slight as to escape observation during
life. Washing out the nose with a detergent spray will
generally completely remove the smell, if the case is one of
true ozaena, but if there is diseased bone the stench, though
milder, can still be detected. Fetid discharges occur in cancer
of the nose, in tubercular disease of the pituitary membrane,
and in lupus exedens of the Schneiderian membrane ; but
these diseases are happily all rare, and a knowledge of their
distinctive features will prevent the practitioner confusing
them with simple ozaena. In all cases in which there is an
offensive smell a careful search should be made for a foreign
body, instances having often occurred in which such a
condition has simulated ozaena. A very remarkable example
has been reported by Tillaux2 where a cherry-stone impacted
in the nasal cavity gave rise to an odour resembling ozaena,
which disappeared on removal of the stone two years after
the date of its introduction. Cases are also related by
Holmes Coote3 in which a fetid discharge from the nose
was found to depend on the presence, in one instance, nf
a plum-stone, and in another of a boot-button. On their
removal the discharge from the nose at once ceased.

Patholoijij. — The changes occurring in dry catarrh and
ozaena have been considered, to some extent, in dealing with

1 The French call the complaint punaisie, in addition to the equiva-
lent term placed at the head of this article, and some writers affirm
that this word is derived from punaise, the common bed-bug, and
that the stench of ozaena resembles that caused by the crushed
insect. Hut there is in fact no resemblance between the smells, and
the two words puiuiisc and ptuuiisic are simply derived from the same
source, putr, to stink (adj. puiuiis). Any person who has once
perceived the characteristic odour of ozaena will always readily
recognize it again.

' " Bull, de la Soc. de Chir." Jan. 26, 1876.

* "Holmes's System of Surgery." London, 1870, 2nd ed. vol.
ii. pp. 423, 424.

DRY CATARRH. 333

the etiology. Atrophy appears to be always a secondary
affection, or, in other words, the changes are of a quasi-
cirrhotic character, resulting from previous inflammatory
thickening. The recent investigations of Zuckerkandl l prove
that not only the soft tissues, but also the bony structure of
the turbinated body becomes thinner, more elastic, flatter,
and smaller. The mucous membrane shrinks and becomes
wrinkled, the erectile tissue disappears, and the thin, pale,
shining mucosa looks more like serous than mucous mem-
brane. When the morbid process is far advanced, nothing
is left but thin bands of mucous membrane, occasionally,
perhaps, containing some small osseous fragments — the re-
mains of the spongy bones. Schaffer, who, in some cases,
has been able to watch the whole process, found the hyper-
trophic stage last from eight to ten years before any wasting
set in. No doubt, however, the disease sometimes passes
through its various phases much more rapidly, and I have
occasionally seen the atrophic condition reached in the course
of a few months. Bayer,2 of Brussels, has observed hyper-
trophy in the children of patients who have themselves
arrived at the atrophic stage. Both Schaffer and Ziem 3
maintain that ozsena may exist without atrophy, and there
is no doubt that atrophy may occur without ozaena. I have
already (see Etiology) stated my own experience as regards
this matter, but may add here that I recently saw a girl,
aged eighteen, in whom there was marked atrophy of the
turbinated bones with corresponding enlargement of the
nasal channels, but without the least trace of ozaena. Yet
the patient assured me that the symptoms of dry catarrh had
existed since she was four or five years old.

Gottstein 4 has reported a case in which he made an
autopsy on a patient who had suffered from ozsena. The
subject was a young woman, twenty-four years old, afflicted
with insanity, who died of caseous pneumonia. During
life, Gottstein observed that the nasal passages were ex-
tremely wide, and after the removal of a quantity of stinking
crusts, the mucous membrane was seen to be pale, thin, and
free from ulceration. At the post-mortem examination the
bones and cartilages, unfortunately, could not be examined ;

1 " Normale und pathol. Anatomic der Naseuhohle." Wien, 1882,
j>. 87, ft SIMJ.
a "Trans. Intern. Med. Congress." London, 1881, vol. iii. p. 314.

" Monatsschrift fur Ohrenheilkunde. " 1880, No. 4.
4 " Breslauer iirztliche Zeitschrift, " Sept. 1879, Nos. 17 and 18, p. 6

.">:'.! DISEASE or TIII-: THROAT AND NOSE.

but the mucous membrane, so far as it was accessible by
very cart-fill examination, showed no defect, except a certain
tliinncss. ( )n microscopic inrefltagfttion the epithelium was
found In In- normal ; beneath this there was a layer of small
round cells mixed with a few spindle-shaped cells, and
Ijeneath this stratum again was another of fibrillar areolar
tissue generally lying parallel to the surface, the tibrilla-
being here and there collected into bundles in different st.
of development. The vessels were richly developed, and
the elastic tunic of the arteries thickened. The glandnla-
were numerous ; their contents were hazy and infiltrated,
the gland-cells not being recognizable in some places, whilst
in others they were misshapen and scarcely discernible.
As Gottstein l remarks, " the appearances were those of
chronic rhinitis, with more or less advanced cirrhosis of the
mucous membrane, and a partly infiltrated and atrophied
condition, of the glandulae." Krause2 found a horny condi-
tion of the epithelium, atrophy of the mucosa, and degenera-
tion of that structure into a kind of dense connective tissue,
diminution in the number of blood-vessels, more or less
obliteration of those that remained, through thickening of
the advent-Hid and puckering of the intima. He found the
glandulse generally deficient, and those that were left showed
fatty or granular degeneration. Zaufal3 is of opinion that the
diminutive volume of the osseous structures is not due to
atrophy, but to their retaining their infantile dimensions,
whilst the face in general undergoes its normal development.4
This, according to Zaufal, explains the frequent occurrence of
ozsena at puberty, when the arrest of development suddenly
becomes manifest, owing to the maturation of the contiguous
parts. The theory of non-development has, however, recently
been ably combated by Zuckerkandl,5 who, in examining '_'•">-
skulls of young subjects, met with only one in which the
turbinated bones were of insufficient size, and in this <-a-e
there was a clear history of atrophy having taken place.
The mucus of ozsena has been made the subject of invest i-

1 "Breslauer arztliche Zeitschrift," Sept. 1879, Nos. 17 and 18.
p. 6.

1 " Virchow's Archiv. f. path. Anat." Bd. Ixxxv. Hft. 2.

3 Loo. cit.

4 A supposed case of non-development of the turbinated bones had
been previously recorded by Hyrtl ( " Sitzutigsber d. kk. Akad. in
Wien. ' Bd. xxxviii. ), but it was not reported as bearing on tin-
question of ozsena.

5 Op. eit. p. 90.

DRY CATARRH. 335

gallon by several physicians. Frank1 repeatedly examined
fresh specimens from the nares of Michel's patients suffering
from ozaena, but he never found anything more than pus-
corpuscles, granular debris, and some traces of epithelium.
On the other hand, Krause2 maintains that the newly-
formed mucous cells undergo fatty degeneration before they
are detached from the surface of the pituitary membrane,
rendering the secretion viscid, and disposed to fetid change.
He observed that in the membrane thus degenerated, well-
formed cells are not found, but in their place collections of
fatty corpuscles and pigmentary molecules, which constitute
the dried mucus of the adherent crusts. Subsequently the
fatty matter becomes acid, and gives rise to the characteristic
odour of ozaena. This view, however, is not borne out by
the observations of Eugene Frankel,3 who found no fat in
three cases of undoubted ozaena which he had an opportunity
of examining after death.

Prognosis. — Dry catarrh is always a very obstinate affec-
tion, whilst true ozaena is rarely, if ever, cured, except in
the case of young children, in whom the disease sometimes
passes away after it has existed for a few weeks. Ozaena can,
however, be so completely kept in check by the treatment
hereafter recommended, that it practically causes no incon-
venience beyond the necessity of using a detergent wash or
spray once or twice a day, or a tampon for a few hours daily.
The stench diminishes in intensity as age advances, and about
fifty generally ceases altogether.

Treatment. — In dry catarrh and ozaena the first step is
to get rid of the crusts. This may be done by washing,
douching, syringing, or spraying the nasal fossae (see " Xasal
Instruments," pp. 258 — 265).

The best solutions for washes and douches are the Collu-
narium sodae, the C. acidi carbolici, the C. acidi carbolici cum
si )da et borace, or the C. potassae permanganatis of the Throat
Hospital Pharmacopoeia, the formulae for which will be found
in the Appendix. As a rule I prefer washes, as I find them
much less disagreeable to the patient, and generally quite as
efficient in their action. But when the crusts form in the
vault of the nose both washes and douches fail. Here sprays
will often be successful, but sometimes the simple spray-
apparatus (see Figs. 44, 45, and 46), does not act with

1 Michel : " Krankheiten der Nasenhohle." Berlin, 1876, p. 107.
* "Trans. Intern. Med. Congress," London, 1881, vol. iii. p. 311,
et seq. * Ibid. p. 313.

336 DISEASES OF THE THROAT A\D NOSE.

sufficient force, and if this be the case a pneumatic .-pray-
producer (Fig. 47) should be employed. Any of the alkaline
or disinfectant sprays of the Throat Hospital I'hannacop.eia
(see Appendix), answer the purpose well. If tin- spray he
used in the morning and afternoon, it will entirely get rid
of any smell, and generally after a few months it will In-
found sufficient to use it only once a day — in the morning.
Resorcin, a derivative of phenol, allied to carbolic acid, hut
without its irritating properties or its offensive smell, has
recently been tried by Masini,1 who reports very favourably
of its use in cases of ozsena. He first gets rid of the crusts
on the nasal mucous membrane by means of douching, and
then employs sprays of a watery solution of A per cent, of
resorcin, applied twice a day daring three or four minutes.
The medicament may also be painted over the diseased sur-
face in the form of a pomade, consisting of 30 decigrammes
of resorcin to 10 grammes of vaseline. Massei'-' asserts that
in some cases ozena may be radically cured by means of
resorcin ; he prefers, however, to use it in the form of douche
— 2 grammes in 600 of water — rather than spray.

Gottstein has introduced an entirely novel mode of treat-
ment. Noticing that it is only the dried mucus which
smells, he has devised an ingenious arrangement for keeping
the secretion moist. This consists in introducing a tanijxm of
cotton-wool into the nasal passage, the contact of which with
the mucous membrane causes a slight but constant flow of
mucus. The tampon is easily introduced by means of a screw
(see Fig. 73, p. 282), and need only be retained for a couple
of hours in the morning on one side, and for the same length
of time on the other side in the afternoon ; occasionally,
indeed, a shorter period will suffice. Should this method
not succeed at first, it shows that the pledget of wool is not
large enough. It is necessary, in fact, that it should be in
thorough apposition to the mucoiis membrane. Several of
my patients have worn these tampons for the last two or
three years, not only without complaint, but with the
greatest gratitude. It will be observed that this treatment
is purely mechanical, but "Woakes3 has found medicated
wools still more effectual, and a number of these are given
in the Appendix.

The remedies which have hitherto been considered are of

1 " Archivii Italian! di Laringologia." Anno ii. 1882, Octr. 15,
pp. 74-7. 2 Ibid. April 15, 1883, pp. 26-28.

3 "' Lancet." 1880, vol. i. p. 876.

CHRONIC BLEXXORRHffiA OF THE XOSE.

337

a palliative nature, but it is not surprising that in a com
plaint of so intractable and disgusting a character, a great
nmny attempts should have been made to find a radical cure
Nor is it at all remarkable that iodoform should have been
much vaunted. I have used this remedy in powder, dissolved
in ether as a spray, and also in the form of a nasal bougie.
I cannot say, however, that I have found it more effectual
than simple alkaline and detergent lotions, whilst it labours
under the disadvantage of causing an odour which, if less
disgusting than that of oztena, is certainly very penetrating.
Remedies which stimulate the mucous membrane certainly
do good, and sometimes permit the cleansing process to be
carried out at longer intervals, though it cannot be dis-
pensed with altogether. The red gum diluted with starch (1
part of gum to 2 of starch) has seemed to me the most useful
of all these ; but Bosworth1 speaks most highly of sangui-
naria (1 part to 3 of starch), and galanga (equal parts of the
powdered root and starch). These powders should be blown
into the nose after it has been washed out with a detergent
spray. Galanga and sanguinaria somewhat resemble euca-
lyptus in their action, but are much more irritating. If
employed at all, I should advise them to be used in a consider-
ably more dilute form than that recommended by Bosworth.
The application of white heat to the mucous membrane,
with the view of destroying the suppurating surface, has been
advocated by Bernard Frankel, but I have not had sufficient
experience of this method of treatment to be able to speak
with any confidence on the subject. I may state, however,
that in three cases in which crusts have formed quite at the
anterior part of the nose, a few applications of electric cautery
so altered the character of the mucous membrane that the
morbid process was entirely arrested.

CHRONIC BLENNORRHCEA OF THE
AIR-PASSAGES.

NOSE AND

A somewhat rare form of purulent rhinitis has been
described by Stoerk,2 under the name of chronic blennor-
rhoea of the mucous membrane of the nose, larynx, and

1 Op. cit. pp. 216. 217.

- " Krankheiten ues Kehlkopfs." Stuttgart. 1880, p. 161,

Vol.. II. E

l'ISKA.-:> <>K THE THROAT AND NOSE.

trachea. Hi- >avs that this condition is common
the Polish Jews in (lallicia, Poland, Wallachia, ami I'»
abia. Most of the patients seen by him were poor, ami
attached little importance to Arsenal cli-anlin >r<l-

ing to Stoerk's account, in the tii-st st«ge of this ail:
there is a profuse secretion from the m>si- of m<.r«- .,r less
purulent greenish-yellow fluid, whilst the absence of the
vascular injection and succulence generally met with in acute
catarrh should prevent blenaonhoM from Ixung vonfoumli-d
with eoryza. The disease shows a marked cbflpMStiao to
extend through the pharynx to the larynx ami «-v».-n the
trachea. In the nose tin- cartilages and bones are nevt-r
involved, and the nasal affection itself is of little inr
anee except in so far as it is the starting-point of serious
disease which ultimately invades the respiratory pas>.
In the larynx, the ulceration frequently commences at the
stalk of the epiglottis, and this spreads down into the
larynx, involving the edges of the vocal cords near the
anterior commissure, and often leading ultimately to ad-
hesion between the two cords. In this way the glottis is
reduced to a small crescentic opening, the concavity of the
crescent being directed backwards. A web is likewise
frequently formed in the larynx below the level of the
vocal cords, and the disease often involves the wall of
the trachea and may even extend to the minute bronchial
tubes, where it occasionally gives rise to haemoptysis. No
treatment is of much avail, but tracheotomy lias been per-
formed with temporary benefit, and in some rare cases
the induration has spontaneously disappeared.

BLEEDING FROM THE NOSE.

(SYNONYM: EPISTAXIS.)

Latin Eq. — Haemorrhagia narium ; epistaxi-^.
French Eq. — Saignement du nez ; epistaxis.
German Eq. — Nasenbluten.
Italian Eq. — Epistassi.

I >KKiNiTiON. — Heemorrhage from the wo.*- <>n'i/inatni</ • it/fi-
in flf nawil rarit// ]/r<>j>i >-, »r in tlf */?*//.-•''.•.• communicating
it.

History. — Bleeding from the nose was coiiMili-i<-<l by the oM
{ihyicians as a symptom ol' more valuable iuiport than modem

BLEEDING PROM THE XOSE. 339

practitioners usually accord to it. It is referred to by Hippocrates l
as indicating a favourable crisis in acute fevers, or as being ominous
of a fatal result in certain chronic diseases. He was also acquainted '2
with the frequent connection of haemorrhage from the nose with
enlargement of the spleen, and other abdominal viscera, and with
its occasional vicarious occurrence in cases of suppressed menstrua-
tion.3 Galen4 considered it as a natural relief to vascular tension in
fevers, and he mentions a case in which he was able to predict a How
of blood from one nostril in the course of an acute fever, accompanied
by delirium. He recommended 5 that epistaxis should be stopped
by squeezing the nose tightly with the fingers, or, if this failed, by
pushing a pledget of lint or a piece of dry sponge as far into the
nostril as possible. Aretseus 6 regarded nasal haemorrhage as indicative
of resolution in acute pleurisy ; and he advised that, for the relief
of headache, bleeding from the nose should be artificially induced by
means of instruments devised for the purpose.7 It may, indeed, be
gathered from the writings of Paul of ^Egina,8 that this was a
common therapeutic measure among the ancients. In the seven-
teenth century Fabricius Hildanus9 related many cases of bleeding
from the nose which he had treated generally with a styptic
powder of his own invention. Not long after, Sydenham,10 whilst
expressing a great contempt for local haemostatics, urged that blood-
letting was the true principle on which epistaxis should be treated.
In the eighteenth century, the celebrated Hoffmann11 devoted a
chapter of considerable length to the subject of nasal haemorrhage ;
whilst Morgagni,12 though referring to the affection very briefly,
quotes an observation of Valsalva as to the immediate source of the
bleeding in many cases, which is of great practical importance, and
which will be cited further on. To Bellocq 13 we owe the extremely
valuable invention for plugging the posterior nares which bears his
name. Nasal ha-morrhage was classed by the nosologists of last cen-
tury as a substantive disease, and the term "epistaxis," used by the
older writers for every kind of haemorrhage occurring drop by drop,
\vus first proposed by Vogel14 to be confined to bleeding from the nose.
This term was subsequently adopted by Cullen15 and Pinel,16 and

1 " Epidemiorum," lib. i.

" Prorrheticorum," lib. i. cap. viii.
'"Aphorism." Sect. 5.
* "De crisibus."

"De compos, pharm. sec. locos." lib. iii. eh. iv.

" "On the Causes and Symptoms of Acute Diseases," Bk. i. ch. ix. Sytl. Soc.
Transl.
7 "On the Treatment of Chronic Diseases," Bk. i. ch. ii. Syd. Soc. Transl.

"Works," Syd. Soc. Transl. vol. i. p. 326.

9 " Opera Observ. et curat. medico-chirurg. qutc extant omnia." Francofurti.
168-2.

i« " Med. Observ." ch. iv. 48 and 49 ; and " Processus Integri," ch. xlv.
" "Medicinre Ration. System." Pars. Secund. Sect, prima c. i; HofTniauii's
" Op. omnia Physico-Medica," p. 196, et seq. Genevse, 1740.

" De sedibus et causis morborum." Epist. xiv. Art. 28. Patavii, 1765.
13 I have not been able to find the exact date of the invention of this instru-
ment, but it certainly was in use at the commencement of the present century,
for it is mentioned by Deschamps in his thesis "Des Maladies des PoqftM
nasales," which bears date 1804.

'* " Dennitio generum niorborum." Gottinpte, 1764. The term tVio-Ta^nr was
UM-'l by Hippocrates to signify bleeding drop by drop, but was not applied

ially to neemorrhAKe from the nose.

' "Synopsis noRologite medicsc." F.dinburgi, 1785. Ed. Quart.
'« " N'osoxraphie philosophinuc." Paris, 1818, time 6d. t. ii. p. 589.

340 M-K.\-I> OK THK THROAT AND X< >.SK.

. came iuto general use. In the early part of the |>r>>nit century
.'. 1'. Frank1 treated the subject with great fulness, and with much
practical sense. He arrested bleeding by pushing into tin- jmstril a
piece of drii-il hog's intestine, tied at one end so as to form a pouch
like the finger of a glove, ami distending this by injecting water with
a syringe, the proximal end of the gut being then tied, and the plug
left in position as long as required. This simple appliance has
been frequently imitated since in more elaborate forms. A lengthy
chapter, full of curious, but somewhat undigested, erudition concern-
ing epistaxis, or hajinorrhinia, as he preferred to call it; will be found
in Cloquet's2 work, which has been already referred to several times
in this volume. Some valuable remarks on epistaxis, espei-iaii
regards its connection with other haemorrhages, were made by
Layeock 3 in 1862, and in the same year Bawd on Mactmut*4
published" an elaborate article which embodied the results of an
unusually large experience of the complaint, and contained many
useful suggestions as to treatment.

i " De curandis hominuiu morbia." Mannheniii, 1807, lib. v. pars. 2, p. 1-4.
et seq.

'• " Osphrdsiologie." Paris, 1821.

3 " Lectures on the Physiognomical Diagnosis of Disease." — " Med. Times and
Oaz." 1862, vol. i. p. 501.

•» "Dublin Quarterly Journ. of Med. Science," 1862, vol. xxxiii. p. 43, et aeq.

Etiology. — Epistaxis is decidedly more common in men
than in women, possibly, as suggested by Hoffmann,1 because
in the case of the latter there is a periodical depletion by
the monthly discharge. It is also more frequent in childhood
and old age, than in the prime of life ; the bleeding, as
will presently be shown, being usually due to plethora
in the child, and to degenerative changes in the vascular
system in the old. The period of life at which nasal
haemorrhage is absolutely most frequent is probably about
the time of puberty. The causes may be local or consti-
tutional. Amongst the former the most frequent is direct
violence from blows or falls, but sneezing or blowing the
nose will often cause bleeding. "Picking" the nose \>
a common cause of epistaxis in young persons, whilst the
introduction of foreign bodies, such as a piece of WO.H! or
slate-pencil, has sometimes led to severe liifiiiorrhage in
children. In the same way, troublesome Needing occa-
sionally occurs from the passing of nasal bougies. If there
be any ulceration of the nasal mucous membrane a very
slight strain may cause blood to flow from the nose. Fibrous
tumours of the naso-pharynx and malignant growths are
especially apt to induce epistaxis. Irritant particles in the
air, such as arise from strong ammonia, jalap, and i|

1 Op. cit.

BLEEDING FROM THE NOSE. 341

cuanha, when drawn into the nose in breathing, often cause
hemorrhage from the nasal mucous membrane, and strong
snuff has also been known to produce this effect.1 Some
curious idiosyncrasies are recorded of epistaxis being brought
on by extraordinary causes. One of the most remarkable
of these is the case of John a Querceto, a secretary of
Francis I., who is stated, on good authority,2 to have bled
at the nose if he smelt an apple.

Constitutional causes are of four kinds : 1st, the blood
itself may be altered in constitution ; 2ndly, the vessels may
be diseased ; 3rdly, there may be obstruction to the circula-
tion through the lungs, liver, kidneys, or other organs,
causing a sudden tension or strain of the whole system
which gives way at a weak part, viz., the nose, where the
vessels are very superficial and their arrangement is in places
cavernous (see Anatomy, p. 236) ; 4thly, the blood-flow may
be a vicarious discharge.

(1.) The most common cause of bleeding under this head
is the haemorrhage diathesis, or haemophilia, the nose being
the part from which the flow most frequently takes place
in such cases. Laycock3 found that out of 227 "bleeders"
the source of the haemorrhage was the nose in no fewer than
110, whilst in many of these cases epistaxis alternated with
haemoptysis, hsematemesis, and haematuria. In all anaemic
conditions of the system, epistaxis is apt to occur. Out
of eighty-one cases of leukaemia collected by Mosler,4 there
was haemorrhage in sixty-four instances, and in thirty-five
of these the blood came from the nose.

When the blood is abnormally abundant, as in plethoric
children, haemorrhage from the nose is not unfrequent, being
often preceded by a sensation of fulness in the~ head scarcely
amounting to headache. Owing to the intercommunication
between the veins of the nose and the sinuses of the dura
mater, epistaxis often gives great relief in these cases.

In eruptive and relapsing fevers, bleeding from the nose
is by no means an uncommon symptom. In a severe epi-
demic of relapsing fever occurring in Berlin in 1871-72, which
was carefully studied by Felix Semon5 in the Charite

1 Macnamara : Loc. cit. p. 30.

2 Bruyerinus : " De re cibaria." Francofurti, 1600, lib. xi. cap. xvi.
p. 468.

3 Loc. cit.

4 " Leuksemie. " Berlin, 1872.

3 " Zur Recurrens- Epidemic in Berlin, 1871-72." Inaug.-
Dissert, 1873.

oil! DISEASES, OK THK THI«)AT AND N

Hospitiil, epistaxis was a critical symptom in more than 30
per cent, of the cases. In two instances the haemorrhage
continued for two or three days, ami in tin- <M>< ol
'.rcmely exhausted patient it was the actual cause of death.
In scurvy it is usually stated to In- very common. .1. 1'.
Frank1 goes so far as to assert that in his n\vn experience
it has occasionally been the only symptom of this di»
and ho looked upon epistaxis as of the highest diagnostic
importance in relation to scurvy when taken in conjunc-
tion with the previous history of the patient. 1 am in-
formed, however, by Mr. Johnson Smith,- who has had tin-
amplest opportunity for observation during a connection of
fourteen years with the Dreadnought Hospital, that in his
experience epistaxis is by no means a frequent feature in
scurvy. In purpura, however, nasal hemorrhage some-
times takes place. A remarkable case occurred in my own
practice a few years ago. The patient, a middle-tged man,
had lived for many years in the tropics, and had lately
returned home in bad health. He was first attacked with
haemorrhage from the larynx. This yielded after a time
to spray inhalations of tannin, but the arrest of the laryngcal
bleeding was followed almost immediately by such severe
epistaxis that the posterior nares had to be plugged. After
two days alarming hemorrhage came on from the lungs,
and Dr. Walshe saw the patient Avith me. Under the u>e
of large doses of ergot the hemoptysis ceased, but thirty-
six hours later the patient died from sanguineous ajKiplexy.

Both in acute yellow atrophy of the liver and in phot*
phorus poisoning, the general symptoiis and morbid anatomy
of which bear so singular a resemblance to each other, a rapid
softening and fatty degeneration of the walls of the ves.-ds
take place, and under these circumstances epistaxis is not
uncommon.

(2.) When the vessels have undergone atheromatous
change, haemorrhage from the nose is not unfrequent. This
is, of course, most often met with in elderly persons. l)Ut it
may also occur in younger persons who have sum- red from
constitutional syphilis or chronic alcoholism.

(3.) The effect of strain on the vascular system is seen even
in healthy persons after violent exertion, such as lifting
heavy weights, violent coughing, retching, or runn

1 Op. cit. p. 135, et seq.

2 Private communication, dated December 23, 1881.

a In the horse, qiistaxU caused by strain may sometiir.i-

BLEEDING FROM THE NOSE. 343

This cause of nasal haemorrhage is likely to be intensified
if there be at the same time any artificial obstruction to the
return of the blood through the jugular veins. Epistaxis
accordingly often occurred in the old days when tight stocks
were worn. The same effect is sometimes produced by
tumours in the neck, especially goitres. Venous obstruction
from engorgement of the right side of the heart, emphysema,
or severe chronic bronchitis, sometimes causes epistaxis.
Diseases of the liver, kidney, and spleen are also frequently
complicated by troublesome nasal haemorrhage. Strong
emotion1 sometimes gives rise to haemorrhage from the
nose, the immediate cause probably being sudden tension of
the vascular system, which gives way at the point of least
resistance. A striking example of epistaxis from rage is
related by Macnamara of a young man, whom profuse
nasal haemorrhage seems to have saved from an impending
fit of apoplexy. It is more difficult to explain another case
reported by the same writer, in which a girl was brought to
the verge of death by bleeding from the nose, which she
attributed to grief for the death of her father.

(4. ) Epistaxis sometimes occurs vicariously, taking the place
of the menstrual flow in women, or of some periodical escape
of blood from enlarged veins in the rectum, leg, or elsewhere.
Fraukel2 has collected a number of interesting examples of
vicarious bleeding from the nose. In one of these (Fricker's
case) a girl, who had never menstruated, suffered at intervals
of six weeks from such profuse nasal haemorrhage, accom-
panied by menstrual molimina, that she finally died from
exhaustion. In another (Sommer's case), a woman on one
occasion, during the entire period of gestation, had a discharge
of blood from the nose regularly once a month. In a third

observed on the race-course and in the hunting-field. Mr. Doyle
(Macnamara, loc. cit. ) a veterinary surgeon, speaks of two fatal cases
of epistaxis in horses, and mentions a celebrated racer which never
ran without bleeding from the nose.

1 Loc. cit. p. 32. The curious case related by Hildanus (op. cit. cent,
ii. obs. xvii. ) of a plethoric, newly-married young man, who was seized
with furious bleeding from the nose immediately after coition, perhaps
comes under this head, but the etiology is complicated by the fact
that the patient had been exposed for some time to a burning sun.
The peculiar effect of great mental emotion in producing tpistaxis
did not escape the notice of Dickens, who, in "Our Mutual Friend,"
speaks of a spontaneous gush of blood from the nose of Bradley
Headstone, when pursuing Eugene Wrayburn with the intention of
murdering him.

- " Ziemssen's Cyclopaedia," vol. iv. p. 152.

.'544 DISEASES OF THE THROAT AND N«><i:.

instance (Obermeier's case), epistaxis appears to have entirely
lakt-n the place of the normal uterine hemorrhage in a young
woman; it came on at regular intervals of four weeks with
the usual constitutional symptoms, censed durinu pregnaney,
and recurred after delivery. In some of Mosler's caa
leukaemia already referred to, the epistaxis was more or less
menstrual in character. Puech1 also gives several instaiui >
of catamenial epistaxis. Hoffmann2 relates a case of some-
what analogous nature in which the lochial discharge was
suppressed very shortly after parturition, and the patient
died of epistaxis. An instance is recorded by Fabririus
Hildanus" in which epistaxis appeared to take the plan- "i
a periodical haemorrhage from varicose veins of the leg in
an old man, the flow continuing for twenty-four hours, and
leaving the patient prostrate for months afterwards. Bleed-
ing at the nose is sometimes hereditary, a fact which was
known to Hoffmann,4 and of which a striking example has
been recorded by Bahington.5 Of six female children of a
woman who was very subject to epistaxis, three suffered from
this form of haemorrhage. One of these had two daughters
with the same tendency, the elder of whom had afterwards a
son who also inherited the peculiarity. The authenticity of the
rase is vouched for by the fact that Babington himself was
acquainted with the mother, daughter, and grandchild. It
has been asserted that the disease occurs epidemically, and in
proof of this an example referred to by Morgagni6 is brought
forward. This epidemic is supposed to have occurred in
Italy in the year 1200, and it is stated to have proved fatal
to an immense number of ]>ersons within twenty-four hours.7
It is probable, however, that the violent haemorrhage was only
an early symptom of an epidemic fever.

Symptoms. — There is little to be said under this head,
except as to the mode in which the ha?morrhage occurs, and
the amount of blood lost. It may be remarked, however,
that certain prodromata are often present, especially in

1 "Gazette des H&pitaux." 1863, p. 188.
'-' Op. cit. p. 200.

3 Op. cit. cent. ii. obs. xvi.

4 Op. cit. p. 198.

5 " Lancet." 1865, vol. ii. p. 362.

6 Op. cit. epist. xiv. sec. 26.

7 Gillchrist is referred to by Cloquet (op. cit. p. 557) as the
authority for another supposed epidemic of epistaxis, hut I have bcrn
unable to find the original report by Gillchrist, or any particulars of
siu-h an outbreak.

BLEEDING FROM THE NOSE. 345

plethoric persons and in those suffering from fevers. These
signs consist of a feeling of fulness in the frontal region,
Hushing of the face, throbbing of the temporal and carotid
arteries, buzzing of the ears, giddiness, and a sensation of
itching in the nose. According to Hippocrates,1 there is also
abdominal distension, an observation confirmed by Pinel,2 who
adds that "goose-skin" and coldness of the extremities are
likewise often premonitory of epistaxis. The haemorrhage
usually takes place drop by drop, and from this fact the
modern scientific name, as already shown (see History), is
derived ; but sometimes the blood flows so copiously that it
might be supposed that a large vessel had given way. The
bleeding generally comes from one nostril, and it is only
when there is some great alteration of the blood, as in fevers
or allied conditions, that the flow is bilateral. Occasionally,
however, the blood escaping from one nasal passage may
find its way round the septum posteriorly, and issue from the
other nostril, a phenomenon probably due to the formation
of clots at the back of the nose. The blood is of bright
red colour, and the quantity lost varies usually from
two or three drachms to an ounce, though sometimes
much more considerable. Thus Martineau3 relates a case
in which the bleeding is said to have amounted to twelve
pounds in sixty hours ; whilst, in another instance, it is
affirmed4 that seventy-five pounds of blood trickled away
in the course of ten days. In a case related by Rhodius,5
a young man is stated to have lost eighteen pounds in thirty-
six hours ; and Hildanus 6 reports an extraordinary instance
of a man, who, besides losing several pounds of blood from
his nose, in the course of a few hours afterwards vomited
twenty-seven pounds which had flowed from the posterior
nares, and coagulated in his stomach. There can be little
doubt, however, that some of these statements are grossly
exaggerated. The haemorrhage sometimes give rise to very
alarming symptoms, and the patient may pass into a state
of dangerous syncope ; or, if the epistaxis occur fre-
quently, it may cause systemic anaemia of a very serious
character.

1 " Epideuiiorum," lib. i.
- Op. cit. p. 591.

3 "Union Medicale." 1868, 3me serie, t. vi. p. 330.

4 " Acta Eruditorum. " Lipsise, 1688, p. 205.

" Observ. raed. centurije tres." Francofurti, 1576, cent. i. ob.?. xo.
6 Op. cit. cent. vi. obs. xiii.

346 DISEASES OF THE THIU>AT AND N"-K.

Pathnloffy. — The exposed position of the nose, ami the
peculiar cavernous arrangement of the vessels of tin- turbi-
nated bodies, not less than the thinness of th'e mueous
membrane covering those structures, fully explain tlic fre-
quency of bleeding from the nose as compared with hemor-
rhage from other parts A'alsalva ' observed in the dead-house
that the vessels on the outer wall of the nose at the junction
of the lateral cartilages are often very large,, and .1. 1'.
Frank2 states that he has noticed a varicose condition of the
veins of the nasal mucous membrane in patients subject
to epistaxis.

Dia</n(>*tit<. — In all cases of epistaxis it is very important
to make a careful examination of lx>th nostrils and of the
naso-pharynx, in order to ascertain whether there be any
local condition, such as a tumour or an ulcer, which may cause
the haemorrhage. It is scarcely necessary to point out that
after falls or blows on the head epistaxis may be a symptom
of fracture of the base of the skull through its anterior
fossa.

Prognosis. — In giving an opinion as to the danger of
epistaxis regard must first be had to the immediate risk from
actual loss of blood. This, of course, will depend on the
state of the pulse and the general condition of the patient.
After this it must be determined whether the haemorrhage
is accidental, i.e., quasi-traumatic, or whether it is the result
of some serious degenerative change in the walls of the
arterioles, or whether it is due to obstruction in the pul-
monary or hepatic circulation, or a combination of these
conditions. It must not be forgotten that epistaxis, as
Hughlings Jackson3 has shown, may in some cases precede
retinal haemorrhage and apoplexy. Accidental bleeding is
seldom of serious import, for although amongst the older
writers a considerable number of cases are to be found in
which death resulted from nasal haemorrhage, the introduc-
tion of posterior plugging has to a great extent removed all
danger. In elderly people, when epistaxis occurs spontane-
ously or from some very slight cause, it is generally a sign
of degenerative changes in the vessels, and as such must be
considered serious. In certain cases the bleeding appears to
be beneficial, and its sudden stoppage is not unlikely to lead

1 Quoted by Morgagni : Op. cit. ep. xiv. sec. 23.

2 Op. cit. p. 144.

'"London Hospital Clinical Lectures and Reports." 1866, vol.
iii. p. 251.

BLEEDIXG FROM THE NOSE. 347

to mischievous results. Instances are on record in which
mania,1 epilepsy,2 and asthma,3 are said to have ensued as a
consequence of rash interference with this natural depletion,
and in cases of phthisis, renal disease, and cerebral mischief,
the flow of blood from the nose sometimes appears to do good.
So obviously beneficial, indeed, is epistaxis, in some cases,
that, as already stated, its artificial production was a constant
practice among the ancients for the relief of certain cerebral
.symptoms, and was recommended for this purpose by the
enlightened Hoffmann.4 In malarial fevers the old physicians
considered that bleeding from the nose was an evidence of
crisis, and was usually of happy augury for the patient,
whilst in fevers of a low type it was looked upon as of
dangerous import. In diphtheria, especially, it is a most
grave symptom, being generally quickly followed by the
development of false membrane in the nasal fossae, if this
extension has not preceded the epistaxis.

Treatment. — Sir Thomas Watson has well observed5 that
nasal haemorrhage is " sometimes a remedy ; sometimes a
warning ; sometimes really in itself a disease." The
question as to the advisability of arresting the hemorrhage
must therefore first be considered. On this point some
remarks by Peyer6 may be found worthy of attention,
even , at the present day. He observes that plethoric
youths, in whom bleeding from the nose is too quickly
stopped, are prone to be attacked with pains about the
head and in the ears, and with various catarrhal affec-
tions. Hence haemorrhage in these cases should not be
interfered with, unless it is excessive, and produces faint-
ness, pallor, and coldness. Again, -where there is great
venous obstruction, as in certain cases of cardiac and
pulmonary disease, in cirrhosis of the liver, or in women
where the haemorrhage takes the place of the monthly flow,
the physician should be in no hurry to interfere, unless
the bleeding lasts too long.

When it has been determined that it is desirable to arrest
the haemorrhage, measures should be adopted in proportion

1 Van Swieten : " Comment, in Boerhavii Aphorismos." 1124.

2 Hoffmann : " De Epilepsia," obs. i.

8 Raymond : " Maladies qu'il est dangereux de guerir," p. 255.
4 " Med. Rationalis Systema." "Opera omnia pliysieo-medica."
(ItMievae, 1740, p. 200.

•"'."Practice of Medicine." London, 1857, 4tlie d. vol. i. p. 793.
6 "De movbis narium." Basileae, 1766, p. 16.

348 DISEASES OF THE THROAT AND XO8E.

to the activity of the flow. In the great majority <>f
OMM the. bleeding soon ceases spontaneously, <>r if not, it
can be stopped by some simple expedient. Position has
obviously tin important influence, and nothing ran be \v<>r>e
than the common practice of holding the head over a
basin, .lamain1 has pointed out that not only is the How
increased by gravitation, but that the flexion of tin- head
tends to compress the jugular veins, thereby hindering the
return of the blood from the head, and favouring the haemor-
rhage. Hildanus2 appears to have placed great faith in
tightly bandaging the forearms to the arms and the legs to
the thighs, and in very obstinate cases swathing the whole
body in tight wrappings.3 It is not improbable, however,
that the success of this remarkable method was in some
measure due to the fact that he used styptic powders at the
same time. Keeping the patient on his back in the horizontal
position is a simple procedure which I have often seen prac-
tised with excellent results. With the view of diminishing the
flow of blood to the head, the very opposite plan, however,
viz., that of maintaining the patient in an erect attitude,
has been tried and found no less efficacious. A method has
been recommended by Negrier4 as being highly successful,
which consists in raising the arm corresponding to the
bleeding side above the head, and compressing the nose with
the fingers of the other hand ; but it is probable that tin'
firi'Mire on the source of tlu> hemorrhage, like Hildanus's
powder, is the real influence brought to bear. Xegrier
himself, however, considered that the extra strain put upon
the heart to drive the blood to the end of the raised limb
lessens the force of the current to the nose sufficiently to
diminish the haemorrhage. The plan has at any rate the
merit of requiring no apparatus whatever, so that it can
lie practised under all circumstances. The application of
cold yields good results. It can be made cither directly
to the nose, or to other parts more or less remote, such as
the brow, the nape of the neck, the feet, or hands. The
tune-honoured household remedy of putting a large key down
the neck acts in this manner. A more certain plan consists

1 "Gazette des Hdpitaux," 1855, No. 33.
• Op. cit. cent. ii. obs. xv. and xvi.

3 This method is still occasionally practised. Thus Blondeau
("Union Medicale," Dec. 8, 1877) claims to have clicked Ueeding
from the nose by tying tapes tightly round the thigh when other
measures had failed.

4 "Arch. (!eu de Med." 1842, p. 168.

BLEEDING FROM THE NOSE. 349

in applying cold water or ice to the nose itself, or to the
forehead. The patient may be directed to snuff up cold or
(if it can be procured) iced water. Hildanus,1 in a case which
he considered desperate, took what he himself calls the ex-
treme measure of plunging the whole body into a cold bath,
with the result of instantly checking the haemorrhage. The
use of hot water, which in recent years has been highly
recommended for restraining other haemorrhages, has recently
been advised for epistaxis by Keetley,2 who says that the
temperature of the water should be from 120° to 124° Falir.,
and that it need not be syringed into the nasal cavity, but
simply applied freely to the face.

The local application of styptics is often of great use.
Powdered tannin, alum, or matico-leaf, may be snuffed up by
the patient, or blown into the nostril with an insufflator. This
treatment is often at once successful, particularly if the nostril
is previously syringed out with a little cold water. Sprays
of tannic acid (gr. x. ad §j.) or perchloride of iron (n\xx.
ad 5J.) have also often proved very effectual in my hands.

Pressure may sometimes be made directly on the bleeding
spot by introducing the finger into the nostril, the source of tho
haemorrhage being, in .the majority of cases, on the outer wall,
just inside the nose. Valsalva,3 who, as has "already been
remarked, had observed on the dead subject that the veins
on the outer wall of the nostril were often enlarged, used this
ready method with striking success in a most obstinate case
of nasal haemorrhage. Epistaxis may sometimes be controlled
by pressure on the facial artery on the bleeding side. But
undoubtedly the most effectual method of applying pressure
to the bleeding surface is by plugging. The bleeding nostril
should first be plugged anteriorly, and if this prove insuffi-
cient, median or posterior plugging must be resorted to.

Anterior plugging is best effected by pushing small strips
of lint into the nose with a probe until the front part of the.
iMvity is completely filled up. The lint may be used dry, or
may be steeped in a solution of perchloride of iron, or in a
mixture of the tannic and gallic acids.4 Josiah Smyly5
found the following method of plugging very successful. He

1 Op. cit. cent. ii. obs. xvii.

'-' " Practitioner." February, 1879.

3 Quoted by Morgagni, op. cit. ep. xiv. sec. 23.

4 The gargarisma acid. taun. et acid, gallici of the Throat Hospital
Pharmacopoeia (Vol. i. Appendix, p. 577) is the best formula.

s In a letter quoted by Macuamara, loc. cit. pp. 53, 54.

350 DISEASES OF T1IK THROAT AND NOSE.

several strips of lint about a foot in length, ami half
an inch in breadth, and wrapping about two inches of one of
these, round a slender probe, he {>assed it quite through to
the jwsterior orih'ce of the nares, th«1n withdrawing the p;
he carefully pushed in as many strips of lint as were required
to fill the nasal cavity. He also suggested using tampons of
absorbent wick, or blotting-paper. Should the ha-morrhage
continue in spite of. anterior plugging, recourse must be had
to median or to posterior plugging.

M«Han plugging, as has been sho\\n, was recommended
by Galen, and his plan of introducing a piece of sponge into
the nose may often be used with advantage. A uterine
sponge-tent will be found very serviceable for this pur;
but the handiest instrument is Cooper Rose's ingenious
little air-plug, which has already been described (Fig. 69,
p. 280). On the whole, however, this plan does not apjwar
to be so effectual as the combination of posterior with
anterior plugging.

Posterior plugging may be most readily performed with
the aid of Bellocq's sound; the manner of using this
instrument has been already described in the article on
"Nasal Instruments" (p. 277, et seq.). Another apparatus
invented for the purpose by Martin Saint- Ange,1 and called
by him a rkinobymi, may also be referred to (p. 278).

Unfortunately the various ingenious appliances which have
lieen described are seldom at hand just when they are
wanted, and, moreover, those made of skin or india-rubber
are apt to be out of order. Hence, when an emergency
arises, the surgeon is generally obliged to make use of some
more simple, if less perfect, apparatus. The posterior nares
can, however, be easily plugged by means of an elastic, or
a silver female, catheter in the following manner : — A
small piece of thread is fastened through the eyes of the
catheter, and to this a strong silk ligature or piece of
whip-cord is attached. The instrument is passed along the
floor of the nose, and when the string is seen in the
pharynx, it is seized with the fingers or with forceps, and
drawn out through the mouth. A pledget of lint is
attached to the middle of the string projecting from the

1 Laj>eyroux : " Methode pour arreter les Hdmorrhagies nasales."
These de Paris, No. 314. 1836. A similar instrument \va.» invented
liv Kuchenmeister, and culled by him ;i rhiin nnint>.r ("Ik-rlin klin.
Wochenschrift," May %2!». 1871)". See also Cloaset (Ibid. June 19,
1871), and Bruns (Ibid. July 31, 1871).

BLEEDING FROM THE NOSE. 351

mouth, and the nasal end is then firmly pulled till the
plug comes in contact with the posterior nares, and blocks
up the orifice of the affected side. The string is subse-
quently retained^ in position by being fixed behind the ear
with a strip of plaster. A small piece of string should be
left hanging into the pharynx from the plug, by which it
can be removed in due time. It is better to make the
pledget of lint so hard as to be quite impervious, and to
trust to mechanical pressure rather than to saturate the lint
with a styptic solution. For unpleasant, and even serious
consequences, may sometimes follow the use of a styptic
plug, especially if perchloride of iron is employed. Even dry
plugging is not altogether free from danger, Crequy1 having
reported a case in which extensive gangrene of the soft parts
of the face came on almost immediately after this opera-
tion. Colles2 saw tetanus result from plugging, and Haber-
shon3 states that he had met with a case in which pyaemia
ensued. Gross4 also mentions that he was acquainted
with several cases in which death had resulted from blood-
poisoning after plugging. These instances, however, appear
to me only proofs of the danger of allowing the plug to
remain too long in situ. Another possible danger is
erysipelas, which, according to Monneret,5 has been observed
in several cases. The plug should not, as a rule, be left
longer in the nose than forty-eight, or at the most seventy-
two, hours, and it should be removed very gently, so as
not to disturb the clot, and bring on further haemorrhage.
Very gentle irrigation through the healthy nostril with tepid
water, to which common salt has been added in the pro-
portion of a drachm of salt to a pint of water, will assist
in loosening the plug. After its removal the nose should
be gently washed out daily, or on alternate days, with
some disinfectant or mild astringent solution, such as per-
manganate of potash (gr. ij. ad §j.) or carbolic acid (gr.
iv. ad §j.).

< ''institutional Treatment. — As the control of the bleeding
is entirely in the power of the surgeon, medical measures are
seldom needed. It is only in cases where the haemorrhage is

1 "Gazette cles Hopitaux." 1870, No. 56.

2 Quoted by Macnamara, loc. cit. p. 58.
"The Lancet," February 27, 1875.

4 "System of Surgery." Philadelphia, 1882, 6th ed. vol. ii. p.

5 See Martineau: " Union Mc'dicale." 1868, 3me y^ric, t. yi. p. 330.

352 DISEASES OF THE THltOAT AXU XoSK.

frequent, but scarcely sufficiently serious to call fur sui.
treatment, that sonic internal styptic may )«• require.!.
l>est of these is ergot, which may be either given by the
mouth or injected aubcutaneoualy. Thirty drops of tin-
tincture may be taken every two or three hours, or ten
minims of a solution (one in five) of ergotine may !>••
administered hypodermically every four hours. I have
frequently found this method very useful. Laudanum is
also an excellent astringent given in small doses of five t»
eight drops two or three times a day, but it is, of cov
contra-indicated where the epistaxis originates in pulmonary
obstruction. Other styptics, such as acetate of lead and
gallic or sulphuric acid, can also be used for the pur;

With a view of increasing the density of the blood, it
has been recommended to administer sulphate of soda,1 of
which two drachms may be given every three hours, but I
have never tried this remedy. Should the patient, when
he comes under notice, be so exhausted that fatal sym-.-pe
is to be feared, transfusion should, if possible, be carried out.
Mosler2 relates a case of haemophilia in which not only
was the epistaxis arrested by transfusion, but the tendency
to repeated haemorrhage on slight occasions was alt' Aether
subdued. Both Sydenham and Hoffmann recommended
venesection for plethoric persons who bleed from the n
and it appears to have been occasionally employed by
•I. P. Frank,3 but this mode of treatment is only men-
tioned here to be absolutely condemned. In illu.-trution
of its utter futility, Frankel relates an instance in which
epistaxis actually occurred in a girl, during the operation
of transfusion, for which she had offered herself ftl
subject.

In the plethoric cases a saline purgative taken two or three
times a week in the morning, followed by a couple of u<
of digitalis in the day, will be found serviceable. In thu
epistaxis of purpura, Macnamara asserts that turjKJiitih
very efficacious, and he recommends that a wineglassfnl of
spirits of turpentine in a tumbler of brandy or whisky
punch should be administered to the patient as rapidly as
he can be got to swallow it.

1 Kunze : " Compendium d. prakt Mod." 4th. ed. p. 94.

- 0{>. fit. The views attributed to the various other authors from
this point to the conclusion of this article will be found cot iniii.-d in
their works, which have been previously cited in foot-notes.

S0p. cit. p. 140.

NON-MALIGNANT TUMOURS OP THE NOSE. 353

XON-MALIGNANT TUMOURS OF THE NOSE.
POLYPUS OP THE NOSE.

Latin Eq. — Polypi nasi.
French Eq. — Polypes du nez.
German Eq. — Nasenpolypen.
Italian Eq. — Polipi del naso.

DEFINITION. — New formations, nearly always of myxo-
matous structure but sometimes containing a small amount
of Jibro-cellular tissue, usually pedunculated, round, oval, or
pyriform in shape, of pale pinkish colour, semi-transparent,
varying in size from a currant to an acorn, but occasionally
larger, giving rise to more or less obstruction of the nasal
passages, with its associated symptoms.

History. — Nasal polypi have attracted attention from the earliest
times, and they are referred to by nearly every writer on surgery
from Hippocrates down wards. The Father of Medicine,1 indeed,
must have had a large experience in connection with these growths,
for though his classification is somewhat fanciful, his suggestions
for treatment are of a highly practical nature, and show considerable
fertility of resource. He directed that evulsion should be practised
in the following manner : — A piece of sponge of sufficient size to fill
the nasal cavity having been selected, four strings, each one cubit in
length, were attached to it, their free ends being tied together. A
long flexible metal probe with an eye at one end was next passed
through the nostril, and brought out at the mouth ; the united ends
of the strings were threaded through the eye of the probe, which
was then drawn back through the nose. The strings were now seized
by the operator, and by forcible traction the sponge was drawn
through the nose, the mass of the polypus coming away with it.
Whether the growths were removed by evulsion or with the cautery,
Hippocrates afterwards applied a dressing consisting of honey, to
which there was occasionally added some strong caustic, and this
was kept in contact with the parts by means of small leaden plates
inserted into the nostrils. In the case of hard polypi, Hippocrates 2
directed that the nostril should be slit open, in order that the tumour
might be thoroughly extirpated, and the roots afterwards destroyed
with the hot iron. Celsus 3 recommended that polypi should be
destroyed with caustics or the hot iron, but he strongly disapproved
of meddling with the harder tumours, which he considered malignant.
Galen 4 described the disease as a preternatural growth, resembling
in its nature the flesh of a polypus, and recommended the use of
stringent local remedies in preference to the knife. ^Etius,5 on the

1 ' De Morbis," lib. ii. Littre's ed. Paris, 1851, vol. vii. p. 51.

2 ' Ibid." p. 53.

' De Medicina," lib. vi. cap. viii.
4 ' De comp. pharm. sec. locos," lib. iii. cap. iii.
8 ' Tetrabibl." ii. serm. ii. cap. Ixxxix.

VOL. II. A A

354 DISEASES OF THE THROAT AND NOSE.

other hand, advised that the cautery should be used for the de-
tion of polypi. Paul of jEgiua,1 who was an advocate of tin- knife.
recommended the operator to dilate the patient's nostril with his Ld
hand, while with the right he extirpated the polypus from the nasal
passage by a circular sweep of a scalpel of peculiar shape. The mass
was then to be withdrawn from the nose with the other end of the
instrument, which probably ended in a hook. Abulcasis- direeted
that the growth should be drawn out of the nose as far as possiMe
with forceps, and then cut off with the knife. The sturnn was
afterwards to be scraped, so as to destroy the roots of the jxjlypus.
(Hiy de Chauliac8 recommended that polypi should be removed by
evulsion. To William of Salicet4 belongs the credit of introducing
the plan of strangulation of nasal polypi by tying a ligature tightly
round the pedicle. He advised that the channel of the nose should
be widened, if necessary, by means of sponge tents, or serpentary
root, and that the tumour should be tieu tightly as near its root as
possible, with a thread of doubled silk. In cases where this was
impracticable, the growth was to be extirpated by evulsion with
forceps. In any case, the stump was to be destroyed by means of
corrosive applications or the actual cautery. Arantius,6 being dis-
satisfied with the treatment by the knife, also invented a kind of blunt
forceps, with which he tore away the polypus. To obtain a better
view of the parts, he always operated in a darkened room, a round
hole in the shutter allowing the sunlight to fall into the patient's nose ;
or, if the day was dull, artificial illumination was procured from a
lighted candle placed behind a phial of glass containing clear water.
Fabricius ab Aquapendente * claimed to have invented an instrument
for the removal of polypi of such excellence that "patients came to
him from every side, with the firmest confidence of being cured." His
invention appears to have been a pair of forceps, the cutting blades
and shanks of which were deeply hollowed, so that when closed the
instrument formed a kind of canula, through which a hot wire could
be passed, or powder blown. To this surgeon has often been assigned
the merit of having first proposed the evulsion of polypi with forceps ;
but this is certainly erroneous, for it has just been shown that William
of Salicet 7 had recommended this method long before. It may be
added indeed, that Fabricius himself made no claim to be the inventor
of the method, but only of a particular instrument which was designed
to cut polypi without the dangers attending the use of the spalfia, or
ancient scalpel. He may therefore, perhaps, be termed the inventor
of "cutting forceps." In 1628 Glandorp8 published a treatise
on polypus remarkable for its erudition, and, moreover, containing a
very accurate account of the affection. Boerhaave9 afterwards pro-

1 Lib. vi. cap. xxv.

2 Lib. ii. cap. xxlv. (" Chirurgie d' Abulcasis," traduite par le Dr. Lucien Leclerc).
Paris, 1861, p. 93, et seq.

s "Le Guydon [Guy] en Francoys," par Maistre Jean Camappe. Lyon, 1538,
lol. 198.

* " Chirurgia Guilielmi de Saliceto," in " Ars Chirurgica Guidonis Cauliaci."
Venetiis, 1546, p. 308.

s " De t union 1ms prater naturam." Appendix to his treatise " De huniano
fcetu." Venetiis, 1587, p. 170, et seq.

« "Operationes Chirurgicie," cap. xxiv. in "Opera Chirurgica." Lugdoni
Batavorum, 1723, p. 438, et seq.

7 Op. cit. See also Arantius, op. cit.

8 " Tractatus de polypo." Bremen, 1628 cap. vii.
» " Prselectiones ad Institut." ad § 498.

NON-MALIGNANT TUMOURS OF THE NOSE. 355

pounded a theory that nasal polypi are formed by a prolongation of
the lining membrane of the pituitary sinuses. His idea was that the
secretion in one of the cells becoming from some cause or other too
thick, does not escape properly from the cavity, which thus becomes
filled up, till its lining membrane is protruded into the nasal fossa,
where it is suspended as a membranous sac, filled with fluid or semi-
fluid contents. Heister 1 explained the growth of nasal polypi by
obstruction of one or more of the glands of the pituitary membrane
leading to the formation of a tumour. Morgagni 2 may be mentioned
as quoting with approval Valsalva's practice of removing the lamella
of bone on which the polypus grows, with the view of preventing
recurrence. Levret,3 who was chiefly known as a very Successful
gynaecologist, seems to have been led by his experience in dealing
with uterine and vaginal tumours, to turn his attention to nasal
polypi, and he invented several ingenious instruments for applying
and tightening ligatures. Pallucci 4 soon afterwards attempted to
improve upon Levret's method, and, if his statements may be
believed, he was one of the most successful operators in this
branch of surgery that ever existed. Early in the present century
Robertson 5 published an account, together with a drawing, of an
instrument for snaring nasal polypi. The irony of the fate of
inventions is indeed shown in this little instrument, for Robertson's
nasal snare is acknowledged by Wilde to be the instrument on
which he modelled his aural snare, whilst later on, Hilton, unaware
of the original purpose of the appliance, modified Wilde's instrument so
that it might be used for the nose. In modern times short treatises
on nasal polypi have been published by Gruner,6 Dzondi,7 W. Colles,8
JIathieu,9 and Thudichum,10 besides innumerable communications to
the medical journals of Europe and America. The subject has also
been treated of more or less fully in every general text-book on sur-
gery, the contributions of Durham n and Spillman 12 being especially
worthy of mention. One of the most recent works which has refer-
ence to the malady is that of Zuckerkandl,13 whose treatise is of great
value in relation to the morbid anatomy of the complaint.

1 "General System of Surgery," English Transl. London, 1743, pt. ii. p. 437,
et seq.

' De sedibus et causis morb." Ed. sec. Patavii, 1765, epist. xiv. sec. 19-20.
1 ' Obs. sur la Cure radicale de plusieurs Polypes." Paris, 1771, 3rd ed. p. 214,
et seq.

' Ratio facilis atque tuta narium curandi polypos.' Viennse, 1763.

' Edinburgh Med. and Surg. Journ." 1805, vol. i. p. 410.

' De polypis in cavo narium olmis." Lipsise, 1825.

' Ergo polypi narium nequaquam extrahendi." Halse, 1830.

' Nasal Polypi." — " Dub. Quart. Journ. of Med. Sci." Nov. 1848, p. 373, et seq.
9 'Sur les Polypes muqueux des arriere-narines." These de Paris, 1875.
> ' On Polypus in the Nose, etc." London, 1869, 3rd ed. 1877.
1 ' Holmes's System of Surgery," vol. iv.

' Diet. Encyclop. des Sci. Med." Art. " Nez."

' Normale u. pathol. Anatomic der Nasenhohle." Wien, 1882, p. 64, et seq.

Etiology. — The causes of nasal polypus are quite unknown.
That mere chronic inflammation is not sufficient to produce
it is proved by the fact, that whilst persistent catarrh is
lore often met with in children than in adults, mucous

)lypi are very rare under the age of sixteen. In adults the

356 DISEASES OF THE THROAT AND N<»K.

is exceedingly common, Ix-ing found, according to
Xurkt'rkandl1 (if looked for), in every eighth or ninth autopsy.
FiMiu the annexed Table (A) it will be seen that tin- drci-n-
nium from twenty to thirty furnishes the gn-atcst • nunilM-r of
cases — 42 per cent. Men are more liable to the atii-rtion
than women, the proportion in my 200 cases being 123 im-n
to 77 women. The youngest patient I have met was a ^rirl
aged sixteen, the youngest boy having been seventeen. Kx-
amples of much younger patients than these will be found
in medical literature, but I believe that in nearly all of tin -in
the growths were malignant or fibrous. Mason- has, how-
ever, reported a case of a boy, whose age was only twrlvi-,
from whom he removed several large polypi. The greatest
age at which a polypus commenced in my series was sixty
nine, but I have seen two other cases in which the disease
originated at sixty-five and sixty-eight respectively.

TABLE A.

Showing the age and sex of 200 patients with nasal polypus.
Table, indicates as nearly as possible the age at which the
commenced.

Age. Male. Female.

16 to 20 97

20 to 30
30 to 40
40 to 50
50 to 60
60 to 70

51 ... 34

33 ... 13

18 ... 13

9 ... 10

123 77

The older writers, who had somewhat vague ideas in the
matter of etiology, attributed polypi to such influences as
heredity, struma, syphilis, miasma, and suppressed menstrua-
tion, but these antiquated notions will not stand the rigorous
analysis of the present day. Occasionally polypi seem to
arise from mechanical irritation, such as may be produced by
foreign bodies, but the case of Van Meekren,3 in which the

1 Op. cit. p. 70.

2 "Med. Soc. Proceed." London, 1872-4, vol. i. p. 156, et seq.
The date of Mr. Mason's paper is March 2, 1874. In this report
the age of the patient was stated to have been twelve, whilst
according to the catalogue of the Royal College of Surgeons, to
whose museum the growths were presented, the age was ti-n.

"• (.f noted by Morgagni, loc. cit.

NON-MALIGNANT TUMOURS OF THE NOSE. 357

nucleus of a polypus was formed by a splinter of wood, is
open to suspicion. Gerdy1 lias reported a case in which a
large polypus followed a fracture of the bony septum.

Symptoms. — In the earliest stage the patient suffers from
increased secretion, stuffiness of the nose, and sometimes
slight pain in the frontal region, together with a partial and
variable occlusion of one or both nostrils. Polypi being
generally pedunculated, a sensation like that caused by a
foreign body moving backwards and forwards, or up and
down, within the nasal cavity is sometimes experienced
about this period. For the same reason these growths
occasionally have a valve-like action, opposing the passage
of air outwards or inwards as the case may be. They some-
times, indeed, give rise to a peculiar flapping sound, described
by Dupuytreu as the " bruit de drapeau." It need scarcely
be pointed out, however, that in the presence of so many
objective signs, this symptom is of no importance. When
both the nasal passages are blocked up, the patient is of
course compelled to breathe entirely through the mouth, and
the usual phenomena of nasal obstruction supervene, the
voice undergoing the characteristic modification, and the
sense of smell being impaired or altogether lost. It is
very seldom that these growths cause any bulging of the
nasal parietes, and only in quite exceptional cases that the
tear-duct being pressed upon epiphora results. Owing to
the fact that mucous polypi possess a hygrometric pro-
perty, all the symptoms are generally aggravated in damp
weather. The discharge from the nose is usually watery
in character, and seldom offensive, whilst epistaxis only
quite occasionally occurs.

Polypi, when large, numerous, and growing from the
anterior part of the cavity, can usually be seen by simply
looking into the nose with the aid of a strong light, the
tip of the organ being at the same time tilted upwards and
backwards, but the introduction of a speculum will greatly
assist the view. These growths most frequently appear to
originate from the middle turbinated body and the parts
immediately above it (see Table B), but the recent researches
of Zuckerkandl (see Pathology, p. 366) show that the real
origin of nasal polypi is often far deeper than clinical evidence
indicates.

1 " Des Polypes et de leur Traitement." Paris, 1833, pp. 4, 5.

DISEASES OF THE THROAT AND ffOBK.

TA15LK I',.

Showing the apparent situation of 259 polypi observed by th> n iitlmr in
200 jtatients, the armcths having been bilateral Jifty-nine times.

Middle turbinated body ... ... ... ... ... 104

Neighbourhood of su])erior turbinated body and

superior meatus ... ... ... ... ... ... 77

Middle turbinated body and middle meatus 34

Middle meatus ... ... ... ... ... ... 24

Inferior turbinated body ... ... ... ... ... 9

Whole of outer wall of nose (except inferior meatus) ... 11

259

Only in very rare cases is the septum the site of tin-
affection. Bryant,1 Leriche,2 Clinton Wanner, :! ami Hart-
maim,4 each report one example, and Zuckeikandl8 has met
with three specimens. These are the only authentic instances
that I am acquainted with. Polypi, however, springing from
the turbinated bodies sometimes press so firmly against the
septum that it is extremely difficult to pass the finest pn>l>e
between that partition and the tumour, and under such cir-
cumstances a mistake as to the origin of the polypus is likely
to be made. By means of posterior rhinoscopy I have seen
several cases of small symmetrical growths on the septum,
but these were always either of adenoid structxire, or con-
sisted of simple hypertrophy of the mucous membrane.

Mucous polypi generally remain witlu'n the nasal cavity,
but when very large they may extend forward and even
project from the nostril. Sometimes they grow towards the
pharynx, and can then be easily discovered by posterior
rhinoscopy. Occasionally a polypus in its growth liecomes
attached at several different points to the contiguous walls
of the nares, but this result of friction and pressure is more
likely to be seen in the case of fibrous polypi than in those
of myxomatous structure. In very rare instances a mucous

1 "Manual of the Practice of Surgery." 3rd ed. London, 1879,
vol. ii. p. 7.
• "Gaz. des HQpitaux." 1874, No. 73.

3 "Arch, of Clin. Surg." New York, January, 1877.

4 "Deutsch. med. Wocheuschrift. " 1879, Nos. 28-30.

5 " Zur path. u. phys. Anatomic der Nasenhbhle u. ihre
pneumat. Anhfinge.' — " Wien. med. Jahrb." 1879. See also
"Anatomic der Nasenhbhle," p. 84. It appears doubtful from the
description whether all Zuckerkandl's cases were examples of rru«
polypi.

NON-MALIGNANT TUMOURS OF THE NOSE. 359

polypus may by pressure destroy the periosteum, and one case
lias been reported by Colles in which the bones of the nose
were separated by such a growth.1

Mucous polypi are generally multiple, and according to my
experience (see Table B) occur on both sides in nearly 30 per
cent. Globular in shape at first, they most frequently hang
loosely from the nasal wall, being suspended by a narrow
pedicle. It is thus that gravitation acting on their semi-fluid
contents soon determines their characteristic tear-shaped
outline. They do not, however, always retain this form, for,
as Gruner remarks, the larger the size to which they attain
the more they recede from their pyriform shape, as they are
easily moulded by the unyielding structures which after a
time confine them on every side.

The views which have just been expressed are, however,
opposed to the recent anatomical observations of Zucker-
kandl,2 who maintains that there are two kinds of polypus,
viz., those of oval form with narrow pedicle, and those of
round shape with broad base, the former growing from sharp
edges, the latter from flat surfaces. Zuckerkandl maintains
that the globular tumours are never converted into the oval,
but that each kind possesses its peculiar shape from the time
of its first appearance. Polypi vary in size from a tare to a
chestnut, but when requiring treatment are most frequently
between a currant and a grape in size. I have met with
one exceptional case, however, in which the growth, when
stretched out, measured five inches in length, and was seven-
eighths of an inch in diameter at its base (Fig. 78). I re-
moved the polypus from a gentleman aged twenty-two, in
the presence of Dr. Snell, of Mile End. No recurrence had
taken place nine years later. A more remarkable example
still has been reported by Stoerk,3 in which a polypus
springing from within the posterior nares reached down to
the larynx. There are often one or two polypi about the size
of a small grape or currant, and a great number of others
which are scarcely visible. Their colour is generally dull
yellow, but occasionally they are greyish-white or pink.
Their surface is smooth and shining, and when touched
lightly with a probe they dimple through their elasticity,
returning at once to their former shape. When a 'strong

1 "Dub. Quart. Journ. Med. Sci." No. 12. November, 1848,
p. 374.

2 Op. cit. p. 78, et seq.

3 " Krankheiten des Kehlkopfes." Stuttgart, 1880, p. 105.

1U.-KASKS <>}•• TilH TIIKOAT AND NoSK.

light is directed on the polypus, it generally has a somewhat
translucent appearance. Mucous polypi arc devoid uf sensi-
bility, the pain which is felt on their fmvil.le removal being
due to their connection with the mucous membrane.

FIG. 78. — POLYPUS REMOVED BY THE Ai-rmu:.

The ordinary symptoms attending the presence of a
polypus in the nose having been described, it is necessary
to add a few remarks on a much more serious class of
troubles to which attention has been called in recent years.
Soon after Yoltolini1 had recorded an instance in which
asthma resulted from the presence of a polypus in the nasal
passages, similar cases were reported, by Hanisch,2 Porter,3
J)aly,4 Todd,5 Spencer,6 Mulhall,7 Joal,8 and Janjuin,'-' and
the reflex causation of asthma from nasal polypi has been
discussed by Schaffer,10 Frankel,11 and Bresgen.12 The whole

I ' Die Anwendung (1. Galvanokaustik." Wien. 1872, p. 246, 4 Aufl.
a ' Berlin, klin. Wochenschrift." 1874, No. 40.

3 'New York Med. Record," October 11, 1879; also "Arch, of
Laryngology," 1882, vol. iii. No. 2.

4 'Arch, of Laryngology," vol. ii.

5 'Trans. Missouri State Med. Assoc." 1881.
8 ' Quoted by Todd, ibid.

7 'St. Louis Med. Surg. Journ." Feb. 1882.

8 'Gaz. des Hopitaux." 1882, p. 442, et seq.

9 Ibid. 1882, p. 507.

10 "Deutsche med. Wochenschrift." 1879, Nos. 32 and 33.

II "Berlin, klin. Wochenschrift." 1881, Nos. 16 and 17.
12 " Volkmann's klin. Vortrage." 1882, No. 216.

NON-MALIGNANT TUMOURS OF THE NOSE. 361

subject of the reflex effects of nasal obstruction, and especi-
ally of polypi, has been recently studied with great ability
by Hack,1 who considers that nightmare, cough, hemicrania,
brow-ague, certain vasomotor phenomena shown by quasi-
erysipelatous symptoms (in which there is temporary limited
redness of the cheeks), attacks of giddiness, epilepsy, rhinor-
rhoea, and hay fever often owe their origin to polypus, or
tumefaction of the nasal mucous membrane. Hack gives
many illustrative cases in which the various complaints re-
ferred to were cured by surgical operations within the nose,
and it may be added that his etiological views have already
received independent support from other observers. Lowe2
has reported a case in which epileptic fits, which had before
been of almost daily occurrence, suddenly ceased when the
nasal passage was made clear. The obstruction had been
produced by a polypus in the left nostril, accompanied by
hypertrophy of the mucous membrane covering the lower
turbinated body, and adenoid vegetations about the posterior
nares. When these sources of irritation had been removed
the fits only came on under the influence of some extra-
ordinary mental disturbance.

In connection with this last case, I may state that I
have lately treated (with Dr. Hughlings Jackson and Dr.
Sillifant, of Barnsbury) a gentleman, aged fifty-five, who
had suffered for some months from attacks of extreme rest-
lessness, together with such severe dyspnoea that he was
unable to lie down at night. He also had violent paroxysms
of facial spasm, and on one or two occasions epileptiform
seizures, during which he was unconscious for twenty
minutes or half an hour. There was a mass of polypi in
the upper part of the nasal passages on both sides. These
growths having been almost completely removed the pa-
roxysms of dyspnoea entirely ceased, and the other nervous
symptoms gradually disappeared. Elsberg3 has also met
with cases of chorea, epilepsy, supra-orbital headache, and
hemicrania, due to reflex irritation within the nose. Seiler4
has reported two cases, and refers to two others in which
he believes that thickening of the anterior part of the
inferior turbinated bodies was the cause of a troublesome

1 " Wien med. Wochenschrift." 1882, Nos. 49, 50, 51 ; and 1883,
No. 4, et seq.

2 " Allgemein. med. Central Zeitung." 1882. No. 76.
" Philadelphia Med. News." May 26, 1883, p. 604.

4 "Arch, of Laryngology." 1882, vol. iii. p. 240, et seq.

362 DISEASES OK THE THROAT AND

cough. The cases described are not very conclusive, but in
both of them treatment of the nose relieved the laryniri'nl
symptom. John Mackcn/ic1 lias found cough so frequently
a reflex symptom of nasal disease that he has ceased to
regard it as a curiosity. He is of opinion that the posterior
portion -of the middle and inferior turbinuted lw>dics with
the corresponding part of the septum arc the special scats
of reflex irritability. Hack,2 on the other hand, concludes
from his own observations, that reflex phenomena, such as
cough and sneezing, may be produced by irritation of any
part of the lining membrane of the nose, but that sm-h
manifestations do not take place until the anterior part of f/ir
lower tnrMnated body has first become twfji'l.

The following examples of asthma dependent on growths
in the nares occurred in my own practice : —

One of these cases was that of a lady, agt.-d sixty-three, who
consulted me in March, 1874. She had suffered for three years
from severe attacks of asthma, which came on nearly every night.
Various remedies had been used with partial success, but the asthma
was entirely cured by the removal of two large polypi — one from
each middle turbinated body.

In a second case the patient was a gentleman, aged forty-seven,
whom I first saw in July, 1876. During the previous five years he
had suffered occasionally from asthma, the paroxysms, as in the last
case, always occurring at night. The removal of a quantity of small
growths from the neighbourhood of the superior turbinated body on
the right side entirely relieved the patient of his asthmatic attacks,
which, however, returned, after an interval of four months. The
recurrence of the dyspnoea was found to be coincident with a fresh
development of polypi, and on their removal the symptoms again
passed off.

In a third patient, recently sent to me by Dr. Hughes of Llanberis,
very severe attacks of asthma appeared to have been caused by the
presence of polypi in the nose ; violent paroxysms were also prodm-i-d
by the insufflation of tannic acid.

Daly3 has recently maintained that the disposition to
hay fever must be sought for in chronic hypertrophy of the
mucous membrane of the nose, and this theory has been
adopted by Roe,4 of Albany. My own experience, however,
does not confirm the view.

Whilst fully admitting that many reflex phenomena may
arise from disease within the nose, I must caution the
younger specialists that the various complaints referred to
as resulting from nasal disease are much more frequently

1 "Amer. Journ. Med. Sci." July, 1883, p. 106, et seq.

2 Loc. cit. p. 36.

3 "Arch, of Laryngology." 1882, vol. Hi. p. 157, et seq.

4 " New York Med. Journ." May 12, 1883, p. 509, et *<->\.

NON-MALIGNANT TUMOURS OF THE NOSE. 363

due to other conditions, and that every other possible cause
must be eliminated before the nose is incriminated.

Diagnosis. — -Although in most cases it is easy to diagnose
nasal polypi, yet mistakes do occasionally occur. The gela-
tinous softness, elasticity, mobility and pale semi-transparent
appearance of these tumours are, however, very characteristic
features, and serve to distinguish them from most other
swellings. Fibrous, sarcomatous, and cancerous growths are
usually much harder, bleed easily on being touched, cause
considerable pain, and often produce great disfigurement.
Cartilaginous or osseous tumours are so hard that their real
nature is at once evident. Deviation of the septum has
occasionally been mistaken for a polypus ; but when this
condition exists there is an irregular projection into one
nasal passage and a corresponding depression in the other,
showing the character of the affection. Chronic abscess of
the septum has frequently been mistaken for polypus, but it
differs almost diametrically from that complaint. For whilst
a polypus hangs almost invariably from the outer wall of
the nasal cavity by a pedicle, an abscess is situated on the
septum and has a broad origin. Moreover, in cases of abscess
there is, in the vast majority of instances, a similar swelling
in the other nostril, the bases of the tumours accurately cor-
responding with each other on the two sides of the septum.
Blood tumours present the same general characters as ab-
scesses, except that they are of dark purple colour. In both
cases there is usually a history of more or less recent injury to
the nose. In any doubtful instance, however, puncture of
one of the tumours will solve the question as to its nature.

The condition most likely to be mistaken for polypus is
thickening of the mucous membrane covering the inferior
turbinated bones. This mistake is frequently made by
practitioners, owing to the fact that in systematic surgical
works the diagnosis between these conditions has not hitherto
been pointed out. Polypi, however, though often bilateral,
are seldom so symmetrical as is the thickening of the
turbinated bodies, and whilst the colour of the former is
pale yellow or pink, that of the hypertrophied turbinated
bodies is either bright, or dark, red. Again, though the
thickened mucous membrane pits a little under the probe,
the entire body does not move as in the case of a polypus.
It must not be forgotten, however, that polypus and hyper-
trophy often coexist. A foreign body might possibly be mis-
taken for a polypus, but the inflammation and fetid discharge

364 DISEASES OP Till: THROAT AND NOSE.

from the nose which accompany it will make the practitioner
suspect something more than a mucous growth. Am»i
rare conditions, which need only be referred to as curiosities,
may be mentioned mucous distension of the ethmoid*] cells
and hernia of the brain. The museum of St. Thomas's Hos-
pital contains two examples of the former affection, in which
the appearance during life must have closely resembled
mucous polypi.1 As Spencer Watson2 observes with regard
to these specimens, the hard wall of the projecting body
and the escape of the pent-up mucus on puncture would
determine their nature. A curious case was reported by
Cruveilhier,3 in which a hernia of the dura mater and brain
through the cribriform plate of the ethmoid bone, exactly
resembling a polypus, was discovered at a post-mortem exami-
nation. Such a tumour, however, would move rhythmically
with the respiration and pulsate with the systole of the
heart ; moreover, in its development cerebral symptoms
would be almost sure to occur.

PatJioloyy. — The external investment of these polypi is
usually composed of ciliated epithelium, and beneath this
outer layer there are generally a few dilated capillaries
but no nerves. The bulk of the growth is made up of
embryonic connective tissue, consisting of a hyaline gela-
tinous material through which more resisting cellular
trabeculae pass in various directions. The gelatinous sub-
stance is very rich in mucin, and contains in the early
state round and oval cells, which at a later period become
elongated, fusiform or stellate, and for the most part
nucleated and granular. According to Comil and Kanvier,4
the latter kind of cell is most common. The consistency
of the growth depends on the greater or less degree in which
the connective stroma or the mucous substance predominates
in its structure. Here and there small cavities full of
colourless stringy fluid may be met with. Some observers
regard such growths as true cysts, but Follin and Duplay5
consider that the absence of any distinct wall shows that
these formations are not really of cystic character. Zucker-
kandl,G however, maintains that he has occasionally found

1 'Museum Catalogue." Sec. i. Nos. 14 and 15.

2 ' Diseases of the Nose." London, 1876, p. 73.

3 'Anatom. Pathol. du Corps Humain." Paris, 1835-42, t. ii.
livraison xxvi. pp. 5, 6.

4 ' Manuel d'Histol. Path." Paris, 1869, p. 145.

5 'Traite Elem. de Path, externe." Paris, 1877, t. iii. p. 812.
8 Op. cit. p. 100.

NON-MALIGNANT TUMOURS OF THE NOSE.

365

cysts in the neighbourhood of nasal polypi. They are, he says,
of white colour, and generally the size of a bean, but he once
sa\v a cyst as large as a hazel-nut growing from the anterior
part of the lower turbinated body, and containing a honey-
like fluid. Sometimes nasal polypi contain glandulae, but
the growths themselves never appear to be of glandular
origin. Hypertrophy of the mucous membrane is very
frequently associated with the presence of polypi, whilst, on
the other hand, these growths often give rise to atrophy of
the soft structures.

FIG. 79. — FROM SPECIMEN No. 2201A IN THE MUSEUM OF THE
ROYAL COLLEGE OF SURGEONS.

a, polypus hanging from the middle meatus ; b, apron-like flap hanging from
the vault of the nose and upper turbinated body, and partly covering d, the
middle turbinated body, which is greatly thickened ; c, portion of middle, pro-
jecting over the lower turbinated body. Near b are three small abrasions,
possibly caused by the pressure of the inner wall.

The exact site of origin of nasal polypi is a matter of
perhaps even more importance than their minute structure,
and valuable information on this subject may be obtained
from Zuckerkandl,1 who has recently published the post-
mortem reports of thirty-nine cases of polypus and poly-
poid thickening of the mucous membrane of the nose. The
great value of these observations depends on their having
been made after the gradual removal of the various bony

1 Op. cit. p. 64, et seq.

366 DISEASES OF THE THROAT AND NOSE.

parts which interfered with a view of the deep origin <>f t In-
growths. In a few of Zuekerk.'indl's cases, the disease was
nothing more than simple hypertrophy, one or two others
\\vre of doubtful character, one was a papilloma, in two
instances the growth was really in the naso-pharynx, whil>t
in three, polypoid excrescences grew from the septum. In
several instances, however, the polypi were multiple, so that
the exact seat of attachment of forty-two1 distinct growths
could be determined. Fourteen grew from the edges of
the hiatus setnilunaris, three from the edges of the hifttu*
and the infundibuhim, two entirely from within the infundi-
bulum, one from the odium frontale, one from the ostimn
splienoidale, one from the ostium ethmoidale, two from the
antrum, ten from the middle meatua, three from the tipper
meatus, four from the middle, and one from the upper
tnrbinated body.

Prognosis. — Mucous polypi cause great inconvenience and
annoyance, but are very seldom attended with any serious
risk, certain extremely rare reflex phenomena already de-
scribed being perhaps the most alarming features. True
polypus so rarely causes any disfigurement that this matter
may be dismissed from consideration. Even after the growth
has apparently been completely removed, however, there is a
great probability of the patient being again troubled with
the complaint. This is partly owing to the fact that the real
origin often cannot be reached, and partly to the circum-
stance that very small polypi no doubt often exist which
are not visible at the time when the larger growths are re-
moved. When relieved, however, from pressure, the minute
excrescences at once commence to grow.

Spontaneous expulsion2 of a polypus sometimes takes
place, and I have seen several cases where this has occurred.
In my experience, however, it has only happened when
several polypi were crowded together, and has therefore not
affected the prospects of cure. Spontaneous absorption is
said to have occurred in one case ; 8 but as the polypus (?)
gave rise to most intense headache, whilst it grew with
extreme rapidity and finally sloughed away, it can scarcely
be classed with the disease now under consideration.

1 Op. cit. pp. 64 to 84. In reality the actual number of separate
growths was more than this, for in some cases where a single site is
given there were " several " polypi.

2 Michel : Op. cit. p. 55.

3 Haddock: "Lancet" 1836-37, vol. ii. pp. 590, 591.

NON-MALIGNANT TUMOURS OF THE NOSE. 367

Treatment. — Medical remedies have been used from a
very early period with the view of drying up nasal polypi,
a method of cure which the gelatinous nature of the growth
naturally suggested. Galen advised the use of alum and
pomegranate juice. At a later period chloride of antimony
and sulphuric acid were much employed with the same
object, and in modern times various astringents and caustics
have been recommended. In 1821 Primus, of Babenhausen,1
reported two successful cases from the use of the saffronized
tincture of opium of the Prussian Pharmacopoeia. According
to that surgeon, the polypus, if painted with this solution
several times a day for about a week or ten days, under
favourable circumstances shrivels up and becomes detached.
Bryant2 strongly recommends the application of finely
powdered tannin by means of his nasal insufflator (Fig. 37,
p. 256), but though in the case of nervous patients who have
objected to an operation I have tried this remedy, I cannot
say I have ever found it do any good. Nitrate of silver was
successfully used by iSTelaton.3

Reeder,4 of Illinois, is stated to have employed strong in-
jections of perchloride of iron with good effect in two cases.
Erichsen5 mentions that he has seen one case in which
injections of chloride of zinc caused the separation by
sloughing of a polypus so large that it blocked up the nostril
completely and descended into the pharynx. Fredericq0
claims to have obtained excellent results from the appli-
cation of a saturated watery solution of bichromate of potash
to the polypus. He states that it produces some inflamma-
tion, which is followed by absorption of the growth. The
application may have to be repeated once or twice, but
Fredericq affirms that he has cured several cases in this
manner within five or six days, that he has seldom seen
any recurrence, and that he has never known any ill effect
follow the use of the bichromate. Donaldson,7 of Balti-
more, has found great benefit from chromic acid. The
mucous membrane is painted with a solution of lead, and a

1 " Hartenkeil's Medico-Chir. Zeitung." Salzburg, 1821, p. 56.
"Lancet," February," 1867, p. 235.

3 "Pathologic Chirurgicale. " Paris, 1874, 2me ed. t. iii. p. 748.

4 Quoted by Gross: "System of Surgery." Philadelphia, 1882,
6th ed. vol. ii. p. 290.

"Science and Art of Surgery." 6th ed. vol. ii. p. 320.

I8 "Memoire presentee a la Societe de Medecine d*e Gand." 1862.
Quoted by Spillmann, " Diet. Encyclop." t. xiii. p. 88.
7 "Philadelphia Medical News." May 26, 1883, p. 597.

3G8 DISEASES OF THE THROAT AND NOSE.

paste of chromic acid is applied to the polypus liy burying
a glass rod smeared with the agent in the substance of the
tumour. The mass dries up, and can then be easily removed
with forceps at the same sitting.

The general experience, however, is that astringents offer
so slender a chance of doing any good, that it is hardly worth
while to make a trial of them. By the application of strong
caustics or escharotics, no doubt nearly all nasal myxoniata
may be destroyed; but the cure is very tedious and painful,
and, moreover, it is difficult to limit the action of the a:
to the tumour. Electrolytic treatment would no douU some-
times succeed in destroying these growths, but its operation
would probably be extremely tedious.

Surgical Measures. — There are three principal methods of
removing or destroying nasal polypi, viz., evulsion, abscission,
and electric cautery.

Evulsion with forceps is the oldest and still the most
generally practised method, and it must be admitted that
it is a very rapid way of removing polypi, but the ease with
which it can usually be carried out, led practitioners in former
times to suppose that the proceeding was equally applicable
to all intra-nasal growths, wherever situated, and whatever
the nature of their attachments. Acting on such premises,
surgeons of the last century increased the size and leverage
of their forceps, and adapted them by suitable curves for
introduction, either by the nostril or through the pharynx,
as if no more consideration were necessary than to seize
every nasal tumour with tenacity and wrench it away with
violence. Tearing away of the septum, and even great
injury to the ethmoid and nasal bones, not unfrequently
resulted from such vigorous surgery, and it is not sur-
prising that this mode of treatment, after a time, met
with opposition.

But although the practice has since then been placed on
a rational and scientific basis, attempts have been recently
made to revive the prejudice against it which was once
so well founded. Whilst usually practised by general
surgeons, and still almost universally recommended in our
standard text-books on surgery,1 some leading specialists of
the day condemn it in the strongest terms. Voltolini -
says: "Of late years, the forceps has superseded all other

1 Erichsen, Gant, Bryant, Fergusson, Gross, Hueter, Liicke, Albert,
and Duplay.

2 " Die Anwendung der Galvanocaustik, " p. 243.

NON-MALIGXANT TUMOURS OF THE KOSE. 369

instruments, and as the result of its employment, severe
mutilations are frequently seen in the nose. Many distin-
guished surgeons admit that evulsion is one of the most
brutal and disagreeable operations. . . . The forceps, blindly
introduced, tears away or injures everything that comes in
the way, whether it is healthy or diseased, soft or hard
(turbinated bones and nasal septum)." He adds that, "In
operations with forceps, the greatest force has to be used in
some cases ; in fact one has to pull, as it were, ' for life,' in
order to get away the polypus." Michel1 states that, "as
the result of operations by others with forceps, he has seen
luxation of the cartilaginous septum, fracture of the bones,
removal of portions of the turbinated bones, circumstances
which increase the sufferings of the patients, and render the
operation quite horrible." Zaufal,2 in recommending the
snare, says that he hopes " to render utterly impossible in
the future the obsolete, barbarous forceps-operation so un-
worthy of modern surgery."

More recently, Lemere 3 has ransacked French medical
literature in order to bring together all the cases he could
find, in which bad results have followed evulsion. He
divides them into immediate and remote. Amongst the
immediate dangers, however, he only mentions haemorrhage,
and, as an illustration, adduces one case in which Gosselin
had to plug the nares, and another case (from Gerdy)
in which the haemorrhage had to be stopped in the same
way. In the latter case the patient died, but as the tumour
was clearly shown to be a fibroma it does not bear on the
question of evulsion of mucous polypi. Amongst the remote
dangers he adduces the following: — (1) Obliteration of the
nasal duct, (2) injury to the antrum or frontal sinuses, (3)
injury to veins, (4) injury to the bones of the nose and
skull, and (5) rapid exuberant recurrence. Under the first
head, only one case from Pean is given, which was ultimately
cured. In illustration of the injury to the frontal sinuses
and antrum, he adduces a case (also from Pean) in which a
man suffered for twelve years from a deep-seated tumour
on the cheek, which the patient stated commenced after the
evulsion of a polypus. An exploratory puncture gave issue

"Die Krankheiten der Nasenhohle." Berlin, 1876, p. 57.

2 "Die Allgemeine Verwendbarkeit der kalten Drahtschlinge."
1878. See preface.

3 "Sur les Accidents consecutifs a 1'Arrachement des Polypes des
Fosses nasales." Paris, 1377.

VOL. II. 11 B

370 DISEASES OF THE THROAT AND NOSE.

to a syrupy liquid, am1>er in colour, and containing i-h»I.
rine crystals. As an example of injury to the frontal sinus,
LI •nii-iv reports two cases; one (from Broca), in which an
abscess, which formed in the frontal sinus a few weeks after
evulsion of a polypus from the nose, was cured in three
months ; and another case (from Demarquay) in wliich the
patient, aged seventy-four, was attacked with al •
the frontal sinus after a polypus had been torn away. The
bone was trephined and the patient cured. As an instance
of injury to the veins, he brings forward the last case again,
recurrence having taken place the following year. Evulsion
again gave rise to erysipelas, and six months afterwards the
operation was again performed with similar results ; three
months later evulsion was repeated, and the stump treated
with nitrate of silver. This was followed by intense pain on
the right side of the head, and violent inflammation of tin-
pituitary membrane. Twelve days afterwards, the right lower
eyelid became greatly depressed, the right eye fixed, with its
pupil dilated, and insensible to light. Death occurred a fort-
night after the operation. At the post-mortem examination,
• •oiigestion of the meninges was found at the base , .}' the }>rain
on the right side. The body of the sphenoid was friabl", and
pus oozed through the sella turcica. The cavernous sinus
was bathed in pus, and there was purulent infiltration of the
right pituitary membrane. The sphenoidal, ethmoidal, and
maxillary sinuses were full of pus. The case does not exactly
seem to have been one of venous infection, but rather an
extension of inflammation from the nose to the sinuses and
the brain. It is clear that the repeated operations ought not
to have been undertaken, as the patient was an old man,
exceedingly prone to erysipelas ; but as he was a medical
practitioner, he probably insisted on measures which were
clearly unsuitable, and the case has no bearing on the
general merits of evulsion. In illustration of injury to the
bones of the skull, Lemere mentions a case (from Tillaux) in
which a patient applied for relief on account of a constant
flow of liquid from the nose, which, on examination by
Robin and Mehu, was found to be pure cerebrp-spinal fluid.
Evulsion had been previously practised on this patient on
two occasions, and Tillaux considered that, in one of the
operations, the cribriform plate of the ethmoid bone must
have been broken through by the forceps. The only example
wliich Lemere gives of exuberant recurrence was clearly a
of cancer.

NON-MALIGNANT TUMOURS OF THE NOSE. 371

From the above cases, collected from a treatise professedly
written to exemplify the dangers of evulsion, it will be seen
how difficult it is to bring forward any tangible evidence
against the operation. Albert,1 in his recent work, has
defended this method against the attacks of specialists
The following are some of his remarks on the subject : —
" In late years, this method (the operation by forceps) has
been condemned as brutal, painful, and inefficient. There
is no doubt that it can be performed brutally by rough
or clumsy hands ; but the conservative surgeon does not
grope blindly in the nasal cavity ; on the contrary, he places
the patient in a proper position, makes use of a nasal
speculum, and, carefully selecting forceps suitable as regards
the size and situation of the polypus, he seizes it by the
pedicle, and extracts it by gentle rotatory movements." He
adds, that " the hostility to the old universally-practised
method (evulsion by forceps) is merely the outcome of the
elaborate methods used by the specialist with an object which
it is easy to understand." Specialists might perhaps retort
that the hostility of some surgeons to new and improved
methods of cure, which they have themselves failed to
master, has a motive which it is equaDy easy to under-
stand. But such amenities are better avoided in scientific
discussions.

It is curious that the principal objection urged by Voltolini,
Michel, and others, against the practice of evulsion with for-,
ceps, viz., that a portion of one of the turbinated bones is
often torn away, is considered a recommendation by the
Ivocates of the forceps. It has already been shown (sec
[istory) that in the seventeenth century, Valsalva,2 for the
purpose of preventing the recurrence of the growth, intro
luced the practice of removing, together with the polypu?,
the lamella of bone from which it springs ; and in our own
time, the two leading conservative surgeons, Fergusson 3 and
Pirogoff,4 have advocated the same treatment. I may add,
that I have myself frequently removed portions of the

" Lehrbuch der Chirurgie." Wien u. Leipzig, 1881, Bel. i.
p. 305.

- Morgagni : " De sedibus et causis morb." Patavii, 1765,
ep. xiv. sec. 19.

3 Although there is no mention of it in his published writings, I
often heard this great surgeon remark, that one could never feel
sure of the complete removal of a polypus, unless a portion of the
bone was taken away with it.

4 " Klinische Chimrgie," 3tes Heft. Leipzig, 1854, p. 73.

372 DISEASES OF THE THROAT AND NOSE.

turhinated bones without seeing any evil result follow ; and
it appears to me extremely doubtful whether any bad
could be produced by the partial removal of one of
bones.

It is no doubt perfectly true that air breathed through the nose
reaches the lungs at a higher temperature than when it is inspired
through the mouth, and that this is due, in some measure, to the
peculiar vascular structure of the turbinated bodies. The interesting
experiments of Grehant,1 by which the temperature of air c-xjiiivd \>\
the lungs previously inspired through the nose, was compared with
that expired after previous oral inspiration , first proved this to be the
case. The following are the details of the experiments : A sm.-ill
thermometer was enclosed in a glass tube, each end of which was
stopped with a cork perforated so as to allow free passage to a current
of air. This apparatus was then placed inside a second tube, the
space between the two being filled up with cotton wool. The outer
tube having next been introduced into the mouth, with the bulb
of the thermometer at a distance of from one to two centimetres
from the lips, air was inspired through the nose, the aperture in
the outer tube being closed meanwhile with the tongue ; finally
expiration was performed through the apparatus containing the
thermometer. Under these circumstances, the temperature of the atmo-
sphere being 71 '6° F., that of the air expired through the tube was
found to be 95 '7°. On the other hand, when air was drawn in
through the mouth (the tube being closed with the tongue, as
before), the temperature of the air expired through the tube was
only 93 '5°. The temperature of the expired air in these experiments
was found to vary, being lower at the commencement of the act of
expiration than at its conclusion ; the temperature given by Grehant,
therefore, was a mean of that observed at three periods, viz., the
commencement, the middle, and the conclusion of expiration. This
feature, as well as some other points, not appearing quite satis-
factory, I thought it desirable to repeat the experiment in a slightly
modified form , and in the following investigations my assistant, Dr.
George F. Hawley (U.S.A.), afforded me material help. Instead of
expiration being made directly on the thermometer, I employed an
india-rubber bag of the capacity of one gallon. Into the further end
of the bag a thermometer was fitted, whilst to its proximal extre-
mity a piece of tubing, which served as a mouthpiece, was attached.
The temperature of the expired air, when previously inspired
through the nose, was now compared with the expired air after oral
inspiration. With the thermometer set at 70° F., the expired air
after nasal inspiration , as the result of a large number of experiments,
showed an average temperature of 75 '1°, whilst the average tem-
perature after oral inspiration was only 73 '6°, or, in other words,
nasal inspiration raised the temperature a degree and half higher
than oral inspiration.

Such experiments are, however, always open to objection, as they
do not show the actual difference in the air after inspiration through
the nose and mouth respectively, but the only difference in the expiiv.1
air after the two different modes of inspiration. It was thought

i " Recherches physiques sur la Respiration de 1'Homme." These de Paris
No. 161. 1864, p. 30, et seq.

NON-MALIGNANT TUMOURS OF THE NOSE. 373

desirable, therefore, to make more direct experiments. A thermo-
meter was accordingly supported in such a way that it could be
worn in the mouth with the bulb in the pharnyx on one side
between the uvula and the pharyngeal wall. The support of the
instrument consisted of a wooden bar, with a hole in its centre,
just big enough to admit the introduction of the thermometer, and
retain it in position ; it was held between the teeth, like a horse's
bit, in such a way that the subject's lips did not touch the ther-
mometer. When the instrument was placed in the pharynx, and
allowed to attain to a temperature of 90° F., it was found as the
result of a large number of experiments that gentle1 nasal inspira-
tion reduced the temperature only half a degree, whilst gentle oral
inspiration lowered the temperature a degree and a half, showing a
superiority of one degree in the heating power of the nasal channels
as compared with the mouth.

It is possible that if these experiments had been carried out in an
atmosphere at a lower temperature the influence of nasal inspiration
would have been more marked, but, after all, the experiments only
show that when the air reaches the lungs after passing through the
comparatively long and narrow passages of the nose, it arrives in the
pharynx at a higher temperature than when it passes directly
through the mouth.

i Forcible inspiration produced such variable results that the experiments
were unsatisfactory.

The real use of nasal inspiration, however, consists pro-
bably more in the protection it affords against the entrance
of minute foreign bodies rather than in its thermic effects
on the inspired air. The advantage of inspiring through the
nose, in fact, lies in the exclusion of the irritating matters
floating in the air, which, if they elude the vibrissse, are likely
to become deposited in the nasal passages, and are thus pre-
vented entering the lungs.1 The bad effect of oral respira-

1 Catlin ("The Breath of Life." London, 1861, p. 39), the great
apostle of nose-breathing, has carried his enthusiasm somewhat too
far, and has confused cause and effect in a most amusing way. Thus,
in the case of those people who cannot close the mouth, he asserts that
"the derangement and deformity of the teeth" proves the "long prac-
tice of the baneful habit" (mouth-breathing), and he adds "that the
mouth of the hyaena and donkey are agreeable, and even handsome, by
the side of such people." The expression of persons who cannot close
the mouth is not always prepossessing, but it seems a little hard that
they should be compared unfavourably with the donkey, and even the
hyaena. It is scarcely necessary to point out that the deformity of
the teeth referred to does not result from mouth-breathing, but that
in certain cases the direction of the teeth prevents the patient closing
the mouth, and that he is thus naturally inclined to use the mouth in
breathing. The irregularity of the teeth commences at the second
dentition, through the abnormal development and projection forward of
the intermaxillary bone. It is most frequently a hereditary peculiarity,
and is in no possible way caused by breathing through the mouth.

Catlin also states that amongst the American Indians deafness,

•">7t DISEASES OF THE THROAT AND N

tion indeed is not seen in the chest but in tin- pharvnx,
win-re the mucous membrane becomes <lrif<l liy exposure
to the air, and irritated by particles of dust floating in the
atmosphere.

The thermic influence of nasal inspiration is probably din-
to the passage of the air through a narrow canal lined by a
thin mucous membrane abundantly supplied with vessels,
rather than to the special structure of the turbinated bodies.
The peculiar erectile structure of these parts, moreover, is
only seen to perfection in the inferifrr turbinated body, and
it is not this, but the middle body which sometimes requires
partial removal. But if, taking into consideration tin-
peculiar histological character of the turbinated bodies, their
physiological importance be conceded, it docs nut follow
that the ablation of a portion of one of the bones would
l>e attended with any unfavourable results. I go further,
however, and do not hesitate to assert that there are some
polypi, which, from their anatomical situation, cannot b«-
extirpated xmless a portion of a turbinated bone is also
taken away. A mere glance at the annexed sketches
(Figs. 80 and 81) renders it evident that a polypus springing
from any of the localities marked x could not be taken away
except by previous or simultaneous removal of a lamella of
bone, especially when the position of the nares in relation
to those localities is taken into consideration. This view is,
moreover, amply confirmed by the recent observations of
Zuckerkandl (p. 366) as regards the origin of polypi. The
well-known disposition to recurrence of these growths,
which has already been pointed out (see Prognosis), is one
of the great causes of difficulty in dealing with them.
Now there cannot be the least doubt that in some cases the
ablation of the lamella of bone from which the polypus
springs is the most certain method of preventing any fresh
development of the growth, whilst in others its origin can
only be reached by first taking away a portion of bone. In
conclusion, it may be confidently asserted that if any slight
trouble should arise in consequence of the removal of a
piece of bone, this will at any rate be far less than tin-
annoyance caused by a mass blocking up the nose, and
perhaps requiring repeated operations for its eradication.

dumbness, spinal curvature, and death from teething and diseases of
the respiratory passages are almost unknown ; and he attributes this
exemption to the habit of breathing through the nose, so universally
practised by them !

NON-MALIGNANT TUMOURS OF THE NOSE.

375

FIG. 80.— TRANSVERSE VERTICAL SECTION THROUGH THE NASAL
FOSSAE AT A POINT BEHIND THE FIRST MOLAR TEETH (AFTER
HIRSCHFELD). The. x at four different points shows the supposed
origin of polypi.

FIG. 81. — TRANSVERSE VERTICAL SECTION OF THE NASAL Foss* IN

THE PLANE OF THE BlCUSPID TEETH (AFTER HlRSCHFELD). The X

at four different points indicates the supposed point of oriyin of polypi.

37C DISEASES OF THE THROAT AND NOSE.

The subject of the removal of a portion of one of the turbi-
nated bones has been treated here because this ablation is
often accidentally effected in evulsion, but it must not be
supposed that it is an essential feature in the oi>eration. It
is, indeed, only in quite a small proportion of cases that it
occurs. When it is thought desirable to remove a portion of
bone it is certainly better to cut it away (see Abscission) than
to practise evulsion, as by the latter operation the quantity
of bone which comes away cannot be controlled.

The great advantage of evulsion is not only the fwiliti/
with which the treatment can be carried out, but the
rapidity with which relief can always be obtained. M"r>'
growths can generally be taken away at a single sitting
than can be got rid of either with the snare or by electric
cautery. Although, as a rule, celerity is not a chief con-
sideration in treatment, yet cases every now and then occur
in which time is a most important element, and this point
should certainly be thought of in judging of the relative
merits of surgical methods, when it does not involve any
risk to life, health, or the integrity of any important func-
tion. The operation of evulsion holds an intermediate posi-
tion, neither deserving the extreme abuse it has received
from specialists, nor the liigh encomiums of general surgeons.
In my opinion it is altogether an inferior method to removal
by electric cautery, and I feel convinced that no practi-
tioner who has had a large experience in operating with
suitably constructed electrical apparatus would ever allow
evulsion to be performed on himself. Nevertheless, as the
number of surgeons who have the opportunity of acquiring
skill in using electro-cautery will always be limited, it is
necessary to fall back on less perfect modes of treatment ; and
where a more refined method cannot be employed evulsion
may be resorted to with a good prospect of favourable results.
At the same time I think it right to state that though I
formerly practised evulsion extensively I now seldom employ
it, having found that electric cautery gives less pain to the
patient, and causes no haemorrhage. Abscission with cutting
forceps is also, to my mind, a preferable operation.

In practising evulsion, the interior of the nose is to be
first thoroughly exposed (see " The Application of Anterior
Khinoscopy," p. 243), the growth is then seized, the blades
of the forceps firmly compressed, and lastly, the handle
of the instrument moved up and down, and slightly twisted
to one side. The value of this process was first pointed

NON-MALIGNANT TUMOURS OF THE NOSE. 377

out by Dzondi, who recommended that the polypus should
be drawn forwards with one pair of light forceps, whilst
with another pair its root was bruised as close as possible
to its attachment. It is seldom, however, that there is
room for using two pairs of forceps at the same time in so
confined a space. An ingenious modification of the common
forceps (Fig. 54, p. 268) has been made by George Stoker,
by which the tumour can be really twisted off instead of
being torn away. Where the mass is large, and situated
far back, it is best to use the common polypus-forceps
(Fig. 49, p. 265). The blades of this instrument should,
after careful determination of the site of the growth, be
introduced into the nose, when by passing the index finger
of the left hand round the uvula into the posterior nares,
the polypus can easily be seized. In these cases the adminis-
tration of nitrous oxide gas greatly facilitates the operation.

Evulsion by means of a sponge was first recommended by
Hippocrates, and the mode of carrying it out has already
been described (see History). In modern times the practice
has been revived by McRuer,1 who " succeeded in at least
ten cases in bringing away all the adventitious growths."
Voltolini2 has also quite lately reported a case successfully
treated by this method.

When the growth is situated far back it can sometimes
be more easily reached through the pharynx than through
the anterior orifice of the nose. In a case in which Morand3
had failed to get away the mass of a polypus with forceps, he
was able to remove it through the pharynx, loosening it from
its attachment, partly by direct pressure and partly with his
finger-nail. This proceeding was practised with equal success
in another case by Sabatier.4 Gross5 also contrived to remove
a large polypus situated far back in the nasal fossa by "break-
ing it off with the index finger introduced into the mouth,
and carried round the palate."

Abscission. — This method of treatment may be carried out
either with the snare, ecraseur, or cutting-forceps. Since
Hilton (see History) recommended the snare it has been
widely used, and Durham6 observes that in his experience

1 Holmes's " System of Surgery," 1st ed. 1862, p. 216.
1 Monatsschrift fiir Ohrenheilkunde." 1882, No. 1.
'Opuscules de Chirurgie." Paris, 1768-72.
' Medecine Operatoire." Paris, 1824, t. iii. p. 283.
' System of Surgery," 6th ed. Philadelphia, 1882, vol. ii. p. 291,
' Holmes's System of Surgery," 2nd ed. 1870, vol. iv. p. 300.

378 DISEASES OF THE THROAT AXD NOSE.

this method has proved "more easy and effectual, nn<l
painful, and loss likely to prove mischievous than oth<-r
methods commonly adopted." Except when instrument-
provided with ZaufaPs arrangement (p. 270) an1 employed,
the following is the best way of applying the snare : —
The noose having been introduced vertically should lie
turned into a horizontal position, and made to encircle the
polypus, when it is pushed upwards as far as it will go, in
order to seize the pedicle as near as possible to its root. If
the growth be very far back and hang into the naso-pharynx,
the snare may be put round it, by passing a string through
the nose by means of Bellocq's sound. The nasal extremity
of the string is then attached to the noose, which is drawn
up to the tumour by traction on the buccal end of the string.
The loop is next adjusted with the help of the index tii
and tightened in the ordinary way. For the slow strangu-
lation of growths which show a tendency to bleed, Jan
instrument, or one of the modifications of it, is particularly
useful. My nasal ^craseur (Fig. 59, p. 272) will also In-
found serviceable in these cases.

Gant has adapted grape-scissors for the removal of polypus
from the nose, and has successfully used the instrument in
several cases (Fig. 50, p. 265). The most convenient way of
carrying out abscission, will, however, I believe, be found
in the employment of my punch-forceps (Fig. 51, p. 266),
which is so slender that it can be easily passed along
the nasal passages without obstructing the view of the
operator, yet so strong that it readily cuts through the
pedicle of any polypus. With this instrument the slipping
off of the wire which, in spite of every precaution, must
oecur very frequently with the snare, is avoided. Surgeons
who, not having the necessary apparatus, cannot employ the
more perfect method of electro-cautery, will find that with
the punch-forceps they can generally quickly clear the nasal
passages. My clinical experience of the superiority of forceps
over snare and ecraseur has been recently confirmed by the
very important anatomical researches of Zuckerkandl,1 who,
after a careful study of the deep origin of nasal polypi,
points out that in many instances " forceps can accomplish
more than the snare."

In some cases, with the view of preventing recurrence, it
is desirable, as already remarked (p. 371), to remove a small
portion of one of the spongy bones. This can be most easily
1 Op. cit. p. 81.

NON-MALIGNANT TUMOURS OF THE NOSE.

379

done with my punch-forceps. The operation can be carried
out more satisfactorily if an anaesthetic is given, as in re-
moving a part of the middle turbinated bone painful pressure
is sometimes brought to bear on the upper part of the nostril.
The following cases illustrate the advantage of taking away
a piece of a turbinated bone : —

Case 1. — Mr. E. F., aged thirty-seven, consulted me in May, 1875,
on account of polypus in the right nasal passage. The symptoms
commenced in January, 1871, and he then was operated on twice
with forceps by an eminent surgeon. The growth returned, arid
Mr. F. was again treated in the same way by the same operator, in
the following August. The nose remained clear till July, 1872, when
polypi again formed, and Mr. F. placed himself under another surgeon
who in two months (twenty-five visits) removed a number of polypi
with a snare. The patient believed himself cured, but remained well
only seven months. He then went back to the last operator, who per-
formed repeated operations with the snare through the year 1873, and
indeed up to May, 1874, when the nose became quite clear. In Decem-
ber the polypus again showed itself, and the next month the patient
applied to me. On making a careful examination I perceived a large
polypus growing from the anterior half of the middle turbinated
bone. In view of the repeated recurrence, I determined to remove
a portion of bone. This was easily done. (The appearance of the
growth with a portion of bone after its removal is shown in the
annexed cut.) The patient came to me (1880) on account of follicular

FIG. 82. — POLYPUS WITH PORTION OF BONE REMOVED WITH NASAL

BONE-FORCEPS.

disease of the throat, when I learnt that there had been no recurrence
of the nasal polypus, nor any unpleasant effects from the removal of
the bone.

FIG. 83.-

-POLYPUS WITH OSSEOUS LAMINA REMOVED WITH
THE NASAL BONE-FORCEPS.

Case 2. — Mrs. L., aged fifty-nine, consulted me in July, 1878, on
account of polypus in the right side of nose. Since 1871 she had been

380 DISEASES OF THE THROAT AND NOSE.

treated hy seven different practitioners. Of these five had us.>l
forceps, one a snare, and one electric cautery. The latter treatment
had been carried out in 1876 and the heginning of 1877, and the
polypus had been burnt sixty-four times. Mrs. L. said that this
treatment was not painful, but it caused "a peculiar sensation which
went to her brain." I removed a bit of the middle portion of tin-
turbinated bone with a small polypus attached (Fig. 83). I saw
this patient again in June, 1881. The nose had remained free from
any recurrence of the disease, and no inconvenience of any kind
had been experienced since the operation.

Electric Cautery. — This method was first introduced by
Middeldorpf,1 and subsequently improved by Voltolini,2
Thudichum,3 and Michel,4 by all of whom it is strongly
recommended. I consider it by far the best method of
treatment which exists.5 Patients who have had the oppor-
tunity of comparing this method with evulsion invariably
prefer electro-cautery. It is much less painful, and the jmin
ceases tJie moment the current is turned off ; it has also the
great advantage of not causing any haemorrhage. The only
drawback to the method is that it is tedious, and reqxiircs
many sittings. I employ a flat spatula-like electrode, and en-
deavour to push it backwards over the surface of the mucous
membrane, from which the polypus grows. The cure can be
most quickly accomplished by using the cautery and the
punch-forceps on alternate days, the latter being only em-
ployed for taking away the dead tissue. Some practitioners
prefer using the electro-cautery in form of a loop, but the
trouble of applying the snare, in my opinion, complicates
the operation. Sneezing is often caxised by the cautery, but
in my experience never comes on till after the withdrawal
of the electrode.

1 " Die Galvanokaustik." Breslau, 1854.

2 " Die Galvanokaustik." Breslau, 1867.

3 " Polypus in the Nose," 1st ed. London, 1869. See also 3rd ed.
1877.

4 " Krankheiten der Nasenhohle." Berlin, 1876, p. 56, et seq.

5 Those who are not in the habit of working with electro-cautery
will, of course, find it a troublesome method, and it can really be
only carried out successfully by those who constantly employ it.

NON-MALIGXAXT TUMOURS OF THE NOSE. 381

FIBROUS POLYPI OP THE NOSE.

Though fibrous polypus of the naso-pharynx is not tin-
frequently met with, this form of tumour extremely seldom
originates in the nose itself, the only case, as far as I am
aware, in which such a growth has been actually proved to
exist being one of my own, hereafter related, .There are,
however, two other instances in which there is every
reason to believe that the tumours were fibromata. One of
these was reported by Gerdy1 as having occurred in a boy
aged thirteen. The left nostril had been occupied by a
growth for eighteen months, and endeavours had been made
to remove it with the ligature and by evulsion, but the
tumour was so hard that the blades of the forceps were
turned. The patient finally died of haemorrhage, brought on
by an attempt to cut through the base of the polypus with a
bistoury. After death the growth was found to be attached
to the posterior part of the vault of the left nasal fossa ; its
substance was very firm and elastic, and could. not be torn
with the fingers, and on section it was seen to be of purely
fibrous structure. In the other case, which is related by
Lichtenberg,2 the polypus was found to spring from the upper
turbinated body ; there were also some polypoid excrescences,
apparently independent of the larger growth, attached to the
under surface of the cribriform plate of the ethmoid. The
microscope does not appear to have been used in either
Gerdy's or Lichtenberg's cases.

The treatment consists in removal of the tumour, if
possible per vias naturales. According to its situation, it
should be attacked, either anteriorly or posteriorly, by
evulsion, abscission, or electric cautery. Lichtenberg, liow-
ever, in order to obtain access to the growth on which he
operated, was obliged to perform temporary resection of the
bridge of the nose. The following are the details of my
own case : —

Mrs. M., aged thirty-five, consulted me, by the advice of Mr.
Crowdy, of St. John's, Newfoundland, on the 12th February, 1877.
She had suffered for two years from obstruction of the right side of
the nose. On making an examination the pharynx was found to be
very granular, and there was general inflammation of its posterior
wall. The anterior nares were healthy. Owing to the extreme

1 "Des Polypes et de leur Traitement." Paris, 1833, p. 19.
- "Lancet." 1872, vol. ii. p. 773, et seq.

.'5M2 DISEASES OF THE THROAT AND NOSE.

nervousness of the patient, it was impossible to make a satufkctflfj
pi'.st-rhinoscopic examination, and it was not until she had lu-cn under
my care some weeks that I succeeded in obtaining a view. I then
dismvt'n-d a large red, smooth, irregularly oval growth, bilking up
mid projecting beyond the right choaua (Fig. 84). On examination

FIG. 84. — FIBROUS POLYPI'S OF THE
View of the growth as seen by posterior rhiuoscopy.

with the sound, the polypus was found to be hard, but slightly elastic,
and from its mobility appeared to be pedunculated. On the first
attempt I succeeded in seizing it and tearing it away with short,
curved, blunt forceps. After removal the stump could be felt mi
the roof of the nasal fossa, well within the cavity ; the growth was
the size of a pigeon's egg, and on section was hard, 'lease, and
pale. Microscopically it was seen to be composed of closely inter-
laced whitish fibres, with a few minute cells lying among them.

PAPILLOMATA OF THE XOSE.

Small warty growths are sometimes found in the nose,
and according to Hopmann,1 they are much more common
than is generally supposed. In a series of one hundred
cases of growths in the nasal cavities this observer met
with no fewer than fourteen examples of papilloma.- These
were of two pathological varieties, viz., epithelial papilloina,
or benign cauliflower excrescence, and soft papilloma ; the
latter being subdivided, according to the predominance
of gland-structure, vessels, areolar tissue, or prolifnat-
iiig cells, into adenoma, angioma, fibro-sarcoma, and fibro-

1 " Virchow's Archiv." Bd. xciii. 1883.

2 From a more recent paper by Hopmann ("Wien. med. I
1883) it appears that Schiiifer, of Hremen, has found twenty ca-
papilloma among one hundred and eighty-two nasal polypi.

NON-MALIGNANT TUMOURS OF THE NOSE. 383

sarcoma papillare. The growths generally varied in size,
roughly speaking, from a pea to a hazel-nut, but Hopmann
removed l one which measured four centimetres in length
and from one to one and a half in breadth and thickness.
In several instances the tumours were multiple, as many as
ten or twelve being present in one case. They were invariably
attached to the lower turbinated body, generally springing
from its convex surface, or its lower border, but sometimes
from its concave portion. The symptoms caused by the
presence of these tumours were frequent cough and ex-
pectoration, dry catarrh, and in some cases retching of
such severity as to excite suspicion of gastric disease.
There were also the usual signs of obstruction of the nasal
passage, and in two cases there was some bleeding.

Had it not been that Hopmann shows himself 2 to be
perfectly familiar with the appearance and symptoms of
general thickening of the inferior turbinated body, a com-
paratively common complaint, which has already been de-
scribed (p. 317, et seq.), it might have been supposed that he
had mistaken this condition for true papillary neoplasia. It
would seem, however, to result from this observer's investi-
gations, that many growths which closely resemble mucous
polypi, are really of papillary structure ; this, at least, is the
only way in which the wide discrepancy between his observa-
tions and those of other pathologists can be explained. For
my own part I must confess that although I remove polypi
from the nose almost daily I now hardly ever make any
microscopical examination of the growths, and this may ac-
count for the fact that I have met with only five undoubted
examples of intra-nasal papilloma. In all of them the tumour
was situated on the mucous membrane over the lower and
anterior part of the septum, or on the inner plate of the
alar cartilage where it joins its fellow in the middle line
close to the tip of the nose. In no instance was the excres-
cence larger than a split pea, and in four of the cases there
were at the same time mucous polypi in the nasal fossa.
The specimen in the Museum of the Royal College of
Surgeons, described in the catalogue (No. 2,201 C) as a
polypus, has more the appearance (see Fig. 77, p. 320) of
a papilloma. Zuckerkandl 3 met with only one example
of true papilloma, and this was situated on the middle
of the lower turbinated body ; but three other cases which
he describes as " polypoid excrescences," bear a close

1 Loc. cit. p. 225. 2 Loc. cit. p. 247. 3 Op. cit. p. 70.

DISEASES OF THE THROAT AND NOSE.

similarity both to the specimen in the Huntcrian Museum
just referred to, and likewise to some of Hopmann's cases.

The application of strong nitric acid or electric cautery
rapidly destroys these growths, but they can also be removed
with the cutting-forceps or snare, and Fere"1 has reported a
case in which he effected a cure with a ligature.

ERECTILE TUMOUR OF THE PITUITARY MEMBRANE.

An extraordinary case of this kind (probably analogous
in its pathological characters to the vascular variety of soft
papilloma described by Hopmann)was reported by Verneuil,2
in 1875. The patient, a Roumanian, aged fifty -two, had been
subject to frequent and abundant bleeding from the nose
since boyhood. During the ten years previous to his
coming under notice, the haemorrhage had become so formid-
able as to have reduced the patient to an extremely anaemic
condition. Various internal remedies were tried, without
avail, and the inside of the nose was cauterized, with the
view of healing a supposed ulcer within the cavity. AVhen
the eschar came away, however, the bleeding broke out
again as severely as before. At this time he consiilted
Verneuil, who, after a careful examination, found, on the
left side of the septum, a round, dark-red, sessile swelling of
the size of a cherry-stone, pulsating synchronously with the
heart. Several other small erectile patches were found in
various parts of the patient's body — the right temple, the soft
palate, &c. No haemorrhage, however, had ever been known
to occur from any of those spots. At a second examination,
made in the presence of M. Gosselin, Verneuil failed to
discover the tumour in the left nasal fossa, but found a
swelling exactly similar in character on the right side.
Radical measures having been decided on, Verneuil laid
open both sides of the nose, and destroyed the greater part
of the septum with the actusil cautery. The parts were
then douched with cold water for some time, and the
wound was closed on the left side, the right being allowed
to remain open, and plugged with lint steeped in perchloride
of iron. Wet compresses were kept constantly applied to
the brow and nose. In spite of this there was pretty sharp

1 " Bull, de la Soc. Anat." 1880, 4e serie, t. v. p. 587.
'2 " Annales des Maladies de 1'Oreille," &c. t. i. p. 169, <

XOX-MALIGNANT TUMOURS OF THE NOSE. 385

bleeding on several occasions, and Venieuil was obliged once
more to apply the actual cautery to the interior of the right
nasal fossa. There was no further hemorrhage, and in a
short time the patient was able to return to Roumania. Two
years after the operation the patient continued well, but four
years later he appears to have died in a state of extreme
cachexia; Verneuil states, however, that he was unable to
obtain any details on this point.

ENCHONDROMATA OF THE NOSE.

Cartilaginous tumours of the nose are very rare. Examples
have, however, been reported by Erichsen,1 Bryant2 (two
cases), Ure,3 Durham,4 Richet,5 Heurtaux,6 and Verneuil, "
and I have myself met with one example of the affection.
The disease belongs essentially to the period of life when the
growth of the body is most active, all the patients whose
cases have been quoted above having been under the age
of eighteen.8 As regards sex, the disease shows a slight
preference for the male sex.

The most marked symptoms are obstruction of the nasal
passages, and deformity in advanced cases amounting to
"frog-face" (see "Fibrous Polypi of the Naso-Pharynx ").
The ordinary phenomena of catarrh, such as abundant dis-
charge and sneezing, have sometimes been observed. In the
patient I treated the discharge was of such an offensive cha-
racter, that the disease had been mistaken for ozsena. The
)wth may vary in size from a hazel-nut to a man's fist,
jr may be even larger. The tumour, when small, closely

esembles a fibrous polypus, but it is never distinctly pedun-
lated, and usually springs from the cartilaginous part of

le septum, although in rare cases it may originate from

le outer wall or roof of the nose.

1 "Lancet," 1864, vol. ii. p. 152.

2 Ibid. 1867, vol. ii. p. 225.

3 "Holmes's System of Surgery." London, 1870, 2nd ed. vol. iv.
319.

4 Ibid.

5 Casabianca : " Des Affections de la Cloison." Paris, 1876, p. 59_

6 " Bull, de la Soc. de Chir." Nov. 7, 1877.

7 Quoted by Spillmann : "Diet. Encyclop. des Sciences Med." t. xiii.
p. 184.

8 In Heurtaux's case the age is stated as twenty-two, but the disease-
had been in existence for five years.

VOL. II. 0 C

386 DISEASES OF THE THROAT AND NOSE.

The prognosis is favourable if the disease is detected at
an early period, as the growth shows no disposition to
return when once removed, but if it has attained lai^e
dimensions before treatment is romnieneed, it may happen
that a cure cannot be effected without making an external
incision, and thus causing a more or less unsightly scar.

The diagnosis is difficult when the growth has attained a
large size, as it may be mistaken for fibrous polypus, a malig-
nant neoplasm, an exostosis, or an osteoma. The extreme
rarity with which fibroma commences in the nose almost
permits its exclusion from consideration. Malignant tumours
have not the dense consistence of enchondromata, bleed
more readily and grow more rapidly, whilst bony formations
are very hard, and cannot be penetrated by a needle, like
cartilage.

Surgical treatment is alone of any service, and the snare is
the best instrument that can be used, its employment with
electric cautery being especially indicated. In my own case,
however, which is detailed below, I had no difficulty in
cutting through the mass with the cold win-.

CASE OF ENCHONDROMA REMOVED WITH
THE SNARE.

Miss E. , aged thirteen, was brought to me, in September, 1874,
on account of an offensive discharge from the nose, from which she
had suffered for two years. She had been treated for "polypus"
and "ozaena" by different surgeons, but without deriving any per-
manent benefit. There was a marked prominence of the right side
of the nose, mid-way between the inner canthus of the eye and the
xipper border of the alar cartilage. On examining the nose with a
speculum, a round, nodulated tumour was seen in the right nasal
fossa. The growth, which was firmly attached, was of a purple red
colour and slightly ulcerated at its outer part. It so completely
occupied the fossa, that it was only after repeated examinations
that its origin from the upper and back part of the cartilaginous
.septum could be made out.

A needle passed into the tumour without much difficulty, and
•caused but little haemorrhage, and it was thought that the growth
was a fibroma.

Several attempts at removal with the forceps proved unavailing ;
but I ultimately succeeded in passing a wire round the tumour and
•cutting it through. Even after the growth was separated, however,
it was impossible, owing to its size, to draw it through the nostril ;
and it was only by dividing it into two portions with the snare, that
it could be got out. After its removal, its base was seen to be about
half an inch in diameter. On microscopical examination of the
tumour, its central portion was seen to consist almost entirely of
hyaline cartilage, but towards its circumference there were numerous
bundles of white fibres, and a small amount of yellow elastic tissue.

NON-MALIGNANT TUMOURS OP THE NOSE. 387

It looked as if it had originally been covered with a fibrous envelope,
which had been subsequently destroyed in places by erosion. The
patient made a rapid recovery ; but slight thickening of the septum
remained, and indeed had not entirely disappeared nine mouths after
the operation.

OSTEOMATA OP THE NOSE.

Latin Eq. — Tumores ossei nasi.
French Eq. — Tumeurs osseuses du nez.
German Eq. — Knochengeschwiilste tier JS^ase.
Italian Eq. — Tumori ossei del naso.

DEFINITION. — Bony tumours, generally of exceedingly dense
but occasionally cancellous structure, varying in size from
a bean to a hen's egg, and sometimes even larger, having
no connection with the osseous framework of tlie nose, causing
obstruction of the nasal passages, and if allowed to attain
a great size eroding and frequently perforating the parietes
of the nasal cavities.

History. — The mention of "osseous" tumours of the nose is not
uncommon in the older writers, but the actual literature of the
subject is altogether modern, and, as might be presumed from the
rarity of the affection, is also very scanty. Some doubtful cases
were collected by Bordenave1 in the latter half of last century, and a
few scattered examples may be found in the medical journals of the
earlier part of the present century. Follin,2 however, appears to have
been one of the first to call attention to such growths as a substantive
disease, quite distinct from exostosis. Cases have since been reported
by Hilton,3 Pamard,4 and Legouest,5 and the complaint has been made

"ic subject of special research by Ollivier,6 Gaubert,7 and Rendu.8
good chapter on nasal osteomata may be found in Folliu and

)uplay's9 large work, and quite recently Spillmau10 has discussed
these singular growths with great care.

1 " Memoires de I'Acade'mie Royale de Me'decine." Paris, 1774.

2 "Des Tumeurs osseuses sans connexion avec les os."— "Bull, de la Soc. de
Biologic." Paris, 1850-51.

3 "Guy's Hosp. Reports," series i. vol. i. p. 495.

4 " Exostose iburne'e de la Posse nasale droite." — " Bull, de la Soc. de Chir."

SIXi.

s " Exostose .... occupant la Fosse nasale gauche." — " Me'm. de 1'Acad. de
Med." 1865-66.

8 " Sur les Tumeurs osseuses des Fosses nasales." These de Paris, 1869.
" Des OsWomes de 1'Organe de 1'Olfaction." These de Paris, 1869.
i " Des OsWomes des Fosses nasales."—" Arch. Ge'n. de He'd." Aout, 1870.
» "Trait^ E16m. de Pathologic externe." Paris, 1877, torn. iii. p. 8S9,
et seq.
10 " Diet. Encyclop. des Sciences He'd." 2e s^rie, t. xiii. p. 169, et seq.

Etiology. — The causes of osteomata are quite unknown.
The only point about which there is any certainty is that

388 DISEASES OF THE THROAT AND

the affection Ijelongs to the period of adolescence. Most of
tin' patients who have suffered have been about twenty years
of age, though sometimes the disease lias escaped observation
till a later period. As far as can be ascertained Ixtth s>
are equally liable to the complaint.

Symptoms. — The most characteristic symptom in the early
stage of the disease is an itching sensation in and about the
affected part, which is sometimes so intolerable that tin-
patient is compelled to relieve himself by constantly scratch-
ing the inside of his nose. As soon as the tumour attains
any considerable volume it gives rise to the usual symptom-;
of obstruction. There is often impairment of the sense of
smell, and epistaxis generally becomes frequent and severe
as the growth develops. The patient usually complains of
severe neuralgic pain, caused, no doubt, by the pressure of
the bony mass on neighbouring nerve-filaments. The growth,
as a rule, is covered with mucous membrane of a bright pink
colour, but its surface is occasionally dark red or even purple
in hue. At times the membrane is discoloured or even
ulcerated, and, in some instances, necrosed bone becomes
visible. Owing to the ulceration or necrosis, or to the mere
retention of the secretions which the tumour causes, there
is usually a fetid discharge. As the growth enlarges, it
may press on the septum, twist the nose to one side, and
entirely obliterate the genio-nasal furrow ; or, extending
towards the antrum or the orbit it will produce correspond-
ing deformities, such as unnatural fulness of the cheek, or
displacement of the eyeball. The pain in most cases becomes
extremely severe, but occasionally the pressure produces an-
aesthesia of the adjoining parts.

Diagnosis. — A nasal calculus or an exostosis may simulate
an osteoma in the earliest stage of the affection. It should
therefore be remembered that osteomata, unlike bony out-
growths, can at the outset be moved when pressed on with a
strong probe, and that their surface cannot generally be broken
with a sharp needle, as is the case M'ith a calculus. When,
however, an osteoma is encrusted with calcareous deposit, as
in the case of Legouest,1 the diagnosis is rendered extremely
difficult. Enlargement of the turbinated bodies might 1>\
an inexperienced observer be mistaken for an osteoma, but
whilst the latter is almost always unilateral, thickening of the
turbinated bodies almost invariably affects both sides. More-
over, the tissues over the spongy bones are soft, and quite
1 Loc. cit.

XOX-M ALIGN AXT TUMOURS OF THE NOSE. 389

unlike the structure of osteomata. As the disease develops,
the severe pain caused by the pressure of the hard mass at
once differentiates osteomata from any other kind of nasal
tumour except cancer, from which, again, they may be dis-
tinguished by their much slower rate of growth. Fibrous
tumours of the nose are so rare that they need scarcely
be taken into consideration, but an offshoot from a naso-
pharyngeal polypus into one of the nasal fossae might possibly
be mistaken for an osteoma unless the naso-pharynx were
explored. A digital examination of the posterior nares will,
however, soon settle the question. Occasionally a mucous
polypus may coexist with an osteoma, and this may further
complicate the diagnosis.1

Patlioloyy. — The tumours are of two kinds — the ivory
and the cancellous. The former are much the more com-
mon, and they are so extremely firm in structure that the
strongest forceps are sometimes turned by them. They
are covered with periosteum, and well supplied with vessels,
which pass into the substance of the tumour. They are
generally connected with the soft tissues of the nose by a
narrow pedicle. Although they appear to originate from
the mucous membrane, it is more probable that they really
grow from the periosteum, or that they commence as ex-
ostoses, their bony connection with the skeleton being
destroyed at so early a period, that it has never been
observed. It is possible also that in some cases they
may be originally of cartilaginous structure, and subse-
quently undergo ossification. On section these growths
are seen to consist of a number of layers of bone which
correspond with the depressions and elevations on their
surface. The cancellous osteomata, as a rule, present the
usual structure of cancellous bones — that is to say, they
consist of an external envelope of compact tissue, with
spongy tissue internally, between the trabeculse of which is
contained the ordinary reddish marrow ; towards the centre
of the bone there is often a distinct cavity.2

/'for/nosis. — The prospects of the patient are very favour-
able if the tumour can be removed per vias natural es ; but,
if not, the observation made under the head of "Prognosis"
in the last article also applies here.

Treatment. — The only treatment is extirpation. The can-
cellous osteomata can be easily crushed with strong forceps

1 Legouest : Loc cit.

2 Richet : "Bull, de 1'Acacl. de Med." 1871.

390 DISEASES OF THE THROAT AND NOSE.

and removed in fragments, whilst in the case of tin- ivory-
like growths, it is generally necessary to lay open tin- i
Rouge's operation (see " Fibrous Polyj)i of tin N
])harynx,") should he performed in the first instance, but
if sufficient room cannot he obtained in this way, one of
the other methods described in the same article should !•••
adopted.

EXOSTOSES OF THE XO8E.1

Exostoses are not very uncommon, though they seldom
attain a large size, and hence do not give rise to mm li
inconvenience. My clinical experience had led me to
believe that they most commonly spring from the floor
of the nose, a short way from the orifice. This, however,
is not confirmed by observations made on preserved rrania.
for among 2,152 skulls in the Museum of the College of
Surgeons, I found 170 examples of bony outgrowth origin-
ating from the septum, 91 being in the left, and 79 in
the right nasal fossa. In three of these cases there were
two distinct exostoses, both, however, being in each instance
in the same nasal fossa. The size varied from a split
pea to half a haricot bean, and they sprang, as a rule,
by a broad base from the septum, extending horizontally
towards the outer wall and terminating in a more or less
pointed crest. The situation of the tumour was gene-
rally opposite the middle turbinatcd bone, or just mid-
way between that and the lower bone, so that the peak
seemed in some cases actually to run into the oritice by
which the antrum communicates with the middle meatus ;
in a minority of instances the exostosis was opposite the
lower turbinated bone. In many cases these prominences
formed, as it were, the posterior spur of a bony ridge
running along the septum at the junction of the ethmoid
and the vomer, or of the latter and the crest of the
upper maxilla. Ridges of this kind existed in 673 skulls
(31 '2 per cent, of the total number examined). In -"'7-"'
instances the projection was on the left side ; in 231 on the
right; whilst in 67 cases there were ridges on both sides.
The size varied from a slightly raised line to a rough jagged
ledge encroaching considerably on the cavity of the conv-

1 A few forms of exostoses of rare kinds will he referred to under
the head of ' ' Synechise. "

MALIGNANT TUMOURS OP THE NOSE. 391

spending nasal fossa. It is probable that in most cases a
considerable portion of the ridge would be visible from the
front (see Fig. 86, c). According to Thudichum,1 exostoses
sometimes grow from the turbinated bones, but this must be
extremely rare, since in the large number of skulls above
mentioned I only met with one example. In that case the
growth sprang from the middle turbinated bone and ran
horizontally across the nasal fossa almost to the septum.

Exostoses present an irregular surface, and occasionally
cause slight deviation of the septum. It will be found im-
possible to penetrate them with a sharp needle, a peculiarity
which serves to differentiate them from the softer tumours.
I have never met with any instance in which the outgrowth
caused serious inconvenience, but no doubt cases occur in
which, by blocking up the antrum, it may give rise to
disease within that cavity, and there may be others in which
smaller exostoses cause considerable irritation by their pre-
sence. If it is thought advisable to interfere with them,
bony outgrowths would probably be best treated by means
of the dentist's drill, as recommended by Goodwillie,2 of
New York. Thudichum states that they can be removed
by means of the electric cautery wire, but I quite agree with
Spencer Watson,3 who points out the disadvantages of this
mode of treatment in these cases, and remarks that " a pair
of scissors would answer equally well, or even better." The
projecting piece of bone, Avhen small, can also be easily
broken off with the common polypus-forceps ; when it is
large and is attached to the septum by a broad base my
nasal bone-forceps (Fig. 55, p. 268) will be found most
serviceable.

MALIGNANT TUMOURS OF THE NOSE.

Latin Eq. — Tumores maligiii nasi.
French Eq. — Tumeurs malignes du nez.
German Eq. — Bbsartige Geschwiilste der Nase.
Italian Eq. — Tuniori maligni del uaso.

DEFINITION. — Malignant neoplasms, mostly of sarcoKiatoita,
ran-li/ of carcinomatous, nature, originating as a rule

1 "Lancet," Sept. 1868.

2 "New York Med. Record," Nov. 12, 1881.

3 " Diseases of the Nose." London, 1875, p. 290.

392 l>l>KAM-:s UK TIIK IMKCAT AXH

from the septum, />t/t <'<-<-ti.<inn<i//i/ f, -1,1,1 flu' nnti-r trail <>/• flu-
floor of the nasal fostutt, yiviny rise to olmtriu-tiim of tin-
nn.-ifrif, iiiin-n-jiundent discharge often offensive in clmric-t, r,
and I'lnxhu-is, /' it'Untj an tht-ij incfiw in /•<•//////<• f<> f)«-r<>a<-/t
upon the ailjoinimj jxirf*, l<-a<lii«j in XHHK- »Y/.SV.V to .-•"•"//'/«/•//
tli l>nxits in olln-r m-i/unx, and finally f<> <-a<-h<'sia <i/t</ <lnith.

History. — All the old writers who treat of nasal polypi state
that these growths are sometimes of malignant nature. Among the
five varieties of polypi described by Hippocrates1 there is one whieh
he calls a "kind of cancer." He mentions that this form of tumour
is found "on the side of the cartilage near its extremity," and the
treatment indicated is destruction with the hot iron, and subsequent
dressing with powdered hellebore and "flower of copper" boiled in
honey. Celsus2 was strongly opposed to any interference with a
class of nasal polypi which he described as of malignant nature, and
only likely to be made worse by treatment. Abulcasis3 described
cancerous polypus under the name of "scorpion," and other mediaeval
writers, such as William of Salicet,4 Rogerius,8 and Hruuo Lougo-
burgensis,6 expressly distinguished between simple nasal polypi and
those of malignant nature. Ambroise Pare7 reproduced Hippocrates'
five classes of nasal polypi, and his description of their various
characters, including, of course, the malignant kind. Glandorp8
merely echoed the general opinion of antiquity in deprecating any
interference with cancer of the nose except by way of palliation.
Pott9 was emphatic in condemning any attempt at operation in the
case of malignant nasal polypi, saying that he had seen an
"untoward-looking polypus so attached to a distempered septum"
that they were both pulled away together by the surgeon's forceps.
Cases of undoubted cancerous growths in the nose were rejiorted
by Palletta 10 and Gerdy.11 Synie12 strongly disapproved of any
interference with malignant nasal growths, except when the sub-
stance is so soft that it can be scooped out with the finger. In
recent times cases of sarcoma of the nasal fossae have been pub-
lished by Fayrer,13 Viennois,14 Mason,18 Grynfeldt,16 Duplay,17 and

1 " De morbis," lib. ii. Littre's edition. Paris, 1851, vol. vil. p. 53.

2 " De medicinft," lib. vi. cap. viii.

3 "La Chirurgie tl'Abulcasis," lib. ii. c. xxiv. Trad, du Dr. Lucien Leclerc.
Paris, 1861, p. 98.

•» " Chirurgia Guilielmi de Saliceto," lib. i. cxvii. Venetiis, 1546.

" Rogerii inedici eeleberrimi Chirurgia," cxxxiii. Decancro qui fit in naribus.
8 "Bruni Longoburgensis Clu'rurgia magna," lib. ii. c. ii. De polypo. Veiietii>,
1546.

7 "(Euvres Completes," livr. 6, ch. ii. vol. i. p. 378 of Maljraigne's edition.
Paris, 1840. The distinguished editor appears to have been under the impression
that this classification of Park's was original (see note, ibid. p. 379).

8 " Tractatus de polypo, narium atfectu gravissimo, observationibus illus-
tratus." Bremne, 1628, cap. xvii. p. 47, et seq.

» " Some Remarks on the Polypus of the Nose " in " Chirurgical Observations."
London, 1775, p. 59.

i« "Exercitat. pathol." Mediolani, 1820. p. 1, et seq.
11 " Traite des Polypes." Paris, 1833.
is " Principles of Surgery," p. 493.
is " Medical Times," July 4, 1868.
14 " Lyon Medical," 1872, No. 18.
is " Medical Times," May 22nd, 1875.
i« " Montpellier Medical," Oct. and Dec. 1876.
17 " TraiW Eltoi. de Pathologic ext«rne. Paris, 1877, t. iii. p. 846.

MALIGNANT TUMOURS OF THE NOSE. 393

Hopmaim,1 whilst examples of epithelioraatous disease of the same
cavities have been met with by Verneuil2 and Pean.3 Duplay 4 men-
tions a case of eucephaloid cancer of the septum, which was mistaken
for an abscess ; and a case of medullary carcinoma of the nasal pas-
sages was reported by Neumann.5

1 "Virchow's Archiv." Bd. xciii. 1883.

2 Bonheben: "De 1'Extirpation de la Glande et des Ganglions sous-maxil-
laires." These de Paris, 1873.

3 Quoted by Casablanca, "Des Affections de la Cloison des Fosses nasales."
Paris, 1876, p. 67, et seq.

•» Op. cit. t. iii. p. 788.

5 " CBsterr. Zeitschr. f. prakt. Heilk." 1858, iv. 17.

Etiology. — Malignant disease of the nasal fossae is not of
frequent occurrence, carcinoma in particular being extremely
rare in this situation. Its causation is as obscure as that of
cancer or sarcoma in other parts of the body. Although in
most of the cases on record the patients have been women,
the number is too small to form a trustworthy index as to
the relative liability of the sexes. It is possible that
syphilitic ulceration may sometimes lead to the development
of malignant disease, but this has received little confirma-
tion from clinical- facts. The only reported instance, so far
as I am aware, in which such a relation appears probable,
is that of ^Neumann. This was a case of medullary car-
cinoma, occurring in a woman whose age is not stated;
there had been complete occlusion of the nostrils for eleven
years, and there were also signs of former syphilitic ulcera-
tion of the throat. There was hypertrophy of the mucous
membrane covering the turbinated bones, and on removal
one portion of the redundant tissue was proved to be malig-
nant. In this case I think it is clear that the disease had
only recently assumed a malignant character.

Symptoms. — There is at first nothing more than the
symptoms common to all growths in the nasal fossae, viz.,
obstruction to the free passage of air through the channel,
with the usual alteration of the voice and impairment of
le sense of smell. There is also some discharge from the
lostril, which is often of a greenish tint, and extremely
fetid. Frequent and severe epistaxis takes place in most
es, and great pain is often complained of in the infra-orbital
sgion. As the tumour increases in size, the bones forming
ic bridge of the nose may be pushed forward or separated
)m each other, and protrusion of the eyeball may be caused
by pressure on the inner wall of the orbit ; or the base of the
skull may be eroded, and even perforated, by the upward
growth of the tumour. In one of Gerdy's cases, nothing

394 DISEASES OF THE THROAT AND NOSE.

remained of the ethmoid bone but the crista galli, whilst in
another, related by Puletta,1 the cribriform plate of the same
li'ine was destroyed, and the diseased mass extended into the
brain. It is obvious that, under such circumstances, cerebral
symptoms are likely to occur, whilst if the growth e\tend>
backwards through the posterior nares, deafness, dysphagia,
and difficulty of breathing may lie caused.

Although malignant tumours most frequently originate
from the septum, they may spring from any part of the
interior of the nose, and Viennois states that he has twiee
seen melanotic sarcoma develop from the ala. In one of
the cases reported by Gerdy, several polypi of malignant
natiire were found on dissection growing from the pituitary
membrane covering the spongy bones, whilst in another a
large malignant mass was seen to spring from the mucou-
lining of one of the sphenoidal cells.

The tumours vary in size from a pea to an orange, though
of course they may attain to much greater dimensions if
not interfered with. Sarcomata, unlike simple polypi, are
generally single and sessile ; they are soft, smooth, and
usually pinkish in hue, though sometimes dark brown, or
even black. They are highly vascular, and bleed easily
when touched. Cancerous formations mostly begin as small
warts or pimples, which are reddish in colour, and usually
very soft and friable. In Pean's case, the growth, although
proved to be distinctly epitheliomatous in character, had a
kind of pedicle, but this is quite exceptional. As a rule,
such tumours show a marked tendency to ulcerate, the ulcer
presenting the well-known raised, hard, ragged edges, and
sanious base ; after a time there is enlargement of the neigh-
bouring lymphatic glands, especially of those lying below
the ramus of the lower jaw. Sarcomata are characterized
by extreme rapidity of growth, and both forms of disease
show a marked tendency to recur after removal.

Diat/nvsis. — The recognition of malignant tumours of the
nasal fossae is not always easy in the early stage of their
development. There is little likelihood, however, even at
the outset, of their being confounded with mucous polypi, a-
the latter are nearly always attached by a pedicle to tin-
outer wall of the nasal cavitj', whilst malignant tumours, in
the great majority of cases, grow from the septum by a broad
base. When the disease is advanced it bears no resemblam-e
to the benign growth. Though originating from the septum,
1 Op. cit. pp. 7, 8.

MALIGNANT TUMOURS OF THE NOSE. 395

the density of the swellings, the absence of fluctuation, and
the frequent ulceration of their surface, will serve to dis-
tinguish them from septal abscess. Cartilaginous or osseous
tumours may be mistaken for malignant growths, but in
most cases the extreme hardness, together with their slow
increase in size, and the permanently local nature of the
affection, should guide the surgeon to a right conclusion.

Rhinoliths and impacted foreign bodies should not be for-
gotten in examining tumours of the nose, but the former are
often movable, whilst their calcareous surface can generally be
recognized on scraping, and they can often be made to sound
when struck with the probe ; in the case of foreign bodies,
on the other hand, the symptoms are not progressive, and
the patients are mostly children. Great rapidity of growth,
particularly after partial removal, is a well marked, if not
quite distinctive, feature of sarcomatous tumours, whilst
epithelioma not unfrequently gives rise to general constitu-
tional infection and cachexy. In all cases, however, which
present the least doubt, the nature of the growth should be
established by microscopic examination of a small portion of
its substance.

Prognosis. — In carcinoma of the nasal fossse the chance
of the patient's ultimate recovery is as hopeless as in cancer
of any other part of the body ; but in the case of sarcoma
there appears to be some ground for belief that if the disease
be treated early and thoroughly, the prognosis is not abso-
lutely bad. Whilst these sheets are passing through the
press, as an illustration of this I may mention that I
have had an opportunity of seeing a patient from whom
Mr. Francis Mason removed a mass of myeloid sarcoma
attached to the septum. The ala was raised by means of
an incision carried downwards along the side of the nose,
and the tumour completely taken away, the raw surface being
then saturated with a solution of chloride of zinc (gr. xl.
ad gj.). Although the man is sixty-seven years of age, and
has never been very healthy, there is no appearance of recur-
rence of disease in the nose, though the operation was done
more than seven years ago.

Patholoyy. — Concerning the pathology of these tumours,
little need be said in this place. Both sarcomatous and
cancerous polypi offer the characters common to such neo-
plasms in other regions of the body.

Treatment. — The only proper method of treating malignant
disease of the nasal fossae consists in the thorough removal

396 DISEASES OP THE THROAT AND N

of the growth whore practicable. The plan of procedure
to be pursued, however, .should be carefully considered, as
the difficulties of exposing a tumour in those intricate
•chambers sufficiently to allow of its complete extirpation
are very great, and partial removal only aggravates the mis-
chief. A "preliminary operation" (see "Fibrous Polypi of
the Naso-Pharynx ") is always necessary.

Often the disease has reached such a stage before t In-
patient comes under treatment, that only palliative measures
are applicable. Local astringents are sometimes of use in
this way by causing temporary shrinking of the mass, and
I have occasionally found electric cautery serviceable in
restraining haemorrhage. This was notably the case in a
patient whom I recently treated with Dr. Slimon, of Bow,
where bleeding was a very troublesome feature.

SYPHILITIC AFFECTIONS OF THE NOSE.1

Latin E(j. — Mala venerea nasi.

/•'/•< ,«•// Eq. — Affections syphilitiques du nez.

German Eq. — Nasensyphilis.

Italian Eq. — Malattie sifilitiche del naso.

DEFINITION. — Tlie local man if Nation in tin' interior of
the nose of constitutional *i/i>liilis in its so-call<'<l
secondary, tertiary, ami congenital form*, yiriwj /•/»• in
cases to sliyltt obstruction of the naml chanm-h />//
of tin' unirnii* UK inhrani', <nt<l in .svmv cases to extensive
idceration and necrosis of the Ixmes irj/irji mat/ end in ?//«/•'
•or less complete destruction of the frame-work <>f fit/- nose.

History. — A graphic and fairly accurate description of nasal syphilis
is to be found in the writings of the Chinese emperor Hoang-ty, which
•date from more than 2,600 years before Christ. Severe swelling, cory/a,
ulceratiou, ozsena, and partial or complete destruction of the iiose are
there described as being among the consequences of a virulent MUV
on the genitals. This ancient writer also appears to have been ar.
qnainted with infantile syphilis as it affects the nose. In the writings

1 Syphilitic lesions of the naso-pharyngeal region will be considered further
on in the section on "Throat-Deafness." This arrangement appears the most
•convenient, as the nasal phenomena in such cases are usually of quite secondary
importance as compared with the aural symptoms caused l>y the disease attacking
the Eustachian tula*.

2 See Fabry : " La Me'decine chez les Chinois." Paris, 1863, p. 260, et seq.

SYPHILITIC AFFECTIONS OF THE NOSE. 397

of Susruta,1 together with a description of other unmistakable
syphilitic lesions,' there is. an account of certain nasal disorders due to
the same constitutional poison. Doubtless many of the severe affec-
tions of the nose described under the general name of ozcena by the
Greek and Roman writers (see "Dry Catarrh," pp. 324, 325) were of
syphilitic origin, but no suspicion of such a relation is shown by these
authors. Dion Chrysostome,2 however, possibly intended to allude to
syphilis of the nose in the following passage : — "They say that Aph-
rodite, to punish the women of Lesbos, inflicted upon them a disease
of the armpits ; it is thus that the Divine anger has destroyed the
noses of the greater number among you." After the terrible outburst
of the venereal plague that followed the return of Columbus and his
companions in 1496, specific disease of the nose was distinctly recog-
nized by physicians,3 and the disfigurements of the unlucky feature
that often ensued became a favourite subject of jesting among poets
and satirists. Possibly this, as well as other serious results of syphi-
litic inoculation, were more common formerly than at the present day
when the treatment of the disease is better understood. In recent
years the introduction of the sharp curette by Volkmann4 has made
an important advance in treatment in the more serious cases. In
1876 a pamphlet was published by Clinton Wagner,5 which contains
some useful hints as to the treatment of nasal syphilis, and in the
following year Schuster6 wrote a valuable practical paper, detailing
the highly favourable results which he had obtained by Volkmann's
plan of treatment, and containing, moreover, a most important con-
tribution to the pathology of the affection by Siinger.

1 " A'yurvedas." Nidanasthana, cap. ii. Translated by Hessler, Erlangen,
1844-50. This Indian treatise on medicine, which probably dates from about
B.C. 600, is a compilation by Susruta from the teaching of his master D'hanvantare.
It has been suggested (Khory : " Digest of the Principles and Practice of Medi-
cine," London, 1879, Preface, p. vi.) that the work is merely a Sanskrit version of
some of the Hipprocratic writings, but there appears to be no real foundation
for such a statement ; and, indeed, the works present no similarity either in
matter or form.

2 " Orationes" ex recens. J. J. Reiskii. Leipsioo, 1784, vol. ii. orat. 33. (Quoted
by Lancereaux, " Treatise on Syphilis." Syd. Soc. Transl. 1868, vol. i. p. 15.)

3 As nearly every author who treats of syphilis mentions the nasal form of the
affection, it seems unnecessary to give a detailed history of the subject. The
reader may be referred to the enormous collection of writers on venereal disease
contained in the " Aphrodisiacus," first published by Aloysius Luisini, at Venice,
in 1599, republished and enlarged up to date by Langerak, at Leyden, in 1728,
and continued by Gruner down to 1793.

* " Uber d. Gebrauch d. scharfen Loffels, &c." Halle, 1872; and "Beitrage z.
Chirurgie." Leipzig, 1875, p. 267.

' " Syphilis of the Nose and Larynx." Columbus, Ohio, 1876.

8 " Beitrage z. Pathologie u. Therapie der Nasensyphilis," von Dr. Schuster
u. Dr. Sanger. " Vierteljahrsschr. fur Dermatol. u. Syphilis," 1877, 1 u. 2 Heft,
and Ibid. 1878.

Etiolof/y. — An instance of primary syphilitic chancre of
the nostril has been related by Spencer Watson.1 The
patient was a nurse in attendance on a lady who gave birth
to a syphilitic child. The sore could not be distinctly seen,
but there was a swelling within the nostril, accompanied
by severe pain, fever and mental depression. The ordinary
secondary symptoms followed in due course. The vehicle
1 " Med. Times and Gaz." 1881, vol. i. p. 428.

DISEASES OF THE THROAT AND NOSE.

of infection in this case was probably the patient's own
finder. The causes which predispose- the nose to attacks
of the secondary and later forms of syphilis are unknown,
but it is probable that, in persons suffering from vcner-al
disease, chronic catarrh, or any other accidental affection
of the nose tends to localize the poison. The strumous
diathesis also seems to render its subjects particularly
liable to severe forms of nasal syphilis. Extreme cachcxia
often coexists with the more advanced tertiary lesions of
the nose, but it is difficult to say whether this is a cause
or a consequence of the local mischief. There seems to be
much less liability to the disease at the present time than
formerly. It appears, however, that in countries where
syphilis has been allowed for centuries to rage without the
mitigation of rational treatment, the disorder retains an ex-
traordinary virulence, and shows a strong tendency not only
to attack the nose, but to do so at a very early period. The
fact of rapid development of tertiary symptoms is well illus-
trated by the case of some patients received at the Val de
Grace Hospital in Paris on the return of the French troops
from Mexico.1 The disease had been caught from native
women, and in two cases severe tertiary symptoms showed
themselves within a year, whilst in a third they occurred
in less than six months from the date of inoculation.
Among the modern Arabs, symptoms which in Europe would
be called tertiary not unfrequently come on almost at once,
the face, and especially the nose, being the most common
point of attack. In Europe, secondary syphilis of the nose
is generally met with from three to nine months after the
primary sore, whilst tertiary lesions are very seldom noticed
until some years after the inoculation of the poison. An
exceptional case, however, is related by Mauriac,'- in which
the patient, who had contracted syphilis in Paris, sufien-d
from necrosis of the nasal bones in the seventh month from
the appearance of the disease.

Secondary phenomena are either rare in the nasal f<>-
they are frequently overlooked. Davasse and Deville3 found
mucous patches in the nose in eight out of one hundred and

1 Spillmaun : "Diet. Eucycloped. ties Sciences Medicates," t. xiii.
Ime part, p. 39.

2 " Syphilose pharyngo-nasale." " Union Medicate," 1877, t. i.
p. 342.

3 Quoted by Lancereaux : "Treatise on Syphilis." Syd. Soc.
Trausl. London, 1868, vol. i. p. 174, et seq.

SYPHILITIC AFFECTIONS OF THE NOSE. 399

eighty-six cases occurring in women, the tonsils having been
affected nineteen times in the same series. Bassereau,1 on
the other hand, in a hundred and ten male patients found
mucous patches at the edge of the nostrils only twice, the
tonsils being affected in no less than one hundred instances.
The experience of Bassereau accords much more nearly with
my own than that of the first-named observers. At the Val
de Grace in Paris,2 only one per cent, of the cases treated
during five consecutive years showed secondary syphilides
of the nose. Tertiary lesions are more common, but even
these appear to be rare at the present day, for Willigk3 met
with only 2*8 per cent, in 218 cases.

Symptoms. — The phenomena of nasal syphilis vary accord-
ing to the stage and severity of the disorder. In the
secondary period there is generally nothing more than
hypersemia of the mucous membrane, producing symptoms
of somewhat intractable catarrh. Sometimes, however,
mucous patches can be seen at the external angle of the
nostrils, or just inside the nasal fossae, either on the septum
at its anterior part, or on the inferior turbinated body.
Similar patches may also be visible, with the aid of the
rhinoscope, on the margins of the posterior nares. These
lesions sometimes give rise to intractable coryza, with muco-
purulent secretion, whilst at the same time roseolar eruptions
appear on the skin. In tertiary syphilis perforation of the
septum not unfrequently takes place, and the carious bone ex-
hales a horribly offensive odour, to which the term " ozaena,"
now limited to certain forms of dry catarrh (see p. 330), was
formerly applied. In such cases the discharge from the nose
is generally abundant, and is often of a blackish colour, and
the most careful washing away of the discharge by irrigation
or spraying fails to get rid of the stench. Should the
vomer be extensively involved, the bridge of the nose
may fall in, causing a characteristic flattening, as if the
organ had been crushed, whilst if the cartilaginous portion
of the septum is destroyed, the tip of the nose sinks in and
becomes flattened, and hangs loosely from the bony part of
the nose (Fig. 85). Occasionally the whole substance and
framework of the feature is disintegrated, and it is represented
only by two small apertures surrounded by cicatricial tissue.
The disease may extend to the superior maxilla, may destroy
the bony walls of the lachrymal canal, or slowly eat away large

1 Ibid. p. 175. 2 Spillmaun : Op. cit. p. 38.

3 " Prager Vierteljahrsschr. " 1856, xxiii. 2, p. 20.

400

MSKAMCS i iF Till: TIllt'iAT AM> N<>>K.

portions of the ethmoid and sphenoid bones, the basilar
cess of the occipital bone may entirely perish by slow carirs.
or large pieces of these bones may be thrown off by rapid
necrosis. The cranial cavity is indeed sometimes laid open,

FIG. 85. — FLATTENING OF THE NOSE FROM DESTRUCTION OF THK.
CARTILAGINOUS SEPTCM BY SYPHILITIC DISEASE.

and, if this occurs, it is generally soon followed by fatal
inflammation of the brain and its membranes. In a case
related by Trousseau,1 a large piece of the ethmoid, consti-
tuting about a quarter of the entire bone, almost suffocated a
patient by falling unexpectedly into his throat. He died on
the following day with acute cerebral symptoms, due no
doubt to the disease having spread to the brain or its cover-
ings. Brodie2 and Graves3 mention instances in which the
disorder, having extended through the cribriform plate of the
ethmoid, gave rise to epileptiform and maniacal convulsions
which terminated fatally. A case, however, has been recently
reported by Baratoux 4 in which almost the entire body of
the sphenoid was expelled from the nose without any signs
of cerebral mischief having been observed.

On examination of the nose in cases of tertiary syphilis,

1 "Clinique Medicale de 1'Hotel-Dieu." Paris, 1868, t. i. p. 546.

2 "London Med. Gazette." 1844.

8 "Clinical Lectiires," vol. ii. p. 484.

4 "Archivii Italian! di Laringologia." Anno iii. July 15, 1883,
pp. 19-21.

SYPHILITIC AFFECTIONS OF THE NOSE. 401

deep foul ulcers with ragged edges and dirty greyish bases
can often be made out. When caries exists the part over the
diseased bone generally appears blackish in colour, the surface
being rough and uneven. Occasionally, however, nothing
can be perceived beyond dark-coloured crusts and greenish'
yellow mucus, by which the true condition of the underlying
tissues is quite concealed. In other cases the pieces of dead
bone may be situated so high up in the nasal cavity that
nothing can be seen, but even then the probe will sometimes
serve to discover them. Now and then, however, the most
careful observation may fail to disclose the actual seat of
disease, as is well shown by some cases reported by E. Frankel
(see Pathology).

Diagnosis. — There is seldom much difficulty in recog-
nizing the affection, the only disease with which it can be
confounded being lupus exedens when that disorder com-
mences within the nose. The age, however, at which lupus
begins will generally serve to distinguish it, showing itself,
as it does, earlier than any form of syphilis except the
hereditary disease, which, on the other hand, has symptoms
quite peculiar to itself. Moreover, even at a very early
period, the papules or tubercles of lupus are sufficient to
identify it, whilst, later on, the marked preference which
the morbid process shows for the cartilages is very charac-
teristic. Dry catarrh accompanied by ozaena is sometimes
mistaken for syphilitic caries, but to those who have had
any experience the smell is quite different; moreover, the
stench of true ozsena can be got rid of by syringing, whilst
the most persevering irrigation leaves the odour arising from
diseased bone comparatively unaffected. Should any doubt
arise, however, the use of Gottstein's plugs will settle the
question, for whilst they quickly put an end to the stench in
true ozaena, they greatly intensify it if there is any necrosis
or caries.

It is important to remark here that though perforation of
the septum far more often results from tertiary syphilis than
from any other cause, it is by no means, as is often supposed,
an exclusively syphilitic lesion. Leaving congenital deformity
and injury out of the question, a permanent hole may result
both from septal abscess and blood-cyst, and possibly also
from tubercular ulceration (see "Tubercular Disease of the
Pituitary Membrane," p. 409).1 I dwell on this matter with

1 See also perforation of the septum in typhoid fever and acute
rheumatism (p. 425).

VOL. II. D D

402 DISEASES OF THE THROAT AND X08B.

si niii- emphasis, as I have known painful mistakes mail*'
through ignorance of the facts just mentioned.

In all <l"ul)tful crises the previous history should be care-
fully ininiired into, the skin should he examined for coppery
]>atuhes, i>eriosteal nodes sought for in the usual situations,
whilst cicatrices and induration should IM- looked for in the
tongue, pharynx, and larynx. In the absence of other
'•vidences, the action of iodide of potassium will generally
soon determine the nature of the case.

/'<if/i»/»tft/. — Sander,1 who examined several specimens of
polypoid excrescences removed by Schuster from the nasal
fossae of patients affected with syphilis, arrived at the fol-
lowing results : — The mucous membrane at one spot was
greatly hypertrophied as regards all its elements, and the
fold thus formed tended to increase in size as the pr»
continued, and finally, being acted on by gravitation, became
pendulous. On section, the mass presented two dearly-
defined structural zones : 1st, an inner or erectile one, con-
sisting of a network of venous capillaries, surrounded by
connective tissue of dense fibrillar structure, and end
acinous mucous follicles, the lobes of which appeared to
be encroached upon by the neighbouring tissue, and wen-
undergoing atrophy ; 2ndly, an outer cortical zone, consisting
of an enormous number of small round cells, uniform in
size, and lying closely packed together in a strorua of very
delicate areolar tissue. These cells had each a nucleus, and
often several nucleoli, and were surrounded by blood-vessels,
the coats of which they had, in some places, partly pene-
trated. Covering the cortical zone was epithelium of the
Cylindrical non-ciliated variety. In some parts, this epi-
thelium had disappeared, leaving microscopic excoriations,
and at those points the round cells were especially numerous.
From these appearances Sanger infers that the process had
consisted in a primary hypertrophy of the mucous membrane
with its vessels and glands, followed by formation of small
round cells at the periphery of the tumour, which by
gradually encroaching on the vessels and follicles, produced
obliteration of their channels at one part, with corre-
sponding dilatation farther back. In this manner the
c-u-tieal layer of round cells and the erectile zone of
dilated venous spaces had been formed. That this infil-
tration of the muecnis membrane by proliferating small
round cells is distinctively syphilitic, was proved by
1 Loc. i-it.

SYPHILITIC AFFECTIONS OF THE NOSE. 403

comparison of the sections with others of undoubted
-syphilitic products found in the intestines. Sanger also
concluded, from other specimens, that a similar infiltration
of the mucous membrane with proliferating small round cells
may take place without hypertrophy of the mucous membrane
itself. In all cases the cellular infiltration extended some
way into the neighbouring tissues, so that no definite boun-
dary could be traced. In other instances, true syphilitic
neoplasms (condylomata) were found, the mucous membrane
itself being entirely altered in structure, and the epithelium
either altogether absent, or reduced to a few layers of
poorly-nourished cells. The changes presented by the car-
tilages and bones at points corresponding to the infiltrated
patches of mucous membrane consisted — 1st, in exfoliating
necrosis, resulting from suppuration ; 2ridly, in rarefying
syphilitic osteitis or caries sicca, the bone having been
absorbed and replaced by exuberant granulations of the
mucous membrane ; and 3rdly, in rarefying and plastic osteitis,
the connective tissue of the periosteum and the bone having
been transformed into spindle-shaped cells, which had become
partly organized again into ordinary connective tissue, and
partly into new bone.

Sanger points out that the view commonly held, that
ulceration of the nasal mucous membrane is a necessary
antecedent of caries of the underlying bones and cartilages
is erroneous, and he maintains, on the contrary, that the
bony framework of the nose may be the primary seat of
syphilitic caries, in the same way that the frontal bone or
the tibia may be attacked by primary syphilitic periostitis.

It should be borne in mind, as pointed out by E. Frankel,1
from the post-mortem inspection of three cases, that the
necrosis of bone may be molecular, the ulcerations being so
minute as altogether to escape observation during life.
Frankel found cirrhotic thickening of the mucous mem-
brane, with partial absorption of the glandulse, in addition to
the disease of the bone.

Profjiwisis. — In secondary syphilis, and in mild tertiary
disease, where the destruction has been slight and the bodily
vigour of the patient is but little diminished, recovery is
almost certain to take place under a well-directed course
of anti-syphilitic treatment. When, however, active caries
is going on, the prognosis is necessarily grave, especially if,

1 " Vivchow's Archiv." Bd. Ixxv. 1 Heft, 1879.

404 DISEASES OP THE THROAT AND NOSE.

as is common in such cases, the patient is in a very exhausted
condition.

Treatment. — Syphilitic coryza in the adult rapidly passes
away. An ordinary tonic may be given, whilst, locally, tin-
use of a nasal wash of bicarbonate of soda or permanganate
of potash will generally effect a cure in a week or two. When
i-iiiiiti/fotitata are present, they should be touched with tincture
of iodine or solid nitrate of silver. In tertiary nijjth ///.<, im in-
active treatment is required, and constitutional and Im-al
measures are alike essential. Iodide of potassium must be
given, the dose l>eing gradually increased to ten or fifteen
grains three times a day. If this drug, after being fairly tried
for some months, fails to bring about a cure, or produces but
slight benefit, mercury must be resorted to, either alone or in
combination with iodide of potassium. Small doses of the
corrosive sublimate may be given twice or three times a day
in a decoction of sarsaparilla, or the cyanide of mercury may
be administered twice a day in the form of a pill.1 Con-
siderable advantage will often be found in alternating the
remedies. Thus, a case which has improved up to a certain
point under iodide of potassium, will generally make some
further progress under the influence of mercury, whilst, after
a short interval, a return to the iodide will often be attended
with very marked and rapid improvement of the symptoms.
When there is cachexia, analeptic treatment must, of course,
be assiduously carried out.

In all tertiary forms of the affection, local measures are
useful, and, indeed, frequently essential. In cases of caries ( >f
the bony structures, with foul-smelling discharge, the nasal
cavity should be thoroughly cleansed two or three times
a day with a lotion of detergent and deodorizing charac-
ter. Any superficial ulcers which may exist within the nose
will be soon brought into a healthy condition by these
washes ; but, for deep, spreading ulcers, more concentrated
remedies are necessary. For this purpose, nitrate of silver,
fused on the end of a piece of aluminium wire, suitably
curved, may be used. In intractable cases, however, the
daily application to the ulcer of iodoform, by means of an
insufflator, will often effect a cure where more seven-
measures have failed. At the same time, stimulating and
antiseptic inhalations, such as the Vapor lodi, V. Creasnti,
or V. Pini Sylvestris of the Throat Hospital Pharma-

1 R Hydrarg. Cyanid. gr. ^ ; Sacch. Lactis, gr. } ; Tragaoantb,
q.s. ; M. ft. pil.

HEREDITARY SYPHILIS OF THE NOSE. 405

copceia, maybe inspired through the nose, or antiseptic sprays
may be employed. Dead bone should be removed with suit-
able forceps ichen the fragments are loose and within view,
but it is highly dangerous to use much force in detaching
sequestra. Schuster l has found the greatest benefit in cases
of obstinate ulceration from the free use of Volkmann's sharp
spoons (Fig. 66, p. 277), even when no exposed bone could
be detected with the sound. The ulcers are first scraped,
and afterwards any indurated tissue that may remain is
destroyed with nitrate of silver or electric cautery. Schuster's
experience agrees with Volkmann's2 own on this point, viz.,
that it is precisely in the most severe and apparently hopeless
cases of extensive destruction of the bony framework of the
nose that treatment with the sharp curette yields the most
brilliant results. I have employed these sharp spoons in a
few instances, but always with the greatest care. Their
use is not altogether free from danger, a case having
recently been brought to my knowledge in which death
occurred from haemorrhage whilst the surgeon was scraping
out the nasal fossae of a patient suffering from syphilitic
necrosis.

When the diseased bone cannot be seen by the ordinary
methods of examination, whilst the symptoms are urgent, it
may be advisable to expose the interior of the nose in order
to apply strong remedies directly to the affected part. Celsus3
suggested the extreme measure of laying the nose completely
open from the outside, but a sufficiently good view of the
cavities and access to all their recesses may be obtained
by Rouge's operation (see " Fibrous Polypi of the Naso-
Pharynx").

Should the nose be completely destroyed, an attempt may
be made to remedy the deformity by a rhinoplastic operation,
for a detailed description of which the reader is referred to
the ordinary text-books of surgery. Slighter disfigurement
may be mitigated by an artificial nose.

HEREDITARY SYPHILIS OF THE NOSE.

Hereditary syphilis is apt to attack the nose at two periods
of life, viz., at the time of birth or soon after, and later on

1 Loc. cit.

2 " Beitnige zur Chirurgie." Leipzig, 1875, p. 267.

3 "De MediciiiA," lib. vii. cap. ii.

406 i>i>i:.\>i:s OF THE THK«»AT AND NOSE.

in childhood. Newly-born infants are, however, its especial
victims, and in them the disease takes the form of severe
catarrh. It gent-rally appears within a week or two of liirth,
seldom commencing after the t-nd of the second month. It
is probably dependent, in most cases, on the presence of
mucous patches on some portion of the pituitary membrane,
although, as a rule, none can be seen. The discharge may
be thin at first, but it usually soon becomes muco-purulent.
The nasal channel becomes blocked up to such a degree that
the troubles described in connection with acute catarrh in
infants (see p. 293) as regards sucking and sleeping are often
observed. From the swelling of the pituitary membrane and
the accumulation and drying of the mucus, the nasal breathing
Incomes difficult and noisy, and a child thus affected is
popularly said to have the "snuffles." The secretion irritates
the margin of the nostrils and the upper lip, rendering the
skin and mucous membrane at those points red and exco-
riated. The malady is very chronic in its course, showing
little or no inclination to subside spontaneously, and in most
cases, if not subdued by treatment, it becomes gradually
worse. If caries of the bones and cartilages of the nose
ensues, the child is not unlikely to be disfigured for life by a
flattened nose.

Where there is caries with discharge, the sudden *]«>\i-
taneous cessation of the secretion is ordinarily, according to
Hermann AYeher,1 the precursor of a serious and often fatal
brain-lesion. In one case related by that physician, as soon
as the discharge ceased, cerebral symptoms showed themselves.
Four days later the little patient was seized with rigors and
well-marked signs of pyrexia, and on the thirteenth day from
the first attack of shivering, death took place. At the post-
mortem examination, thrombi were found in the cavernou>
sinus and left ophthalmic vein. There was evidence of severe
meningitis, and the under surface of the left cerebral hemi-
sphere was bathed in pus. Purulent collections were also
found in the pleura*, lungs, and liver.

Syphilitic children are mostly small and feeble, and
have an aged, withered appearance. Their skin is of a
greyish tint, if it be not covered with a copper-coloured
papular eruption or with }X')it}>hi<fit# wi>ii<tt<iritin. Sometimes
the infants are apparently healthy at birth, the marasmus
only coming on three or four weeks later. Mucous patches

1 "Med.-Clur. Trans." vol. xliii. \>. 177.

HEREDITARY SYPHILIS OF THE NOSE. 407

will generally be found at the anus, and often at the corners
of the mouth and the margins of the eyelids.

Syphilitic coryza occurring in an infant requires both
systemic and local treatment. Although in many cases of
constitutional syphilis in adults I do not consider that mer-
cury is necessary (see Vol. i., Preface, and pp. 93, 94), yet,
in this form of the disease, mercurial treatment appears to
me to be the best that can be adopted, the administration of
this drug having a very marked influence on the duration
and intensity of the affection. It should be given to children
in the form of grey powder in doses of from one to two
grains twice a day, and if this is found to cause diarrho?a,
one grain of Dover's powder or an additional grain of chalk
should be combined with each dose of the grey powder.
Erichsen1 recommends the external application of mercury
in the manner first proposed by Brodie, as the readiest way
of introducing the remedy into the system of a syphilitic
child. The following is the method : — A drachm of mercu-
rial ointment should be spread on a flannel roller, which
should then be stitched round the child's thigh just above
the knee, the medicated surface being next the skin. This
ought to be renewed every day for a period of two or three
weeks, after which iodide of potassium should be adminis-
tered in milk or cod-liver oil.

Local treatment is also required almost always, but the
difficulty of carrying this out in infants has led to its being
much neglected, and the ravages of syphilis in the nose in
such cases are largely due to this cause. The following is
the best method of washing out the nasal passages of an
infant : — The child should be placed in the nurse's lap, and
the naso-pharynx plugged by means of the temporary sponge-
tampon (Fig. 74, p. 283). The little patient's head should
then be slightly raised, and the nose washed out with a fine
syringe, or, if it be preferred, a spray or nasal douche can
be applied, care being taken in the latter case that too much
force is not used. The Collunarium Acidi Carbolici cum
Borace, or the C. Potassa? Permanganatis of the Throat
Hospital Pharmacopoeia, may be employed in half their usual
strength.

1 "Science and Art of Surgery." London, 1872, 6th ed. vol. i.
p. 670.

408 DISEASES OF THE THROAT AND NOSE.

TUBERCULAR DISEASE OF THE PITUITARY
MEMBRANE.

Latin Eq. — Tubercula membranse pituitariae.
/•'/•• nch Efj. — Tubercules de la membrane pituitaire.
German Eq. — Tuberkel der Membrana pituitaria.
Italian Eq.— Tubercoli della membrana pituitaria.

DEFINITION. — A chronic affection of the now,
always preceded by tubercular disease of the lungs or
Aryans, arising from the deposit in the mucous membrane of
tultercles which form tumours prone to ulceration.

History. — Very few examples of tubercular disease of the nasal
mucous membrane have hitherto been recorded. In the year 1853
Willigk l mentioned that he had once found tuberculosis of the mem-
brane covering the septum. In 1877 Laveran 2 described two cases ;
and in the following year Riedel 3 added two more. Volkmann *
soon afterwards briefly referred to the subject, and expressed a belief
that many cases of supposed hereditary syphilis of the nose are really
of a tubercular character. In 1880 Tornwaldt8 published a very
'nteresting example of the complaint ; and more recently Weichscl-
baum 6 has given an elaborate pathological report on two cases which
came under his notice.

1 ' Frag. Vierteljahrsschrift." 1853, Bd. xxxviii.

2 ' Union M6dicale." Nos. 35 and 36.

* ' Deutsche Zeitschrift fur Chirurgie." Bd. x.

* ' Sammlung klinischer Vortrage." Leipzig, 1879, No. 168-109, p. 31.
» ' Deutsches Archiv fur klin. Med." Bd. xxvii. p. 586.

6 ' Allgemeine Wien. med. Zeitung." 1881, NOB. 27, 28.

Etiology. — Tubercular disease of the nasal mucous mem-
brane is no doubt a very rare affection, but it is likely to be
more carefully sought for in future, and in all probability
some cases will be met with from time to time. As all these
are tolerably sure to be reported, the complaint may in a
few years appear to be much more common than it really is.
Willigk found the disease once in 476 tuberculous bodies.
Weichselbaum noticed only two examples in 146 autopsies
of patients dying with tubercle. In 50 bodies of con-
sumptive patients, which E. Frankel1 carefully examined
by Schalle's method, the nasal cavity was in every case
entirely free from tubercular disease. I have never observed
a case of tuberculosis of the nasal mucous membrane, but I
have no doubt that I have sometimes overlooked it amongst

1 "Archives of Otology." June, 1881, vol. x. No. 2.

TUBERCULAR DISEASE OF THE PITUITARY MEMBRANE. 409

the thousands of cases of laryngeal phthisis which have come
under my notice. I have, however, met with two instances in
which there was a large perforation in the septum which may
possibly have resulted from tubercular ulceration. There
was no apparent cause for the lesion ; in particular, there
was no history of syphilis, nor any trace of that complaint.
Tubercular disease is probably always secondary, though in
Tornwaldt's case the nasal symptoms preceded by a long
time those subsequently developed in the larynx and lungs ;
and in one of Riedel's cases, though the patient had a some-
what cachectic appearance, there were no physical signs of
pulmonary tuberculosis nine months after the removal of a
large tubercular tumour on the septum.

Symptoms. — Tubercular deposit in the mucous membrane
of the nose may be seen either in the form of tumours,
varying in size from a millet-seed to a bantam's egg, or there
may be slight thickening and ulceration of the mucous
membrane. In either case there is generally a troublesome
and more or less fetid discharge. Though the deposit may
occur at any part, it appears to show a preference for the
septum. In Tornwaldt's case, however, the mucous mem-
brane covering the turbinated bones was greatly hypertro-
phied, and there were two reddish-grey tumours of the
shape and size of split peas. In Riedel's cases there were
both tumours and ulcers. In one a raised ulcer near the
left nasal orifice had partly destroyed the ala on that side,
whilst in the other the ulcer had perforated the septum.
In both instances large tumours occupied the septum.
One was two and a half centimetres in length, two centi-
metres in height, and one and a half in thickness. la-
the other case there was a somewhat similar tumour, though
considerably smaller in size. In both, the growths occupied
the posterior part of the septum. Laveran found ulcers on
the anterior part of the septum. They were about the size
of a (silver) twenty-centime piece, of a greyish colour, and
not at all painful. In one of "Weichselbaum's cases there
were four small ulcers, varying in size from a hemp-seed to a
lentil, all situated on the septum, whilst greyish-white nodules
were also seen on that partition near the floor of the nose on
the right side. Similar nodules were present on the vault of
the pharynx, whilst several of the retro-pharyngeal glands had
undergone cheesy degeneration. In Weichselbaum's second
case the patient, a woman, aged sixty-two, had a soft yellow-
ish-grey nodule of the size of a hemp-seed on the anterior

4'10 DISEASES OF THE THROAT AXD NOSE.

« xtrcmity of the right inferior turbinated lx>dy. A
white nodule as large as a poppy-seed was also .-••••n <>n tin-
anterior portion of the right middle meatus, ami a small
tumour about the size of a hemp-seed was situated at the
anterior extremity of the left middle turbinated body. This
small tumour was undergoing ulceration at its apex.

The progress of tubercular disease of the mucous mem-
brane is generally slow, and in one of Riedel's cases the
uh.-eration existed for twenty-seven years.

Diaynosi*. — When obstinate ulceration or growths are
found in the nose of a person suffering from well-market 1
tubercle of another organ, it may be suspected that the nasal
affection is of the same nature. Certainty, however, can
only be arrived at by excising a portion of the mucous mem-
brane or growth, and submitting it to microscopic examination.
If (lupus or glanders being excluded) clusters of lymphoid
cells with giant cells in their centre are found in a reticular
connective tissue, there can be no doubt of the present •<• of
tubercle. The absence of giant cells is not, however, to be
taken as disproving it.

PatlnJ»yy. — Tubercle, when deposited in the mucous
membrane of the nose, generally forms minute tumours,
varying in size from a poppy to a hemp-seed ; occasionally,
however, large growths are formed, as in the cases reported
by Riedel. The small tumours may be seen to be undergoing
cheesy degeneration, and the mucous membrane covering them
shows signs of softening, and commencing ulceration. In
Laveran's cases, tubercles and giant cells were found in the
sub-epithelial stratum forming the base of the ulcers, and als-i
in the tissues immediately surrounding them. The large
tumours observed by Riedel consisted in the main of very
vascular granulation-tissue. Grey nodules could be seen
with the naked eye, which, microscopically, were found to
"consist of masses of large cells, the centres of which did
not contain the giant cells so constantly met with in lupus."

In Tornwaldt's case the portion of growth first excised was
examined by Fame, of Dantzig. The specimen contained
distinct groups of small nucleated cells, with several larger
epithelioid cells in a reticular stroma. In two preparations
giant cells could be clearly demonstrated. Other portions
of the growth subsequently removed were examined by
Baumgarten, with the assistance of Neumann. The follow-
ing is their report : — •' We conjointly agree in stating that
the specimen is, as you surmised, a tubercular node. In a

TUBERCULAR DISEASE OF THE PITUITARY MEMBRANE. 411

tissue densely infiltrated with small round cells, circumscribed
groups of larger epithelioid cells, containing in their centre
(in scanty number, it is true) veritable giant cells, are seen.
The limited amount of the specimen affords some ground of
objection to our diagnosis of tubercle."

The most detailed account of the microscopic appearance
of tubercle in the nasal mucous membrane has been given
by "Weichselbaum. He states that the peripheral parts of
the nodules are composed of lymphoid cells, which form
larger or smaller groups, and present an interstitial structure
of reticular connective tissue. Gland-tubes of various shapes,
cut transversely, obliquely, and longitudinally, are scattered
here and there in the round-celled mass. These represent
the acini and excretory ducts of the follicles separated by
the lymphoid infiltration. The lumen of many of the
ducts is encroached upon by " epithelia of low type," whilst
some of them, on the other hand, are over-distended by
the quantity of round cells within them. The nodule
may contain giant cells with oval peripheral nuclei, and a
fine granular centre can be made out, or it may be in a
state of cheesy degeneration, consisting merely of granular
debris, indistinct nuclei, and the remains of cells. The
sub-epithelial layer of the mucous membrane in the
neighbourhood of the nodules is densely infiltrated with
lymphoid cells, the latter being clustered for the most part
around the blood-vessels. The edges of the ulcers show an
infiltration of round cells or of elements which in their
form resemble endothelial cells, whilst the base of the ulcers
is covered with a thick layer of finely granulated detritus
(cheesy mass). Under this proliferating connective tissue
endothelial cells are met with. The mucous follicles are seen
undergoing two kinds of degeneration. In the one the
lymphoid or endothelial elements invade the inter-acinous
structure, encroach upon the acini, and ultimately destroy
the entire gland, which, whilst retaining its shape, is trans-
formed into a mass of cells ; in the other the gland-cells
are not merely pushed aside, but appear themselves to
participate in the morbid process. The sub-epithelial layer
of the mucous membrane, not only in the immediate
vicinity of the ulcers, but also at some distance from them,
shows round-celled infiltration.

I'mttnosis. — It is doubtful whether the disease cnn bo
eradicated when once deposit of tubercular matter has
occurred. In Tornwuklt's case the wounds healed very

412 DISEASES OF THE THROAT AND NOSE.

rapidly after the removal of the tumours, but subsequently
new granulations appeared.

Treatment. — If there be any troublesome discharge, mildly
astringent or disinfectant collunaria should be used ; and if
tumours of any size cause serious inconvenience by inter-
fering with nasal respiration, they may be removed. Should
much pain be felt — which, however, is seldom the case —
insufflations of morphia and bismuth would probably give
relief.

LUPUS OF THE PITUITARY MEMBRANE.

Latin Eq. — Lupus membranae pituitariae.
French Eq. — Lupus de la membrane pituitaire.
German Eq. — Lupus der Membrana pituitaria.
Italian Eq. — Lupus della membrana pituitaria.

DEFINITION. — A deposit of "granulation tissue"
primarily in tlie mucous membrane of the nasal fossce, which
slowly ulcerates.

History. — A few cases of this rare complaint are found scattered
through medical records, examples of the disease having been reported
by Cazenave J and others. The disease was fully described by
Hebra and Kaposi 2 in their systematic work on cutaneous affections,
and afterwards by Moinel 3 in a short monograph.

1 "M£m. sur le Coryza chronique." 1848.

2 "Diseases of the Skin." Syd. Soc. Transl. London, 1875, vol. iv. pp.
65-68.

» " Essai sur le Lupus scrofuleux des Fosses nasales." Paris, 1877.

Etiology. — The causes producing lupus are quite unknown,
but it generally occurs in young persons of strumous con-
stitution, and the female sex is more liable to it than the
male.

Symptoms. — Lupus, as is well known, generally first attacks
the skin of the nose, but cases are occasionally met with in
which the disease commences in the nasal mucous membrane,
and sometimes it remains confined to that tissue. The
malady may appear as lupus exedens or non exedens. The
former variety usually begins on the cartilaginous septum,
where small red excessively irritable tubercles are seen at
an early period. In the next stage ulcers appear, which
have a great tendency to spread, often eating away in their
course the whole of the cartilaginous septum, the alar carti-
lages, and sometimes even portions of the bones themselves.

LUPUS OF THE PITUITARY MEMBRANE. 413

These ulcers are always covered with crusts, under which the
process of destruction goes on in one part, whilst healing
may be taking place in another. At the same time there is
a foul discharge from the nose, which, though at first resem-
bling that of common coryza, later on often assumes the
character of virulent ozsena. In lupus non exedens there
is no ulceration, but atrophic degeneration and shrinking of
all the tissues affected, including the bones and cartilages,
occur. A disagreeable odour is exhaled, as in the ulcerative
form of the complaint.

Diagnosis. — Lupus is easy of recognition by a practitioner
who has previously seen examples of the disease ; the youth
of the patient, the slowly destructive process, and the crusted
ulcers showing a disposition to heal at certain parts, being
eminently characteristic. The malady may be mistaken for
a syphilitic affection, from which, however, it can generally
be distinguished by the curative action of iodide of potassium
in the latter disease ; it must not be forgotten, however, that
syphilis and lupus may coexist in the same patient. It is
often extremely difficult, and sometimes impossible, to differ-
entiate lupus in its early stage from epithelioma, but after
a time the characteristic features of each affection become
manifest.

Pathology. — The microscopic characters of lupus are,
briefly, infiltration of the integument with small cells
arranged in " nests," at first separate from each other, and
at a later stage becoming confluent, so as to involve a
considerable area ; large numbers of cells are also heaped
around the blood-vessels. Fatty degeneration of the cells
next occurs and ulceration is produced. Micrococci have
recently been discovered in parts affected with lupus by
Max Schiiller,1 and it has been shown by him that the
offshoots of the micrococci spread into the neighbouring
connective tissue, the extremities of their root-like pro-
cesses being covered with granules. These organisms are
found in the walls of the small vessels surrounded by round
and epithelioid cells.

Prognosis. — Lupus can sometimes be subdued by a well-
directed course of treatment, but there is always a great
tendency to relapse, and this is especially to be dreaded
when the cicatrix remains indurated, and is of a red colour
or covered with arborescent vessels. In some cases the
disease shows a tendency to pass backwards and involve the
1 " Centralblatt fur Chirurgie." 1881, No. xlvi.

414 DISEASES OF THE THROAT AND NOSE.

pharynx, ami this must be regarded as an unfavourable
feature. As the patient gets older, the disease in many
instances shows a tendency to spontaneous cure.

Treatment. — The local measures to be adopted in <-a>es
xvln-re lupus attacks the inside of the nose, leaving the
integuments unscathed, consist in destroying the di.-eased
tissues by means of powerful caustics, such as nitric acid,
caustic potash, or chloride of zinc, or by the use of galvano-
cautery. All crusts should be cleared away before employing
the caustic, the application of which generally has to I*-
repeated several times. Care must be taken to destroy
every portion of the affected part, as any place left un-
cauterized forms a starting-point for a fresh outbreak of the
disease. Constitutional treatment is also of the greatest
importance in lupus. Cod-liver oil and tonics, especially
iron, are often useful Hunt1 maintained that arsenic is a
specific in this complaint, and other practitioners have found
this drug of service.

RHINOSCLEROMA.

This exceedingly rare disease was first described by Hebra2
in 1870, and examples of it have since been published by
Geber,3 Tantuzzi,4 Mikulicz,5 AVeinlechner,6 Billroth,7 and
Coniil.8 The subject has been fully treated by Kaposi,9
^Neumann,10 and Pellizzari.11

Nothing is known as to the causation of the malady,
neither sex, constitutional disease, nor personal habits apj.i-ar-
ing to have any definite influence in producing it. Most of
the cases on record have occurred between the ages of fifteen
and forty-five. The climate or conditions of life in the
south-east of Europe would .appear to predispose in some
measure to the complaint, since of a total of about forty

1 " Brit. Med. Journ." 1862, vol. i. p. 8.

2 " \Vien. med. Wochenschr. " January, 1870.

3 " Archiv. f. Dermatol. u. Syph." 4 Heft, 1872.

4 "II Morgagni," 1872.

8 " Langenbeck's Archiv." Bd. xx.

8 Quoted by Neumann, op. infra cit. p. 567.
7 Quoted by Kaposi, op. infra cit. p. 635.

» " Pftgrta Medical." July 28, 1883, p. 587.

9 " Pathologic u. Therapie der Hautkrankheiten." Zweite Anf-
lage, Wioi u. Leipzig, 1883. Zweite Halfte, pp. 632-637.

Kim"

Lehrbuch der Hautkrankheiten." Fiinfte Auflage, \Vii-n.
•p. 566-569.
1 Rinoscleroma." Firenze, 1883.

1880, pp. 566-569.

IK.f]-

RHINOSCLEROMA. 415

cases hitherto observed, all but three were met with in
Vienna or its neighbourhood. Two of these occurred in
Italy and one in France, but I am not aware of a single
instance in which the disease has been noticed in any
other country. Cases of " rhinoscleroma " are mentioned by
Spillmann1 as having been seen by Verneuil and others,
but from the description of the complaint it was evidently
merely perichondritis of the septum.

Rhinoscleroma shows itself generally at the edges of the
nostril and on the neighbouring part of the upper lip, in the
form of flat, slightly raised patches which are smooth on the
surface, and of ivory-like hardness. The integument over
them is natural, or sometimes dusky red in hue, but round
the patches it is neither thickened nor discoloured. The
swellings are tender on pressure, but otherwise the disease is
unattended with pain. The patches may be discrete or con-
fluent, and the disease spreads by gradual infiltration of the
surrounding tissues. There is seldom any sign of ulceration,
and the growth does not take on increased activity when
interfered with. Although the disorder may appear in two or
more places simultaneously, or successively, it shows no ten-
dency to generalize itself, either by the blood-vessels or the
lymphatics, and there is never any sign of constitutional in-
fection. Its course is very slow, and the patient experiences
nothing beyond purely local symptoms. The swelling may
involve the septum and the alee of the nose, so as to make
that feature feel as if it were " made of plaster of Paris,"
and it may invade the upper lip, spreading afterwards to the
gums and the alveoli. The morbid process occasionally
extends back through the nose to the throat as far as the
larynx and trachea, or through the mouth to the velum.
In each case certain symptoms will be manifested, s\ich as
obstruction of the nose, aphonia, or stenosis of the glottis.
Rhinoscleroma has to be distinguished from syphilis, epithelial
cancer, and keloid. It differs from venereal disease mainly
in its very chronic course, the absence of softening or ulcera-
tion, and its absolute intractability under every kind of
medication. From epithelioma, again, it can be discriminated
by its smooth glistening surface, its hardness, the absence of
bleeding or ulceration, and its persistently local character.
The history and progress of the case can alone differentiate
rhinoscleroma from keloid in many instances.

1 "Diet. Encyclop. des Sci. Me<lieale8,"art. "Xez,"t. xiii.pp. 45, 46.

416 DISEASES OF THE THROAT AXD NOSE.

The prognosis is most unfavourable as regards cure, recur-
rence of the growth taking place even after complete removal
The disease, however, does not tend to shorten life, unit ss
it spreads down to the larynx.

Patkaiogiedttyt the growth is allied to round-celled sar-
coma, the essential feature of rhinoscleroma, according to
Kaposi,1 being infiltration of the corium and papillae with
small cells.

This observation is confirmed by Cornil, who, moreover,
states that, scattered about among the vessels, there are large
spheroidal cells containing one or more nuclei. These are
imbedded in a reticular protoplasm, and in this there ;in-
also small refracting hyaline bodies, which finally, in the
course of development of the cell, fill its whole cavity.
These hyaline bodies in some cases pass out of the body of
their parent cell into the surrounding tissue. They are not
of amyloid or fatty nature, and, according to Cornil, do not
contain micrococci. They constitute the distinctive patho-
logical product of rhinoscleroma. True cartilage was found
in one instance by Kaposi,2 and in Chiari's3 case there was
not merely cartilage but commencing ossification.

Medical treatment has no effect on the disease, and surgery
can do nothing but palliate the more troublesome symptoms.
The knife and various caustic agents have been freely em-
ployed without success, for, as already remarked, the most
complete removal or destruction of the morbid formation
has always been followed by recurrence of the disease.
Temporary good can, however, often be done. If the nose
becomes blocked up, the obstructing growth should be
removed or destroyed with the cautery, and the narrowed
passage dilated by means of laminaria tents. In threatened
suffocation from invasion of the larynx, tracheotomy must of
course be performed without delay.

GLANDERS.

Latin Eg. — Equinia ; Malleus humidus.
French Eq. — Morve.
German Eq. — Rotz.
Italian Eq. — Ciamorro.

DEFINITION. — A contagious disease generated by the intro-
duction into the system of a specific poison derived directly or
1 Op. cit. p. 635. 2 Op. cit. p. 635. 3 Ibid.

GLANDERS. 417

indirectly from a horse suffering from the same affection ;
characterized by the formation of pustules, followed by spread-
ing ulceration of tJte skin in various parts of the body (farcy}
and of the mucous membrane of the nose and throat, from
which a viscid, muco-purulent or sanious secretion is dis-
charged in great abundance ; accompanied by tJie usual
constitutional symptoms of blood-poisoning, and ending
generally in death.

History. — The earliest actual observation of the occurrence of
glanders in man was made in 1783 by Osiander,1 whilst it was not
till 1812 that farcy was described by Lorin,2 as affecting the human
subject. The first detailed account of the whole malady was pub-
lished by Schilling3 in 1821. Five years later, three instances of the
disease were recorded by Travel's,4 who, however, does not appear
to have understood the true nature of the phenomena which he
observed. A fatal case of glanders in man was related by Brown5
in 1829. In the two or three following years the affection was
investigated by Elliotson,6 who, in a series of papers constituting a
short monograph on the subject, described several cases which he hail
himself met with, in addition to a few which he had been able to
collect from other sources. Shortly afterwards two examples of
glanders and farcy in the human subject were published by Graves,7
who claims to have been the first to call attention to the occurrence
of "button-farcy" in man.8 In 1837 appeared the elaborate report
of Rayer,9 which had a great effect in inducing the establishment of
strict sanitary regulations as to infected horses. In 1843 Tardieu10
published his well-known essay on glanders and farcy. In more
recent times, considerable attention was given to the subject by
Virchow,11 and an excellent account of the disease was published
by the brothers Gamgee 12 in 1866 ; since then elaborate articles
dealing with human glanders and farcy in the fullest manner have
been published by Bellinger13 and Brouardel.14 Quite recently the
pathology of the disease has been carefully investigated by Bendall 1S
and Boyd,16 whilst bacilli have been discovered almost simultaneously
by several French and German observers (see Pathology).

1 " Ausfiirliche Abhandlung iiber dieKuhpocken." 1801.

2 " Jotirn. de Med. Chir et Phann. Milit." F^vrier, 1812.

" Rust's Magazin f. d. gesammte Heilkunde.' Berlin, 1821, vol. xl. p. 480.
*" Inquiry concerning Constitutional Irritation." London, 1826, p. 350,
et seq.
* " London Med. Gaz." 1829, vol. iv. p. 134.

6 " Med.-Chir. Trans." London, 1830, vol. xvi. pt. i. p. 171. Ibid. 1833, vol.
xviii. pt. i. p. 201. Ibid. vol. xix. p. 237.

7 " London Med. Gaz." vol. xix. p. 939.

» " Clinical Lectures." Dublin, 1848, 2nd ed. vol. ii. p. 336.
» M<?m de 1'Acad. de Mckl." Paris, 1887, t. vi.

10 " De la Morve et du Farcin chroniques chez l'Homme et les Solipedes."
These de Paris, No. 15, 1843.

11 " Die Krankhaften Gesehwiilste." Berlin, 1864-65, vol. ii. p. 543, et seq.

12 " Reynolds's System of Medicine." London, 1866, vol. i. p. 693, et seq.

is " Ziemssen's Cyclopaedia of Medicine." English Transl. 1875, vol. iii. p. 348.
et seq.

M " Diet. Encyclop. des Sciences M6dicales." Art. " Morve." Paris, 1876.
2e se'rie, t. x. p. 166, et seq.

is "Trans. Path. Soc." 1882, vol. xxxiii. p. 417, et seq.

16 Ibid. p. 420, et seq.

VOL. II. B E

418 DISEASES OF THE THROAT AXD XO8B.

niji/.— There can be no controversy as to the cause of
this rare disease in the human subject, although there may
be some difference of opinion as to the conditions ncrc.-sary
for its production. The complaint as it affects the //«/-x>-
is seen under two forms, viz., farcy and glanders. The
former is characterized by inflammation along the coum- of
the lymphatic vessels, leading to painful swelling <>f the
glands, which suppurate, and after a time burst, giving rise
to ulcers secreting a virulent discharge. Glanders, on tin-
other hand, shows itself by the deposit of small nodular
growths in the nasal fossae, accompanied by ulceration of the
mucous membrane, and by a discharge from one or Txith
nostrils, at first very thin, but quickly becoming thick, viscous,
and foul-smelling. Both farcy and glanders appear under
the types of acute or chronic ailments ; but there is this
remarkable feature about each, that whilst an animal may lie
suddenly attacked by either disease in its acute form, the
chronic malady is never found as a consequence of the acute
stage, but on the contrary very often precedes it. Farcy and
glanders frequently coexist, or the one complaint may follow
the other. Their identity is further proved by the fact that
whilst the discharge from the nostrils of a glandered horse
may produce an attack of farcy in another animal, on the
other hand, the inoculation of matter from " farcy-buds "
may give rise to glanders.

Both forms of the complaint are met with in man, but the
affection is so uncommon that very few physicians have ever
had an opportunity of observing it. Taking into account the
vast number of persons whose business or pleasure brings
them much in contact with horses, and the comparative
frequency of the equine disease, the extremely rare occur-
rence of glanders or farcy in the human subject seems to
show that some special predisposition is necessary for the
poison to be effective. As might be expected, the great bulk
of sufferers belong to the class of veterinary surgeons,
grooms, coachmen, and others whose occupation requires
much handling of horses. From a table drawn up by
Bellinger l it appears that out of one hundred and six cases
of glanders, in forty-one the patients were ostlers, in eleven
coachmen, in fourteen landed proprietors owning horses, in
ten veterinary surgeons, in twelve horse-butchers, in five
soldiers, in four surgeons, in three gardeners, and in two

1 "Ziemssen's Cyclopaedia of Medicine." English Trausl. 1875,
vol. iii. p. 352.

GLANDERS. 419

horse-dealers. Of the remaining four patients, one was a
policeman, one a shepherd, one a blacksmith, and one a
servant at a veterinary school. Men, being more exposed
to infection, are of course much more liable to the disease
than women. In 120 cases Bellinger1 found only six
females, and these were mostly wives or relatives of men
whose employment lay among horses.

The most common mode of transmission of the malady is
by inoculation — that is to say, by the actual contact of dis-
charge from the nostrils of a glandered horse, or of piis
from a farcy-abscess, with a wound or abrasion in the skin
or mucous membrane. In a fatal case which occurred in my
practice some years ago, the source of infection was traced to
a diseased horse in a hansom cab. The patient, who had
only driven a short distance, noticed that the animal sneezed,
and he was annoyed by some of the secretion coming on his
face. The infection may be carried by rags used to clean
out the nasal fossae of a diseased animal, or by anything on
which the discharges have fallen. One case2 is on record
of the complaint having been communicated by biting, the
poison having presumably been carried in the saliva. The
disease may be transmitted in its worst form from man to
man. There is some doubt whether the poison can be con-1
veyed into the system through the stomach, Decroix's3 fool-
hardy and disgusting experiments having yielded negative
results.

Symptoms. — Although, as already stated, glanders and
farcy are merely different expressions of the same morbid
condition, it does not fall within the scope of this work to
deal in detail with the latter complaint. As a matter of
fact, moreover, the lymphatic system is much less often
directly attacked by the poison in man than in the horse.

Glanders, as already remarked, may be either chronic or
acute, and it will be convenient to consider the former type
of the complaint first, as in the natural evolution of the
disease it often precedes the latter. There is usually but little
swelling or redness to be seen in the nasal fossae, and often
no discharge, but the mucous membrane is covered with dirty
scabs, and ulcerated in several places. The mouth and throat

1 Op. cit. p. 352.

- Landouzy: " Gaz. Med." 1844, p. 460.

3 "Bull, de la Soc. Cent, de Med. Vet.," 1870-71. This ardent
seeker after truth devoured the flesh of diseased horses, both raw ami
cooked in various ways, and no unpleasant consequences appear to
have ensued.

420 DISEASES OF THE THROAT AND N<»K.

are also affected, although not often to any great degree. The
breaking down of the nodules, however, may give riw to
ulceration of the tongue, back of the throat, and larynx, and
huskiness of voice, slight cough, and even some trouble
in breathing may ensue. The expectoration is occasionally
bloodstained. The complaint runs a very chronic course,
lasting, as a rule, from four to eight months, but often much
longer. Bellinger1 relates a case in which traces of the
disorder, such as cough, dyspnoea, and great prostration,
remained after eleven years of suffering. The proportion
of recoveries is stated by the same author to be about fifty
per cent., but a considerable number of those that are said
to be cured are never restored to perfect health. Of the
cases that end fatally, in some, death is caused by the
exhaustion of the slow fever, with its accompanying night-
sweats and diarrhoea, and the septic effect of prolonged sup-
puration, whilst in the remainder the malady suddenly takes
on the acute character.

The acute form of the disease is almost always fatal,
whether it follows chronic glanders or farcy, or comes on
as the immediate result of inoculation. Its onset is 7iiarked
by shivering, sudden rise of temperature, and the usual
symptoms of high fever ; an erysipelatous rash shows itself
on the face, beginning, in most cases, in the nose, but soon
spreading over the cheeks and forehead. The surface of
the inflamed skin becomes covered with vesicles, whidi
by-and-by burst, and discharge a thin serous fluid, whilst
patches of the integument may even show signs of imminent
gangrene. The characteristic glander-pustules appear in crops
OH the face, intermingled with blebs. The secretion from the
pustules soon dries up, and forms a scab, and when this sepa-
rates, an ulcerated surface remains, which tends to spread
on all sides, often with almost phageda?nic rapidity. Tin-
patient at the same time is afflicted with a painful sense of
obstruction in his throat and nasal passages. This is due to
the mucous membrane of those parts being thickly studded
with pustules. A glairy liquid constantly flows from the
nose, and is hawked up from the throat, and there is often
a similar secretion from the eyes. As the disease progresses
the discharge becomes thicker and more glutinous ; it is often
streaked with blood, and always very fetid. Occasionally
there are sickness, diarrhoea, and abdominal pains. It should
be borne in mind, however, that the discharge may be very
1 Op. cit. p. 350.

GLANDERS. 421

scanty or, indeed, altogether wanting. When the disease is
fully established the voice grows hoarse or may be entirely
lost ; whilst difficulty of swallowing is induced by swelling
of the epiglottis. The expectoration generally becomes more
abundant and more bloody as the disorder pursues its course
in the larynx, Paroxysms of dyspnoea ensue from the partial
obstruction of the glottis, and the patient gets delirious or
falls into the so-called " typhoid " condition, which gradually
passes into coma and death. The acute stage of glanders
following the chronic form is much more speedily fatal than
when it occurs independently, for whilst in the latter case
the disease may last for twenty days or more, in the former
death usually puts an end to the patient's sufferings in less
than a week.

Diagnosis. — This malady probably sometimes escapes recog-
nition, for unless there be a clear history of inoculation, the
practitioner is not likely to think of so rare a disease as
glanders. In all instances, therefore, of nasal obstruction and
discharge, especially if accompanied by marked derangement
of the system, pains in the limbs, and abscesses in various
parts of the body, the history of the patient should be care-
fully inquired into, particularly as regards his occupation and
habits. It is only from a broad view of the circumstances
that a correct opinion can be arrived at in cases that are at all
doubtful. The pustules and ulcers have nothing absolutely
distinctive in themselves, and the general symptoms of both
glanders and farcy bear a strong resemblance to the salient
features of many other more common affections. Thus the
pains about the joints which are met with in farcy are sug-
gestive of rheumatism, until a minute examination reveals
that it is not the articulation itself that is complained of,
but the muscles and tendons surrounding it. The rigors
and abscesses will probably lead the practitioner to suspect
pyaemia, especially if there be a history of a dissecting wound ;
it should be remembered, therefore, that shivering is a much
less marked feature in farcy than it is in pyaemia, and that in
many instances this symptom is altogether absent. When
the complaint is accompanied, as it not unfrequently is, by
•Castro-intestinal disturbance, it may simulate typhoid fever
very closely, but the absence of the rose-coloured spots and
of the characteristic wave-like rise in temperature will serve
to distinguish it from that disorder. Glanders is particu-
larly likely to be mistaken for venereal disease of the nose
and throat, but the great amount of constitutional disturb-

422 DISEASES OF THE THROAT AND

in the former complaint, and the favourable action of
iodide of potassium in the latter, afford ample grounds of
distinction. From scrofulous eruptions and ulcers about the
t i ie and within the nose the disorder can likewise be distin-
guished by the severity of the constitutional symptoms which
accompany it. With every possible precaution, however, a
certain diagnosis cannot always be arrived at, and a striking
example of the difficulties surrounding the practitioner who
has to deal with this obscure disease is related by Virchow,1
who records a case in which the autopsy on a patient, whose
complaint had not been recognized during life, led to tin-
discovery of a severe epizootic of the malady among horses
•which had been previously overlooked.

Pathology. — The disease is of the same pathological type
as syphilis and tuberculosis, and it bears a close resemblance
to pyaemia. The morbid process exhibits the ordinary
sequence of phenomena due to blood-poisoning, viz., infec-
tion through broken skin or mucous membrane, inflamma-
tion of the lymphatic vessels connected with the point of
entrance of the virus, swelling and suppuration of the
related lymphatic glands, and gradual generalization of
the disease through the entire system. The specific morbid
product, if such it can be called, of glanders is a nodule
or tubercle,, deposited on the skin and mucous membrane
in some part of the body, notably on the face, limbs, and
walls of the nasal passages. These nodules are usually not
much larger than a grain of hemp-seed, and they may he
scattered about, or grouped together in clusters. They
are at first almost colourless, but, rapidly increasing in size,
they become first red, and then gradually yellowish in hue,
and acquire all the characters of pustules. On microscopic
section, these bodies are found to consist of pus cells and
numerous small nuclei densely packed together ; and, quite
recently, rod-shaped bacteria, somewhat resembling tubercle-
bacilli, have been detected in the pustiiles and ulcers of men
and animals suffering from glanders, by Schiitz and Loffler2
in Germany, and almost at the same time by Bouchard,3
Capitan,4 and Charous5 in France. The nodules show a
marked tendency to break down and become converted into
small abscesses. These in many cases burst, and a foul sore

1 "Die Kraukhaften Geschwiilste." Berlin, 1864-5, vol. ii. p. 554.
8 " Deutsche med. Wochenschr." 1882, No. 52.

3 " Revue Med. Francaise." Dec. 30, 1882.

4 Ibid. 5 Ibid.

GLANDERS. 423

with irregular edges is produced, which has little or no dispo-
sitii »n to heal, and in the acute form of the malady may even
spread to the neighbouring parts of the skin, or, penetrating
deeply through the underlying tissues, may reach the skeleton.

Prognosis. — Acute glanders is almost invariably fatal, but
a few cases of recovery have been recorded.1 In the chronic
disease the prospects of the patient are less gloomy as regards
the immediate issue, but the malady leaves ineffaceable marks
of its presence, and complete restoration to health can hardly
ever be looked for. As to the disease in general, perhaps the
best practical guide for the physician in forecasting the result
of a case is to be found in the rule laid down by Brouardel,2
that so long as the nose is not affected there is still room for
hope.

Treatment. — The treatment of glanders, when once the
system has been impregnated with the poison, is confessed
by all writers on the subject to be almost utterly ineffecttial.
Certain general principles must, of course, be adhered to,
such as carefully attending to all the symptoms as they are
developed, and watching the constitutional condition of the
patient, so as to give stimulants when the strength be ;ins
to flag, anodynes or sedatives if there be pain, excitement, or
sleeplessness. Emetics and purgatives have been recom-
mended, but the former should never be given, and the latter
only when clearly indicated. Various preparations of iodine
anil sulphur have been at different times proposed as specific
remedies, and recoveries have been attributed to the use of
each of those drugs.3

Certain local remedies should not be neglected, as, even if
they fail to prolong the patient's life, they may lessen his
suffering, and, what is also of importance, diminish the
risk of this loathsome disease being conveyed to his attend-
ants. Elliotson4 states that he succeeded in stopping the
discharge from the nose by injecting a solution of two
grains of creasote in a pint of water three times a day.
Ulcerated surfaces should be frequently dressed with lint
steeped in carbolic acid solution (1 in 60 or 80).

It need hardly be added tliat the most vigorous prophy-
lactic measures should be carried out wherever the disease

1 Brouanlel, op. cit. p. 184 ; Harrison, "Lancet," vol. ii. 1872, p.
910 ; Hay nes Walton, " Med. Times and Gaz." 1877, voL ii. p. 13.
- Op. cit. p. 191.

3 See Brouardel : op. cit. p. 202.

4 Loc. cit.

4:24 DISEASES OF THE THROAT AND XOSE.

is found to exist. In the case of horses this is enforced by
legal enactment, and though the malady is less likely to be
eomumiiieated by man to man, the utmost care should always
be taken to destroy or disinfect anything by whirh the virus
may be conveyed. According to the experiments of ( ierlach,1
carbolic acid destroys the activity of the poison, and any one
who is in attendance on a case of glanders, whether in man
or beast, should on no account neglect to \vash his hamls
and instruments in a strong solution of this antiseptic agent
after every dressing.

An interesting observation has lately been published by
Meyrick2 which tends to show that (as might be expected)
the virus becomes attenuated by long exposure to the air,
and that animals inoculated with this milder poison sutler
from a modified form of the disease. A cavalry party was
picketed on a sandy plain in the neighbourhood of Cairo,
near to a spot which had been occupied some months before
by a detachment of Indian cavalry, whose horses had suffered
severely from glanders. Two horses belonging to the former
contracted glanders, and several others had swelling of the
submaxillary glands and vesicles on the Schneiderian mem-
brane, which burst, but healed quickly without ulceration.
The important question to be decided now is whether the
inoculation of virus, weakened by proper cultivation, would
act as a preservative against the effects of glanders-poison in
its more active form. On tliis point there is not yet, so far
as I am aware, any evidence whatever.

AFFECTIONS OF THE NOSE IX ERUPTIVE
FEVERS, AND OTHER ACUTE DISEASES.

Measles. — In measles, serous flux from the nose, with con-
gestion of the conjunctiva, is one of the earliest symptoms.
Occasionally this is followed by severe rhinitis, and in these
cases epistaxis not unfrequently occurs. If these acute
symptoms subside, and the patient recovers, dry catarrh and
ozaena sometimes remain behind. Ulceration of the septum
has also been observed.3

Scarlet Feoer. — In scarlatina anginosa the nasal mucous

J Quoted by Bellinger, op. cit. p. 370.

2 "Veterinary Journal," 1883, vol. xvii. p. 179.

3 Joffroy : " Bull, de la Soc. Anat." 1870, p. 164. Also Dechant ;
" De la Rougeole." These de Paris, 1842, p. 24.

AFFECTIONS OF THE XOSE IX ERUPTIVE FEVERS, ETC. 425

membrane is often involved. The affection may be of
merely catarrhal character, or, on the other hand, the inflam-
mation may be very severe, and accompanied by great
swelling of the mucous membrane and an abundant irritating
discharge. Ulceration sometimes takes place, and this may
be followed by epistaxis.

Small Pox. — In this disease, especially in the confluent
variety, pustules occasionally form inside the nose, causing
obstruction of the passage, and in certain cases producing
epistaxis. Complete obliteration of one or both nostrils has
more than once resulted from the xinion of the opposite raw
surfaces of the outer and inner walls of the nostril when
the scabs have come away. An instance of this kind has
been recorded by Luc,1 who succeeded in remedying the
condition by incising the nostril and afterwards keeping it
open by dilatation.

Typhoid Fever. — In all adynamic fevers it is well known
that there is a tendency to acute inflammation of tissue, with
formation of abscesses. The influence of position, which in
typhoid fever is so largely concerned in the production of
throat affections, does not come into operation in the case
of the nose, but changes are apt to occur in the mucous
membrane from the drying of masses of mucus within the
nasal fossae. The ulcers thus formed often spread, and
necrosis of the septum may take place, resulting finally in
perforation. Cases due to long and exhausting fever have been
observed by Roger,2 Lecoeur,3 Gietl,4 Lagneau,5 and Charcot.6

Rheumatism. — In rheumatic fever, severe inflammation
and ulceration of the pituitary membrane sometimes occur,
and even necrosis of the cartilaginous portion of the septum
has been noticed. An instance of this kind has been related
by Roger," in which a young man suffering from very severe
rheumatism, with well-marked cardiac complications, lost a
portion of his septal cartilage of about the size of a grain of
rice two months before his death. A somewhat similar case
has also been reported by Corbel.8

1 Quoted by Casabianca : ' ' Des Affections de la Cloison des Fosses
nasales." Paris, 1876, p. 17.

"Gazette des Hopitaux." 1860, p. 153.
:i Ibid. p. 214.
4 "Union Medieale." 1862, t. xvi. p. 523.

"Gazette Hebdom." 1863, p. 440.
B Quoted by Casabianca, op. cit. p. 33.

7 "Union Medieale." 1860, nouvelle serie, t. v. p. 168.

8 "Gazette des Hopitaux." 1860, p. 178.

426 DISEASES OF THE THROAT AND N

Influenza. — It has not appeared t<> me desirable t<> treat
influenza in a separate article, as the symptoms aH'ecting the
bronchial tubes and the lungs are so much nn>re important .
than those which manifest themselves in the n<>si-. It must
not he forgotten, however, that the latter are the first t<>
attract attention.

.V'/.-vf/ DifihthiTia. — This affection has already been fully
considered (Vol. i. p. 185).

FRACTURES OF THE NOSE.

Latin Eq. — Fractura ossium nasL
French Eq. — Fracture des os du nez.
(ii-mtan Eq. — Fractur tier Nasenknochen.
Italian Eq. — Frattura delle os.sa del naso.

DEFINITION. — Fracture* of tlie. bones or cartilfii/f* <\f tJif>
wr>.sr, often compound, either from a imnnil in t)i>' *kin, »r
from laceration of the mncowi membrane, //'if rally accom-
panied by considerable contusion an<l

History. — Fracture of the nasal bones has been familiar to prac-
titioners from the earliest times of surgery. Hippocrates * discusses
such injuries at some length, and the methods of treatment which
he recommends shows that lie must have bad a large experience of
broken noses ; and when it is remembered that he practised among
a people who held boxing in high esteem, this is hardly to be won-
dered at. Hippocrates mentions that fractures of the nose were done
up in such an elaborate way that every young surgeon was anxious
to meet with an example of the injury, in order that he might have an
opportunity of showing his skill in bandaging. It may be remarked
iu connection with this subject that Hippocrates recommends the
application of shreds of linen steeped in white of egg as the best means
of Keeping the bones in place — a remarkable anticipation of the starch
bandage of modern days. In the sixteenth century Ambrose Pare •
strictly followed Hippocrates in his mode of treatment. In modem
times, Jarjavay3 has written at some length on certain sequel* of
fracture of the nose; and William Adams4 has published sonic im-
portant improvements in the mode of treating the injury, especially as
regards the avoidance of subsequent deformity.

1 " De Artubug." Pang, 1884. LlttnS'g edition, vol. Iv. p. 150.

2 " (Euvres," livr. 8, ch. xxvi. Paris, 1840, Maleaigne'g edition, vol. ii. p. 86.

3 " Bull. General de Therap." 1867, t. hdi. p. 539, et seq.
•» " Brit. Med. Journ." 1875, vol. ii. pp. 421, 422.

Etioloyy. — Owing to the arched form of the nasal }><>nes,
and their sheltered position between the prominence of tin-
os front in and the cartilaginous tip of the nose, they are
seldom broken, except, when a person falls against a sharp

FRACTURES OF THE NOSE. 427

corner, such as the edge of a step or a table, or the angle of
a wall, or when an angular body, such as the knuckles of a
man's fist, or the iron shoe of a horse, is driven violently
against the nose. The nasal bones are, however, liable to be
fractured by blows which fall on them sideways. In such
cases both bones are usually broken transversely, the lower
fragments being dislocated towards the opposite side to
that on which the blow is received. Falls on the head
sometimes produce fractures of the roof of the nose, i.e.
of the ethmoid bone, but in these cases the injury of
the base of the skull is, of course, very much more im-
portant than that of the nose. On the other hand, it has
been found experimentally by Hamilton,1 that direct injury
to the septum will not cause fracture of the cribriform plate.
The nose would, however, be much more liable to fracture
were it not for the yielding character of the cartilage, on
which blows mostly fall, breaking the shock in great measure.
Giuit2 found that out of a total of 225 fractures of the
bones of the head, there were twenty -two of the nose, seven-
teen of the upper jaw and zygoma, and fifty-six of the lower
jaw ; whilst Otto Weber,3 in fifty-six fractures of the cranial
bones, met with ten of the nose, four of the upper jaw and
zygoma, and nine of the lower jaw.

It is possible that the delicate skeleton of an infant's nose
may be irretrievably damaged by the blades of the forceps
in childbirth, but I am not aware of any actually recorded
case of this accident, except the somewhat questionable one
of Tristram Shandy. Fibrous and malignant tumours of the
nasal fossae or the neighbouring parts sometimes produce
fracture of the bony roof or parietes of the nose, but more
often the pressure of such growths causes absorption of the
bone.

Symptoms, — The injury varies from a simple fracture
without displacement to complete crushing of the nasal
arch. A case has come under my notice in which the wheel
of a tramcar passed over the face of a gentleman, com-
pletely crushing his nose, but doing him very little damage
otherwise. The disfigurement, however, was so great that
the patient had to retire from his profession. In another

1 " Practical Treatise on Fractures and Dislocations." Philadelphia,
1866, 3rd ed. p. 93.

2 " Handbuch der Lehre von den Knochenbruchen." Hanover,
1864, vol. ii. p. 499.

8 Op. cit. p. 179.

428 DISEASES OF THE THROAT AND NOSE.

instance with which I am acquainted the bony part of the
nose was crushed flat by a fall, leaving an ugly knob corre-
sponding to what had been the tip of a very shapely feature,
and giving tin- whole face a markedly simian expression.
The sufferer, a highly popular abbt'-, had to hide his dis-
figurement in a monastery. Even in the slighter forms of
injury there is ordinarily great swelling of the soft parts,
with widespread ecchymosis and oedema of the eyelids and
cheeks. There is always some epistaxis,1 and occasionally,
when the mucous membrane has been torn, emphysema
occurs. This usually follows the accident on violent
sneezing or blowing of the nose, and, although very alarm-
ing to the patient, is of no importance. In order to make
a satisfactory examination, the patient should be fully
anaesthetized, when the nature of the injury will, as a rule-,
be ascertained, although it is in most cases difficult to detect
crepitus. By passing a small probe up the nose with one
hand, whilst with the other the parts are gently manipulated
externally, any displacement will generally be discovered.
Hamilton 2 judiciously points out that a small probe is much
more useful than a catheter, which is usually recommended,
and which, from its size, often cannot be passed, even when
force is used. The sense of smell is frequently impaired, and
sometimes even destroyed, from injury to the terminal twigs
of the olfactory nerves.

Diagnosis. — If the directions already given be followed
(see Symptoms), the nature of the accident will in most
cases be recognized without much difficulty.

Patliolofji). — The only special point that need be referred
to in connection with the pathology is the remarkable disposi-
tion to rapid union in fracture of the bones of the nose.
This peculiarity attracted the attention of Hippocrates,3 and
it is now recognized as being due to the extraordinary plastic
power of the bones hi the upper part of the face, a property
which has been taken advantage of in the "osteoplastic
operations " of Langenbeck, Oilier, and others, hereafter
detailed.

Prognosis. — The greatest disfigurement may always be

1 One fatal case of hemorrhage was observed by Rossi. Quoted
by 0. Weber in v. Pitha und Billroth's " Handbuch der Chirurgie."
lid. iii. 1 Abtheil. 2 Heft. Erlangen, 1866, p. 181. Another was
recorded by West ("Lancet," 1&62, vol. i. p. 660). Bleeding re-
curred again and again, and the patient, a man aged sixty, dii-d
exhausted on the twenty -third day after the injury.

2 Op. cit. 3 Op. cit. p. 167.

FRACTURES OP THE NOSE. 429

anticipated if the accident be not properly treated, and this
may have the most serious results as regards the patient's
future career. It must not be forgotten that such injuries
may also be attended with danger to life. Gurlt l has
shown that in cases in which at the time of the accident
there was no evidence of injury to the brain, cerebral
symptoms have afterwards come on. Out of fourteen
examples of fracture of the nose collected by Weber2 in
the Bonn Clinic, there were four in which there was con-
cussion of the brain, one of them terminating fatally.

Treatment. — The rapid union which takes place after
fractures of the nose just referred to, though a highly
conservative process, makes it of the utmost importance
that the condition should be discovered in time to avoid
deformity from improper xmion. As the tissues covering
the broken bones are usually much contused, the first thing
to be done is to attempt to disperse the swelling by means
of evaporating lotions or other cold applications. The frag-
ments should then be, as far as possible, replaced. This can
generally be done by means of a pair of fine dressing-forceps
or a female catheter introduced within the nose, combined
with manipulation with the fingers of the left hand on the
outside. Once restored to their proper position the frag-
ments show little tendency to separate, for, as pointed out
by Holmes Coote,3 they are not acted on by any muscles.
There is seldom, therefore, any necessity for splints or other
supporting apparatus, which are, moreover, as a rule, intoler-
ably irksome to the patient. If, however, the septum has been
fractured, and displacement has been produced, Adams 4
advises that the fragments should be forcibly restored to their
proper position with forceps, and retained in situ by means
of a special splint and truss (p. 282). Jurasz's ingenious
modification of Adams's instrument (see p. 282), which com-
bines both forceps and splints, may also be advantageously
used for the same purpose. Mason 5 has recently described
a new method of treating fractures of the nose where the
nasal processes of the superior maxillary bone are involved,
and where, consequently, there is marked depression of the

1 Op. cit. p. 240.

2 V. Pitha uml Billroth's " Handbuch der Chirurgie." Bu. iii.
1 Abtheil. 2 Heft. Erlangen, 1866, p. 181.

3 " Holmes's System of Surgery." 2nd ed. 1870, vol. ii. p. 427.

4 Loc. cit.

8 "Annals Anat. and Surg. Soc. Brooklyn." New York, 1880,
vol. ii. p. 107, et seq., and pp. 197-199.

430 DISEASES OF THE THROAT AND XO8E.

fragments. After reduction a needle is passed through the
skin behind the fragment and brought out through the skin
on the other side of the nose. A narrow hand of india-
rubber is fastened over each end of the needle, so as to
make gentle pressure on the sides of the nose. This makes
a firm support for the broken piece, preventing it from be-
coming depressed. Evaporating lotions or other dr<-ssings
can be easily applied without disturbing the apparatus. The
needles are to be removed from the sixth to the tenth day.
Mason says that the wounds produced by the needle arc
quite insignificant. The plan appears to have been tried in
only one case as yet, but the result was very encouraging.

DISLOCATION OF THE NASAL BONES.

Separation of the nasal bones from the frontal bone, or
from the nasal process of the superior maxillary, is so rare
that its occurrence has been denied. Benjamin Bell 1 states
that " instances of it are sometimes met with," but without
furnishing any details. Malgaigne,2 however, gives the par-
ticulars of a case in which the existence of luxation of the
nasal bones was established as certainly as any form of injury
can be made out by touch and appearance without actual dis-
section. A man in falling struck the left side of his nose with
great violence against the edge of the pavement. On examina-
tion, shortly after the accident, the upper third of the nose was
seen to be deflected towards the right side, the lower part pre-
serving its normal direction. The lower edge of the right nasal
bone projected over its corresponding cartilage, whilst on tin-
left side the inner edge of the nasal process of the .superior
maxillary stood out in sharp relief from the depression of the
left nasal bone, a gap being evident between the upper edge of
this latter and the frontal bone. There was no fracture. It
is evident from this description that whilst on the right side
the nasal bone was only separated along its lower edge, them
was complete luxation of the corresponding bone on the left
side, where the blow had been received.

In a case recorded by Longuet,3 in which a soldier received

1 "System of Surgery." Edinburgh, 1788, vol. vi. p. 184.

2 " Revue Med.-Cliir. de Paris." • 1851, t. x. p. 82.

3 "Recueil de Memoires de Med. de Chir. et de Phar. Milit." t.
xxxvii. 3e fascicule. May— June, 1881, No. 202, p. 284,

DEVIATION OF THE NASAL SEPTUM. 431

a very heavy blow near the inner angle of the right eye, the
upper part of the nasal bones appeared to have been pushed
over bodily towards the left side, the septal cartilage, how-
ever, remaining in its normal position. The edge of the
nasal bone could be plainly felt overriding the nasal process
of the upper jaw on one side, whilst on the other the cor-
responding edges were visibly separated by a groove wide
enough to admit the thumb-nail.

It will be observed that the mode of production of the
injury is almost identical in these two cases, viz., a violent
blow striking the nose sideways. It was only in this manner,
also, that Longuet was able to produce luxation of the
nasal bones in several experiments which he made on the
dead body. The nasal bones may also be pushed asunder
by a fibrous or sarcomatous mass, giving rise to the unsightly
" frog-face " hereafter described. (See " Fibrous Polypi of
the Naso-Pharynx.:>) The symptoms in the two cases related
above were very much alike, consisting in epistaxis, swell-
ing, tenderness, and a characteristic deformity. Reduc-
tion, which in Longuet's case was exceedingly difficult, and
only partially successful, is best accomplished by combined
manipulation of the displaced bones from the interior of the
nose and the outside. As the pain of the operation is very
great, it is desirable to anaesthetize the patient before the
reduction is commenced.

DEVIATION OF THE NASAL SEPTUM.

Latin Eq. — Incurvatio septi narium.
French Eq. — Deviation de la cloison du nez.
German Eq. — Yerbiegung der Nasenscheidewand.
Italian Eq. — Deviazione del setto nasale.

History. — More than a century ago, a short monograph was pub-
lished by Quelmalz l on curvature of the nasal septum, which he
appears to have considered as resulting in nearly all cases from injury
or disease. Later on, Morgagni,2 who claims to have given special
attention to this matter, was disposed to attribute the condition to too
rapid growth of the septum in proportion to that of the upper jaw.
Soon afterwards, Haller 3 pointed out the frequent occurrence of this
deformity, which he thought rendered the stibjects of it more liable
to catarrh than other people. The subject was briefly referred to by

i " De narium, earumque septi, incurvations. " Lipsiw, 1760.
- "De sed. et cans, morb." Lugil. Eatav. 1767, epist. xiv. art. 16; vol. i. p.
207.
•> " Elem. physiol. corp. human." Lausannae, 1769, t. v. p. 138.

432 DISEASES OF THE THROAT AND NOSE.

Hildfbrandt,1 and again by Velpeau.2 In 1851 Chassaignac3 dealt
with deviation of the septum in its cartilaginous portion, and dcscriU-d
a method by which he succeeded in correcting the deformity.
Another plan of procedure was tried by Blandin,4 and an operation
has been devised by Adams,5 and improved by Jurasz,6 for which
excellent results are claimed. Theile7 seems to have been the first
who attempted a numerical estimate of the frequency with which
asymmetry of the nasal septum is found in the dry skull, a matter
which has recently received further illustration at the hands of
Semeleder,8 Sappey,9 Harrison Allen,10 and Zuckerkandl,11 and a
highly scientific anatomical work has been recently published on
the subject by Welcker.12 Lowenberg18 has lately written a sugges-
tive paper on these deviations, and their influence on the condition
of the singing voice has been pointed out by Walsham.14

1 " Lehrb. d. Anat." Wien, 1802, Bd. iii.

'-' " Traite complet d'Anat. Chir." Paris, 1837, 3e ed. t. i. p. 252.

3 " Bull, de la Soc. de Chir." 1851-52, t. ii. p. 253.

4 " Compendium de Chir. Prat." t. iii. p. 33.
» " Brit. Med. Journ." Oct. 2, 1875.

8 " Berlin, klin. Wochenschr." 1882, No. 4.

" " Zeitschr. f. rationelle Medicin." Neue Folge, 1855, Bd. vi. p. 242, et seq.

8 " Die Khinoskopie." Leipzig, 1862, p. 64.

9 " Anatomic descriptive," t. iii. 3e ed. Paris, 1877, p. 674.

10 " Amer. Journ. Med. Sci." Jan. 1880, p. 70.

11 " Anatomic der Nasenhohle." Wien, 1882, p. 44, et seq.

12 " Asymmetrien der Nase." Stuttgart, 1882.

" " Arch, of Otology," vol. xii. No. 1, March, 1883.

i* " St. Bartholomew's Hosp. Rep." vol. xviii. p. 11, et seq. See also " Lancet,"
April 12, 1883, p. 705.

Etiology. — An asymmetrical position of the septum is very
common. Numerical observations as regards tne frequency
have at present only been made on dried specimens, in which
the cartilage is very seldom present. In 117 skulls Theile
found deviation in 73'5 per cent. Semeleder in 49 crania
met with it in 79*5 per cent., the septum being bent towards
the left side in twenty, and towards the right in fifteen
cases. In four instances the curvature was of a sigmoid
outline, thus bulging into both nasal fossae in different places.
Allen, in 58, found the septum so much deflected in 68*9
per cent, as to come in contact with the upper and middle
spongy bones ; whilst Zuckerkandl, in 370 skulls, met with
ait asymmetrical position in 140 cases, i.e., in 37*8 per cent.
In fifty-seven cases the bend was to the right, in fifty-one to
the left, and in thirty-two it was S-shaped. With the view
of investigating the whole subject of septal asymmetry
on a larger scale, I have lately made a careful examination
of the collection of skulls in the Museum of the Royal
College of Surgeons, with the assistance of Mr. C. L. Taylor.
The total number of crania actually examined was 3,102, but
of these only 2,152 had the bony septum in sufficient preserva-
tion to be tested. In each instance of septal asymmetry, the

DEVIATION OF THE NASAL SEPTUM. 433

degree of deflection from the middle line of the face was
measured as accurately as possible by means of a little instru-
ment 1 which I devised for the purpose. It was found that
the average deviation of the septum in the 2,152 skulls was
about 4 millimetres ; the greatest degree being 9 millimetres,
and the least half a millimetre.2 Among them 110 fewer than
1,657, or 76'9 per cent., presented a more or less unsym-
metrical position of the septum. In 838, or 38'9 per cent,
of the cases, the deviation was towards the left side ; in 609,
or 28 '2 per cent., towards the right ; in 205, or 9 '5 per cent,
the deflection was " sigmoid " in character, bulging towards
both sides at different levels, whilst in 5, or 0'23 per cent.,
the irregularity was of a type that may be called " zig-zag,"
i.e., the perpendicular lamina of the ethmoid and the vomer,
instead of joining accurately to form a smooth plate of bone,
lay in different planes, and overlapped each other at their
contiguous edges. It must be remembered that these figures
have reference onty to the bony septum, and that deviations
of the cartilaginous part probably occurred in a large pro-
portion of those cases in which the bone itself was straight.
Hence the actual percentage of deflections is much higher
during life than would appear from the above statistics.
According to Zuckerkandl the superior races show a greater
disposition to this deformity than those of a lower type, for
in 103 non-European crania it was present ,in only 23'3 per
cent. My investigations yield very similar results, for of 438
examples of symmetrical septa only 2 2 '6 per cent, were from
Europeans,3 the rest being from Africans, aborigines of the
American Continent, natives of the Polynesian Islands, and
a few from the Andaman Islands, the New Hebrides, Xew
Guinea, the Solomon Islands, and from the Island of Teneriffe.
The cause of deviation of the bony septum is very obscure.
Cloquet4 somewhat oracularly veils his ignorance of the

1 This consisted of a couple of short metal bars supported on- a
cross-piece placed at right angles to one of them, the other being
midway between the two — that is to say, at an inclination of 453 to
each. The angle between the two little bars was subtended by a
curved piece of metal constituting an arc which was graduated in
millimetres, so that by placing the upright bar in a position corre-
sponding to the middle line of the nose, the degree of obliquity of any
object within the nasal cavity could be easily read off on the scale.

2 Septa showing a deviation of less than half a millimetre were
counted as straight.

3 It is remarkable that nearly half of these were Italian skulls,
which as a class were of strikingly symmetrical proportions.

4 " Osphresiologie." Paris, 1821, 2me ed. p. 165.

VOL. II. F F

43-t DISEASES OF THE THROAT AND NOSE.

matter tinder tin- high-sounding phrase, that curvature of the
septum " depends on a primary law of organization." It
•\vas at one time thought that the condition was often of con-
genital origin, but according to the researches of Zuckerkandl
the septum is always straight before the seventh year. It
is not impossible that the deflection may result from the fact
that ossification of the septum proceeds from centres situated
in t\vo different bones, and that these deposits of ossific
matter do not subsequently meet in the same plane. As
regards deviation of the cartilaginous septum, various causes
have been assigned for the anomaly, such as always blowing
the nose with the same hand, or habitually sleeping with the
same side of the face on the pillow ; but the evidence in
support of these views is, to say the least, insufficient.
Chassaignac 1 suggests that there may be a tendency to over-
growth in the vertical direction, and this being prevented
by the firm bony attachments, the elastic substance of the
cartilage necessarily bulges out laterally .into one or other
nasal fossa.

Symptoms. — When the deflection is considerable, the
whole nose is twisted to one side, and the most casual
observer notices the disfigurement ; but when the deviation
of the septum i& not great, it may merely cause a slight twist
of the tip of the nose, or it may not even give rise to any
external alteration. Anterior rhinoscopy, however, makes
the condition at once apparent, and though the deformity
scarcely ever (never, according to my observations) affects the
posterior part of the septum, the rhinal mirror often reflects
the deviation in the central and anterior portions of the nose.
The tumour frequently encroaches on the corresponding nasal
channel, and in some cases completely occludes it. In such
instances the distortion of the septum, in addition to its
unsightly appearance, gives rise to functional troubles which
may occasionally amount to serious inconvenience. Respira-
tion through the nose is interfered with, the voice acquires the
characteristic nasal twang, the discharge of the pituitary secre-
tion through the nostril is prevented, and post-nasal catarrh,
with its attendant evils, results. The turbinated bodies are
not unfrequently so pressed upon that they undergo atrophy,
and dry catarrh may then ensue. In a case recently under
my care, the most troublesome symptom was epistaxis, caused
by erosion of the outer wall of the nose.

Diagnosis. — It is difficult to understand how any error
1 "Bull, de la Soc. de Chir." 1851—52, t. ii. p. 253.

DEVIATION OF THE NASAL SEPTUM

435

could be made as regards this disease, except by those who
do not make a proper rhinoscopic examination, or who
are entirely unacquainted with nasal affections. Yet the
deformity has frequently been mistaken for thickening and
sometimes for polypus.1 Careful comparison of both sides
of the septum at once determines the former point ; but
an ingenious " septometer " has been invented by Seiler,2
which serves to distinguish thickening from deviation when
these affections occur separately. Polypus can be easily
recognized by its comparative softness, elasticity, mobility,
and pale colour.

Pathology. — The deviation is almost always limited to the
anterior three-fourths of the septum.

FIG. 86. — ANTERIOII NARES AND PART OF SKULL, SHOWING THE
SEPTUM DEVIATED ACCORDING TO THE SIGMOID TYPE.

a, upper part of the septum bent towards the left side ; b, concavity on left
surface corresponding to convex portion bulging into right nasal fossa ; c, bony
crest or ridge projecting into left fossa ; dd, middle, and ee, lower spongy bones.
(The amount of deviation here shown is seen in several specimens in the
Museum of the Royal College of Surgeons, and bony ridges also occur in
many of them. The above cut is a composite drawing of various deformi-
ties met with in different skulls.)

The bony ridges already described as being common on
the lower half of the septum (p. 390) are frequently found
associated with curvature of that partition. Thus in 673

1 Chassaignac : Loc. cit. p. 256. I have myself also known this
mistake to be made in more than one instance.

2 " Diseases of the Throat, &c." 1883, 2nd ed. p. 83.

436 DISEASES OP THE THROAT AND NOSE.

specimens, in the Hunterian Museum, in which a ridge
existed, the septum was deviated in 588. In 414 instances
the ridge was on the side towards which the septum pro-
jected, in 107 on the opposite side, and in 85 skulls there
was a ridge without any deflection of the partition itself.
Although, owing to the difficulty of determining with cer-
tainty the sex from the cranium alone, it is not possible for
me to give exact figures on the subject, I am inclined to
think that these bony ridges are relatively less common in
women than in men, and that when they are present in
the former they are (as might naturally be expected) both
less thick and less prominent. The foregoing woodcut (Fig.
86) gives a very good representation of such a ridge, and of
septal asymmetry in general.

Treatment. — When the bony septum is the seat of marked
deviation it might sometimes be possible to remedy the
condition by fracturing the distorted partition with Adams's
forceps (Fig. 72, p. 281), and fixing the fragments in a more
symmetrical position by means of his splint introduced into
each nostril. I am not aware that this method has ever
been used for the rectification of natural deformity, but
Adams has had such excellent results1 from it in the treat-
ment of fracture of the septum that it seems worth trying in
cases of non-traumatic deviation. It is only, however, when
the deflection is extreme that so severe a procedure would
be justifiable.

The treatment of the bony outgrowths sometimes found
in connection with a deviated septum has been already
discussed (p. 391).

When the deviation is in the cartilaginous portion, the
simplest plan of treatment is that of Michel,2 who directs
the patient to make gentle pressure on the nose with the
finger, towards the opposite side. This must, of course, be
done very frequently each day, and it is obvious that it is
applicable only in the case of young persons, and where the
deformity is comparatively trifling. Where the object of
the surgeon has been more to remove a source of disease than
to correct a deformity, good results have been obtained by
establishing free communication between the unobstructed
fossa and its fellow. This was first proposed and accom-
plished by Blandin,3 who removed a piece of the cartilage

1 "Brit. Med. Journ." Oct. 2, 1875.

2 " Krankheiten der Nasenhohle." Berlin, 1876, p. 29.

3 "Compendium de Chirurgie Pratique," t. iii. p. 33.

BLOOD-TUMOURS OF THE NASAL SEPTUM. 437

with a kind of punch. Chassaignac1 relieved a very bad
case by dissecting up the mucous membrane, and paring
off slices of the protuberant cartilage, thus reducing its bulk
and freeing the nasal channel from the greater part of the
obstructing mass. Walsham2 forcibly replaced the bent
septum of a patient in whom the deformity had caused loss
of the singing-voice, at the same time incising the cartilage
in a stellate manner to overcome its resiliency. The voice
was completely restored.

1 Loc. cit. p. 256. 2 Loc. cit.

BLOOD-TUMOURS OF THE NASAL SEPTUM

History. — The first clear account of haematomata and abscesses of
the nasal septum was given by Cloquet in 1830,1 and three years later
the affection was described by Fleming,2 from his own observations.
Examples have since been published by Berard,3 Maisonneuve,4
Velpeau,8 and others; and in 1864 Beaussenat6 took these affec-
tions as the subject of his inaugural thesis. A brief account of
them was given by Casabianca,7 in a short essay published in 1876.
I have myself met with only one case of blood-tumour and one of
septal abscess.

1 ' Journ. Hebd. de Med." No. 91, t. vii. p. 545.

2 'Dublin Journ. of the Med. Sciences." Sept. 1833, vol. iv. p. 16, et seq.

3 'Archiv. Gen." t. xiii. 2e ser. p. 408.

4 'Gazette des Hdpitaux." 1841, p. 59.

5 Ibid. 1860, p. 178.

6 ' Des Tumeurs sanguines et purulentes de la Cloison." These de Paris.

7 'Des Affections de la Cloison." Paris, 1876, p. 23, et seq.

Violent blows on the nose, which give rise to fracture of
the bony or cartilaginous septum, sometimes cause blood-
tumours, which collect within a few hours after the accident.
The swelling results from the effusion of blood between
the deep layer of the mucous membrane and the underlying
cartilage, and as this accident seldom occurs without fracture,
the collection of blood usually takes place on both sides of
the septum, and a bilateral tumour is formed. Two cases
of spontaneous unilateral haematoma of the septum have
been recorded. One was related by Luc,1 in which an Arab
boy, aged ten, had complete obliteration of both nostrils,
dating apparently from an attack of confluent small-pox,
from which he had suffered five years before. On dividing
the cicatricial tissue, a blood-cyst was found in one nostril
attached to the septum. In the other case, reported by
Pean,2 few details are given, but the tumour, which was

1 " Bull, de la Soc. de Chir." 1875.

2 Nelaton : " Pathologic Chirurgicale." 2e ed. t. iii. p. 740.

438 DISEASES OF THE THROAT AND NOSE.

connected with the septum, was soft, pale blue in colour,
and contained blood. Blood-tumours have a smooth surface
and are purple in colour, the rest of the mucoxis membrane
of the nose, as pointed out by Fleming, being often of a
.similar ecchymotic hue. They are situated just within the
nostrils, and in the only case which I have met with had
very much the appearance of cysts. They are easily seen,
and their symmetrical character, together with the tluctua-
tion from one side of the septum to the other, which can
be perceived when the tumour is examined with a fore-
finger in each nostril, generally serve to determine its nature.
When the swellings are large, they sometimes even pro-
trude from the nostrils. Their soft consistence serves to
distinguish them from bony or cartilaginous tumours, and
their symmetrical origin by a broad base from each side of
the septum differentiates them from polypus. It is difficult,
however, to discriminate between these tumours and septal
abscesses, into which, if not cured, they soon pass. The
patient rarely recovers without a permanent aperture in the
septum.

If treated sufficiently early, hsematomata may sometimes
be dispersed by the free use of evaporating lotions ; but if
this plan does not succeed within a day or two, there is every
chance of purulent degeneration of the extravasated blood
taking place, and of the formation of an abscess. It is better,
therefore, to empty the sacs by opening one of them at its
most dependent part ; and should this not suffice for the
complete evacuation of the contents of both tumours, the
other one should also be opened. Jarjavay1 recommends that
general antiphlogistic treatment should be combined with
these surgical measures, especially at the outset.

CASE OF H.EMATOMA OF THE NOSE.

W. H. E., aged twenty-seven, a farrier, was brought under my
notice at the Throat Hospital, in March, 1863, by Dr. Frodsham.
The patient stated that in shoeing a horse about ten days .previously
he had received a slight kick on the nose, but that the hoof had
scarcely touched him. Since then, however, he had felt a constant
dull aching sensation in the nose, which he said was " completely
stuffed up." On examination, both nasal passages were seen to be
blocked up by dark, red, round tumours, which appeared rather
tense. On marking an exploratory puncture into the swelling on the
right side, blood slowly oozed from the wound. A large opening
was now made at the lowest part of the right tumour, and tnrougE

1 " Bull. Ge"n. de Therap." 1867, t. Ixxii.

ABSCESS OF THE NASAL SEPTUM. 439

ii both cysts (for such they appeared to be) were evacuated. The
next day, however, they had tilled again. An incision, nearly half
an inch in length, was next made in the left tumour, but three
days later this also closed up. An opening was then made in both
tumours, and a small piece of lint inserted in each. This treatment
proved successful. Some sanious matter continued to escape from
the left swelling for about fourteen days, when the wound healed.
A purulent discharge from the right tumour gradually ceased at the
end of a month. It was then noticed that there was a semi-circular
aperture in the anterior part of the septum, about half the size of a
fourpenny-piece, the edges of which were ulcerated. The patient
had never noticed any solid matter come away. The rest of the
mucous membrane of the septum was rather dry and of a deep red
colour. With the exception of the opening the patient ultimately
recovered completely.

ABSCESS OF THE NASAL SEPTUM.

(For History see last Article.}

These abscesses may be acute or chronic.

The Acute septal abscess is mostly of traumatic origin,
and comes on within a few days, though sometimes not for a
week or two, after the injury. It may result directly from the
inflammation of the parts, or it may be due to the degenera-
tion of a blood-tumour, as described in the foregoing article.
Like the latter, the abscesses are generally situated at the fore
part of the septum, and they are almost always symmetrically
bilateral. They present the ordinary characters of an inflamed
part, and may be accompanied by some slight constitutional
disturbance. The nose is obstructed, the voice muffled, the
conjunctivse are red and extremely sensitive to light, whilst
there is frequently profuse lachrymation. There is often
also a good deal of redness and tenderness of the skin of
the nose itself. Chronic abscesses have the same shape and
position as those of an acute character, and usually arise from
the same causes. They are, however, much less quick in
forming, less painful, of a lighter colour, and are accom-
panied by little or no systemic disturbance. They have
been mistaken for mucous polypi, but the points of dia-
gnosis already indicated in dealing with hsematomata are
amply sufficient to differentiate these tumours. Like blood-
tumours, their cure is generally followed by a permanent
opening in the septum. The only effectual treatment' is to
evacuate the contents of the sacs ; and free drainage can only
be insured by opening both the tumours, and keeping the
incisions patent with a small linen tent or by the occasional
introduction of a probe.

440 DISEASES OP THE THROAT AND NOSE.

CASE OF CHRONIC SEPTAL ABSCESS.

Charles H. , a labourer, aged thirty-one, had been under my care at
the London Hospital, for a short time, in the early part of 1870, on
account of general weakness after typhoid fever, when at one of my
\ :-it> he complained of difficulty of breathing and "stoppage " in his
nose. On making an examination, I found two pale pinkish yellow
swellings, Mocking up each nostril. They were rather tense, did not
pit on pressure, nor show signs of fluctuation. The patient had at
the time been convalescent from his attack of fever for seven weeks ;
that is to say, he had been going regularly out of doors during that

Jieriod, and he stated distinctly that until a week before he had never
elt anything the matter with his nose. On making an incision into
one of the tumours, pus freely poured out, and on pressing the other
tin n our, it also was completely emptied, a small quantity of chalky
matter coming away with the contents. On passing a probe, an
oval opening, nearly half an inch in length and a quarter of an inch
in height, was found at the anterior part of the cartilaginous septum.
An incision was made into the other abscess, not previously opened,
and rapid healing took place, leaving, of course, the perforation in
the septum already described.

FOREIGN BODIES IN THE NOSE.

Latin Eq. — Corpora adventitia in naribus.
French Eq. — Corps Strangers des fosses nasal t-s.
German Eq. — Frenidkb'rper in der Nasenhohle.
Italian Eq. — Corpi stranieri nolle narici.

DEFINITION. — Foreign substances lodged in tlie nose
commonly gaining access by the nostrils, but occasionally
passing iqnrards from the throat or penetrating tJie integu-
ment*.

History. — The literature of foreign bodies impacted in the nasal
channels consists almost wholly of scattered cases reported in medical
treatises and periodicals. Among the most remarkable examples on
record may be mentioned one1 in which a fragment of an explosive
shell remained in a imfn's nostril for seventeen years, and finally
found its way out ; and another2 in which a musket-ball was lodged
within the patient's nose for twenty-five years without its existence
being discovered. Several instances have been reported by Renard,3
Boyer,4 and others,8 in which vegetable bodies lodged within the
nose have, to the great discomfort of the patient, germinated in situ.
Remarkable examples of the long sojourn of foreign substances within
the nasal cavity have been related by Hickman6 and Tillaux,7 and an
interesting paper has been written on the whole subject by Bron.8

1 " Ephem. Nat. Cur." Dec. iii. ann. v. et vi. obs. 300.

2 Ibid. Cent. x. obs. 80.

3 " Journ. de M^decine," t. xv. p. 525.

* "Trait6 des Malad. chirurg." Paris, 1846, t. v. p. 65.

B Blasius : " Obs. Med. Rarior." p. ii. No. 8 ; and " N. Act. Nat. Cur." vol. ii
obs. 20.

6 " Brit. lied. Journ." 1867, vol. ii. p. 266.

7 "Bull, de la Soc. de Chir." January 26, 1876.

8 " Gazette M<§dicale de Lyon." 1867, No. 36.

FOREIGN BODIES IN THE NOSE. 441

Etiology. — The accident most frequently happens to
children, who amuse themselves by putting beads, peas,
beans and other small bodies into their noses. Insane people
also sometimes introduce foreign bodies into the nasal
cavity. In vomiting, hard substances, such as fruit stones,
which had previously accidentally reached the stomach,
have been forced into the nasal passages and have become
impacted there. This accident is, of course, more likely to
occur if the soft palate is paralysed. Further, foreign bodies
may occasionally be driven into the nares from below, when
a person swallows " the wrong way," the effort to prevent
the foreign substance passing below the glottis, causing it
to be forcibly driven up into the nose. An extraordinary
instance is related by Hickman,1 in which he removed from
the posterior nares of a girl a steel ring, three-quarters of an
inch in diameter and half an inch wide, which had been
lodged there for thirteen years and a half. Portions of
knives,2 bayonets,3 or bullets4 that have pierced the skin
sometimes become lodged in the nasal fossae, but such bodies
usually give rise to wounds, without becoming themselves
impacted. A case is recorded by Legouest,5 in which a
carpenter stabbed a man in the nose with a pencil, the
broken end of which was subsequently removed through the
nares.

Symptoms. — Foreign bodies, when introduced by children
or insane persons, generally lodge in the lower part of the
nasal fossae, but this is by no means an absolute rule. The
symptoms depend on the size, form, and nature of the foreign
body. If the substance be small and round, it may remain
for a long time in the nose without producing any symp-
toms at all. Vegetable bodies, however, such as peas or
beans, imbibe moisture, and thus swell considerably. As
already remarked, they sometimes germinate in the warm,
moist atmosphere of the nasal chambers, and they may thus
give rise to very troublesome symptoms. In Boyer's case
a haricot bean shot out ten or twelve roots, and pro-
duced the appearance of a polypus, for which it was, in

1 Loc. cit.

2 Legouest : "Traite de Chirurgie d'Armee." Paris, 1863, p. 383.

3 Ibid.

4 Lemaistre : "Bull, de la Soc. Anat." Oct. 1874, p. 632. Lawson:
"Diseases and Injuries of the Eye," 2nd ed. p. 336. Gaujot, quoted
by Casabianca : "Des Affections de la Cloison des Fosses nasales."
Paris, 1876, p. 22.

6 Op. cit. p. 383.

442 DISEASES OP THE THROAT AND NOSE.

fact, mistaken. If the foreign body is sharp-pointed or
irregularly angular in shape it causes very great irritation,
and an attack of acute rhinitis frequently supervenes. \Vln-u
the substance is large, more or less obstruction of the pass. •,
is produced, and the patient is obliged to keep his mouth
constantly open. In the earlier period there is often inteu-e
headache with pain in the nose and cheek, and these pains
occasionally assume a distinctly neuralgic character. A \i-ry
instructive case of this kind has been published by Verneuil,
in which the pain came on two or three times a month, ;md
perfectly simulated facial neuralgia. If the foreign body
remain in the nose for any time, the acute rhinitis gradually
passes off, leaving, however, in its place, obstinate chvonii-
inflammation and an extremely fetid discharge from the
nostrils.

Diagnosis. — The recognition of the accident presents no
difficulty, if there be a clear history of the introduction of a
substance into the nasal passage, but in many cases such
information Avill not be forthcoming, either from wilful
suppression or genuine ignorance. When, therefore, a case
of fetid discharge from the nostril is met with, especially if
the patient is a child, the possibility of the complaint bi'ing
caused by the presence of a foreign body should always be
borne in mind, and a thorough examination of the nasal
fossae should be made, both from the front and from behind.
As, however, an impacted foreign body is very likely to be
covered with mucus, the nasal passages should be washed
out with a spray of tepid salt water before rhinoseopy is
practised. If careful inspection should fail to detect any
foreign substance, a search shoidd still be made with the
nasal probe ; and in order that the examination may be quite
satisfactory, it may be necessary, in some cases, that the
patient should be rendered insensible.

Prognosis. — The prognosis is almost always favourable, for
the foreign body can, in the majority of instances, be easily
removed, and then all the symptoms rapidly disappear.

Treatment. — The foreign body should be extracted as soon
as practicable, but it should be remembered that the con-
dition is not in itself dangerous, and that therefore there
need be no undue haste in carrying out treatment. A
thorough inspection of the nasal cavities should first be made
with the help of the speculum, and if this does not prove
successful the offending substance should be searched for
with the probe. If the examination is badly borne, and

FOREIGN BODIES IN THE NOSE. 443

especially if the patient is a child, an anaesthetic should be
administered. When the situation of the foreign body has
been accurately determined by either of these methods, it
should be removed with fine forceps, bent at the proper nasal
angle (see Fig. 39, p. 257). Sometimes when the foreign
body is situated very far back, as in Hickman's case already
referred to, it may be more easily removed by means of forceps
passed through the mouth behind the soft palate. Gross's
spuds and hooks (Fig. 70, p. 281), may be useful for the
extraction of peas and seeds of various kinds. Should it be
found impossible by careful exploration to discover the
whereabouts of the foreign body, or should the latter be so
firmly impacted that it cannot be dislodged without using
undue violence, other measures must be resorted to. If the
patient be an adult, or a child who has attained the age of
eight or nine years, it is a good plan to make use of the
continuous douche, a little warm salt water being passed up
the free nostril and brought out through the side where
the substance is lodged. When the foreign body is small,
a pinch of strong snuff will often enable the patient to
expel it by sneezing. An ingenious, but unpleasant, method
was adopted in a case related by King.1 A cherry-stone
had become impacted in a child's nose and could not be
dislodged ; at last a powerful emetic was given, and when
vomiting was about to commence a handkerchief was held
tightly over the little patient's mouth, so that the fluid
was thrown through the nares, washing out the foreign
body in its course. If it can be avoided, it is very undesir-
able to attempt to push the foreign substance backwards, in
the manner sometimes recommended, as there is danger of its
falling into the larynx ; but if the body is large and tightly
impacted into the posterior part of the nares, the practitioner
may be obliged to risk this accident. He should, of course,
take the precaution of introducing his left index finger
through the mouth into the naso-pharynx, whilst with the
right hand he is manipulating through the front of the nose.
If the substance be large, and the symptoms caused by
its presence very troublesome, Rouge's operation (see "Fibrous
Polypi of the Naso-Pharynx") may be necessary.

1 "Amer. Journ. Med. Sci." April, 1860.

444 DISEASES OF THE THROAT AND NOSE.

RHINOLITHS.

History. — The earliest allusion to these deposits is in a work by
Matthias de Gardi,1 who, however, merely mentioned, somewhat
vaguely, a case at second hand. Two examples were observed by
Bartholin,2 one apparently of spontaneous origin, the other contain-
ing a cherry-stone as a nucleus. Clauder,8 Kern,4 and Reidlinus,6
each recorded one case, and Wepfer6 described two instances of the
complaint. In 1733 a case was related by the great anatomist
Ruysch,7 and soon afterwards Plater8 discussed the origin of nasal
concretions. Other examples were recorded by Savialles,9 Grafe,10
Thouret,11 Axmann,12 Brodie,13 and Demarquay.14 The last-named
author, in describing a case of nasal calculus, which he had had an
opportunity of observing while it was under the care of Blandin,
discussed the whole question of the origin, symptoms, composition,
and treatment of these bodies, and collected all the previously recorded
cases that he could find. It is, in fact, to his careful account of
the literature of the subject that I am mainly indebted for the above
brief historical summary. Cases have since been reported by Cook,1*
Kostlin,16 Rouyer,17 W. N. Browne,18 Verneuil," West,20 Roe,"
Hering,22 and Nourse.23

i " Pratica." Venetiis, 1502, pars. ii. cap. 14, p. 308.
" Hist. Anatom. Rar." 1654, cent. i. p. 47 ; also cent. iv. p. 404.

3 " Ephem. Nat. Curios." 1685, dec. ii. ann. xili. obs. 78.

4 Ibid. 1700, dec. iii. ann. v. and vi. obs. 43, p. 100.

5 Ibid. 1706, dec. iii. ann. ix. and x. obs. 145, p. 268.

6 " Observ." 192, p. 905. 1727.

7 " Obs. Anat." Amstelodami, 1733. Obs. 44, p. 42.

8 " De Olfactus Lesione." 1736, lib. i. c. 9, p. 264.

9 "Bull, de la Facultd de M<5d." 1814, t. iv. p. 44.

10 " Annales d'Oculistique." 1828, t. viii. 4e et 6e livraison, p. 203.

11 " Arch. G6n. de M6d." 1829, t. xix. p. 27.

12 Ibid. 1829, le se>ie, t. xx. p. 102.

13 " Lancet." Jan. 6, 1844.

i* "Arch. G6n. de M6d." 1845, 4e se'rie, t. viii. p. 174, et seq.

IB "Banking's Abstracts." 1847, vol. vi. p. 132.

is " Wiirtemberg Corresp.-Blatt." 1854.

17 " Bull, de la Soc. Anat. de Paris." 1857, p. 60.

is "Edin. Med. Journ." 1859, vol. v. p. 50.

i» " Gaz. cles Hdpitaux." 1859, p. 25.

«) " Lancet." 1872, vol. i. p. 147.

21 " Archives of Laryngology." 1880, vol. i. No. 2, p. 149, et seq.

22 " Monatschr. f. Ohrenheilk." 1881, No. 5.

23 " Brit. Med. Journ." Oct. 1883, p. 728.

Rhinoliths generally owe their origin to the accidental
impaction of small foreign bodies around which the salts
of the pituitary secretion collect. Thus in Bering's case the
nucleus of the formation was a button, which had become
firmly fixed in the nasal passage of a boy aged fourteen.
Grafe suggested that rhinoliths are usually of gouty origin,
but out of fifteen cases collected by Demarquay there was
only one in which a gouty diathesis could be distinctly
recognized. Occasionally in the .centre of the calculus an
albuminous liquid or a fatty proteine substance has been
found, but it appears doubtful whether in these cases the

EHINOLITH8. 445

matter contained in the centre of the calculus was the
remains of the original morbid secretion, or whether it was
due to the softening of some foreign material primarily
forming the nucleus of the stone. Chronic inflammation
no doubt promotes further deposition, and may in some
cases give rise to the original formation. Any cause which
obstructs the outflow of the secretion may lead to the
formation of a calculus. In Browne's case the nostril had
been blocked up for some years.

The symptoms caused by rhinoliths are similar to those
already described as being produced by foreign bodies ; but
they generally come on more slowly, and as the calculus
continues to increase in size, in the end they cause more
inconvenience. A fetid discharge is usually the most
troublesome feature of the complaint. The shape of the
stone varies, but it is generally irregularly oval, and varies
greatly in size. In Browne's case it attained the enormous
dimensions of an inch and three-quarters in length, one inch
in breadth, and nearly half an inch in thickness, whilst its
weight was three drachms and thirty-three grains. When
the calculus is situated in the upper and anterior part of
the nasal cavity it may cause a swelling on the face (see
Case 2 below), and under these circumstances the lachrymal
canal is apt to be obstructed. The stone is usually single,
though occasionally, as in the cases of Axmann and of
Blandin, several calculi may be present, and in one of my
own cases (No. 1) there were two. Their surface may be
smooth, but, as a rule, it is somewhat rough and mam-
millated, and their colour is most frequently greyish-black.
Sometimes they are partly covered by the mucous mem-
brane, in which they have become imbedded, the edges of
the membrane being, under these circumstances, puffy and
ulcerated, and disposed to bleed.

The diagnosis is often very difficult ; indeed, a calculus
cannot always be readily distinguished from an osteoma, and
owing to the fungous bleeding appearance of the mucous
membrane, and the great swelling which may be present,
a rhinolith has even been mistaken for cancer.1 If the
calculus is movable, or if its surface can be penetrated by
a sharp probe or needle, it is not likely to be confounded
with an osteoma. The slow course of the disease, and
the absence of pain, serve to distinguish it from cancer,

1 Jacquerain, quoted by Spillmann : "Diet. Encycl. des Sci.
Med. " t. xiii. p. 24.

446 DISEASES OF THE THROAT AND NOSE.

whilst the most casual examination will at once enable the
experienced surgeon to recognize a polypus. The composi-
tion of nasal calculi is very simple, for they merely consist,
as Prout1 has shown, of mucus and phosphate of lime.
They are generally hard on the surface, and softer towards
the centre, an outside wall being formed round them, and
constituting a covering something like an egg-shell. This,
however, is not an invariable rule, for in one of my cases the
calculus was of extreme hardness throughout. The prognosis
is favourable, as, when once discovered, the stone can nearly
always be removed, and the patient cured. The treatment,
consisting, as it does, in extraction of the calculus, can
usually be carried out with common polypus-forceps, but
if the stone has attained to too great dimensions to permit
of its immediate removal, it should first be crushed with a
lithotrite of a size and shape suitable for use within the
nasal cavity. In one of my cases the stone could only In-
brought away after being cut through with powerful bone-
forceps. Hering having failed to get the stone out with
forceps, pushed it backwards through the posterior nares,
when the patient himself 'was able to "hawk" it out.

The following examples of this complaint have occurred in
my own practice : —

Case 1. — James S., aged thirty-seven, a gentleman's servant,
applied at the Throat Hospital in May, 1876, on account of a dis-
charge from the left nostril, from which he had suffered for six
years. On examining the nose a calculus was seen in the middle
meatus. The stone was in a great measure covered by mucous mem-
brane, which had grown over it. Several attempts at extraction were
unsuccessful, and it was only after making an extensive incision along
the lower border of the middle turbinated body, that the calculus was
brought away in several fragments. The patient was subsequently
treated with mild alkaline washes, and at the end of six weeks had
completely recovered ; the nasal passages being perfectly clear, and
there being no discharge. From an examination of the fragments,
it appeared that there had been two oblong stones placed in a line
one with the other, and touching at one end. One of them
measured a centimetre and a half in length and eight millimetres
across, the other was rather smaller ; neither of them appeared to
have any nucleus. The surface of both calculi was harder than the
interior, and of a lighter colour. They weighed together forty-seven
grains.

Case 2. — Mr. H. S., aged sixty-three, a Government official at
Jamaica, consulted me in June, 1882, on account of a troublesome
discharge from the right nostril. He had previously seen several
practitioners with reference to his ailment, one of whom had told him

1 " Lancet," Jan. 6, 1844.

RHINOLITHS. 447

that he had a polypus in his nose, whilst another assured him that
he had nothing the matter with him, and a third frankly confessed
himself unable to discover the cause of his complaint. Mr. S. had
resided for some years in the tropics, and had suffered from severe
attacks of ague, but otherwise he had been a very healthy man till
about four years before he came under my notice, when he had been
treated for stone in the bladder, and a " mulberry" calculus had been
removed by crashing.

On inspection I found the right side of the nose from near the
angle of the eye to the upper border of the lower lateral cartilage
filled out by a hard tumour, the skin over it being perfectly healthy.
A dark brown fetid discharge came from the right nostril, and on
examining the interior of the nose with the speculum, the right nasal
cavity was found to be occupied by a large calculus extending from
the level of the inferior turbiuated body to the roof of the nose. The
surface of the stone was rough, of a greyish-black colour, and
veiy hard. On attempting extraction with forceps, some small frag-
ments were got away, together with a little slimy grit, but no sensible
diminution in the size of the calculus was effected. I subsequently
attempted to use a lithotrite, but owing to the shape, hardness, and
situation of the stone, I found it impossible to crash it ; I finally suc-
ceeded, however, in dividing it with powerful bone-forceps. Even
then the large fragments could not be extracted. As a last resource
I passed a string through the nose into the mouth, and having
attached a strong plug of lint to the distal end, drew it forward
again through the nasal fossa, and in this manner managed to
bring the divided stone within reach of the blades of the lithotrite,
and finally to crush it. On examining the fragments no nucleus
could be discovered, but if there had been one it might easily have
eluded observation. The total weight of the debris was seventy
grains. Considerable haemorrhage followed this operation ; and
rather extensive facial cellulitis,1 without, however, very marked
pyrexia, supervened on the following day. This lasted for nearly a
week, and recurred on four subsequent occasions at intervals of a
few days, although no further operation was attempted. By the time
Mr. S. had recovered from these attacks his leave of absence had
expired, and he was obliged to return to Jamaica. Unfortunately
a small fragment of the stone still remained in the extreme upper
part of the nose, and this is very likely to become enlarged by further
accretions.

1 Hack (" Beitrage zur Rhinochirurgie," Wien, 1883, p. 24) has recently drawn
attention to the fact that a tendency to a low form of erysipelas of the neigh-
bouring parts of the face is a not unfrequent complication of inflammatory
disease within the nose.

448 DISEASES OF 'THE THROAT AND NOSE.

MAGGOTS1 IN THE NOSE.

Latin Eq. — Myasis narium.

French Eq. — Larves dans les fosses nasales. Myase du in •/,.

German Eq. — Wiirmer in der Nasenhbhle.

Italian Eq. — Larve nelle fosse nasali.

DEFINITION. — Destruction of the. soft tissues, and some-
times of the bones, of the nose, by maggots hatched from
deposited within or close to the nostrils by dipterous
causing gnawing pain, insomnia, and sometimes conmltions,
cvma, and death.

Though this affection is the cause of wide-spread suffering
among the native population of our extensive tropical posses-
sions, it is scarcely referred to in any standard English work.
Indeed, in the entire medical literature of the world there
is not a single essay dealing fully with the whole subject.
Under these circumstances it seems to me desirable to lay
before my readers an analysis of the scattered articles
which have appeared from time to time, for the most part,
in rare books or inaccessible journals.

History. — Previous to the present century there are only a few
examples of myasis of the nose on record. Gahrlieb1 reported an
instance in which a peasant, afflicted with great pain in the fore-
head and root of the nose, made a decoction of pungent herbs, and
inhaled the steam. Epistaxis came on, and was followed by the
expulsion of several living maggots. The next case is that of
Behrends,2 who treated a woman, suffering from unbearable head-
ache and slight swelling of the face, by injecting into the nose
decoctions of tansy, rue, and absinth. Thirty maggots were brought
away, and the patient was cured. A still more striking example of
myasis was published twenty years later by Wohlfahrt,8 in which a
patient suffering from terrific headache was treated by inhalations of

1 " Ephem. Nat. Curios." Dec. iii. ann. vii. et viii. obs. 141, p. 260.
" Scharschmidt's Med. und Chir. Nachrichten." Berlin, 1743, 1 Jahrg. p. 214.

3 "Observ. de Vermibus per Nares Excretis." Halfe Magdeburgicse, 1768.
These cases will all be found in Tiedemanu (" Wiirmer in den Geruchsorganen,"
.Mannheim, 1844), but the reader who is anxious to pursue the subject will find
these and many other references in Ploucquet's laborious Index (" Literatura
Medica Digesta," Tubingse, 1809, sub voce " Vermis").

1 This subject has been briefly referred to in some text-books
under the general head of "Parasites in the Nasal Fossae," but this
designation is inaccurate. Maggots can hardly be said to be
parasites, for, as Moquin-Tandon ("Elements de Zoologie Medicale,"
Paris, 1859, page 215) points out, the essence of parasitism con
in the remarkable fact that an individual may live at the expense
of another, without any very serious results occurring to the animal
fed upon.

MAGGOTS IN THE NOSE. 449

alcohol, and eighteen maggots were brought away. These were
placed in a box, and in thirty days developed into flies. Fifty
years later, a case in which an infant eight months old expelled some
worms from the nose was briefly referred to by Tengmalm,1 and
towards the end of the last century, Azara2 had several opportunities
of witnessing the effect of maggots within the nose, in Paraguay.
In 1830, Macgregor3 published an example of the disease, which he
had observed in British India. Cases met with in the same country
have since been reported by Lahory,4 Moore,5 and Ohdedar6 ; whilst
the affection was closely studied by Coquerel7 in Cayenne ; by
Morel,8 Gonzalez,9 Jacob,10 and Weber," in Mexico ; and by
Frantzius,12 in Costa Rica. In Europe, Mankiewicz 13 reported a case
which had been treated by himself, Moquin-Tandon1* related ex-
amples which had been witnessed by D' Astros and others, and an in-
stance was recorded by Petrequin,15 which he had met with in Italy.

Of the observations made in British India, Macgregor's was the
first. The patient was a man who for three months had felt pain in
the left cheek and inside the nostril. On blowing his nose violently
some worms came out, which alarmed him very much, but gave him
some relief. Subsequently his cheeks swelled, a fetid bloody dis-
charge issued from the nose, he became greatly excited, and had
attacks of shivering ; ammonia was used to excite sneezing, and about
a hundred larvae were expelled. They were about half an inch in
length, thinner at the front than behind, segmented, and without
feet. Their colour was white, but they had black spots at the
posterior extremity.

Lahory, a native practitioner, educated in the European system
of medicine, wrote an interesting article on ' ' Peenash, " 16 a term
used in Hindostan for an ulcerative disease of the nose in which
maggots are present. He states that he has seen it in patients of all
ages, from nine years to eighty, and that it is most common in the
hot weather, from July to September. He observed that bad food

1 " Kongl. Vetenskaps Academiens Handlingar." 1796, p. 285.

2 "Voyages dans I'Ame'rique meridionale." 1781 — 1801. Par Don Felix de
Azana. With notes by Cuvier. Paris, 1809, t. i. p. 216.

3 " London Med. and Phys. Journ." 1830, vol. Ixiv. p. 498, et seq.

4 " Edin. Med. Journ.' Oct. 1856, vol. ii. pp. 371, 372.
* " Indian Med. Gazette." 1871.

6 Ibid. 1881, vol. xvi. p. 80.

7 "Archiv. Gfti. de M<kl." 1858, t. ii. p. 513, et seq. See also " Annales de la
Soc. Entomolopique." 1858, p. 173.

" Recueil de M£d. Milit." 1865, Se s£rie, t. xiv. p. 516, et seq.
9 " La Mosca Hominivora." " Disertacion leida en la Academia Medico-farma-
centica de Monterey la noche del 3 de Marzo, 1866, por el Profesor de Medicina y
Cirugia D. .Tos£ Eleuterio Gonzalez,"

10 " Rec. de M6d. Milit." Ife66, 3e serie, t. xvii. p. 58, et seq.

11 Ibid. 1867, 3e serie, t. xviii. p. 158, et seq.
M " Virchow's Archiv." Bd. xliii. p. 98.

13 Ibid. 1868, Bd. xliv. p. 375.

u " Etem. de Zoologie Medicale." Paris, 1859, p. 212.

" Fricke u. Oppenheim's Zeitschr. f. d. gesammte Med." 1838, p. 276.

16 The word is said to be of Sanskrit origin, but its resemblance to the French
word punaisie is very remarkable, and it is not impossible that the term now
used in India may have been introduced by the French at Pondicherry. . On the
other hand, it is possible that both words are derived from a common root (see
foot-note 1, p. 332). If it could be shown when the term was first employed, it
would have an important bearing on the etymological question. It may be
remarked that camels in India are commonly led about by a ring which passes
through the cartilage of the nose, and the ulcerated surface is constantly covered
with maggots, the animals being said to suffer from " Peenash" (Moore : " Native
Practice in Rajpootana "— " Iml. Med. Gaz." 1871).

VOL. II. G G

450 DISEASES OF THE THROAT AND NOSE.

and dirt predispose to the disease, and that it is most frequently
seen in persons whose noses are flattened from falling-in of the
bridge. The symptoms which he noticed were deep-seated inde-
scribable pain over the frontal sinuses, in the orbits, and in the ears,
with a crawling sensation inside the nose. Epistaxis very often
occurred. The patient had a disposition to hold the head down, and
there was so much ecchymosis and swelling of the eyelids that
vision was often obstructed. As the disease went on, ulueration of
the nose took place, and a large portion of the organ frequently
sloughed away. There was often high fever, with severe constitutional
symptoms. At Allyghur, between December, 1851, and March, l*.~i.">,
there were 91 admissions to hospital for " Peenash." Of these cases 46
were cured, 14 relieved, and 29 ceased to attend, whilst 2 died.
Lahory describes the maggots as being white or yellow, and often
having black spots on the head and tail, their size being that of the
ordinary maggots seen in putrid animal matter. They have a distinct
head, eyes (?), mouth, body, and a tail generally arranged in eleven
spiral turns, each spire being a separate joint, by means of which
the animal moves. The worms are free, or loosely confined in mem-
branous cysts. The treatment recommended by Lahory consists
in the injection of turpentine or infusion of tobacco, combined with
the internal use of alteratives and tonics.

In a case of "Peenash" recently described by Ohdedar, a native
surgeon in the Indian sen-ice, the patient was a woman, about
whom a disagreeable smell was noticed, but whose nose only
showed thickening of the mucous membrane. In the hard palate,
however, there was an opening of the size of a four -anna piece (a
centimetre and a half in diameter), and through it eight maggots
were removed, each having a distinct nidus. Epistaxis occurred on
more than one occasion, and there was subsequently oedema of tin-
face and eyelids. The throat and nose were syringed with a weak
solution of muriate of iron, and afterwards with oil of turpentine.
Ulceration took place near the inner canthus of both eyes, and
through the broken skin maggots escaped, causing great pain. Ery-
sipelas of the nose and eyelids ensued, and the patient ultimately
died from coma.

Of the information collected in South America, that obtained by
Coquerel is of great value. This surgeon, an officer in the French
naval service, temporarily stationed at Cayenne, in French Guiana,
has given the most detailed report of myasis of the nose which has
yet been published. He does not appear to have seen any patients
himself, the cases having been treated 'by his brother officers, MM.
St. Pair and Chapuis, but he had access to their reports, and was
able to determine the class of insect whose larva caused the disease.
In his article it is not stated whether flies deposited their eggs within
the healthy nose, or'whether, as in the case of the Indian " Peeuash,"
the maggots were only found when the mucous membrane was in a
morbid condition. The principal symptoms noticed at Cayenne were
formication in the nose with severe frontal headache, accompanied in
some cases by a sensation resembling "blows with an iron bar" ;
there was also ojdematous swelling of the nose, extending over the
face, and especially involving the eyelids. Severe epistaxis was often
met with, and not unfrequeutly there was considerable inflammation
of the internal tissues of the nose, which in some cases spread to
the meninges, and thus caused death. Tumours occasionally formed

MAGGOTS IX THE NOSE. 451

on the outside of the nose, which after "pointing" opened spon-
taneously, and from them large numbers of larvae escaped. When
the nose was syringed with a solution of alum or a decoction of
tobacco, a quantity of larvae were frequently expelled, the aggre-
gate number in a single case sometimes amounting to two or
three hundred. In the patients that recovered, the septum was
frequently in a great measure destroyed, and in many cases the
nose was almost eaten away. Of six men treated by St. Pair,
three died with symptoms of meningitis ; whilst in two of the
survivors the nose had completely disappeared, and in one it was
terribly deformed. In the fatal cases the meninges were found of a
deep red colour and full of blood, especially at the base of the brain.
The cerebral substance itself was injected, and the ventricles filled
with bloody serum. One patient who had nearly recovered was
attacked by erysipelas of the face and scalp, from which he died ;
and in this case, at the post-mortem, bundles of larva? were found
encrusted in the frontal sinuses and antrum. Coquerel states that
the surgeons at Cayenne generally insufflated alum, or injected a
decoction of tobacco, but with indifferent success, as this treatment
often made the membrane puffy, and closed the openings into the
sinuses. He observes that if killed, the maggots no doubt often
putrefy within the sinuses, and thus give rise to new symptoms.
When there was reason to suspect that they had entered the frontal
sinuses or the antrum, the Cayenne surgeons trephined these cavities.
Coquerel carefully describes the insect which causes this fatal disease.
The account of the maggot, pupa, and fly, as given by him, will be
deferred to Etiology (p. 454), as it serves as the standard description
of the insect.

When it was decided by the French Government, in 1862, to send a
military expedition to Mexico, the Conseil de Sante directed the army
surgeons to collect all the information they could concerning the
disease produced by the entrance of flies into the nose ; but, as far as
I have been able to ascertain, the only officers who responded were
Morel, Jacob, and Weber. The information, however, which they
collected in Mexico added to our knowledge of the disease, and led
to more certain methods of cure.

Morel based his observations on five cases which had come under
his own notice. He thinks that the fly always enters the nose during
sleep, and believes that dirty people and those suffering from ozaena are
particularly liable to be attacked. In four out of his five cases such
persons were the subjects of the disease, whilst in the fifth the patient
was suffering from a boil close to the spot attacked. Morel observes
that in the nasal fossae, the mucous membrane and all the tissues
are rapidly reduced by the maggots to the condition of a pulp, whilst
the cartilages and bones are laid bare and soon become necrosed.
His article is specially remarkable on account of its containing
Assistant-Apothecary Dauzats's recommendation of the use of chloro-
form as a specific for the destruction of maggots. He advised that
chloroform diluted with half its volume of water should be shaken
up, and injected before the two liquids have time to separate. ' Morel
observes that all the patients on whom he used this remedy recovered
as if by magic, except one on whom it was tried too late. Inhalation
of chloroform generally detaches and brings away the larvse at once,
but if they are very deeply situated it should be injected.

Jacob learnt from the natives that the malady was tolerably

452 DISEASES OF THE THROAT AND NOSE.

common amongst them. They attributed it to a neglected cold, and
hence regarded coryza with considerable dread. He reports a very
severe case of myasis, which was cured by the use of chloroform
injections and inhalations. Pure chloroform was injected several
times. Although Jacob's paper was published subsequently to that
of Morel, he claims to have invented the treatment after trying it
with Dauzats on worms.

Weber spent a considerable time in Mexico between 1862 and
1866, especially at Orizaba, Cordova, and Montery, where, though
the disease is said to occur, he did not see any cases himself, his
information being principally derived from the published works and
oral communications of Dr. Gonzalez. The highest situation at
which the fly is found is at Orizaba, which is 1,200 metres above the
sea-level, the point of greatest prevalence being at Acatlan, one of the
hottest places in the southern part of the province of Pue'ula. The
disease does not seem to be very common in Mexico, for in about
twenty years Gonzalez had only collected fifteen cases ; of these six
died, four recovered with more or less destruction of the nose, and
live were cured without any deformity. He points out that the most
troublesome symptom is the insomnia caused by the movements of
the worms at night. In the cases which had come under his notice
the nasal fossae, frontal sinuses, orbits, mouth, and sometimes the
muscles and the skin of the face, were attacked, and once the entire
face was destroyed. Gonzalez describes a case in which a young
man saw a fly buzzing round him,1 and tried to drive it away, but
did not succeed, and it flew into his right nostril with great force.
In the act of sneezing, which soon after occurred, the fly was
driven out. Formication in the nose immediately came on, together
with a little fever, and subsequently about a dozen large maggots
were expelled. Others could be seen moving about in the nose in
the midst of sanguinolent mucus. The patient suffered from sleep-
lessness, and epistaxis came on after many injections had been used.
Altogether one hundred and thirty-four maggots were expelled, in
addition to those which the patient sneezed out before he came under
treatment. He left the hospital cured on the 4th of September,
having been admitted on the 28th of the previous month. From this
it will be seen how rapid is the course of the disease in a favourable
case.

Before dismissing the descriptions by the French surgeons in
Mexico, it may be observed that none of them appear to have made
any special investigations respecting the natural history of the fly
which causes so much havoc. This subject is indeed only referred
to by Weber, who observes that he fully endorses the description of
the fly given by Coquerel.

Frantzius, a German physician practising in the nearly adjoining
region of Costa Rica, published some interesting remarks on the disease
now under consideration. He observed that sneezing was an early
and constant symptom, and attributed it to the tickling sensation
caused by the gliding movement of the larvse when they were seeking
a suitable nidus. Considerable swelling and slight redness of the face
were generally present, but the fetid, sero-sanguineous discharge from
the nose, which, according to this observer, only becomes purulent

1 Moquin-Tandon observes (op. eit. p. 225) that the gadfly can often be seen
hovering round a sheep, trying to enter its nose, whilst the sheep buries its
nose in the turf in order to prevent the insect getting in.

MAGGOTS IN THE XOSE. 453

after the expulsion of the larvae, was a distinctive feature. The larvae
showed a preference for the floor of the nose posteriorly, and hence
swelling of the soft palate was not unfrequently seen. In these cases
the voice had often a nasal tone. There was usually some fever
together with loss of appetite, and occasionally diarrhoea. Frantzius ,
considered that the frontal symptoms often noticed were not due to
the presence of worms in the sinuses, but to the extension of the
inflammatory process to the mucous membrane lining these cavities.
In one instance he removed ten maggots, in others from thirty to
fifty. In the only case that ended fatally a hundred were taken
away. The patient was an old woman, and Frantzius observes
that the presence of larvae in the nasal fossae is a very serious
condition when occurring in the aged and debilitated. The not
inconsiderable destruction of tissue, the incessant discharge, the
violent headache, the loss of sleep, and the constant fever, all tend
to undermine the vital powers. He recommends the insufflation
of calomel and powdered chalk (equal parts), and the removal of
larvae with forceps, pointing out that the fact of their being clustered
closely together facilitates this procedure. Frantzius does not
attach much importance to the various remedies which have been
recommended for these cases, and believes that many of the supposed
curative agents owe their apparent efficacy to the fact that when
they were used the maggots had attained their full duration of larval
life>

In addition to the older cases already briefly referred to at the
beginning of this historical sketch, four others have been recorded
in the present century, as occurring in Europe. Petrequin, whilst
making a tour in Italy, observed one in a hospital at Sienna.
A woman, who complained of an extremely painful red swelling
on the right cheek, and had some fever and slight delirium, passed
several small white maggots from the nose. Curious as it seems,
anthelmintic remedies were prescribed internally, and she was ordered
to use them also as an inhalation. In the course of eight days fifty-
eight maggots were expelled, and these subsequently developed into
lucilice.

Mankiewicz, a medical practitioner in Berlin, was induced to
publish the following case on reading Frantzius' article, of which an
abstract has been given : In a delicate boy, aged nine years, suffer-
ing from scrofulous ozaena, enormous quantities of maggots were
seen adhering to the septum, and it was found impossible to remove
them until they had been smeared over with a solution of balsam of
Peru. A complete cure was effected, though the boy lost the tip of
his nose.

Moquin-Tandon also records the two following cases : — In the first
the patient was a woman under the care of D' Astros of Aix (Pro-
vence). She had fallen asleep in a field, when it is supposed that a
fly deposited its eggs inside the nose. Soon after, slight pain came
on in the frontal sinuses, with a sensation of formication about the
root of the nose, and " a noise was heard by the patient and others
like that produced by worms gnawing wood." (!) After severe ejiis-
taxis one hundred and thirteen maggots were expelled. In the
second case, which occurred in a girl nine years of age, the patient

1 Frantzius seems to be under the mistaken impression that maggots arriving
at maturity <|Uit their previous habitat in order to form a cocoon. Their natural
history in this respect will be found explained under the head of " Etiology."

454 DISEASES OF THE THROAT AND NOSE.

suffered from intense headache and convulsions, but was cured liy
cigarettes of arseuite of soda.

The only case recorded from the United States is one lately
published by Prince,1 of Jacksonville, Illinois, in which a fly deposited
its ova within the nose of an Irish farmer who was suffering from
n/;i'!i;i. In a short time maggots were developed ; erysipelas and
iedcma of the nose and adjoining parts of the face supervened,
jind the patient could not breathe through his nostrils. Syring-
ing with water proved utterly ineffectual, and the larv;e \\cn-
gradually picked out with forceps. They were found to have
stripped bare a considerable portion of the bony framework of the
nose, and it is asserted that the ozaena was thereby completely cured.

1 "(Philadelphia) Medical News." Oct. 14, 1882, p. 445.

Etiology. — The disease is seldom met with out of tin-
tropics. Elevated situations, owing to their coolness, even
in hot climates, are free from this pest, the observations
of Gonzalez, already referred to, showing that, in Mexico
itself, the affection is not met with at a level higher than
1,200 metres above the sea. Only a very few cases have
been described as occurring in Europe. The disease is
undoubtedly caused by the hatching of eggs laid by a fly
(allied to our bluebottle and meat-fly) within the nose, or
close to its orifice. The natural situation for these insects
to deposit their eggs is in putrid meat, which affords proper
nutriment for the larvae when hatched ; but instinct some-
times goes astray, as is seen in the case of the bluebottle
fly, which occasionally deposits its eggs on the common
snake-root (A mm dracunculus), being deceived by the cada-
veric odour which that plant emits. It is by a similar
error of instinct that the fly of hot climates occasionally
deposits its ova within the nose. No doubt it is the fetid
discharge from the nose which attracts the insect, and it
is probably only by accident that eggs are deposited on a
healthy mucous membrane. It has already been pointed
out, that a great many morbid conditions of the nose are
included under the head of "Peenash." In fact, the word
corresponds to the vague term " ozaena," l as formerly em-
ployed in European medicine, the only difference being that
in " Peenash " maggots are sometimes present. The follow-
ing is the description of the Lucilia hommivora : — The fly
is nine millimetres in length, has tawny palps, and a
light tawny face, the cheeks being covered with golden-
yellow down. The head is large, wider in front than behind,

1 See p. 330.

MAGGOTS IX THE NOSE.

the thorax being dark blue, with black and yellow stripes,
and the abdomen of the same colour. The feet are black,
the wings transparent. The larva is dull white, fourteen or
fifteen millimetres long by three or four broad, and narrower
in front than behind. It is made up of eleven segments, the.

FIG. 87. — LUCILIA HOMINIVOUA.
a, the fly ; 6, larva ; c, a mandible ; d, magnified view of the insect's head.

widest part of the body corresponding with the sixth. The
head is indistinguishable from the first segment ; there are
no eyes ; the mouth is formed by a sort of lip, on which are
two small protuberances, at the base of which near the middle
line there are two corneous mandibles placed side by sido, the
mandibular booklets being very sharp and separated outside,
though closely united in the thickness of the tissues. On
each side of the first segment there is a brown corneous patch,
which covers the orifices of the upper stigmata. At the base
of each segment there is a projecting part, covered with small
spines, very numerous and close together.

Macgregor's account of the maggot corresponds closely with
Coquerel's, but the maggot described by Lahory is said to
have had eyes. As these organs are not found either in the
larva of Lncilia hfmiinivora or in that of Lucilia O.iwii1
(common bluebottle), Lahory's maggot must have belonged
to some other variety, or that observer must have made a
mistake. He also speaks of the maggots as being confined
within loose membranous cysts, whilst Ohdedar states that in
his case each maggot had a distinct nidus.

There are three kinds of European flies, all belonging to
the order of Mu&citlcK, which may deposit their ova within
the nose or near its entrance, viz.,' SarcopkttgcB, Cal I ij;/i <>/•//,
and Ltifilue. The Sarcophaga is black, its thorax, however,
being streaked with grey, and its abdomen chequered with
white. The insect has a small head, its antenna! bristle
being hairy, but naked at the tip. The female is viviparous,

456 DISEASES OF THE THROAT AND NOSE.

the larvae being hatched within the oviduct. The ovaries
often contain as many as 20,000 eggs. The larvae are foot-
less, white, fleshy, and narrower in front than at the posteri< >r
part. The CallipJiora, or Vomitoria, the common large meat-
fly, is too well known to require any description ; its larvae are
white, and obliquely truncated at the posterior extremity.
They have no feet, but have two fleshy horns on the head,
and two fleshy booklets in the mouth. The last segment
of the body is provided with eleven points, arranged like
rays.

The Lucilia is represented by the common bluebottle.

The larvae of Diptei'ce develop in seven or eight days in
Europe. In the Muscidw the larva changes into a pupa
within the larval skin, which contracts into a cylindrical
puparium, corresponding in use to the cocoon. The Hies
almost always deposit their eggs in the light and heat of day.

Symptoms. — After the deposit of the ova, the mucous
membrane soon becomes irritable, a constant tickling sensa-
tion is felt, and sneezing is a common symptom. In a
short time the tickling becomes very troublesome, and a
crawling feeling or formication is perceived. This is
mostly followed after a short time by a sanious bloody dis-
charge, and epistaxis often occurs. (Edema of the face,
and especially of the eyelids, is a characteristic symptom,
and swelling of the palate takes place in some cases.
Occasionally, but not very frequently, small tumours form
over the nose, which open and allow the larvae to escape.
Severe and constant pain is generally felt, especially at the
root of the nose and over the frontal region. The headache
is often of a throbbing character, and has been described both.
in India and Cayenne as resembling the sensation which
might be caused by repeated blows with a hammer or iron
bar. The pain in some cases never intermits, but gives rise
to the most distressing sleeplessness ; this is, indeed, some-
times so unbearable as to lead to suicide. Larvae are often
sneezed out, or can be seen in the nose crawling about in the
fetid mucus. When it is remembered that as many as from
two to three hundred maggots are sometimes ejected in a single
case, the injury and loss of substance which they can cause
will be readily appreciated.1 Not only is the mucous mem-
brane destroyed, but the cartilages and bones of the nose

1 Linnseus states that " three flies devour the body of a dead horse
as quickly as a lion." ("Syst. Nat." Ed. decima tertia. Lipsiae,
1788, t. i. pars v. p. 2,840. This extraordinary power of destruction

MAGGOTS IN THE NOSE. 457

and head become carious. Convulsions, followed by coma,
generally terminate the Me of the patient in fatal cases.

Diagnosis. — Although there are many symptoms which
might lead to a suspicion of myasis, it is only the actual
finding of maggots which can prove its existence.

Pathology. — The morbid changes produced by maggots
have already been described in dealing with the symptoms,
and it only remains to be remarked here that in cases which
have not been treated sufficiently early, not only the soft
tissues, but the ethmoid, sphenoid, and palate bones are often
destroyed by caries, and that the meninges are found after
death to be much inflamed. There is a section of a skull
in the Museum1 of the Medical College at Calcutta taken
from the body of a man who died of " Peenash," in which a
large number of maggots were found on the sphenoid and
ethmoid bones.

Prognosis. — This disease, if neglected, is probably always
dangerous in tropical climates. Its fatality, however, seems
to vary greatly in different countries, for whilst Lahory met
with only two fatal cases out of ninety -one patients, of six
patients seen by St. Pair three died. This discrepancy is
perhaps to be explained by many cases having been described
under the name of "Peenash," in which no maggots are
present — cases, in fact, in which there was syphilitic disease
of the nose or merely dry catarrh.

Treatment. — Dauzats's discovery of the highly beneficial
effects of chloroform will probably cause this remedy to
supersede all others. Inhalations of chloroform are often
sufficient to effect a cure ; but should the maggots resist
this mode of administration, the patient should be rendered
insensible by the vapour, and then equal parts of chloroform
and water should be injected; or should even this fail, pit re
chloroform may be syringed up the nose. The undiluted
chloroform does not appear to do any harm to the mucous
membrane, but it causes extreme pain when the patient is
not under an anaesthetic. The remedies formerly used, viz.,
injection of turpentine, infusion of tobacco and lemon-juice,
insufflations of calomel, the local application of Peruvian
balsam, though all to some extent efficacious, do not seem to
be at all comparable in their effects to chloroform. Consti-

is, of course, due to the rapidity with which the insect passes through
its successive stages of development, and to the great number of
eggs laid in each cycle when the condition of imago is reached.
'See " Indian Annals of Med. Sci." Oct. 1855.

458 DISEASES OF THE THROAT AND NOSE.

tutional treatment must not be neglected: opium should he
given to relieve the pain and induce sleep ; and if tin- myasis
is complicated by syphilis, iodide of potassium should IK-
administered. Stimulants and highly nutritious food are
required to sustain the \ital powers.

In the above article the severe nasal affections produced
by the larvae of Muscidce have been considered, and it is
only very rarely that other Dipterm deposit their ova within
the nose. There are a few cases, however, mostly reported
l>efore entomology was studied scientifically, in which the
larvae of the gadfly (CEatrus ovin) and of the leather-eater
(Dermesfaf) are suppose to have attacked the nose.1

The gadfly is a regular parasite of sheep and goats, in the
nostrils of which animals the insect constantly lays its eggs.
Moquin-Tandon denies that there is any instance on record
in which a human being has been attacked ; but the follow-
ing case, reported by Razoux,2 leaves no doubt as to the
occasional occurrence of the accident. A woman was seized
with burning fever, inflamed eyes, dry skin, and gradually
increasing headache in the frontal region. Tartar emetic
was prescribed, to produce vomiting, but with no beneficial
result. Attacks of sneezing, however, afterwards came on,
and the patient expelled from the nose seventy-two live
worms of the gadfly. Quite recently, Kirschmann3 lias
reported a case in which a peasant woman was attacked with
bleeding from the nose which lasted three days. The blood
came from the left nostril, and the corresponding side of the
face was enormously swollen. The haemorrhage was arrested
by injections of perchloride of iron, and this treatment was
followed by the expulsion of a mass of maggots of the
CEtstrm ovis. The patient made a good recovery. Two ca>es
are on record in which the maggots of the leather-eater
are said to have been found in the nose. One4 was that of
a young woman, who complained of great headache, which

' A case is recorded by Hope (quoted by Moquin-Tandon : " EU'in.
de Zoologie Medieale," p. 217) in which it is stated that death resulted
from the presence of a mealworm (Tenebrio molitor) in the nasal
fossae, but as this maggot is a vegetable feeder the case nmst In-
looked upon with doubt.

2 "Journal de Medecine " (Roux), tome ix. p. 353.

3 "\Vicn. nied. Wochenachrift" 1881, Dec. 3.

* Paulliui: "Ephein. Acad. Nat Curios." dec. ii. aim. v.
p. 63, obs. 101.

ENTOMOZOARIA IN THE NOSE. 459

was entirely relieved by the expulsion of five reddish-brown
hairy maggots. The other1 was that of a man who suffered
from excruciating headache, with epistaxis, which lasted three
days. After the passage of eighteen small hairy worms from
the nose all the symptoms disappeared.

EXTOMOZOARIA IN THE NOSE.

This subject belongs to the curiosities of medical literature,
rather than to the domain of practical therapeutics, but
amongst the entomozoaria which occasionally find lodgment
in the nasal passages may be mentioned leeches, ascarides,
centipedes, and earwigs.

In former times, when leeches were so largely used, it is
highly probable that these animals not unfrequently got up
the nose. Their size, however, would render them easily
visible, and they were no doubt quickly removed with forceps,
or expelled by means of injections. That they did occasion-
ally enter the nose is rendered more than probable by the
animated discussions which took place in the fifteenth and
sixteenth centuries, as to whether leeches could penetrate
from the nose into the brain. There are, however, only two
cases on record, so far as I have been able to discover, in
which it is actually stated that a leech lodged in the nose.
One is that of Lusitanus,2 in which it is said that a man
who suffered severely from headache, after every other
kind of treatment had failed, had a leech applied to the
anterior part of the nose. The animal accidentally crawled
into the nasal passages, and could not be removed, and two
days afterwards the man died. In the other case3 a student,
who had suffered for a long time from violent headache,
accompanied by epistaxis and sneezing, was relieved of his
troublesome complaint by the expulsion of a worm, which
closely resembled a leech.

Ascarides are occasionally found in the nose after death,4

1 Wohlfalirt : "Observ. de Vermibus per Nares excretis." Halre
Magcleburgicae, 1768, p. 3, et seq. The case is illustrated by some
good drawings.

2 " De Praxi Admiranda," lib. iii. obs. 61. Amst. 1641.

3 " Ephem. Acad. Nat. Curios." dec. ii. aim. i. obs. 99.

4 Troja ( " Rarissima observatio de magiio lumbrico in frontali
sinu reperto et totam ejus cavitatem replente," Napoli, 1771) found a
large asoaris occupying the entire cavity in one of the frontal sinuses
of a corpse, \\risberg (in Bluuienbach's " Prolusio auatomica de

460 DISEASES OF THE THROAT AND NOSE.

as indeed they are in the larynx and trachea, but in the latter
case there is no doubt that the worms creep up into the air-
passages from the intestinal canal immediately after the
death of the patient, and it is highly probable that tin-
same course of events has taken place when worms have
been observed in the nose. There are a few instances,
however, on record in which the worms were expelled
from the nose during life. Thus Benevenius1 describes the
case of a man who, suffering from delirium and convulsions,
appeared about to die, when he expelled a worm of about
five inches in length from the right nostril, and made a good
recovery. Forest,2 Lanzoni,3 Langelott,4 Tulpe,5 Fehr,6
l>ehr,7 Bruckmann,8 Albrecht,9, Habber,10 and Lange,11 have
also reported cases in which the Ascaris IwmMeoidft was
expelled from the nose.

Numerous instances are on record in which centipedes
have lodged in the nose or its adjacent sinuses for months
and even years, no less than ten such cases having been
collected by Tiedemann.12 Most of the patients suffered
from agonizing headaches, and some from vertigo and
trembling. A case occurred in the practice of Marechal, of
Metz,13 in which a centipede measuring six centimetres in
length was expelled from the nose. The patient was a
farmer's wife, who had suffered from formication in the
nostrils, and a copious discharge of mucus, often fetid
and mingled with blood, and from severe headaches, the
sensation being compared by the woman to repeated blows

sinibus frontalibus," Gottingae, 1779, p. 425) also found a similar
specimen. Deschamps ("Maladies des Fosses nasales," 1804, p. 307)
has also reported a case in which an Ascaris lumbricoides was found
in the antrnm after death.

1 ' Med. Obs. Exempl." Colonise, 1581.

' Obs. et Cur. Med." lib. xxvii. obs. 28. p. 351.

* ' Ephem. Acad. Nat. Curios." dec. iii. aim. ii. obs. 38.

4 Thomae Bartolini : " Epist. Med." Cent. ii. epist. 74, p. 640.

5 ' Observat. Med." lib. iv. cap. 12.

6 'Ephem. Acad. Nat. Curios." dec. iii, ann. iii. p. 261.

'Act. Physico-Med. Acad. Nat. Curios." t. iv. ohs. 30, p. 111.

8 'Commer. Noricum." t. ix. ann. 1739, art. i. p. 113.

9 'Act. Physico-Med. Acad. Nat. Curios." t. iv. obs. 51, p. 158.

10 "Haarlem Verhadl." Bd. x. Heft 2, p. 465.

11 Blumenbach's " Medizinische Bibliothek." Gottingen, 1788,
lid. iii. p. 154.

u "Wiirmer in den Geruchsorganen." Mannheim, 1844.

18 Moquin-Tandon, p. 217. See also Coquerel, loc. cit. p. 525. A
similar case will be found reported in the "Hist, de 1'Acad. des
Sciences." Paris, 1709, p. 42.

ANOSMIA. 46 1

with a hammer. She was also troubled with constant lachry-
mation and vomiting. The unfortunate patient often passed
into a state of extreme excitement, and the least noise caused
her great torture. There were periods of remission, but she
had five or six severe attacks every day, and several during
the night. One of them, however, lasted fifteen days without
ceasing. The centipede was expelled alive after a year, and
was pronounced to be a Scolopendron electricum.

Earwigs being only found in cool climates, and then only
in the autumn months when few people live out of doors,
seldom have an opportunity of finding their way into the
nose. The only case with which I am acquainted is that
of Sandifort,1 in which a woman very fond of smelling
strongly-scented flowers was suddenly attacked by great
pain in the forehead on the right side, whilst at the same
time a fetid discharge from the nose came on. After
inhaling hot steam she expelled a live earwig, when the
pain and discharge soon ceased.

The symptoms caused by the various entomozoaria usually
consist in sleeplessness, pain in the lower part of the fore-
head, sanious discharge from the nose, vomiting, lachrymation,
and in some cases great cerebral excitement. Sternutatories
generally effect a cure, and in one or two instances the
expulsion of the worm took place after spontaneous sneezing.
Occasionally, however, when these animals enter the frontal
sinus, it may be necessary to trephine the bone, and Morgagni2
reports a case in which Caesar Magatus performed this opera-
tion successfully.

ANOSMIA.

Latin Eq. — Odoratus perditus.
French Eq. — Perte de 1'odorat.
German Eq. — Verlust des Geruchsinns.
Italian Eq. — Perdita del odorato.

DEFINITION. — Loss or impairment of smell primarily
depemlent on disease of the olfactory nerves or lobes, or
of their cerebral centres.3

1 " Exercitatio Acad. Lugd. Bat." 1785. lib. ii. cap. xvii. p. 130.
" De forficula viva naribus excussa."

* "De sed. et cans, morborurn," lib. i. art. ix. Lugd. Batav.
1767, t. i. p. 12.

3 A remarkable case has been reported by Berard ("Journal de
Physiologic experiinentale et pathologique," 1825, t. v. p. 17, et

462 DISEASES OF THE THROAT AND NOSE.

History. — Several cases of anosmia, congenital and acquired, \\eiv
rolh-'-tcd bv Bonet,1 and in 1751 a thesis on loss of smell was
written by Bauer ; 2 whilst at the beginning of the pre^-nt century
Deschaiups3 recorded some curious instances of the affection. Tin-
whole subject was treated in great detail by Cloquet4 in 1821,
in a work specially devoted to the sense of smell. A very striking
instance of the destruction of the sense by too powerful stimula-
tion was reported by Graves8 in 1834, and soon afterwards ;i
case of congenital absence of the olfactory nerves, with eomplcte
anosmia, was published by Pressat.8 Some careful observations on
senile atrophy of the olfactory nerves were made by Provost7 in

' Sepulchretum." Genevte, 1700, t. i. p. 441, et seq.

' De odoratu abolito." Altorfli Noricorum, 1751. Sometimes quoted as the
work of Jantke, under whose presidency it was delivered.

' Maladies des Fosses nasales." Paris, an xii. [1804] p. 56.

1 Osphresiologie." Paris, 1821.

' Dublin Journ. of Med. Sci." 1834, No. 16.

1 Obs. d'un Cas d' Absence du Nerf Olfactif." These de Paris, Dec. 18, 1837.

' Gazette M<klicale." 1866, No. 37, p. 597, et seq.

seq.), in which it is asserted that in the case of a man whose sense
of smell had been perfect, there was nevertheless found after death
complete destruction, not only of the olfactory nerves, but also of
the olfactory lobes, of the pedicles which unite them to the surface
of the hemisphere in front of the Sylvian fissure, of the fissure
itself, and in short, thorough disorganization of the whole olfactory
region. The grounds on which it is maintained that the patient
retained his sense of smell are, first, that he was able to appre-
ciate the difference between various kinds of snuff: and, secondly,
that he was annoyed by the stench of an abscess from which
a patient in the next bed was suffering. This evidence, however,
appears to me to be inadequate ; the pleasurable sensation pro-
duced by snuff mainly depending on its stimulating effects on the
fifth nerve, the functional activity of which is apparently intensi-
fied when that of the olfactory nerve is abolished (see foot-note 1,
E. 467). It is more difficult to explain away the patient's dis-
ke of the stench from the abscess, but it is possible that lie
objected to his neighbour on other grounds than those of smell.
It appears tluit the sense of smell was never actiially tested </<//-i/t</
life, and this fact, to my mind, entirely destroys the value of the
observation. Desmoulins, in commenting on the above case, adds
(loc. cit. p. 17) an account of a patient who had lost his sense
of smell on- one side, although the olfactory nerves, lobes, pedicles.
and the adjacent parts of the brain were perfectly sound. On
the same side the ganglion of the fifth nerve had undergone de-
generation, the grey matter having been destroyed, and the nerve
filaments softened and altered. It is not stated what tests were
used in this case for ascertaining the condition of the patient's
sense of smell ; but, if ammonia or some other pungent vapour
was employed, as was commonly done at that time, the fallacy
of the experiment is obvious. Althaus has published a very n.n!-
plete and instructive case ("Med.-Chir. Trans." 1869, vol. Hi. p. -27,
et seq.), in which the mucous membrane of the nose was absolutely
insensible to the contact of blunt or even sharp instruments, and no
sneezing was brought on by snuff, yet the sense of smell was perfectly
normal, the patient having no difficulty whatever in recognizing the
different varieties of scents with which he was tested.

ANOSMIA. 463

1866 ; and an essay on various affections of the sense of smell, ami
the causes producing them, was written by Notta 1 in 1870. In the
same year an elaborate article on anosmia was published by William
Ogle.'-1 The subject has recently been treated of by Althatis.3

1 " Arch. (ten." 1870, t. i. p. 385, et seq.

2 "Med.-Chir. Trans." 1870, vol. liii. p. 263, et seq.

3 " Lancet." May 14 and 21, 1881.

Etiology. — Any disease or injury of the olfactory nerves,
tracts, or centres, is likely to interfere with the sense of smell,
but for the satisfactory discharge of the function it is neces-
sary that certain secondary conditions should be maintained.
Not only is the integrity of the fifth and seventh nerves
essential, but there must not be any mechanical obstruction
which prevents the odorous particles from reaching the
olfactory region, and the Schneiderian membrane must
possess its normal moisture of surface. Further, it is highly
probable that the presence of pigment in the cell-processes of
Schultze is a necessary condition of healthy olfaction.

Cases are on record in which the exposure of the olfactory
nerves to the prolonged action of an exceedingly disagreeable
smell appears to have been the cause of injury to the function
of this nerve, and it is not improbable that the mode of action
of the odour consists in over-stimulation, in the same way
that strong light sometimes produces amaurosis. A remarkable
case of this sort has been recorded by Bauer,1 in which a sur-
ge* m, who dissected a very putrid body, lost the sense of smell
for the rest of his life. Graves2 has reported an instance in
which, during the Irish rebellion of 1798, an officer had to
take charge of some soldiers who were engaged for many hours
searching for pikes supposed to have been concealed in a very
offensive sewer. Next day he perceived he had lost his smell.
It might be thought that scavengers would sometimes suffer in
a similar manner, but, from inquiries I have made, this does
not appear to be the case. The explanation probably lies in
the fact that when sewers are at all foul the workmen remain
in them only a very short time.3 The inhalation of strong
fumes of ammonia, or other irritant vapours, may likewise
affect the terminal twigs of the olfactory nerves in such a
way as seriously to impair their function. Snuff-taking some-
times acts in a similar manner.4 I have seen two cases in

1 Op. cit. p. 188.

2 "Dub. Journ." 1834. No. 16.

3 A superintendent of sewers, who had spent a large portion of his
life underground, once informed me that the sewers were generally
far sweeter than most private houses.

4 " Virchow's Archiv." 1868, Bd. xli. p. 290.

464 DISEASES OF THE THROAT AND NOSE.

which the use of the nasal douche has been followed by
permanent anosmia. Wendt1 refers to three cases within
his own knowledge in which the sense of smell was per-
manently destroyed by the local use of solution of alum.
Strieker'2 has reported a case in which the action of sulphuric
ether appeared to destroy the function of the olfact< >ry nerves,
.the patient having been an entomologist, who spent many
hours daily in preparing insects which he killed with that
vapour. Loss of smell sometimes follows frontal neuralgia, ;i
and a case was observed by Maurice Raynaud,4 in which
the loss of function was distinctly periodic, the patient
having been a woman, aged thirty-eight, who suffered from
anosmia every twenty-four hours from 4 p.m. one day to
10 a.m. the next. She rapidly recovered under the use
of quinine. This patient was not in the least degree hys-
terical, but had previously suffered from crural neuralgia,
which had also been cured by quinine. The most common
cause of anosmia is prolonged catarrh,6 few practitioners
having failed to meet with some examples. In these cases
the cell-processes of Schultze are probably destroyed by
cirrhotic shrinking of the inflammatory exudation. A
remarkable case has been recorded by J. P. Frank,6 but
without details, in which he affirms that "loss of smell
and taste occurred in a man from a deposit of rheumatic (?)
matter on the nose and tongue." Unless this was a case in
which a diphtheritic membrane was deposited, it is difficult
to understand its nature.

Owing to the extremely soft consistence of the olfactory
bulbs, they are occasionally separated from the brain by falls
on the head. Sometimes these accidents are accompanied by
concussion of the brain, and the anosmia is associated with
deafness, ringing in the ears, or even bleeding from one ear ;
in these latter cases there is probably a fracture of the base
of the skull, but in other instances temporary abolition of
consciousness and loss of smell are the only symptoms. Such
cases are by no means rare, and several have been described
by Xotta.7 One instance of this kind has come under my own

1 'Ziemssen's Cyclopaedia," vol. vii. p. 56.

2 'Virchow's Archiv." 1868, Bd. xli. p. 290.

3 Notta : " Archives Gen." 1870, vol. L p. 385, et seq.

4 'Union Medicale." July 10, 1879.

5 ' Ephem. Nat. Curios. " dec. iii. ann. iv. obs. 3.

8 ' De Curandis Hominum Morbis." Mannhemii, 1793, lib. v.
p. 132.
7 Loc. cit. See also a case " Ephem. Nat. Cur." ann. iv. obs. 3.

ANOSMIA. 465

notice, the patient having been a surgeon, who was thrown
from his gig with considerable force, and alighted on his head.
He was stunned for a few minutes, and the next day became
aware that he had lost his sense of smell. Although this
gentleman subsequently recovered his health completely, the
anosmia was permanent.

Long-continued paralysis of the fifth nerve interferes
with the proper nutrition of the mucous membrane, and
peripheral changes of a secondary character may then take
place in the olfactory nerves, and thus cause true anosmia.
In cases of paralysis of the seventh nerve (portio dura) the
patient is unable to smell, for two reasons — first, because
he is unable to sniff up the olfactory particles ; and, secondly,
because the orbicularis muscle of the eye being paralysed,
the conjunctival fluid overflows on to the cheek instead of
passing through the lachrymal duct, causing dryness of the
nasal mucous membrane, and so destroying the receptivity
of the olfactory nerve.

The influence of obstruction in interfering with the
function of smell is seen in the case of polypi and of
swelling of the mucous membrane of the nose. When the
obstruction, however, is due to nasal or naso-pharyngeal
growths, or to adhesions which block up the posterior
nasal openings, the patient can smell odorous substances
placed near the nostrils, though in eating he can no longer
appreciate flavours, and he therefore thinks he has lost his
sense of taste.

Moisture of the mucous membrane of the nose is as
essential to the sense of smell as that of the tongue is to
taste. The influence of the seventh pair of nerves in
indirectly causing dryness has already been pointed out, and
it is only necessary here to call attention to the arrest of
secretion in the first stage of nasal catarrh, which often
gives rise to temporary anosmia.

The presence of pigment in immediate contact with the
cell-processes of Schultze is probably essential to olfaction
in many animals, but, as far as I am aware, Hutchison's1
case is the only one on record which supports this view
as regards the human subject. The patient was a young
negro in Kentucky, whose parents were both black, and
who up to his twelfth year had the usual dark skin of an
African. At this period a white patch appeared near the
left eye, which in ten years extended all over the body, so

1 " Amer. Journ. Med. Sci." 1852, vol. xxiii. p. 146, et seq.

VOL. II. H H

466 DISEASES OF THE THROAT AND NOSE.

that had it not been for his woolly hair the young man
illicit have been taken for a very fair Knropean. When
he first began to change his colour, his sense of smell
was weakened, and by the time he had become white
olfaction was almost completely lost. This case was pass<-d
over as a mere medical curiosity until its importance was
recognized by William Ogle.1 Althaus2 has recorded tin-
case of a well-known statesman who is an Albim*, in whose
case smell had always been weak, and who lost this sense
entirely at the age of sixty-three. Althaus regarded the
case as one of "ultimate atrophy of a nerve which had
never been highly developed." It appears from the re-
searches of Ogle3 that the pigmentation of the olfactory
region is darkest in those animals which have the most
acute sense of smell, and that in the coloured races of men
this sense acquires a much greater degree of perfection
than in the "white man. He further points out that, it
has often been observed that white animals, owing to their
defective sense of smell, are more liable than those of
a dark colour to eat poisonous herbs.4 Thus, in some
parts of Virginia, white pigs are poisoned by the roots
of the Lachnanthes tinctoria; whilst in the Tarantino, the
inhabitants only rear black sheep, because the white ones
are poisoned by eating the abundant Hypericum crispum of
that region. It is stated also that the white rhinoceros
perishes from eating the Euphorbia carulKlabrtun, which the
dark rhinoceros refuses.

The sense of smell generally becomes impaired in the
decline of life — a change probably resulting from atrophic
degeneration of both the nerve centre and its periphery.

Defective olfaction is probably sometimes hereditary,5 and
cases of congenital deficiency of the sense of smell have been
recorded by Frankenau6 and Notta.7 It is not improbable
that in some of these instances the cause of anosmia was pro-
longed nasal catarrh in infancy ; but this explanation does
not always apply, for congenital deficiency of the olfactory
nerves has sometimes been observed (see Pathology).

1 "Med.-Chir. Trans." 1870, vol. liii. p. 276.
z "Lancet." 1881, vol. i. p. 813.

3 Loc. cit. p. 278, et seq.

4 Loc. fit pp. 281, 282.

6 Breschet : "Diet, des Sciences Medicales." 1819, vol. xxxvii.
p. 241.

6 " Ephem. Nat. Curios." dec. iii. ann. iv. obs. 3.

7 Loc. cit.

ANOSMIA. 467

In conclusion it must be admitted that there are some
cases of anosmia in which it is impossible to discover any
cause for the loss of function. Several instances of this
kind have been reported by Notta, under the term of anosmie
tttentidle.

Symptoms. — Taste is so closely associated with smell that
it is necessary to make a few observations on the subject of
these two senses.

The recognition of the bitter, sweet, salt, and acid cha-
racters of food by the tongue and fauces constitutes taste.
The appreciation of the savour of meat, the flavour of fruit,
and the bouquet of wine, depends entirely on smell. It is
necessary to call attention to these facts, because the mistake
is not unfrequently made by medical writers, of describing
cases as loss of taste, when it is clear from the context that
they mean loss of smell. But whilst taste is rarely impaired,
smell is often altogether lost, and the acuteness of the
sense varies very much in different people. It is generally
somewhat feeble in young children, attains its greatest vigour
in adult life, and, as already remarked, becomes dull in old
age. It is only when the sense of smell is completely lost
that the power of distinguishing flavours is destroyed ; people
who have no perception of odours diffused in the atmosphere
often retaining a keen relish for savoury food. Loss of smell
may be either unilateral or bilateral, and in the former case it
may be of import as indicating localized lesion of the brain,
or some disease in the upper part of one of the nasal channels.

It has been remarked that in cases of anosmia the
sensibility of the mucous membrane to irritants has some-
times become even more acute than it was whilst the
olfactory nerves were in a healthy condition.1

Pathology. — The pathology of anosmia is still very obscure,
though there are a number of scattered observations on the
subject. A remarkable case has been related by Bonet,2
in which a man who had suffered towards the end of his
life from headache, together with blindness and loss of
smell, was found after death to have an abscess involving
the olfactory bulbs. In a second case, recorded by the same
author, an abscess was found involving the olfactory • bulbs
and causing erosion of the frontal and ethmoid bones. The

1 See a case related by Deschamps ("Maladies des Fosses nasales,"
These de Paris, 1804, p. 56), in which a student who had totally lost his
sense of smell became, after a time, able to distinguish one kind of
snuff from another, simply from their different degrees of pungency.

2 "Sepulchretum." Genevse, 1700, lib. i. sec. xx. obs. 1, p. 441.

468 DISEASES OF THE THROAT AND NOSE.

patient was a man aged twenty-two, who, shortly before
death from convulsions, had suffered from headache, blind-
ih -s, and loss of smell. This was, no doubt, an example of
syphilitic disease of the bones. It is more difficult to explain
the pathological nature of the following case, which is also
reported by Bonet1: — "A 'stone,' flattened like a coin but
not so round, and of an ashy colour, was found at the base
of the brain, pressing on the sphenoid (.•>•/<•) and olfactory
nerves." The patient in whom this was observed had
been attacked with fever, accompanied by severe pain and
heaviness in the head, and had died nine days after the
commencement of the illness. I feel quite unable to make
any suggestion as to the nature of the " stone," but the case
seems worthy of mention as being the record of a fact by an
accurate observer.

As the olfactory nerve-tract can be traced to the island
of Reil,2 to a point not far from Broca's convolution, it
might be expected that in aphasic patients anosmia would be
often present. But although such cases have been reported
by Fletcher,3 Hughlings-Jackson,4 and Ogle,5 the association
of these symptoms does not appear to be common. The
statistics of Ball and Krishaber,6 indeed, tend to show that
disease of the left side of the brain does not frequently cause
anosmia, but that it is more common when the lesion is in
the right lobe. Thus, out of seventy-five cases in which
there was a tumour in the left side of the brain, there -was
not a single instance of anosmia, though aphasia was present
in seventeen. On the other hand, out of sixty-three cases of
tumour affecting the right side, in three of which aphasia
was a symptom, anosmia was observed in two. Further, out

1 Op. cit. obs. 4. p. 443.

2 The experiments of " Terrier (" Functions of the Brain," London,
1876, p. 184), tend to show that the olfactory centre is situated
at the tip of the temporo-sphenoidal lobe — the faradization of this
spot in animals being followed by a suit!', which is evidently the out-
ward expression of the excitation of the centre. Not only dors
destruction of this part seem to cause loss of smell, but it is observed
to be much developed in animals which have a keen sense of smell.
Injury of the external olfactory tract, which is lost in the island of
Reil, has been shown by Serres ( " Anat. Com p. du Cerveau," t. i.
p. 295), in nineteen post-mortem examinations of paralytic patients,
to be associated with loss of smell in a much more marked inaniu-r
than injury of the internal tract.

8 "Brit." M.>d. Journ." April, 1861.

4 "Lond. Hosp. Rep." vol. i. p. 10.

5 Loc. cit. p. 273, et seq.

6 "Diet. Encyclop. des Sci. Med." Paris, 1873, t. xiv. p. 456.

AXOSMIA. 469

of forty-seven cases of cerebral tumour, where the growth
was median or bilateral, or where the exact situation was not
stated, there were four cases of loss of smell ; but it is not
recorded that anosmia and aphasia coexisted. Although it is
evident, from the above statistics, that anosmia is sometimes
caused by the pressure of tumours in the brain, it is remark-
able that abscess in the cerebral substance very seldom
interferes with the function of the olfactory centre, for out
of eighty-nine cases of this affection collected by Ball and
Krishaber,1 in thirty-eight of which the left side of the brain
was affected, anosmia was not present in a single instance.
In connection with aphasia, it must not be forgotten that
anosmia, unless specially looked for, would be very likely
to escape notice. The fact that the loss of smell in these
cases is only unilateral would probably prevent the patient
noticing it, but even were it to be observed by him,
his limited powers of articulate expression would probably
prevent his calling attention to it. In connection with this
subject, it may be mentioned that Hughlings- Jackson2 has
shown that plugging of the anterior cerebral, or possibly of
the middle cerebral artery, sometimes gives rise to anosmia.

Prevost3 has reported fourteen cases in which he had
examined the olfactory nerves after death. In six of these
the sense of smell had not been tested during life, and no
conclusion, therefore, can be drawn from the observations.
In four others, in which it had been absent or deficient for
some time before death, there was found distinct degeneration
of the nerve-tissue of the olfactory bulbs. In the remaining
four cases, however, similar pathological changes were dis-
covered in the nerves, although the sense of smell had been
proved during life to be perfectly sound.

Congenital absence of the olfactory nerves has been ob-
served by Bonet,4 Rosenmiiller,5 and Pressat.6 In Pressat's
case, at the post-mortem examination of a patient who during
life never had any sense of smell, it was found that there
was complete absence of the olfactory nerves, and not even a
trace of the bulb or roots could be discovered. The brain in
the immediate neighbourhood was quite healthy, and no other

1 Op. cit.

2 "Loud. Hosp. Reports." 1864, vol. i. p. 410.
"Gaz. Med. Sept. 15, 1866, No. 37, -p. 597, et seq.

4 "Sepulchretuin." Genevae, 1700, lib. i. sect, xx. obs. 2.

5 " De Defectu Nervi Olfactorii. " Leipzig, 1817.

6 Op. cit.

470 DISEASES OP THE THROAT AND NOSE.

nerves were wanting. ( )n the left of the crista galli there was
a groove, but on the right side tliere was no trace of this.
The ethmoid did not present the usual perforations, there
lii-ing only a single small aperture on the left side near
the ethmoidal fissure, where the nasal branch of the fifth
nerve passed through. There was no alteration of any kind
affecting the pituitary membrane. The case related by IJonet
is somewhat analogous in character, and it possesses additions]
interest as being quoted from Schneider. In this instance
the patient was a young man who had suffered from con-
genital anosmia, and it was found after death that the
olfactory nerves did not send any branches to the pituitary
membrane. The same author records a second case,1 in
which, in the case of a man who had no smell, the olfactory
nerves were absent.

Diagnosis. — It is very important to differentiate the
various forms of anosmia. Mechanical obstructions can be
easily recognized with the help of the speculum and mirror,
and in most of the cases of a neurotic character there an-
associated symptoms which point to the real nature of the
affection. In all cases where the patient complains of im-
pairment of smell, the function should be tested by first
closing one nostril, and then the other, when it will at once
be ascertained whether the sense is destroyed on one side,
or blunted on both ; and it should be remembered that in loss
of smell dependent on injury to the seventh or fifth nerves
the affection is almost always unilateral.

In testing the smell the patient should not be allowed to
know what scent is presented to his nostrils, but at the same
time it is important that the test-odours should be familiar.
Oil of cinnamon, oil of peppermint, turpentine, valerian, or a
well used tobacco-pipe will be found to serve the purpose well.

Prognosis. — The prospect of restoration of function de-
pends, of course, on the nature of the lesion. Where there
is cerebral disease the sense of smell is seldom recovered.
Notta 2 has pointed out that, strange as at first sight it may
appear, in anosmia resulting from injury of the head the sense
of smell is more often restored when the associated lesions
have been severe — that is to say, when there has probably
been fracture of the base of the skull — than when the accident
has apparently been less violent. The explanation is to l>e
fo\md in the fact that anosmia following a comparatively
slight injury is likely to be due to separation from the brain
1 Op. cit. lib. i. sect. xx. obs. 3. 2 Loc. (it.

ANOSMIA. 471

of the olfactory bulbs, a condition which, of course, is
irreparable.

Where anosmia is dependent on catarrh, a favourable
prognosis may be given, but I have never known recovery to
take place in such cases where loss of smell has existed for
two years or more. Where, however, the loss of smell is
simply the result of mechanical interference with the con-
ditions necessary for the proper exercise of the function, as
in the case of polypi and other growths, the sense, in most
cases, will be restored when the obstruction is removed, even
after a lapse of many years. Bauer1 has reported a case which
came under his own notice, in which a man who had lost
his smell for fifteen years suddenly recovered it after a
voyage. The cause of the anosmia is not stated.

Treatment. — In true anosmia — that is to. say, in loss of
smell dependent on loss of nerve-power — no treatment has
hitherto proved of any avail. In cases of cerebral injury or
disease, or when the continuity of the nerve is interrupted,
it is obvious also that nothing can be done. Where the
function of the nerve is merely blunted, however, benefit
may be looked for from therapeutical measures. Beard and
Rockwell 2 have met with success from galvanism, applied
both inside and outside the nose ; but though I have
employed this treatment in favourable cases, such as loss
of smell after prolonged catarrh, I have never found it do
any good. Althaus 3 has found that a very powerful current
is required to stimulate the olfactory nerve, no less than
thirty-five plates being necessary to obtain any response.
This, by affecting the contiguous nerves, causes extreme
pain, dazzling flashes of light, a hissing noise like that of
a' steam-engine, together with faintness and giddiness — a
condition which is really worse than the original complaint.
Hence this treatment cannot be recommended. The insuffla-
tion of a powder containing one-twenty-fourth of a grain of
strychnia with two grains of starch, twice a day, will some-
times do good. If no effect is produced, the strychnia may
be increased to one-sixteenth or one-twelfth of a grain. This
remedy, which was originally recommended by Althaus,4 has
twice proved of service in my hands. Should the anosmia

1 "De Odoratu Abolito." Altorfii Noricorum, 1751, p. 192.

2 "Practical Treatise on the Med. and Surg. Uses of Electricity."
London, 1881, 3rd ed. pp. 646, 647.

3 "Lancet." 1881, vol. i. p. 772.

4 Ibid. p. 815.

472 DISEASES OF THE THROAT AND NOSE.

be intermittent, quinine should, of course, be given, as in t In-
case reported by Maurice Raynaud.1

PAROSMIA.

The subjective perception of a disagreeable odour is not
very uncommon. It is often a species of epileptic o//m, and
this doubtless results, as Althaus 2 remarks, in certain cases,
from disturbances in the olfactory centre, and subsequent
extension of the morbid impression to the motor centres.
Parosmia is often met with in lunatics, although in them,
as Schlaeger3 has pointed out, the apparent hallucination
often really depends on a lesion involving the olfactory
centre. A case reported by Lockemann 4 furnishes a good
illustration of this condition. The patient was a woman a-rd
fifty-five, who, after suffering from giddiness and epilepsy for
a year began to notice that immediately before a seizure she
experienced sensations of " indescribable " smells, which were
sometimes agreeable in character, and which ceased when the
fit was over. This symptom gradually disappeared in the
course of a few months, and, till the death of the patient
from coma two years later, nothing peculiar as regards the
sense of smell was observed. The autopsy revealed a caivi-
nomatous tumour about the size of a duck's egg in the left
cerebral lobe. This growth had destroyed 'every vestige
of the left olfactory tract. There can be no doubt that
towards the end of her life this patient suffered from uni-
lateral anosmia, although the symptoms escaped observation.
In a somewhat similar case related by Sander,5 a man aged
thirty-three was subject to epileptic fits, which were ushered
in by an excessively disagreeable smell. Symptoms of
insanity came on after a time, and before death the patient
became totally blind. The post-mortem examination showed
that a glioma of the size of an apple was situated on the
under surface of the left temporal lobe, extending into its
substance for a depth of two inches and a half. The growth
also reached the under part of the frontal lobe, and the
posterior part of the left olfactory tract was lost in it. It is
not clearly stated whether the parosmia occurred only in the

1 Loc. cit. 2 " Lancet." 1881, vol. i. p. 814.

3 "Zeitschr. d. Gesellschaft. d. Aerzte zu Wien." 1858, Nos. 19
and 20.

4 "Zeitschr. f. rat. Med." 1861, 3 Reihe, xii.

8 " Archiv f. Psychiatric. " 1873-74, Bd. iv. p. 234, et seq.

PAROSMIA. 473

first attacks, or whether it was a constant precursor, as in
Lockemann's patient above mentioned. A case was recorded
by Whytt,1 which has been often referred to by subsequent
writers. The subject was a boy aged ten, who, between attacks
of hystero- epilepsy, used to complain of a peculiar smell ;
but as the lad had at the same time a purulent discharge
from the nose, I do not think the case deserves the con-
sideration it has received. Westphal2 has reported a much
more pertinent example of parosmia, which occurred in a
syphilitic patient who suffered from convulsions. In this
instance, at the autopsy, the olfactory bulb was found
" adherent," and near it were seen two small gummata on
the pia mater. In the case of a lunatic, related by
Schlaeger, the patient had complained of disagreeable smells
for many years, and after death a fungous tumour of the
dura mater was found on the cribriform plate of the ethmoid.
A patient referred to by Hughlings- Jackson3 used to be
troubled with the smells as the epileptic fit was passing off.
Perversion of the sense of smell, however, is not uncom-
monly met with in persons in whom there is not the slightest
evidence of disease of the nervous centres. Sometimes the
disagreeable smell is constantly present, but in other instances
it is provoked by substances the odour of which is generally
considered to be agreeable, or at any rate indifferent. In a
patient recently under the care of Sir William Jenner and
myself the smell of cooked meat was so exactly like that
of stinking fish that scarcely any animal food could be taken.
The patient was a lady of about fifty years of age, in whom
the menstrual function still continued active. She was a
person of remarkable vigour, both of body and of mind, fond
of outdoor exercise, and never having shown the least sign of
hysteria. She was under treatment for several months. After
a time the digestion became upset, and the function of the liver
was somewhat disturbed ; but these symptoms appeared to
depend on the patient's inability to take proper food, and were
the result rather than the cause of the parosmia. Every kind
of local and constitutional treatment was tried. After some
months complete recovery took place, but I could not attribute
it in any way to the remedies.

1 ' ' Observations on the Nature, Causes, and Cure of those Disorders
which have been commonly called Nervous." Edinburgh, 1765,
p. 144, et seq.

2 "Allgem. Zeitschr. f. Psychiatric. " Bd. xx. p. 485.

3 "Lancet." Jan. 24, 1866.

474 DISEASES OF THE THROAT AND NOSE.

In persons otherwise perfectly healthy, permanent nlmor-
ni.-ilitii's in the sense of smell may sometimes be observed.
Thus a leading member of our profession has informed me
that violets always smell to him exactly like phoephonuy
ami I know nf another person to whom mignonette has the
odour of garlic. It is not improbable that an affection of
the olfactory sense, analogous to colour-blindness, may occa-
sionally exist.

Anomalies in the function of smell are probably sometimes
due to inflammatory changes in the olfactory nerve itself, or
to conditions corresponding to neuralgia in a nerve of com-
mon sensation. A very remarkable example was published
several years ago by Robertson,1 in which the patient, a
woman, aged fifty, a week after the removal of a cataract
from her right eye, began to suffer from inflammation
of the iris and choroid. This was followed by subjective
sensations of smell of the most disgusting nature, a symptom
which was at once relieved by a hypodermic injection of
morphia. An instance has been related by Althaus.-' in
which a patient, after exposure to cold, was startled by
perceiving a strong smell of phosphorus, which overpowered
all other accidental smells, and never left him for six weeks.
At the end of that time he noticed that he had become
insensible to odours of any kind, though the function of
the fifth nerve was still quite unimpaired. Symptoms of
locomotor ataxy gradually came on, and the patient died
eight years after the commencement of his illness. The
olfactory lobes showed the naked-eye appearances of neuritis,
but through an unfortunate accident they were not submitted
to microscopic examination.

No rules can be laid down for treatment, the great variety
of the diseased conditions giving rise to parosmia, making
it necessary to adopt different measures according to the
circumstances of the case.

DISEASE OF THE FIFTH NERVE, OR ITS
NASAL BRANCH KS.

When the fifth nerve or its nasal branches are injured or
diseased, the mucous membrane of the nasal fossae loses its
sensibility. Under such circumstances a pungent vapour,

1 " Boston Med. and Snrg. Journ." 1873, vol. Ixxxix. p. 280.

2 "Lancet." 1881, vol. I. p. 814.

CONGENITAL DEFORMITIES OF THE NOSE.

475

such as ammonia or ether, is not perceived, and does not
give rise to the reflex phenomenon of sneezing. On the other
hand, when these nerves are subjected to abnormal irritation,
excessive sneezing may take place. In ordinary catarrh
there is no doubt that irritation of the branches of the fifth
nerve occurs, and that the hyper-secretion taking place is
the effect of vaso-motor paralysis. A really typical example
of the affection, however, has been related by Althaus,1 in
which the complaint was purely neurotic in character.

The treatment of conditions, the cause of which is so
obscure, is not very hopeful. In the case of deficient
sensibility, however, some good may possibly be done by
frequent mild applications of the galvanic current directly
to the mucous membrane. The therapeutics of catarrh have
been already fully disciissed (p. 290, et seq.), whilst for
nervous sneezing, I can only suggest large doses of bromide
of potassium, combined in some cases with insufflations of
morphia.

1 "Med.-Chir. Trans." 1869, vol. lii. p. 27, et seq.

CONGENITAL DEFORMITIES OF THE NOSE.

Latin Eq. — Deformitates nasi ingenitse.
French Eq. — Vices de conformation du nez.
German Eq. — Missbildungen der Nase.
Italian Eq. — Vizi di confonnazione del naso.

DEFINITION. — Congenital deviation from the normal shape
of the nose, consisting in the absence or reduplication of the
whole organ, or any of its constituent parts, or in complete or
partial closure of its canals.

History.1 — The only case on record, so far as I am aware, of com-
plete absence of the nose, is one reported by Maisonneuve.2 The
patient was a girl, who, when first seen by that surgeon, at the age
of seven months, presented th« following anomaly : — The nose was
represented by a flat surface pierced only by two round holes, each
being scarcely one millimetre in diameter. These apertures were three
centimetres apart. It is not stated whether the internal structures of
the nose were normal, or whether there was any coexisting deformity
of any other part of the body.

The septum is sometimes altogether wanting. An instance of

1 In dealing with the history of the subject, the bibliography has not been
treated in the usual chronological method, but the few scattered cases on record
have been reproduced in the order in which they are referred to in the Definition.

2 " Bull. Gen. de Therapeutique." 1855, t. xlix. p. 559.

476 DISEASES OF THE THROAT AND NOSE.

complete absence of this partition in a stillborn foetus was
by Fernet1 in 1864. In this case the floor of the nose was also
partly deficient, the palate being cleft in its whole length. There
was besides double harelip, and the eyeballs and optir nerves were
absent. The posterior lobes of the brain were atrophied, and each
hand and foot had six digits. The septum occasionally presents a
deficiency of substance in one spot, so tnat the two nasiil tns.si cum-
in unicate through a congenital aperture ; cases of this kind have
been recorded by Portal," Hildebrandt,3 and Hyrtl,4 who states that
he has met with the abnormality three times in the course of his
"anatomical life." Zuckerkandl,8 however, who says that he found
a hole in the cartilaginous part of the septum eight times in one
hundred and fifty bodies, holds that the opening is not caused by
arrest of development, but is really a loss of substance due to previous
perichondritis.

A remarkable example of congenital deformity of the nose was
reported by Thomas,8 in 1873. The patient was a boy three months
old, born of healthy parents who had previously had several per-
fectly formed children. On the right side of the face there was a
triangular opening with somewhat rounded base, which corresponded
to the anterior orifice of the nasal fossa, the aj>ex reaching beyond
the inner angle of the eye almost to the upper border of the orbit.
The cavity of the right fossa was thus exposed as high as the
root of the nose. Tne opening was bounded externally by the
integuments of the cheek and eyelids, which were continuous with
the nasal mucous membrane, internally and above by the skin of the
nose, which also was continuous with the mucous membrane at
the edge of the cleft, whilst lower down the opening was bounded
on its inner side by the mucous membrane of the right ala nasi,
which was turned inwards and upwards. Through the fissure
could be seen the lower spongy bone, the upper and inner j>art
of which was adherent to the internal surface of the everted ala.
The right eye and orbit were normal, but the inner extremity of
the lower eyelid with the caruncula lachrymalis was half a centi-
metre lower in level than the corresponding part on the left side.
As the upper eyelid was normal in direction, there was thus a
gap between the right eyelids at the inner canthus of more than a
centimetre in width. This gap was bridged over by a strip of skin
about three millimetres wide, which separated the eye from the nasal
fissure. Along the middle line of the nose there was a raphe pro-
jecting to the extent of about one millimetre, which seemed to mark
the line of union of parts originally separate. There was no defor-
mity iu any other region of the body. In 1859 Hoppc7 reported
a case of congenital malformation of the nose, in which there was a
furrow along the middle line, the nasal bones being entirely absent.
Their place was occupied by two cylindrical pieces of cartilage, and

1 " Bull, de la Soc. Anat." 1864, 2e slrie, t. 9, p. 130.

2 " Cours d'Anat. Medicate." Paris, 1804, t. iv. p. 481.

3 " Lehrbuch der Anatomic dea Menschen." Wien, 1802, vol. iii. p. 162, § 1647,
foot-note. This writer, who was professor of anatomy at Gottingen, states that
he himself had a congenital hole in the cartilaginous part of his septum large
enough to admit a pea.

•* " Lehrbuch der Anatomic des Menschen." Wien, 1882, pp. 576, 577.

5 " Normale und pathol. Anatomic der Nasenhbhle." Wien, 1882, pp. 99, 100.

6 " Bull, de la Soc. de Chir." 1873, 3e s«$rie, t. 2, p. 162.

? " Med. Zeitung des Ver. f. Heilk. in Preussen." 1859, p. 164.

CONGENITAL DEFORMITIES OF THE NOSE. 477

a fissure existed along the middle of the nose from the root to the
tip, where there were two round knobs. The nostrils were well formed
and properly separated.

Quite recently, Lefferts 1 has described a case of double septum in
a man aged twenty-five. The upper half of the posterior edge of the
partition was divided in the vertical direction into two distinct
portions, which were separated widely enough to admit the end of
a lead pencil between them. The space thus enclosed was triangular
in shape, the widest part being above, and the mucous membrane
covering it had a natural appearance.

A case of double nose was related by Borelli,2 but without suffi-
cient anatomical details to establish the true character of the malfor-
mation. Although many of the cases reported by the earlier medical
writers are undoubtedly fabulous, still a positive statement of fact
by so celebrated a man is not to be too lightly dismissed. It is
obvious, however, that a vague expression like nasiis duplex might
refer to a lipomatous tumour or elephantiasis, as well as to a veritable
double organ.

Cases of congenital occlusion of the posterior nares have been
reported by Emmert,3 Luschka,4 Voltoliui,5 Betts,6 Cohen,7 and
Ronaldson.8 In Emmert's patient, a boy aged seven, there was
complete bony obstruction of both choanae. Luschka's case occurred
in a female child, and the openings were also closed by bone. Thin
osseous lamina; extended from the horizontal plate of the palate-bone
to the inferior surface of the sphenoid, to which they were united by
a dentated suture. In Voltolini's case only the right choana was
closed, the atresia being due to "congenital adhesions." Betts found
both posterior uares closed by bony partitions in a foetus seven months
old. In Cohen's case the nature of the occlusion is not stated, but
it was probably membranous. The example related by Ronaldson
occurred in a female child, born at full time and presenting no other
malformation, who died very soon after birth, from inability to
breathe through the nostrils. The posterior nares were found to be
completely occluded by a thick membrane of such firm texture that
a probe could hardly be forced through it.

Harrison Allen 9 has lately called attention to an occasional irregu-
larity in the relative size of the nasal fossae, caused not by deviation
of the septum, but in congenital narrowness of one chamber as com-
pared with the other.

1 ' Philadelphia Medical News." Jan. 7, 1882.

2 ' Obs. Rarior. Medico-Phys." cent. iii. obs. 43.

3 ' Lehrb. d. Chirurgie." Stuttgart, 1853, Bd. ii. p. 355.

4 ' Schlundkopf der Menschen." 1868, p. 27.

' Die Anwendung d. Galvanocaustik." Wien, 1870, 2nd ed. pp. 240-262.
« ' New York Med. Journ." July, 1877, p. 97.

7 ' Diseases of the Throat and Nasal Passages." New York, 1879, 2nd ed.
p. 385. To Cohen I am indebted for most of the references relating to this malfor-
mation.

8 ' Edin. lied. Journ." 1880-81, p. 1035 (May, 1881).

» ' Philadelphia Medical News." May 26, 1883, pp. 605, 606.

Etiology. — The causes of such anomalous formations &re pro-
bably the same as those which determine imperfect or abnormal
development of other organs. The principal theories on this
obscure subject have already been discussed in a previous
article (see " Malformations of the Gullet," p. 220, et seq.),

478 DISEASES OP THE THROAT AND NOSE.

and need not In- further referred to in this place. With regard
to the unequal capacity of the nasal chambers, Allen stairs
that he has observed it chiefly in idiots, and he surest s a
possible cause for it in the irregular depth of the depressions
in the base of the skull, owing to unequal development in
different parts of the brain. I may say, however, that in
none of the skulls in the Museum of the College of Surgeons
was I able to detect any inequality in the size of the nasal
fossae not dependent on the position of the septum.

Stjiiil>t<nm. — In the cases of deficiency of a portion of the
nose mentioned in the above short historical retrospect, no
symptom was noticed beyond the disfigurement arising from
the malformation. Where there is atresia of the posterior
nares, the child's breathing is difficult, and the serious troubles
attending obstruction ensue (see p. 293).

Prognosis. — None of the deformities described can be
said to threaten life except congenital closure of the pos-
terior nares, and that only in infancy.

Treatment. — Various plastic operations may be under-
taken for the correction of these deformities. Maisonneuve,
who claims that his case is the first instance on record of
rhinoplasty for congenital malformation, has given such an
incomplete description of the procedure which he adopted
that it is useless to reproduce it; and I can find no state-
ment of the ultimate result of the procedure, either as to the
appearance of the organ, or as to its functional utility.

In the case of fissure exposing one nasal fossa up to the root
of the nose, Thomas made an incision along the inner edge of
the cleft at the junction of the skin with the mucous membrane.
He then dissected \ip the skin, beginning at the narrow strip
between the eyelids, which, moreover, he detached by a cross-
cut from its union with the upper eyelid. The outer edge
of the fissure was then pared, and an incision was carried
vertically up the brow from the apex of the fissure. From
the upper end of this cut another was carried horizontally
towards the other side for about one centimetre, the object
being to loosen the integuments on the brow. The ala was
next separated from the inferior turbinated bone, to which it
was adherent. The integuments of the nose having been
dissected up towards the middle line, the parts were made
sufficiently movable to enable the operator to bring the ala
over into contact with the outer edge of the fissure without
using undue violence. The surfaces thus brought into apposi-
tion were fixed together by a pin passed through the upper

CONGENITAL DEFORMITIES OF THE NOSE. 479

lip and the ala, whilst a suture held the cheek and the inner
edge of the fissure in position. The narrow strip of skin
between the eyelids, which had been separated from the
upper eyelid, was then drawn up with forceps, and inserted
between the edges of the vertical incision previously de-
scribed, being fastened to its new connections by sutures
on each side. Finally, the upper angle of the original fissure
was closed by a suture passed through its borders just under
the lower eyelid. The sutures were removed in four days,
when it was found that the ala was firmly united to the
outer edge of the nostril, but there was no union at the
upper part, a circumstance which Thomas attributed to the
somewhat rough usage which the small transplanted flap had
received in the course of the dissection necessary to loosen
it. In a fortnight the lower part of the nose was almost
normal in appearance, but the lower eyelid was still too
widely apart from its fellow at the inner canthus, and a
fissure from two to three millimetres in width remained
between the inner angle of the right eye and the nose. The
patient was then unfortunately lost sight of, and nothing
seems to be known as to the ultimate result of the case ;
but, as Thomas remarks, a decided improvement in appear-
ance had so far been achieved, and a subsequent operation
for the purpose of remedying the remaining defects would
have been much less difficult and severe.

In cases of congenital occlusion of the posterior nares,
treatment is imperatively called for, and no time should be
lost in carrying it out. A passage must be forced through
the obstructing membrane with a strong probe, as in
Ronaldson's case, or with the galvanic cautery, as was
done by Voltolini, and the opening should be gradually
dilated and kept open by the passage of bougies. Trache-
otomy is advised by Ronaldson, but this measure would only
be justifiable as a last resource.

Congenital deficiency of the olfactory bulbs has already
been described under the head of Anosmia (p. 469).

SYNECHLE OF THE NASAL FOSSAE.

Under this term Zuckerkandl l has described , certain
anomalous conditions which may be briefly referred to here.
As the name implies, these consist of connecting bands of
tissue between particular portions of the interior of the

1 " Anatomie der Nasenhohle." Wein, 1882, p. 95, et seq.

480 DISEASES OF THE THROAT AND

nose whicli arc normally separate. The junction is
times made merely by continuity of the investing mem-
brane, and sometimes by true bony union. Four chief
varieties of " synechia " appear to occur: (1) meiiibramni.-
bridges spanning the interval between two opposite surfaces —
r.'/., between the middle turbinated body and the septum :
(2) broad membranous junctions between the mucous cover-
ing of one of the turbinated bodies and that of the outer
wall of the nasal fossa, or between the corresponding angles
of neighlxni ring turbinated bodies; (3) oxxr^/x bridges con-
necting one of the turbinated bones with the septum ; (4)
wide bony union between the edge of the lower turbinated
bone and the floor of the nose. It must be understood that
all these varieties or any number of them may coexist, ami
that any one of them may be found in several places. In
one case Zuckerkandl found synechiae between the lower
turbinated body and the floor of the nose, between the
middle turbinated body and the septum, and again between
the same body and the outer wall. In 2,152 skulls examined
in the Museum of the College of Surgeons I met with but
four instances of bony synechia. In one, the lower tur-
binated bone was greatly enlarged and adhered to the
septum. In a second, in which the septum was deviate.!
to the left, two thick osseous bands, not connected together,
ran across from the convexity of the deflected part to join
the lower turbinated bone and the portion of the outer wall
above it. In a third case, in which there was no septal
deviation, there were two bony plates bridging over the
space between the left side of the septum and the corre-
sponding outer wall ; one was narrow and ran horizontally
across from the middle of the septum to the upper part of
the lower turbinated bone, whilst the other crossed from the
lower edge of the middle turbinated bone to join the septum
by an attachment one-third of an inch in width, and sloping
slightly upwards from behind forwards along the septum.
In the fourth instance the edge of the vomer projected some-
what into the right nasal fossa and from the lower edge of
the ridge thus formed an osteo-cartilaginous plate extended
horizontally across to the under edge of the lower turbi-
nated bone ; this plate ran backwards in the nasal fossa
for about an inch, and converted the inferior meatus into a
covered way.

I have also recently seen a patient in whose case a lirm
membranous band, covered with mucous membrane, passed

CONGENITAL DEFORMITIES OF THE NOSE.

481

across the cavity of the right nasal fossa from the lower
turbinated bone to the septum.

Synechise are occasionally symmetrical, being present in
both nasal fossae in corresponding situations. It is probable
that the condition is nearly always congenital, though it is,
of course, possible that it may in certain cases be due to
morbid outgrowths followed by ulceration and subsequent
adhesion of adjacent parts. This latter view ts, perhaps,
somewhat confirmed by the fact that synechise have been
found associated with perforation of the septum.

The condition is in most cases little more than a patho-
logical curiosity. In the example referred to above, which
came under my own notice, the patient experienced great
difficulty in blowing his nose on the affected side. Should
treatment seem, desirable, any abnormal piece of bone may
be removed by dividing both its attachments with my nasal
bone-forceps (Fig. 55, p. 268) ; or, in the membranous cases,
a cure may be effected by means of the galvano-caustic loop.
Even osseous bands, when slender, may be got rid of by
this method ; a case having been reported by Brandeis1 in
which a transverse bony synechia, that caused obstruction of
the nasal canal, was removed with the electric cautery.

1 " New York Med. Record." Nov. 12.-1881.

VOL. II.

I I

482 DISEASES OF THE THROAT AND NOSE.

SECTION VI. -DISEASES OF THE NASO-PHARYNX

THE anatomy of the naso-pharynx has already been
in the first volume of this work, whilst the instruments
required for the examination ami treatment of this part
have been described tinder " Nasal Instruments." It only
remains, therefore, to consider the few but very important
diseases which occur in the post-nasal region.

CHRONIC1 CATARRH OF THE NASO-PHAKYNX.

(SYNONYMS : POST-NASAL CATARRH. RETRO-NASAL CATARRH.
FoLLicuLAR DISEASE OF THE NASO-PHARYNGEAL SPACE.
AMERICAN CATARRH.2)

Latin Eq. — Catarrhus longus pharyngis nasalis.
French Eq. — Catarrhe chronique du pharynx nasal.
German Eq. — Chronischer Catarrh des Nasenrachenraumes.
Italian Eq. — Catarro cronico della faringe nasale.

DEFINITION. — Clironic inflammation of the lining mem-
brane of the naso-pharynx, giving rise to a more or lefts vin>-i'(
secretion, the adhesion of which to the part causes a most dis-
agreodble sensation, and induces the patient to make freqwnt
'•forts to gat rid of it by " hawking " and " clearing the
throat."

History. — The disease was first described by J. P. Frank3 as a
form of chronic catarrh the seat of which is the pharynx. Many
years later a detailed account of the affection was given by Dobell.4
The complaint has been familiar to all those who study throat -di^<

1 As acute catarrh of the naso-pharynx either rapidly disappears or passes intu
the chronic form of the disease, it has not been, thought necessary to treat it
separately.

- The complaint is so extraordinarily prevalent in America as compared with
any other country, that it may be regarded with all propriety as a national
ancction.

3 " De Curand. Homin. Morbis." Lib. v. parsi. pp. 124, 125. Maiinlieniii, 1704.

•i "Winter Cough." London, 18«6, 1st ed. appendix, p. 172, et seq. Dr.
Uohi-ll states that he had already called the attention of the profession to the
subject of "post-nasal catarrh" in a pajmr read before the Abernethian Society
of St. Bartholomew's Hospital in 1864.

CHRONIC CATARRH OF THE NASO-PHARYNX. 483

from the time of the invention of the laryngoscope ; and since I com-
menced teaching at the Throat Hospital, in 1863, I have constantly
called the attention of students to the various features of this important
malady. In 1874 Wendt l described both the moist and the dry forms
of the affection in considerable detail. Lennox Browne2 in 1878 gave
a description of the disease in connection with nasal catarrh and
ozaena. Two years later, Beverley Robinson* of New York, published
a work on catarrh, in which, under the title of " Follicular Disease
of the Naso-pharyngeal Space," he gave a very complete account of
the complaint. Since then the disorder has been incidentally referred
to by Woakes,4 Rumbold,5 Bosworth,6 and by every writer on nasal
catarrh. The latest contributor to the literature of the subject is
Bresgen,7 who has recently brought together the views of nearly
all preceding writers on this matter.

1 ' Ziemssen's Handbuch." Leipzig, 1874, Bd. vii. erste Halfte.
1 The Throat and its Diseases." London, 1878, p. 153, et seq.
' Practical Treatise on Nasal Catarrh." New York, 1880. p. 117, et seq.

•» 'Deafness, Giddiness, and Noises in the Head." London, 1880, 2nd ed.
p. 178, et seq.

5 ' Hygiene and Treatment of Catarrh." St. Louis, 1881, part ii. p. 237, et seq.

« 'Manual of Diseases of the Throat and Nose." New Y'ork, 1881, p. 179,
et seq.

7 "Der chronische Nasen- und Rachen-Katarrh." Wien und Leipzig, 18S3,
p. 41, et seq.

Etiology. — The causes of catarrh in general have been
frequently discussed in this work, but for my views on the
subject, I would refer especially to the remarks made in
connection with acute catarrh of the larynx (Vol. i. p. 265).
The affection is exceedingly common in America ; indeed
so much is this the case that the term " catarrh," as com-
monly used in America, means post-nasal catarrh — i.e.,
catarrh of the naso-pharynx. It is possible that a review
of the conditions under which post-nasal catarrh exists in
America may throw some light on the etiology of the
complaint. Unfortunately, however, up to the present,
American physicians, though assiduously studying the thera-
peutics of the disease, have given little attention to its causes.
Indeed, the only practitioner who appears to have seriously
investigated this subject is Beverley Robinson,1 who in a
thoughtful and suggestive work, remarks : —

" In New York, Boston, and Philadelphia, in many of
our western cities, on the sea shore, and in the interior, in
fact, over widely extended and very different sections of our
country, post-nasal catarrh prevails to an extent which
originates much inquiry, and occasions more than passing
anxiety to those who have observed its course. Vast

1 "Nasal Catarrh." New York, 1880. See the article on
' Follicular Disease of the Naso-pharyngeal Space (Post-nasal
Catarrh)."

1 > 1 DISEASES OF THE THROAT AND NOSE.

numbers of people are already affected with it. Men,
women, and children are alike its prey. All ages and pro-
fessions are subjected to its symptoms and complications.
.Moderate differences or changes of climate only partially
affect its growth; for while in individual instances its on-
ward and rapidly progressive march appears to be somewhat
delayed, if not completely arrested, by breathing a high,
ei I uable, and dry atmosphere, or by the respiration of air
impregnated with balsamic odours, other and numerous
examples there are when once the catarrhal affection has
become firmly seated, but little influenced for the better by
the most rational hygiene and an ambient medium seemingly
the most perfectly adapted to their individual needs.
I'sually speaking, however, a cold damp atmosphere, subject
to sudden and great changes of temperature, is supposed to
be a general and efficient, if not exclusive, cause of the
production and extension of post-nasal catarrh. No doubt
this accepted belief has some basis in fact; and yet the more
closely I have been able to investigate the subject, in its
multiple aspects, the more thoroughly am I persuaded that
the received opinion is in part erroneous. The development
of the malady is not much affected by habit or occupations,
and strong and weak organizations are similarly attacked.
No constitution is entirely exempt, but certain persons are
more disposed to contract it than others."

Though I would not for a moment place my experience of
American catarrh on a level with that of any of the eminent
specialists who have given attention to the subject in the
United States, I may remark that in a recent tour through
that country I had a very favourable opportunity of studying
the complaint. For I not only saw examples of the disease
over a very wide tract of country, but also observed the
atmospheric conditions under which these cases occurred,
enjoying, moreover, the great advantage, in many localities, of
discussing the subject and hearing the views of able physi-
eians who had been studying the disorder on the spot for many
years. I was greatly astonished at the extremely wide diffu-
sion of the affection. I met with it all over the Eastern States,
it was very common in Chicago and St. Louis, which may now
be called the central cities of America, I found it prevalent
in Nebraska and to a slighter extent in Utah, and again 1
encountered it on the Pacific coast, finding it of frequent
occurrence in San Francisco. I had not the opportunity of
seeing any patients in Nevada, as I merely travelled through

CHRONIC CATARRH OF THE NASO-PHARYXX. 485

that State without stopping; but in London I have treated
many American travellers for post-nasal catarrh who had
acquired the disease on the alkaline plains of the Silver State.
I also saw a good many patients suffering from catarrh of the
naso-pharynx in Colorado. In Southern California and Ari-
zona I scarcely met with any cases, and in Canada the affection,
though much more common than in Europe, did not seem to
be so universal as in the States. American catarrh, it would
seem, principally prevails between latitudes 44 and 38.

My travels in America were made in the latter end of
August and in September and October — that is, during the
most favourable season of the year ; and I have little
doubt that had I been there in the winter I should have
seen a great deal more of this wide-spread ailment, hi
many of the regions referred to there are local conditions
which tend to irritate the mucous membrane. Thus, all
along the eastern seaboard the atmosphere during the
winter months is cold and moist, whilst in the summer
it is excessively hot. In San Francisco fogs prevail in
the summer in the early part of the day, whilst in the
afternoon a cutting wind blows continuously. In Colorado,
on the other hand, the climate is so extraordinarily dry
that only those who have been there can thoroughly ap-
preciate it. The inhabited portion of the country consists
of extensive plains situated at an elevation of 5,000 or
6,000 feet above the level of the sea. The dryness of the
climate may be gathered from the fact that not a drop
of rain falls during nine months of the year, the result being
that no trees can flourish, the scrub oak being almost the
sole representative1 of our forest trees, and this being only
found in the narrow valleys or canons, as they are called.
Indeed, so dry is the soil that not unfrequeiitly all the
prairie grass perishes. The atmospheric conditions, though
admirably suited for some forms of consumption, are never-
theless extremely irritating to the mucous membrane of
many persons. The white alkaline dust which covers
hundreds of miles in Nevada is also met with here and then-
in Colorado. In the winter and spring the winds are often
rather strong, and it will easily be imagined that at such
times the abundant dust of this extraordinarily diy country
is very irritating.

1 The cotton tree, though indigenous in certain parts of South
America, appears to be an exotic in Colorado, and I only saw it as
an ornamental tree in the streets and gardens of some of the cities.

486 DISEASES OF THE THROAT AND NO8E.

The soil of the American continent varies so widely in
different parts that it is impossible to suppose that it is con-
cerned in the etiology of the affection. Again it will be
readily understood that the meteorological conditions over
this vast area are so various that they cannot l»c regarded
as a cause acting with anything like uniformity. The general
character of the atmosphere of the American continent, a-;
compared with that of Great Britain, and also with mo>t
parts of Europe, is that it is drier, that the changes of tem-
perature are more sudden, and the extremes of heat and cold
much greater. There is nothing, however, in these conditions
to account for the localization of the complaint in the naso-
pharynx, and it would seem that post-nasal catarrh is not due
to what may he strictly called climatic influence, but to some-
thing which is accidentally introduced into the atmosphere
of widely differing localities; in other words, that there must
l»o irritant particles floating in the air over very wide areas.
This is actually the case, for dust is to be found everywhere
in America.

The universal prevalence of catarrh is indeed fully ex-
plained by the abundance of dust, both in the country and
the cities. Owing to the immense size of the country, and
its sparse rural population, the country roads have not, as a
rule, been properly made, and except in some of the oli lei-
States are merely the original prairie tracks. In the citi"<,
notwithstanding the magnificence of the public buildings,
the splendour of many of the private houses, and the beauty
of the parks, the pavement is generally worse than it is in
the most neglected cities of Europe, such, indeed, as are only
to l)e found in Spain or Turkey. It must be recollected also
that whilst in the decayed towns of the Old World there is
very little movement, in the American cities there is a cea>e
less activity and an abundance of traffic. Hence, the dust is
-et in motion in the one case, but not in the other. The
eharacter of the dust, of course, varies greatly according to
locality. lu some parts it is a fine sand, in others an alkaline
powder, whilst in the cities it is made up of every conceivable
abomination, among which, however, decomposing animal
and vegetable matters are not the least irritating elements.
An idea may, perhaps, be formed of the state of the atmo-
sphere from a consideration of the fact that in many cities
the functions of the scavenger arc quite unknown.

That a dusty atmosphere is the real cause of post-nasal
catarrh is rendered probable by a consideration of the

CHRONIC CATARRH OF THE NASO-PHARYNX. 487

anatomical relations of the nasopharynx. For owing to its
being a cul-de-sac out of the direct line of the respiratory
tract, particles of foreign matter which become accidentally
lodged in its upper part are got rid of with difficulty — most
likely by an increased secretion, which, as in the case of the
conjunctiva, washes away any gritty substance which may
temporarily alight on the membrane. In the larynx, irri-
tating dust is dislodged by coughing, which may be either
reflex or voluntary ; and again in the case of the nasal
passages, the minute particles of matter which constitute
dust are expelled, if they happen to be obnoxious, either
by sneezing or blowing the nose. But reflex acts, such as
coughing and sneezing, have no effect on the upper part of
the naso-pharynx, and it is only by a voluntary effort, known
as " hawking," that this cavity can be partially cleared.
It is probable also that owing to the sensibility of the naso-
pharyngeal mucous membrane being less acute than that of
either the nose or the larynx, minute foreign bodies acci-
dentally lodged in the vault of the pharynx do not cause an
amount of discomfort at all corresponding to that in the
adjacent parts ; hence particles of matter are more likely to
remain in situ for a long time in the post-nasal region, than
in either of the other parts, and are, of course, very apt to set
up disease. In this country the complaint is most common
in persons whose pharynx is large in the antero-posterior
direction, a form of throat which facilitates the entrance,
without favouring the expulsion, of foreign particles. It
will be readily understood that any morbid state of the
posterior nares may lead to chronic inflammation, and thereby
establish a catarrhal condition of the naso-pharyngeal region.
In young subjects, adenoid growths are often a source of
irritation. In such cases, however, the discharge which is set
up does not tend to become adherent, as in true post-nasal
catarrh, but flows away with comparatively little inconveni-
ence. In fact, the catarrhal affection is altogether different
from the idiopathic post-nasal catarrh which is met with in
its typical form in America.

Whilst, however, it is highly probable that dust is the
most frequent cause of post-nasal catarrh, no doubt it is not
the only one. Many circumstances favour its development.
Thus I have noticed that in many cases the sufferers have
been persons who partake largely of pungent condiments,
and the habit (almost universal in America) of taking sauces
iind pickles with every dish may be concerned in the prodiic-

1SS DISEASES OF THE THROAT AXD XOSE.

tion of the disease. The national dyspepsia is also probably
a most powerful factor, and a well-known American states-
man tells me that he has known many cases cured by
"abstemiousness and farinaceous diet." Some physicians
have attributed the complaint to the custom of over-heating
houses by hot air and steam, as is commonly done in America.
In the winter the temperature is never allowed to fall
Ijelow 70° Fahr., and is generally much higher. The sud-
den passage from this temperature to that of the street is
not unlikely often to set up catarrh ; but as the same mode
of heating is used in Russia without, as far as I am aware,
giving rise to any post-nasal affection, its influence cannot be
very great. The importance of heredity in the etiology of
catarrh lias been recently strongly insisted on by Bresgen,1 and
although no extensive series of exact observations has yet
been made on this point, there is every probability that a
disposition to catarrh may be inherited. I have seen so
many instances, however, in which foreigners making a short
stay in America have become affected with post-nasal catarrh,
that I think there can be little doubt that atmospheric con-
ditions— and those, let me add, of an accidental and control-
lable character — are much more powerful than heredity.

It is supposed by some that catarrh is contagious, but
though the popular belief is strong on this point, there is
very little scientific evidence in its favour. On this sub-
ject Beverley Robinson2 asks — " How is it that a disease
which is so prevalent in many sections of our country is
certainly less known and familiar in England and on the
Continent? Certainly, if the extensive propagation of this
affection is merely a direct consequence of intimate contact
there would be just the same probabilities of the increase
there as here." It is somewhat remarkable, that at the
present time, when germs are supposed to give rise to so
many diseases, post-nasal catarrh has not been referred to
this source, to which it may be remarked coryza has been
attributed. Failing to discover any atmospheric cause for
American catarrh, Beverley Robinson3 suggests that " a
special constitutional tendency exists in the individual." He
observes that " post-nasal catarrh must not be confounded, as
it almost universally is, with ordinary rhinitis. It is not
simply an acute or chronic inflammatory condition of the
pituitary membrane, nor should it, therefore, be treated in
the same way ; for if it is, signal failure almost will follow
1 Op. eit. p. 41. * Op. cit. 3 Op. cit. p. 145.

CHRONIC CATARRH OF THE NASO-PHARYXX. 489

our every effort. An acute or chronic coryza is, without
doubt, a predisposing and at times a proximate and partially
efficient cause of its becoming manifest. But in order to
effect the grafting of post-nasal catarrh, a certain diathetic
condition is essential." He proposes to call this diathesis
" catarrhal," and appears to think that there is some relation
between it and the herpetic disposition. In putting forward
an hypothesis which has no facts to support it, Robinson
appears to have adopted the fallacies of the French School
(see Vol. i. p. 29, note 6). I entirely agree with him, how-
ever, that catarrh of the naso-pharynx very frequently com-
mences in coryza ; and, notwithstanding his views as to the
" catarrhal diathesis," it would appear that he does not
attempt to circumscribe the diathesis too closely, for in
referring to this complaint he observes that, " while folli-
cular disease is at times due to the catarrhal diathesis pure
and simple, so it may be and frequently is attached to the
gouty, herpetic, syphilitic, scrofulous, and tubercular. The
malarial influence may likewise be evident "

Lennox Browne1 considers that the diathesis of patients
suffering from catarrh of the naso-pharynx is " generally of a
scrofulous character." Seeing, however, that the complaint
is so very common in America, that it affects people of every
temperament and constitution, and that it is readily acquired
by visitors to the United States, it more probably depends on
atmospheric conditions than on any diathesis.

Symptoms. — In slight cases the patient is troubled with
a disagreeable sensation, as of something sticking in the
upper part of the throat, which has to be frequently cleared
away from the back of the nose. Distinctness in articu-
lation is often interfered with. There is, in fact, a want of
resonance or definition, more especially in the pronuncia-
tion of gutturals. This may be so slight as to be inappreci-
able by any one but the patient himself, who, if he is
an educated person, and one who has to employ his
voice in public, is almost sure to complain of it. When
the disease is more severe the mucus is often extremely
tenacious, and the patient has then to make the most
violent and frequent efforts to " hawk " it from the naso-
pharynx, a proceeding which is as disagreeable to the
patient as it is disgusting to those about him. The effort
to get rid of the mucus is often accompanied by nausea,
and in some cases by actual sickness. A very unpleasant
1 "The Throat and its Diseases." London, 1878, p. 463.

li'O DISEASES OK THE THROAT AND NOSE.

sensation is constantly felt at the back of the throat,
and in severe cases the patient experiences a dull aching
feeling in the upper part of the throat, and occa-
sionally weight or pain is complained of in the occipital
region. On looking into the naso-pharynx moist yellowish
white masses of mucus aie seen adhering to the posterior wall
and sides of the cavity. Post-nasal catarrh is often the cause
of throat-deafness, and in some cases it gives rise to slight
haemorrhage, which occasionally stains the patient's pillow,
or occurs when he wakes in the morning; the source of
the blood is apt to puzzle physicians who do not examine
the naso-pharynx. The mucous membrane, after it has
been cleansed with a spray or syringe, generally looks
very red, but if a short time, say fifteen or twenty
minutes, is allowed to elapse, much of the congestion,
which is evidently due to the cleansing process, disappear*.
Raised rod granulations can then be seen on the posterior
wall and sides of the naso-pharynx. Sometimes they are
small, oval or round in form, but, not unfrequently, those
situated on the sides of the naso-pharynx are long and
narrow, often from five millimetres to a centimetre and a
half in length, and from three to five millimetres in width,
but only slightly raised above the surface. In severe cases
small erosions may be seen here and there, and occa-
sionally ecchymotic spots. In young subjects adenoid
growths are sometimes present, or there may be simple en-
largement of Luschka's tonsil. Congestion and swelling of
the Eustachian orifices are often apparent, and now and then
one or both of the openings are completely blocked up by
adherent mucus. The oro-pharynx will generally be found
more or less congested, and presenting in places a granular
appearance. Varicose veins are also often visible on tin-
posterior wall, whilst the pillars of the fauces are infiltrated
or thickened.

1'athnhnjii. — The morbid changes which take place in the
naso-pharyngeal region have not hitherto been studied on
the dead subject, but no doubt they are identical with those
which usually occur in catarrhal inflammations. As far as
can be seen during life, the morbid process seems to be the
same as has been described under the head of " Hypertrophic
Granular Pharyngitis " (Vol. i. pp. 32, 33).

DiayHoxix. — Post-nasal catarrh is occasionally altogether
overlooked by medical practitioners who are unacquainted
with the affection, but those who have studied rhinoscopy

CHRONIC CATARRH OF THE NASO-PHARYNX. 491

are unlikely to make any mistake. "When the patient is a
young subject, catarrh of the naso-pharynx will sometimes
be found to be due to adenoid growths ; but, as already
pointed out, the secretion differs altogether from that of
true post-nasal catarrh. These formations, moreover, can
generally be easily felt with the finger, and seen with the
mirror. The possible presence of polypi should be borne
in mind. Syphilis, likewise, both in its secondary and
tertiary manifestations, may cause symptoms analogous
to catarrh. If the naso-pharynx is well cleansed, however,
condylomata or ulcers, if present, can usually be seen. In
cases of tertiary disease, the administration of iodide of
potassium will soon set the question of diagnosis at rest.

Prognosis. — The disease is not dangerous, but it is often a
lasting inconvenience, and if it has existed for several years
before it comes under observation, it is seldom cured ; in
recent cases, however, the complaint may occasionally be
completely eradicated, and old-standing cases can, as a rule,
be kept under control by judicious treatment.

Treatment. — This may be constitutional or local, or may
combine both systems. Those who believe in the cliathetic
origin of the complaint naturally recommend internal reme-
dies. IJeverley Robinson x has found benefit from sulphur,
cubebs, and ammoniacum ; the sulphur may be given in the
form of Harrogate waters ; cubebs may be administered in a
tincture with an equal part of tincture of orange to cover
the taste ; and ammoniacum may be prescribed in very small
doses — one, two, or three grains — combined with ipecac-
uanha. Other writers have recommended cod-liver oil and
phosphate of iron. Of course, in any case in which there
is marked debility, tonics are likely to do good. In my
experience, however, little benefit is, as a rule, derived
from general remedies, whilst local treatment affords much
relief. The first thing to do is to completely remove all the
mucus from the naso-pharynx, or, in other words, to cleanse
the parts thoroughly. If this can be accomplished by the
use of sprays, it is the most advantageous method for the
patient ; but both anterior and posterior sprays are likely to
be required. One of the best solutions is that introduced
by Dobell (see Appendix), but if the carbolic acid is objec-
tionable or irritating, the " compound alkaline wash " (see
Appendix) maybe substituted. If the secretion cannot be re-
moved by spraying, the post-nasal syringe must be used ; and
1 Op. cit. p. 146.

492 DISEASES OF THE THROAT AND NOSE.

if this again does not succeed, a medium-cued lamina! brush
should be employed After the mucus has been got rid of. I
have found most benefit from astringent insufflations. ( )f
these, pale catechu, persulphate of iron (one part to three of
starch), and eucalyptus are the most etti< -acinus : but tin-
eucalyptus (one part of the gum to two of starch) is the
preparation that I most rely on. The patient can often
cleanse the naso-pharynx with a hand-wash ->r nasal douche,
and may be taught to insufflate the powder himself.

In those fortunate cases in which great benefit has re-
sulted from these measures, a complete cure may sometimes
be effected by winding up the treatment with a course of
Mont-Dore or Bourboule waters.

The diet should always be non-irritating, strong drinks
and pungent food being carefully avoided. Lennox Browne1
thinks that "it is advisable to restrict the amount of fluid
food to a minimum." I have no experience of this method
of treatment, and do not see how it could have much effect
on a complaint of so chronic a type as the one under con-
sideration. In all cases the use of tobacco should be given
up, particularly the smoking through the nose which is the
practice of those who indulge in cigarettes.

Persons who show a predisposition to post-nasal catarrh
should take special precautions against it. Travellers in
dusty places — especially if the dust is of an alkaline cha-
racter— should wear Gottstein's tampons (Fig. 73, p. 2S2)
in the nose, and should also make use of respirators or keep
the mouth constantly shut. Irksome as these measures may
be, they are less troublesome than the annoying complaint
against which they are meant to guard.

DRY CATARRH OF THE XASO-PHARYXX.

This disease closely resembles dry catarrh of the nose ;
and to the article on that subject (p. 324, et seq.) the
reader must be referred for a detailed description of
the etiology and pathology of the disease. Like dry
catarrh of the nose, it very frequently leads to ozaena.
It is probably in most cases a sequel of moist catarrh,
but sometimes it appears to be dry from the <-om-
mcncement. As in the case of moist catarrh of the naso-

1 Op. cit. p. 164.

DRY CATARRH OF THE NASOPHARYNX.

493

pharynx, it is most common in persons who have a somewhat
roomy pharynx. On looking into the throat, the buccal
pharynx may be simply dry and shiny, but on examining
the naso-pharynx flakes of dried mucus of a dark-brown or
black colour are often seen. It is characteristic, however, of
this form of catarrh for the objective symptoms to be very
slight. When the complaint has reached the stage of ozsena
a disagreeable smell is noticed in the breath, and every few
days a round or oval mass, from two to three centimetres in
length, and from one to two centimetres in width, is ex-
pelled. These lumps of inspissated secretion are generally
of a dirty-white or green colour, but they may be brown, or
even black ; they are of somewhat dense consistence, moist
externally, but dry and very compact towards the centre.
Sometimes on section they show a sort of concentric arrange-
ment, as if they were made of successive deposits. Their
probable mode of detachment has already been explained
in dealing with the nasal form of the complaint. Occasion-
ally, by digital examination, one of these lumps can be felt
in the naso-pharynx, occupying a corner of .the vault on one
side of the median raphe, or even extending right across it.
The disease is frequently associated with a similar condition
of the nose, but in some cases it is limited to the post-nasal
region. On cleansing the mucous membrane it generally
presents, after a short interval of time, a pale and atrophied
appearance.

The remarks which have been made on the diagnosis and
pathology of dry catarrh of the nose (see p. 332, et seq.) are
applicable to the naso-pharyngeal region. Dry catarrh of the
naso-pharynx is extremely obstinate, and the prognoeie, as
regards cure, is very unfavourable.

The treatment must be carried out in the way recommended
for moist catarrh, but disinfectants are even more necessary.
Dobell's solution, which has been already mentioned (p. 491),
is one of the best sprays, but if continued for any length
of time the proportion of carbolic acid should be reduced by
one-half. The Nebula Alkalina of the Throat Hospital
Pharmacopoeia will also be found very serviceable.

494 DISEASES OF THE THROAT AND N

ADENOID VEGETATIONS OF THE NASO-
PHARYNX.

Latin Eq. — Tumores glandulosi pharyngis nasalis.
French Eq. — Tumeurs adenoides du pharynx nasal.
German Eq. — Adenoide Vegetationen des Nasenrachen-

raumes.
Italian Eq. — Tumori adenoidi della faringe nasale.

DEFINITION. — Minute glandular vegetations groirim/ fi-«ni
the vault and sides of tlie naxo-pJtarynx, causing the >••
to be dull and nasal in tone, the respiration to be burr at,
frequently inducing deafness by setting up inflammation »f
the middle ear, and in the case of children often ,'//'•/»</
rise to the const itutional pJtenomena which follow prolon<j»l
na*al obstruction.

History. — In the year 1860 Czermak1 observed two small tumours
at the upper part of the naso-pharynx on the left side, close to the
opening of the Eustachian tube, one portion of which somewhat
resembled a "cock's comb." These were probably the first adenoid
growths ever seen. Five years later Voltolini* reported the case
of a man, aged forty-one, who had come under his care t\v<>
years previously, on account of extreme deafness. Under various
treatment the patient's hearing had greatly improved ; but in the
summer of 1865 Voltolini, on making a rhinoscopic examination,
perceived "stalactite-like growths projecting into the free cavity
of the naso-pharynx." These tumours having been destroyed in
three sittings, by means of electric cautery, further improve-
ment took place in the hearing. In the same year Lowenberg3
published three cases in which he had found vegetations in the
naso-pharyugeal region of patients suffering from deafness, which,
he pointed out, were probably identical in their nature with the
hypertrophied mucous glands characterizing granular pharyngitis.

i " Der Kehlkopfspiegel and seine Verweithung fur Physiologic und Medizin."
Leipzig, 1860. Soon after, Semeleder reported some cases of growths in the
vault of the pharynx, but they seem to have been rather of the nature of fibrous
polypi than adenoid vegetations (" Die Rhinoscopie," &c. Leipzig, 1&62, p. 46,
et seq.).

• " Al'gem. Wien. med. Zeitung," Xo. 83, 1865. In the previous year
Andrew Clark published a short article on " Xasopalatine Gland Disease "
(" Lond. Hosp. Reports," vol. i. p. 211), which, I have no doubt, was the same
disease as that subsequently described by Meyer under the name of "Adenoid
Vegetations." Clark remarked that this disorder can be " demonstrated
<mly by rhinoscopic examination," but an otherwise accurate description of
adenoid vegetations is marred by the statement that "fetid cheesy masses" are
sometimes contained in the cavities of the glands. It is probable, therefore,
that Clark's cases were complicated by the "exudative form of follicular
pharyngitis." (See Vol. i. p. 33 of this work.)

' " Archiv fur Ohrenheilkunde," 1865, Bd. ii. p. 116. et seq. These
Archives are published in parts, vol. ii. covering the years 1865, 1866, and 1867,
hut Lb'wenberg's article appeared in 1865. As, however, the whole volume
bean the date 1867, it has been erroneously supposed that Lowenberg's article
was not issued till that year. In his recent work Lowenberg calls attention
to these facts, which, on investigation, I have found admit of no dispute.

ADENOID VEGETATIONS OF THE NASO-PHARYNX. 495

In 1868 Wilhelm Meyer,1 of Copenhagen, for the first time gave
a complete picture of glandular disease in the naso-phaiyngeal
legion, under the name of "Adenoid Vegetations." Whilst fully
describing the symptoms and progress of the affection, he detailed
the microscopic appearance of the growths, and pointed out a mode
of surgical treatment which he had found highly effectual. Meyer
had already at that time examined 2,000 children in the National
Schools of Copenhagen, and had met with the affection in 1 per cent
of the cases examined. Indeed, he may be justly considered the
discoverer of adenoid vegetations in the vault of the pharynx ; for
although not the first to observe these growths, he certainly first
realized their importance, and fully described them. Subsequent
workers have done little but confirm Meyer's observations. A
short paper on adenoid tumours was presented to the International
Medical Congress at Brussels, in 1875, by Guye,2 of Amsterdam ;
and in the following year the subject was still further elucidated
by Carl Michel,3 of Cologne. A short note was published in
1879 by Victor Lange,4 of Copenhagen, in which he suggested a
modification of Meyer's method of operation ; and in the same
year an excellent account of the disease was given by Solis
Cohen5 in the second edition of his valuable work. Lowenberg,6
moreover, returned to the subject in 1879, when he published a
very complete monograph on the disease. Special mention may also
be made of a paper by Tauber,7 of Cincinnati, who found '6 per cent,
of adenoid growths amongst his cases of nasal and pharyngeal disease.
Adenoid vegetations were made the subject of public discussion at the
International Medical Congress, held in London, in 1881, when most
of the above-mentioned writers gave the result of their increased
experience ; and Capart, of Brussels, who has been very successful in
his treatment of these growths, exhibited several hundred specimens
— or, to speak more correctly, several large bottles filled with vegeta-
tions. On the same occasion, Woakes8 read a paper founded on the
observation of one hundred cases, and, in opposition to the usual
opinion that they are of adenoid structure, maintained that these
growths are mainly papillomatous in texture.

1 "Hospitals Tidende." Nov. 4 and 11, 1868; also "Trans. Med.-Chir. Soc."
London, 1870, vol. liii. p. 191, et seq.

2 International Med. Congress, Brussels, 1875.

3 " Krankheiten der Nasenhohle und des Naseurachenraumes," 1876, p. 77,
et seq.

•* ' Note sur leg Tumeurs ad^noides." Copenhague, Aout, 1879.

' Diseases of the Throat and Nose." New York, 1879, 2nd ed. p. 253, et seq.
• ' Tumeurs ad6noides du Pharynx nasal." Paris, 1879.

7 ' Cincinnati Lancet and Clinic," April 24, 1880.

8 'Trans. Intern. Med. Congress." London, 1881, vol. iii. p. 291, et seq. See
also this author's work on Deafness, Giddiness, etc. London, 1880, p. 32.

Etiology. — The disease is more commonly observed in
the young than in adults. The great abundance in the
naso-pharynx of children of lymph-follicles, some of them
solitary, and others united to form the tonsil of Luschka
(Vol. i. pp. 1, 2), explains the frequent occurrence of allied
morbid growths in early life. That lymphoid tissue is also
easily excited to active growth in young subjects is seen in
the case of the tonsils and cervical glands, and it is highly

496 DISEASES OP THE THROAT AND NOSE.

probable that very slight catarrh of the naso-pharynx often
1« -HI Is to the excessive development of the tissue in question.
It must not, however, be forgotten that vegetations which in
children would cause marked symptoms, might product- but
little inconvenience in the larger naso-pharynx of the adult,
and hence that they may be easily overlooked in the lat in-
case. Sex has no influence : out of one hundred and two
cases observed by Meyer,1 fifty-two belonged to the male
and fifty to the female sex ; whilst Woakes2 found the com-
plaint almost equally prevalent in the two sexes. In eighty-
two cases3 seen by myself, forty-seven were females and
thirty-five males. Between the ages of five and ten then-
wen; fifty-one ; between ten and fifteen, twenty-seven ;
IK -tween fifteen and twenty, two ; and at the ages of twenty-
four and twenty-seven, one. Dr. Felix Semon has furnished
me with a table of fifty-six cases observed by himself, in
fifty-three of which the patients were under twenty years
of age. Dr. Semon, however, thought that in all the cases
the disease commenced in the first decade of life. Golding
Bird4 has recently reported two cases in which the first
symptoms of the complaint showed themselves after the
age of forty. The number of observations hitherto collected,
however, with reference to age and sex is at present too
limited to furnish any trustworthy conclusion ; and it may
be remarked that for statistics as to age to be of any value
etiologically, it would be necessary to ascertain when the
growths first commenced.

It is likely that the acute exanthema, and whooping-cough
which so frequently gives rise to a catarrhs! condition of
the lining membrane of the throat, may have some influence
in producing adenoid growths.5 It has been suggested
that those who inherit a scrofulous constitution are more
liable to the development of the disease than others,
but in connection with this point I may remark that
my experience is quite in accordance with that of Meyer,
for I have noticed that children suffering from adenoid
vegetations seldom show any other marked sign of strum a,
such as enlarged cervical glands, ophthalmia tarsi, or
otitis. In some of the cases published by Lowenberg*

1 Loc. cit. p. 208. 2 Loc. cit.

3 These were all observed before the end of 1879. Since then I
havt- of course seen a great many additional cases.

4 "Guy's Hosp. Reports," 1881, 3rd series, vol. xxv. pp. 441-413.,
8 See Vol. i. p. 301. e Op. cit p. 12.

ADENOID VEGETATIONS OF THE NASO-PHARYNX. 497

heredity appears to have had a marked influence, but here
again the statistics are too limited, and, moreover, attention
has been directed to the subject too recently for satisfactory
observations to have been collected. In the next generation
this point will be more easily determined. A cold moist
climate has probably a considerable influence in the produc-
tion of the disease, which is much more prevalent in the
north than in the south of Europe.

Meyer1 points out that in three out of four cases of cleft
palate which came under his notice, these growths were
present, and he attributes this to the direct irritation to
which the mucous membrane is subjected from food and
cold air. Oakley Coles,2 who has had an exceptionally
large experience in connection with cleft palate, has noticed
the extremely frequent association of adenoid vegetations
witli this deformity. I do not know what the cause of the
occurrence of these growths may be in these cases, but I
may add that I have scarcely ever met with an example of
cleft palate without finding a profusion of adenoid growths
in the naso-pharyngeal region.

'Symptoms. — In infants the first symptom to attract
attention is, as a rule, "hard" breathing or snoring during
sleep, sometimes even such attacks of dyspnoea as have been
described under the head of " Acute Coryza in Infants " (p.
293). In older children it is the dull voice and deafness which
generally claim our notice. It will mostly be found that
symptoms of chronic catarrh of the nose and naso-pharynx
exist; and on looking into the throat, a yellowish-green
secretion may be seen trickling down the back wall of the
pharynx. In the morning, the child's pillow is occasionally
found stained with dark mucus, and sometimes with a little
blood, which has dribbled from the mouth during sleep. In
rare cases, indeed, the patient expels a small quantity of
pure blood. The constantly open mouth and a certain stupid
expression of countenance are, in the absence of enlargement
of the tonsils, characteristic symptoms of post-nasal growths.
David3 has recently gone so far as to assert that these form-
ations reveal themselves externally by a modification of the

1 Loc. cit. p. 209.

2"Proc. Royal Med.-Chir. Soc. of London," Nov. 23, 1869;
" Brit. Med. Journ." 1869, vol. ii. p. 619. See also Coles's work :
"Deformities of the Mouth." London, 1881, 3rd ed. p. 51,
et sen..

:t " Ri>vu(> Mensuelle de Laryngologie, &c." 1883, No. 12, pp.
380, 381.

VOL. II. K K

4'JS DISEASES OP THE THHOAT AND NOSE.

physiognomy, which consists essentially in a deformity of the
upper ja\v, with projection of the incisor teeth and narn >\ving
of the ]»alatine arch. He holds that the patient being only
able to breathe through the mouth in such cases tin- palate
(>till in course of development and comparative! \
subjected to constant pressure on its buccal surfa. e. and
thereby pushed unduly upwards. This, however, is evi-
dently an erroneous explanation of an irregular mode of
development well known to dentists.1 The deformity of the
ehest which has been described (Vol. i. pp. 63, 64) as occa-
sionally associated with chronic enlargement of the tonsils, is
not unfrequently present when post-nasal vegetations Mock
up the naso-pharynx. Xoisy respiration whilst the child is

Fie. 88. — VEGETATIONS OVEKSHAKOWIXI; LEFI KrviA< HIAX

APEKTVKR.

awake, and, as already observed, snoring during sleep, an-
also common symptoms of the affection. When the child is
old enough to talk, it not only speaks "through its nose.
the term is popularly employed, but, in addition to this,
the voice is muffled, or as Meyer terms it, " dead." In adults,
this is sometimes the only symptom of the complaint, the
other troubles having disappeared with the enlargement of
the naso-pharynx. In cases of long standing, deafness often
results from mechanical closure by the growths of the Kusta-
chian orifice, a condition well exemplified by a case which I
recently treated with Sir "William Jenner and Dr. (Unison,
of Witham (see Fig. 88). The hearing may also become
impaired in consequence of the vegetations causing catarrh
of the tube or even of the middle ear. (See "Tliroat-
deafness.")

On making a rhinoscopic examination, the growths can

1 See Oakley Coles : Op. cit. p. 86, et seq.

ADENOID VEGETATIONS OF THE NASO-PHARYNX.

499

often be seen partly covering the posterior nares. They are
generally of a pale colour, but are sometimes pink, and
even bright red ; as a rule, they are rounded in form,
and vary in size from a hemp-seed to a currant, but are
occasionally much larger, and often occur in clusters. In
some cases they hang down from the roof of the phaiynx
(Fig. 89) like stalactites, and, more rarely still, they are flat,

Fm. 89. — ADENOID GROWTHS IN THE VAULT OF THE PHARYNX.
(FROM A YOUNG WOMAN.)

like the granulations often seen on the posterior wall of the
pharynx ; sometimes a broad pad-like growth will stretch
almost across the naso-pharynx. The vegetations are most

FIG. 90. — ADENOID GROWTHS IN A CHILD.

abundant on the vault and upper part of the posterior wall
of the naso-pharynx, but they are not unfrequently grouped
round the Eustachian orifices. Occasionally they cover the
entire mucous membrane of the posterior nares, but the
septum is seldom attacked. Owing to the difficulties which
have been already described (see " Khinoscopy," p. 247, et
seq.), it is not always possible, especially in young children,
to make a rhinoscopic examination, but by passing the index
linger behind the uvula the growths can generally be easily
felt, when they are found to be smooth, soft, and yielding

500 DISEASES OF THE THROAT AND NoSK.

to the touch, and prone to bleed. When they are abundant,
as was first pointed out by Meyer,1 they give a sensation very
much like a bunch of earthworms. Not (infrequently, how-
ever, separate vegetations can be felt.

Diagnosis. — The morbid conditions with which adenoid
growths may be confounded are : chronic catarrh, general
hypertrophy of the mucous membrane alxmt the posterior
nares, jwlypus, and post-pharyngeal abscess. It is vi-ry
unlikely that the merest tyro would confound fibrous or
bony tumours or exostoses from the walls of the naso-
pharynx with the complaint now under consideration.
The condition of the mucous membrane of the nares can
usually be ascertained by anterior rhinoscopy, and hence
catarrh and thickening can generally be readily eliminated.
In cases, however, where these conditions coexist with
adenoid growths, the diagnosis can only be made by direct
observation, or digital examination. Those who are inex-
perienced in rhinoscopy should look for the upper arches of
the posterior nares, for if their sharp outline is obscured
by any tissue hanging down over them, this is exceedingly
likely to be of adenoid nature. This is the plan which
Dr. Felix Semon informs me he is in the habit of recom-
mending to his class, and it appears to me to be an exceed-
ingly good one. Polypi are extremely rare before the age
of sixteen, and retro-pharyngeal abscess, though often in-
sidious, is accompanied with pain and difficulty in swallow-
ing, and the symptoms come on much more rapidly than
those caused by adenoid growths. The abscess, moreover,
in most cases comes into view, or, at any rate, can be felt
with the finger, and there is usually some tenderness on
pressure. Fibrous tumours of the naso-pharynx rarely com-
mence before the age of fifteen, and it is only in their very
earliest period that they can be confounded with adenoid
growths, for, as a rule, they grow rapidly, and soon cause
so much displacement of the surrounding tissues that their
nature cannot be mistaken. Osseous tumours are seldom,
if ever, met with except in adults, and, when large enough
to give rise to obstruction, generally cause pain and haemor-
rhage. Digital examination also at once enables the prac-
titioner to recognize their nature.

Notwithstanding the number of diseases with which it is
possible that adenoid vegetations might be confounded, yet,
taking into consideration the age of the patient and the
1 Loc. cit. p. 193.

ADENOID VEGETATIONS OF THE NASO-PHABYNX.

501

marked symptoms caused by the growths, there is practically
very little likelihood of a mistake occurring.

Pathology. — Microscopic examination of these naso-
pharyngeal growths shows 'that they consist of cylindrical

FIG. 91. — SECTION OF ADENOID GROWTH ( x 60).

Showing a small portion of the cylindrical epithelium (whether ciliated or not
cannot be determined) covering the surface, the vascular nature of the growths,
the vast number of cells of which they are composed, and two follicles (similar
to those seen in the tonsil), one of which is filled with cells, whilst the other is
empty.

FIG. 92. — PORTION OF THK SAMK (Jitowrii AS FIG. 91, BUT MORE

HIGHLY MAGNIFIED ( X 240).

(The lymphatic or adenoid character of the tissue is very evident.)

502 DISEASES OF THE THROAT AND NOSE.

Mini sometimes ciliated epithelium, with an abundance (if the
retiform adenoid tissue of His, containing in its meshes quan-
tities of lymph cells. True follicles are als.. met with ami
.occasionally a conglomerate gland, and the structures are
generally highly vascular. The glandular element is, as a
rule, more marked in growths, taken from the vault of
the pharynx, whilst in vegetations removed from the lateral
walls, the stroma of His is found in greater abundance. 1
am indebted to Mr. Butlin, of St. Bartholomew's Hospital,
for admirable microscopical drawings (Figs. 91 and 92) of
an adenoid growth which I removed by means of the
" sliding forceps " from the extreme upper part of the vault
side of the pharynx of a boy, aged ten, who suffered from
deafness and a thick voice.

Prognosis. — Considering that these growths can produce
such grave evils as have been described, they ought imt
to be regarded too lightly; but, on the other hand, as
frequently happens in the case of recently -discovered dis-
eases, there is at present, perhaps, a slight tendency to
exaggerate their importance. Although the complaint may
justly be looked upon as serious when the vegetations are
large enough to interfere with nasal respiration or to cause
inflammation in the neighbourhood of the Eustachian tube,
it need not, as a rule, give rise to much anxiety. It is,
indeed, highly probable that in many cases the growths
spontaneously undergo atrophic changes in early adult life,
whilst, as already pointed out, the larger size of the naso-
pharynx makes their presence less injurious. Before ado-
lescence has been reached, however, permanent deafness,
defective articulation, and a lasting deformity of the thorax
may have been produced.

l)r. Meyer informs me that in his experience the growths
have a tendency to spront up anew in greater luxuriance
than before if the whole mass be not thoroughly cleared
away, but I do not think that this observation accords with
the experience of others who have given attention to the
subject.

Treatment. — This consists in the removal or destruction
of the growths. When they originate from the vault
removal can best be effected with the cutting forceps of
Lbwenberg (see Xasal Instruments) or Solis Cohen.1 Both
these physicians appear to have suggested this mode of

1 "Diseases of Throat and Nasal Passages." New York, 1879,
2nd ed. p. 262. The author gives a woodcut of his instrument .

ADENOID VEGETATIONS OF THE NASO-PHARYNX. 503

removal at about the same time. Cohen observes, "I have
long used a gouge-cutting forceps, modelled on Mackenzie's
similar instrument for cutting off laryngeal growths, with the
shank curved to suit the anatomical disposition of the parts
over which it must be passed."1 The shape of Lb'wenberg's
instrument with Woakes's modification of the cutting edges
appears to me rather more convenient than that of Cohen,
the blades being shorter and forming a rather more obtuse
angle with the shaft. In children who are likely to struggle
much during the operation, or to resist its being repeated
— that is to say, in those between eight and thirteen or
fourteen years of age — I generally have chloroform adminis-
tered. For younger children, however, and for adults I do
not employ any anaesthetic. It is seldom that forceps can
be used while the mirror is in position, and it will mostly
be found sufficient first to make an accurate diagnosis and
then immediately to introduce the forceps. Some operators
guide the instrument with the index finger of the left hand ;
but this procedure is seldom necessary except when the
patient is under an anaesthetic. For removal of growths from
the lateral walls Lowenberg recommends a modification of
Volkmann's sharp spoons, suitably curved for introduction
into the posterior nares. In operating with this instrument
the index finger of the other hand should be used for the pur-
pose of firmly adjusting and securing the growth. For these
vegetations, however, my sliding-forceps (Fig. 63, pp. 274,
275) will be found to answer well. Meyer lately recommended
a somewhat similar instrument, but he still strongly advo-
cates the use of his "ring-knife" (pp. 275, 276), and employs
it almost exclusively. In this country, however, patients
greatly dislike the passage of instruments of any size through
the nose, and nearly all operators effect removal of the
growths through the posterior nares.

Zaufal2 has succeeded in removing vegetations from the
naso-pharynx by passing through one of his funnels (Fig. 28,
p. 242) a steel wire which, by an ingenious contrivance,
is pushed out so as to form a loop and catch the growth.
Capart3 has adopted this method of expanding the loop and
applied it to electric cautery. The latter physician also
often uses a sort of ring-knife or sharp scraper, carried on
a metallic finger-shield (see Xasal Instruments, Fig. 65,

1 Op. cit. p. 262.

2 " Prag. metl. Wochenschr. " 1878.

3 " Bull. Acad. Roy. de Med. de Belg.' 1879, 3 ser. xiii. 1151.

."tilt DISEASES OP THE THROAT AND N<>-i:.

p. 276), whilst Guye,1 of Amsterdam, uses his finger-nail for
tin- same purpose.

In the course of operations on these growths there is
<>lten pretty free bleeding, and in some cases a ha-nmstatie.
is required. The nasal douche may he employed, n»ld water
being passed through the nares, and powdered tannin or
mati<;o leaf may be insufflated behind the uvula. As a
matter of fact, however, I have never met with hemorrhage
profuse enough to require the use of any styptic.

If the electric cautery is used, Lincoln's instrument (Fig.
61, p. 273) would, no doubt, be found very convenient.

In order to re-establish respiration through the nose it is
most important to teach patients to keep the mouth shut,
and, during sleep, a chin-piece, with tapes to tie over the
head, as recommended by Lbwenberg,2 may be worn, or a
respirator, as suggested by Guye, of Amsterdam.3 Lowen-
berg's plan appears to me most suitable for young children,
and I have put it in practice once or twice with satisfactory
results.

FIBROUS POLYPI OF THE NASO-PHARYNX.

Latin Eq. — Polypi fibrosi pharyngis nasalis. Polypi naso-

pharyngei.

/•'reach Eq. — Polypes fibreux du pharynx nasal.
< lennan Eq. — Xasenrachenpolypen.
Italian Eq. — Polipi fibrosi della faringe nasale.

DEFINITION. — Tumours of fibrous structure, generally
xjiringing from the vault of the nasopharynx, often extending
into one of the nasal fossce or even into the ant rum, or
reaching tloirn in the pharynx to the epiglottis, and icffu
<>f large size giving rise to great disfigurement of the /</'•'•,
to obstruction of the nose, and sometime* to considerable
dyspnoea. These tumours, which are nearly alway* fouinl
in Male* lii-ttr-'eu the ages of fifteen and twenty-five, are
generally solitary, Heed very readily ivJien touched and
sometimes spontaneously, hare a marked tendency to ;>•/•«/•
after ri'inora/, and .iJio/r a d/.-</,<ixifi(>n to arrest of dev/<>/>-
n>ent or even afr»jJty after the age of twenty-five.

1 "Trans. Intern. Med. Congress." London, 1881, vol. iii. p. 290.

* Op. cit. p. 70.

:l Intern. Med. Congress, Brussels, 1875.

FIBROUS POLYPI OF THE NASO-PHARYNX. 505

History. — Although mention is frequently made by the older
writers of polypi hanging from the back of the nasal passages into
the pharynx, the literature of naso-pharyngeal fibromata may be said
to begin with Mamie's1 account of his method of removing such
growth, which was published in the early part of last century.
Soon after the subject was briefly referred to by Garengeot,2 and
a few years later Manne3 published a second tract containing
some additional cases. Examples were recorded by Taranget 4 and
Eustache,5 and a somewhat elaborate memoir on naso-pharyngeal
polypi, valuable even now for the number of carefully-related cases
which it contains, was presented to the Royal Academy of Surgery of
Paris by Icart,6 in 1731. In Levret's7 work on polypi some valuable
suggestions were made for the removal of fibrous growths of the
naso-pharynx, chiefly by means of ligature, of which method this
ingenious surgeon was the inventor. Morand 8 afterwards succeeded
in removing a polypus with his fingers alone, by what he called
" ebranlement " — that is to say, by rocking the tumour on its base
between one finger introduced as far as possible into the nostril, and
one or two fingers of the other hand passed up behind the soft palate.
A few years later Nannoni 9 removed a large naso-pharyngeal growth
by Mamie's method. Early in the present century Whately 10 devised
an ingenious plan for guiding scissors or cutting-forceps to the base
of such tumours. In 1816 Ansiaux n reported a case in which he used
Manne's method, and failing to get the growth away with forceps,
destroyed it by repeated cauterizations. In 1832 Syme,12 in dealing
with a naso-pharyngeal polypus, for the first time removed the upper
jaw as a preliminary step towards extirpation of a tumour not con-
nected with that bone itself. Mott,13 of New York, was referred
to by Syme as claiming to have excised the upper jaw for naso-
pharyngeal polypus at about the same date, but I have not been
able to find any record of his case. In 1834 Dieffenbach u pub-
lished a number of cases in which he had removed fibromata with
the bistoury, scissors, and forceps, generally dividing the soft palate
as a first step. This, as already shown, had been frequently done
before, but solely for the purpose of opening a freer way of access
to the tumour, whereas Dieffenbach was, so far as I am aware,
the first to point out how valuable this measure may be in itself
for the relief of the urgent dyspnoea often caused by the presence
of a large fibrous polypus in the naso-pharyngeal region. Blandin 1!S

1 " Dissertation curieuse au sujet d'un Polype extraordinaire qui occupoit la
Narine droite, qui bouchoit les deux fentes nasales, et qui descendoit par une
grosse masse extirpde a un pastre du Dauphin£." Avignon, 1717.

" Traite des Operations de Chirurgie." Paris, 1731, t. iii. p. 50, et seq.

3 " Observation au sujet d'un Polype extraordinaire." Avignon, 1747.

•* " Documents ine'dits de I'Acade'mie R. de Chirurgie," republished by Verneuil ;
see " Gaz. Hebd. de M<M. et de Chir." June 15, 1860, p. 388.

» Ibid.

« Ibid. July 20, 1860, p. 465.
" Obs. sur la Cure radicale de plusieurs Polypes." Paris 1771.

i "Opuscules de Chirurgie." Paris, 1772, 2me partie, p. 196.

9 Nessi : " Istituz. di Chirurgia." Venezia, 1787, p. •_'->.

10 " Cases of two extraordinary Polypi removed from the Nose." London, 1805.

11 " Clinique Chiriirxieale," t. viii. Lietie. 181(5, p. V.fi, et seq.

12 " Edin. Mril. ami Surg. .lourn," vol. \\vvii. ji. :;-_!•!.

13 Ibid. The statement rests on a private letter from Mott.

14 "CUnugtaba Erfahrungen." Berlin, 1834. Dritte und Vierte Abtheilung,
p. 236, et seq.

is il Diet, de M<5d. et de Chir. prat." Art. " Polypes." Paris, 1835, t. xiii.

.506 DISEASES OF THE THROAT AND NOSE.

jml in practice with sonic success a iiictlioil which is im-rcly .Mnriiinl's
"cbranlenient " carried out with forceps instead of the fingers. In 1840
Flaubert ' removed the whole of the upper ja\v for the eradication
of a growth which had baffled several previous attempts to remove
it by ordinary means. He was apj»arently under the impression
that his was the first operation of the kind, and, in fact, ablation
of the superior maxillary for disease unconnected with that hone
is. even now, spoken of by French writers as "Flaubert's operation."
It has been shown, however, that he was anticipated, both in
the conception and the performance of this operation. Adelmann-
reported a case of a very large naso-pharyngeal polypus which
(besides other ravages) had perforated the hard palate. This opening,
enlarged by division of the soft palate with the knife, was used as a
way of access to the tumour. This possibly suggested to Nelaton :;
his plan of trephining the hard palate, which, though rarely if ever
practised in this country, has apparently found great favour among
French surgeons. Nelaton devoted much attention to naso-pharyn-
geal growths, their attachments, and the means of extirpating them.
Although little is to be found on the subject in his own writings,
his views have been fully set forth, and his cases and methods
of treating them have been related, by several of his pupils.4
Chassaigiiac,* Langenbeck,8 Huguier,7 Demarquay,8 and Oilier9 have
invented different methods of ' ' temporary resection " of the bony roof
of the nose or of part of the upper jaw, whilst Roux10 has suggested a
method of "mobilizing" the whole of the upper jaw, enabling the
surgeon to separate the two maxillaries, and thus obtain the widest
possible view of the pharynx and base of the skull. This formidable
procedure, however, has never been attempted on the living subject.
The operations performed by Langenbeck and Von Bruns were
described in 1872 by Paul Bruns,11 who claimed for these surgeons
the merit of devising the methods which are generally attributed to
Huguier and Chassaiguac. An elaborate article was published by
Oosselin and DenonvilTiers, 12 which has served as a very useful store-
house for subsequent writers on naso-pharyngeal growths. Maison-
neuve13 modified Mamie's operation by making a "button-hole" in
the soft palate instead of completely dividing it. On the other hand,
Nelaton s procedure was altered by Richard,14 who trephined the
hard palate without dividing the velum. A very full account of
naso-pharyngeal growths was given in 1864 by Robin-Masse,15 who
wrote as a professed follower of Nelaton. Several English and
American surgeons have reported cases of naso-pharyngeal polypi,

I " Arch. G6n. de M<5d." 1840, 3me s6rie, t. viii. p. 430, et seq.

- •• I ntersuchungeii iiber Krankhafte ZustSnde der Oberkieferhbhle." Dorpat
und Leipzig, 1844.

s Botrel : " D'une Operation nouvelle dirig£e centre lea Polypes naso-pharyn-
giens." Paris, 1849. Ndlaton's first operation was done in 1848.
•» Botrel, Desgranges, D'Ornellas, Vauthier, Robin-Massed
6 " Trait6 des Operations chirurg." t. ii. p. 448.
« " Deutsche Kliink." No. 48, 1859.

- " Bull, de 1' Academic de Med." Paris, May 28, 1861.
» "Gazette Helnloinadaire." Aug. 29, 1862, p. 554.

9 "Bull, de la Soc. de Chir." 1866, p. 263, et seq.
10 " Gazette des H6pitaux." July 30, 1861.

II "Berlin klin. Wocheiischrift," vol. ix. pp. 138 and 149.
i'- "Compendium de Chirurgie pratique," vol. iii.

i» " Gazette Hebdomadaire, " Sept. 2 and Sept. 10, 1859, p. 612.

14 Beuf : " Des Polypes flbreux de la Base du Crane." These de Paris, 1857

15 " Des Polypes naso-pharyngiens. " Paris, 1864.

FIBROUS POLYPI OP THE NASO-PHARYNX. 507

for the removal of which severe surgical measures were found neces-
sary ; among them may be mentioned Bryant,1 Cheever,2 Rouse,3
Thomas,4 Waterman,5 Clark,8 Cooper Forster,7 Whitehead,8 Sands,9
Berkeley Hill,10 MacCormac,11 Ratton,12 Ogilvie Will,18 and Henry
Morris.14 A good description of the various operative methods of
dealing with these growths was published by Sands,19 in 1873, and in
the following year Cheever,16 in describing a new plan of temporary
displacement of the upper jaw, compared the different "preliminary
operations" together in a very judicial spirit. A short but complete
essay on naso-pharyngeal tumours was published in 1878 by Bensch,17
and Spillmann s18 recent ai'ticle on the same subject is full of informa-
tion. The latest contribution to the literature of these growths is an
instructive paper by R. P. Lincoln,19 giving the results of different
modes of treatment in fifty -eight cases.

1 " Trans. Path. Soc." London, vol. xviii. p. 107.
- " Boston Med. Surg. Journ." March 11, 1869.
3 " Lancet," Feb. 27, 1869.
•i Ibid. May 1, 1869.

6 "Boston Med. Surg. Journ." April 8, 1869.
« Ibid. Oct. 19, 1871.

7 " Lancet," May 20, 1871.

8 " New York Med. Record," Jan. 2, 1872.

» " Brown-Sequard's Arch, of Med." June, 1873.
i« " Lancet," June 20, 1874.

11 " St. Thomas's Hosp. Rep." 1875, p. 65, et seq.

12 " Lancet," Nov. 3, 1878.
is Ibid. Dec. 6, 1879.

M " Med. Times and Gaz." June 4, 1881 ; and Ibid. June 11, 1881.
is Loc. cit.

16 " Boston Med. Surg. Journ." 1874, vol. xc. p. 545, et seq.

17 " Beitrage zur Beurtheilung der chirurg. Behandlung der Nasenrachenpoly-
pen." Breslau, 1878.

is " Diet. Encyclop. des Sciences Med." 1881, 2me s£rie, t. xiii. Art. " Nez."
i» " Archives of Laryngology." 1883, vol. iv. Xo. 4, p. 258, et seq.

Etiology. — The disease is decidedly rare. Paget l states
that he has never had an opportunity of examining any
of these growths in the fresh state, and indeed that he has
seen very few of them in any condition. It would appear,
however, from the numerous cases recorded by French sur-
geons, that the affection is less uncommon among their
countrymen than it is with us. Fibrous tumours of the naso-
pharynx generally originate between the ages of fifteen and
twenty-five, but they occasionally commence in infancy, and
more rarely after the period of adolescence is past. Bensch2
has collected 118 cases of tumour in the naso-pharynx, many
of which, however, for various reasons he excludes from
consideration. Some were clearly of malignant nature,
others cartilaginous or simply mucous in structure, whilst
many of the cases were too incompletely reported to be made
use of. Allowing for these omissions, there remain 66 cases,

1 "Lectures on Surgical Pathology." London, 1870, 3rd ed.
p. 475.

2 Op. cit. p. 106, et seq.

508 DISEASES OF THE THROAT AND NOSE.

and in 58 of these the patients were males from eleven to
twenty-five years of age ; 7 of the remaining 8 occurred in
boys under ten years of age, whilst in the eighth case the
patient was a girl of fourteen.1 Bensch's table contains
examples of patients of both sexes2 over twenty-five years
of age, but even when the tumours were fibn.us in structure,
these cases had not, according to Bensch, presented th>- i-lini>'nl
features which are considered to be truly characteristic of
naso-pharyngeal fibromata. Lincoln's statistics comprise
59 examples of naso-pharyngeal tumour, reported in tin-
period from 1867 to 1873, and of these probably not less
than 38 were genuine fibromata, in all of which the patients
were males under the age of twenty-five. Nelaton,3 indeed,
went so far as to say that he did not know of a single
authentic example of true naso-pharyngeal fibroma becoming
developed in a female of any age, or in a male over thirty-five.
Whilst granting that the law thus laid down is too absolute,
the fact remains that instances of the disease occurring in
women must be looked upon as altogether exceptional.

There is no evidence that the affection is hereditary,
though one congenital case has been recorded.4

The causes which lead to the development of naso-pharyn-
geal fibromata are unknown, but the disease is probably due
to an irregular evolution, during the growing period, of a
tissue which under normal conditions is exceptionally abun-
dant on the under surface of the base of the skull. The a^<-
(fifteen to twenty-five) at which these growths are most
prone to originate is precisely the time at which many of the
fibrous tissues of the body are in the most important stage
of their development. It is then that the articular ligaments
are acquiring their full firmness, and it seems not unlikely
that it is to an exaggerated plastic activity during this phase
of development that these terrible growths owe their origin.

Symptoms. — In the early stages of the complaint the patient
becomes aware of some obstruction of one or other nostril,
and suffers from a disagreeable feeling at the back of the

1 This case is reported as that of a woman aged twenty-five, but she
had suffered from the complaint eleven years.

8 Among these is one of Verneuil's (" Bull, de la Soc. de Chir."
1873, t. ii. 3me serie, p. 347), in which the patient was a woman aged
sixty-two.

3 "Rapport sur les Progres de la Chirurgie," by MM. Deuonvilliers,
Nelaton, Velpeau, &c. Paris, 1867, p. 325.

4 Voisin : cited by Verneuil, "Gaz. Hebd." 1860. From "Docu-
ments inedits tires des Archives de I'ancieime Academic de Chirurgie."

FIBROUS POLYPI OF THE NASO-PHARYNX. 509

nose. As the disease develops, both nasal passages generally
become completely obstructed, and if the growth hangs low
in the pharynx there is often considerable dyspnoea. There
is usually deafness of one ear, and sometimes both sides are
affected. The articulation is frequently indistinct, and even
unintelligible, from pressure on the soft palate, whilst dys-
phagia is occasionally a troublesome complication. A curious
symptom which has been observed in many of these cases
is drowsiness, the patient sometimes falling asleep even when
standing upright. Whately1 gives remarkable illustrations
of this symptom in the case of his patients, one of whom
would fall asleep in his shop in the act of serving a customer,
or even when on horseback in the street ; whilst another,
who was a barber's apprentice, went to sleep when curling a
cxistomer's hair, and dropped the hot iron on his head. A
great sense of fatigue accompanies this drowsiness. There is
generally an abundant purulent secretion, which is some-
times of a fetid character. Epistaxis is of almost constant
occurrence, and is often very severe. Thus Whately2
mentions that in one of his cases the patient bled at the
nose on three different occasions at intervals of a year, the
haemorrhage each time lasting six days, and the amount of
blood lost being between four and five pints. The bleeding
is in many instances so frequent and profuse that the patient
is reduced to a dangerously ansemic condition.

By means of posterior rhinoscopy the growth can be seen
at an early period of the disease, and it can also be felt with
the finger. It is generally smooth, hard and unyielding,
red or purple in colour, and often ulcerated and covered with
sanious secretion. The tumour is usually pedunculated, the
stalk, however, in most cases being broad. There has been
much controversy as to the exact seat of implantation of
these fibromata. The usual opinion is that they may spring
from the vomer, the inner surface of the pterygoid processes,
the front of the upper siirface of the upper cervical vertebrae,
or, in fact, any part of the roof or lateral walls of the naso-
pharyngeal cavity. Nelaton,3 however, whose teaching has
been widely accepted in France, holds that the primary
point of origin is in all cases the periosteum covering a
limited area on the under surface of the base of the skull
corresponding to the basilar process of the occipital and the
body of the sphenoid bone. He maintains that where the

1 Op. cit. pp. 3 and 20. 2 Op. cit. p. 2.

3 Robin-Masse, op. cit. p. 12.

510 I'lSKASKS, OK THK THKoAT ANI> M i»K.

tumour appears to be attached to other parts, cither in the
naso-pharynx or the nose, these are merely points when-
secondary adhesions have been contracted in tlie course of
expansion of the growth. It may, at least, be admitted that
this view is correct in the great majority of cases. In order
to ascertain its exact origin, it is often useful to introduce a
probe through the nostril while the finger is in the mouth,
for by this means the polypus can be moved and its relations
more easily made out. As the mass enlarges, it becomes
visible in the pharynx, whilst in other cases where it h;<
down into the throat, additional room can be obtained by
drawing the velum forwards (see p. 247, et seq.).

The subsequent symptoms depend on the direction which
the tumour may take in its development. If it extends
towards the throat it presses the soft palate forwards and
interferes with deglutition. At the same time it generally
causes inflammation, which may spread along the Eustachian
tube, set up catarrh of the middle ear, and tlms give rise
to considerable deafness. If the tumour grows into the nose
it may separate the nasal bones from each other, flatten out
the bridge, at the same time pushing the eyes farther apart
and making them bulge almost out of the orbits, thus pro-
ducing the hideous deformity known as "frog-face." It may
also press on the lachrymal canal and cause epiphora. Should
the mass extend outwards it may displace the eyeball, causing
exophthalmia, and even setting up destructive inflammation
of the eye, or it may reach into the antrum, giving rise to a
large swelling in the cheek. A similar effect is produced
when the growth projects through the pterygo-maxillary iissure
and extends to the cheek beneath the zygoma. The most
dangerous extension is upwards through the base of the skull,
the cranial cavity being opened, and the substance of the
brain pressed on or destroyed by the invading mass. It is
remarkable, however, that the cranium may be perforated or
eroded over a considerable area by the tumoxir without any
cerebral disturbance being produced.1

Diagnosis. — In the early stages the disease can generally
be recognized with the rhinoscope and by digital examina-
tion, and when well advanced it can scarcely be mistaken
for any other affection. It is often impossible to dis-
tinguish between fibrous tumours and sarcomata except

1 See several cases in a thesis by Petit, " De quelques Considera-
tions sur les Polypes naso-pharyugiens et leur Propagation auCerveau."
Paris, 1881, pp. 25, 26, 32, and 37.

FIBROUS POLYPI OF THE NASO-PHARYNX. 511

by microscopic examination, but the age and sex of the
patient greatly assist in arriving at a correct opinion.
Cartilaginous tumours are so rare in the naso-pharynx, that
they may be excluded from consideration, and bony growths
have never been observed in that region. Occasionally
curious and almost unavoidable mistakes have been made.
An instance of this is the well-known case in which Vacca
Berlinghieri l endeavoured to remove what appeared to be a
polypus, but proved to be a neuroma of the size of a peach
on the second division of the fifth nerve. The case already
mentioned (p. 364), in which a hernia of the brain simu-
lated a polypus, may be again referred to. Sometimes the
ophthalmoscope may reveal evidence of pressure on the optic
nerve, but in a case reported by Oilier 2 cerebral symptoms
occurred without any atrophy of the disc having been
observed.

Patholor/y. — Fibrous tumours of the naso-pharynx present
the ordinary characters of fibromata. They are exceedingly
dense, and only differ from similar growths in other situations
in being, as a rule, destitute of elastic fibres. The vessels
in the substance of the tumour are usually small, whilst
those of the investing membrane are often of large size.
According to Gross,3 all these vessels have very brittle
walls, and it is to this peculiarity that he attributes their
proneness to bleed, a tendency which is further favoured
by the fact that the vessels are imbedded in a dense fibrous
network which does not allow of their retraction when cut.
Muron,4 who made a careful examination of a growth removed
by Verneuil from a boy between fifteen and sixteen years of
age, states that in that case the vessels, which were exceedingly
numerous, had for the most part a more or less embryonic
structure. The walls of the smallest consisted merely of a
single row of slightly fusiform cells, others had two such
rows, whilst some had three or four. The vessels presenting
a fully organized structure with the ordinary three coats
were extremely few in number. Occasionally a considerable
portion of the tumour may be of true erectile structure,5 and
in such cases haemorrhage is, of course, particularly likely
to occur. Virchow 6 suggests that this is in some cases duo

1 "Arch. Gen." t. xxiii. p. 431.

2 " Bull, de la Soc. de Chirurgie." 1866, p. 264.

3 "System of Surgery." Philadelphia, 1872, 5th ed. p. 371.

4 " Bull, de la Soc. de Biologic." July 3, 1869, p. 223.

5 E. Neumann: " Virchow's Archiv. " Bd. xxi. p. 280.

6 "Die Kraiikhaften Geschwiilste. " Bd. iii. p. 463.

512 DISEASES OF THE THROAT AND NOSE.

to an extension of the cavernous structure normally covering
the turbinated bones.

Prognosu. — This is unfavourable, unless the disease be
recognized and treated at a very early stage. The only
satisfactory feature in these, growths is that they do in it
tend to increase, but rather show a disposition to become
absorbed, after the age of twenty-five. If, therefore, by
repeated removal, the spread of the disease <-an he kept
within bounds, its spontaneous arrest may fairly be
looked for when the period of adolescence is past. An
example of the disappearance of a fibroma without any
treatment whatever has been related by Lafont.1 The
patient was a man, aged twenty-four, who had suffered t'n>iu
the characteristic symptoms for three or four years, and
who when seen had a large naso-pharyngeal growth with
prolongations into the nose and cheek. As the symptoms
were not urgent, surgical measures were postponed, and a
few months later the patient returned with hardly a trace
of the tumour remaining. Fibrous tumours of the naso-
pharynx have also sometimes sloughed away. In an in-
stance related by Birkett2 this took place after repeated
haemorrhages, for which deligation of the left common
carotid had been necessary. Another example3 of slough-
ing of a naso-pharyngeal growth, which had recurred after
evulsion with forceps, was seen in a woman in St. George's
Hospital. In this case it is stated that the tumour dis-
appeared " so entirely .... that no trace could be dis-
covered of any part remaining."

Treatment. — The method of dealing with these growths
is likely to undergo a fundamental change. Until a com-
paratively recent period they had, as a rule, attained con-
siderable dimensions before their true nature, or in some
cases, their very existence, was discovered. Now, however,
that the nose and naso-pharyngeal region can be thoroughly
examined by direct inspection, fibromata are sure to be
observed at a stage when they are amenable to treatment
of a tolerably mild nature. It is not improbable, therefore,
that the severe " preliminary operations " presently to be
described, may, after a time, become almost obsolete, and
that electric cautery applied pw vias natural ex will, in gn^t
measure, supersede all other methods. Should the growth,

1 "Gaz. Hebdom." January 15, 1875, p. 37.

2 " Brit. Med. Joum." February 13, 1858, p. 119.

3 Ibid. January 23, 1858, p. 61.

FIBROUS POLYPI OF THE NASO-PHARYXX. 513

however, have reached a large size before the patient comes
under observation, the first question which the surgeon will
have to decide is whether an attempt at radical cure should
be made, or whether merely palliative measures should be
adopted. The natural tendency of the disease to come to
a standstill after the twenty-fifth year affords a strong argu-
ment in favour of doing nothing in the way of active treat-
ment beyond what is absolutely required for the relief of
urgent symptoms. An excellent illustration of this has been
furnished by Gosselin.1 The disease had first attracted the
patient's attention by the usual symptoms, when he was
between sixteen and seventeen years of age, but it was not
till three years later that he sought medical advice. Almost
every method was employed for the radical extirpation of
the growth, but recurrence was very rapid after each opera-
tion, and Gosselin was finally obliged to allow the patient
to leave the hospital for the ostensible purpose of recruit-
ing his health before submitting to further measures. But
at this time his face was hideously deformed, there was
distinct evidence of commencing pressure on the brain, and
his vital strength was at the lowest ebb. Gosselin owns that
he looked upon the lad as inevitably doomed to death at
no very remote date. He saw his patient once more, how-
ever, when he had reached the age of five-and-twenty, and was
astonished to find that, although no treatment whatever had
been attempted in the meantime, all trace of the growth had
disappeared. Gosselin is, therefore, strongly of opinion that
whilst urgent symptoms, such as difficulty of breathing or
swallowing, or great loss of blood from the nose, should, if
possible, be palliated by the removal of part of the growth,
the bulk of it should be left alone. If, when adolescence is
complete, the mass is still unabsorbed, thorough eradication
may be attempted with a fairly well-founded hope that there
will be no return of the disease.

Electric cautery is, as already remarked, the plan of
treatment which will probably prevail in the future. It
is safe and easy of application, and Lincoln's2 recently
published results conclusively show that it is thoroughly
effectual, when the growth is of moderate size. He has
used it in three cases, in none of which has there been

1 " Clinique Chirurgicale de I'HSpital de la Charite." Paris, 1873,
t. i. Le9on 8me, p. 92.

a "Archives of Laryngology." 1883, vol iv. No. 4, p. 258,
et seq.

VOL. II. L L

") 1 1 DISEASES OF THE THROAT AND XOSE.

any sign of recurrence since the time of operation. Two
of the patients have remained free from the disease for
more than eight years, and the third has continued well
during nearly eleven months. It is to be noted that the
ages of those patients were respectively fifteen, sevrnto n,
and twenty-one, so that all were within the period when tin-
growth of fibromata is, as a rule, most active. Lincoln1
quotes cases treated by electric cautery by Gulcke and Roth ;
in the former there had been no recurrence during four and
a half years, whilst in the latter the patient had remained
free from disease for two and a half years.

The best method of using electric cautery in these cases
is, if possible, to remove the growth within the galvanic
ecraseur passed through the nose or mouth. The stump
should afterwards be thoroughly destroyed by electric cautery
applied at such intervals of time as may seem desirable.;
once a week will be sufficient in most cases. The simplest
and most convenient instrument for this purpose is Lincoln's
post-nasal electrode (Fig. 61, p. 273).

Amongst other modes of treatment may be mentioned
electrolysis, ligation, removal with Hie t'i-ratti>nr, f>i;t<li*i»n, >-.,;-i-
sion, crushing, gouging, actual cautery, and the application
of escharotics.

Electrolysis can be carried out by means of any battery
generating a continuous current of moderate strength. The
operator should introduce one or more curved needles con-
nected with the negative pole into the tumour behind the
uvula, whilst the current from the positive pole is conducted
to the growths by means of a needle passed through the nose,
or a sponge-electrode placed in contact with the sternum. A
convenient needle for the purpose of applying electrolysis to
post-nasal tumours has been invented by Cohen.2 The opera-
tion should be continued for ten or fifteen minutes at a time,
and it may be made every day, or on alternate days. Very
siiccessful examples of this mode of treatment have been
recorded by ^elaton,3 Paul Brans,4 Ciniselli,5 Fischer,6 and

1 "Archives of Laryngology." 1883, vol. iv. No. 4, pp. 274, 275.
- "Diseases of Throat and Nasal Passages." New York, 1879,
2nd ed. p. 270.

3 Robin-Masse : " Des Polypes naso-pharyngiens." Paris, 1864,
p. 78.

4 " Berlin klin. Wocheuschr." July, 1872, No. 27, p. 321 ; No.
2S, p. 336.

5 "Gazette Medicale." 1866, p. 223.

6 "Wien. med. Wochenschr." 1865, No. 61.

FIBROUS POLYPI OF THE NASO-PHARYNX. 515

Lincoln.1 In Xelaton's case a bulky growth, which bled
very easily, and which had resisted the cautery and eschar-
otics, was dispersed by electrolysis in six sittings. In
that of Bruns, a large tumour, which had baffled previous
efforts to remove it with the snare, was destroyed by electro-
lysis. In this instance, however, the treatment had to be
continued for eleven months ; and one hundred and thirty
sittings, each lasting about a quarter of an hour, were
required. In Lincoln's case electrolysis was used as a
palliative measure, the patient's weakness making a radical
operation unadvisable. There were twenty-two sittings, the
treatment being continued for about a year. At the end of
that time the tumour had " shrunk very much in all dimen-
sions, and the patient's health was so much improved that the
remaining portion of the growth could be removed with the
ecraseur." In Gosselin's2 case, already referred to, electrolysis
was one of the methods resorted to, and it was tried under
fair conditions. It was found, however, that although some
diminution in the bulk of the tumour was effected at each
sitting, this was so slight as to be regained by the natural
process of growth by the next time electro-puncture was
applied, so that no real progress was made. It may be
added, that in this case the operation was so painful as to
be extremely dreaded by the patient, who, nevertheless, had
borne, without much complaint, repeated examinations and
many attempts to remove his growth by cutting, ligature, and
caustics.

Lifjation. — Ligatures have been employed for the removal
of these growths from an early period in the history of surgery.
When the tumour has been thoroughly exposed by a " pre-
liminary operation," a ligature can usually be applied with
ease, but when strangulation has to be done^r vias natnrales
there is often the greatest difficulty in placing the ligature
round the stalk of the growth. To accomplish this an im-
mense variety of instruments have been invented ; indeed,
almost every surgeon who has had occasion to apply this
method has devised some fresh arrangement. Perhaps the
simplest plan is that recommended by Dubois.3 This consists
in passing a double ligature through a piece of elastic catheter
fifteen to thirty centimetres in length, to which a piece of

1 " Naso-pharyngeal Polypi." St. Louis, 1879, p. 6, et seq. Re-
printed from the " St. Louis Medical and Surgical Journal."

2 Loc. cit.

3 "Gazette des Hopitaux," February, 1863.

516 DISEASES OF THE THROAT AND NOSE.

coloured thread is attached. As the ends of the ligature
are gradually drawn out through the nostrils by moans of
Bellocq's sound, the surgeon, with his fingers in the patient's
mouth, carries the open loop over the pedicle of the growth.
Whon the loop is in position, the piece of catheter is removed
by means of the coloured thread. An obvious objection to
this method is that it is useless in the numerous cases
where it is impossible to reach the pedicle with the
finger. In carrying out ligation, there is some danger, if
the tumour be large, that when it separates it may fall
down into the throat during sleep, and cause death by
suffocation. In such cases, therefore, a thread should bo
passed through the body of the tumour, and brought out
by the mouth, the two ends being tied round one of the
ears. During sleep the patient must be watched in order
that the polypus may be at once withdrawn should it become
detached.

The great advantage of the ligature is that the danger
from haemorrhage during the operation is reduced to a
minimum. The disadvantage is that it is often extremely
difficult to apply the ligature, except after a " preliminary
operation," and that when the mass has come away a stump
is left behind from which the growth may sprout anew.

Removal with ihe Ecraseur. — For this purpose a strong,
slightly curved instrument must be used, and a loop of
suitable size having been made, it should be directed upwards
behind the uvula, and made to encircle the growth as close
to its root as possible. In some cases it will be found easier
to pass the wire round the tumour by pushing it, bent double,
through the nose. In either case, when the wire is round the
growth, its ends should be threaded through the eyes of the
ecraseur, and the loop gradually tightened.

Evulxion. — As in the case of mucous polypi, evulsion with
forceps has its advantages. Instead, however, of the delicate
instruments which are used in dealing with soft growths,
very powerful forceps are required for fibrous tumours.
They must be curved at an obtuse angle, and the blades
should be rough, or even toothed, to enable the operator to
get a firm grasp of the tumour.

It is desirable to seize the growth as near its base as
possible, and twist the pedicle as much as the space will
permit. Such is the resisting character of these growths,
however, that even when very strong forceps are employed,
their blades are often wrenched so as to become useless.

FIBROUS POLYPI OF THE NASO-PHARYNX. 517

Occasionally the tumour may be seized with the fingers and
torn off, but this can seldom be done until the origin of
the polypus has been well exposed by a " preliminary
operation."

In any case it is most important to follow any offshoots of
the growth which may project into the nose, sphenoidal
fissure, or antrum, and to root them out thoroughly. The
great advantage of evulsion is that when the tumour is not
very large it can be removed in this way without any " pre-
liminary operation," and that it can often be torn away by
the roots. The objection to it is that the growth is some-
times so extremely dense that it altogether resists any reason-
able degree of force,1 and serious accidents may result from
injudicious violence. Though Icart 2 has related an instance
in which he brought away a fragment of the ethmoid bone
as large as a shilling, without any bad consequences ensuing,
it must not be forgotten that two of Ollier's 3 patients died
from cerebral complications after evulsion. In one of these,
however, the growth was found, on post-mortem examination,
to have invaded the middle cerebral lobe. Cooper Forster4
also lost a patient twelve days after evulsion, and the
necropsy showed fracture of the cribriform plate of the
ethmoid with general arachnitis and localized sloughing of
the cerebral substance. A great part of the tumour having
been left behind, it appears probable that these lesions were
due to the operation.

Exc.ision with a curved blunt-pointed bistoury was fre-
quently performed by Dieffenbach, who, though he sliced
these growths in the freest manner, did not meet with any
dangerous haemorrhage ; this experience, however, is of a
very exceptional character, for Deguise,5 Verneuil,6 and
Dumenil 7 have reported cases in which death occurred from
the furious bleeding which took place when the tumour
was divided. Whately succeeded in curing a very severe
case by excision, or rather amputation, with a curved knife.
His mode of operation was ingenious, and at the same time

1 This has been especially observed by M. Oilier, the well-known
surgeon of Lyons, who, considering their great rarity, has had an
unusually large experience of these tumours.

• Loc. cit.

a Spillmann : "Diet. Encyclop. des Sciences Medicales," 2e serie,
t, xiii. p. 100.

4 " Lancet." May 20, 1871.

5 " Bull, de la Soc. de Chir." March 13, 1861.

8 Ibid. 1870. 7 Ibid. June 18, 1873.

M8 DISEASES OF THE THROAT AND NOSE.

simple. A string was first passed through the nose round
the growth, and into the pharynx, from which it was
drawn out of the mouth. The end of the string was then
tlireaded through a small eye near the point of the knife,
and the nasal extremity of the string being pulled tight by
an assistant, whilst the other was held in the surgeon's left
hand, the knife with its point carefully guarded was run
along the string to the upper part of the pharynx, where tin-
edge was guided to the base of the tumour, which was cut
through. Although the diameter of the growth at the point
of section was 2 by If inches, there was no serious bleeding.1
In spite, however, of this experience of Dieffenbach and
"NVhately, the danger of haemorrhage renders their plan of
treatment unworthy of imitation.

Crushlwj. — This method has never been extensively prac-
tised. It was tried by Velpeau 2 with very powerful forceps
armed with strong teeth. Different portions of the growth
were successively seized, and violently compressed, and in
this way a considerable portion of the tumour was destroyed.
The crushed portions, together with some of the immediately
adjacent parts of the polypus, subsequently sloughed away.
Although cases have been reported by Dolbeau3 and Jarjavay 4
in which this treatment was successful, it is so apt to give
rise to septic infection that it has fallen into disuse.

Gougiruj. — This mode of treatment was once much in
vogue. But though a favourite practice in the sixteenth and
seventeenth centuries for the destruction of every kind of
tumour, it does not appear to have been employed for the
removal of naso-pharyngeal polypi till it was advocated by
Borelli.5 The method has since been followed by (hurin,';
Bonnes,7 and Herrgott,8 but it requires the performance of
a " preliminary operation," except in cases where the growth
is attached to the base of the skull. Under these circum-
stances the plan is most conveniently carried out by passing
an extremely fine chisel through the nose, and pushing it
along the vault of the pharynx.

1 "Cases of Two Extraordinary Polypi, &c." London, 1805, p. 14.

- " Bulletin de Therapeutic} ue. 1847.

8 Spillmanu : Loc. cit. p. 101.

4 Ibid.

6 " Gaz. des Hopitaux." 1860, p. 179.

6 " Bull, dela Soc. de Chir." June 24, 1866.

7 Ibid. July 14, 1869.

8 Quoted by Postel : "Des Polypes naso-pharyngiens." These de
Pa is, 1867.

FIBROUS POLYPI OF THE XASO-PHARYXX. 519

Although gouging is of very limited application for the
actual removal of growths, it has been extensively employed
for destroying the stump when the bulk of the tumour has
been taken away by some other plan. Baudrimont,1 however,
says that out of eight cases operated on by Dieffenbach
recurrence took place in seven, in every one of which gouging
had been carried out ; whilst in the eighth case, in which
cauterization was used instead of gouging, there was no re-
currence of the disease. Oilier,2 on the other hand, affirms
that he has no confidence in any method of treating naso-
pharyngeal growths except by evulsion followed by vigorous
gouging, and he is never satisfied that the latter procedure
has been thoroughly carried out, unless he can feel that the
bony tissue of the basilar process of the occipital bone
has been scraped quite bare. Whilst admitting that the
periosteum which furnishes the elements for the reproduction
of the tumour must be destroyed as completely as possible,
a word of warning seems to be called for here against a too
energetic use of the gouge. A case has come to the author's
knowledge in which a distinguished surgeon, now deceased,
actually drove the chisel into the patient's brain whilst
scraping the vault of the pharynx.

Thermic Cautery. — The red-hot iron used by the older
surgeons has been abandoned in favour of improved methods
of applying the actual cautery.

Paquelin's thermo-cautery is available in some cases, and
Nelaton successfully employed a simple gas flame for the
cauterization of the stump of a tumour which had been
removed. For this purpose he used a small india-rubber
ball full of gas, connected with an elastic tube, to which
suitable nozzles of varying degrees of fineness could be
adapted. The nozzle was provided with a stop-cock, so that
the flame could be exactly regulated in its application. By
this means it was found possible to cauterize the parts very
quickly and thoroughly, whilst radiation was so slight that
the finger could be held at a distance of a centimetre and a
half from the flame without any heat being perceived.

Excharotics. — Various agents of this kind have been em-
ployed in different ways. Nelaton treated some cases by the
application of nitric acid passed through a suitably cur veil

1 "De la Methode nasale dans le Traitement des Polypes naso-
pharyngiens. " These de Paris, 1869.

2 "Traitt! exper. et cliu. de la Regeneration des Os." Paris, 1867,
p. 485.

f)20 DISEASES OF THE THROAT AND NOSE.

irlass tube. In spite, however, of every precaution tin* vapour
of this acid is apt to escape and give rise to violent
dyspnoea. Moreover, to produce any real effect, tin- n -medy
must be applied daily for months. In France chloride »\
zinc paste (pate de Canquoin) has been recommended by
several surgeons, and a special apparatus has been devi.-i'd by
Desgranges1 for maintaining the caustic in conta>'t, as li.ng
as may be necessary, with the part to be destroyed. This
consists of a thin metal plate, on the upper surface of which
is placed the caustic agent, whilst the apparatus is kept
in position by metallic bands which go round the head.
Although I have never had an opportunity of trying them
in a case of naso-pharyngeal fibroma, I think the caustic
darts2 which I am in the habit of occasionally using in
cases of fibrous bronchocele might also here prove of service.

French surgeons distinguish two methods of employing
cauterization, viz., the rapid process and the dine pr<»-< •»•.
The former consists in freely cauterizing the stump of a
polypus immediately after the bulk of it has been removed.
The slaic cure consists in keeping the base of the growth
accessible for some weeks after a " preliminary operation "
has been done, and applying the caustic every second or
third day. The slow cure can be most conveniently carried
out through the wound left after Nekton's "palatine opera-
tion." This procedure, however, is objectionable, as almost
necessarily leaving a permanent fissure of the palate ; whilst,
iu the case of operations on the face, the prolonged mainte-
nance of an open wound is likely to lead to hideous deformity.

Preliminary Operations for gaining A<'<-< «* f<> AWi-//// «/•//»-
geal Tumours. — Although attempts have been made to dilate
the orifice of the nostril by means of serpentary root, gentian,
sponge, and more recently by laminaria, these methods are
practically of little value, and, owing to the frequently in'ac-
cessible situation not less than to the large size and numerous
offshoots of the growths, it often becomes necessary to expose
the tumour by a preliminary surgical operation. This neces-
sity was perceived at a very early period, and on referring to
the short historical retrospect prefixed to the article on "Masai
Polypi" (p. 353, et seq.), it will be seen that Hippocrates
recommended that the nasal cavity should be laid freely
open in cases where the application of the actual cautery was

1 "Gazette Hebdom." June 30, 1854, p. 633, et seq.
• These consist of one part of chloride of zinc to one or two parts
of wheat flour.

FIBROUS POLYPI OF THE XASO-PHARYNX. 521

judged necessary. An operation of this kind seems to have
been frequently done in the sixteenth and seventeenth-
centuries, but it had fallen into disuse until revived by
Dieffenbach.1 It has since been often performed with various
modifications according to the exigencies of particular cases.
The older surgeons carried the incision down the centre of
the nose, but, with the view of concealing the scar as far as
possible, Garengeot2 suggested that the cut should be made
along the genio-nasal furrow.

At a later period more severe procedures came into use,
the naso-pharynx being laid open by resection of the upper
jaw, or the growth being reached by division of the hard
palate. Hence the following preliminary operations for the
removal of naso-pharyngeal tumours have come to be recog-
nized, viz., 1, nasal ; 2, maxillary ; and 3, palatine.

These procedures are in themselves attended with con-
siderable risk. Sedillot3 and Demarquay 4 each lost a patient
from haemorrhage in the course of the "preliminary opera-
tion," and in twenty-one cases collected by Lincoln,5 in
which a " preliminary operation " was done, death took
place on the table in three,6 whilst in a fourth " the patient
succumbed within a few hours. In a fifth 8 instance
haemorrhage very nearly proved fatal during the operation.
If Lincoln's statistics are accepted in the gross they show
still less favourable results, for in thirty-nine cases in which
" preliminary operations " were performed death quickly
ensued in eight. In some of these, however, the disease

1 Op. cit.

2 "Traite des Operations de Chirurgie." Paris, 1731, 2e ed. t. iii.
p. 53.

3 Spillmann : Op. cit. p. 145.

4 Ibid. p. 146.

8 Loc. cit. pp. 264 — 281. Lincoln's tables include altogether
fifty-eight cases of naso-pharyngeal tumour. Of these seven were
unquestionably malignant, three were h'bro-mucous, whilst in ten
the nature of the growth is either not stated, or from internal
evidence (age or sex of the patient, cause of the disease, &c.) may be
judged to have been not truly tibromatous. I have, therefore,
reckoned only thirty-eight of Lincoln's cases as examples of the
disease treated of in this article, and even a few of these must be
looked on with some suspicion.

6 Verneuil: " Gaz. drs Hi'jpitaux," Aug. 9, 1870; Berkeley Hill:
"Lancet," June 20, 1874; H. Morris: " Aled. Times and Gaz."
June 4, 1881.

7 Ratton : " Lancet," Nov. 3, 1878.

8 Sands : " Brown-Stquard's Archives of Scien. and Praet. Med."
June, 1873.

."il'li DISEASES OF THE Til HO AT AND N'»K.

was decidedly malignant, ami they have, then-fore, been
excluded from consideration. Even as regards the twenty-
one cases of undoubted fibroma, it must not be forgotten
that a " preliminary operation " was presumably judged
necessary because the tumour was very large, and the
mortality may, therefore, have been in great measure due
to the unavoidable violence which must sometimes be used
in separating the mass from its attachments. The feeble
and anaemic condition of the patients in such circum-
stances has also to be taken into account. It is hardly
fair, therefore, to compare the statistics of cases in which
"preliminary operations" have been performed with those
in which a cure has been effected by means of electric
cautery or any other simple method of treatment.

The various- "preliminary" procedures must now be
described in detail.

Na*al Operations. — Dupuytren1 suggested opening the
nasal fossa by an incision carried round the base of the nose,
detaching the cartilages from the bone, thus enabling the
operator to tilt up the tip of the organ, and explore the
anterior orifice of the nares. Syme enlarged the aperture of
the nostril by dividing the upper lip in a vertical direction
from a point midway between the septum and the ala of the
affected side. The two flaps were then dissected well back
on each side. A procedure, however, which, besides exposing
the nasal cavity more freely, has the advantage of not
causing an unsightly cicatrix, has been proposed by Rouge.2
The following is his own description of this operation :
" The patient is anaesthetized, and placed with his head bent
towards the right side to allow the blood to escape, whilst
the operator stands at the right side of the bed. Seizing
the upper lip, near the commissure, with the thumb and
index finger of the left hand, I lift it up a little, whilst an
assistant does the same on the other side. The lip being so
held and stretched out, I incise the mucous membrane in the
gingivo-labial groove from the first molar tooth on the left
side to the corresponding point on the right, the centre of this
incision being at the frenum of the lip, which is divided at
the root. I rapidly cut through the tissues in their whole
thickness, and reach the anterior nasal spine, over the
prominence of which the knife should be carried, detaching

1 " Journal de la Clinique." 1830, t. ii.

* " Nouvelle Methode Chirurgicale pour le Traitement de I'Oz&ne."

Lausanne, 1873.

FIBROUS POLYPI OF THE NASO-PHARYXX. 523

the cartilaginous part of the septum at its base. This
often suffices, for by raising the nose there is room to
introduce the finger into the nasal fossa, and a good view
can be obtained of its cavity when the blood has been
sponged out. If, however, this does not suffice, the alar
cartilages should be separated from their attachment to the
upper jaw with scissors, and the nose being thus completely
detached, should be thrown upwards upon the forehead,
when the whole extent of the anterior opening of the nares
will be exposed. If the uncut portion of the septum
prevents the turning back of the nose, it should be
divided with scissors. When the operation is finished, the
wound should be carefully cleansed, the blood and clots
being washed away with water ; the lip is then replaced, and
union takes place without any sutures being required."1

It is sometimes, however, necessary to open the nasal
cavity from the face. This may be partially done by
slitting the nostril in the middle line from below up to the
lower edge of the nasal bone. If this does not afford
sufficient space, the skin incision should be prolonged to the
root of the nose, and the nasal bones separated from each
other in the middle line with scissors or bone-forceps ; the
whole side of the nose, consisting of the nasal bone, the os
unguis, the nasal process of the upper jaw, with the lateral
and alar cartilages, can now be pressed outwards upon the
cheek and held there by an assistant, while the surgeon
examines the attachments of the growth and attempts to
remove it through the gap thus formed. As Roser2 says,
" operations of this kind are rendered more easy by the
fact that the patients are young, and their bony sutures
soft, yielding, and easily dislocated."

Langen beck's operation, which is practised by many sur-
geons, is done in the following manner : — The patient lying
on his back, an incision is carried from the junction of the
nasal and frontal bones downwards along the middle line of
the nose to the upper margin of the alar cartilage, from which
point a second incision is made outwards along the upper edge
of the cartilage of the affected side. The triangular flap thus
formed is dissected back, care being taken to avoid injuring

1 This operation has been clone several times in England, but chiefly
for the purpose of removing diseased bone from the nasal cavity. See
in particular one very successful case by Harrison Cripps in " Lancet,"
May 5, 1877, p. 643," et seq.

2 Quoted by Spillmann : " Diet. Encyclop. des Sciences Medicales,"
2e serie, t. xiii. p. 131.

524 DISEASES OF THE THROAT AND XO8E.

the periosteum. The cartilage is next severed from the
bone ami the os nasi separated from its fellow with bone-
1'orceps. 1 'art of the nasal process of the superioi maxillary
should then be separated from the body of the bone, t In-
line of section being kept to the inner side of the orbital
ridge, in order to avoid injuring the lachrymal canal. The
quadrilateral osseous plate thus marked out is now con-
nected with the frontal bone only by the natural suture
and by the periosteum and mucous membrane, and it should
be forced upwards with an elevator so as to lay open the
upper part of the nasal cavity. When the operation has
been completed it is recommended that the wound should be
kept open for some months in order that any recurrence of
disease may be at once observed. MacCormac1 has per-
formed a similar operation on both sides, but he carried
the vertical incision down the cheek instead of along the
middle line of the nose.

Chassaignac's operation consists in loosening the attach-
ments of the nose on one side, so as to allow of its being
turned over on the opposite cheek. The following are the
steps of the procedure : — A transverse incision is made across
the root of the nasal prominence, from the inner angle of the
orbit on the right side to the corresponding point on the
left ; a second cut is next made from the left extremity of the
first incision to the outer margin of the left ala at its lower
part; lastly, the knife is carried across the upper lip close
under the nose to the external edge of the right ala. The
nasal walls are now drilled through in the direction of
the first incision, and, a chain-saw having been introduced
through the aperture thus made, the upper part of the nasal
processes of the superior maxillaries and the ossa nasi are
divided from behind forwards. The saw is then carried
downwards in the direction of the second incision, cutting
through the osseous wall on the left side, whilst the septum
and the bones on the right are snipped through with scissors
or cutting forceps. Care must be taken not to injure the
skin or soft tissues on the right side, as it is on the integrity
of these that the vitality of the feature depends when it is
replaced. The nose, having been detached in this manner on
three sides, can be turned over towards the right " like the
lid of a snuff-box," leaving free access to the naao-pharyngeal
cavity. \Vhen the tumour has been extirpated the parts

1 " St. Thomas's Hospital Reports." 1875, p. 65, ct seq.

FIBROUS POLYPI OF THE XASO-PHARTXX. 525

are to be carefully replaced, and the edges of the wound
accurately brought together with sutures.

Ollier's operation, which he calls "vertical and bilateral
osteotomy of the bones of the nose," is performed as follows : —
An incision, somewhat resembling a horse-shoe in outline,
is made through the skin from the outer edge of the ala
upwards along one side of the nose to its root and down to
the edge of the other ala. The knife should be carried at
once through all the soft tissues. The bones of the nose
are next to be divided in the direction of the first incision
with a fine Butcher's saw, held parallel to the plane of the
patient's forehead, whilst the cartilages of the septum and
alae should be snipped through with scissors. If necessary,
the two small internal nasal arteries must be tied. The
nose can now be pulled down, leaving free access to the
naso-pharyngeal cavity. When the growth has been re-
moved, the nose is replaced, and the edges of the wound
brought together with fine wire sutures. Oilier1 points
out that this procedure does not endanger the vitality of
the nose, as its chief arterial supply is left intact. Union
takes place very quickly, one patient having been able to
blow his nose on the fourth day after the operation.2 Ample
room is afforded for the treatment of the tumour, Oilier him-
self having removed one weighing more than six ounces and
a half,3 which he says is perhaps the largest naso-pharyngeal
fibroma that has ever been removed. He4 is careful to point
out, however, that all noses are not equally suitable for this
operation, the long narrow ones being especially unfavour-
able, and generally rendering it necessary to sacrifice the
turbinated bones. When the tumour is at all large, however,
the pressure of the mass usually dilates the nasal passages
much beyond their normal width, which makes the operation
easier and more effectual.

A somewhat analogous method was carried out more than
twenty years ago by Lawrence,5 who, however, loosened the
nose from below, leaving it attached only at the root, so that
it could be thrown upwards on the brow. He made a cut
from the inner edge of each lachrymal sac downwards along

1 " Bull, de la Soc. de Chir." 1866, p. 264.

2 Ibid.

3 Ibid.

4 " Traite exper. et clin. de la Regeneration ties Os." Paris, 1867,
t. ii. p. 484.

8 " Med. Times and Gaz." 1862, vol. ii. p. 491. Lawrence's
operation was undertaken for the removal of mucous polypi.

526 DISEASES OF THE THROAT AND NOSE.

the naso-labial furrow to the point of junction of the septum
with the upper lip, where the two incisions met. The bones
of the nose and the septum were then divided from IM-IMW
with forceps, and the whole feature thrown upwards. The
nose was afterwards replaced, and fixed with sutures. Union
took place in a few days. The only disadvantage of this
plan, as compared with Ollier's, is that the pedirle <>f the
displaced mass is less vascular, and gangrene is, therefore,
more likely to take place.

A procedure which may fitly be classed under the head of
nasal operations was proposed and carried into execution
almost at the same time by two Italian surgeons, Palasciano1
and Rampolla.2 This may be briefly described as follows : —
A small incision is made to the inner side of the lachrymal
sac, which should be partly dissected out and held aside by an
assistant ; the inner wall of the tear-duct, formed by the
os unf/uia, is then pierced with a curved trocar and canula,
which is to be pushed into the nasal fossa by the superior
meatus. The trocar is next withdrawn, and the canula is
twisted so that its concavity looks upwards and passed into
the pharynx. Through it a ligature is then passed, which is
made to encircle the tumour. The results of the operation
have not been brilliant, one of the four cases in which it
has been practised having ended fatally, whilst in another
abscess of the eyeball ensued, and in the remaining two the
growth speedily recurred. The plan has been tersely described
by Robin-Masse3 as simple ligation applied in the most
inconvenient way possible.

Maxillary Operations. — These consist of excision, and
temporary resection of the superior maxillary bone. The
history of these procedures has been already given (p. 505,
et seq.).

The superior maxillary bone may be removed in its
entirety, or partially, or it may be temporarily displaced.
Excision of the upper jaw is done in the following way : —
A cut is made from the inner canthus along the side of
the nose and carried through the whole thickness of the
upper lip at its middle part ; it is sometimes necessary
to make a second incision from the upper extremity of
the one just described, horizontally outwards, about half
an inch below the lower margin of the orbit to the malar

1 " Moniteur dcs Sciences." August 25, 1860, p. 393.
- " Hull, cle la Soc. de Chir." March and May, 1860.
3 Op. cit. p. 60.

FIBROUS POLYPI OF THE NASO-PHARYXX. 527

prominence. Although this second cut is required for re-
moving the superior maxilla when a large tumour springs
from any part of that bone itself and causes considerable
projection of the cheek, it can generally be dispensed with
when the excision is performed for a naso-pharyngeal growth,
and thus a very unsightly cicatrix can be avoided. The
remainder of the operation cannot be better described than
in the words of Heath:1 "The skin having been reflected
in the manner described above, the incisor teeth of the side
to be removed are extracted, and a narrow saw with movable
back is passed into the nostril. With this the alveolus and
hard palate are divided, and the small saw is then applied to
the malar process of the maxillary bone (or, if need be, to
the malar bone itself), and to the nasal process of the superior
maxilla, so as to notch both these points of bone, the division
being completed with the bone-forceps. With the 'lion-
forceps,' devised by Sir William Fergusson for the purpose,
the jaw can be now grasped and broken away from the
pterygoid process and the palate bone, any detaining point
being severed with the bone-forceps. Lastly, when the bone
is quite loose, the infra-orbital nerve is to be divided, and
the soft palate dissected off the bone so as to leave as much
as possible of it uninjured." Haemorrhage should be con-
trolled by means of ligatures or the actual cautery, and at
the conclusion of the operation the edges of the wound
should be brought accurately together with hare-lip pins and
the interrupted suture.

A method of partial and temporary resection, as already
mentioned, was proposed and carried out by Huguier, in
the following manner : — A transverse slit having been made
in the soft palate, a thread is carried through one nostril
by means of Bellocq's sound, and brought out through the
wound in the palate ; to the end of this thread is fastened a
string, which is to serve for making traction on the loosened
piece of bone in the way to be presently described. An
incision is next carried through the whole thickness of the
cheek, from the corner of the mouth to the anterior border of
the masseter ; a second cut is then made from near the inner
corner of the eye, along the genio-nasal furrow, detaching
the ala of the nose, and ending in the middle of the upper
lip. This triangular flap is dissected back and thrown out-
wards. The saw is afterwards to be carried horizontally

1 "Diseases and Injuries of the Jaws." London, 1872, 2nd ed.
pp. 275, 276.

528 DISEASES OF THE THROAT AN'D NOSE.

through the upper jaw from immediately above tin- maxillary
tuberosity to just above the floor of the correaponding nasal
fossa. The first incisor of the opposite side should be dis-
placed with the elevator, and the floor of the nose sawn from
before backwards, but not completely through. The base of
the pterygoid process should next be cut through with bone-
forceps, thus leaving the lower portion of the superior maxilla
separated from the bones of the face, and oidy connected t<>
them by the mucous membrane covering the palatine vault,
which was spared in the division of the floor of the nose.
With the forceps used as a lever, traction being at the same
time made on the separated portion of bone by means of
the string previously passed through the nose and the soft
palate, the lower part of the upper jaw can be dislocated
into the mouth. The nose and naso-pharynx are now fully
exposed, and after the growth has been removed, and the
bleeding stopped, the loosened maxillary bone should be
replaced, gags should be put between the molar teeth on
each side, the wound closed with hare-lip pins, and a "bandage
passed round the chin and fastened over the top of the head.
Considerable trouble is sometimes caused by the displaced
fragment not uniting and showing a tendency to fall into the
mouth. Huguier, however, secured perfect union by means
of a gutta-percha splint, carefully moulded to the alveolar
border, and worn for a month or two ; he states that the
disfigurement left by the operation was slight.1

A procedure has been invented by Cheever2 for the
partial resection of both upper jaws, of which the following
are the steps : — An incision is made from the inner canthus
through the soft parts on either side, and carried downwards
along the genio-nasal furrow to the middle of the lip. These
flaps are next to be dissected back as far as the malar pro-
minences. The body of the superior maxillary must then be
cut through with a narrow saw, the line of division passing
from the tuberosity forwards under the zygoma into the
middle meatus on each side. Lastly, the septum and the
alee should be snipped through with scissors. The upper
jaw, which is now attached only at the back part, is to be

1 Robin-Masse, however, states (Op. cit. p. 86) that from an
examination of the patient, made a considerable time afterwards,
it appeared that the bone had never firmly united, and that all the
teeth growing from it were carious, so that the replaced maxillary
simply served as an indifferent obturator.

J " Boston Med. and Surg. Journ." 1874, vol. xc. p. 547.

FIBROUS POLYPI OF THE NASO-PHARYNX.

529

forced downwards, and the growth removed. The bone is
then put back into its place, and firmly fixed in position by
wire sutures passed through the malar bones on each side.
Cheever claims for this plan that the vascular supply of
the bone is not interfered with, since the palatine arch and
the alveolar border are left uninjured.

A case which is probably altogether unique has been
recorded by Oilier,1 in which he performed temporary resec-
tion of an upper jaw of new formation. He had removed
the superior maxillary more than three years previously in
order to gain access to a naso-pharyngeal polypus. When
the patient again presented himself, a solid bony bridge was
found joining the malar bone to the anterior nasal spine.
This was divided at each of the points named, and raised,
being afterwards replaced when the growth had been extir-
pated. Union was complete in thirty days.

Palatine Operations. — Division of the soft palate Avas,
as already stated, performed by Manne as a " preliminary
operation " for the removal of a naso-pharyngeal polypus.
He gives a very meagre description of his procedure, but
appears to have divided the velum in its whole length near
the middle line, cutting from below upwards with a curved
bistoury. This method was subsequently practised by
Petit,2 Morand, Xannoni, Ansiaux, Dieffenbach and others.
Levret proposed the division of the pillars of the fauces
on each side, with the view of making the curtain of the
soft palate more movable. Jobert3 appears to have modi-
fied this plan by incising the velum, beginning at the
base of the pillars on each side, and cutting upwards as
far as seemed necessary. Maisonneuve 4 improved Manne's
operation by leaving the lower edge of the velum undivided.
He made a longitudinal incision through the soft palate,
commencing close to the posterior edge of the palate bone,
and carrying the knife to within one centimetre of the
edge of the velum. This aperture he calls the " palatine
button-hole." The finger is passed through it to explore the
shape and attachments of the growth, which is then drawn
through the " button-hole," the sides of which are very

1 " Traite exper. et clin. de la Regeneration des Os." Paris, 1867,
t. ii. pp. 492, 493.

2 Quoted by Garengeot : "Traite des Operations de Chirurgie "
Paris, 1731, t. iii. p. 51.

3 " Gazette des Hopitaux," July 22, 1858.

4 "Gazette Hebdomadaire, " September 2, 1859.

VOL. II. M M

530 DISEASES OF THE THROAT AND NOSE.

elastic. Round the sort of pedicle formed in the mass by
this procedure a wire noose is placed, and pushed as far l>;u k
tlirough the velum as possible ; it is then tightened, and kept
in position till the tumour is cut through. Huguier1 used
a transverse " button-hole " in connection with his method of
temporary resection of the upper jaw, and Begin 2 employed
this method in combination with division of the nose in
front Adelmann 3 also practised it as part of an extensive
operation for the removal of a growth which had depressed
the hard palate and caused perforation of the bone in the
middle. Nelaton 4 subsequently proposed trephining of the
hard palate combined with division of the velum as a
means of reaching the tumour to be extirpated, and of watrh-
ing for any sign of recurrence after removal of the mass.
His plan of procedure is as follows : — The soft palate is
divided, from its bony attachment to its free border, the
cut being carried through the middle of the uvula. This
incision should then be prolonged through the tissues covering
the hard palate for the posterior half of its extent. Fnnn
the anterior end of this cut two others should be carried
outwards and slightly backwards on each side. These in-
cisions should be made with a strong sharp knife, so as to cut
through the periosteum and reach the bone. The posterior
layer of the velum being next divided with the bistoury, the
soft parts should be raised from the bone, and the two flaps
thus formed should be held aside by assistants. The hard
palate should be bored through with a perforator at the
front part of the space thus exposed, the holes being made at
about one centimetre from the middle line. Into these holes
the blades of a pair of fine bone-forceps are then inserted, and
the intervening portion of the palate is broken through, the
separation of the osseous plate being completed, if necessary,
by dividing the bone on each side.5 The fragments of bone,

1 " Bull, de 1'Acad. de Med." May 28, 1861.

*"Nouveaux laments de Chir. et de Med. Oper." Paris, 1838,
t. ii. p. 586, et seq.

3 " Uutersuchungen iiber krankhafte Zustande der Oberkiefer-
hbhle." Dorpat und Leipzig, 1844.

4 Botrel : " D'une Operation nouvelle dirigee contre les Polyi>es
uaso-pharyngiens. " These de Paris, 1850.

8 Tnis operation is not so difficult in actual execution as may appear
from the description. When the bones are pressed on by a polypi]
they are usually so atrophied as to make it an easy matter to break
perforate them. Oilier ("Traite exper. et clin. de la Regeneration
des Os," Paris, 1867, t. ii. p. 487) mentions a case in which the hard
palate was so thin that it could be pierced with an ordinary pin.

FIBROUS POLYPI OF THE NASO-PHARYNX.

531

which generally include part of the vomer, should be care-
fully detached from the mucous membrane, so as to allow of
subsequent repair. Through the opening thus made the
polypus is removed in whatever way the surgeon may prefer,
the wound being subsequently kept open as long as may
be desired in order to allow of thorough destruction of
the roots of the growth, and the immediate treatment of
any recurrence. Botrel1 suggested Maisonneuve's "button-
hole" method in combination with Nelaton's trephining of
'the hard palate as affording more hope of ultimate perfect
healing of the wound.

The great danger of haemorrhage, both during the " pre-
liminary operations" and the actual ablation of naso-pharyn-
geal fibromata, has been already mentioned, and it now only
remains to make a few remarks on the best way of meeting
these complications. It is most important to proceed with
deliberation, securing the vessels, if possible, as they are
divided; and it has been pointed out by Spillmann2 that it
is very desirable not to attack the polypus till the patient
has recovered from the anaesthetic, so that he may be able
to expectorate any blood which may flow into his trachea.
In some cases it may be well to perform tracheotomy and
use Trendelenburg's instrument (Vol. i. p. 515) before the
" preliminary operation" is commenced, but one case3 proved
fatal in spite — possibly in consequence — of previous laryngo-
tomy. Tying the carotid is seldom of any use unless it has
been found beforehand that pressure on the vessel will stop
the blood; and in very severe cases the actual cautery is
more to be relied on. Oilier plugs the naso-pharyngeal space
with sponges after the operation, and this plan is generally
adopted by English surgeons.

Notwithstanding all precautions, however, fatal syncope
sometimes occurs after removal of these growths, probably
owing to the sudden withdrawal of a large mass of blood
from the immediate neighbourhood of the brain.4

1 Loc. cit.

2 " Diet. Encyclop. des Sciences Medical es," t. xiii. p. 150.

3 Ratton : " Lancet," November 3, 1878.

4 Pozzi's experiments on dogs ("Gaz. Hebd." September 4, 1874,
p. 576) clearly show that death is more rapidly caused by the escape
of a comparatively small amount of blood from the carotid artery than
by the withdrawal of a much larger quantity from the femoral.

532 DISEASES OP THE THROAT AND NOSE.

FIBRO-MUCOUS POLYPI OF THE
NASO-PHARYNX.

These tumours vary in size from a pigeon's to a hen's
«gg, and are generally smooth, dark red, and more or less
ovoid in form. Though certainly rare, they are more com-
mon than true fibromata in this situation. I have notes
of only seven cases, though I have seen two or three others.
The symptoms to which they give rise are principally tlmsc
proceeding from nasal obstruction, but occasionally they cause
•deafness. They do not lead to haemorrhage, nor do they tend
to destroy the bones with which they come in contact ; and
these points will serve to establish a diagnosis between such
growths and true fibromata.

The pathology of these tumours has been rendered interest-
ing by the researches of Panas,1 who has shown that the
mucous membrane round the posterior nares, and in the
immediate neighbourhood of these orifices, presents a kind of
transitional form between the mucous membrane of the nasal
fossae, and the dense closely adherent fibro-mucous lining of the
pharyngeal vault. Growths in these situations are composed,
to a great extent, of the structural elements of the tissue from
which they originate, and whilst a polypus springing from
the pituitary membrane may be expected to be of mucous
texture, one from the under surface of the basilar process is
likely to be fibrous, and a tumour taking origin from the mem-
brane round the posterior nares, where the fibrous and mucous
elements are mingled, will probably present a corresponding
fibro-mucous structure. This observation, however, must
not be interpreted as being the statement of an absolute
law, for as has been already seen, polypi of purely fibrous
structure may be found within the nasal fossae, and, on the
other hand, growths of genuinely fibro-mucous character have
been seen arising from near the roof of the pharynx. In
those cases in which the tumour has branches extending
both into the pharynx and into the nasal fossae, the pharyn-
geal part is, as a rule, altogether fibrous, whilst the nasal
offshoot is mucous in character. Panas2 himself, who had
been led by his anatomical investigations to conjecture that
such mingled forms of polypi would be found in the naso-

1 " Bull, de la Soc. de Chir." 1873. The original statement,
according to the author, was made in 1858, but he gives no reference.
3 Ibid, p. 378, et seq.

FIBRO-MDCOUS POLYPI OF THE NA8O-PHARYNX. 533

pharynx, met with an example in 1865. The patient was a
man, aged sixty-eight, who had suffered from obstruction in
the left nostril for three years. On examination by anterior
rhinoscopy only a small reddish protuberance could be seen
far back in the cavity, but on looking into the mouth, the
soft palate was seen to be pushed down by a tumour of
whitish appearance. This was found to be extremely hard to
the touch, and to be distinctly pedunculated. Panas divided
the velum, and removed the polypus with scissors, having
previously twisted the pedicle to prevent haemorrhage. The
growth was round, smooth, and of fibrous appearance, both
externally and on section, except the part that had blocked
up the nostril, which was mucous in structure. In another
instance recorded by Panas l the patient was a woman, aged
twenty-six, who had suffered from obstruction of both nostrils
for two years. Nothing could be seen by anterior rhinoscopy,
but with the finger passed up behind the soft palate, a some-
what hard, pedunculated, and movable tumour was found
hanging from the posterior nares into the pharynx. This mass
was removed in the same manner as in the previous case, and
it was found to consist of two polypi, each attached by a
pedicle to the posterior edge of the vomer. Each tumour
closed one posterior orifice like a lid, and part of the larger
one of the two rested on the soft palate. They were red-
dish in colour, in density intermediate between a fibrous
tumour and a myxoma, and on section a certain quantity
of serosity escaped. In addition to these, Mathieu 2 has
collected four cases belonging to Legouest, Bonnes, Dumenil,
and Trelat, in which growths originating from the base
of the skull were apparently of a fibro-mucous character, but
in only one of these instances was the structure accurately
determined by microscopic examination. In two other
cases3 (viz., those of Trelat and Labbe), where the growths
originated from the upper part of the posterior nares, careful
examinations by Cornil and Coyne proved that the polypi
were of truly fibro-mucous character.

The prognosis is very favourable, as fibro-mucous polypi
show but little tendency to recurrence after removal. The
treatment should be to extirpate the polypus by the most
suitable operation that offers itself. I have generally effected

1 Ibid.

2"Sur les Polypes inuqueux des Arriere-narines." Th&se de
Paris, 1875.
3 Ibid.

534 DISEASES OP THE THROAT AND NOSE.

a cure by evulsion with forceps introduced through the
mouth, as that is the readiest and most efficient method ;
but in some cases a wire can be passed through the nose
round the pedicle, and in others the tumour can be attai k« d
in the naso-pharynx by electric cautery. For this purpose
Lincoln's post-nasal electrode (Fig. 61, p. 273) will be found
very useful. Of the seven cases that I have met with,
I succeeded in curing five ; in one instance the disease
recurred, but I heard that the patient was afterwards cured
by another practitioner. The seventh case was lost sight of,
and its ultimate result is unknown to me. Severe "pre-
liminary operations," such as are usually necessary for the*
removal of fibrous polypus of the naso-pharynx, are never
required in the case of the growths now under consideration.

ENCHONDROMA OF THE XASO-PHARYNX.

A case of true cartilaginous growth springing from the
basilar process of the occipital bone has been reported by
Max Miiller.1 From the history of the case it appears that
the patient, a man aged twenty-four, had noticed some
obstruction in his nose five or six years before he came under
observation. As the malady progressed he began to suffer
from excruciating pain, together with frequent drowsiness,
and occasional loss of consciousness. The growth increasi-d
in size, pressing the soft palate downwards, completely filling
both nostrils and displacing the nasal septum. The pressure
of the mass produced absorption of the lamina papyracea of
the ethmoid, and the tumour extended into the orbit. Miiller
removed the growth with a wire loop, having first performed
temporary resection of the nose according to Langenbeck's
method. The tumour, which was found to be attached to the
basilar process, was of the size of a man's fist, and weighed
about four ounces. It was proved by microscopic examina-
tion to be of truly enchondromatous nature.

This is the only instance, so far as I am aware, in which
a cartilaginous growth is stated to have originated within
the naso-pharyngeal cavity. Two cases, however, are on
record in which a tumour primarily fibromatous in consti-
tution is said to have become wholly or in part transformed

1 " Langenbeck's Archiv. f. klin. Chirurg." 1870, Bd. xii. p. 323.

ENCHONDROMA OF THE NASO-PHARYNX. 535

into cartilage. In one of these the patient was a boy, aged
twelve, who died whilst under the care of Samuel Cooper.1
The face was shockingly disfigured, the nose being bulged
out on the left side to an extreme degree, and the eyes
being four inches apart. The pharynx was so filled with
the tumour that feeding even with the help of a spoon was
most difficult, and it was impossible to examine the hard
palate. The left eye had been completely blind for some
time ; and a week or two before the patient's death paralysis
of the legs and bladder came on. At the autopsy " a good
deal of the tumour was found to be of a cartilaginous
consistence." A piece almost as large as an orange had
penetrated the skull and destroyed the anterior lobe of the
left hemisphere of the brain. All the neighbouring bony
structures had been more or less absorbed, so that it was
impossible to discover the point of origin of the tumour.
A most remarkable feature in this case is that, in spite
of such extensive cerebral lesions, the patient had felt no
pain, and had not lost consciousness till the last moments
of life. The second case is that of a boy, seventeen years of
age, who had suffered for some time from the usual symp-
toms of naso-pharyngeal polypus. He was operated on by
Le Dentu2 according to Nelaton's palatine method, and
the growth, which was found to spring from the basilar
process, and presented all the naked-eye appearances of a
fibroma, seemed to be completely destroyed. Recurrence,
however, took place within a twelvemonth, and Le Dentu
performed a second operation, this time gaining access to
the tumour by laying the nose open from the front. In
this manner he removed a cartilaginous growth as large as a
date, which was attached to the posterior edge of the vomer,
and sent branches into each nasal fossa. Behind this, and
connected with it, was another cartilaginous mass, which
seemed to be attached to the base of the skull. It was not
judged safe, however, to meddle with this portion of the
growth. The patient appears to have made a good recovery,
but the ultimate issue of the case is not stated. With
reference to the nature of the tumour in this instance, it is
to be noted that no microscopic examination was made of
the mass removed at the first operation. It is therefore at

1 "Diet, of Practical Surgery," edited by Lane. London, 1872,
Art. " Polypus," vol. ii. p. 463.

'-Petit: "De quelques Considerations sur les Polypes naso-pha-
ryngiens." These de Paris, 1881, p. 32, et seq.

536 DISEASES OF THE THROAT AND NOSE.

least possible that it may have been of enchondromatous
nature from the outset. Petit1 suggests that the transfor-
mation may have been due to irritation of the neighbouring
osseous tissue. The fact, however, that no such sequence of
events has been observed in similar cases makes this hypo-
thesis somewhat difficult of acceptance.

MALIGNANT TUMOURS OF THE NASO-
PHARYNX.

Cases of malignant disease, in this situation, were men-
tioned without any details -by Otto Weber,2 and instances
have since been related by Verneuil,3 Rabitsch,4 Gross,6
Demarquay,6 and Bryk,7 whilst a short monograph on the
subject has been published by Veillon.8 The cause* of
such growths are utterly unknown, and the disease itself
does not appear to be very common. The rarity of the
complaint, however, is probably not so great as might be
inferred from the extremely small number of recorded cases,
the affection, no doubt, having in some cases been mistaken
for .simple fibrous polypus. In certain rare instances a
growth of the latter kind may gradually become transformed
into genuine sarcoma.9

The symptoms are those characteristic of all tumours which
obstruct the nasal channels, viz., an annoying sense of impeded
respiration, which may gradually increase to actual dyspnoea,
occasional epistaxis, more or less constant coryza, post-nasal
catarrh (the secretion being often extremely fetid), alteration
'of voice, and imperfect articulation. Great pain is a frequent,
but by no means invariable accompaniment of malignant

1 Op. cit. p. 34.

'Pithau. Billroth: "Chirurgie." Bd. iii. 1 Abtheil. 2. Heft.
Erlangen, 1866.

9 'Bull, de la Soc. de Biologic." Paris, 1869.
4 'Allgem. Wieu. med. Zeitung." 1869, No. 42.
6 'Gazette Med. de Strasbourg. " 1872, No. 2.
' Bull, de la Soc. de Chir." June 18, 1873.
'Arch. f. klin. Chirurg." Bd. xvii. 4 Heft. p. 562.
' Contribution a 1'^tude des Tuineurs malignes naso-pharyn-
giennes." These de Paris, 1875.

90ttp Weber: Op. cit. p. 207. See particularly Fig. 37 (ibid.),
which is a representation of a naso-pharyngeal fibrous polypus that
had undergone sarcomatous degeneration.

MALIGNANT TUMOURS OF THE NASO-PHARYNX. 537

tumours in the nasopharynx ; it is often described by the
patient as " shooting through the ear, and is, as a rule, most
troublesome at night. As the tumour increases, dysphagia
may be produced, and finally general cachexia may super-
vene. Anterior rhinoscopy will probably show that there is
an obstructing mass in one or both of the nasal channels,
and a careful use of the probe will enable the surgeon to
ascertain whether this substance is attached to the septum or
any other part of the fossa. On looking into the mouth the
velum will probably be seen to be dense, and perhaps bulged
forwards at one part ; if the tumour is of considerable size
part of it may be visible on drawing aside or raising the
soft palate. Sarcomatous tumours of the naso-pharynx are
not unfrequently pedunculated and somewhat pyrifonn in
shape, whilst occasionally they are more or less distinctly
lobulated. They are covered by the mucous membrane of
the pharynx,, and present no special features by which the
eye or the touch can detect their true nature. These tumours
have the usual characteristics of malignancy, viz., rapidity
of growth, recurrence after removal, and in many cases a
disposition to form secondary deposits in other organs. The
diagnosis can seldom be made with certainty except by
microscopic examination. A very practised and delicate sense
of touch might possibly enable the surgeon to distinguish
the moderate density of a sarcoma from the extreme hard-
ness of a true fibroma. Tactile investigation, however,
is a most untrustworthy guide in such cases, as it has
to be exercised under difficult conditions, and, moreover,
the structure of tumours in the naso-pharyngeal region is
seldom uniform throughout their whole mass, both fibrous
and sarcomatous growths having frequently a certain ad-
mixture of mucous tissue. The prognosis in cases of malig-
nant growths of the naso-pharynx is altogether hopeless. As
regards the pathology of such tumours, they appear to be
mostly of sarcomatous nature. They often, however, pre-
sent a considerable amount of mucous or fibrous tissues,
in addition to the characteristic round or spindle-shaped
cells ; and it is possible that in such cases the malig-
nant growth may have supervened on what was originally
a mere hyperplasia. Sometimes, as in cases recently re-
ported by Thornley Stoker1 and McDonnell,2 cartilage-cells
are contained in the tumour. If the disease be met with in

1 " Brit. Med. Jourii." Jan. 19, 1884, p. 113.

2 Ibid.

538 DISEASES OF THE THROAT AND NOSE.

an early stage the treatment should consist in the entire
removal of the mass with the snare or electric cautery. In
most cases a " preliminary operation " (p. 520) will be
necessary to expose the tumour. The surgeon should care-
fully watch for any signs of recurrence, in order that he
may at once attack the disease again, if necessary ; but the
best that can be done is often merely to prolong a miserable
existence.

THROAT-DEAFNESS.

DEFINITION. — Deafness caused by moi'bid conditions in the
naso-pliarynx near the orifice of the Eustachian tube, 01- by
changes in the ^cdlls of the tube itself, which interfere with
the free passage of air to the tympanic cavity.

History. — Many of the older writers have mentioned that deafness
may be caused by mechanical obstruction of the pharyngeal orifice
of the Eustachian tube, or inflammation of its interior, resulting
from syphilitic disease. Thus Valsalva l speaks of deafness arising
from obliteration of the tube by ulceratign of specific origin. Van
Swieten2 describes the extension of venereal ulceration from the
pharynx along the Eustachian tube to the internal ear, and Plenck3
mentions stricture of the tube dependent on the same cause. Similar
observations were made by Nisbet,4 B. Bell,5 Swiedaur,8 Saunders,7
and Cullerier.8 The actual term "throat-deafness" was first em-
ployed in comparatively recent times, and was applied to a form of
deafness which was supposed to be due to enlargement of the tonsils.
This view was strongly insisted on by Yearsley9 in 1853, but was suc-
cessfully combated by Harvey,10 who showed on anatomical grounds
that it is impossible for the Existachian orifice to be blocked up in this
way, and suggested that the affection might be due to an extension of
the inflammation of the mucous membrane covering the tonsils to the
contiguous lining of the Eustachian tube. This theory soon gained
general acceptance, and nearly all cases of throat deafness were looked
upon as examples of catarrh of the middle ear, originating in the naso-
pharyngeal region. From the more accurate knowledge gained in
late years, however, throat-deafness has come to be attributed to
various other diseased conditions of the Eustachian tube. In 1862

1 ' De aure humana." Bologna, 1704, p. 90.

2 ' Comment, in H. Boerhaave Aphorismos." Lugd. Batav. 1772, t. v. pp. 369,
371, 373.

3 ' De morbi venerei doctrina." Viennw, 1779, p. 89.

< ' First Lines of the Theory and Practice of Venereal Disease." Edinburgh,
1787, p. 330.

5 'Treatise on Gonorrhoea." Edinburgh, 1793, vol. ii. p. 65, et seq.
« ' TraiW de la Maladie v<5n<5rienne." Paris, 1801, t. ii. p. 144.

7 ' Anatomy of the Human Ear, &c." London, 1806, p. 79.

8 « Joum. de M^decine." 1814, t. xlix. p. 202.

» "Throat-Deafness." London, 1853, 1st ed. p. 2, et seq.
10 < The Ear and its Diseases." London, 1856, p. 157.

THROAT-DEAFNESS. 539

Hinton1 distinguished two forms of throat-deafness, one dependent
on inflammatory thickening of the palato-pharyngeal region, the other
on relaxation of those parts. The recognition of the importance of
adenoid growths in the naso-pharynx as a frequent cause of deafness
by Meyer2 in 1869, marks an epoch in the history of throat-deafness.
In 1873 a most important work was published by Weber-Liel,3 who
brought forward a considerable amount of evidence to show that
what had hitherto been looked upon as a catarrhal affection of the
Eustachian tube and middle ear was in fact a neurosis, the chief
feature of the complaint being paralysis of the tensor palati —
the muscle mainly concerned in maintaining the patency of the
Eustachian canal. According to Weber-Liel the paralysis of this
important muscle leaves the tensor tympani unbalanced, a condition
producing many evils, which will presently be referred to. In 1879
Woakes 4 described, at the annual meeting of the British Medical
Association, a form of throat-deafness in which both the tubal
muscles and the tensor tympani are paralysed.

1 " Holmes's System of Surgery." London, 1862, 1st ed. vol. iii. pp. 159—162.

2 " Med.-Chir. Trans." 1870, vol. liii. p. 192, et seq.

3 "Ueber das Wesen u. die Heilbarkeit der haufigsten Form progressiver
Schwerhorigkeit." Berlin, 1873.

4 " Brit. Med. Journ." 1879, vol. ii. pp. 328, 329.

Etiology. — The disease may depend on a paretic condition
of the Eustachian tube, on chronic inflammatory thickening
of its lining membrane, or on any morbid state of the naso-
pharynx which gives rise to obstruction of the Eustachian
orifice. These three factors in the production of throat-
deafness will now be considered in detail.

In the nervo-muscular cases the immediate cause of the
affection seems to be paralysis of the tensor palati, a lesion
which, according to Weber-Liel, may be either central, reflex,
or vaso-motor in its origin. The impaired contractility of
the tube most frequently results from morbid conditions
of the fifth nerve, but in like manner, neuroses of the
facial, glosso-pharyngeal, vagus, and spinal accessory, and
of the sympathetic plexuses in the naso-pharynx and neck
may lead to atrophy and fatty or fibrous degeneration of the
muscles. The remote causes of these nervous affections are
usually mental strain, depressing emotions, excessive exer-
tion, parturition, and, speaking generally, all unhealthy
modes of life. Weber-Liel's work contains examples of
throat-deafness following phthisis and typhoid fever. Diph-
theritic affections of the naso-pharynx would, of course, be
likely to lead to disease of the Eustachian tube and middle
ear, and that this complication is not uncommon may be
inferred from the fact that Wendt1 found the middle ear
involved in two-fifths of the cases in which there was false
1 " Ziemssen's Cyclopaedia," vol. vii. p. 71.

540 DISEASES OP THE THROAT AND NOSE.

membrane in the nasopharynx. Rheumatism, progressive
muscular atrophy, chlorosis, and even extreme anaemia may
likewise impair the muscles. Weber-Liel is of opinion that
paresis is sometimes favoured by congenital defect in the
development of these muscles.

Chronic inflammation of the Eustachian tube sometimes
follows catarrh of the naso-pharynx, but it must not be for-
gotten that catarrh is extremely likely to occur in parts
whose innervation is impaired, and that in many cases
of catarrhal affection of the middle ear, the neurosis has
been the starting-point. According to Zaufal,1 however, dry
catarrh frequently brings on deafness by extension of the
unhealthy condition to the Eustachian tube. He states that
he found this complication in as many as 80 per cent, of the
cases of ozaena which he had examined. I have not myself
met with deafness in patients suffering from ozsena in any-
thing like the same proportion, though I have occasionally
found the two conditions coexistent.

The disease of the naso-pharynx which most frequently
interferes with the Eustachian orifice is the presence of
adenoid growths in that region. Among 175 patients suffer-
ing from these vegetations in the naso-pharynx, Meyer2
found associated defect of hearing in 130. Syphilitic lesions
may also occur in the neighbourhood of the Eustachian
tube, and lead to impairment of hearing by mechanical
obstruction or inflammation of the canal. This, as already
remarked, was noticed by several of the older writers. In
recent years Zaufal3 has called attention to the frequent
occurrence of gumma'ta in the immediate neighbourhood of
the Eustachian tube. Among more obscure forms of throat-
deafness may be mentioned phlebectasis of the mucous mem-
brane covering the Eustachian cartilage, which, according
to von Trb'ltsch,4 may narrow the lumen of the tube to a
degree sufficient to diminish the power of hearing. Zucker-
kandl5 states that the veins of the internal pterygoid
plexus may, if enlarged, produce the same effect by their
pressure on the Eustachian cushion. Schwartze6 asserts
that oedema of the tubal prominences, and consequent

1 "Die allgemeine Verwendbarkeit der kalten Drahtschlinge."
Prag. 1878.
- " Archiv. fur Ohrenheilkunde. 1874, Bd. viii. p. 243.

3 Loc. cit.

4 " Lehrbuch der Ohrenheilkunde." 1877, p. 310.

8 " Monatsschrift f. Ohrenheilkunde." Jahrgang x. Sp. 52, p. 231.
6 "Pathol. Anatomic des Ohres," p. 104.

THROAT-DEAFNESS. 541

partial occlusion of the Eustachian tube, may be caused by
obstruction to the blood-current in the superior vena cava.
The Eustachian canal is, in certain instances, blocked up by
exostoses situated in the vicinity of the tube ; von Trbltsch1
found this condition produced in one case by hypertrophy
of the posterior extremity of the inferior spongy bone, and in
another by a bony outgrowth from the septum.

Symptoms. — Throat-deafness being dependent on so many
different conditions, the symptoms vary considerably. The
phenomena even in paretic cases differ greatly, one set giving
rise to distressing symptoms, and tending to get worse in spite
of all treatment, whilst the other causes much less inconve-
nience, and generally yields to remedial measures. The first
class is that described by Weber-Liel. One of the earliest
signs is fatigue in listening. It shows itself by the patient
perceiving a difficulty in hearing, after a prolonged conver-
sation, the auditory power being good at the commencement,
but gradually failing as the strain continues. The patient
finds it particularly difficult to hear when general conversa-
tion is going on, though he can do so with ease when one
person is speaking alone. The difficulty in the former case
arises from a loss of the " power of accommodation," the
tympanum being unable to adapt itself readily to the different
sounds caused by voices of varying quality and intensity,
proceeding from persons situated at different distances and
in different directions in relation to the listener. Together
with this, noises are frequently perceived in the affected
ear, whilst snapping sounds are heard by the patient in
chewing and swallowing. As the disease advances, giddi-
ness is sometimes felt. The patient often complains of an
uneasy tickling or scratching sensation in the throat, and on
inspection, paralysis of one or both sides of the pharynx
may be noticed. Though Weber-Liel2 first called attention
to this paralysis, Woakes has rendered good service in
insisting on the great importance of carefully examining
the soft palate in every case of deafness in order to ascer-
tain whether its innervation is normal. This examination
is of the utmost importance in the cases here described, as
the neurosis does not of itself attract notice, the paresis being
seldom sufficiently severe to modify the patient's voice by
giving it the peculiar intonation so characteristic of paralysis
of the soft palate. On examining the ear the tympanum is

1 " Archiv. fur Ohrenheilkunde." Bd. iv. p. 140.
- Op. cit. pp. 33—36.

542 DISEASES OP THE THROAT AND NOSE.

often seen to be retracted, and sometimes opaque and
thickened. Owing to the collapse of its walls the Eustachian
tube cannot be inflated with Politzer's bag, but the catheter
can be passed with ease.

The affection just described most frequently begins on the
left side, and it shows great intractability. According to
Weber-Liel the troublesome character of the symptoms is
largely due to the unbalanced action of the tensor tympani,
causing an intense strain on the drumhead and the ossicles.
A much milder neurosis has been described by Woakes, in
which, however, the innervation, both of the tubal muscles
and the tensor tympani, is impaired. The obstruction of
the Eustachian tube is only partial, for the two sets of
muscles being alike affected, they balance each other exactly,
and on examining the ear, the drumhead is seen to be normal
or only slightly flattened. In these cases noises in the
head and giddiness are not perceived, but the deafness is
marked from the very commencement of the affection, which,
however, shows a tendency to recovery.

Throat-deafness dependent on any of the morbid con-
ditions of the naso-pharynx already described, presents
the symptoms of those affections with the addition of
deafness.

Diagnosis. — A careful examination of the palate, the
naso-pharynx, and the auditory canal will serve to deter-
mine whether the disease is Eustachian in its origin. The
state of tension of the membrana tympani will enable the
practitioner to discriminate between the different kinds of
paresis, and it must not be forgotten that in the severer
form structural disease of the middle ear is very apt to be
set up.

Pathology. — The pathology of the various affections of
the naso-pharynx, which may accidentally lead to obstruc-
tion of the Eustachian orifice, has been considered in its
appropriate place, and it now only remains to make a few
remarks on the paretic forms of throat-deafness. In the
severer cases, through collapse of the tube the air in the
tympanic cavity becomes unduly rarefied, whilst the tensor
tympani being no longer balanced, tension of the tympanic
membrane takes place, the chain of ossicles is put on the
stretch, and the stapes is pressed into the labyrinth.
Secondary changes soon follow : passive congestion of the
tympanic cavity leads to trophic changes of a more or less
cirrhotic character, consisting at first in the growth and

THROAT-DEAFNESS. 543

afterwards in the atrophy of a low form of connective tissue.
Adhesion takes place between parts normally separate, the
stapes becomes fixed in the fenestra ovalis, and the laby-
rinth becomes the seat of disease. As already remarked,
Weber-Liel thinks that the starting-point of these serious
changes may be either central, reflex, or vaso-motor. The
less severe complaint described by Woakes is, according to
that physician, always of vaso-motor origin. He believes
that in such cases the nerve force, especially of the sympa-
thetic system, is exhausted.

Prognosis. — In the nervous cases the age and condition of
the patient must be taken into account. If the subject of
the affection be a person worn out by disease, overwork, or
anxiety the prognosis is very unfavourable. The tendency
towards permanent loss of hearing is indeed so marked
in this class of cases that Weber-Liel, who first described
them, calls the affection "progressive deafness." The
presence of tinnitus must also always be a matter of serious
import.

When the disease is due to adenoid growths a favourable
prognosis may be given, as the vegetations can always be got
rid of. In other cases of a mechanical nature the prospects
of the patient must depend on the possibility of removing
the cause of the obstruction.

Treatment. — The nervous cases should be treated in the
early stage by inflation of the Eustachian tube by Politzer's
method, if the tube responds to that treatment, and if not,
by means of the catheter. Intra-tubal galvanism has been
found useful by Weber-Liel in the commencement of the
more severe type of the disease, and Woakes asserts that it
is of very great service in the slighter cases. Von Troltsch 1
maintains that the act of gargling, by exercising the palato-
pharyngeal muscles, is often beneficial. In the later period
of the disease, when secondary changes have taken place
in the middle ear, nothing remains but the doubtful opera-
tion of paracentesis of the tympanum and tenotomy of the
tensor tympani. Long before the complaint has reached
this stage, however, constitutional treatment should have
been carried out. The patient ought, if possible, to be re-
lieved from worry and anxiety; if overworked he should
diminish his labours or desist from them altogether and seek
change of scene, whilst his system should be invigorated in
every possible way. Nerve-tonics, especially phosphorus and
1 "Archiv. f. Ohrenheilkunde," Bd. iv. p. 140.

544

DISEASES OF THE THROAT AND NOSE.

strychnia, are useful in some cases, whilst for the ansemic,
preparations of iron are more beneficial.

Where the disease depends on actual obstruction the cause
must, if possible, be removed. Adenoid growths must be
got rid of in the manner already indicated (p. 502, et seq.).
Syphilitic webs and enlarged veins should, if possible, be
destroyed with the electric cautery, oedematous swellings
must be scarified, and exostoses, if they can be reached,
should be broken off with curved forceps.

APPENDIX.

SPECIAL FORMULA FOR TOPICAL REMEDIES,

MOST OF WHICH ARE CONTAINED IN THE THROAT HOSPITAL
PHARMACOPEIA.

Those Formulae which are printed in black (Egyptian) type have
been found of especial use by the Author.

FORMULAE FOR INHALATIONS HAVE ALREADY BEEN GIVEN (VOL. I.,
pp. 573 — 576), AND FOR LOZENGES (Ibid. p. 578).

BUGIXARIA.

MEDICATED bcmgies are useful in chronic affections of the nasal
passages. The indications for the employment of the different
kinds of buginaria will be gathered from their constitution.
The basis of the bougie is "gelato-glycerine," which con-
sists of gelatine, glycerine, and water, in the following
proportions : —

R. Refined Gelatine (by weight) §v.
Glycerine „ Jvj.

Water „ §vj.

Soak the gelatine in the water for twelve hours, with
occasional stirring, add the glycerine, dissolve in a water-
bath, and evaporate to produce fifteen ounces by weight of
the gelato-glycerine. In making bougies the gelato-glycerine
must be melted, the medicament added, and the substance
poured into moulds of such a shape that eacli bougie has
a length of eight centimetres, and is of a tapering form
(Fig. 93), the diameter of the larger end being eight
millimetres, and that of the smaller extremity three

VOL. II. N N

546 APPENDIX.

millimetres. The annexed wood-cut shows the shape <>f
the bougie as it is made in tin- mould.

Via. 93. — THE NASAL MKI>ICAII.I> 15i>n;iK.

When required for use it can, of course, !»• shortened or
pared down if desired. The following may be taken as a
typical formula : —

R. lodoform, in fine powder, gr. ss.
Glycerine, ny.

Rub together, and add the mixture to

Gelato-glycerine, melted in a water-bath, gr. xl.
Mix and pour into the mould. When solidified, remove
for use.

Uuginarium Acidi Carbolic! (Acid. Carbol. gr. ss., Gelato-
Glycerini, gr. xl.).

„ Bismuth! (Bismuth. Subnitrat. gr. v., Gly-
cerin! N\iij., Gelato-Glycerini gr xl.).
„ Cupri Sulphatis (Cupri Sulph. Pulverisati

gr. -j-g-, Gelato-Glycerini gr. xl.).
„ lodoformi (lodoformi Pulverisati gr. ss., Gly-
cerin! TTjj., Gelato-Glycerini gr. xl.).
,, Morphiae (Morph. Acetat. gr. 11T7, Gelato-
Glycerini gr. xl.).
,, Plumbi Acetatis (Plumbi Acetat. gr. ss., Gly-

cerini §ij., Gelato-Glycerini gr. xl.).
,, Thymolis (Thymol, gr. J^, Sp. Yin. Kect. 11^ ss.,

Gelato-Glycerini gr. xl.).

,, Zinc! Sulphatis (Zinc. Sulph. Pulverisati gr. ^$,

G«lato-Glycerini gr. xl.).

COLLUXARIA— XASAL DOUCHES.

Not more than twenty ounces of fluid should ever be used
for a nasal douche, and ten ounces are generally sufficient.
If an apparatus on the syphon principle l>e employed, it
should be placed just above the level of the patient's head,
in order to avoid too great force of current.

The temperature of the fluid slum Id be about 90° Fahr.

APPENDIX. 547

Astringent.

Collunarium Acidi Tannici (Acid. Tannic. gr. iij., ad §j.).
„ Aluminis (Aluminis gr. iv., ad gj.).

,, Zinci Sulpliatis (Zinc. Sulph. gr. ss., ad 33.).

Detftrt/cnt.

,, Acidi Carbolici cum Soda et Borace (Acid.

Carbol. gr. iv., Sodae Bicarb, gr. xij.,
Boracis gr. xij., Aquae |j.).

,, Potassse Permanganatis (Sol. Potass. Per-

mang., B.P.. Tl^yj., Aquam ad §j.).
„ Sodae (Sodse Bicarb, gr. xxx., ad §j.).

„ Sodii Chloridi (Sodii Chloridi, gr. xx., ad §j.).

Antiseptic.

„ Acidi Carbolici (Acid. Carbol. Puri gr. iij.,

Glycerini Tl^xx., Aquam ad §j.).

,, Zinci Sulpho-Carbolatis (Zinc. Sulpho-Carbol.

gr. ij. ad gj.).

LOTIONES— NASAL WASHES.

T]iese lotions should IK- sniffed up into the nose from
the hollow of the hand, or gently injected by means of a
small glass or india-rubber syringe. The fluid should be
made to traverse the whole length of the nasal fossae till it
trickles into the pharynx, when it must be spit out. The
lotions should be used at a temperature of about 100" Falir.

Deteiyent.

Lotio Alkalina (Sodae Bicarb, gr. xij., Acid. Carbol. gr. iss.,
Aquae &j.).

,, Ammonii Chloridi Alkalina (Sodae Bicarb, gr. vj.,
Ammon. Chlorid. gr. vj., Aquae &j.).

„ Potassae ChWatis Alkalina (Sod* 15icarb. gr. vj.,
1'otass. Chlor. gr. vj., Aquae sj.).

648 API'KNDIX.

Lotio Alkalina Composita (Sodae Bicarb., Sodae Biborat.,
Sodii Cblorid. aa. gr. vij., Sacch. Alb. gr. xv.).

The powder thus formed should In- dissolved in
nl >< >ut half a tumblerful of tepid water.1

Astringent.

,, Aluminis (Alum. gr. vj. or more, Acid. CarboL gr. iss..

Aquae §j.).
„ Ammonii Chloridi Astringens (Ammon. CMoridi

gr. vj., Aluminis gr. vj., Aquae gj.).
„ Zinci Sulphatis (Zinc. Sulph. gr. vj., Acid. Carl ml.

gr. iss., Aquae §j.).

XEBUL^E— NASAL SPRAYS.

In using these the ordinary hand-ball spray-producer
answers well. Besides a long tapering straight nozzle for
the anterior part of the nasal fossae, another, curved upwards
almost at a right angle about an inch and a half from the
point, will be required for the posterior nares.

Antiteptie.

Nebula Acidi Carbolici (Acid. Carbol. gr. iij., ad §j.).
„ Acidi Sulphurosi (Acidi Sulphurosi q.s.).

Forty to sixty drops should be used at a time. Tin-
spray should be inhaled very slowly.
,, lodi cum Acido Tannico (Tr. lodi Tl\iij., Glycerini

Acid. Tann. TT\xij., Aquam Destill. ad |j.).
„ lodoformi (lodoform. gr. xl., JEtheris, Sp. Gr.

•735, Jj.).
,, Potassae Permanganatis (Potass. Permang. gr. v.,

Aquae Destill. jy.).
,, Sodae Benzoatis (Sodae' Ben/oat, gr. xx., Aqua?

Destill. &.).

,, Zinci lodati (lodated Zinc Caustic u\ij. or more,
Aquam Destill. ad §j.).

Astringent.

„ Acidi Tannici (Acid. Tannic. gr. v., Aquae Destill.

1 Tlie autlior has constantly ]>resn-ilx-<l tliis lotion during tlie last
few years for chronic inflammatory conditions of the nares and naso-
pharynx, and with very satisfactory results.

APPENDIX. 549

Nebula Aluminis (Liq. Alumin. Chlorid. n\_iij., Aquam

DestilL ad gj.).

,, Aluminis (Alum. gr. viij., Aquae Destill. §j.).
,, Ferro-Aluminis (Ferro-Alum. gr. iij., Aquas Destill.

&)•
,, lerri Perchloridi (Ferr. Perchlor. gr. iij., Aquae

Destill. 3J.).
„ Ferri Sulphatis (Ferr. Sulphat. gr. ij., Aquae Destill.

. &)•
„ Zinci Chloridi (Zinc. Chlorid. gr. ij., Aquae Destill.

3J-)-
„ Zinci Sulphatis (Zinc. Sulph. gr. v., Aquas Destill.

s-x

Detergent.

„ Alkalina (Sodae Bicarb, gr. xv., Boracis gr. xv.,
Acid. Carbol. gr. iv., Glycerini Tt^xlv., Aquam
ad £.).

And the following, which is alluded to in the body of the
work as " Dobell's Solution." l

R. Boracis, 3j-

Glycerini Acidi Carbolici, 3ij-
Sodae Bicarbonatis, 3j-
Aquae, Oss.2

Xebula Potassae Chloratis (Potass. Chlor. gr. xx., Aquae sj.).
„ Sodii Chloridi (Sodii Chlorid. gr. v., Aquae destill.

Sedative.
„ Potassii Bromidi (Potass. Bromidi gr. xx. ad §j.).

Useful in Diphtheria.

,, Acidi Lactici (Acid. Lactic., U.S.P., TT^xxx., Aquam

Destill. ad §j.).
„ Calcis (Aq. Calcis q.s.).
,, Sodae Salicylatis (Sodae Salicylatis gr. xx., Aquas 5J.).

1 "Winter Cough." London, 1875, 3rd eel. p. 211.

'- The water should be warm. Chloride of ammonium, chlorate of
potash, or Condy's fluid may be substituted for the borax in the above
formula.

550 APPENDIX.

( K KSSYPIA MEDICATA— MEDICATED C< »TT< >X

WOOLS.

N;i-;d plugs of unmedieated cotton-wool have been used
for some time by Gottstein in cases of simple ozsena with the
happiest results. A full description of his method of apply-
ing them hits already been given in the body of the work
(p. 282 and p. 336). In wises of active inflammation or
syphilitic ulceration affecting the interior of the nose or the
naso-pharyngeal region, medicated wools, as proposed by
Dr. Woakes, answer hest, the remedy being by this means
brought into direct and constant contact with the diseased
part. The ingredients are first mixed together and dis-
solved, the wool is then to be saturated evenly with the
solution and dried by exposure to the air with a moderate
heat.

Astringent.

(Jossypium Acidi Tannici (Acid. Tannici gr. xxx., Glycerini

N\_X., Aquae 3vj., Cotton Wool, in a thin

sheet, gr. lx.).
„ Aluminis (Alum. gr. xxx., Glycerini TT^x., Aqua?

3j., Cotton Wool as above).
„ Ferri Perchloridi (Liq. Ferr. Perchlor. ^ss.,

Glycerini IT^x., Cotton Wool as above).
„ -Cubebae (Tr. Cubebse §j., Glycerini IT]_x., Cotton

Wool as above).
,, Hamamelis (Tr. Hamamel. §ss., Glycerini

M\XM Cotton Wool as above).
,, Krameriae (Tr. Kramerise sss., Glycerini n\x.,

Cotton Wool as before).

Antiwyfic and Disinfectant.

,, Acidi Boracici (Acidi Boracici gr. lx., Glycerini
n\xx., Aquae §vj., Cotton Wool as above).

„ Camphorse (Camphorae gr. xxx., ^ther. Pur.

5J., Cotton Wool as above).

N.B. — This wool should be prepared in a room
where there is neither artificial light nor fire.
„ lodi (Tr. lodi 335., Glycerini TT^x., Cotton Wool
as before).

APPENDIX. 551

Gossypium lodoformi (lodofonni gr. Ixx., JEther. Pur.
fl. 3x., Alcoholis fl. 3ij., Glycerini TT^x.,
Cotton Wool as before).
N.B. — This wool should be prepared in a roon
where there is neither artificial light nor fire.

Sedative.

„ Opii (Tr. Opii gss., Glycerini n^x., Cotton Wool
as above).

OLFACTOKIA— OLFACTOKIES.

These are dry inhalations of the nature of smelling-salts,
and should be used in the same way, i.e., a little cotton- wool
or sponge should be saturated with the medicament and
placed in a stoppered glass bottle. The remedy is to be
sniffed up the nose.

The following is very popular in Germany, and has been
alluded to in the body of the work (p. 291) as the Hager-
Brand's " Anti-catarrhal Kemedy."

R. Acid Carbolici

Liq. Ammon. Fort, aa 3v.
Alcoholis, §ij.

To l)e kept in a dark place or in a tinted glass bottle.

PASTILS.

This is a soft variety of lozenge, somewhat resembling in
appearance and consistence the "jujubes" sold by confec-
tioners. The basis of the preparation is glyco-gelatine, a
compound much employed in the manufacture of pessaries
and soluble bougies. Its adaptation to the present purpose
was advocated by Dr. Whistler ("Med. Times and Gaz,"
Xov., 1878) as a means of applying iodoform to the throat,
and as affording a ready method of prescribing lozenges to
meet the requirements of individual cases. Pastils are
especially suited to cases of inflammation of the tongue or
palate, and their mucilaginous nature gives much relief in
dryness of the throat. Their soft consistence renders them
particularly useful in cases of oasophageal disease.

Xo substances, such as tannin, rhatany, or kino, which are

552 APPENDIX.

chemically incompatible with gelatine, can be employed with
the basis.

The following is the formula for the glyco-gelatine : —

R. Refined Gelatine jy.

Glycerine (by weight) Jiiss.
Ammoniacal Solution of Carmine q.s.
Orange-flower Water §iiss.

The process to be pursued in making the basis is as
follows : — Soak the gelatine in the water for two hours, then
heat in a water-bath till dissolved; add the glycerine, and
stir well together. Let the mixture cool, and when it is
nearly cold add the carmine solution ; mix till uniformly
coloured, and set aside to solidify. After medicating, as
directed in the following formulae, it is cooled by pouring
into an oiled tray, and when solidified, cut into the required
number of pastils. One ounce of the mass will make
twenty-four.

The following is a typical formula, iodoform being taken
as an example : —

R. Iodoform, in fine powder, gr. j.
Glycerine ny.

Rub together and add the mixture to the

Glyco-gelatine (melted in a water-bath), gr. xviij.

Mix and set aside to cool, and make one pastil.

Antiseptic.

Pastillus Acidi Boracici (Boracic Acid, in fine powder, gr. ij.)
„ Acidi Carbolici (Carbolic Acid, gr. ss.)
„ lodofonni (Iodoform in fine powder gr. j., or more
or less if prescribed).

Stimulant.

„ Ammonii Chloridi (Chloride of Ammonium gr. ij.)
„ Bismuth! (Carbonate of Bismuth gr. iij.).
„ Bismuthi et Potassae Chloratis (Carbonate of
Bismuth gr. iij., Chlorate of Potash gr. ij.).

Sedative,

,, Bismuthi et Morphias (Carbonate of Bismuth gr. iij.,
Acetate of Morphia gr. j1^).

APPENDIX. 553

IN8UFFLATIONES.

(See also " Snuffs.")

The general composition of powders for this purpose has
already been described (see Vol. i. p. 580). Most of those
which are there mentioned are also available for the nasal
passages and the naso-pharynx. The following are a few
additional formulae which 1 have found very useful. Where
a vehicle is required for the medicinal agent, I generally
prefer dried maize starch. Powdered myrrh and phosphate
of lime are also occasionally serviceable in order to give
bulk to the powder. The indications for use are clearly
shown by the nature of the remedy. Two or more may
sometimes be advantageously combined together, e.g., a little
acetate of morphia or bismuth may be added to catechu or
eucalyptus if these powders are found too irritating.

Insufflatio Bismuthi Oxychloridi (gr. £ — |).x
„ Aluminis Exsiccati (gr. ss. — j.).
„ Catechu Pallidi Pulverisati (gr. £ — £).
„ Gummi Rubri (one part to two of dried maize

starch).
„ Ferri Persulphatis (one part to three of dried

maize starch).
„ Ferro- Aluminis (with an equal quantity of dried

maize starch).
„ lodoformi (gr. £ — £, with an equal quantity of

dried maize starch).

SNUFFS.

(See also " Insufflationes.")

These are chiefly useful for checking catarrh in its initial
stage. They should be taken frequently, but not for more
than forty-eight hours continuously.

R. Morphiaj Sulph. gr. ij.
Bismuth. Subcarb. 3j-
M. ft. pulv.

1 This is a more impalpable and less irritating preparation than
either the carbonate, subnitrate, or oxide of bismuth. It is also
less soluble, which renders it more adapted to produce the mechanical
effect of forming a coating over inflamed or raw mucous surfaces.

554 API'KMMX.

The following is the formula known as "Dr. Fcrricr's
Snuff,"1 or—

Fulvis Bismuth! Compositus.

R. Morphia' Hydrochlorat. gr. ij.
I'ulv. Acacia 7,ij.
Bismuth. Subnitrat. 3vj.
M. ft. pulv.

One-quarter to one-half may be used in twenty-four hours.
The following snuff is recommended by Dobell2 in chronic
post-nasal catarrh : —

R. Camphor

Tannic Acid

White Sugar

High-dried Welsh Snuff ful 3j.
M. ft. pulv.

A pinch to be taken once in the morning and evening,
and once or twice during the day. The snuff is to In-
discontinued if a fresh attack of nasal catarrh sets in,
but should be resumed on the subsidence of inflammatory

symptoms.

1 " Lancet," 1876, vol. i. p. 525.

2 Op. cit. p. 211.

555

INDEX OF SUBJECTS.

Abscess ot nasal septum, 439
Abscess, pericesophageal, 56

history, 57 ; etiology, 58 ;
symptoms, 59 ; diagnosis,
61 ; pathology, 62 ; pro-
gnosis, 63 ; treatment, 63
Acids, uusophagitis from swallow-
ing, 40
Acute cesophagitis, 26

history, 26 ; etiology, 27 ;
symptoms, 28 ; patho-
logy, 29 ; diagnosis, 31 ;
prognosis, 32 ; treatment,
32 ; cases of, 33
Adams's forceps for breaking down

the septum, 281
Adenoid vegetations of naso-pha-

rynx, 494

history, 494 ; etiology, 495 ;
symptoms, 497 ; diagnosis,
500; pathology, 501; pro-
gnosis, 502 ; treatment, 502
Adenoma polyposum in gullet, 102
Affections of . the nose in eruptive
fevers and other acute diseases,
424

Agger nasi, 233
Air-passages, chronic blennorrhoea

of, 337

Alkalies, cesophagitis from swallow-
ing, 40
Allen, Harrison, his caustic-holder,

258
American catarrh, 482

history, 482 ; etiology, 483 ;
symptoms, 489 ; patho-
logy, 490 ; diagnosis, 490 ;
prognosis, 491 ; treatment,
491

Anatomy of the gullet, 1
Anatomy of the nasal fossse, 232
Anosmia, 461

history, 462 ; etiology, 463 ;
symptoms, 467 ; patho-
logy, 467 ; diagnosis, 470 ;
prognosis, 470 ; treat
ment, 471
Antimony, cesophagitis produced

by, 41
Asthma, hay, 299

history, 299 ; etiology, 301 ;
(a) predisposing causes,
301 ; (b) exciting do., 303;
symptoms, 309 ; diagnosis,
310; prognosis, 310; patho-
logy, 310; treatment, 310
Auscultation of the cesophagus, 7
Auto-rhinoscopy, 254
Baber, Cresswell, his nasal specu-
lum, 239

Bellocq's sound, 277
Bleeding from the nose, 338

history. 338 ; etiology, 340 ;
symptoms, 344 ; patho-
logy, 346 ; diagnosis, 346 ;
prognosis, 346 ; treat-
ment, 347
BlennoiThcea, chronic, of the nose

and air-passages, 337
Blood tumours of the nasal septum,

437

Bougies, oesophageal, 10
,, method of passing, 1 1
,, nasal, 254
Brushes, ci'sophageal, 17

,, nasal, 257

Bryant's nasal auto-insufflator, 256
Bulla ethmoidalis, 234

556

INDEX OF SUBJECTS.

Calcification of oesophagus, 98
Cancer of gullet, 71

history, 71 ; etiology, 73 ;
symptoms, 78 ; pathology,
85 ; diagnosis, 90 ; pro-
gnosis, 92 ; treatment, 92 ;
table of cases, 74 ; most
frequent seat of, 87 ; sar-
coma, 97

Cartilaginous stricture of oesopha-
gus, 98
Catarrh, acute nasal, 283

history, 283 ; etiology, 284 ;
symptoms, 288 ; diagnosis,
289 ; prognosis, 290 ; pa-
thology, 290 ; treatment,
290
,, American, see chronic catarrh

of naso-pharynx

,, chronic, of naso-pharynx, 482
history, 482 ; etiology, 483 ;
symptoms, 489 ; patho-
logy, 490 ; diagnosis, 490 ;
prognosis, 491 ; treat-
ment, 491

,, chronic nasal, 312
„ dry, 324

history, 324 ; etiology, 326 ;
symptoms, 330 ; diagno-
sis, 332 ; pathology, 332 ;
prognosis, 335 ; treat-
ment, 335

,, dry, of naso-pharynx, 492
,, purulent nasal, 294
,, summer, 299

history, 299 ; etiology, 301 ;
(a) predisposing causes,
301 ; (b) exciting do., 303;
symptoms, 309; diagnosis,
310; prognosis, 310; patho-
logy, 310; treatment, 310
Caustics, a-sophagitis from swallow-
ing, 40

Choante, nasal, 232
Chronic bleniiorrhoea of the nose

and air passages, 337
Chronic catarrh of the uaso-pha-

rynx, sec catarrh
Chronic cesophagitis, 46
Cicatricial stricture of the gullet, ]

129

etiology, 130 ; symptoms,
130 ; position, 131 ; dia-
gnosis, 132 ; pathology,
132 ; prognosis, 133 ; i

treatment, 134 ; gentle di-
latation of, 134 ; forcible
dilatation of, 135
Cohen, Solis, his post-nasal syringe.

265

Coin -catchers, 20
Compression of the gullet, 158
Congenital deformities of the nose.

475

Corrosive sublimate, appearance of
oesophagus after poisoning by,
43
Coryza, 283

,, acute, in infants, 293
Curette, nasal, 277

„ Capart's, 276
Cysts in gullet, 101
Czermak, his palate hook, 248
Deformities, congenital, of the nose,

475

Deviation of the nasal septum, 431
Dilatations of the oesophagus, 114
simple, 115 ; (a) primary,
115; (b) secondary, 119 •
sacciform, 121 ; symptoms.
125 ; pathology, 125 ;
mortality in, 126
Diphtheria of the gullet, 69
Disease of the, fifth nerve or its

nasal branches, 474
Diseases of the gullet, 26
Dislocation of the nasal bom
Diverticula, traction-, 126
Douche, nasal, 259

„ Parson's, 259
Dry catarrh, 324

history, 324 ; etiology, 326 ;
symptoms, 330 ; diagnosis
332 ; pathology, :;:;-J :
prognosis, 335 ; treat-
ment, 335
Dry catarrh of the naso-phar

492
Duplay's cesophageal resonator,

,, nasal speculum, 240
Dysphagia lusoria, 213
Ecraseur, nasal, 269
,, Jarvis's, 270
,, the author's, 272
Electrode, cesophageal, 17
,, nasal, 273
,, Lbwenberg's nasal, 273
,, Lincoln's post-nasal, 273
Elsberg's nasal speculum, 241
Enchondromata of the nose, 385

INDEX OF SUBJECTS.

557

Enchondroma of the naso-pharynx,

534

Entomozoaria in the nose, 459
Epistaxis, 338

history, 338 ; etiology, 340 ;
symptoms, 344 ; patho-
logy, 346 ; diagnosis, 346 ;
prognosis, 346 ; treat-
ment, 347
Erectile tumour of the pituitary

membrane, 384
Ethmoidal fissure, 234
Examination of gullet, 6
Exostoses of the nose, 390
Feeding-bottle, rectal, 24
Feeding tube, cesophageal, 23
Fibromata in gullet, 101
Fibro-imicous polypi of the naso-
pharynx, 532
Fibrous polypi of the naso-pharynx,

504

history, 505 ; etiology, 507 ;
symptoms, 508 ; diagnosis,
510 ; pathology, 511 ;
prognosis, 512
treatment, 512

electric cautery, 513 ;
electrolysis, 514 ; liga-
tion, 515 ; removal with
the ecraseur, 516 ; evul-
. sion, 516 ; excision, 517 ;
crushing, 518 ; gouging,

518 ; thermic cautery,

519 ; escharotics, 519
preliminary operations for

gaining access to naso-
pharyngeal tumours, 520 ;

(a) nasal operations, 522 ;

(b) maxillary operations,
526 ; (c) palatine opera-
tions, 529

Fifth nerve, or its nasal branches,

disease of, 474
Fish-hooks, removal of, from gullet,

194

Fistula, tracheo-tt'sophageal, 84
Follicular disease of the naso-
pharyngeal space, sec post-
nasal catarrh
Foreign bodies in the gullet, 185

history, 185 ; etiology, 186 ;
symptoms, 189 ; patho-
logy, 192 ; diagnosis, 192;
prognosis, 193 ; treat-
ment, 193

Foreign bodies in the nose, 440
Fractures of the nose, 426
Frankel, his nasal speculum, 238
,, his post-rhinal mirror, 247
„ his palate hook, 248
Forceps, oesophageal, 18
,, ordinary polypus, 265
,, Gant's vine-scissor, 265
,, the author's punch-, 266
,, the axial polypus-, 267
,, Beverley Robinson's toothed

and locking, 267

,, Stoker's rotatory polypus-, 268
,, the author's nasal bone-,

268

,, post-nasal, 274
„ Lb'wenberg's post-nasal, 274
,, the author's sliding post-nasal,

275
, , Adams's, for breaking down the

septum, 281

Gaut's vine-scissor forceps 265
Gastrostomy, 145

history of operation, 146 ;
method of performing
operation, 146 ; manner of
feeding after operation,
150 ; statistics of opera-
tion, 150—152 ; ail van-
tages of operation, 151 ;
disadvantage of operation,
152
Glanders, 416

history, 417 ; etiology, 418 ;
symptoms, 419 ; diagnosis,
421 ; pathology, 422 ; pro-
gnosis, 423 ; treatment, 423
Goodwillie's nasal speculum, 239
Gottstein's cotton-wool tampon, 282
Grafe's coin -catcher, 20
Gross's nasal spuds, 281
Gullet, abscess of, 56

history, 57 ; etiology, 58 ;
symptoms, 59 ; diagnosis,
61 ; pathology, 62 ; pro-
gnosis, 63 ; treatment, 63
,, adenoma polyposum in, 102
.. anatomy of, 1
,, aphtha; of, 64
,, auscultation of, 7
,, cancer of, see malignant

tumours of
,, calcification of, 98
„ calibre of, 2, 3, 4
,, cartilaginous stricture of, 98

INI'KX OF SUB.IK< I-.

Gullet, cieatricial stricture of, 129
history, 129 ; etiology, 130 ;
symptoms, 130 ; position,
131 ; diagnosis, 132 ; patho-
logy, 132; prognosis, 133;
treatment, 134 ; case of,
154; geiitledilatation, 134;
forcible dilatation, 135
,, compression of, 158
,, cysts in, 101
,, dilatations of, 114

simple dilatations, 115 ; (a)
primary, 115; (b) second-
ary, 119; sacciform, 121 ;
symptoms, 125; pathology,
125 ; mortality, 126
diphtheria of, 69
diverticula in 126
examination of, 6
experiments on, 163
fibromata in, 101
foreign bodies in, 185
history, 185 ; etiology, 186 ;
symptoms, 189 ; patho-
logy, 192 ; diagnosis, 192 ;
prognosis, 193 ; treat-
ment, 193
,, inflammation of, sec oesopha-

gitis, acute, 26
,, lipomata in, 102
,, malformations of, 216

history, 217 ; etiology, 219 ;
symptoms, 222 ; patho-
logy, 222 ; diagnosis, 224 ;
prognosis, 224 ; treat-
ment, 225 ; case of, 226
,, malignant tumours of, 71 ;

cancer, 71

history, 71 ; etiology, 73 ;
symptoms, 78 ; pathology,
85 ; diagnosis, 90 ; pro-
gnosis, 92 : treatment, 92 ;
table of cases of, 74 ; most
frequent seat of, 87
,, myomata in, 102
,, neuroses of, 198
,, non-malignant tumours of, 98
polypi, 98 ; warty growths.

101 ; cysts, 101 ; fibro-
mata, 101 ; adenoma poly-
posum. 102 ; lipomata,

102 ; myomata, 102
,, ossification of, 98

,, paralysis of, 198

history, 198; etiology, 199:

symptoms, 201 ; patho-
logy, 203 ; diagnosis, 203 ;
prognosis. 204 ; treatment,
204 : ease of, 205
Gullet, ]H-rforation of, 84
polypi of, 98

jKist-moitem softening of, 22!'
relations of, ">

removal of fish-hooks from, 194
rupture of, 160

position, 164 ; history, 161 ;
etiology, 162 ; symptoms,
170: pathology, 170; dia-
gnosis, 171 : prognosis
172 : treatment. 17L' ;
of cases, 178; l'>oerlia.i\.\
case of rupture, 173; Fitx's
case of rapture, 176
,, sarcomata in, 97
,, simple stenosis of, 156
„ sounding the, 10
„ spasm of, 207

history. 207 : etiology, 208;
symptoms, 211 : diagnosis.
213; pathology, 213; pro-
gnosis, 214 ; treatment,
215

spasmodic stricture of, 90
structure of, 5
syphilis of, 105
thrush of, 64

traction-diverticula of, 126
traumatic stricture of, 91
tubercular disease of. 112
ulcer of, 38
varicose veins of, 50
warty growths in, 101
wounds of, 182
Hiematoma of the nasal septum, 437
Hiemostatie instruments, nasal. 277
Hay fever, 299

history, 299 ; etiology, 301 :
(a) predisposing causes,
301 ; (6) exciting. 303 :
symptoms, -50'.': diagnosis.
310: pi'ogiiosis,310: patho-
logy, 310 : treatment, 310
Hereditary syphilis of the nose. IK;,
Hiatus semilunaris. -j:!4
Hilton's improved snare, 269
Hypertrophy of the mucous mem-
brane of the nose, 317
Infants, <esophagitis in, 35
Inhalations, nasal, 264
Injectors, wsophageal, 17

INDEX OF SUBJECTS.

559

Insects, cesophagitis caused by stings

of, 45
Jarvis's combined tongue-depressor

and post-nasal mirror, 246
,, nasal ecraseur, 271
Letferts's spray-producer, 262
Lincoln's post-nasal electrode, 273
Lipomata in gullet, 102
Livingston's pneumatic spray-pro-
ducer, 263
Lowenberg's nasal electrode, 273

,, post-nasal forceps, 274
Lupus of the pituitary membrane, 412
Maggots in the nose, 448

history, 448 ; etiology, 454 ;
symptoms, 456 ; diagnosis,
457 ; pathology, 457 ; pro-
gnosis, 457 ; treatment,
457

Malformation of the oesophagus, 216
history, 217 ; etiology, 219 ;
symptoms, 222 ; pathology,
222 ; diagnosis, 224 ; pro-
gnosis, 224 ; treatment,
225 ; case of, 226
Malignant tumours of the gullet, sec

gullet

Malignant tumours of the naso-
pharynx, 536

Malignant tumours of the nose, 391
Massei's modification of Duplay's

nasal speculum, 241
Mucous membrane of the nose, de-
scription of, 234
,, hypertrophy of, 317
Myomata in gullet, 102
Xasal bones, dislocation of, 430
,, bougies, 254
,, brushes, 257
,, catarrh, acute, 283

history, 283 ; etiology, 284 ;
symptoms, 288 ; diagnosis.
289 ; prognosis, 290 ; patho-
logy, 290; treatment, 290
catarrh, purulent, 294
catarrh, chronic, 312
caustic-holders, 257
choana;, 232
curette, 277

Capart's, 276
,, douche, 259

Parson's, 259
,, erraseurs, 269
.litrvis's, 270
the author's, 272

Nasal electrodes, 273

Lowenberg's, 273
Lincoln's post-nasal, 273
,, forceps, 265

Gant's vine-scissor, 265
the author's punch, 266
the axial polypus-, 267
Beverley Robinson's toothed

and locking, 267
Stoker's rotatory, 268
the author's bone-, 268
Lowenberg's post-nasal, 274
the author's sliding post-
nasal, 275
Adams's, for breaking down

the septum, 281
,, fossa?, anatomy of, 232

synechiae of, 479
hfemostatie instruments, 277
inhalations, 264
inhaler, Whistler's, 264
insufflators, 255
plugs, 277

C90per Rose's, 280
Frank's, 279
Gottstein's, 282
St. Ange's, 278
,, probes, 254
,, septum, abscess of, 439
blood tumours of, 437
deviation of, 431
,, shields, 255
,, snare, 269
,, specula, 238

Cresswell Baber's, 23.T
Duplay's, 240
Elsberg's, 241
Friinkel's, 238
Goodwillie's, 239
Massei's modification of Du-
play's, 241
Schuster's, 241
Spencer Watson's, 239
Thudichum's, 239
Voltolini's, 241
Von Troltsch's modification

of Friinkel's, 238
Zaufal's funnel-, 242
,, spray-producer, anterior, 261
posterior, 262
Letterts's, 262
Livingston's pneumatic,

263

,, spuds, 281
,, syringes, 265

560

IM'KX OF SUBJECTS.

Nasal tampon, Gottstein's, 282
,, the author's temporary

sponge-, 283

Naso-pharynx, adenoid vegetations
of, 494

history, 494 ; etiology, 495;
symptoms, 497 ; diagnosis,
500 ; pathology, 501 ; pro-
gnosis, 502 ; treatment, 502
,, chronic catarrh of, 482

history, 482; etiology, 483;
symptoms, 489; pathology,
490 ; diagnosis, 490 ; pro-
gnosis, 491 ; treatment, 491
,, dry catarrh of, 492
,, enchondroma of, 534
,, fibro-mncous polypi of, 532
,, fibrous polypi of, 504

history, 505 ; etiology, 507;
symptoms, 508 ; diagnosis,
510; pathology, 511; pro-
gnosis, 512
treatment, 512

electric cautery, 513 ; elec-
trolysis, 514; ligation, 515;
removal with the ecraseur,
516 ; evulsion, 516 ; ex-
cision, 517; crushing, 518;
gouging, 518; thermic cau-
tery, 519 ; escharotics, 519
preliminary operations for
gaining access to naso-
pharyngeal tumours, 520 ;
(a) nasal operations, 522 ;
(6) maxillary operations ;
526 ; (c) palatine opera-
tions, 529

,, malignant tumours of, 536
Neuroses of the gullet, 198
Non-malignant tumours of nose, sec

nose

Nose, affections of, in eruptive
fevers, and other acute
diseases, 424

diphtheria, Vol. i. p. 185
influenza, 426
measles, 424
rheumatism, 425
scarlet fever, 424
small-pox, 425
typhoid fever, 425
anatomy of, 232
bleeding from the, 338
history, 338 ; etiology, 340;
symptoms, 344 ; pathology,

346; diagnosis, 346; pro-
gnosis, 346 ; treatment,
347

Nose, chronic blennorrhoea of, 337
congenital deformities of, 475
enchondromata of, 385
• ntomozoaria in, 459
exostoses of the, 390
fibrous polypi of, 381
foreign bodies in, 440
fractures of, 426
hereditary syphilis of, 405
hypertrophy of mucous mem-

' brane of, 317
maggots in, 448
history, 448 ; etiology, 454;
symptoms, 456; diagnosis,
457; pathology, 457; pro-
gnosis, 457 ; treatment, 457
,, malignant tumours of, 391
,, 11011 -malignant tumours of,

353

enchondromata, 385 ; erectile

tumour of the pituitary

membrane, 384 ; exostosrs.

390 ; fibrous polypi, 381 ;

osteonjrta, 387 ; papillo-

mata,^B ; polypus, 353

,, osteomata of, 387

, , papillomata of, 382

,, polypus of, 353

history, 353 ; etiology, 355 ;
symptoms, 357 ; diagnosis
363 ; pathology, 364
prognosis, 366; treatinrnt
367 ; («) evulsion, 368 ; (4
abscission, 377 ; (e) elect
cautery, 380
,, syphilitic affections of, 396

history, 396 ; etiology, 397;
symptoms, 399 ; diagnosis,
401 ; pathology, 402 ;
prognosis, 403 ; treatment,
404

(Esophageal abscess, 56
,, bougies, 10

method of passing. 11
brushes, 17
electrode, 17
feeding tube, 23
forceps, 18
injectors, 17
permanent tube, 22
resonator, 17
sound, 8

INDEX OF SUBJECTS.

5G1

(Esophagism, 207
CEsophagitis, acute, 26

history, 26 ; etiology, 27 ;
symptoms, 28 ; pathology,
29 ; diagnosis, 31 ; pro-
gnosis, 32 ; treatment, 32 ;
cases of, 33
,, chronic, 46

etiology, 46 ; symptoms,
47 ; pathology, 48 ; dia-
gnosis, 48 ; prognosis, 49 ;
treatment, 49
from stings of insects, 45
from swallowing acids, 40
from swallowing alkalies, 40
in infants, 35
phlegmonous, 37
produced by antimony, 41
traumatic, 39

history, 39 ; etiology, 40 ;
symptoms, 40 ; patho-
logy, 43 ; diagnosis, 43 ',
prognosis, 44 ; treatment,
44

(E.sophagoscope, Bevan's, 14
,, Semeleder's, 13
,, Stoerk's, 15
,, the author's, 15
,, Waldenburg's, 14
(Esophagoscopy, 13
(Esophagostomy, 139

history of the operation,
139 ; method of perform-
ing, 142 ; advantages of,
144 ; disadvantages of,
145

(Esophagotome, 21
(Esophagotomy, external, 196
,, internal, 136

advantages of, 137 ; dis-
advantages of, 138
(Esophagus, abscess of, 56

etiology, 58 ; symptoms, 59 ;
diagnosis, 61 ; pathology,
62 ; prognosis, 63 ; treat-
ment, 63

adenoma polyposum in, 102
anatomy of, 1
aphtha of, 64
auscultation of, 7
calcification of, 98
calibre of, 2, 3, 4
cancer of, see malignant

tumours of

,, cartilaginous stricture of, 98
VOL. II.

(Esophagus, cicatricial stricture of,

129

history, 129 ; etiology, 130 ;
symptoms, 130 ; position,
131 ; diagnosis, 132 ; patho-
logy, 132; prognosis, 133:
treatment, 134 ; case of,
154 ; gentle dilatation of,
134 ; forcible dilatation
of, 135

„ compression of, 158
,, cysts in, 101
,, dilatations of, 114

simple, 115 ; (a) primary,

115 ; (b) secondary, 119
sacciform, 121

symptoms, 125; pathology,
125 ; mortality in, 126
„ diphtheria of, 69
,, examination of, 6
„ fibromata in, 101
,, foreign bodies in, 185

history, 185 ; etiology, 186 ;
symptoms, 189 ; patho-
logy, 192 ; diagnosis, 192 :
prognosis, 193 ; treat-
ment, 193
,, lipomata in, 102
,, malformations of, 216

history, 217 ; etiology, 219 :
symptoms, 222 ; patho-
logy, 222 ; diagnosis, 224 ;
prognosis, 224 ; treatment,
225 ; case of, 226
,, malignant tumours of, 71

history, 71 ; etiology, 73 ;
table of cases, 74 ; symp-
toms, 78 ; pathology, 85 ;
diagnosis, 90 ; prognosis,
92 ; treatment, 92 ; most
frequent seat of, 87
,, myoinata in, 102
„ non -malignant tumours of, 98
adenoma polyposum, 102 ;
cysts, 101 ; fibromata,
101 ; I'ipomata, 102 ;
myornata, 102 ; polypi,
98" ; warty growths, 101
,, ossification of, 98
,, paralysis of, 198

history, 198 ; etiology, 199
symptoms, 201 ; pathology
203 ; diagnosis, 203 ; pro-
gnosis, 204 ; treatiiu-iii
204 ; case of, 205

O O

562

INDKX OF SUK'i

(Esophagus, perforation of, 84
, polypi of, 98

post-mortem softening of, 229
relations of. .">

removal of tisli-hooks from, 194
rupture of, 160

position, 1»'>1 : history, 161 ;
etiology, 162; symptom*.
170 ; pathology, 170 ;
diagnosis. 171 : prognosis,
172 ; treatment, 172 ;
table of cases of, 178
Boerhaave's case of, 173
Dr. Fitz's case of, 176
,, sarcomata in, 97
,, simple stenosis of, 156
,, sounding the, 10
.. *pasui of, 207

history, 207 ; etiology, 208 ;
symptoms, 211 : diagnosis.
2~13 ; pathology, 213 ;
prognosis, 214 ; treatment,
215

,, spasmodic stricture of, 90
., structure of, 5
,, syphilis of, 105
,, thrush of, 64
,, traction -direrticula in, 126
,, traumatic stricture of, 91
,, tubercular disease of, 112
„ ulcer of, 38
,, varicose veins of, 50
,, warty growths in, 101
,, wounds of, 182
Ossification of (esophagus, 98
Osteomata of the nose, 387
Ostium maxillare accessorium, 234
Palate-hooks, 247
Papillomata of nose, 382
Paralysis of the gullet, 198

history, 198 ; etiology. 199 ;
symptoms, 201 ; pathology,
203 ; diagnosis, 203 ;
prognosis, 204 ; treat-
ment. 204
case of, 205
Parasol probang, 19
Parosmia, 472
lYii-u'sophageal abscess, 56
Pharyngeal sound, 8
Phlegmonous cesophagitis, 37
Phosphorus, poisoning by, 41, 44
IMtuitary membrane, lupus of,

412
,, tubercular disease of, 408

Plugs, nasal, 277

Cooper Rose's, 280
K rank's, 279
St. Ange's 278
Poisons, cesophagitis caused by

corrosive, 40
Polypi of the gullet, 98
,, iibro-mucous, of the naso-
pharynx, 532

,, fibrous, of the nose, 381
,, fibrous, of the uaso-pharynx,

history, 505 ; etiology, 507;
symptoms, fiOS : diagnosis,
510 ; pathology, 511 ;
prognosis, 512
,, treatment, 512

electric cautery, fil-"> ; elec-
trolysis, ',} 1 ; ligation,

515 ; removal with the
ucraseur, 516 ; evulsion,

516 ; excision, 517 ; crush-
ing, 518 ; gouging, 518 ;
thermic cautery, 519 ;
escharotics, 519

preliminary operations for
gaining access to naso-
pharyngeal tumours.

(a) nasal operations. ',-!•>. ;

(b) maxillary operations.
526; (c) palatine ope ration*.
529

Polypus of the nose, 353

history, 353 ; etiology, 355 ;
symptoms, 357 ; diagno-
sis, 363 ; pathology. :!«;•! ;
prognosis, 366 ; treat-
ment, 367 ; (a) evulsion.
368 ; (b) abscission, 377 ;

Post-nasal catarrh, 482

history, 482 ; etiology, 483 ;
symptoms, 489 ; patho-
logy, 490 ; diagnosis, 490 ;
prognosis, 491 ; treat-
ment, 491

,, electrode, Lincoln's, 273
,, forceps, 274

Lbwenberg's, 274
the author's sliding,
,, mirror, Frankel's, 247

Jarvis's, 246
,, plug, St. Ange's 278

INDEX OF SUBJECTS.

563

Post-nasal snare, Stoerk's, 276.
Post-oesophageal abscess, 56
Post-rhinal image, 252
Probang, parasol-, 19

sponge-, 21

Rectal feeding-bottle, 24
Resonator, Duplay's cesophageal, 17
Retro-nasal catarrh, see post-nasal

catarrh

Retro-cesophageal abscess, 56
Rhinal mirror, 246
Rhinitis, traumatic, 296
Rhinobvon, 278
Rhiuoliths, 444
Rhinoscleroma, 414
Rhinoscopy, anterior, 237
,, the application of, 243
,, median, 245
,, posterior, 245
,, the application of, 251
,, by double reflection, 254
Robinson, Beverley, his toothed and

locking forceps, 267
Rose catarrh, see hay fever
Rupture of gullet, 160

history, 161 ; etiology, 162 ;
symptoms, 170 ; patho-
logy, 17/0 ; diagnosis, 171 ;
prognosis, 172 ; treatment,
172

Sarcoma in gullet, 97
Schrb'tter's porte-caustique, 257
Schuster's nasal speculum, 241
Shurly's nasal shield, 255
Smith, Andrew, his nasal insuffla-
tor, 256

his modified caustic -holder, 258
Snare, Jefferson Bettman's modifi-
cation of Jarvis's, 271
,, Hilton's improved, 269
,, Jarvis's, 270
,, the author's polypus-, 270
Sound, pharyngeal, 8

,, oesophageal, 8
Sounding the oesophagus, 10
Spasm of the oesophagus, 207

history, 207 ; etiology, 208 ;
symptoms, 211 ; diagno-
sis, 213 ; pathology, 213 ;
prognosis, 214 ; treat-
ment, 215
Sponge-probang, 21
Stenosis of gullet, simple, 156
Stoker's rotatory polypus-forceps,
267

Stricture of the cesophagus, rica-

tricial, 129

etiology, 130 ; symptoms,
130 ; position, 131 ; dia-
gnosis, 132 ; pathology,
132 ; prognosis, 133 ; case
of, 154
treatment, 134

gentle dilatation, 134
forcible dilatation, 135
,, malignant, see cancer
,, spasmodic, 90
,, traumatic, 91
Summer catarrh, see hay fever
Synechise of the nasal fossa, 479
Syphilis of the gullet, 105

,, hereditary, of the nose, 405
Syphilitic affections of the nose
396

history, 396 ; etiology, 397 ;
symptoms, 399 ; diagnosis,
401 ; pathology, 402 ;
prognosis, 403 ; treatment,
404
Tampon, Gottstein's temporary

cotton-wool-, 282
the author's temporary

sponge-, 283
Throat-deafness, 538
Thrush of the gullet, 64
Thudichum, his nasal speculum, 239
Tongue-spatulas, 251
Traction-diverticula, 126
Traumatic cesophagitis, 39

history, 39 ; etiology, 40 ;
symptoms, 40 ; pathology,
43 ; diagnosis, 43 ; pro-
gnosis, 44 ; treatment, 44
,, rhinitis, 296

Tubercular disease of the gullet, 112

„ of the pituitary membrane, 408

Tumour, erectile, of the pituitary

membrane, 384
„ malignant, of the gullet, see

gullet

of the nose, 391
of the naso-pharynx, 535
„ non-malignant, of the gullet,

see gullet

,, of nose, see nose
Turbinated bones, structure of, 236
,, occasional fourth, '2-'<:',
,, arrangement of veins ov.r. -2:{t;
„ erectile tissue covering, '236
Ulcer of gullet, 38

564

IXDHX OF KUB.MJ W.

V.'ins, varicose, of gullet, 50
Voltolini, his nasal speculum, 241

,, his pultitr-hook, 248

,, his uvula-noose, 249
Von Troltsch s modification of Friin-
kel's nasal speculum, 288

Warty growths in gullet, 101
Watson, Spencer, his nasal >|i«-.-u-

lum, 239

Whistler, his nasal inhaler, 264
Wounds of the gullet, 182
Zaufal, his funnels, 242

565

INDEX OF AUTHORS REFERRED TO.

Abercrombie, 57, 61

Abulcasis, 354, 392

Actuarius, 325

Adams, 161, 281, 282, 426, 429, 432

Adelmann, 186, 188, 506, 530

^Etius, 198, 324, 353

Albert, 146, 149, 368, 371

Albrecht, 460

Alibert, 285

Allbutt, Clifford, 7

Allen, Harrison, 258, 432, 477

Althaus, 316, 462, 463, 466, 471,

472, 474, 475
Amory, 215
Anders, 146
Andral, 65, 67, 112
Andrew, 192
Anglada, 284, 286, 306
Annandale, 83, 141, 144, 218
Ansiaux, 505, 529
Arantius, 354
Arbuthnot, 64
Aretams, 339
Arrowsmith, 99
Atherton, 195
Audibert, 51
Avicenna, 72
Axmann, 444
Ayres, 218
Azara, 449
Baber, Creswell, 239
Babington, 344
Bailey, 161
Baillie, 65, 72, 99
Baizeau, 188
Ball, 468
Ballot, 58, 63
Baraffio, 186
Baratoux, 400

Ban-as, 30

Barthez, 58, 61, 63

Bartholin, 444, 460

Basham, 131

Bassereau, 399

Baster, 205

Bastian, 308

Baud, 187, 194

Baudrimont, 519

Bauer, 462, 463, 471

Baumes, 245

Baxt, 251

Bayer, 333

Bayle, 130

Beard, 300, 301, 471

Beaussenat, 437

Becourt, 297

Begin, 197, 530

Behier, 40, 72, 74, 76, 130

Behr, 460

Behrends, 448

Belfrage, 37

Bell, 72, 114, 130, 186

Bellocq, 277, 339

Belz, 125

Bendall, 417

Bendz, 218

Benevenius, 460

Bensch, 507

Benson, 38

Berard, 437, 461

Berg, 65

Bert, Paul, 53

Bertier, 64

Bettali, 210

Betts, 477

Beutel, 72, 129

Bevan, 14

Bidau, 144

566

IM'KX "1- .U'THiiKS HKrKltUED TO.

Birrl'ivtllid, 187

I '.inflow, 236

Billard, 27, 35, 65, 106, 284

I'.illroth, 96, 107, 122, 187, 414

Birkett, 512

Blarhe, 65

Bla.'kley, 300, 302, 304, 305, 307,

310

Hlake, Clarence, 270
Blaudin, 432, 436, 505
Blasius, 114, 115, 156, 217, 440
Bleuland, 26, 57, 65, 67, 207
Blondeau, 348
I '.(..•hia, 26
Boerhaave, 65, 105, 161, 171, 173,

295, 354

Bellinger, 417, 418, 419, 420
Bonet, 462, 467, 468, 469, 470
Bonnes, 518, 533
Bonnet, 72
Bonlenave, 185, 387
Borelli, 477, 518
Bostock, 299
Bosworth, 272, 313, 320, 323, 337,

483

Botrel, 506, 530, 531
Bouchard, 422
Boucher, 218
Bouchut, 284, 293
Boulard, 188
Bourceret, 160
Bourneria, 186
Bouteille, 210
Bowman, 163
Boyd, Stanley, 161, 417
Borer, 182, 440
Bozzini, 245

Bradley, Messenger, 146
Brandeis, 481
Braune, 2, 10
Brazier, 120, 208
Breschet, 466

Bresgen, 313, 314, 360, 483, 488
Bretonneau, 70
Brinton, 209
Bristowe, 51
Broca, «15

Brodie, 217, 400, 444
Bron, 440

Brouardel, 417, 423
15ro\vn, 417

Browne, Lennox, 159, 483, 489, 492
Browne, W. N., 444
Brurkmann, 460
Bums, 50tf, 514

Bums, Von, 140, 350, 506

Bruycrimis, 341

Bryant, 107, 146, 358, 367, 368,

385, 507
Bryk, 141, 536
Buchanan, 146
Budd, 229
Biifjantz, 146

Butlin, 72, 75, 85, 88, 142
Biicking, 124
Callender, 146
Canierarius, 284
Canton, 229
Capart, 276, 495, 503
Capitan, 422
Carmichael, 61
Can-on, 210

Casablanca, 298, 425, 437, 441
Casper, 40, 43
Cassan, 156
Castresana, 187
Catlin, 373
Catti, 317
Caulet, 58, 60
Cayol, 130

Cazenave, 313, 325, 412
Celsus, 65, 324, 353, 392, 405
Chapman, 98
Charcot, 425
Charles, 161
Charous, 422

Chassaignac, 432, 434, 435, 437, 506
Chauliac, Guy de, 354
Chauveau, 204
Cheever, 140, 507, 528
Chclius, 296
Chevallier, 297
Chevers, Xonnan, 188
Chiari, 416

Chrysostome, Dion, 397
Chvostek, 112
Ciniselli, 514

Clark, Andrew, 146, 494, 507
Claubry, Gauthier de, 190
Clauder, 444
Cloquet, 284, 285, 286, 287, 325,

340, 433, 437, 462
Closset, 350
Coats, Joseph, 85, 100
Cohen, Solis, 260, 291, 313, 328,

477, 495, 502, 503, 514
Coiter, 72
Coles, Oakley, 497
Colles, W., 351, 355, 359
Cook, 444

INDEX OF AUTHORS REFERRED TO.

567

Coomes, 288

Cooper, Sir Astley, 57, 159

Cooper, Simuel, 535

Coote, Holmes, 332, 429

Coquerel, 449, 460

Corbel, 425

Cornil, 46, 290, 364, 414, 416

Courant, 207

Courvoisier, 146

Cozzolino, 326

Crato, Johannes, 325

Crequy, 351

Cripps, Harrison, 523

Cruveilhier, 65, 119,* 156, 218, 364

Cullen, 33*9

Cullerier, 538

Cumin, 130

Curling, 146

Cusack, 106

Cutter, Ephraim, 288

Czermak, 237, 246, 247 194

Czerny, 96, 133, 136

Dallas, 99, 100

Daly, 300, 308, 360, 362

Darwin, 307

Davasse, 398

David, 497

Davis, 218

Davy, 117

Daykin, 288

Dechant, 424

Decroix, 419

De Gardi, Matthias, 444

De Graef, 99

Deguise, 517

Delle Chiaje, 116

Delpech, 297, 298

Demarquay, 444, 506, 521, 530

Bendy, 123

Denonvilliers, 506

Desault, 205

Deschamps, 460, 462, 467

Desgranges, 188, 520

Deville, 398

Do war, 130

Dieffenbach, 505, 519, 521, 529

Dionis, 237

Dobell, 482

Dolan, 209

Dolbeau, 22, 136, 518

Donaldson, 367

Bonders, 284

Bryden, 161

Dubois, 99, 103, 515

Dumenil, 517, 533

Duparcque, 58, 60

Duplay, '59, 237, 251, 364, 36S.

387, 392, 393

Dupuytren, 182, 195, 357, 522
Duret, 51
Durham, 23, 146, 182, 355, 377,

385

Durston, 217
• Dusaussay, 51
Dzondi, S55, 377
Eberth, 51, 100
Ebstein, 51
Eckhold, 185, 197
Edwards, 295
Egeberg, 146
Elias, 146

Elliotson, 299, 314, 417, 423
Elsberg, 7, 136, 361
Emmert, 477
Emminghaus, 159
Erichsen, 367, 368, 385, 407
Escher, 146
Espagne, 70
Esqmrol, 199
Eustache, 505
Evans, 141
Fabricius ab Acquapendente, 325,

354

Fabricius Hildanus, 339, 344
Fabiy, 396

Fagge, Hilton-, 78, 100 156
Fauvel, 51
Fayrer, 392
Fehr, 460
Felizet, 147
Fenger, 146
F&l, 122, 384
Fergusson, 368, 371
Fernel, 72
Fernet, 476
Ferrand, 70
Ferrier, 291, 468
Fischer, 514
Fitz, 161
Flaubert, 506
Flaudin, 199
Fleming, 57, 58, 61, 437
Fletcher, 468
Follin, 59, 72, 106, 140, 1-14, 208,

364, 387
Foot, 208
Forcellini, 324
Forest, 460

Forster, Cooper, 80, 146, 507, 517
Fournier, 186

568

INHi:X OF AUTHORS RKFEKRKI) TO.

Fowler, 146, 147

Fox, 146

Frank, 335

Frank, J. P., 26, 284, 293, 340,

342, 346, 352, 464, 482
Frank, 1'., 51, 284
Frankenau, 466
Franks, Kendal, 130, 135, 326,

329

Frantzius, 449, 453
Fninkel, B., 237, 326, 328, 329,

330, 337, 343, 352, 360, 387
Friinkel, E., 326, 332, 335, 403,

408

Fri'-dt-ricq, 367
Fridberg, 115, 126
Friedreich, 284, 287
Fritsche, 76, 77
Fugier, 131
Ga'hrlieb, 448
Galen, 26, 51, 57, 72, 198, 324,

339, 353
Galhvay, 331
Gamgee, 417
Gant, 265, 368
Gaivngeot, 505, 521, 529
Gassner, 123
Gaubert, 387
Gautier, 58, 60, 62
Gay, 186
Geber, 414
Gebser, 186
Gi-ndron, 130
Gerdy, 357, 381, 392
Gerlach, 424
Gernet, 218
Gianella, 114
Gibb, 159
Gietl, 425
Gillette, 58
Glaudorp, 354, 392
Godinet, 191
Godou, 107

Golding-Bii-d, 83, 146, 496
Gonzalez, 449
Goodwillie, 239, 322, 391
Gordon, 39, 299
Gosselin, 506, 513, 515
Gottstein, 282, 319, 326, 329, 330,

333, 334, 336
Gouguenheim, 120
Gradenwitz, 120
Grammatzki, 161
Grashuis, 114
Graves, 27, 400, 417, 462, 463

Gnife, 20, 444

Greenhovr, 70

Givhant, 372

Grittin, 161

Gritti, 146

Gross, 142, 153, 280, 351, 368, 377,

511, 536
Gruber, 238
Gruner, 355, 359
Grynfeldt, 392
Guattani, 196
Gubler, 51, 52, 215
Guerin, 518
Guersant, 161
Guise, 183
Gulcke, 514
Gurlt, 427, 429
Gnye, 495, 504
Giinz, 325
Gyser, 76, 98
Habber, 460
Habermann, 238
Habershon, 31, 75, 87, 351
Hack, 300, 308, 319, 361, W'2,

447

Hadden, 51
Hadlich, 141, 159
Haken, 186
Haller, 431
Hamburger, 7, .27, 76, 172. '208.

212

Hamilton, 427, 428
Hannay, 116
Harrison, 186, 187, 423
Hartmann, 329, 358
Harvey, 538
Hanisch, 360
Heath, 146, 217, 527
Hebra, 412, 414
Hedenius, 37
Heister, 185, 355
Helmholtz, 300
Henoch, 77
Henocque, 186
Hering, 444
Herrgott, 518
Heurtaux, 385

Kevin, 185, 186, 187, 188, 195
Heyfelder, 161
Heymann, 159
Hickman, 440, 441
Hildanus, 343, 345, 348, 349
Hildebrandt, 432, 476
Hill, Berkeley, 108, 507, 521
Hillairet, 297, 298

INDEX OP AUTHORS REFERRED TO.

569

Hilton, 387
Hinton, 539
Hippocrates, 65, 207, 284, 339, 345,

353, 392, 426, 428
Hirschsprung, 217, 218, 220
Hjort, 146
Hocken, 59
Hoffmann, 199, 207, 230, 339, 340,

344, 347, 352

Holmes, Timothy, 142, 144, 226
Holmer, 141, 187, 189
Home, Sir Everard, 72, 87, 156, 210,

211

Honkoop, 26
Hope, 458

Hopmann, 382, 383, 393
Hoppe, 476
Horsey, 133, 141
Horteloup, 182, 183
Houston, 218
Howse, 148, 149
Howship, 72, 209
Hueter, 368
Huguier, 506, 530
Hume, 146
Hunt, 414
Hutchison, 465
Hiinerswolff, 306
Hyrtl, 334, 476
Icart, 505, 517
Ilott, 218
Jackson, V., 146
Jackson, Hughlings, 346, 468, 469,

473

Jacob, 449
Jacobi, 146, 147
Jacquemin, 445
Jacquin, 360
Jamain, 348
Jarjavay, 426, 438, 518
Joal, 360
Jobert, 184, 529
Joflroy, 424
Jones, Sydney, 80, 146
Jouon, 146
Jurasz, 282, 432
Kaposi, 412, 414, 416
Kappeler, 96, 141, 146
Keetley, 349
Keller, 40, 130, 133
Kern, 444
King, 443

King, Wilkinson, 161
Kirschmann, 458
Klebs, 52, 87, 116

Klose, 124

Knott, 27, 38, 106, 112, 116, 159,

182

Kohlrausch, 236
Kohts, 284, 293
Kohler, 200
Kblliker, 221
Konig, 52, 72, 89, 141
Kostlin, 444

Krause, 326, 329, 330, 334, 335
Krishaber, 23, 468, 469
Kronlein, 146
Kunze, 352
Kussmaul, 284, 293
Kiichenmeister, 278, 350
Kiihne, 123
Kiister, 146
Labbe, 533
Laboulbene, 27, 28, 30, 41, 58, 70,

102, 109, 112
Lafont, 512
Lagneau, 425
Lahory, 449
Lallemand, 218
Lamb, 219
Lancereaux, 398
Landouzy, 419
Lanelongue, 136, 146
Lange, 460
Lange, Victor, 495
Langelott, 460
Langenbeck, Von, 186, 187, 195,

197, 506

Langenbuch, 147
Langton, 146
Lanzoni, 460
Lapeyroux, 278, 350
Laprade, 188

Larrey, 182, 190, 199, 214
Laurent, 194
Lavacherie, 139
Laveran, 408
Lawrence, 525
Lawson, 441
Laycock, 340, 341
Lebert, 72, 73, 76, 84, 89
Lecceur, 425
Lediberder, 51
Le Dentu, 146, 535
Left'erts, 262, 477
Legouest, 387, 388, 389, 441, 533
Lehmann, 218
Lelut, 65
Lemaistrc, 441
Lemere, 369

OO '1

670

INDEX OF AUTHORS REFERRED TO.

Leriche, 358

Leroux, 77, 130

Leroy, 187, 194

Leube, 25

Levillaiu, 182

Levret, 355, 505

Levy, 218

Lichtenberg, 381

Lieutaud, 72

Lincoln, R. P., 507, 513, 514, 515,

521

Lindau, 119
Linneeus, 456
Little, 21
Littlewood, 146
Lockemann, 472
Longoburgensis, Bruno, 392
Longuet, 430
Lorent, 293
Lorin, 417
Low, 146

Lower, Richard, 292
Lozach, 217
Loffler, 422
Lowe, 361
Lbwenberg, 273, 289, 313, 432, 494,

495, 496, 504
Luc, 425, 437
Ludlow, 114, 123
Luschka, 117, 218, 220, 477
Liisitanus, 459
Luton, 40, 72, 107, 195
Liicke, 146, 368
MacCormac, 146, 507, 524
Macgregor, 449
Mackenzie, John, 362
Macnamara, Rawdon, 340, 341,

352

Macquart, 99
Maddock, 366
Maisonneuve, 112, 136, 437, 475,

506, 529
Malgaigne, 430
Mankiewicz, 449, 453
Manne, 505
Marchand, 121
Marechal, 460
Markusovzsky, 237
Marriques, 218
Marsh, 300
Martin, 186, 217, 326
Murtineau, 345
Maschka, 218
Masini, 336 '
Mason 146, 356, 392, 429

Massei, 241, 326, 330, 336

Mathi«-u, 355, 533

Mauriac, 398

Maury, 106, 146

Maydl, 142, 146, 149, 152

Mayern, Sir Thomas, 325

Mayo, 114

McCarthy, 146

McDonnell, 537

McGill, 146

McKibben, 214

McRuer, 377

Meckel, 219, 220

Mellor, 217

Menzel, 140

Mdplain, 188

Merkel, G., 128

Meyer, 161, 192

Meyer, H., 233

Meyer, Wilhelm, 275, 495, 497,

500, 539, 540
Meyrick, 424
Michael, 275
Michel, Carl, 237, 247, 313, 326,

329, 335, 366, 369, 371, 380,

436, 495

Middeldorpf, 1, 99, 380
Mignot, 186
Mikulicz, 16, 414
Moinel, 412
Mondiere, 27, 28, 31, 58, 59, 72,

84, 159, 186, 199, 208
Monneret, 52, 351
Monod, 140
Monro, 72, 99, 119, 161, 199, 204,

208, 210
Montaut, 200
Monti, 187
Moore, 299, 449
Moore, Milner, 146
Moquin-Tandon, 448, 449, 452, 453,

458

Morand, 377, 505, 529
Morel, 449
Morgagni, 57, 72, 77, 98, 114, 130,

159, 199, 314, 339, 344, 355,

431, 461

Morris, Henry, 146, 507, 521
Mosler, 341, 352
Mott, 505
Motta, 87
Moure, 64
Mouton, 1, 2, 224
Moxou, 106, 119, 160
Moller, 146

INDEX OP AUTHORS REFERRED TO.

571

Mulhall, 360

Muron, 511

Miiller, Max, 534

Nannoni, 505, 529

Negrier, 348

N^laton, 367, 506> 508, 509, 514,

530

Nessi, 505
Nettleship, 316
Neumann, 78, 393, 414, 511
Nevot, 186
Nicoladoni, 120, 141
Niemeyer, 64
Nisbet, 538

Notta, 463, 464, 466, 470
Nourse, 444
Ogle, 117, 123, 218, 463, 466,

468

Ohdedar, 449
Ollenroth, 201
Oilier, 506, 511, 517, 519, 525,

529, 530
Ollivier, 387
Oppolzer, 112, 116, 161
Osiander, 417
Padieu, 218
Padova, 27, 28
Pagenstecher, 218
Paget, 507
Palasciano, 526
Palletta, 30, 106, 392, 394
Pallucci, 355
Parnard, 387
Panas, 235, 532, 533
Pare, Ambroise, 182, 325, 392, 426
Parkes, 183
Parrot, 66, 67, 69
Paul of ^Egina, 324, 339, 354
Paulicki, 112
Pawlikowski, 186
Pean, 393, 437
Pellizzari, 414
Perier, 218
Peter, 289

Petit, 146, 510, 529, 535, 536
Petrequin, 449, 453
Petri, 75, 76, 87
Petrunti, 57, 58, 59, 63
Peyer, 347
Phoebus, 299
Pinard, 218
Pinel, 339, 345
Pirogoft', 371
Pirrie, 299
Plater, 444

Plenck, 538

Pliny, 324

Ploucquet, 448

Podrazki, 106, 140

Poinsot, 83, 140

Polaillon, 218

Porro, 218

Portal, 51, 476

Porter, 317, 360

Postel, 518

Pott, 392

Power, 214

Pozzi, 531

Pressat, 462, 469

Provost, 462, 469

Primus, 367

Prince, 454

Prout, 446

Puech, 344

Purton, 114, 116

Pye-Smith, 146 .

Quain, 1

Quelmalz, 431

Quincke, 230

Rabitsch, 536

Rampolla, 526

Ranse, 17, 45

Ranvier, 46, 284, 290, 328, 364

Ratton, 507, 521, 531

Rayer, 284, 417

Raymond, 347

Raynaud, Maurice, 208, 464, 472

Razoux, 458

Reeder, 367

Reeves, 142, 145, 146

Reimer, 107

Reininger, 325, 329

Reinsch, 288

Renard, 440

Rendu, 387

Rhodius, 105, 345

Richard, 506

Richet, 140, 385, 389

Riedel, 408

Riedlinus, 444

Riescl, 146

Rilliet, 58, 61, 63

RindHcisch, 87

Roberts, 300, 312

Robertson, 355, 474

Robin, 65

Robin-Masse, 506, 509, 526, 528

Robinson, Bevcrley, 267, 313, 322,

323, 326, 483, 488, 491
Rockwell, 471

572

IN'DEX OF AUTHORS REFERRED TO.

Roe, 21, 136, 139, 300, 308, 362, 444

Roederer, 218

Roger, 425

Rogerius, 392

Rokitansky, 51, 87, 90, 92, 99, 114,

115, 127
Ronaldson, 477
Roosa, 260
Rose, 146
Rose, Cooper, 279
Rosenbach, 97
Rosenmuller, 469
Rosenthal, 212
Roser, 523
Rossi, 219, 428
Roth, 514
Rouge, 326, 522
Rouse, 507
Roux, 208, 506
Rouyer, 444

Rumbold, 258, 3.13, 314, 483
Ruysch, 105, 444
Ryan, 37
Sabatier, 377
St. Ange, 278
Sainte-Marie, Gaston, 13
Sajous, 323
Salisbury, 288
Sampson, 98
Sander, 472
Sandifort, 461
Sands, 507, 521
Santorini, 233
Sappey, 2, 100, 432
Saunders, 538
Savialles, 444
Sanger, 402

Schafier, 326, 327, 333, 360, 382
Schilling, 417
Schilz, 136
Schlaeger, 472
Schmieder, 98
Schneider, 99, 284
Schnitzler, 242
Scholler, 218, 220
Schonborn, 146, 147
Schrotter, 238, 326
Schuster, 241,397,405
Schiiller, Wax, 413
Schiitz, 422
Schwartze, 540

Sedillot, 83, 146, 205, 226, 521
Seller, 289, 297, 320, 361, 435
Seitz, 70
Semeleder, 13, 246, 432, 494

Semon, 90, 341, 496

Seney, 211

Serres, 468

Seux, 65, 66, 67

Severinus, 105

Shaw, John, 210

Sigmund, 296

Simon, 186

Smith, Abbott, 299, 307

Smith, Andrew, 146, 211

Smith, Johnson, 342

Smith, Priestley, 316

Smith, R. W., 112

Smyly, Josiah, 349

Smyth, Carmichael, 161

Sommerbrodt, 159

Sonderland, 217

South, 296

Spencer, 360

Spengler, 116

Spies, 199

Spillman, 355, 387, 398, 399, 415,

445, 507, 517, 518, 523,

531

Spitta, 193
Squire, 70
Steenberg, 218
Steffen, 35, 66, 68, 70, 106
Stevenson, 208
Stoerk, 13, 15, 246, 250, 251, 276,

326, 327, 337, 359
Stoffel, 139
Stoker, Thornley, 536
Stoll, 284
Strieker, 464

Studsgaard, 136, 141, 146
Sue, 196
Sundewall, 218
Susruta, 397
Swiedaur, 538
Sydenham, 339, 352
Syme, 130, 392, 505
Symonds, Addington, 292
Taendler, 161
Tantuzzi, 414
Tardieu, 417
Tarenget, 139, 505
Tauber, 495
Tay, 146
Taylor, 40, 41
Temple, Sir William, 286
Tengmalm, 449
Tenon, 217
Terrier, 140, 141, 197
Theile, 432

INDEX OF AUTHORS REFERRED TO.

573

Thomas, 476, 507

Thouret, 444

Thuclichum, 237, 259, 355, 380, 391

Tiedemann, 448, 460

Tilanus, 218

Tillaux, 136,332,440

Tillot, 313, 326

Todcl, 163, 360

Tonoli, 100

Tornwaldt, 408

Trallianus, Alexander, 325

Travers, 159, 417

Trelat, 22, 136, 533

Trendelenburg, 70, 146, 150

Troup, 146

Trousseau, 325, 400

Tulpe, 460

Turtle, 192

Tiirck, 246, 249

Ure, 385

Vacca-Berlinghieri, 142, 197, 511

Valleix, 65, 67

Valsalva, 346, 349, 371, 538

Van Cruyek, 218

Van der Wiel, 199, 205

Van Helmont, 207

Van Meekren, 356

Van Swieten, 26, 72, 77, 199, 347,

538

Van Thaden, 146
Vater, 99
Vaii(]uelin, 284
Veillon, 536
Velpeau, 432, 437, 518
Verduc, 196
Verneuil, 146, 147, 384, 385, 393,

442, 444, 508, 517, 521,

536

Veron, 65
Viennois, 392
Vieussens, 325
Vimont, 99

Virchow, 106, 324, 417, 422, 511
Vogel, 41, 339
Voisin, 508
Volkmann, 397, 408
Voltolini, 236, 237, 238, 243, 245,

246, 248, 249, 250, 254, 360.

368, 371, 377, 380, 477,

494
Von Langenbeek, 186, 187, 195,

197

Von Trbltsch, 238, 540, 541, 543
Wagner, 69
Wagner, Clinton, 257, 358, 397

Waldenburg, 14, 124

Wales, 250

Walsham, 432, 437

Walshe, 72, 73, 191, 307

Walton, Haynes, 423

Ward, 218

Warner, 218

Waterman, 507

Watson, 139

Watson, Spencer, 239, 364, 391, 397

Watson, Sir Thomas, 64, 119. 347

Weber, 259

Weber, 449

Weber, Hermann, 295, 406

Weber, Otto, 325, 427, 429. 530

Weber-Liel, 238, 260, 539, 541

Wedel, 284

Weichselbaum, 408

Weigert, 102

Weinlechner, 414

Welcker, 432

Wendt, 464, 483, 539

Wepfer, 199, 444

Wernher, 159

Wertheim, 245

West, Charles, 70

West, of Birmingham, 106, 120,

428, 444
Westbrook, 218
Westphal, 473
AVhately, 505, 509, 518
AVhistler, 264
Whitehead, 507
AVhytt, 473

AVilks, 106, 119, 121, 156, 160
Will, Ogilvie, 507
Willett, 140

Williams, C. J. B., 161, 292
AVilliam of Salicet, 354, 392
AVilligk, 112, 218, 399, 408
Willis, 198, 205
AVilson, 200
AVoakes, 274, 336, 483, 495, 496,

539
Wohlfahrt, 448, 459

Wolff; 180

AVolzendorf, 130, 134

Worthington, 114

Wrisberg, 459

AVyman, Morrill, 300, 306

Wyss, 100

Yearsley, 538

Zaufal, 238, 270, 326. 32>. 334.

369, 503, 540
Zenker, 30, 37, 51, 62. (is. 72. 78,

.'>7 '; INDEX <>r Al'lll"!;^ i;|-;i KKKKI" T« >.

;: >4, 85, 87, 10-2, 112, 114, 114, li:,. 1 •_'•_'. l-j:;. ]-j«;. ]-j7.

11.', 116, 122, 123, 126, 127, 16(5, 167, 2 2!'. •_':•! 1

141, 156, 166, 167, 2<'* /it-si;.

, 333 /n<-k«-rkjui«ll. 283, -J:;>.

, 30, 37, 70, 7-2, 7-'-. 7."-. 355, -°,.>;. 358,

78, 85, 87, 88, 100, J02, 11 'A :57v 176, 179,

•i.xd Sons, Printers, 1'attrn' *( r linw, nml \\~ntt ojtice Court, •

OPINIONS OP THE PRESS

ON THE

FIRST VOLUME

THIS WOEK.

" This is the first volume of a comprehensive work in which Dr. Mackenzie
proposes to give a systematic account of the morbid conditions of the upper
parts of the respiratory and alimentary passages — diseases to which lie has long
and successfully devoted himself as a specialist, and upon which he is decidedly

recognized as a high authority Within a comparatively small space,

the author has compressed a vast store of information, which he has put together
with much literary skill, and supplemented by exhaustive bibliographical refer-
ences. The v?ork is practical in tone throughout. We commend it as a
thoroughly reliable text-book."— British Medical Journal.

" The work is the outcome of Dr. Mackenzie's unrivalled experience of the
affections of which he treats, and it exhibits in every part — though as was to be
expected, with some differences of more or less— the extensive research, clearness
of description, close observation, completeness with conciseness of practical
detail, and fulness of experience that Dr. Morell Mackenzie has accustomed us
to expect in his writings." — Medical Timeg and Gaze'te.

" There is no appearance of any effort at " bookmaking," no insertion of records
of cases which have not unusual or special interest ; but the reader is taken

systematically from the definition of the affection to its treatment

It would be impossible in a brief notice to give any sketch of the portion of the
work devoted to laryngeal and tracheal affections. Full of new hints for dia-
gnosis, and suggestions for treatment, we can only recommend it as a book of
reference of real value, and we say advisedly, indispensable to all who use the
laryngoscope." — Medical Press and Circular.

" We have spent a very pleasant and profitable time in reading this manual,
and we sincerely hope that it may have a very wide circulation, and become, as
we feel sure it is bound to do, the standard guide to the student and general
practitioner." — Birmingham Medical Review.

" This work is most carefully got up, and is, in fact, a small encyclopaedia upon
the subject treated of, and well worthy of a place upon the medical man's l»>ok
table. The illustrations are numerous and well executed."— Ediitl>u,-<jh Medical
Journal.

" For clear style and keen close analysis of the whole bearings of each depart-

ment of the subject, this book must be allowed to stand in the highest rank of
English contributions to medical science ; while the extensive experience of the
author, handled in his well-known candid and independent way, gives tin-
greatest force to the conclusions arrived at."— Glasgow Medical Journal.

" All who wish to acquire a knowledge of modern laryngoscopy must study this
treatise for themselves. It adds another to the list of standard works on sin-rial
subjects which have of late years appeared from the hands of men who. by
enormous experience in these special branches, are particularly well fitted to
assume the part of leaders and reliable teachers to their less favoured brethren.
. . . . There can be but one verdict of the profession on this manual— it
stands without any competitor in British medical literature as a standard
work on the organs it professes to treat of.'— Dublin Journal of M'

flWMMh

" Mackenzie's manual evinces more systematic labour in its preparation than
any of the others on the list ; and general. acknowledgment is given in the pre-
face for a certain amount of aid, without which it would have been practically
impossible for a busy practitioner to prepare a volume so copious and accurate
in its references, so exhaustive in its historic compilations. When we take into
consideration the facility of the access of British and continental authors to the
large medical and scientific libraries of the great literary centres of Europe, the
wonder is that similar avail is not more frequently resorted to. Mackenzie's
volume will remain valuable to all time for its historic interest alone. The
published records of contemporaneous observers are frequently alluded to, more
or less directly, in illustration of views accepted or criticized by the author, and
incorporated with the collated statistics and vivid impressions of probably the
most extensive personal experience in the profession on the subjects in hand,
they are wrought into a lucid exposition of the present state of our knowledge of
them." — American Journal of the Medical Sciences.

" For twenty years the reputation of Morell Mackenzie as practitioner, writer,
and teacher in this department of medicine has been unrivalled. In truth, the
history of his professional life, covering as it does the period of the inception,
growth, and full development of modern laryngoscopy, would represent almost
the history of that art; while his brilliant mental endowments, extraordinary
clinical opportunities, and systematic methods of observation, render him better
fitted to produce a work upon diseases of the throat than any specialist of his
time. To say that his book exceeds our expectations is but half to express the
satisfaction which it gives. Both from a scientific and from a literary standpoint
it is in all essentials as nearly perfect as possible. From beginning to end, its
clearness, accuracy, and conciseness are admirable, while the completeness with
which every subject is considered causes us to wonder that so much could have
been included within the limits maintained. The richness of the bibliography
is remarkable, and full credit is given in all cases to authors quoted. Details of
cases, excepting when such histories are particularly interesting or instructive,
have been omitted. Dr. Mackenzie's work is classic, and as such it must support
most amply his claim to the first position among laryngologists."--AVir }"<>;•<•
Medical Journal.

" This is in every sense a most admirable work, reflecting lasting credit upon
its distinguished author. The labour which is so well attested in every page is
truly surprising. All sources of information have been thoroughly sifted. Not
only is the bibliographical research most praiseworthy in its extent ; it is equally
so in its exactness ; to which is added the result of his own valuable experience."—
Archives of Laryngology.

"The author treats his subject in a thorough and systematic manner, and his
large experience and intimate acquaintance with the results of the labours of
others are sufficient guarantee that the book is fully up with the times."— Medical
and Surgical Reporter.

"An excellent book, as was expected from the long special experience and
known literary skill of the author. The subjects are thoroughly, and at the
same time concisely treated, and we think Dr. Mackenzie has succeeded admir-

ably in crystallizing his experience into text-book limits."— Boston Medical
and Surgical Journal.

" In the recent flood of literature of the throat the work of Mackenzie takes
an exceptional place. Unlike most of the late effusions on laryngology,
et cetera, this book owes its origin not alone to the author's desire for a reputa-
tion, but also to a real demand by the profession. It is intended as a complete
text-book on the subject, and as such it has no peer in our language. It
embraces fully the topics indicated in the title, presenting them in a practical
and thorough manner, and with but few exceptions introduces all that is really
known up to date." — Chicago Medical Revieie.

" It would be expected that the chapter upon laryngeal paralysis would be a
masterpiece, for Dr. Mackenzie was the pioneer, as he is the authority, in this
special study, and we are not disappointed. We commend it to the intelligent
physician as embracing all thus far known upon the subject. . . . This work
throughout is so condensed and complete that only a few of its features can
be noticed. As a special treatise by a specialist, it is broad and unbiased ; as a
scholarly production it is remarkable for terseness, sound sense, and good
English. If our many authors would only imitate Dr. Mackenzie's patience, care,
and candour, and be as concise and unostentatious as he, we would have not
so many books, but better ones, and fewer tired and disgusted readers. We
thank him as much for the way he has written as for what he has written."—
St. Louis Clinical Record.

"This work seems complete in every part, and coming from one of the best
known specialists in England, the views advanced are worthy of the most atten-
tive consideration." — Peoria Medical Monthly.

" No practitioner can afford to be indifferent to a publication of this character,
which brings together and formulates for the first time the results of the excep-
tionally large experience of one of the most distinguished of English specialists."
—Philadelphia Dental Cosmos.

" Prom this remm.6 of the contents it will readily be seen what a large field is
covered by the treatise. It need only be added that it seems to be very complete
in all its parts, the views held with reference both to diagnosis and treatment
carrying with them the weighty authority of one of the most able and experienced
specialists of Great Britain. The book is illustrated with a large number of
woodcuts, and is gotten up in very good style." — Canada Medical and Surgical
Journal.

" The book is one which may be read by the studious medical practitioner
with much advantage."— Canada Lancet.

" We are pleased to say that the expectations we had formed of this hook have
not merely been realised in the fullest manner, but far exceeded. Although
many of the author's scattered essays had already found their way to Germany,
we have not till now had an opportunity of considering his views in their
entirety. The publication of the present work has gratified a wish that has long
been felt, and we hardly know which most to admire— the vast opportunities for
observation which the author has enjoyed, or the thoroughness, diligence, and
impartiality with which he has handled the voluminous literature of the sub-
ject."— Deutsches Archivfiir klinuche Medicin.

" When an author like Mackenzie undertakes to write a treatise on diseases of
the throat and nose, our expectations are raised to the highest pitch, not only
because he has been working throughout the twenty years in which the diseases
of the pharynx and larynx have been studied in a really scientific manner, but
also because from the circumstances of his position he has had opportunities for
observation such as few others have enjoyed. Our hopes have been fully
realized, for although only the first part of the work has yet appeared, we
have already a handsome volume which owes its bulk neither to padding nor
diffuseness, but to such a thorough handling of the subject as is not to be
found in any other text-book. It is easy to see that the pictures of disease art-
drawn from a rich personal experience, whilst at the same time full use is made
of the labours of others."— Centralblatt fur CVmi<r.<//>.

\\ lu-ii the leading English laryngologist, as Morell Mackcii/ie must un-
doubtedly be allowed to be, publishes the results of his ripe experience ami
~tiiili.\s in a new work, high expectations are naturally excited. We arc glad to
gay that so far from our hopes being disappointed they are in many r- -
greatly surpassed. The book is written in a spirit of the utmost tlioioii-'
ami yet with careful consideration for the wants of the busy practitioner."—
ZeitKchrift fi'r k/ini.irhe Medicin.

"The author of the present work on Diseases of the Throat and Nose, which
has lately been published both iu English and in Gentian, is not unknown to our
ivaders, as we have on several previous occasions expressed our appreciation of
his writings. It is impossible to deny that Morell Mackenzie is one of the most
distinguished writers on diseases of the larynx, as well as a skilful practitioner in
i li.it special line. To a clinical experience of quite exceptional range, he adds an
unusually wide acquaintance with medical literature, and he has not only the
power of giving clear and logical expression to his ideas, but the far rarer gift of
being able ungrudgingly to do full justice to the labours of his fellow-workers."—
Wiener medizinische Presse.

" The author has certainly put his whole medical life into this excellent treatise.
No one has ever been in a better position for raising such a monument of tin-
healing art. Connected with two important hospitals, and eagerly sought after in
private practice, he has seen and made his own everything within the range of
the specialty to which he has devoted himself . More, however, than nn-i
perience was needed, viz., the power of observing facts, together with sagacity in
analysing and classifying them, and acuteness in drawing fruitful instruction
from them. To the faculty of observation Dr. Morell Mackenzie adds solid
learning, and the capacity of dealing with his subject so as to omit nothing of any
practical value. His book will live, and we are happy to recommend it to the
members of our medical fraternity."— Union Medicate.

"The work is so complete that it would be impossible, without devoting an
entire volume to the subject, to analyse its numerous chapters in detail. \\ •
only tell the reader that Morell Mackenzie's book is a perfect mine of informa-
tion."— Gazette Medicale.

" We had not previously a complete treatise on diseases of the larynx. I>r.
Moure and our colleague, Dr. F. Bertier, have now supplied this want by their
translation of Morell Mackenzie's important work." — Lyon Medical.

[CATALOGUE C]

LONDON, May, 1884.

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Organic Chemistry (being Vol. II. of the Twelfth Edition of
Fown«s' Manual of Chemistry). With Engravings. Crown 8vo, 10s.

CHILDREN, DISEASES OP.
DAY. — A Treatise on the Diseases of Children.

For Practitioners and Students. By WILLIAM H. DAY, M.D., Physician
to the Samaritan Hospital for Women and Children. Crown 8vo,
128. 6d.

ELLIS. — A Practical Manual of the Diseases

of Children. By EDWARD ELLIS, M.D., late Senior Physician to the
Victoria Hospital for Sick Children. With a Formulary. Fourth
Edition. Crown 8vo, 10s.

SMITH.— On the Wasting Diseases of Infants

and Children. By EDSTACE SMITH, M.D., F.B.C.P., Physician to
H.M. the King of the Belgians, and to the East London Hospital
for Children. Fourth Edition. Post 8vo, 8s. 6d.

By the same Author.

Clinical Studies of Disease in Children.

Second Edition. Post 8vo. [/« preparation.

STEINER.— Compendium of Children's Dis-
eases; a Handbook for Practitioners and Students. By JOHANH
STKISER, M.D. Translated by LAWSON TAIT, F.R.C.S., Surgeon to the
Birmingham Hospital for Women, <tc. 8vo, 12s. till.

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DENTISTRY.
GORGAS. — Dental Medicine : a Manual of

Dental Materia Medica and Therapeutics, for Practitioners and
Students. By FERDINAND J. 8. GOROAS, A.M., M.D., D.D.S., Professor
of Dentistry in the University of Maryland ; Editor of " Harris's
Principles and Practice of Dentistry," <fec. Royal 8vo, 14s.

SEWILL.— The Student's Guide to Dental

Anatomy and Surgery. By HENRT E. SEWILL, M.R.C.8., L.D.S., late
Dental Surgeon to the West London Hospital. Second Edition.
With 78 Engravings. Fcap. 8vo, 5s. 6d.

STOCKEN.— Elements of Dental Materia Medica

and Therapeutics, with Pharmacopeia. By JAMES STOCK.EN, L.D.S.B.C.S.,
late Lecturer on Dental Materia Medica and Therapeutics and Dental
Surgeon to the National Dental Hospital; assisted by THOMAS GADDES,
L.D.S. Eng. and Edin. Third Edition. Fcap. 8vo, 7s. 6d.

TAFT.—A Practical Treatise on Operative

Dentistry. By JONATHAN TAFT, D.D.S., Professor of Operative Surgery
in the Ohio 'College of Dental Surgery. Third Edition. With 134
Engravings. 8vo, 18s.

TOMES (C. £.).— Manual of Dental Anatomy,

Human and Comparative. By CHARLES S. TOMES, M.A., F.R.S.
Second Edition. With 191 Engravings. Crown 8vo, 12s. 6d.

TOMES (J. and C. £.).— A Manual of Dental

Surgery. By JOHN TOMES, M.R.C.S., F.R.8., and CHARLES S. TOMES,
M.A., M.R.C.S., F.R.S. ; Lecturer on Anatomy and Physiology at the
Dental Hospital of London. Third Edition. With many Engravings,
Crown 8vo. [In the prest.

EAR, DISEASES OF.

BUKNETT.— The Ear: its Anatomy, Physio-
logy, and Diseases. A Practical Treatise for the Use of Medica
Students and Practitioners. By CHARLES H. BURNETT, M.D., Aural
Surgeon to the Presbyterian Hospital, Philadelphia. With 87 Engrav-
ings. 8vo, 18s.

DALBY. — On Diseases and Injuries of the Ear.

By WILLIAM B. DALBY, F.RC.S., Aural Surgeon to, and Lecturer on
Aural Surgery at, St. George's Hospital. Second Edition. With
Engravings. Fcap. 8vo, Os. 6d.

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EAB, DISEASES Of— continued.

JONES.— A Practical Treatise on Aural Sur-
gery. By H. MACNAUGHTON JONES, M.D., Professor of the Queen's
University in Ireland, late Surgeon to the Cork Ophthalmic and Aural
Hospital. Second Edition. With 63 Engravings. Crown 8vo, 8s. 6d.

By the same Author,

Atlas of the Diseases of the Membrana

Tympani. In Coloured Plates, containing 59 Figures. With Ex-
planatory Text. Crown 4to, 21s.

POEENSIC MEDICINE.
OGSTON. — Lectures on Medical Jurisprudence.

By FRANCIS OGSTON, M.D., late Professor of Medical Jurisprudence
and Medical Logic in the University of Aberdeen. Edited by FRANCIS
OGSTON, Jun., M.D., late Lecturer on Practical Toxicology in the
University of Aberdeen. With 12 Plates. 8vo, 18s.

TAYLOR.— The Principles and Practice of

Medical Jurisprudence. By ALFRED S. TAYLOR, M.D., F.R.S.
Third Edition, revised by THOMAS STEVENSON, M.D., F.R.C.P., Lec-
turer on Chemistry and Medical Jurisprudence at Guy's Hospital ;
Examiner in Chemistry at the Royal College of Physicians ; Official
Analyst to the Home Office. With 188 Engravings. 2 Vols. 8vo, 31s. 6d.

By the same Author.

A Manual of Medical Jurisprudence.

Tenth Edition. With 55 Engravings. Crown 8vo, 14s.

ALSO,

On Poisons, in relation to Medical Juris-
prudence and Medicine. Third Edition. With 104 Engravings.
Crown 8vo, 16s.

TIDY AND WOODMAN.— A Handy- Book of

Forensic Medicine and Toxicology. By C. MEYMOTT TIDY, M.B. ; and
W. BATHURST WOODMAN, M.D., F.R.C.P. With 8 Lithographic Plates
and 116 Wood Engravings. 8vo, 31s. 6d. ,

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HYGIENE.

PARKES. — A Manual of Practical Hygiene.

By EDMUND A. PARKKS, M.D., F.R.S. Sixth Edition byF. DBCHAUJIOHT,
M.D., F.K.8., Professor of Military Hygiene in the Army Mutliiral
School. With 9 Hates and 103 Engravings, 8vo, 18s.

WILSON.— A Handbook of Hygiene and Sani-
tary Science. By GEORGE WILSON, M.A., M.D., F.R.S.B., Medical
Officer of Health for Mid Warwickshire. Fifth Edition. With En-
gravings. Crown 8vo, 10s. 6d.

MATERIA MEDICA AND THEBAPEUTICS.

BINZ AND SPARKS.— The Elements of Thera-
peutics; a Clinical Guide to the Action of Medicines. By C.
BINZ, M.D., Professor of Pharmacology in the University of Bonn.
Translated and Edited with Additions, in conformity with the British
and American Pharmacopoeias, by EDWARD I. SPARKS, M.A., M.B.,
F.R.C.P. Lond. Crown 8vo, 8s. 6d.

OWEN. — A Manual of Materia Medica ; in-
corporating the Author's " Tables of Materia Medica." By ISAHBARD
OWEN, M.D., Lecturer on Materia Medica and Therapeutics to St.
George's Hospital. Crown 8vo, 6s.

ROYLE AND HARLEY.—A Manual of Materia

Medica and Therapeutics. By J. FORBES ROYLE, M.D., F.R.S., and
JOHN HARLET, M.D., F.R.C.P., Physician to, and Joint Lecturer on
Clinical Medicine at, St. Thomas's Hospital. Sixth Edition. With 139
Engravings. Crown 8vo, 15s.

THOROWGOOD. — The Student's Guide to

Materia Medica and Therapeutics. By JOHN C. THOROWQOOD, M.D.,
F.R.C.P., Lecturer on Materia Medica at the Middlesex Hospital.
Second Edition. With Engravings. Fcap. 8vo, 7s.

WARING.— A Manual of Practical Therapeu-
tics. By EDWARD J. WARING, C.I.E., M.D., F.R.C.P. Third Edition.
Fcap. 8vo, 12s. 6d.

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MEDICINE.
BARCLAY. — A Manual of Medical Diagnosis.

By A. WHYTE BARCLAY, M.D., F.R.C.P., late Physician to, and
Lecturer on Medicine at, St. George's Hospital. Third Edition. Fcap
8vo, 10s. 6d.

CHARTERIS.—The Student's Guide to the

Practice of Medicine. By MATTHEW CHARTERIS, M.D., Professor of
Materia Medica, University of Glasgow ; Physician to the Royal In-
firmary. With Engravings on Copper and Wood. Third Edition.
Fcap. 8vo, 7s.

FENWICK.— The Student's Guide to Medical

Diagnosis. By SAMUEL FENWICK, M.D., F.R.C.P., Physician to the
London Hospital. Fifth Edition. With 111 Engravings. Fcap. 8vo, 7s.

By the same Author.

The Student's Outlines of Medical Treat-
ment. Second Edition. Fcap. 8vo, 7s.

FLINT.— Clinical Medicine : a Systematic Trea-
tise on the Diagnosis and Treatment of Disease. By AUSTIN FLINT,
M.D., Professor of the Principles and Practice of Medicine, &c., in
Bellevue Hospital Medical College. 8vo, 20s.

HALL. — Synopsis of the Diseases of the Larynx,

Lungs, and Heart : comprising Dr. Edwards' Tables on the Examination
of the Chest. With Alterations and Additions. By F. DE HAVILLAND
HALL, M.D., F.R.C.P., Assistant-Physician to the Westminster Hos-
pital. Royal Svo, 2s. 6d.

SANSOM. — Manual of the Physical Diagnosis

of Diseases of the Heart, including the use of the Sphygmograph
and Cardiograph. By A. E. SANSOM, M.D., F.R.C.P., Assistant-
Physician to the London Hospital. Third Edition. With 47 Woodcuts.
Fcap. Svo, 7s. 6d.

WARNER.— Student's Guide to Medical Case-
Taking. By FRANCIS WARNER, M.D., F.R.C.P., Assistant-Physician
to the London Hospital. Fcap. Svo, 58.

WEST.— How to Examine the Chest : being a

Practical Guide for the Use of Students. By SAMUEL WEST, M.D.,
M.R.C.P., Physician to the City of London Hospital for Diseases of
the Chest, &c. With 42 Engravings. Fcap. Svo, 5s.

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MEDICINE — continued.
WHITTAKER.— Student's Primer on the Urine.

By J. TRAVIS WHITTAKER, M.D., Clinical Demonstrator at the Royal
Infirmary, Glasgow. With Illustrations, and 16 Plates etched on
Copper. Post 8vo, 4s. 6d.

MIDWIFERY.
BARNES. — Lectures on Obstetric Operations,

including the Treatment of Haemorrhage, and forming a Guide to the
Management of Difficult Labour. By ROBERT BARNES, M.D., F.R.C.P.,
Obstetric Physician to, and Lecturer on Diseases of Women, &c., at, St.
George's Hospital. Third Edition. With 124 Engravings. 8vo, 18s.

CLAY.— The Complete Handbook of Obstetric

Surgery ; or, Short Rules of Practice in every Emergency, from the
Simplest to the most formidable Operations connected with the Science
of Obatetricy. By CHARLES CLAY, M.D., late Senior Surgeon to, and
Lecturer on Midwifery at, St. Mary's Hospital, Manchester. Third
Edition. With 91 Engravings. Fcap. 8vo, 6s. 6d.

RAMSBOTHAM.— The Principles and Practice

of Obstetric Medicine and Surgery. By FRANCIS H. RAMSBOTHAM, M.D.,
formerly Obstetric Physician to the London Hospital. Fifth Edition.
With 120 Plates, forming one thick handsome volume. 8vo, 22s.

REYNOLDS. — Notes on Midwifery: specially

designed to assist the Student in preparing for Examination. By J. J.
REYNOLDS, L.R.C.P., M.R.C.S. Fcap. 8vo, 4s.

ROBERTS.— The Student's Guide to the Practice

of Midwifery. By D. LLOYD ROBERTS, M.D., F.R.C.P., Physician to
St. Mary's Hospital, Manchester. Third Edition. With 2 Coloured
Plates and 127 Engravings. Fcap. 8vo, 7s. 6d.

SCHROEDER.— A Manual of Midwifery; includ-

ing the Pathology of Pregnancy and the Puerperal State. By KARL
SCHROEDER, M.D., Professor of Midwifery in the University of Erlan-
gen. Translated by CHARLES H. CARTER, M.D. With Engravings.
8vo, 12s. 6d.

SWAYNE.— Obstetric Aphorisms for the Use of

Students commencing Midwifery Practice. By JOSEPH G. SWAYNE
M.D., Lecturer on Midwifery at the Bristol School of Medicine.
Seventh Edition. With Engravings. Fcap. 8vo, 3s. 6d.

11, NEW BURLINGTON STREET.
10

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MICROSCOPY.

CARPENTER.— The Microscope and its Revela-
tions. By WILLIAM B. CARPENTER, C.B., M.D., F.R.S. Sixth Edition.
With 26 Plates, a Coloured Frontispiece, and more than 500 Engravings.
Crown 8vo, 16s.

MARSH. — Microscopical Section-Cutting : a

Practical Guide to the Preparation and Mounting of Sections for the
Microscope, special prominence being given to the subject of Animal
Sections. By Dr. SYLVESTER MARSH. Second Edition. With 17
Engravings. Fcap. 8vo, 3s. 6d.

MARTIN. — A Manual of Microscopic Mounting.

By JOHN H. MARTIN, Member of the Society of Public Analysis, &c.
- Second Edition. With several Plates and 144 Engravings. 8vo, 7s. 6d.

OPHTHALMOLOGY.
HIGGENS.— Hints on Ophthalmic Out-Patient

Practice. By CHARLES HIGGENS, F.R.C.S., Ophthalmic Surgeon to,
and Lecturer on Ophthalmology at, Guy's Hospital. Second Edition.
Fcap. 8vo, 3s.

JONES. — A Manual of the Principles and

Practice of Ophthalmic Medicine and Surgery. By T. WHARTON JONES,
F.R.C.S., F.R.S., late Ophthalmic Surgeon and Professor of Ophthalmo-
logy to University College Hospital. Third Edition. With 9 Coloured
Plates and 173 Engravings. Fcap. 8vo, 12s. 6d.

NETTLESHIP.—Tht Student's Guide to Diseases

of the Eye. By EDWARD NETTLHSHIP, F.R.C.S., Ophthalmic Surgeon
to, and Lecturer on Ophthalmic Surgery at, St. Thomas's Hospital.
Third Edition. With 157 Engravings, and a Set of Coloured Papers
illustrating Colour-blindness. Fcap. 8vo, 7s. 6d.

WOLFE. — On Diseases and Injuries of the Eye :

a Course of Systematic and Clinical Lectures to Students and Medical
Practitioners. By J. R. WOLFE, M.D., F.R.C.S.E., Senior Surgeon to
the Glasgow Ophthalmic Institution; Lecturer on Ophthalmic Medicine
and Surgery in.. Anderson's College. With 10 Coloured Plates, and 120
Wood Engravings, 8vo, 21s.

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PATHOLOGY.

JONES AND SIEVEKING.—A Manual of Patho-
logical Anatomy. By C. HANDFIELD JONES, M.B., F.R.S., and EDWARD
H. SIEVEKINO, M.D..F.R.C.P. Second Edition. Edited, with consider-
able enlargement, by J. F. PAYNE, M.B., Assistant-Physician and
Lecturer on Oeneral Pathology at St. Thomass Hospital. With 1%
Engraving. Crown 8vo, 16s.

LANCEREAUX.— Atlas of Pathological Ana-
tomy. By Dr. LANCERADX. Translated by W. 8. GREENFIELD, M.D.,
Professor of Pathology in the University of Edinburgh. With
70 Coloured Plates. Imperial 8vo, £5 5s.

VIRCHOW. — Post- Mortem Examinations: a

Description and Explanation of the Method of Performing them,
with especial reference to Medico-Legal Practice. By Professor
RUDOLPH VIRCHOW, Berlin Charite Hospital. Translated by Dr. T. B.
SMITH. Second Edition, with 4 Plates. Fcap. 8vo, 3s. 6d.

WILKS AND MOXON.— Lectures on Pathologi-
cal Anatomy. By SAMUEL WILK8, M.D., F.R.S., Physician to, and late
Lecturer on Medicine at, Guy's Hospital ; and WALTER MOXON, M.D.,
F.R.C.P., Physician to. and Lecturer on the Practice of Medicine at,
Guy's Hospital. Second Edition. With 7 Steel Plates. 8vo, 18s.

PSYCHOLOGY.
BUCKNILL AND TUKE.—A Manual of Psycho-

logical Medicine : containing the Lunacy Laws, Nosology, Etiology,
Statistics, Description, Diagnosis, Pathology, and Treatment of Insanity,
with an Appendix of Cases. By JOHN C. BUCKNILL, M.D., F.R.S.,
and D. HACK TUKE, M.D., F.R.C.P. Fourth Edition, with 12 Plates
(30 Figures). 8vo, 25s.

CLOUSTON. — Clinical Lectures on Mental

Diseases. By THOMAS S. CLOUSTON, M.D., and F.R.C.P. Edin.; Lec-
turer on Mental Diseases in the University of Edinburgh. With
8 Plates (6 Coloured). Crown 8vo, 12s. 6d.

MANN. — A Manual of Psychological Medicine

and Allied Nervous Disorders. By EDWARD C. MANN, M.D., Member
of the New York Medico-Legal Society. With Plates. 8vo, 24s.

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PHYSIOLOGY.

CARPENTER.— Principles of Human Physio-
logy. By WILLIAM B. CARPENTER, C.B., M.D., F.R.S. Ninth Edition.
Edited by Henry Power, M.B., F.R.C.S. With 3 Steel Plates and
377 Wood Engravings. 8vo, 31s. 6d.

DALTON. — A Treatise on Human Physiology :

designed for the use of Students and Practitioners of Medicine. By
JOHN C. DALTON, M.D., Professor of Physiology and Hygiene in the
College of Physicians and Surgeons, New York. Seventh Edition.
With 252 Engravings. Royal 8vo, 20s.

FREY.— The Histology and Histo-Chemistry of

Man. A Treatise on the Elements of Composition and Structure of the
Human Body. By HEINRICH FREY, Professor of Medicine in Zurich.
Translated by ARTHUR E. BARKER, Assistant-Surgeon to the University
College Hospital. With 608 Engravings. 8vo, 21s.

SANDERSON.— Handbook for the Physiological

Laboratory : containing an Exposition of the fundamental facts of the
Science, with explicit Directions for their demonstration. By J.
BURDON SANDERSON, M.D., F.R.S.; E. KLEIN, M.D., F.R.S.; MICHAEL
FOSTER, M.D., F.R.S.; and T. LAUDER BRUNTON, M.D., F.R.S. 2 Vols.
with 123 Plates. 8vo, 24s.

YEO.—A Manual of Physiology for the Use of

Junior Students of Medicine. By GERALD F. YEO, M.D., F.R.C.S.,
Professor of Physiology in King's College, London. With 301 Engrav-
ings. Crown 8vo, 14s.

SURGERY.
BELLAMY.— The Student's Guide to Surgical

Anatomy ; a Description of the more important Surgical Regions of
the Human Body, and an Introduction to Operative Surgery. By
EDWARD BELLAMY, F.R.C.S., and Member of the Board of Examiners ;
Surgeon to, and Lecturer on Anatomy at, Charing Cross Hospital.
Second Edition. With 76 Engravings. Fcap. 8vo, 7s.

BRYANT,— A Manual for the Practice of

Surgery. By THOMAS BRYANT, F.R.C.S., Surgeon to, and Lecturer OB
Surgery at, Guy's Hospital. Fourth Edition. With about 700 En-
gravings (nearly all original, many being coloured). 2 Vols. Crown 8vo.

[In the prest.

11, NEW BURLINGTON STREET.

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SURGERY — continued.
CLARK AND WAGSTAFFE. — Outlines of

Surgery and Surgical Pathology. By F. LE GROS CLARK, F.R.C.S.,
F.R.S., Consulting Surgeon to St. Thomas's Hospital. Second Edition.
Revised and expanded by the Author, assisted by W. W. WAGSTAFFK,
F.R.C.S., Assistant Surgeon to St. Thomas's Hospital. 8vo, 10s. 6d.

DRUITT.—Tht Surgeon's Vade-Mecum ; a

Manual of Modern Surgery. By ROBERT DRUITT, F.R.C.S. Eleventh
Edition. With 369 Engravings. Fcap. 8vo, 14s.

FERGUSSON. — A System of Practical Surgery.

By Sir WILLIAM FERGUSSON, Bart., F.R.C.S., F.R.S., late Surgeon and
Professor of Clinical Surgery to King's College Hospital. With 463
Engravings. Fifth Edition. 8vo, 21s.

HEATH. — A Manual of Minor Surgery and

Bandaging, for the use of House-Surgeons, Dressers, and Junior Practi-
tioners. By CHRISTOPHER HEATH, F.R.C.S., Holme Professor of
Clinical Surgery in University College and Surgeon to the Hospital.
Seventh Edition. With 129 Engravings. Fcap. 8vo, 6s.

By the same Author.

A Course of Operative Surgery : with

Twenty Plates drawn from Nature by M. LEVEILLE, and
Coloured. Second Edition. Large 8vo, 30s.

ALSO,

The Student's Guide to Surgical Diag-
nosis. Second Edition. Fcap. 8vo, 6s. 6d.

MA UNDER.— Operative Surgery. By Charles

F. MAUNDER, F.R.C.S., late Surgeon to, and Lecturer on Surgery at,
the London Hospital. Second Edition. With 164 Engravings. Post
8vo, 6s.

PIRRIE. — The Principles and Practice of

Surgery. By WILLIAM PIRRIE, F.R.S.E., late Professor of Surgery in
the University of Aberdeen. Third Edition. With 490 Engravings.
8vo, 28s.

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SUE GER Y — continued.

SOUTHAM.— Regional Surgery : including Sur-
gical Diagnosis. A Manual for the use of Students. BY FREDERICK
A. SOUTHAM, M.A., M.B. Oxon, F.R.C.S., Assistant-Surgeon to the
Royal Infirmary, and Assistant-Lecturer on Surgery in the Owen's
College School of Medicine, Manchester.
Part I. The Head and Neck. Crown 8vo, 6s. 6d.
„ II. The Upper Extremity and Thorax. Crown 8vo, "s. 6d.

TERMINOLOGY.
DUNGLISON.— Medical Lexicon : a Dictionary

of Medical Science, containing a concise Explanation of its various
Subjects and Terms, with Accentuation, Etymology, Synonyms, Ac.
By ROBERT • DUNGLISON, M.D. New Edition, thoroughly revised by
RICHARD J. DUNGLISON, M.D. Royal 8vo, 28s.

MAYNE. — A Medical Vocabulary : being an

Explanation of all Terms and Phrases used in the various Departments
of Medical Science and Practice, giving their Derivation, Meaning,
Application, and Pronunciation. By ROBERT G. MAYNE, M.D., LL.D.,
and JOHN MAYNE, M.D., L.R.C.S.E. Filth Edition. Crown 8vo,
10s. 6d.

WOMEN, DISEASES OP.
BARNES.— A Clinical History of the Medical

and Surgical Diseases of Women. By ROBERT BARNES, M.D., F.R.C.P.,
Obstetric Physician to, and Lecturer on Diseases of Women, &c., at, St.
George's Hospital. Second Edition. With 181 Engravings. 8vo, 28s.

CO URTY.— Practical Treatise on Diseases of

the Uterus, Ovaries, and Fallopian Tubes. By Professor COURTY,
Montpellier. Translated from the Third Edition by his Pupil, AGNKS
M'LAREN, M.D., M.K.Q.C.P. With Preface by Dr. MATTHEWS DUNCAN.
With 424 Engravings. 8vo, 24a.

DUNCAN. — Clinical Lectures on the Diseases

of Women. By J. MATTHEWS DUNCAN, M.D., F.R.C.P., F.R.S.E.,
Obstetric Physician to St. Bartholomew's Hospital. Second Edition,
with Appendices. 8vo, 14s.

EMMET. — The Principles and Practice of

Gynaecology. By THOMAS ADDIS EMMET, M.D., Surgeon to the
Woman's Hospital of the State of New York. With 130 Engravings.
Royal 8vo, 24s.

11, NEW BURLINGTON STREET.

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WOMEN, DISEASES OP— continued.

GALABIN.—The Student's Guide to the Dis-
eases of women. By ALFRED L. GALABIN, M.D., F.R.C. P., Obstetric
•Physician to, and Lecturer on Obstetric .Medicine at, Guy's Hospital.
Third Edition. With 78 Engravings. Fcap. 8vo, 7s. 6d.

REYNOLDS.— Notes on Diseases of Women.

Specially designed to assist the. Student in preparing for Examination.
By J. J. REYNOLDS, L.R.C.P., M.R.C.S. Second Edition. Fcap. 8vo,
2s. 6d.

SMITH.— Practical Gynaecology : a Handbook

of the Diseases of Women. By HEYWOOD SMITH, M.D., Physician to
the Hospital for Women and to the British Lying-in Hospital. With
Engravings. Second Edition. Crown 8vo. [In preparation.

WEST AND DUNCAN.— Lectures on the Dis-
eases of Women. By CHARLES WEST, M.D., F.R.C.P. Fourth
Edition. Revised and in part re-written by the Author, with numerous
additions by J. MATTHEWS DUNCAN, M.D., F.R.C.P., F.R.S.E.,
Obstetric Physician to St. Bartholomew's Hospital. 8vo, 16s.

ZOOLOGY.

CHAUVEAU AND FLEMING.— The Compara-

tive Anatomy of the Domesticated Animals. By A. CHAUVEAU
Professor at the Lyons Veterinary School ; and GBORGE FLEMING
Veterinary Surgeon, Royal Engineers. With 450 Engravings. 8vo,
31s. 6d.

HUXLEY. — Manual of the Anatomy of Inverte-

brated Animals. By THOMAS H. HUXLEY, LL.D., F.R.S. With 156
Engravings. Post 8vo, 16s.

By the same Author.

Manual of the Anatomy of Vertebrated

Animals. With 110 Engravings. Post 8vo, 12s.

WILSON.— The Student's Guide to Zoology :

a Manual of the Principles of Zoological Science. By ANDREW WILSON,
Lecturer on Natural History, Edinburgh. With Engravings. Fcap.
8vo, 6s. Cd.

11, NEW BURLINGTON STREET.

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