present state of our knowledge rendered it possible for us to drop the term, or some equivalent of it.

He strongly endorsed what had been said as to the importance of constitutional as well as local treatment, and the necessity for a prolonged and thorough course in order to accomplish satisfactory results.

Dr. D. N. RANKIN, of Allegheny, Pa., read a paper entitled

SOME REMARKS ON THE HISTORY OF RHINOLOGY.

QUELQUES REMARQUES SUR L'HISTOIRE DE LA RHINOLOGIE.

EINIGE BEMERKUNGEN ÜBER DIE GESCHICHTE DER RHINOLOGIE.

BY D. N. RANKIN, A. M., M.D.,
Allegheny, Pa.

Until a comparatively recent date the nasal cavities have been sadly neglected. This neglect is more surprising in face of the fact that the nares furnish the natural medium for respiration; that they are the organ of smell, thereby protecting the lungs from the inhalations of deleterious gases, and assisting the organ of taste in discriminating the properties of food; and as an adjunct to the vocal apparatus in making a pleasant voice, they are indispensable.

It is certainly very desirable to have an acute sense of smell, though it is not so important as some of the other senses.

Of its pleasures, let me here mention a few: Every hill, and vale, and shore is tributary to the sense of smell. There appears to be a scale in odors with respect to the pleasures which they excite in the organ of smell. The rose appears to be at the head of this scale, the shrub next, the pink, the jessamine, the tuberose, the honeysuckle, the sweetbriar, all gradually descend from it. The pleasure derived from odors is much increased by mixture. There can be little doubt that these odors are so related to each other as to produce from different mixtures greater or less degrees of harmony analogous to the vibrations of musical sounds.

The odor of flowers, certain vegetables, and meats in the process of cooking, is not only pleasant, but nutritious and medicinal, from the stimulus it imparts to the whole system through the medium of the sense of smelling. Country air owes one of its beneficial effects on invalids to this cause.

The sense of smell is liable to be perverted, as we see in the artificial pleasure which some people derive from the fetor of the civet, musk, asafoetida, and even of the snuff of a candle.

Who that never saw or experienced it, would believe that the odor of the rose could produce fainting, or that the heliotrope and the tuberose have made some persons asthmatical. The smell of musk, so grateful to many people, sickens some.

It is well known that the sense of smell guides many of the lower animals to their food, or warns them of danger, as is exemplified in the hunting dog. The distance at which a dog tracks his master is scarcely credible.

The acuteness of the sense of smelling in animals is such that in many instances our observations have been deemed fabulous. Birds of prey will scent the battle field

at prodigious distances, and they are often seen hovering instinctively over the ground where the conflict is to supply their festival.

Ancient historians assert that vultures have cleft the air one hundred and fifty leagues to arrive in time to feast upon a battle field.

Whence comes it that the red-wing, that passes the summer in Norway, or the wild duck, that summers in the woods and lakes of Lapland, is able to track the pathless void of the atmosphere with the utmost nicety, and arrive on our own southern coasts uniformly in the beginning of October.

It has been observed that animals which possess the most acute smell have the nasal organs the most extensively developed. The American Indians are remarkable for the acuteness of this sense, which accounts for their wonderful power of tracking their enemies.

By a glance over the text-books, you will find in the chapter on nasal diseases that they do not receive that attention they deserve. It is an undeniable fact, that perhaps no department of medicine has been so much invaded by quacks. It is true they often acquire reputation and wealth, but this must be ascribed to the credulity of their patients, and to the zeal with which they exaggerate and advertise their cures, or palliate or deny their mistakes.

It has been said, and well said, that quacks are the greatest liars in the world, except their patients. "Quacks and impostors," said Lord Bacon, "have always held a competition with physicians."

Galen observed that patients placed more confidence in the oracles of Esculapius and their own idle dreams, than in the prescriptions of doctors.

No science has been cultivated with more difficulty than that of this specialty. Sir Astley Cooper used to complain that a knowledge of the nasal cavities is by no means general in the profession, and still less are their diseases understood.

Compare the armamentarium of thirty years ago with the outfit of the nasal specialist of to day. What was it previous to thirty years ago? Literally nothing; no perfect rhinoscope, no insufflator, no inhalers, no galvano-cautery, no incandescent light, no sponge holders, no guillotine, no ecraseur, no snares. A single pair of polypus forceps and a cumbersome nose speculum constituted the set. While visiting the mountainous districts of western Pennsylvania, some years ago, I went into the office of the village doctor to pay my respects. He was a man of perhaps seventy years of age. In conversation I inquired if he had much nose and throat disease to treat. He said he had considerable of that class of disease to look after. He then exhibited his nose and throat instruments, which consisted of a tongue depressor and polypus forceps. He informed me that the tongue depressor was made by the village blacksmith. Our forefathers depended principally upon general treatment and snuffs, as then treatment locally was not thought of. If a person was unfortunate enough to have any of the many forms of disease of the nasal cavities, it was allowed to progress uninterruptedly, short of a constitutional treatment.

It appears from historical accounts that the ancients, especially the Egyptians, made rhinoscopic examinations, but with what success is not stated. Since Prof. Czermak, of Pesth, conceived the idea of, and introduced to the attention of the profession, the rhinoscope, wonderful indeed has been its utility in diagnosing affections of the nares which previously had been very unsatisfactory and obscure. The usefulness of the rhinoscope, however, would have been greatly lessened had it not been for the ingenuity of other eminent rhinoscopists, who have devised many useful surgical instruments as well as means for making therapeutical and electrical applications to the nasal cavities, whereby local applications can as readily be made to the posterior nares as to the pharynx. Czermak has done for the nasal organs what the illustrious Laennec has done for the organs of respiration.

The therapeutics of the nares have kept pace with the surgical and electrical pro

Vol. IV-2

cedures of that organ. Among the many excellent remedies that have been locally utilized, I would merely mention four-iodoform, bismuth, chromic acid and cocaine. The general practitioner, when summoned to see a case of nasal disease, is too often satisfied with ȧ too superficial examination. Generally, he raises the point of the nose somewhat, and then the vague pronunciations are uttered: "high up in the nares," or 'deep down in the nares," or, in the case of a child, "let it alone, it will grow out of it." Therefore, it cannot be wondered at that the diagnosis and treatment of nasal diseases have been in a mixed condition.

66

We live, gentlemen, in a revolutionary age; our science has caught the spirit of the times, and more improvements have been made in this specialty within the past twentyfive years than had been made in a century before. From these events, so auspicious to our department, we may cherish a hope that advancement may draw nearer perfection. Great Britain is entitled to a large share of the influence in the advancement of this specialty. It has contributed much to this movement by careful clinical observations of diseases of the nose, and by numerous contributions to our anatomical and physiological knowledge of nasal diseases. The German spirit, recognizing the importance of this new era, joined in, hand in hand. Austria, Denmark, Russia, France, Spain and Italy are all well represented by men eminent in this specialty.

America, never behind in anything that conduces to the benefit of mankind, is represented by men of marked ability as writers and teachers, as well as successful practitioners in this department.

The American Laryngological Association and the American Rhinological Association are institutions we feel proud of. The former, with a fellowship of over fifty members, is composed of the very best talent in this country, who have already made their mark, and are still actively engaged in prosecuting their valuable labors. The American Rhinological Association, being of recent origin, is composed of excellent material and doing good work. It was my good fortune, during the last meeting of the International Medical Congress at Copenhagen, Denmark, to meet most of the gentlemen of the Laryngological Section, and without a single exception those I met were persons of the highest medical attainments, and gentlemen in every sense of the word. Here permit me to say a word in memory of the father of Rhinology and Laryngology in America. I refer to the late Lewis Elsberg, a man whose memory we should all revere, as not only a gentleman and scholar, but most eminent in Rhinology and Laryngology. He unquestionably did much to advance these specialties.

Dr. Daly

To America is due the credit of bringing rhinology to its present status. has doubtless done more to accomplish this end than any man in this country. The ample means we now possess of investigating diseases of the nares, and the facility with which the true nature of these diseases is arrived at, is certainly very encouraging.

Comparing rhinology to a house, the different stories of which have been erected by different architects, Czermak, Elsberg, etc., have a large claim to our gratitude for having, by their arduous and successful labors, advanced the building to its present height. It belongs to the rhinologists of the present and future generations to place a roof upon it, and thereby complete the fabric of rhinology.

DISCUSSION.

Dr. M. F. COOMES, of Louisville, Ky., remarked: In 1859, Dr. Troupe Maxwell, of Kentucky, had a mirror constructed, and obtained a view of the vocal cords, not the posterior nares. He was certainly the first American to use a mirror for looking at the vocal cords.

SECOND DAY.

The Section was called to order at 11 A. M., the President in the chair.
Mr. LENNOX BROWNE, of London, read a paper entitled-

RECENT VIEWS ON THE PATHOLOGY AND TREATMENT OF TUBER-
CULOSIS OF THE THROAT AND LARYNX.

APERÇU RÉCENT SUR LA PATHOLOGIE ET TRAITEMENT DE LA TUBERCULOSE

DE LA GORGE ET DU LARYNX.

NEUE ANSICHTEN ÜBER DIE PATHOLOGIE UND BEHANDLUNG DER TUBERKULOSE DES
SCHLUNDES UND KEHLKOPFES.

BY MR. LENNOX BROWNE, F. R. C. S., EDIN.,

London.

At the present time it is almost universally accepted that the tuberculous process is
initiated by the settlement of a specific bacillus on a suitable nidus, or, as it was form-
erly called, at the spot of least resistance. This bacillus is of the nature of a fungus,
and partakes of the special characteristic of all fungi, in that it requires for its growth a
soil in which organic decay is taking place. Bacilli gain access to the lungs by means,
primarily, of the main air passages; they may be deposited at a portion of the lung,
for example, an apex, which is ill supplied with blood and especially with air, or in
the altered pulmonary tissue which invariably exists after an acute lung disease; of
this we see an example in the case of tuberculosis following basal pneumonia.

Like all parasites, bacilli are highly irritating, expression of which quality is evi-
denced in the formation of the miliary tubercle, a tissue of very low vitality, prone to
break down. As to whether the bacilli reach the tissue through a break of epithelial
continuity, by diapedesis or otherwise, is a question which cannot now be entered on.
What we do know is that the bacilli, having once established themselves, multiply in
large numbers, and this circumstance leads not only to a local increase in the morbid
process, but also to access of bacilli to the general circulation by the lymphatic system.
When the tubercles are broken down so as to form cavities, bacilli are more or less
abundant in the sputa. It is thus evident that bacilli may arrive at the region of the
larynx by at least two routes.

Taking into account the fact that tuberculous infiltration usually invades the deeper
tissues of the larynx at an early period of the disease, and before any breach of con-
tinuity of surface, I am inclined to the conclusion that when laryngeal phthisis follows
a pulmonary disease of the same nature, the tubercles are transplanted through the
systemic circulation. Without doubt, however, it occasionally happens that there is
direct infection by the sputa through a breach of surface, the result of a coincident
catarrhal laryngitis more or less acute. But, as a general rule, there must be in the
larynx, as in the lungs, a condition of local receptivity. One factor, at least, of this
predisponent is that of anemia. This is manifested preferably at marginal and apical

regions of the larynx, as of the lungs, and we thus find that the general seats of earliest infiltration are the inter-arytenoid space, the coverings of one or both of the arytenoid cartilages, the ary-epiglottic folds and the epiglottis. On the other hand, in those cases in which functional abuse is an exciting cause of the local process, the tumefaction may first occur in the vocal cords and the ventricular bands. In this last class of cases, and in some few others not due to functional causes, the first condition is one of persistent hyperæmia instead of anæmia, and instances will occur to every practitioner illustrative, in its special application to the throat, of Trousseau's dictum, that a neglected catarrh is often a consumption commenced. There is, in fact, a condition of the larynx predisposing to tuberculous deposit very analogous to that of an unresolved pneumonia.

Ulcerations of laryngeal phthisis are characterized by their small size, their multiple character, and their tendency to coalesce and to extend laterally rather than to penetrate deeply. As before mentioned, erosions non-tuberculous in character may appear in the larynx of a tuberculous patient the subject of a fortuitous catarrh. Doubtless, some of those that heal under treatment are of this nature. It remains to say a few words as to the mode of origin of tuberculous manifestations in the fauces. A long experience has assured me that disorders of absorption, assimilation, and digestion generally play a far more important part in the production of faucial, tonsillar and pharyngeal inflammations than any faults of atmosphere, climate or even exposure to cold and damp, these last preferably and mainly affecting the respiratory tracts. When the pharynx is attacked in the case of an advanced pulmonary or laryngeal phthisis, we may not presuppose a breach of surface to be absolutely necessary for infection of this region by bacilli contained in the sputa and oral fluids, but we may postulate that the absorption of the liquid portions of the contaminated oral secretions must lower the vitality of the faucial and pharyngeal mucous membrane; in fact, a nidus is formed for the settlement of bacilli brought thither by the general circulation. When the fauces are primarily attacked we must admit the probability of a previous breach of continuity. I have reported a case in which the local irritation of diseased teeth, as evinced by marked improvement following their extraction, was the exciting cause of a tuberculous ulceration of the gums and mouth.

In my experience, evidence of the tuberculous process is manifested later in the fauces than in the larynx, but, as I could show by relation of many cases, this region may be attacked at any stage of the disease; several circumstances, especially the now well known case of Demme*, have confirmed the opinion long entertained, though until recently unsubstantiated, that laryngeal phthisis may precede the pulmonary disease, † and it is quite possible that similar evidence will be afforded regarding the fauces and pharynx. At present we are not in a position to do more than assume its probability.

Some six and a half years ago I reported, in conjunction with Dundas Grant, two cases-one arising, as just recorded, from direct irritation of decayed teeth, in which the first manifestation in the mouth and fauces had occurred between two and three years previously to any chest attack, or even before the suspicion of pulmonary disease. Last December I exhibited a patient at the Medical Society of London, and I have

* Demme's case is that of a boy aged four and a half years, who died of tubercular meningitis; the necropsy showed the presence of laryngeal ulceration with tubercle bacilli; the thoracic and abdominal organs being at the same time free from tubercular disease.

Ziehl has also related a very pertinent example, in which a woman was tracheotomized for laryngeal stenosis. The pulmonary secretions, which could thus be perfectly separated from those of the larynx, were free of bacilli, while those taken directly from the laryngeal ulceration contained them.