Diseases of the nose and throat; a text-book for students and practitioners

Front matter

©fjap Capi^M i/c-

UNITED STATES OF AMERICA.

DISEASES

Preface

Although the following pages are especially intended for practical aids to the advanced medical student and general practitioner, it is hoped that they will also prove of value to the specialist in affections of the nose and throat. It was intended, at first, to treat each division exhaustively; but, when the material was, collected, it was seen that the book would be too unwieldy for the student and not sufficiently concise for the general practitioner. Only sufficient anatomy and physiology of the nose and throat have been given to render clear the remaining text.

In preparing the therapeutic indications it has been my endeavor to present a few of the remedies which are characteristic and reliable ; it is, however, not always easy to separate the true from the spurious. Where possible, I have tested the various symptoms recorded, and, finding most of them reliable, have allowed them to stand upon their own merits. Those remedies which have disappointed, where I have been taught to expect much, have been divided into two classes : First, those which have failed in a few instances, but have not been expunged, as failure may have been due to the fact that the remedy was not applied carefully enough. Second, those which, although long recommended, I have never found to act well, even after many trials of the various potencies and preparations ; the latter have been mentioned with the natural comment. Another class of symptoms deserves especial reference, namely, those that have repeatedly proved curative from a clinical stand-point; where, if the symptom stand out boldly from all of its

VI PREFACE.

class, I have usually noted it as clinical ; but if interwoven with others, the clinical aspect has not been separately stated.

Even with this intended care in the selection of the therapeutic feature, it will be found far from accurate. In order to hasten its revision, I would invite criticism and suggestions, for it is only in this way that we can hope to establish the true merits of the curative sphere of drugs where it is impossible to produce, upon the healthy, such symptoms as are often found in the diseased. It is unfortunate that the instruments of precision— the ophthalmoscope, the rhinoscope, the laryngoscope, etc. — were not in existence when Hahnemann and his early followers made most of our best provings.

No attempt has been made to give all of the symptoms of any one internal remedy as indicating it in a given case, but the chief points have been mentioned as referable to the local symptoms mainly, or those bearing directly upon the condition present. Occasionally some reference is made to general characteristic drug symptoms where the prescription is to be based chiefly upon these. In prescribing for any given case there are many conditions to be borne in mind besides the special pathological change which most attracts attention, namely, the various reflexes are to be noted ; the collateral symptoms of the patient are to be investigated ; the special temperament is to be considered ; but, above all, the previous pathological changes, the ancestry, and the mental peculiarities are to be carefully reviewed. Thus, while remedies and symptoms are given, it will be seen that they form but the sign-posts to direct attention. Each prescription must be worked out on the broad lines of the nearest similar, if possible ; if not, the resort to alternation and the empirical prescription are not to be neglected at the expense of the patient.

PREFACE. Y11

The arrangement and treatment of some of the subjects do not correspond with those of other text-books. These differences are the result of various tests, practically applied, during my twelve years' lectures. For more ready reference a special heading, " Remedies for the Vocal Defects of Singers," has been introduced.

With few exceptions (cuts of instruments excluded), the illustrations are from my original photographs, drawings, or oilsketches, and any short-comings in this direction must be attributed to a desire for original work. In order to preserve the accuracy of the anatomical photographs, I have prepared explanatory keys to accompany the engravings, so that the latter need not be marred. After repeated trials it was found that the best results were obtained by photographing most of the dissections about four-fifths natural size.

At the beginning of Part III (page 320) will be found the reproduction of a photograph kindly sent me by Signor Manuel Garcia, the inventor of the laryngoscope.

In concluding, I wish to express my hearty thanks to Dr. Charles Monroe Thomas for many valuable suggestions in the manuscript ; to Dr. R. B. Weaver for his kindness in making the beautiful dissections from which the anatomical photographs were taken ; to my wife for much aid in preparing for the press, as well as for the oil-paintings reproduced on pages 350 and 459 ; and to those who have aided by direct information, and to whom credit has been given in the body of the work.

Horace F. Ivins.

1319 Arch Street, Philadelphia, February, 1893.

Chapter II

Rhinoscopy, Examination of the Nasal Passages, ... 14 Illumination, 15 — Anterior Rhinoscopy, 18 — Posterior Rhinoscopy, 20.

CHAPTER III. •Catarrhal Diseases of the Nasal Cavities, .... 26 Acute Nasal Catarrh, 26 — Rhinorrhoea, 33 — Chronic Nasal Catarrh, 34 — Hypertrophic Rhinitis, 39 — Atx-ophic Nasal Catarrh, 47.

CHAPTER IV. Various Diseases of the Nasal Cavities, 57

Rhino-scleroma, 57 — Chronic Blennorrhoea of the Upper Air- Passages, 58 — Acute Purulent Rhinitis of Children, 59 — Chronic Purulent Rhinitis of Children, 61 — Phlegmonous Rhinitis, 62 — Glanders, 63 — Croupous, or Pseudomembranous, Rhinitis, 65 — Primary Diphtheria of the Nose, 67 — Parasitic Affections of the Nose, 68.

CHAPTER X. Defects in Bones and Cartilages, 130

Dislocation of the Bones and Cartilages, 130 — Fracture of the Nasal Bones, 131 — Deviation of the Septum, 132 — Atrophy of the Septum, Congenital Malformations, 136.

CHAPTER XL

Diseases op the Accessory Cavities, 138

Antra of Highmore, 138 — Frontal Sinuses, 142 — Ethmoid Cells, 145— Sphenoid Cells, 146.

CHAPTER XIV. Pharyngeal Diseases, 163

Acute Catarrhal Pharyngitis, 163 — Subacute Catarrhal Pharyngitis, 169 — Angina Ulcerosa, Chronic Catarrhal Pharyngitis, 170 — Acute Traumatic Pharyngitis, 178 — Acute Follicular Pharyngitis, 179 — Chronic Follicular Pharyngitis, 181 — Atrophic Pharyngitis, 186.

X TABLE OF CONTENTS.

CHAPTER XXIV. Uvular and Tonsillar Diseases, 288

Uvulitis, Acute Inflammatory CEdema, 288 — Relaxed Uvula, 289— Tumors of the Uvula, 291— Acute Tonsillitis, 292— Acute Follicular Tonsillitis, 299— Enlarged Tonsils, 301— Supernumerary Faucial Tonsils, Atrophy of the Tonsils, Enlargement of the Lingual Tonsil, 310 — Calculi and Concretions in the Tonsils, 311 — Diseases of the Valleculse and Pyriform Sinuses, 312.

CHAPTER XXXVIII. Diseases of the Trachea, 494

Acute Tracheitis, 494 — Chronic Tracheitis, Tracheal Syphilis, 495.

LIST OF ILLUSTRATIONS.

FIG. PAGE

Frontispiece. (From a photograph.)

1. Transverse vertical section through posterior portions of orbits. Looking for-

ward. With key. (From a photograph.), 2

2. Vertico-antero-posterior section : septum removed. With key. (From a photo-

graph.), 4

3. Spheno-palatine ganglion. (From Sajous.), 8

4. Kramer's nasal speculum, 14

5. Author's self-retaining wire speculum, 15

6. Oval, hard-rubber nasal speculum, 15

7. Zaufal's speculum, 15

8. Argand gas-bracket with three arms, 16

9. Mackenzie's condenser for Argand burner, 17

10. Photophore, 17

11. Head-mirror with band and handle, 18

12. Spectacle-frame, 18

13. Position for anterior rhinoscopy. (From a photograph.), 19

14. Rhinoscopic mirror, 21

15. Fraukel's rhinoscopic mirror, 21

16. Rhinoscopic mirror in position. (From a photograph.), 22

17. Posterior rhinoscopic image. (Modified from Sajous. Colored.), ... 24

18. Finger-guard, 25

19. Burgess' atomizers, 28

20. Air-compressor, with two outlets, 29

21. U-shaped nasal tube, 36

22. Dessar's nasal cup, 36

23. Post-nasal syringe, 37

24. Posterior hypertrophy of middle and inferior turbinated bodies, both sides.

(From Sajous. Colored.), 42

25. Author's nasal probe, 44

26. Sajous' guarded acid applicator, 44

27. Author's guarded post-nasal acid applicator, 44

28. Jarvis' snare, as modified by Sajous, 44

29. Cautery-knife and points, 45

30. Galvano-cautery handle and snare, 45

31. Angular forceps, 52

32. Insufflator, 52

33. De Villbis' atomizer, 60

34. Politzer's air-bag, 74

35. Eustachian catheter, 103

36. Bellocq's cannula, 103

37. Gross' curette and hook, 107

38. Myxomata of the nose. (From a retouched photographic negative.), . . . 110

39. Sajous' snare, with three tips, 112

40. Wright's snare, 113

41. Mackenzie's cog-wheel snare. 114

(xiv)

LIST OF ILLUSTRATIONS. XV

FIG. PAGE

42. Caugh try's light angular forceps, 115

43. Nasal saws, 122

44. Jarvis' transfixing needles, 123

45. Teets' cutting nasal bone-forceps, 124

46. Burrs and trephines, . 125

47. Von Klein's nasal bone-forceps, 126

48. Melanosarcoma of the nose. (Colored.), 127

49. Bosworth's clamp, 134

50. Adams' forceps, 135

51. Steele's septum-forceps, 135

52. Transverse vertical section through orbits : looking backward. With key.

(From a photograph.), 138

53. Bleyer's tongue-depressor and incandescent lamp, ....... 140

54. Vertico-antero-posterior section. (From a photograph.), 143

55. Vertical section through basilar process. (From a photograph.), . . . 150

56. Normal palate and pharynx, 152

57. Key to Figure 55, page 150, 154

58. Antero-postero-vertical section, revealing naso-pharyngo-laryngeal region. With

key. (From a photograph.), 156

59. Cohen's hard-rubber tongue-depressor, . . . 161

60. Hinged, metal tongue-depressor, 161

61. The American nebulizer, 166

62. Author's pharyngeal and post-nasal applicator, 173

64. Curved trocar-cannula, 200

65. O'Dwyer's intubation apparatus, 228

66. Primary epithelioma of right tonsil. (From a photograph by Dr. N. W. Fryer.), 259

67. Separate mucous investment of the palato-glossus muscles, 269

68. Youthful physiognomy of adenoid vegetations. (From a photograph.), . . 278

69. Aged physiognomy of confirmed mouth-breathing, 279

70. Adenoid vegetations and hypertrophy of turbinateds, posteriorly. (From Sajous.

Colored.), 280

71. White's palate-retractor, 281

72. Loewenberg's forceps, 282

73. Gottstein's curette, 282

74. Curette finger-tip, . 282

75. Major's antero-posterior adenotome, . . 283

76. Inhibitor, ' 283

77. Enchondroma, actual size. (From a photograph.), . . . . . . 2S6

78. Sajous' uvula-scissors, . 290

79. Acute follicular tonsillitis. (Colored.), 300

80. Mackenzie's tonsillotome, as modified by Mandeville, 305

81. Author's tonsillotome, - 306

82. Knight's galvano-cautery snare tonsillotome. 308

83. Leffert'e bulbed insufflator, 316

84. Signor Manuel Garcia, inventor of the laryngoscope, 320

85. Laryngeal frame-work : anterior view. With key. (From a photograph.), . 322

86. Laryngeal frame-work : posterior view. With key. (From a photograph.), . 322

87. Left side of larynx. (From a photograph.), 327

88. Posterior crico-arytenoid muscles. With key. (From a photograph.), . . 32S

89. Right lateral crico-arytenoid muscle. With key. (From a photograph.), . . 330

90. Laryngoscope, 341

91. Laryngeal mirrors. (Natural size.), 342

XV1 LIST OF ILLUSTRATIONS.

FIG.

92. The S. S. White Dental Mfg. Co. 's electric laryngoscope, ^43

93. Beseler's lime-light apparatus, ' .'344

94. Laryngoscope in position, [ 345

95. Reflection of V-shaped figure on a laryngeal mirror, 349

96. Epiglottis, arched and vertical. (Colored.), . 350

97. Epiglottis, arched and inclined forward. (Colored.), ...... '350

98. Epiglottis, angular. (Colored.), .'.'.' \ 350

99. Epiglottis, omega-shaped. (Colored.), .350

100. Epiglottis, pointed and depressed, of children. (Colored.), . . . ' 350

101. Epiglottis, horseshoe-shaped. (Colored.), ! 350

102. Normal larynx during respiration. With key. (Colored.), ' 351

103. Normal larynx during phonation. (Colored.), .... 352

104. Auto-laryngoscope, ' ^

105. Freshly dissected larynx, showing cadaveric position of vocal bands. With

key. (From a photograph.), _ 35g

106. Left recurrent paralysis, during attempted phonation, 359

107. Bilateral thyro-arytenoid paralysis, during vocalization, 360

10S. Bilateral posterior crico-arytenoid paralysis, during inspiration, . . . .362

109. Arytenoid paralysis, during vocalization, 363

110. Author's modification of Mackenzie's laryngeal electrode, 365

111. Subacute laryngitis. (Colored.), 387

112. Acute (submucous) laryngitis. (Colored.), , 392

113. Mackenzie's laryngeal bistoury, ' 393

114. Laryngeal applicator, ' 4(l0

115. Laryngeal phthisis, showing pyriform arytenoids and ulceration of left vocal

band. (Colored.), 426

116. Schrotter's hard-rubber bougies, 446

117. Web-like stenosis, due to syphilis, 447

118. Browne's hollow cutting-dilator, .'447

119. Schrotter's metal bougie, 448

120. Papillomata following typhoid fever, 457

121. Papillomata in a boy, 458

122. Papillomata in an army officer, 45g

123. Papillomata in an inveterate drinker of alcoholics. (Colored.),. . . . 459

124. Polypus of right vocal band. (Colored.) .460

125. Mackenzie's antero-posterior laryngeal forceps, 465

126. Mackenzie's lateral laryngeal forceps, .466

127. Schrotter's universal handle with various tips, 466

12S. Author's modification of Schrotter's laryngeal tube-forceps, 467

129. Author's case of instruments, § 49$

PART I. The Nose and its Diseases

.—Transverse-Vertical Section through Posterior Portions of Okkits, Looking Forward. (From a photograph.)

Eye.

Ethmoid cells.

Antro-nasal opening.

Antrum of Highmore.

Inferior turbinate'!.

Roof of mouth.

nal cavity.

Superior meatus.

Superior turbinated.

Middle meatus Middle turbinated.

Septum.

Inferior meatus.

Hard palate.

CHAPTER I. Anatomy of the Nose

The nasal passages may be designated double air-tunnels. They begin at the anterior nares (nostrils), pass through a highly vascular, nervous, and tortuous region, and terminate in the posterior nares (choanse). These tunnels are separated, antero-posteriorly and vertically, by the nasal septum, which is partially cartilaginous, but chiefly bony. The nasal passages are narrow above and quite broad below. The septal walls are smooth, but, owing to the presence of the turbinated bodies, the external walls are very irregular. Connected with these canals are several accessory cavities, which often participate in pathological changes similar to those which occur in the nasal fossae

The septum narium is about one-tenth of an inch thick anteriorly and one-eighth posteriorly. It is formed above by the perpendicular plate of the ethmoid bone, posteriorly by the vomer, and anteriorly by the triangular (septal) cartilage. These various portions are united at their edges, forming a continuous, smooth, inner wall to each canal. There is generally a prominence (tubercle of the septum) a little anterior and inferior to the anterior end of the middle spongy bone.

The roof of each fossa is about one-fourth of an inch wide, and formed by the cribriform plate of the ethmoid, the nasal spine of the frontal, the under surface of the body of the sphenoid, and by the nasal bones ; the external walls, composed of the palate and superior maxillary bones, slant outward and downward ; the floor is formed by the horizontal processes of the same bones.

Two scroll-like bones (the turbinated, concha, or spongy bones) project from each lateral surface toward the septum ; the third, superior, is quite small and descends almost perpendicularly from the roof (see Fig. 1). The middle is larger than the superior, has a decidedly curled edge, and projects well toward the middle line. Between these two bones lies the superior meatus, into which the posterior ethmoidal cells and sphenoidal

Fig. 2.— Vertico-antero-posterior Section. Septum Removed, During Section, Revealing Left Nasal Region. (From a photograph.)

sinus open through a small aperature situated posteriorly. According to Zuckerkandl (" Anatomie der Nasenhole"), the ethmoid cells are occasionally continued into the middle, or ethmoidal, turbinated bone. The inferior is the largest of these bones, and assumes more nearly a horizontal position. Its

ANATOMY OF THE NOSE. 5

lower edge is occasionally deeply notched or cleft. The space between the inferior and middle turbinateds is known as the middle meatus, into which enter the canals from the frontal sinus (the infundibulum), the anterior ethmoidal and the sphenoidal cells, and the antrum of Highmore (the latter occasionally by two passages). Within the middle meatus is a crescentic opening, the hiatus semilunaris, the upward and downward continuations of which pass into the frontal cells and antrum of Highmore, respectively. Below the inferior turbinated is the an £ i 4 . o £

Vault of pharynx.

Eustachian orifice.

Superior turbinated.

Superior meatus.

Middle turbinated.

Middle meatus.

Inferior turbinated.

Inferior meatus.

Hard palate.

inferior meatus, into which the nasal duct opens by a somewhat expanded mouth, provided with a partial valve formed of mucous membrane. A fourth bone frequently exists in close relation to the upper turbinated ; this, according to Zuckerkandl, is the rule at birth, and Voltolini considered it characteristic of the negro race.

As the accessory cavities are in such close relationship to the nasal cavities, it is customary to describe these sinuses, or pneumatic chambers, in this connection. They lighten the b DISEASES OF THE NOSE AND THROAT.

bones in which they are situated, and are supposed to afford increased resonance to the voice.

The frontal cells, usually wanting in early childhood, are two triangular spaces situated just above the nose and inner portions of the orbits, between the two tables of the frontal bone (see Fig. 2). They are sometimes separated, but more frequently a passage exists between them. Their floors are formed by the roofs of the orbits ; occasionally, openings are found between the frontal cells and the orbit or ethmoid cells. They are drained by the infundibuli.

Two sphenoidal sinuses are usually found in the body of the sphenoid bone ; they are separated by a thin, bony plate. Communication with each superior meatus is accomplished by means of a small perforation in the bone. The plate of bone which separates these sinuses from the brain is rarely more than one-twelfth of an inch thick.

The antra of Highmore, or maxillary sinuses, are the largest of the accessory cavities (see Fig. 1). Each sinus communicates with the upper part of the corresponding middle meatus by a duct (occasionally two) large enough to admit an ordinary silver probe. This opening is hidden, in the normal condition, by the middle turbinated body. The floors are formed by the alveolar processes of the superior maxilla, and it is not unusual for the roots of the first and second molar teeth to pass into these cavities. The roofs of the antra form a part of the orbital floors.

The ethmoid sinuses are composed of a number of small cells, thus differing from the other accessory nasal cavities ; in this characteristic they resemble the mastoid cells. They are divided into two (occasionally three) groups, the anterior and posterior ethmoids, — the former opening into the nasal cavity proper, the latter into the superior meatus. One of the ethmoid cells is, occasionally, so markedly developed as to project prominently into the middle meatus. This condition is called by Zuckerkandl the bulla ethmoidal is. Rarely, there is a direct communication

ANATOMY OF THE NOSE. 7

between the anterior and posterior ethmoidal cells and the summit of the antrum.

The nasal channels, with their prominences, convolutions, and accessory cavities, are lined with mucous membrane, continuous with that of the pharynx, including the Eustachian tubes and middle ears. From the inferior meati, it extends along the lachrymal canals to form the conjunctivge. The upper portions of the nasal cavities — as low as the middle turbinated bodies and upper third of the septum — are lined with tessellated epithelium, but it is especially important to note that the remainder of these spaces is lined with ciliated columnar epithelium. In health the wave-like motion of these cilia helps to move the mucus toward the natural outlets, the posterior nares, where some suppose it is partly absorbed by Luschka's tonsil, while others believe it is directed, by the uvula, to the base of the tongue and the lingual tonsil.

The characteristics of the nasal (pituitary or Schneiderian) mucous membrane vary greatly in different localities. It is thickest over the turbinated bones and thinnest over the greater part of the septum. The thickness of the turbinateds goes far toward reducing the size of the nasal chambers, and is partially due to the abundant supply of glands found in this region. The deepest layer of the membrane, that which lies in contact with the covering of the inferior turbinated bone, is chiefly an erectile, cavernous tissue, a small amount of which is found on the crest of the middle turbinated, and another small mass on the septum nearly opposite the anterior third of the middle spongy bone. This layer is composed of large venous sinuses capable of rapid sanguineous distension and sudden erection, under vasomotor influence. It is this erection, during acute rhinal disorders, which occasions difficult nasal respiration. It has been noted that this tissue is frequently erected during menstruation and sexual excitement, thus showing a reflex or correlated sympathy between the nose and the sexual sphere. Some forms of nasal disorder, especially hypertrophy and ozaena,

DISEASES OF THE NOSE AND THROAT.

are aggravated, in certain persons, during the menstrual period, and nasal (vicarious) menstruation is a familiar example of this correlation. Irritation of these areas may give rise to ren\ex symptoms. The mucous lining of the upper, or olfactory, area is not very vascular, and contains but a small number of serous glands. It is provided with an almost continuous layer of branched mucous glands, with ducts opening upon the surface of the membrane. Between the tessellated, columnar epithelial cells of this region are the delicate, spindle, olfactory cells of Schultze, which ramify on the free surface. They are joined to a deeper, delicate nerve-plexus, and to the olfactory nerves.

Fig. 3.— Spheno-palatine Ganglion. (From Sajous.)

a, Sphenopalatine ganglion ; h, posterior area ; c, middle area ; d, anterior area ; e, olfactory bulb.

Destruction of these cells causes loss of smell, just as does section of the olfactory bulbs or nerves.

The olfactory nerve (special sense of smell) passes through from fifteen to twenty perforations in the cribriform plate of the ethmoid bone, and is then distributed to the superior turbinated body, to the upper part of the middle spongy bone, and to the upper third of the septum. The nasal branches of the sphenopalatine ganglion (sympathetic) are distributed to the lower edge of the superior, the under surface of the middle, the entire inferior turbinateds, and to the middle and posterior parts of the septum. The vidian passes to the superior spongy bone and to

PHYSIOLOGY OF THE NOSE. 9

the superior and posterior portions of the septum. The nasal branch of the fifth nerve is distributed to the anterior surface of the lower turbinateds, to the floor of the nasal fossae, to the upper and anterior portions of the septum, and to the external walls of the nasal passages.

The arteries which supply blood to the nasal cavities are the ophthalmic, passing to the vault, upper part of septum, and external walls ; the spheno-palatine branches of the internal maxillary, to the turbinated bodies, remainder of septum posteriorly, and the greater portion of the external walls ; and the artery of the septum, a branch of the superior coronary, to the anterior portion of the septum. The entire arterial supply forms a dense net-work in the mucous membrane. The veins empty chiefly into the internal jugular, although a few of them flow into the veins in the interior of the skull, through the cribriform plate of the ethmoid.

The nasal lymphatics, according to Simon (Schmidt's Jahrbuch, Bd. cvii, p. 161), form a wonderfully close intercommunicating net-work ; they are especially abundant (1) at the upper portion of the superior turbinated body, (2) on the external face of the middle turbinated, and (3) in the space directly anterior.

Physiology of the Nose.

The special nasal function is that of olfaction ; its most important, respiration. Around these are grouped a number of lesser, though important, duties in the human complex.

The upper portion of the nasal cavities to which the olfactory nerve is distributed is known as the olfactory tract or area ; the lower part, the respiratory. Each of these has its appropriate function. Recent investigations, however, prove that the olfactory tract participates in respiration to a slight degree.

The function of the sense of smell is usually described as follows : Odorous bodies cast off minute particles which, floating in the air, are drawn into the nasal passages during inspiration, where they come in contact with the terminal olfactory fibres. As the mucous membrane in which these nerve-filaments terminate is always moist, the odorous particles adhere to it, and are speedily dissolved by the mucous secretions, when the peculiar functions of olfaction are at once established. With most substances this process of solution is almost instantaneous, the excess of odorous material immediately yielding to the flow of mucus excited by the presence of the particles. In this way one odor may follow another at a very short interval without, in any way, conflicting with the olfactory sense.

In just what manner the nerve-terminals are affected is an unsolved problem. Graham advanced the chemical theory, the essential process of which was the oxygenation, within the nasal passage, of the odorous particles, thus stimulating the sentient olfactory terminals. Ogle promulgated the theory which connects olfaction with pigmentation, the secretion of pigment by Bowman's glands having, according to him, much to do with the olfactory sense. Liegeois claims that the odorous particles irritate the olfactory terminals mechanically. Ramsey advances the theory that olfaction is the result of molecular vibration. Tyndal has found that odorous particles act in proportion to their heat-absorbing quality.

It is evident that to have the sense of smell acute the olfactory mucous membrane must be in a moist condition, its surface must be free from dried or thick secretions, nothing should prevent the entrance of odorous particles to this tract, the nerve-terminals must not be concerned in an hypertrophic process of the mucous membrane, and, finally, the nerve itself, as well as its terminals, should be in a healthy condition. In this connection Greville MacDonald (" The Forms of Nasal Obstruction ") speaks thus of the functions of the turbinated bodies : "Indeed, it would not be incorrect to style the superior spongy bone the organ of taste, the middle turbinated and plain surface of the ethmoid that of smell." In explanation, he says that " the expired air, which during mastication is laden with odoriferous particles, is driven by the thorax directly upwards to the vault

PHYSIOLOGY OF THE NOSE. 11

of the nasopharynx, and readily comes in contact with the projecting superior turbinated bone, over which is distributed the posterior division of the olfactory nerve."

The proper respiratory channel is the nose, not the mouth. Nature so constructed the nasal fossae that cold air is elevated in temperature during its passage over this area, which is constantly warmed by the free circulation of blood. Aschenbrandt, Kayser, and MacDonald have shown that if the inspired air enter one nostril at from 46.4° to 53.6° F. (8° to 12° C.) it will pass out through the opposite nostril, without having reached the lungs, at the uniform temperature of 86° F. (30° C.) ; or, the same as the usual expiratory current. According to the experiments of MacDonald (" Respiratory Functions of the Nose"), air at 19.4° F. (7° C), "breathed in and out of the lungs only, without the intervention of the nose, was raised to 92.3° F. (33.5° C.) ; whereas, when breathing was conducted in at the nose and out at the mouth, the thermometer indicated 95° F. (35° C), the duration of the respiratory acts occupying the same number of seconds in each case." When air passed in through one nostril and out through the other without entering the deeper respiratory passages, the temperature arose to 86° F. (30° C). " A noteworthy fact, moreover, is, that cocaine, by ansemizing and inducing collapse of this [intra-nasal] tissue, lessens the acquired temperature by two or three degrees." Hot air absorbs moisture from the tissues, thus lowering its temperature ; for it is generally stated that a pint or more of serum, composed of 92 to 93 per cent of water, the remainder of solid matter, is poured out by the venous sinuses of the nose each twenty-four hours. Very dry air is moistened and rendered more suitable for contact with the throat and deeper respiratory tract, which would otherwise be dried and irritated. Very moist air gives up some of its humidity on coming in contact with the mucous lining. Dust-laden and smoky air is much purified and sifted by the little hairy processes (the vibrissa), contact with the moist mucous tissue arrests other partides, and the cilia? of the membrane aid greatly in this process of filtration. The vibrissa? also guard against the entrance of insects. Finally, the olfactory nerve warns of the presence of many deleterious substances.

Air thus inhaled passes through a narrow, tortuous tract, perhaps in rotary motion ; so that, doubtless, all of it comes in contact with some portion of the nasal canal, thus rendering it capable of safe respiration. Any affection or condition which interferes with these various functions not only leads to nasal disorders, but goes far to establish disease of other organs directly allied, especially the pharynx, larynx, trachea, and lungs ; and it may induce reflex cough, asthma, nasal vertigo, and similar phenomena.

The resonant function of the nasal fossa? is a very important one. This duty on the part of the nose is not confined to its canals, for the bones participate in the vibratory process, and it is believed that much of the resonance of the voice depends upon the collateral sinuses. If these be obstructed by tumors, abscesses, etc., the vocal tones are impure. When the nasal fossa? are obstructed in any manner, defective speech is marked.

The greater number of both vowel and consonant sounds depend for their purity upon the nose and its surrounding structures ; hence, it may be said that upon the nose (aided by the epiglottis) chiefly depends the vocal timbre, — that peculiar feature which constitutes the especial quality by which we can distinguish one voice from another. The immediate destruction of the timbre can be brought about by the closure of the nostrils between the thumb and finger, — a simple experiment which proves the part assumed by the nose in the production of pure tone. Even should the nasal canals be normal and the pneumatic spaces in good condition, much depends upon the prompt action of the soft palate and epiglottis in controlling the column of sound-waves set in sonorous vibration at the vocal bands. This action is a constant one, both in speech and song. When certain sounds are articulated, — for example, m and n, —