cavernous membrane was not a necessary condition for originating the reflex neuroses. It was remarked in the discussion that followed, specially by Semon, that one must never, whilst treating a nasal affection, lose sight of the patient's general state of health, and that it is impossible à priori to decide how far one may give any decided promise as to the influence of a local rhinosurgical treatment upon the reflex neurosis. Hack's opinions were on the whole cordially received on all sides, he was only accused of being too partial. Gottstein alone was rather in opposition to the question, as he considered the nasal reflex neuroses to be very rare, but did not deny the possibility of their existence, for neuroses might naturally just as well originate in the membrane of the nose as in any other mucous membrane or the skin. Gottstein further believed, that in most cases a special nervous disposition in the patient ought to be accepted. Foremost amongst the sceptics are those, who with Magnus* do not deny that the patients feel or think they feel relief, when certain pathological alterations are removed, but yet are of the impression that it all depends upon the imagination. Amongst the many different writings that appeared in the following years, and which all more or less proved the possibility of influencing neuroses, and amongst them asthma, by local treatment of the nose, only the work of Schmaltz,† in which he criticises Hack's "Schwellkörpertheori" shall be mentioned here. He corroborates the possibility of curing a reflectory asthma by rhinosurgical treatment, and gives several very fine examples, but does not accept the swelling of the cavernous membrane of the nose as a conditio sine qua non for the development of reflex neuroses. To prove the correctness of this supposition, Hack must prove that Kratschmer's experiments on * Magnus, see Schmaltz, Berl. klin. Wochensch., 20th July, 1885, p. 459. † Schmaltz, Berliner klin. Wochenschr., 1885, Nr. 29-32. animals could not give a positive result after the removal of the erectile body. The abnormal swelling of the cavernous tissue was only a symptom of the heightened irritability of the nasal nerves (trigeminus), and not the expression of a general irritability of the whole nervous system, as had been supposed amongst others by Herzog, who, however, had modified it so far as to consider the pure rhinitis vasomotorica as a result of neurasthenia, whereas he does not deny that a chronic rhinitis may cause reflex neuroses in individuals that are not nervously disposed. When asthma continues after removal of the polypes, Schmaltz believes the reason to be that the sensitive mucous membranes have not been treated, and in cases where asthma first appears after removal of the polypes, and disappears again after treatment of the corpora cavernosa, the reason must be sought in the fact that the polypes have only hindered accession to the irritable membrane. It is impossible to draw any prognostic conclusion from the local conditions of the nose, and as Semon remarks, one must be very careful in one's prognosis. On observation of the different contributions that have appeared since Hack's first publications as regards this question, rit will be found that while most authors at first, like Hack, were inclined to lay the chief stress upon the nasal disease, and to consider local treatment as quite sufficient; in later years the opinion has come forward, that asthma depends principally upon a disease in the central nervous system; this is the primary predisposing moment whose presence is necessary, so that a casual irritation which hits some peripheral nerve or other, e.g., the trigeminus threads of the nasal mucous membrane, may be placed in condition to cause the asthmatic attack. Already in 1883 Strübing† had mentioned that the appearance of reflex neuroses was governed by a law. The fact that they * Herzog, Der akute und chronische Nasen catarrh, Graz, 1886. appear in one case and not in another, although there is no difference in the local complaint, is not accidental, but the result of certain decided predestination, as the pathological reflex impressions develop after a given rule. An increased irritability of the mucous membrane of the nose is not sufficient to explain the appearance of reflex neuroses, for in this case it might be expected that all pathological changes, accompanied by an increased irritability of the nasal membrane, would cause the development of reflex neuroses; experience, however, proves that this is not the case. An increased reflex irritability of the sympathetic nervous system, specially of the vasomotor centres, has therefore been supposed (J. N. Mackenzie).* A similar interpretation has, as above mentioned, also been accepted by Gottstein, who believed that in most cases the patient must be of a specially nervous disposition. Roth† expresses himself to about the same purpose, but does not deny the presence of neuroses in cases of strong healthy people. Herzog‡ and Beschorner§ also assume a general nervous disposition, whose treatment is just as necessary as the local nasaltherapy. Rossbach expresses himself most distinctly in a preface to Runge's|| work on this question. He says that Hack's explanation that the reflex neuroses are alone originated from irritation of the sensitive nerves of the mucous membrane, caused by swelling of the cavernous tissue, is not correct, as there are too many exceptions from this rule. To explain the * J. N. Mackenzie, Trans. of Americ. Laryng. Associat., 1884, p. 113; and Medical Record, 19th July and 18th October, 1884, referred to in Intern. Centralb. f. Laryngologie, II., p. 103-105. + Roth, Zur Diagnose und Therapie der mit Nasenkr. zusammenhängenden Reflexneurosen, Wiener med. Wochens., 18855. Herzog, Der akute und chr. Nasenkatarrh, Gratz, 1886, p. 30. § Beschorner, Ueber Heufieber und dessen Behandl., Jahresbericht der Gesellsch. f. Natur und Heilhunde zu Dresden, 1885-1886. Runge, Die Nase in ihren Beziehungen zum übrigen Körper, Jena, 1885. reflexes, one must consider "eine besondere Beschaffenheit der nervösen Reflexbahnen selbst." Only those people contract reflex neurosis combined with nasal complaints whose reflex conductors in the brain and spine are predisposed. "Die Hack'schen Kranken müssen eine ähnliche Beschaffenheit des Nervensystems haben wie Neurastheniker und Hysterische, und möglicherweire sind diese Kranken sogar zum Theil neurasthenische oder hysterische Kranke." Similar views were expressed by Lublinski” in a discussion on asthma and nasal diseases held in the "Verein f. innere Medicin" at Berlin; he looks for the origin of the reflex in an increased irritation of the nasal nerves. He says that asthma and a nasal complaint can very well appear co-ordinate, but that those cases in which the asthmatic attacks can be stopped by pencilling the mucous membrane with cocaine, decidedly prove its causal dependency on the nasal complaint. The reason why reflex neuroses do not always appear in cases of nasal disease, he, like Rossbach, finds in abnormal conditions of the reflectory passages. In the same discussion both P. Heymann† and Krause spoke with appreciation of Hack's great merits in the whole development of this question, even though they, like Lublinski and earlier authors, were rather opposed to his "Schwellkörpertheorie." Krause‡ remarked that when the erectile body in the nose swells up, this must be accepted as a direct irritation, and not as a reflex, for Jolyet, Laffont, Dastre, Morat and Vulpian have by experiments shown that trigeminus contains vasodilatator threads. * Lublinski, Deutsche med. Wochenschr., 1886, Nr. 23 and 24, ref. in Internat. Centralbl. f. Laryngologie, III., p. 475. P. Heymann, Ueber Folgesymptome von Nasenkrankheiten, Deutsch. med. Woch., 1886, Nr. 28-30, ref. in Int. Cent. f. Laryng., III., p. 475. Krause, Die nasalen Reflexneurosen, insbesondere das nasale Asthma und die experimentelle Trigeminusforschung, Deutsch. med. Wochensch., Nr. 32, 1886, ref. in Int. Cent. f. Laryng., III., p. 479. Böcker warns against the abuse of nasal reflex neuroses, and specially against the propensity to accept everything that cannot be explained, as a nasal reflex neurosis. He is also against Hack's theory of corpora cavernosa, and accentuates that one must not be content with treating the nose, but consider the whole state of the organism, which is of great importance. To these men who warn against accepting asthma and other reflex neuroses as the expression of a local nasal complaint which in every case must be treated rhinosurgically, we may add many others, e.g., Beverley Robinson, Andrew Clark and Bishop.§ THE PHYSIOLOGICAL REFLEXES OF THE MUCOUS MEMBRANE OF THE NOSE. Before we begin an examination of the pathological reflexes proceeding from the nose, it is necessary to consider those reflexes which physiologically can originate from the normal mucous membrane, and specially examine whether it is possible to cause a typical asthmatic attack by irritation of the normal membrane. That the normal mucous membrane, under special circumstances, for instance inhalation of strong irritating vapours or particles of dust, can be the origin of sneezing and epiphora, has * Bocker, Die Beziehungen der erkrankten Schleimhaut der Nase zum Asthma und deren Behandlung, Deutsche med. Wochens., Nr. 26-27, 1886, ref. in Int. Central. f. Laryng., III., p. 478. † Beverley Robinson, A contribution to the study of Hay-fever (so called), Medical News, Philadelph., 17th July, 1886, ref. in Int. Cent. f. Laryng., III., p. 284. Andrew Clark, British Medical Journal, 11th June, 1887. § Bishop, Journal of American Medical Association, 23rd July, 1887, ref. in Intern. Centralb. f. Laryngol., IV., p. 439. |