nares are

tissue, and of scrofulous diathesis are well known to every student of materia medica, but there are certain finer distinctions to which I wish to call your attention as indications for its use. The tonsils if hypertrophied are very much so; they are pale in color and soft to the feel. The Luschka tonsil is also soft. It bleeds easily on the slightest touch of probe or finger, the turbinated bodies are pale and puffy. The discharge, nasopharyngeal alone if the nares obstructed, both nasopharyngeal and anterior nasal if the obstruction is not complete, is mucopurulent in character, at times streaked with blood. This latter symptom is particularly prominent if there is an anterior nasal discharge. It is at times profuse, but often scanty with sense of dryness in the nose and nasopharynx. The teeth are late in appearing and after their appearance decay quickly. The calcaria phosphorica patient is also of the scrofulous type, but of dark complexion, of thinness in flesh, and of firmer fibre. The tonsils, if hypertrophied, are smaller and offer greater resistance to the probe. The enlarged Luschka tonsil is also more resisting, and both the faucial and pharyngeal tonsil are of a more natural color than is found. in the calcaria carbonica patient. The nasopharyngeal discharge is not as profuse and is more tenacious, but the larynx and bronchi are much more likely to be affected than in the preceding remedy. The patient almost invariably has either a slight cough or is continually clearing the throat to rid the larynx of its viscid secretion. Excitement arouses the patient to unwonted activity of mind and body, which condition quickly gives way to languor and depression of spirits. Both types take cold easily, the calcaria carbonica. patient being most subject to nose and nasopharyngeal inflammations, the catarrh being greatly aggravated, while the second type of patient is mostly affected by a cold, either in the faucial tonsils, the pharynx, the larynx, or the bronchi, the nasopharyngeal discharge not being altered to any great extent. We find in the third remedy mentioned, calcaria iodata, many of the iodine characteristics, namely, the thinness of flesh, the tendency to glandular swellings, the

diathesis, scrofulous or syphilitic, the latter condition being a strong indication for the use of the remedy. This patient also takes cold readily, but the colds take the form of a vasomotor rhinitis, that is, swelling of the erectile tissue, while itching, heat, watery discharge, etc., or asthma or croup may make manifest the onset of the cold. Dr. Beebe, of Chicago, recommends this remedy above all others in croup, whether it takes the diphtheritic form or of membranous croup. He regards it as a specific if given early in the disease and continued persistently. The tonsils, though enlarged, present a ragged appearance from the numerous crypts and diseased follicles which indent their surface. Luschka's tonsil may be very greatly hypertrophied. It is firm, unlike the calcaria carbonica condition where it is enlarged but soft, unlike also the calcaria phosphorica condition, hard and small. The discharge is mucopurulent in character, like the calcaria carbonica discharge, rather profuse posteriorly, scanty anteriorly, whether the post-nasal obstruction be complete or the contrary. Persistent hoarseness is a common symptom; the calcaria phosphorica patient has a cough but is not hoarse, at least not persistently so. The first two of these remedies I have used in the third and sixth decimal trituration, the latter in the second and third. When I have once chosen the remedy I give it three or four times daily, persisting in its use for weeks or months. In my experience the curative action of these remedies is slow, but in the end extremely gratifying. I wish now to consider an entirely distinct class of cases, not as common as the foregoing, but still frequently met. They also have the symptom post-nasal catarrh, but it is from an entirely different cause, the origin not being constitutional and secondarily localized in the nasopharynx, but constitutional or traumatic and localized in the nasal passages. This form of the disease is not confined to any class or age. Allow me to present a typical case.

Mrs. B., age thirty-nine, occupation teacher, consulted me February 27, 1894, for a post-nasal catarrh which had existed to a greater or lesser extent for ten years. The

patient complained of great accumulation of mucus in the nasal pharynx, causing much irritation in this region and giving rise to constant efforts of clearing. Particularly was this the case at night, so that in consequence her sleep was much broken. There was a sense of fulness and dryness in the nose, though little anterior nasal discharge. Family history good, and but for a worn look of the face with pallor the patient seemed to be in fairly good condition. Could discover no digestive disturbances. Examination. Deviation of the cartilaginous septum towards the right. Marked tumefaction of both middle turbinated bodies, each in contact with the septum. Inferior turbinated bodies and septum reddened and dried in appearance. The vault of the pharynx was so covered with tenacious yellow mucus that its condition could not at first be determined, but after cleansing away this accumulation the parts were seen to be greatly inflamed. The oropharynx was in places atrophied and again covered with enlarged follicles. A mild form of laryngitis was present. Here was a case and a not unusual one where constitutional symptoms were in a degree lacking, and where the indications for the remedy must be found in the nose rather than in the post-nasal space, although it was of a nasopharyngeal discharge that the patient complained. To be sure we had symptoms in the nasopharynx, namely, dryness, irritation, and much stringy yellow mucus; but these conditions in this case could be directly traced to the nasal condition, that is, the inability of the nose to perform its function, that of purifying and warming the inspired air. This case is illustrative of the nasal cause of a persistent and extremely troublesome symptom. The nasal obstruction is hardly ever the same, but some form of hypertrophic rhinitis like the above is, however, frequently present. The origin of this might have been from the constitutional tendency to attacks of acute coryza, these attacks in time producing permanent tissue changes in the nose, or as before suggested, traumatism might originate the condition. If the nasopharyngeal disease is from the latter cause, the nasal obstruction will be primarily from a defected septum, from

the irritation of a septal spur, or from something of a similar nature. Here, of course, the internal remedy can do no good unless preceded by surgical measures. It will be seen

therefore how necessary a correct diagnosis becomes before the prescription is properly made. In the first class of cases also surgical measures may become necessary in the reduction of the hypertrophied tissue, but many cures can be performed by cleansing applications and the indicated remedy. The array of remedies for a hypertrophic rhinitis is small, particularly if one is unaided by constitutional symptoms, but the following have served me well: lobelia cerulia, a remedy to which my attention was called by Dr. Teets, of New York, kali bichromicum, mercurius, and hydrastis. The indications for the first remedy mentioned, lobelia, are, and I give Dr. Teets' indications, depression of spirits, pain in the left side of the head and over the nose, itching and tingling in the nose, followed by frequent sneezing and discharge of thick mucus from the nostrils, with sensitiveness to inspired air or dust; additional indications. for the remedy are found in the objective symptoms follicular pharyngitis and inflammation of the nasopharynx. Here Dr. Teets' symptoms cease, but I am able to add the following: the hypertrophy of the turbinateds is not pale and puffy such as is found in vasomotor rhinitis which the symptoms would indicate as existing, but the tissues are reddened, and after removing the secretion, which is thick, the membranes are left dry with a glazed look, particularly on the cartilaginous septum; this same glazed appearance can also be seen on the posterior walls of the pharynx. The remedy kali bichromicum would be thought of in the clinical case just described, but the tenacious discharge complained of is not a sufficient indication for the drug, and if it is prescribed on this indication alone, disappointment in its effects will quite likely result. It is not often mentioned in the text-books as one of the remedies likely to be called for in hypertrophic rhinitis, but bearing in mind the indication so frequently seen in its symptomatology, the ropy, stringy character of the secretion, and finding it sometimes curative

and sometimes not, an attempt has been made to more exactly differentiate its objective nasal indications, hoping in this manner to intelligently prescribe the drug in nasopharyngeal catarrh. The nasal symptoms for which I prescribe it are sense of fulness, stuffiness in the nose with constant desire to blow it or to remove the supposed obstruction by other means. The discharge is glutinous and is expelled with difficulty. On examining the nasal fossæ this mucus can be seen stringing from the septum to the turbinated bodies.

The septum appears dry, as in the first remedy mentioned, but there is a marked tendency of the septal membrane to break down, showing excoriations. The nose bleeds easily if the concretion covering the excoriation be removed.

The patient's effort to keep the nose free results in an ulcerative process, at the point which was originally an excoriation.

I do not believe that the ulceration of the septum narium, named in the books, is a direct symptom, but that it is the result of the inflammation and dryness, aided by the mechanical irritation of the patient's finger nail. This ulcerative process may become so well established as to involve the cartilage and produce perforation. This perforation is very different in cause and appearance, however, from that found in syphilitic disease of the nose, and when syphilis is present I do not prescribe the remedy.

Further indications for the remedy are huskiness, constant desire to clear the throat, and unreliable voice.

When this stringy mucus is found only in the nasopharynx and not in the nose or elsewhere, I attribute the localized condition mainly to physical causes, and do not, as a rule, prescribe this remedy.

Mercurius has a nasopharyngeal discharge, tenacious if the nasal function is impaired to a sufficient extent, profuse, but the naso- and oropharynx feel dry.

The familiar subjective symptoms, such as pain and fulness over the frontal sinuses, soreness of the nasal bones to external pressure, with much discharge from the nose of thick, yellow, bloody mucus, are, I believe, reliable.