RHINOLITHS OF NOSE-STONES may occasionally form in the nose from the deposition of phosphate of lime and mucus upon either a foreign body which has become lodged in the nose, or a portion of hardened secretion. They give rise to inflammation, swelling of the mucous membrane, and a fetid discharge, and have been mistaken for osteomata, and even carcinomata. When detected they should be removed by forceps, or if too large for this, first broken by the lithotrite. POLYPI.-Three forms are described-the gelatinous, the fibrous, and the malignant. 1. Gelatinous or mucous polypi most frequently spring from the mucous membrane covering the spongy bones, rarely from the roof of the nares, and scarcely ever from the septum. They usually have a myxomatous structure, that is, they consist of delicate connective tissue infiltrated with large quantities of mucine containing round and stellate cells, and are covered with ciliated epithelium. They are usually multiple, sessile or pedunculated, and of an oval, pyriform, or lobulated shape. The usual symptoms are a feeling of stuffiness in one or both nostrils worse in damp weather, a nasal tone of voice, and a mucous discharge. Certain reflex symptoms, such as asthma, cough, etc., are also occasionally present. On inspection, they appear as pinkish or grayish-white, semi-translucent, gelatinous, movable bodies, soft and dimpling when touched with a probe. When high up, or far back in the nasal cavities, the speculum or rhinoscope may be necessary to detect them. Treatment. They are best removed by the galvano-cautery, as this is attended by less pain and no hemorrhage. If the cautery is not at hand, they may be twisted off by the ordinary polypus forceps. The application of cocaine will much diminish the pain. When they project into the naso-pharynx, they may be removed from behind the palate. A snuff of tannic acid, used subsequently to their removal, is said to prevent recurrence, but I have not found it of much service. 2. Fibrous polypi actually arising from the interior nasal cavities are very rare. Those commonly met with usually spring from the basilar process of the occipital bone or body of the sphenoid, that is, from the roof of the naso-pharynx, and then ought properly to be called naso-pharyngeal, as it is only after they have attained some size that they encroach upon the nasal cavities. They consist of fibrous tissues not infrequently mixed with spindle-cells, and often contain large, thin-walled blood-vessels, which give them almost a cavernous structure. The mucous membrane covering them is also very vascular. They may be sessile or pedunculated, and as they increase in size, they invade and displace the surrounding bones, making their way into the nasal cavities and into the pharynx, and projecting below the palate, and even into the interior of the skull. They are usually met with in young adult life. The symptoms are obstruction of one or both nares, a mucous and often foul-smelling discharge, repeated attacks of hemorrhage, deafness, obstruction to breathing and sometimes to swallowing, and in the later periods of the growth, to the characteristic deformity of the facial bones known as frog-face. They may be seen on looking into the nostril from the front, or by the rhinoscopic mirror from the back, or may be felt by the finger behind the soft palate. If not removed, they may end fatally from hemorrhage, although they have apparently a tendency to undergo atrophy as the patient gets older. Treatment. When of moderate size, they are best removed by the galvano-cautery, the wire being passed through the nares and directed over the base of the growth by the finger behind the palate. When too large for this, an attempt may be made to remove them by electrolysis; this failing, or not being considered advisable, they must be exposed by a preliminary operation. If chiefly confined to the naso-pharynx, the soft palate should be split, and part of the hard palate,. if more room is required, cut away (Nelaton's operation). When encroaching chiefly on the nose, a good exposure may be obtained by divid ing the lip in the middle line, and turning it to one side with the ala of the nose; or if more room is required, the superior maxilla must be removed. Rouge's operation of turning up the upper lip and the cartilaginous portion of the nose, and the operation of Langenbeck of turning the maxillary bone outward upon the cheek, and then replacing it after removal of the growth, have their advocates. My experience of these procedures is not very favorable. The exposure obtained by the former is no better than that of turning back the ala; and the shock and hemorrhage attending the latter render it very dangerous. Many other methods and modifications of the above have been proposed, but for these a larger work on surgery must be consulted. 3. Malignant Polypi.-Sarcomatous and cancerous tumors may arise both in the nasal cavities and naso-pharynx, and then constitute what are called malignant polypi. They give rise to symptoms similar to those of the fibrous polypi already described. but their growth is more rapid, and they quickly infiltrate surrounding parts and involve the neighboring glands. They may occur both in the young and in the old. If a small piece can be removed, the microscope will reveal its nature. Treatment.When the growth can be got completely away, early and free extirpation by one of the methods above described is the only treatment. OZENA is a term which has been used very loosely by authors. By some it has been applied to all diseases of the nose attended by a foul-smelling discharge, while by others it has been restricted. to the fetid form of atrophic nasal catarrh. The term, therefore, as designating a disease, is misleading, and should be discontinued in this sense. For purposes of diagnosis it may be mentioned that it is a prominent symptom in the following affections of the nose: 1, atrophic nasal catarrh; 2, necrosis and caries, whether of syphilitic or other origin; 3, strumous, syphilitic and lupoid ulceration of the mucous membrane; 4, foreign bodies and rhinoliths in the nasal cavities; 5, some forms of new growths. DISEASES OF THE SEPTUM NASI.-Blood tumors are occasionally met with as the result of injury. The blood is extravasated between the cartilage and the soft tissues, generally on both sides of the septum, causing in both nostrils a fluctuating circumscribed swelling, which may be readily distinguished from abscess by its coming on immediately after the injury and by the absence of signs of inflammation. It should not be opened, as the blood will become slowly absorbed. It sometimes appears to be associated with fracture of the septum. Abscesses of the septum are not very common, They may be due to injury or the breaking down of gummata, but occasionally occur without any apparent cause. When acute they may lead to perforation of the septum. The parts appear red, hot, and swollen, and fluctuation may soon be detected. A free and early incision should be made. Gummata of the septum occasionally form beneath the perichondrium in the course of syphilis. They are readily dispersed with iodide of potassium, but if neglected may lead to necrosis and perforation of the septum and to destruction of the cartilage, which is sometimes so extensive as to lead to falling in of the bridge of the nose. Deflection of the septum to one or other side may occur as the result of an injury, or as a congenital malformation. It appears as a swelling projecting into and obstructing one of the nasal cavities, while in the other cavity a corresponding depression is seen. The inferior spongy bone on the side of the concavity is often much hypertrophied. The deflection is generally attended with some lateral deviation or even depression of the lateral cartilages, and frequently gives rise to chronic nasal catarrh, and to many distressing symptoms, such as frontal headache, nasal tone of voice, passage of mucus int. harynx, etc. Treat ment. The septum may generally be forcibly straightened by the forceps shown in Fig. 158, and then retained in position for the first few days, while the parts are becoming consolidated, by the retentive apparatus shown in Fig. 159, and subsequently by ivory or vulcanite plugs (Fig. 160). I have found hollow plugs (Fig. 161), useful in that they do not obstruct nasal respiration. In some instances portions of the prominent septum may be removed subcutaneously with advantage. Where the lateral cartilages are deviated they can generally be straightened, even when FIG. 158. FIG. 159. ARNOLD Author's Nasal Forceps for straight- Retentive Apparatus for De- many years have elapsed since the injury. Great force, however, is required, and care must be taken, by properly padding the forceps, not to injure the soft parts. The best retentive apparatus then is, perhaps, the mask shown in the accompanying diagram, since by its means a fixed point is secured to work from. Cartilaginous and osseous tumors of the septum, though rare, occasionally occur, and can be readily diagnosed from a deflection of the septum, by their hard and resisting nature and the absence of a corresponding depression in the opposite nostril. Their removal is the proper treatment. ADENOID VEGETATIONS in the vault of the pharynx are very common in childhood. They are produced by the hypertrophy of the adenoid tissue which is so abundant in this situation, and are frequently met with in connection with enlargement of the tonsils, granular pharyngitis, and nasal catarrh, and if neglected may set up catarrhal otitis and incurable deafness. The chief symptoms to which they give rise are deafness, obstruction to nasal respiration, a nasal or "dead" tone of voice, and a vacant expression of countenance, from the child breathing with the mouth half open. To the finger, behind the palate, they feel soft, pulpy, and velvety, "like a bag of earth-worms;" while in the mirror they appear as pink or reddish, sessile or pedunculated fringe-like masses more or less obscuring the posterior nares (Fig. 156). The treatment consists in removing them, which may be done in several ways. The softer ones may be scraped away with the nail of the finger behind the palate; those near the Eustachian tubes and side of the pharynx are best extirpated by Meyer's ring-knife introduced through the nose; and the larger ones, which are situated on the roof and back of the pharynx, by Loewenberg's forceps passed behind the palate. No after-treatment, beyond compelling the child to breathe through the nose by keeping the mouth closed with a bandage, is usually required. DISEASES OF THE PHARYNX AND ESOPHAGUS. PHARYNGITIS, or inflammation of the pharynx, is commonly of the catarrhal variety (acute and chronic pharyngitis), but it may fall chiefly on the glands of the pharynx (follicular or granular pharyngitis), or, more rarely, may spread deeply and end in suppuration (phlegmonous pharyngitis). At times it is attended with deficient secretion and atrophy of the mucous membrane (pharyngitis sicca), and occasionally assumes an erysipelatous character, and is then generally associated with erysipelas of the face. Here a few words only can be said on the phlegmonous form, which, perhaps, more commonly comes under the care of the general surgeon. It is usually the result of an injury. The pharynx is intensely red and swollen, the neck often brawny and oedematous, swallowing is difficult or impossible, respiration is labored, and death may occur in a few days from sudden spasm of the glottis, or from exhaustion and blood poisoning. The treatment consists in inhalations of steam impregnated with carbolic acid; free incisions if pus forms in accessible situations; the administration of fluid nourishment and stimulants, in the form of enemata if the patient is unable to swallow; and the performance of instant tracheotomy if oedematous laryngitis supervenes. ULCERATION generally occurs in connection with like ulceration of the palate, fauces, and tonsils. (See Tonsils.) Here it need only be said that the healing of the ulcers, especially those of the tertiary syphilitic variety, is sometimes productive of great deformity. Thus, 1, the soft palate may become glued to the back of the pharynx or to the base of the tongue; and 2, the |