be pulled (still touching the bone) completely out of the meatus without meeting any bony obstruction. Unless this most important step is taken, and the attic destroyed as a separate entity, the diseased territory cannot be perfectly curetted, cleansed, and treated, and will always remain a focus of disease.

Another objection which is frequently raised is the possible bad effect upon hearing. While this result, with a properly executed operation, is a possibility, the writer believes its magnitude has been very greatly overestimated, and that a vast majority of cases will emerge from the operation with either uninjured or improved hearing. We have long since passed the time when the drum head and ossicles can be regarded as essential to hearing. No doubt, when in a reasonably healthy condition, they are a great assistance to the best hearing, but the writer believes that many people could hear much better without drum head or ossicles. For instance: The writer believes that a perforated drum head, embarrassed by tympanic adhesions and accompanied by necrosed and retracted ossicles, surrounded by fungating granulation tissue, so far from assisting hearing, actually impedes the transmission of sound waves to the labyrinth, and that the hearing of the individual will, in all probability, be improved by a removal of this obstructing pathological mass. Such are the conditions usually found to a greater or less extent in cases of chronic purulent otorrhoea, and forming the basis for the cheerful prognosis of good hearing capacity after the operation; and the results, in the writer's cases and in the cases of most other surgeons, fully corroborate the foregoing statements.

When surgeons drained the wound, both through the meatus and the unsutured mastoid opening, a forceful objection to the operation. could be found in the extremely protracted healing and in the resulting deformity, consisting in an unsightly meatal opening, a lowered and protruding auricle, a disgusting postauricular scar, and, often, in a large and permanent mastoid aperture. As the operation is at present performed, however, the mastoid wound is entirely sutured at the time of operation, thus preventing a postauricular opening, and, by holding the parts up and in place, dispensing with the malposed auricle. A properly made Panse, Küster, Baliance, or other meatal flap does not deform the meatal opening, and assists greatly in the rapid lining of the operative cavity with new skin, and, when this is combined with the grafting of skin sections to the exposed bone, as recommended by Ballance, Dench, and others, little is left to be

desired tending toward a perfect and satisfactory result. The writer's patients can usually leave the hospital in less than two weeks, and a thorough cure is generally effected in from four to eight weeks.

From the foregoing answers to some of the important objections to the radical mastoid operation, it will be seen that a great and favorable evolution of improved operative technics has taken place through the last few years; that the operation is gradually losing its terrors and disadvantages; and that conscientious, honest surgical work and investigation will soon quiet our fears by placing this operation in such a position of safety and assurance that its performance cannot be avoided by those pretending to do the best and most advanced aural surgery.

The foregoing pages of this fragmentary article have been devoted largely to a recitation of the principal objections to the radical mastoid operation, an attempt at answering these objections. and a few words of inspiration toward future. work and investigation. The writer cannot leave the subject, however, without briefly reminding his hearers that purulent tympanic infections are responsible for about one half of the brain abscesses of the world, and that in the United States alone 4000 otitic brain abscesses occur annually (this proportion is trebled in Germany); that chronic purulent otorrhoea is responsible for most of these; and that death occurs in about one to every thousand ear cases (of all kinds) that come under treatment. With an array of figures like these, we must inevitably recognize the importance of the subject, and we cannot and should not seek to evade surgical responsibility if chronic purulent otorrhoea is producing this significant mortality. Hundreds of cases of chronic purulent otorrhoea present themselves to us to be cured. Shall we be satisfied, with these statistics before us, with eternally, month after month and year after year, cleansing, drying. powdering, scraping these middle ears, when we must know that the real seat of the disease can never be even touched, except by the radical operation? Shall we shirk operative responsibility or enhanced labor? Or shall we not rather by study, investigation, and operative experience so perfect our knowledge, precautions, and operative technics that this great surgical procedure may be performed with practically no danger either to life or function, thus enabling us to perform our legitimate part in lessening the world's mortality? These questions must be settled by each of us according to our personal equation. 92 STATE STREET.

BY OSCAR WILKINSON, A. M., M. D.,

WASHINGTON, D. C.

Headache as a symptom in nasal and nasopharyngeal diseases dates back to the incipiency of rhinology as a specialty. To no one man does the glory of properly diagnosticating these headaches belong. It was a gradual development, following a more perfect knowledge of the anatomy of these parts and the invention of more efficient instruments, by the use of which such cavities might be examined.

For the head mirror or reflector and the small laryngoscope we are indebted to a number of men, each of whom did more or less to develop these valuable aids. First of these was M. Levret, a French gynæcologist, in 1743. It was a half century after him before Dr. Bozzini, the next who used reflectors, caused a sensation throughout Germany by announcing his invention for illuminating the various cavities of the body. Twenty years later we see Dr. Senn, of Geneva, and still a few years later Dr. Babbington, of England, gradually improving on the former instruments. These were still improved upon by Garcia, a Frenchman, and still more by Türck, of Vienna, but it was left to Professor Ozermak, of Pesth, to perfect these instruments, in 1857, and hand them down to us almost as we have them to-day. Rhinology as a specialty might be said to have had its beginning from that date: though it did not attain a conspicuous position in the profession till several years afterward.

The minute anatomy of the nasopharynx was not known until about the middle of last century. Some books published on rhinology as late as 1880 do not illustrate or mention all these cavities. We are indebted to Dr. Zuckerkandl, of Vienna, for a more perfect knowledge of the anatomy of the nose, and especially of the accessory sinuses.1 He probably did more original anatomical work in the pneumatic nasal cavities than any other early investigator. His books, published in 1882, on Physiology and Anatomy of the Nose and Pneumatic Cavities would be a credit to a modern author.

With these few historical remarks I will pass to the subject proper, i. e., headache in relation to diseases of the nose and nasopharynx.

I have handed out a few sheets on which I have made a classification of the diseases of the nose

Read before the Medical Society of the District of Columbia, February 17, 1904. Med.-Jarhb. Wien, 1880.

PHILA. MED. JOURNAL.

The

and nasopharynx that produce headache. first of these, as you will observe, is morbid conditions of the mucous membrane, under which heading we have acute and chronic rhinitis, and as subdivisions of acute rhinitis, we have simple, specific, and neurotic.

There are few conditions with which we are more familiar than with acute coryza, with its almost constant symptom, headache. Many of us have grown painfully familiar with it from frequent personal attacks. Morell Mackenzie, Seiler, Sajous, Hack, and many other early writers noted this constant symptom. Even Galen, writing in the second century, noted it; he says in lib. xiii: "For the most part, either a cold or moist distemper doth vitiate the head." It was not until about 1880 that the writers on headache in general medicine mention headache in relation to nasal diseases. Dr. Weatherhead, in his Treatise on Headache, published in 1841, does not mention a headache of nasal origin; however, he does give as the exciting cause of headache, under the title of "rheumatic headache," "exposing the head to a draft of cold damp wind; riding in a carriage with window down; sitting under skylight with head uncovered and in state of perspiration, etc." all which conditions we know to be conducive to acute coryza. Copeland, in his Encyclopædic Dictionary, of 1845, does not mention headache of nasal origin, except frontal sinusitis.

The associate symptoms in acute rhinitis are chilly sensations of the body; stuffy, full sensation in the nose and front part of the head, associated with more or less obstruction of the nasal canals; a burning dryness, followed by acrid watery discharge. These symptoms are so common, so constant, and so annoying that the patient, no matter how ignorant, can make his own diagnosis.

Headache with coryza is often the first symptom in some of the febrile diseases; but the conditions are so similar in each case, regardless of the cause, that they are not diagnostic, and we must wait for after symptoms to help us out. I will, with these remarks, dismiss the subject of acute rhinitis, feeling that headache, as one of its most constant symptoms, is too well known to deserve further discussion.

In specific rhinitis, in its incipiency, we have the symptoms of acute simple rhinitis, but of decidedly more exaggerated form. There is more pain, more headache, and greater constitutional disturbances. This is especially true in the glandular. gonorrhoeal, and diphtheritic types. The other specific rhinitis conditions, the tuberculous, and those of lupus, leprosy, and larvæ may vary

very much in their symptoms in dieffrent individuals. In some they are decidedly acute, while in others they are chronic. Headache is not so constant a symptom in chronic cases. In the acute forms, however, headache is almost always a prominent symptom and may be due to two causes: First, a local condition due to obstruction of the nasal canal from inflammatory changes; second, a constitutional condition due to infection from bacteria present.

The associate symptoms in these specific conditions are so prominent and the pain so constantly localized, that the physician's attention is directed at once to the source of irritation. His final diagnosis is made by the use of the microscope. This valuable aid is sometimes unnecessarily deferred. However, the diagnosis of gonorrhoeal rhinitis was made, and very probably correctly so, long before our knowledge of bacteria or the modern microscope. Boerhaave reports a case in 1751, Sigmond one in 1852, and Edwards one in 1857.

We come now to the neurotic type of acute rhinitis. Under this heading we have placed hay fever, asthma, and hyperæsthetic rhinitis.

The symptoms of hay fever are those already enumerated in acute coryza, the difference being in the less febrile symptoms, the longer duration of hay fever, lasting during a period of two or three months, and its tendency to recur annually at the same time of the year. It is especially the more annoying, in that there is so little relief from the stuffiness and head symptoms for so long a period. The symptoms are so constant and so similar in different individuals and recur with such exactness each year that the diagnosis is usually made, and various means for relief tried before we see these patients. Hay fever, like influenza, is so often alleged when not present that its diagnosis should be made with more care than is customarily used. A few years ago it was quite popular to call every slight coryza influenza, and this same tendency has caused the laity to call each unduly prolonged attack of cold "hay fever."

I hope I may be pardoned for digressing enough here to mention the experimental work done by Dr. Meyer, of New York, and Dr. Alexander McCoy, of Philadelphia, with Dr. Dunbar's antitoxine serum in hay fever. Dr. Meyer's reports were flattering, but Dr. McCoy's were so very good as to be almost incredible. I hope to be able to give it a trial next hay fever season.

The modern rhinologist feels that he has been robbed of his own if he examines an asthmatic's nose and finds no polypus, no deflected sæptum,

stenosis, spur, or sensitive area acting as an exciting cause. The first symptoms of an asthmatic paroxysm are usually those of a cold-sneezing, watery discharge from the nose, nasal stenosis, headache. The stenosis becomes worse, mouth breathing is necessary, and the paroxysm is complete.

There are two forms of headache in asthma to which I would like fo invite your attention. The first is rather acute and often severe, due to pressure in the nasal canals from stenosis. The second form is a dull, languid headache, which occurs after a night spent in wrestling with an asthmatic attack. This condition is probably due to the character of the inhalation which has been used to relieve the paroxysm. It is also probable that the loss of sleep and a night spent in a close, stuffy room are in part responsible. I now have under my care a young lady whose first symptom of an asthmatic attack is a frontal headache, and last winter I had under my care a law student who was an asthmatic and who had been in the habit of burning certain pastilles for relief, which always caused him to have a headache on the following day.

Hyperesthetic Rhinitis.-Hyperæsthetic rhinitis, by most authors, is classified as hay fever, but there is a series of symptoms in hyperæsthetic rhinitis, which, while related to the hay fever type, are distinctly different from it. In hay fever we always have a stuffy and more or less stenosed nasal canal, while in hyperæsthetic rhinitis this is not at all necessary. We may have sneezing,

peculiar dry, aching sensation, hydrorrhoea without stenosis. The special diagnostic point in these hyperæsthetic cases is the test with the applicator. By passing the cotton covered end of the nasal applicator into the nose and gently touching the different areas we shall find what is known as the sensitive areas; areas which, when touched, set up a violent fit of sneezing or coughing, or cause a frontal headache. Great credit is due Hack, of Paris, for his work along this line. He has probably done more than any other man to call our attention to these nasal reflexes and head symptoms in hyperæsthetic rhinitis. Before dismissing this topic we feel that we must mention the work of Morell Mackenzie and Lennox Browne, of London, and of Bosworth, of America.

We now wish to invite your attention to chronic rhinitis as a factor in producing headache. Under the head of chronic rhinitis we have hypertrophic rhinitis, atrophic rhinitis, foetid and nonfœtid.

Hypertrophic rhinitis, next to simple acute.

Caries of the osteocartilaginous frame work is usually syphilitic; however, it may have its origin in some other constitutional condition. Headache with any manifestation of tertiary syphilis is so common as not to demand any speIcial notice here. We usually get a history of syphilis, and our duty is clear.

Sinusitis.-Headache is almost as constant a symptom in sinus inflammations as is unilateral purulent discharge. This is especially true of frontal sinus affections and perhaps not less true in the case of sphenoidal and ethmoidal. In many cases headache is so prominent a symptom as to overshadow the real affection, and it is not recognized until many other causes of the head symptoms have been suspected. In inflammation of the maxillary sinus we usually get a unilateral headache-a pain beginning in the maxillary affected, after affecting the associated eye, and extending to the head. The associate symptoms here are usually so much more prominent than the headache that the casus morbi are easily recognized.

The acute stage of all these sinus inflammations is much the same. They are as a severe cold with an unusual amount of pain in the head, which localizes itself over the sinus involved. This is especially true of the frontal sinus and the ethmoid. We have less head symptoms in the maxillary inflammations than in the others. Headaches are not prominent symptoms in chronic antrum troubles, but this statement certainly does not apply to any other of the sinuses.

The head symptoms are much the same in inflammation of the ethmoidal cells and of the frontal sinuses. It is a fact that when one is involved the other is mentally affected. There is probably less disturbance generally and less headache where the ethmoidal cells alone are involved, and the pain is usually more nasally localized. In frontal sinus inflammation frontal headache is always present, increased or decreased by posture; worse in the mornings, and associated with supraorbital neuralgia, lacrymation, nasal stenosis, and unilateral purulent discharge. Headache is here often the most distressing symptom, and the one for which we are consulted.

The sphenoidal sinus being so difficult of access, its inflammations are often overlooked. A purulent nasal discharge, not accounted for by the other sinuses, and especially where pus is found high up in the nasal fossa, bottling the posterior portions of the turbinates, and dripping into the nasopharynx, offers a strong suggestion of sphenoidal inflammation. It is very probable that many so called idiopathic headaches, asso

ciated with chronic, "incurable" catarrh, have their origin in the sphenoidal sinus.

Of the benign growths of the nasopharynx which may cause headache might be mentioned adenoids, polypi, syphiloma, enchondroma, papilloma, osteoma, and rhinoscleroma.

The last four of these may be dismissed with a few words. They all cause headache, when they cause it at all, either by pressure or stenosis. These are conditions which are so seldom seen as to deserve being only mentioned.

Syphiloma is very much more common, and is nearly always associated with headaches. It is not seen in this country so often, but it is not an infrequent occurrence in such countries as Mexico, where a very high percentage of the lower classes are syphilitic, and still a larger percentage go untreated. Its diagnosis is not usually difficult. It is to be differentiated from malignant growths, and usually a history of syphilis, or other manifestation of same can be obtained; when not, the therapeutic test, or if haste demands it, the microscope, can be brought to our aid.

There are two stages in the growth of the polypus in which it is especially liable to cause reflex symptoms, such as asthma, headache, etc. At the very beginning it seems that the polypoid tissue is often extremely sensitive and causes pain and headache. This is particularly true where the polypus arises from a centrally placed middle. turbinate. The second stage in which the polypus causes trouble is when it becomes so large as to cause stenosis, pressure, and displacement of the normal parts of the nose. When one removes from two to twenty polypi from a person's nasal chambers he will not wonder that the patient had headache and other nasal neuroses, but will wonder how he could have been free from them.

In treating of the benign growths which cause headache I have purposely left adenoids, the chief of sinners, to the last. All classes of medical men recognize the baneful effects of these growths. There is no minor operation in surgery so fruitful of good results and so gratifying, alike to the doctor and the patient, as adenotomy. To see one of these little strugglers for breath, shut his never before closed mouth, straighten up his prematurely humped back, and develop a heretofore unknown mental capacity, after one of these operations, is a great pleasure to all concerned. We feel that this condition is so well known as not to need discussion. The experienced clinician can often make a diagnosis of these cases at a distance. The open mouth, pinched face, narrow