Very copious bleeding can be caused by intranasal tumors which are partly made up of cavernous tissue. This applies to benign polypi, suspicious adenomatous tumors, as well as to malignant cancers. Excessive hemorrhage may also be due to an unmixed angiomatous growth. Postnasal fibromata are likewise very prone to bleed freely, more, however, into the pharynx than through the nose. Slight nosebleed occurs to some extent in children with enlarged pharyngeal tonsil.

Transient bleeding may be caused by a blow, usually without lasting lesion. Any nasal operation may be followed by secondary bleeding within the first few days. Sudden diminution of air pressure in ascending high mountains starts bleeding from the nose in many

persons.

Nosebleed with or without visible septal lesion may depend on various systemic conditions. After typhoid fever, in the course of grave anemia, but especially in any form of pernicious anemia, as well as in leukocythemia, it may prove difficult to manage. In scurvy and hemophilia it is more likely trivial if spontaneous, but if traumatic in a bleeder, it gives cause for anxiety. Nosebleed is an early symptom in typhoid fever, less so in measles and scarlatina, in which latter case it is said to be indicative of severe infection.

In middle or advanced life epistaxis may indicate arteriosclerosis and thus prove a forerunner of cerebral softening. The nosebleed referable to the climacteric period in women is probably also dependent on some change in the blood-vessels. Hemorrhage from the nose, vicarious for suppressed menstruation, is occasionally observed, but its frequency has been exaggerated.

If epistaxis occurs with symptoms of nasal inflammation, fibrinous rhinitis or nasal diphtheria should be thought of.

126. In any ordinary case of nosebleed the patient should be instructed to sit up, or, better still, stand up, in order to lower the blood pressure and to plug the nostrils

with cotton. Wiping and other useless meddling merely protracts the bleeding. The popular practice of placing anything cold (for instance, a key) on the nape of the neck probably causes reflex action of the vasomotor nerves and is not without some utility. Severe bleeding requires surgical plugging with gauze (or cotton in case of emergency). Slight bleeding is easily controlled by the use of suprarenal solution on cotton. But there has not been enough experience with this agent to state definitely whether it can be relied upon in grave cases and whether it checks hemorrhage permanently. Pledgets wet with antipyrin solution (10 per cent.) often act quicker than mere mechanical plugging, especially if the pledgets are dusted with tannin powder. The latter alone, however, is not of much use. In dangerous cases Monsell's solution of iron is certain in its action, but very disagreeable by reason of the firm clot which it produces. Whenever the blood flows into the pharynx in spite of nasal plugging, a tampon must be placed in the nasopharynx by means of Belloc's sound (or by aid of a rubber drainagetube pushed through the nose) (¶ 29). In all instances the lesion causing the bleeding should be looked for as soon as practicable and treated.

127. Nasal hydrorrhea (or rhinorrhea), a discharge of a clear watery fluid from the nose, is a symptom of variable significance. It is most frequently seen in connection with sneezing fits in nasal irritability. This may depend in some instances on abnormal turgescence of cavernous tissue in neurotic subjects (vasomotor coryza), while in others it is due to the presence of polypi. In cases of this nature the hydrorrhea occurs as a spell of short duration. In less common instances the watery discharge lasts longer and is very profuse. Within less than an hour many handkerchiefs may be saturated. Much less common is a continuous discharge lasting day and night. Its cause can usually not be determined. A few times it has been seen in connection with disease of the fifth nerve, either neuralgia or paraly

sis. In some instances the internal use of atropin has proved of service. In other instances the fluid dropping from the nose is cerebrospinal fluid. This diagnosis is favored by finding in it chemically a substance reducing Fehling's (copper sulphate) solution like sugar. An escape of cerebrospinal fluid may occur as the result of a fracture of the base of the skull. A few fatal cases have been reported in which a continuous flow of clear fluid from the nose accompanied atrophy of the optic nerves with pronounced contraction of the visual fields. and with the presence of other cerebral symptoms (headache and vertigo). The autopsies showed a perforation of the roof of the sphenoid sinus due to tumors of the hypophysis cerebri or other basal tumors or hydrocephalus.

CHAPTER XVIII.

ANATOMY OF THE TONSILS. ACUTE INFLAMMATION OF THE PHARYNX AND OF THE TONSILS (ANGINA).

128. Anatomy of the Adenoid Tissue and Tonsils. -The shape and topographic anatomy of the pharynx have been described in Chap. I., ¶ 6, and Chap. III.,

24, the structure of its lining membrane in Chap. I., ¶ 7. For a study of the diseases of this region some further details concerning the adenoid tissue are necessary. The entire mucous membrane of the pharynx is normally infiltrated with lymphoid cells, but a special localized development of lymphoid tissue surrounds the anterior entrances into the pharynx in the form of a "lymphatic ring," as termed by Waldeyer. This is constituted by the two faucial tonsils, the bridge of adenoid tissue stretched across the base of the tongue (the lingual tonsil), and the pharyngeal tonsil at the roof of the pharynx. Under morbid circumstances lymphatic tissue may also develop in visible masses in the form of follicles on the posterior wall of the pharynx, and especially in the form of the (hypertrophied) lateral cords of the pharynx.

The faucial tonsils form a slightly prominent cushion in the space bounded by the anterior and posterior pillars. The pillars themselves are projecting folds of mucous membrane, practically the downward prolongation of the free border of the soft palate extending down to the tongue. Above each tonsil and underneath the superior junction of the two pillars is a recess, sometimes a deep pocket-the supratonsillar sinus. The tonsil itself is a thickening of the mucous membrane due to the develop

ment of lymph-follicles within a delicate capsule (Fig. 72). The tonsil is marked by about one dozen pits lined by mucous membrane (and pavement epithelium)-the lacunæ or crypts. Any distinct prominence of the tonsillar tissue must be considered a morbid enlargement.

Across the base of the tongue there extends a bridge of lymphoid tissue-the lingual tonsil. Besides the diffuse development of lymph-follicles, this area presents a trans

Soft

FIG. 72.-Histologic structure of the hypertrophied faucial tonsil. (cellular) form of childhood. The normal pavement epithelium is penetrated by leukocytes to such an extent normally that the appearance of stratification is partly effaced. The epithelium sends offshoots into the underlying adenoid tissue. The lymphatic structure does not differ essentially from a normal specimen. The blood-vessels are larger and more numerous than in the normal tonsil.

verse row of larger lymphatic nodules, each from 1 to 4 mm. wide, containing a central crypt.

The pharyngeal tonsil consists of a cushion of mucous membrane thickened by the development of follicles so as to project in the form of shallow sagittal ridges, six or seven in number, which coalesce in front and behind. It begins at the roof of the pharynx, about 5 mm. behind the upper rim of the choanæ, and has a length of about 2 cm. Transversely it does not extend into the fossæ of Rosenmüller. The recess between the central ridges is sometimes developed into a deeper pit, the pharyngeal bursa. This is not always present. Like in