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BACKGROUND ANATOMY: In ancient times the paranasal sinuses, without any anatomical differentiation, were thought to be a system of hollow spaces through which mucus produced by the brain was drained. Leonardo da Vinci in Milano in 1489 was the first to prepare and draw anatomical specimens of the paranasal sinuses; the drawings, however, only became accessible to scientific evaluation as late as 1901. N. Highmore in England in 1651 presented the first detailed description and drawing of the maxillary sinus, and hence it is named Highmore's antrum. C. V. Schneider in Wittenberg, Germany, in 1660 realized that the mucus is not a product of the brain but is produced by the mucous lining of the region itself. F. G. J. Henle in Berlin in 1841 differentiated between various epithelia and described the special function of the ciliated epithelium of the respiratory tract. FROM OZENA TO SINUSITIS: In ancient times the word ozena originally denoted any kind of foul breath, but in the 1st and 2nd century AD (Celsus, Galenus) the term became restricted to foul odor coming from the nose. J. Drake and W. Cowper in England in 1707 reported that in some cases ozena was due to suppuration in the maxillary sinus and could be cured by extraction of a tooth and opening the sinus via the alveolus. L. H. Runge in Rinteln, Germany in 1750 compiled a nearly complete systematic survey of all diseases localized in the maxillary sinus. EARLY STAGES OF SURGERY: A. L. B. B. Jourdain in France in 1765 tried to cure suppurations of the maxillary sinus by irrigation via the natural ostium in the middle nasal meatus, however, his method did not meet with approval. L. Lamorier in Montpellier in 1743 opened the maxillary sinus form the buccal cavity, but his paper was only published in 1768. Lamorier's method and opening the sinus via a dental alveolus remained standard procedures for a long time. K. Ziem in Danzig, Germany, in 1886 analyzed 26 cases of chronic suppurations discharging from the nose, among them his own history, and found out that they can originate from different foci and that the treatment must be centered around the relevant focus. CLASSICAL OPERATIVE PROCEDURES: J. Mikulicz-Radecki in Vienna in 1886 was the first to open the maxillary sinus from the inferior nasal meatus. G. W. Caldwell in New York in 1893 published his method: opening the canine fossa wall, removal of the mucous membrane, and opening a window in the lateral wall of the inferior nasal meatus. G. Boenninghaus in Breslau, Germany, in 1896 was the first in Europe to adopt this method, and he modified it by placing a mucosal flap in the window. Unaware of Caldwell's publication, H.-P. Luc in Paris in 1897 reported on his own operative procedure, which in fact was identical to that of Caldwell's. DEVELOPMENT DURING THE LAST 100 YEARS: The operative procedures and especially the preoperative diagnosis were continually improved so that the surgical treatment of chronic suppurations of the maxillary sinus reached a high standard. During the last decades less radical interventions using an endonasal approach by endoscopy have partly superseded the classical procedures. This development is described in great detail with literal quotations of the original papers, anecdotal details, and illustrations.
Even in ancient times the existence of an open pathway between the ear and the respiratory tract was assumed. Up to the middle ages, however, Aristotle's idea that the air in the ear is an innate part of the body prevailed. The first anatomical description of the tube was given by Eustachius (1563). He still adhered to the concept of "innate air" and regarded the tube only as a pathway for draining pathological matter from the tympanic cavity. Duverney (1683) realized that an important function of the tube was replacing and adjusting the pressure of the air in the tympanic cavity. He thought that the tube is permanently open, thus offering a vent to the air, when the tympanic membrane is moving inwards and outwards. Valsalva (1704) discovered a muscle for opening the tube, and he presumed that in hearing this muscle would come into action. He described the maneuver that is named after him as a method to expel pus from the tympanic cavity into the external auditory canal. E.G. Guyot, a postmaster in Versailles, was the first to try catheterization of his own Eustachian tube via the mouth. Cleland (1741) inserted the catheter via the nose, and Wathen (1756) after studies on corpses described in detail the technique how to carry out this procedure. The therapeutic application of Eustachian catheterization as practiced by physicians such as Itard (1821) centered around irrigation with water and medications as well as inflation of various fumes. Deleau (1836) later advocated a douche of pure air and, in analogy to the auscultation of the lung, described the different noises that could be perceived during this procedure. Numerous models of pumps were constructed for this air douche, which became one of the most widely used therapeutical means in otology. There were also lethal incidents caused by cutaneous emphysemata. Toynbee realized that at rest the tube is closed and that there is a constant absorption of air in the tympanic cavity. The tube would be opened only by the act of swallowing and air would then be allowed to enter to equalize pressure. He believed that the maneuver he described, namely swallowing while the nostrils are closed, would produce a positive pressure in the tympanic cavity. He died when he applied these maneuvers in order to press fumes of chloroform or cyanic acid into his ears to treat his tinnitus. Politzer could demonstrate that after Toynbee's maneuver the middle ear is left with a negative pressure, and consequently, in 1861-63, he devised his own method for actively inflating the middle ear. The history of these events is described in detail and illustrated by a number of figures and anecdotal episodes.
BACKGROUND: The etymology of the anatomical terms and their use in history are elucidated: "Tonsil" (from Latin tonsa = the oar) in use since Celsus (about 40 AD). The Greek terms of that time, "antiádes", "paristhmia", were not adopted in later medical terminology. "Amygdala" (Greek/Latin = the almond) was introduced by Vesalius in 1543. Vesalius was also the first to depict the tonsils in a specimen of the whole human body; Duverney (1761) gives the first exact depiction of the pharyngeal region. Special anatomical and histological studies of the tonsils were carried out in the 19 century. DIGITAL EXTRACTION OF THE TONSILS: Cornelius Celsus in Rome (about 40 AD) described the blunt removal of the tonsils by use of the finger. This method was favoured anew by numerous laryngologists at the beginning of the 20th century when it had been realised that a gentle enucleation of the entire tonsil including its capsule was advisable against cutting off a slice, but before long this procedure was discarded again for hygienic reasons. OPERATION WITH SNARES AND CUTTING INSTRUMENTS: Precursors of special instruments for tonsillectomy were instruments designed for shortening the uvula: uvulotomy. Paré (1564) and Scultetus (1655) devised instruments that permitted placing a thread shaped like a snare around the uvula and cutting it off by strangulation. Hildanus (1646), Scultetus (1655) and Heister (1763) presented an instrument of the guillotine-type for uvulotomy. This instrument was modified by P. S. Physick (USA 1828) and used for tonsillotomy. It became the prototype for a number of similar instruments which were to follow: W. M. F. Fahnestock (USA 1832). M. Mackenzie (London 1880), G. Sluder (USA 1911). Besides these guillotines snares were also perfected and used for tonsillotomy, e.g. by W. Brünings (1908). The concentration on tonsillotomy aimed at performing the operation as quickly as possible, especially in children, as it was not yet possible to sustain general anaesthesia for a longer period of time while doing surgery in the pharynx. The operation of the tonsils, that had been started by general surgeons, at the end of the 19th century became the domain of the otolaryngologists because they had the superior technique of illumination. Important steps of progress were later on mouth-gags combined with tongue-depressors, and placing the head in a suspended and reclined position. This position had already been advocated by Killian in 1920, but it could only be introduced after improved techniques of general anaesthesia were available. These stages of historical development are described and illustrated with many details.
ETIOLOGY AND ANATOMY: Up to the Middle Ages, nosebleeds were considered a natural means of purification in internal diseases. In addition injuries, extreme physical exertion, and influences from the sexual sphere were recognized causes. In the 19th century, low atmospheric pressure on mountains and in balloons was also assumed to be an etiological factor. It was only at the end of the 19th century that the importance of high blood pressure and defective coagulation were diagnosed in context with nosebleeds. In ancient times, it was known that compressing the nasal alae can often stop the bleeding, but that blood may as well run down the throat and mimick a hemorrhage coming from the trachea. Between 1874 and 1884, several authors, among them J. L. Little in USA and W. Kiesselbach in Germany, recognized the anterior part of the nasal septum as a frequent location of bleeding. GENERAL THERAPY AND ANTERIOR NASAL PLUGGING: General measures of hemostasis recommended already in ancient times were the application of cold and diverting the blood to other regions of the body by applying tourniquets to legs and arms, or by cupping. Anterior nasal plugging was already known to the ancient Assyrians and Hippocrates. Scribonus Largus (1st century) was the first to describe a nasal plugging around a tube, thus preserving a patient respiratory passage. During the Middle Ages local application of assumedly hemostatic substances of the apothecary of that time played an important part, among them "cranial moss", the lichen that grew on the skulls of hanged corpses exposed to the weather for a long time, and "mumia", a black unctuous substance made of Egyptian mummies. Plugging the nares with an inflated balloon, fabricated from animal intestines, was described first by J. P. Frank in 1807. During the second half of the 19th century, numerous varieties of rubber balloons, rubber caps, and condoms came in use for this technique. The first nasal balloon combined with a respiratory tube was presented by Dionisio in 1890. POSTERIOR NASAL PLUGGING: Plugging of the posterior nares was anticipated by Hippocrates technique of removing a pendulous polyp by pulling a sponge tied to four strings backwards through the nasal cavity. Le Dran, surgeon in Paris in 1731, was the first to adopt this technique for stopping a nasal hemorrhage. The instrument named after Belloc (or Belloq) for placing a posterior nasal plug consists of a metal tube in which a curved spring can be pushed forwards and backwards. The first description of this instrument remains a mystery. There were at least two French surgeons named Belloc and Belloq, and this has been the source of some confusion. A paper of a certain Belloq of 1757, which is generally regarded as the source, deals with means of stopping certain hemorrhages. It exists in two different printed versions with identical wording and describes the application of candle wax for stopping severe hemorrhages after tooth extraction and abdominal puncture; however, it makes no mention of nosebleeds. Bellocq's tube was made known by Deschamps' book on diseases of the nose in 1804. For about 150 years, it was one of the instruments most frequently illustrated in textbooks and most rarely used in practice because surgeons generally preferred a simple catheter for placing a posterior nasal plug. The article concludes with a short survey of the history of chemical and thermal cauterisation and ligation of blood vessels for stopping nosebleeds.
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BACKGROUND: G. Cardano, physician, mathematician, and astrologer in Pavia, Italy, in 1550 described how sound may be perceived through the skull. A few years later H. Capivacci, also a physician in Padua, realized that this phenomenon might be used as a diagnostic tool for differentiating between hearing disorders located either in the middle ear or in the acoustic nerve. The German physician G. C. Schelhammer in 1684 was the first to use a common cutlery fork in further developing the experiments initiated by Cardano and Capivacci. For a long time to come, however, there was no demand for this in practical otology. THE INVENTION OF THE TUNING FORK: The tuning fork was invented in 1711 by John Shore, trumpeter and lutenist to H. Purcell and G.F. Händel in London. A picture of Händel's own tuning fork, probably the oldest tuning fork in existence, is presented here for the first time. There are a number of anecdotes connected with the inventor of the tuning fork, using plays on words involving the name Shore, and mixing up pitch-pipe and pitchfork. Some of these are related here. The tuning fork as a musical instrument soon became a success throughout Europe. THE PHYSICS OF THE TUNING FORK: The German physicist E. F. F. Chladni in Wittenberg around 1800 was the first to systematically investigate the mode of vibration of the tuning fork with its nodal points. Besides this, he and others tried to construct a complete musical instrument based on sets of tuning forks, which, however, were not widely accepted. J. H. Scheibler in Germany in 1834 presented a set of 54 tuning forks covering the range from 220 Hz to 440 Hz, at intervals of 4 Hz. J. Lissajous in Paris constructed a very elaborate tuning fork with a resonance box, which was intended to represent the international standard of the musical note A with 435 vibrations per second, but this remained controversial. K. R. Koenig, a German physicist living in Paris, invented a tuning fork which was kept in continuous vibration by a clockwork. H. Helmholtz, physiologist in Heidelberg, in 1863 used sets of electromagnetically powered tuning forks for his famous experiments on the sensations of tone. Until the invention of the electronic valve, tuning forks remained indispensible instruments for producing defined sinusoidal vibrations. The history of this development is presented in detail. The diagnostic use of the tuning fork in otology will be described in a separate article.
The natural history of chromoblastomycosis was studied in Madagascar by analysing the characteristics of 1323 confirmed cases observed since 1955, including 45 patients receiving a new antifungic drug (terbinafine) during a multicentric study organized in 1995. The surveys data, conserved by the histopathology laboratory in the Institut Pasteur of Madagascar during 40 years, permit this retrospective analysis. The description of two ecosystems, one in the North with Fonsecaea pedrosoi evolving in the tropical rainforest and one in the South with Cladophialophora carrionii (41% of the whole sample) isolated in the spiny desert, demonstrates that the deforestation, in order to product charcoal and to build houses, is the primary factor associated with this disease. The epidemiologic (87% of patients are male and 96% are more than 16 years old, with more than 74% of the lesions located on feet and legs), mycologic (62% of the isolated strains belong to the F. pedrosoi species) and therapeutic (low efficiency of thiabendazole in long-term lesions, high efficiency of terbinafine especially on recent lesions and on Cladophialophora-infected patients) aspects of the natural history of chromomycosis confirmed that Madagascar is the most important focus in the world (global prevalence of about 1 for 8500 inhabitants), with few sporadic cases in the other islands of the Indian Ocean (La Reunion, Comoro islands and Mayotte). In the difficult context of Madagascar, the need for a non-specialized laboratory-applicable diagnostic technique that provides infection and species identification led the Institut Pasteur de Madagascar to develop an ELISA-based technique. A large-scale control throughout the country, with the assessment of effective oral chemotherapy with terbinafine, is seen as possible by the authors with the help of the manufacturer.
BACKGROUND: In 1854 the Spanish singing teacher Manuel Garcia succeeded in inspecting his own larynx. In 1857 the neurologist Ludwig Türck in Vienna, without knowledge of Garcia's achievement, had been experimenting on laryngoscopy with his patients using a small mirror and sunlight. When in the winter of 1857-1858 he had to suspend his experiments for lack of sunlight, he lent his mirror to physiologist Johann Czermak in Budapest. Czermak, using artificial light reflected by a perforated mirror, developed modern laryngoscopy within a few weeks and made it a clinically valuable method. He described it in March 1858 as his own invention. This was the beginning of a an embittered fight with Türck about whose development had priority. DIAPHANOSCOPY OF THE LARYNX: During his very first studies on laryngoscopy Czermak noticed that the interior of the larynx could be inspected very well when the neck was illuminated by a strong light from without and the mirror was held in the dark pharynx. The tissue would then appear transilluminated in a glowing deep red. When sufficiently bright electric lamps became available in 1889, Rudolph Voltolini in Breslau, Germany, took up the transillumination of the larynx and even carried out some minor intralaryngeal operations using this method. Although suitable diaphanoscopes were soon on the market this technique was not widely adopted. It was ony used once in 1954 (Pellnitz et al.) for diagnosing early stages of laryngeal cancer. DIAPHANOSCOPY OF THE PARANASAL SINUSES: Voltolini in Breslau and Cozzolino in Naples experimented independently of each other with small electric lamps with the aim of finding new techniques of rhinoscopy. Both of them placed their lamp in the nasopharynx and performed anterior rhinoscopy using an ordinary speculum. However, it was only Voltolini who noticed the transillumination of the maxillary sinuses when the lamp was placed in the oral cavity. On October 29, 1888, in Breslau he demonstrated diaphanoscopy of the maxillary sinus for the first time. Cozzolino claimed that he had introduced this technique prior to Voltolini. Voltolini had died in 1889 and could not comment on this. A careful study of the original publications, however, shows that Cozzolino had only inspected the nasal cavity with retronasal illumination, but had not demonstrated the maxillary sinus by transillumination. The diaphanoscopy of the paranal sinuses was very soon elaborated to perfection: Vohse in 1890 applied it to the frontal sinuses, Gerber in 1900 invented a double diaphanoscope for examining both frontal sinuses simultaneously. Although the shortcomings of diaphanoscopy soon became apparent, the method was widely used for about half a century, but in the end could not compete with modern techniques of radiography and ultrasound. The history is related in detail and illustrated with numerous figures.
Friedrich Hofmann, medical officer in Burgsteinfurt, Westphalia, Germany, in 1841 described a concave mirror with a central aperture in it as the ideal instrument that allowed reflecting and focussing light into the external auditory canal and simultaneously inspecting the tympanic membrane without obstructing either the light or the view. He recommended his device also for the inspection of other concealed regions of the body. His invention was referred to by Martell Frank in his textbook of otology in 1845, but otherwise attracted no attention. Hermann Helmholtz, physiologist in Königsberg, East Prussia, devised his ophthalmoscope in 1850-51 in order to study the phenomenon of glowing eyes. With this instrument he was the first to see the retina of a living human. As means of illumination he used small panes of glass similar to cover-glasses which were introduced into the common visual axis of the observer and the subject at such an angle that light from a lamp was reflected into the subject's eye while the observer inspected the subject's retina through the glass and an appropriate lens. He recommended this type of illumination also for otoscopy. His invention was at once acclaimed throughout the world and opened completely new opportunities in ophthalmology. The slanting panes of glass, however, were not the ideal solution for illumination. It was only one year later that Ruete in Göttingen replaced them with a concave mirror with a central aperture, and there is every indication that Frank's report on Hofmann's mirror had suggested this technique to him. During the following two years quite a number of other modifications of the ophthalmoscope were constructed, all of them using the concave mirror with a central aperture, which soon became synonymous with the ophthalmoscope as such. Von Tröltsch, otologist and ophthalmologist in Würzburg, presented a concave mirror with a central aperture for otoscopy in Paris in 1855-56. His instrument was obviously derived from the already well known ophthalmoscope by adapting the diameter and focal distance to this special application. His primary concern was to use daylight instead of artificial light for otoscopy. Von Tröltsch did not know Hofmann's publication, but later did not hesitate to acknowledge Hofmann's priority. It was von Tröltsch who popularized the concave reflector with a central aperture as the instrument of choice in otoscopy, and subsequently also for rhinoscopy and laryngoscopy. Further modifications were devised to have the hands free for operations. Thus the reflector was fixed to the forehead by strap and buckle or a vulcanite band, or it was provided with a handle that was to be held between the teeth, or it was attached to a spectacle frame. The details of this interwoven history are related and highlighted by numerous quotations and historical illustrations.
Anatomy, nomenclature, first clinical observations: In ancient Greece and Rome and in the Middle Ages the posterior opening of the nasal passage was known (Greek "choane" = funnel) as an atomical structure, and it was also known that chronic nasal catarrh is common in children, but it was not realized that this was associated with special pathological alterations. The anatomist H. von Luschka in Tübingen, Germany, was the first to describe the nasopharynx in detail, and he coined the term "pharyngeal tonsil." The otologists of the 19th century like Kramer and Toynbee had placed the Eustachian tube in the center of their investigations and carried out numerous dissections with demonstration of the tubal orifice. They also knew that middle ear infections usually originated in the nasopharynx, but they did not realize that the hypertrophic pharyngeal tonsil was the cause. Posterior rhinoscopy and the diagnosis of the hypertrophy of the pharyngeal tonsil: Czermak in Budapest in 1860 had invented posterior rhinoscopy, and he was the first to diagnose hypertrophic alterations around the tubal orifice and the first to realize that they were the cause of tubal malfunction. Wilhelm Meyer in Kopenhagen in 1868 and 1873-1874 described hypertrophy of the pharyngeal tonsil ("adenoid vegetations") in detail and associated this finding with a syndrome characterized by mouth-breathing, snoring, a typical facial expression, deafness, recurring middle-ear affections, and characteristic alterations of speech. He based his conclusions on 5 years' experience with 175 observations in his office and on examination of 2700 children in Denmark and England. Surgical therapy of adenoid vegetations: Voltolini in Breslau in 1865 had observed a few cases of hypertrophy of the pharyngeal tonsil, and he was the first to treat them by galvanic cauterization. Meyer developed various instruments for reducing the pharyngeal tonsil. They were introduced through the nose while the application of the instrument was assisted digitally via the mouth and pharynx. The operation of the pharyngeal tonsil was adopted very eagerly by a great number of nasal surgeons. Among the numerous special instruments that subsequently were invented the most promising was the ring knife invented by Gottstein in 1886. Anesthesia and positioning: The pioneers of this intervention, Voltolini, Meyer, Semon and others, all operated without any anesthesia, but they usually would need up to 12 sessions (Semon) until the pharyngeal tonsil had been sufficiently reduced. Beckmann in Berlin, who had invented a modification of Gottstein's ring knife, reported in 1897 on more than 5000 cases in which he had removed the adenoids in just one session, in each case without anesthesia. Besides these surgeons, others used cocaine for local anesthesia or chlorethyl or bromethyl for general anesthesia. The German surgeon Edmund Rose (Berlin and Zürich) in 1874 introduced the position with the head suspended for larger interventions like resection ot the maxilla. Rudloff in Wiesbaden, Germany, in 1900 adopted this position for adenoidectomy, but this was generally accepted only after the mouth gags developed by Davis-Boyle and Negus had been introduced. The diagnostic and surgical interventions in the nasopharynx were a powerful link in the process of fusion between otology and rhinolaryngology around the turn of the century. This historical development is described in great detail with many figures and quotations from the literature.
BACKGROUND. Inspection of or interventions in the external ear canal and the nostrils pose similar technical problems. This is the reason why early instruments devised for otoscopy and rhinoscopy were based on an identical principle. They were shaped like a pair of tongs, comparable to nasal specula of today. A similar type of instrument had been developed earlier by barber surgeons for inspecting narrow wound cavities. TONG-SHAPED SPECULA. The first description and illustration of an aural and nasal speculum was provided by Guy de Chauliac in Montpellier, France in 1363. Sophisticated models were presented by Fabricius Hildanus in Germany in 1646 and J.J. Perret in Paris in 1772, who offered them in his illustrated catalogue of surgical instruments at fixed prices. W. Kramer (1836) in Berlin improved this tong-shaped instrument and devised the ear speculum named after him that was generally favored during the first half of the 19th century. Further variations of this type were presented by Lincke and Schmalz (1846) in Germany. FUNNEL-SHAPED SPECULA. Ignaz Gruber in Vienna in 1838 devised the first tunnel-shaped ear specula made of metal. They had a simple conical shape, were not divided into separate jaws, and could not be spread. Gruber himself did not publish his invention, but he demonstrated his ear specula to W. R. Wilde from Dublin, who had paid a visit to his office in Vienna. Wilde reported on this in 1844, and subsequently systematically refined Gruber's specula. A. v. Tröltsch from Würzburg (Germany) had seen these instruments at Wilde's office and it was Wilde himself and v. Tröltsch who helped this type of ear speculum to gain acceptance on an international scale. A different type of bottle-shaped ear speculum was first used by Schmalz (1846) and Erhard (1859) in Germany, but it was only developed into a commercially available instrument by Josef Gruber in Vienna in 1870. The ear specula most in use today were first presented by A. Hartmann in Berlin in 1881. SUPPLEMENTARY INVENTIONS. An important supplementary invention was the pneumatic ear speculum by E. Siegle in Stuttgart (Germany) in 1864. It permitted not only inspecting the tympanic membrane but also examining its compliance and response to variations in air pressure in the ear canal. The importance of this instrument was recognized at once and has remained undisputed to this day. J. Bruton, an English military surgeon, presented his otoscope in 1862. It was the first device to incorporate interchangeable ear specula, illumination by a perforated mirror, and a magnifying lens into one handy instrument. It is the precursor of the modern diagnostic sets comprised of a battery-handle, various specula, and accessories for otoscopy, rhinoscopy, and ophthalmoscopy which started to come into use in the late twenties of this century. This historical development of the ear specula is described and illustrated in detail.
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BACKGROUND: Injections are part of the arsenal of all medical disciplines. In addition to this common ground, each specialty has its own particular aspects; the historical development of these are presented here with respect to otorhinolaryngology. INTRAVENOUS INJECTIONS: The first experiments with intravenous injections were carried out in 1642 by a gentleman's hunting servant in eastern Germany. Similar experiments were done in 1656 by Christopher Wren, the astronomer, mathematician, and architect in Oxford, England, and a group of scientists around the physicist Robert Boyle. These experiments were prompted by new knowledge about blood circulation provided by William Harvey in 1628. The first books on the applications of intravenous infusions in humans were published in Germany by Major 1664 (Chirurgia Infusoria) and Elsholtz 1667 (Clysmatica Nova). Bladders of animals or enema syringes were used as instruments. Because of lethal accidents the infusions soon fell from favour. Köhler in Germany in 1776 eliminated a large bolus impacted in a patient's esophagus by an intravenous infusion of tartar emetic thus inducing violent vomiting. After this crucial experiment, foreign bodies in the esophagus were the most important indication for applying intravenous injections until Killian introduced extraction by esophagoscopy in 1990. CALIBRATED SYRINGES AFTER PRAVAZ: The French surgeon C. Pravaz in Lyon in 1853 invented a small syringe, the piston of which could be driven by a screw thus allowing exact dosage. A sharp needle with a pointed trocar could be introduced into the vessel making a dissection unnessessary. Pravaz used his syringe for obliteration of arterial aneurysms by injection of ferric sesquichlorate. Pravaz's syringe initiated the invention of a great number of various calibrated syringes made of glass or metal combined with glass. SUBCUTANEOUS INJECTION AND LOCAL ANAESTHESIA: The calibrated syringes were commonly used in the treatment of syphilis by mercurialization. In otorhinolaryngology, they had and still have their primary application in local anaesthesia, which was introduced by Carl Ludwig Schleich in Berlin in 1892. PARAFFIN-INJECTIONS: Around 1900 the injection of liquid paraffin for closing defects in subcutaneous tissues came into use (Gersuny in Vienna, Delangre in Tournai). This technique was immediately applied to rhinological indications such as a saddle nose (Stein 1901). This gave rise to the invention of special syringes and modifications of paraffin with different hardness and melting points. Around the middle of this century, paraffin was abandoned for this application because of serious complications, and new substances were introduced such like teflon, silicone and collagen. The historical development of these techniques of injections is described in details with many literature citations and figures.