LIBRARY OF CONGRESS. 
 
 Chap. Copyright No. 
 
 Shel£R_TE4 £ 
 
 UNITED STATES OF AMERICA. 
 
DISEASES 
 
 OF THE 
 
 Nose and Throat 
 
 J. PRICE-BROWN, M.B., L.R.C.P.E. 
 
 \ \\ 
 
 Member of the College of Physicians and Surgeons of Ontario; Laryngologist to the Toronto 
 
 Western Hospital; Laryngologist to the Protestant Orphans' Home; Fellow of the 
 
 American Laryngological, Rhinological, and Otological Society; Member 
 
 of the British Medical Association, the Pan-American Medical 
 
 Congress, the Canadian Medical Association, the 
 
 Ontario Medical Association, etc., etc. 
 
 Illustrated with 159 Engravings, including 6 Full-page 
 
 Color=plates and 9 Cclor=cuts in the Text, 
 
 many of them Original 
 
 PHILADELPHIA, NEW YORK, CHICAGO 
 
 THE F. A. DAVIS COMPANY, PUBLISHERS 
 1900 
 
TWO COPIES RECEIVED, 
 
 Ufefafy of Congrr9f% 
 Offloo of fba 
 
 M*P7-1900 
 
 KtgliUr of C»pyHg»t» 
 
 56702 
 
 COPYRIGHT, 1900, 
 
 BY 
 
 THE F. A. DAVIS COMPANY. 
 
 Registered at Stationers" Hall, London, Eng.] 
 
 SECOND COPY. 
 
 Philadelphia, Pa., U. S. A. : 
 
 The Medical Bulletin Printing-house, 
 1914-16 Cherry Street. 
 
 
IN RECOGNITION OF HIS UNTIRING ENERGY IN THE 
 INVESTIGATION OF SCIENTIFIC TRUTH 
 
 AND 
 
 HIS EMINENT SERVICES IN THE ADVANCEMENT OF 
 
 LARYNGOLOGY AND RHINOLOGY 
 THIS VOLUME 
 
 IS 
 
 Affectionately Dedicated 
 
 TO 
 
 PROF. E. L. SHURLY, M.D., 
 
 BY 
 
 HIS SINCERE FRIEND : 
 
 THE AUTHOR. 
 
 *»*« 
 
PBEFACE. 
 
 In adding one more to the long list of works that have been pub- 
 lished upon diseases of the nose and throat the author is aware that he 
 has undertaken neither a light nor an irresponsible task; and were it 
 not for the fact that there is a professional field in -a large measure still 
 unoccupied he would not have ventured to present to the medical public 
 another volume upon this subject. 
 
 As a practitioner who for nearly twenty years was engaged in gen- 
 eral practice, and who for the last ten years has devoted himself ex- 
 clusively to nose-and-throat work, he has frequently been struck with 
 the small amount of knowledge possessed by the profession at large 
 upon the diseases of these important organs. Patients are sent to the 
 specialist of acknowledged skill, by physicians of towns and cities far 
 remote from the residence of the specialist himself. But these patients 
 are the fortunate few : those who have comfortable homes with all that 
 good food, kind friends, and hygienic surroundings can do to restore 
 them to health, as well as means to pay the specialist whose services 
 they require. What about the larger number? the impecunious? the 
 poor? those who might pay a small fee for relief from constant suffer- 
 ing, but who are unable to make long journeys, and to meet the obliga- 
 tions required by staying in the city and remunerating the laryn- 
 gologist for his work? It is for physicians and surgeons who so fre- 
 quently meet patients of this class and for students preparing for the 
 Tegular practice of their profession that this book is written. 
 
 In this rushing age, when a thousand and one things demand the 
 attention of the busy practitioner, any work of this kind to be of real 
 use must be terse and to the point. At the same time, when the pro- 
 fession is overcrowded, and the physician's fees often small and diffi- 
 cult to collect, a large price for a book is often out of the question. 
 To meet these requirements in a reasonable and candid w T ay has been 
 the author's aim. 
 
 In order to do this he has left out certain subjects which are usu- 
 ally considered to belong to this specialty. For this, however, there is 
 ample reason, as some of these are dealt with in works on general medi- 
 cine, and others in works on ophthalmology and otology. This may 
 he said of descriptive anatomy of the nose and throat, which is touched 
 
VI PEEFACE. 
 
 upon only so far as it relates to the practical treatment of diseases of 
 these organs. Diseases of the frontal sinus and the lacrymal canal, 
 coming usually under the domain of the oculist, have been left entirely 
 to his care. Still further, diseases of the ear are not spoken of, except 
 to the extent that naso-pharyngeal diseases affect the Eustachian tube. 
 Asthma, too, is discussed more exhaustively in well-recognized works 
 on general medicine than it could be within the limits of these pages, 
 and consequently has not been treated of. In one other point it is 
 hoped the profession will agree with the author, and that is in the 
 exclusion of diphtheria from this volume. The medical literature of 
 the day is full of the subject. Every medical journal of any standing 
 can tell the latest with regard to this disease. Toxins and antitoxins 
 monopolize the attention of the medical world, and yet the exact status 
 of one and of the other in regard to the propagation and prevention 
 of disease it may take another half-century to fully and absolutely 
 define. 
 
 It is not the author's desire to speak in any way slightingly of the 
 importance and interest of these subjects, or of the absolute necessity 
 of investigating to the utmost all that science can advance in reference 
 to this disease. What he wishes to say is that, after taking all the cir- 
 cumstances into consideration, he has acted advisedly in not placing 
 diphtheria upon the list of subjects treated of. 
 
 Another reason for limiting this work strictly within certain lines 
 was the desire to enter as fully as space would permit into the many 
 subjects within its range, and to do so in accordance with the results 
 of the most recent scientific investigations, bringing the record of the 
 art and science of laryngology and rhinology down to the immediate 
 present. 
 
 Another departure from the ordinary rule in works of this kind 
 has been made. It is one, however, for which, in the minds of most 
 thinkers, the time has arrived. This is the substitution throughout 
 the work of the metrical system of weights and measures for the old 
 Eoman, which is gradually losing its grasp among the civilized nations 
 of the world. • 
 
 In one other point has he strayed from the old and well-beaten 
 way, and that is by entirely leaving out the enumeration of synonyms. 
 In carefully selecting in each case the title that he deemed most ap- 
 propriate, he trusts that he has made a selection that will be suffi- 
 ciently distinguishing, and at the same time fully acceptable to the 
 reader. 
 
PREFACE. Yll 
 
 In conclusion, the author, with much diffidence, offers his com- 
 pliments to the profession, and he trusts that, in their criticism of his 
 work, they will extend to him that forbearance and kindly interest to 
 which honest labor, however faulty, always looks for its reward. 
 
 37 Carlton Street, 
 Toronto, December, 1899. 
 
ACKNOWLEDGMENT. 
 
 In preparing this work for publication the author feels that he is 
 under deep obligation to very many. Haying gathered much of his 
 material from books and journals of recent date, he extends to their 
 writers his thanks for the valuable aid with which he has thus been 
 favored. In this he feels that he is particularly indebted to Dr. Bos- 
 worth for granting so freely the use of pictures and plates from his 
 most recent work. To Mr. Lennox Browne, also, the author is under 
 the highest obligation, as his kindness has enabled him to place in the 
 present work a long series of illustrations taken throughout from Len- 
 nox Browne's fifth edition upon "Disease of Throat and Nose," issued 
 so recently. 
 
 Among other authors whose writings he has so freely consulted 
 he might mention particularly Bishop, Casselberry, Delavan, Fraenkel, 
 Gleitsmann, Grant, Griinwald, Heryng, Ingals, Jonathan Wright, 
 Knight, Kyle, Lake, Max Thorner, Myles, Morell Mackenzie, Noland 
 Mackenzie, Boe, Sajous, Semon, Shurly, Wagner, and Zuckerkandl. 
 
 In his own city of Toronto he is under - obligation to Professor 
 Primrose for the series of frozen sections which he kindly permitted 
 him to obtain from the Museum of the Anatomical Department of the 
 University of Toronto; and to Mr. Arthur Bensley, also of the uni- 
 versity, for pictures of pathological sections furnished by the author. 
 
 He would also acknowledge his indebtedness to Miss Wrinch for 
 the care and skill with which she prepared many colored and Indian- 
 ink illustrations. 
 
 Drs. Amyot, Sweetnam, Caven, Carveth, and Wilson also cordially 
 contributed a share to the pathological work required. 
 
 To the F. A. Davis Co. the author owes much for the unfailing 
 promptitude and kindness with which he has always been treated; and 
 for the suggestions and co-operation which they have ever been willing 
 to grant. 
 
 (viii) 
 
METRICAL WEIGHTS AND MEASURES. 
 
 AND THEIR 
 
 ENGLISH EQUIVALENTS. 
 
 1 gramme marked thus 1| equals loA32 grains. 
 
 1 centigramme marked thus. . |01 equals x / 6 to x / 7 grain. 
 
 1 milligramme marked thus. . |001 equals about 1 / 65 grain. 
 
 1 centigramme is 1 / 100 part of a gramme. 
 
 1 milligramme is 1 / 1000 P ar t of a gramme. 
 
 1 litre equals 35.2754 fluidounces. 
 
 1 metre equals 39.37979 inches. 
 
 1 cubic centimetre, marked 1 c. c, equals 17 minims. 
 
 In dispensing, according to the metrical system, all 
 liquids, as well as solids, are supposed to be weighed, and the 
 terms gramme, centigramme, and milligramme only are used. 
 
 To facilitate writing prescriptions, it is more convenient 
 to place a perpendicular line between the gramme and the 
 decimal than the ordinary plan of placing a dot to indicate the 
 fractional part. 
 
 (ix) 
 
CONTENTS. 
 
 PAGE 
 
 Title i 
 
 Dedication iii 
 
 Peeface v 
 
 Acknowledgment viii 
 
 Metrical Weights and Measures ix 
 
 Table of Contents x 
 
 List of Illustrations xvii 
 
 SECTION 1. DISEASES OF THE NASAL PASSAGES. 
 
 Chapter I. — Anatomy of the External Nose, Nasal Passages, 
 
 and Accessory Sinuses 3 
 
 External nose, 3; nasal fossae, 3; frontal sinus, 6; sphenoid, 7; 
 ethmoid cells. 7; maxillarv sinus, 8; nerves, 11; blood-vessels, 
 11; glands, 11. 
 
 Chapter II. — Physiology of the Nose and Accessory Sinuses 12 
 
 Sense of smell, 12; the nose in phoration, 12; the nose in respira- 
 tion, 13. 
 
 Chapter III. — Instruments Used for the Examination and Treat- 
 ment of Diseases of the Nose and Throat 15 
 
 Electric lamp, 15; head-mirrors, 16; Mackenzie concentrator, 17; 
 nasal speculum, 17; Bosworth's, 18; Shurly's, 18; Goodwillie's, 
 18; Myles's, 18; Sincrock's, 18; post-rhinal mirror, 19; self- 
 'retaining palate-retractor, 19; cotton-applicators, 20; tongue- 
 depressor's 21; atomizers, 22; insufflators, 23; post-nasal 
 syringes, 23; compressed-air apparatus, 23; nasal saws, 24; 
 chisels, 25; drills, 26; cold- wire snares, 26; galvanocautery 
 snares, 27'; spokeshaves, 28; punches, 28; curettes, curved 
 scissors, nasal burrs, etc., 28; anterior rhinoscopy, 29; posterior 
 rhinoscopy, 30. 
 
 Diseases of the Nose. 
 
 Chapter IV. — Acute Rhinitis 32 
 
 Pathology, 32; etiology, 32; symptomatology, 32; diagnosis, 33; 
 prognosis, 33; prophylaxis, 33; treatment, 34. 
 
 Chapter V. — Chronic Rhinitis 37 
 
 Pathology, 37: etiology, 37; symptomatology, 37; diagnosis, 38; 
 prognosis, 38; treatment, 38. 
 
 Chapter VI. — Purulent Rhinitis of Children 41 
 
 Pathology, 41; etiology, 42; symptomatology, 42; diagnosis, 42; 
 prognosis, 63; treatment, 43. 
 
 Chapter VII. — Hypertrophic Rhinitis 45 
 
 Pathology, 45: etiology, 47; symptomatology, 49; diagnosis, 50; 
 prognosis, 51; treatment, 51; operation by chromic acid, 52; 
 operation by galvanoeautery-knife, 52; galvanocautery-snare, 
 54: operation by electrolysis, 55: turbinectomy, 56: electro- 
 cauterv-puncture. 57; submucous knife incision, 57. 
 
 (x) 
 
CONTEXTS. XI 
 
 PAGE 
 
 Chapter VIII. — Atrophic Rhinitis 58 
 
 Pathology, 58: etiology, 59; symptomatology, 60; diagnosis, 61; 
 prognosis, 62; treatment, 62; use of the post-nasal syringe, 63; 
 Gottstein's pings, 64; treatment by massage, 64. 
 
 Chapter IX. — (Edematous Rhinitis 67 
 
 Chapter X. — Fibrinous Rhinitis 70 
 
 Non-diphtheritic, 70; traumatic membranous rhinitis, 72; ques- 
 tion of identity of fibrinous rhinitis with diphtheria, 73. 
 
 Chapter XI. — Deformities of the Nasal Septum 74 
 
 Prevalence of septal deformities among civilized races, 74; rarity 
 of deformities among aboriginal races, 74 ; examination of Indian 
 skulls, 74; classification of deviations, 75; etiology, 75; views 
 of Zuckerkandl, Roe, Trendelenburg, Mayo Collier, upon causa- 
 tion, 76; symptomatology, 81; diagnosis, 81; prognosis, 82; 
 treatment, 82; by use of saws, 83; knives, 83; burrs, 83; 
 Ingals's method, 83; Loeb's method, 83; by electrolysis, 84; by 
 use of silver tubes, 85; by Watson's method, 86; by use of 
 rubber splints, 88. 
 
 Chapter XII. — Distortion of the Columnar Cartilage 89 
 
 Chapter XIII.— Perforation of the Septum 91 
 
 Etiology, 91; treatment, 91. Abscess of the septum, 92. Ulcera- 
 tion of the septum, 92. 
 
 Chapter XIV. — Hay Fever, or Vasomotor Rhinitis 93 
 
 Pathology, 93; etiology, 94; abnormally-sensitive nerve-centres, 
 94; hypersesthesia of the peripheral termini, 94; pressure of an 
 irritating agent, 95; the pollen theory, 95; the uric-acid theory, 
 96; symptomatology, 96; diagnosis, 98; prognosis, 98; pre- 
 ventive measures, 98; treatment, 99; constitutional treatment, 
 99; treatment of the diseased condition of the nasal passages, 
 100; treatment of the spasmodic attack, 100. Nasal hydror- 
 rhoea, 103. 
 
 Chapter XV. — Anosmia; Parosmia; Furunculosis 104 
 
 Anosmia, 104; parosmia, 105; furunculosis, 105. 
 
 Chapter XVI. — Epistaxis 106 
 
 Pathology, 106; etiology, 106; symptomatology, 106; diagnosis, 
 107; prognosis, 107; treatment, 107. 
 
 Chapter XVII. — Rhinoliths; Foreign Bodies; Parasites 110 
 
 Rhinoliths, 110; symptomatology, 110; diagnosis, 111; prognosis, 
 111; treatment, 111. Foreign bodies, 112; symptomatology, 112; 
 diagnosis, 112; treatment, 113. Parasites, 113; Musca vomi- 
 toria, Gompsomyia macceUaria, 114; symptomatology, 114; 
 treatment, 115. 
 
 Chapter XVIII. — Nasal Polypi 116 
 
 Pathology, 116; site of attachment, 117: etiology, 118; symptom- 
 atology, 119; diagnosis, 121; prognosis. 121: treatment. 122: 
 by snares, 122; by the use of forceps, 125; by electrolysis. 125. 
 
 Chapter XIX. — Papilloma 126 
 
 Pathology, 126; treatment, 127. Bilateral tumors of the septum. 
 127; lvmphoid variety, 127; erectile variety, 127; treatment, 
 127. 
 
 Chapter XX. — Fibroma 128 
 
 Pathology, 128; etiology, 128; symptomatology, 128: diagnosis, 
 129; prognosis, 129; treatment, 129. History of a ease, 130. 
 
Xll CONTENTS . 
 
 PAGE 
 
 Chapter XXI. — Adenoma ; Angioma 132 
 
 Adenoma, 132; angioma, 133. 
 
 Chapter XXII. — Cystoma of the Nose 134 
 
 Chapter XXIII. — Chondroma; Osteoma 136 
 
 Chondroma, 136. Osteoma, 136; pathology, 137; etiology, 137; 
 symptomatology, 137; treatment, 137. 
 
 Chapter XXIV. — Sarcoma 138 
 
 Pathology. 138; etiology. 138: symptomatology, 139; diagnosis, 
 139; prognosis, 139; treatment.' 139. 
 
 Chapter XXV. — Carcinoma 141 
 
 Pathology, 141; etiology, 141: symptomatology, 141: diagnosis, 
 142; prognosis, 142; treatment, 142. 
 
 Chapter XXVI. — Tuberculosis 143 
 
 Pathology, 143; etiology, 144; symptomatology, 144; diagnosis, 
 144; prognosis, 144; treatment, 145. 
 
 Chapter XXVII. — Lupus ; Glanders 146 
 
 Lupus, 146; pathology, 146; etiology. 146; symptomatology. 
 
 146; diagnosis, 147; prognosis. 147: treatment. 147. Glanders. 
 
 148. 
 Chapter XXVIII. — Rhinoscleroma 149 
 
 Chapter XXIX. — Syphilis 151 
 
 Mucous patch, 151; superficial ulcer, 151; bony necrosis, 151; 
 pathology, 152; symptomatology, 152; diagnosis, 153; prog- 
 nosis, 153; treatment, 153. 
 
 Chapter XXX. — Congenital Syphilis 155 
 
 Symptomatology. 155; diagnosis. 155; prognosis. 156: treatment, 
 "156. 
 
 Diseases of Accessory Sinuses of the Nose. 
 
 Chapter XXXI. — Acute Sinusitis 159 
 
 Etiology, 159; symptomatology, 160; treatment, 161. 
 
 Chapter XXXII. — Chronic Disease of the Antrum of Highmore. . . 162 
 Pathology, 162; etiology, 165; symptomatology, 165: diagnosis, 
 166; prognosis. 169: treatment, 169; first, by direct irrigation 
 through the ostium, 169; second, by opening through the in- 
 ferior meatus, 169; third, by removing a tooth and washing 
 through the alveolus, 170; fourth, by opening the canine fossa, 
 170; fifth, by the combined method. 171. Cvst of the antrum, 
 174. 
 
 Chapter XXXIII. — Ethmoid Disease 175 
 
 Pathology, 175: etiology. 176; symptomatology. 177: diagnosis, 
 177; prognosis, 177; treatment. 178. 
 
 Chapter XXXIV. — Sphenoid Disease 180 
 
 Frontal-sinus disease. 181. 
 
 SECTION II. DISEASES OF THE PHARYNX. 
 
 Chapter XXXV. — Anatomy of the Pharynx 185 
 
 Boundaries, 185: openings into the pharynx. 185; mucous mem- 
 brane, 189; pharyngeal glands. 190; arteries, 190; veins, 190; 
 nerves, 190; naso-pharynx, 190; faucial tonsils, 191; lingual 
 tonsils. 191. 
 

 CONTENTS. Xlli 
 
 PAGE 
 
 Chapter XXXVI. — Physiology of the Pharynx 193 
 
 Division into naso-pharynx and oro-pharynx, 193; the soft palate, 
 193; tissues of the oro-pharynx, 193; deglutition, 193; physio- 
 logical functions of the tonsils, 194. 
 
 Diseases of the Naso-pharynx. 
 
 Chapter XXX V 11. — Xaso-pharyngeal Catarrh 195 
 
 Pathology. 195: etiology, 196: symptomatology, 198; diagnosis, 
 199; prognosis, 199; treatment, 199. 
 
 Chapter XXXVIII. — Adenoid Growths of the Naso-pharynx 204 
 
 Pathology, 204: etiology. 20G; symptomatology, 207; general 
 symptoms, 208; external deformities of nose and chest due to 
 the disease, 209; diagnosis, 210; prognosis, 210; treatment, 211 ; 
 general anaesthesia during operative treatment advisable with 
 children, 212; relative merits of ether, bromide of ethyl, nitrous 
 oxide, and chloroform, 213; operations by galvanocautery, 214; 
 snares, 214; post-pharyngeal forceps, 214; curettes, 215. 
 
 Chapter XXXIX. — Myxofibroma of the Nasopharynx 217 
 
 Pathology, 217; etiology, 218; symptomatology, 218; diagnosis, 
 219; prognosis, 219; treatment, 219; report of cases, 220, 221. 
 
 Chapter XL. — Fibroma of the Nasopharynx 223 
 
 Pathology, 223: etiology, 223; symptomatology, 224; diagnosis, 
 224; prognosis, 224; treatment, 224. 
 
 Chapter XLI. — Malignant Diseases of the Naso-pharynx 227 
 
 Sarcoma. 227; pathology, 227; etiology, 227; symptomatology, 
 227: diagnosis, 227; prognosis, 228; treatment, 228. Carci- 
 noma, 229. Chondroma of the naso-pharynx, 230. Foreign 
 bodies. 230. 
 
 Diseases of the Oropharynx. 
 
 Chapter XLII. — Acute Pharyngitis 231 
 
 Pathology, 231; etiology. 231; symptomatology, 232; diagnosis, 
 233; prognosis, 233; treatment, 233; comparison of the values 
 of cocaine and eucaine, 233. 
 
 Chapter XLIII. — Chronic Pharyngitis , 237 
 
 Pathology, 237 ; etiologv, 237 : symptomatology, 238 ; diagnosis, 
 238; prognosis, 238; treatment, 239. 
 
 Chapter XLIV. — Follicular Pharyngitis 240 
 
 Pathology, 240: etiology, 240; symptomatology. 241; diagnosis, 
 242; prognosis, 243; treatment, 243. 
 
 Chapter XLV. — Acute Tonsillitis, or Quinsy 245 
 
 Pathology, 245; site of abscess, 246: etiology, 247; symptom- 
 atology, 247; diagnosis. 248; prognosis, 249; treatment. 249. 
 Question of the time the abscess should be incised, 250. 
 
 Chapter XL VI. — Diseases of the Uvula; (Edema; Elongation. . . . 252 
 (Edema, 252; etiology, 252; symptomatology, 252; prognosis, 252 : 
 treatment, 252. Elongation of the uvula, 253; pathology, 253: 
 etiology, 253; symptomatology, 254; diagnosis, 254; prognosis, 
 254: treatment, 255. 
 
 Chapter XL VII. — Retropharyngeal Abscess 258 
 
 Pathology, 258; etiology, 258; symptomatology. 259; diagnosis. 
 259; prognosis, 260: treatment. 260. 
 
XIV CONTEXTS. 
 
 PAGE 
 
 Chapter XL VIII. — Hypertrophy of the Faucial Tonsils 262 
 
 Pathology, 262; etiology, 264; symptomatology, 264; diagnosis, 
 265; prognosis, 266; treatment, 267; medical, 267; surgical, 
 267; tonsillotomy, 267; secondary haemorrhage after tonsil- 
 lotomy, 269; operation by cold- wire snare, 270; scissors, 270; 
 cautery, 271. 
 
 Chapter XLIX. — Lacunar Tonsillitis 272 
 
 Pathology, 272; etiology, 273; symptomatology, 273: diagnosis, 
 274; prognosis, 275; treatment, 275. 
 
 Chapter L. — Pharyngeal Mycosis 277 
 
 Pathology, 277; etiology, 279; symptomatology. 281; diagnosis, 
 282; prognosis, 282; treatment, 282. 
 
 Chapter LI. — Hypertrophy of the Lingual Tonsil 284 
 
 Pathology, 284; etiology, 285; symptomatology, 286; diagnosis, 
 287; prognosis, 287; treatment, 287; operation by galvano- 
 cautery, 288; by lingual tonsillotome, 288; by hot or cold snare, 
 288. 
 
 Chapter LII. — Benign Tumors of the Pharynx 290 
 
 Papilloma, 290; fibroma, 290; operative treatment, 291. Adenoma, 
 291. Dermoid tumors, 292. 
 
 Chapter LIII. — Tuberculosis of the Pharynx 293 
 
 Pathology, 293; etiology, 293; symptomatology, 294; diagnosis, 
 294; prognosis, 295; treatment, 295. 
 
 Chapter LIV.— Lupus of the Pharynx 297 
 
 Pathology, 297; etiology, 298; symptomatology, 298; diagnosis, 
 299; prognosis, 300; 'treatment, 300. 
 
 Chapter LV. — Syphilis of the Pharynx 301 
 
 Pathology, 301; primary, secondary, and tertiary lesions, 301; eti- 
 ology, 302; symptomatology, 302; diagnosis, 304; chancre, 
 syphilitic erythema, mucous patch, gummy tumors, deep ulcers, 
 cicatricial tissues, 304, 305; prognosis, 305; treatment, 305. 
 Actinomycosis, 306. 
 
 Chapter LVI. — Sarcoma of the Fauces 307 
 
 Pathology, 307; etiology, 307; symptomatology, 308: diagnosis, 
 308; prognosis, 309; treatment, 309. Leukoplakia palati, 310. 
 
 Chapter LVII. — Carcinoma of the Fauces 311 
 
 Pathology, 311; etiology, 313; symptomatology, 313; diagnosis, 
 314; prognosis, 315; treatment, 315. 
 
 Chapter LYIII. — Neuroses of the Fauces 318 
 
 Neuroses of sensation. 318: hyperesthesia, paresthesia. 318; 
 neuralgia, 318. Neuroses of motion, 319; spasm of the pharynx, 
 319; paralysis of the pharynx, 319: myopathic paralysis, 319; 
 palato-glosso-pharvngeal paralysis, 320; acute bulbar paralysis, 
 320. 
 
 Chapter LIX. — Tonsilliths. Foreign Bodies in the Fauces 321 
 
 Tonsilliths, 321. Foreign bodies. 322; svmptoms. 322; prognosis, 
 323; treatment, 323. 
 
 SECTION III. DISEASES OF THE LARYNX. 
 
 Chapter LX. — Anatomy of the Larynx 327 
 
 Anatomy of the cricoid. 327; the thyroid, 328; the arytenoids, 
 329; the epiglottis. 330; the ligaments, 331; the articulations, 
 334; the muscles, 335; the arteries, 335; the lymphatics. 335; 
 the nerves, 335 ; the mucous membrane. 335. 
 
 
CONTENTS. XV 
 
 PAGE 
 
 Chapter LXI. — Physiology of the Larynx 337 
 
 Functions of the larynx, 337; respiration, 337; phonation, 338; 
 pitch, 339; intensity, 339; quality, 339. 
 
 Chapter LXIL— Laryngoscopy 340 
 
 The use of the throat-mirror, 340; examination of the larynx, 340; 
 holding the tongue, 340; view of the vocal cords, 342; position 
 of the epiglottis. 342; picture of the larynx, 343; position of pa- 
 tient in laryngological examination, 344. 
 
 Chapter LXIII. — Atjtoscopy 345 
 
 Chapter LXIV. — Intubation 350 
 
 Chapter LXV. — Tracheotomy ; Thyrotomy 354 
 
 Instruments required, 354; diseases for which the operation may 
 be required, 354; necessity for anaesthesia, 355; choice of anaes- 
 thetics, 355; the use of cocaine, 356; the high operation, 357; 
 the low operation, 358; thyrotomy, 358. 
 
 Chapter LXVL— Acute Laryngitis 362 
 
 Pathology, 362; etiologv, 362; symptomatologv. 363; diagnosis, 
 363; prognosis, 364; treatment, 364. 
 
 Chapter LXVII. — Acute Laryngitis of Children 367 
 
 Pathology. 367; etiology, 367; symptomatology, 368; diagnosis, 
 368; prognosis, 369; 'treatment, 369. 
 
 Chapter LXVIIL— Acute (Edematous Laryngitis 371 
 
 Pathology. 371; etiology, 371; symptomatology, 372; diagnosis, 
 372; prognosis, 373; treatment, 373. 
 
 Chapter LXIX. — Simple (Edema of the Larynx 375 
 
 Pathology, 375; etiology, 375; symptomatology, 375; diagnosis, 
 376; prognosis, 376; treatment, 376. 
 
 Chapter LXX. — Chronic Laryngitis 377 
 
 Pathology, 377; etiology, 377; symptomatology, 378; diagnosis, 
 379; prognosis, 379; treatment, 380. 
 
 Chapter LXXI. — Atrophic Laryngitis . . . 384 
 
 Pathology, 384; symptomatology, 384; diagnosis, 385; prognosis, 
 385 ; treatment,' 385. 
 
 Chapter LXXII. — Pachydermia Laryngis ■ 387 
 
 Pathology, 387: etiology, 387; symptomatology, 388: diagnosis, 
 388; prognosis, 388: treatment, 389; pachydermia conscripta, 
 389; pachydermia diffusa, 389. Subglottic chronic laryngitis, 
 390. 
 
 Chapter LXXIII. — Pseudomembranous Laryngitis 391 
 
 Chapter LXXIV. — Laryngeal Perichondritis 393 
 
 Pathology. 393; etiology, 393; symptomatology, 393; diagnosis, 
 394; history of a case, 395; prognosis, 395; treatment, 396. 
 Affections of the cricoarytenoid articulation, 396. 
 
 Chapter LXXV.- — Tuberculosis of the Larynx 39S 
 
 Pathology, 398; etiology, 399; symptomatology, 399; diagnosis. 
 400; prognosis, 401; treatment, 402; intralaryngeal surgical 
 treatment, 403; curettement, 403; contra-indications of curette- 
 ment, 403; tracheotomy and laryngotomy, 403. 
 
 Chapter LXXVL— Lupus of the Larynx 406 
 
 Pathology and etiology. 406; symptomatology , 407: diagnosis, 
 407; prognosis, 408; treatment, 408. 
 
XVI CONTEXTS. 
 
 Chapter LXXVII. — Leprosy of the Air-passages 410 
 
 Leprosy of the nose, 411. Leprosy of the mouth and pharynx. 412. 
 Leprosy of the larynx, 412; treatment. 414. 
 
 Chapter LXXVIII. — Syphilis of the Laryxx 415 
 
 Pathology, 415: etiology, 416; symptomatology. 417: diagnosis, 
 417; prognosis, 418; treatment, 418: surgical treatment, 418. 
 Congenital syphilis of the larynx, 420. 
 
 Chapter LXXIX. — Xeuroses of the Laryxx 421 
 
 Neuroses of sensation, 421. Anaesthesia, hyperesthesia, parses- 
 thesia, neuralgia, 421; treatment, 421. Nervous aphonia, 422; 
 symptomatology. 422; treatment, 422. Xeuroses of motion, 423. 
 Spasm of the glottis, 423; etiology, 423; symptomatology, 423; 
 diagnosis. 424; prognosis, 424; treatment, 425. Paralysis of the 
 larynx, 426. Abductor paralysis, 426. Bilateral paralysis, 427: 
 treatment, 428. 
 
 Chapter LXXX. — Non-malignant Tumors of the Laryxx 429 
 
 Papilloma, 429; fibroma, 429; cystoma. 430; lipoma, 430; an- 
 gioma, 430; symptomatology, 430; diagnosis, 431; prognosis, 
 432: treatment, 432. Enehondroma, 433; multiple papillomata 
 of children, 434; treatment by tracheotomy, 434. 
 
 Chapter LXXXI. — Malignant Tumors of the Laryxx 436 
 
 Pathology, 437; symptomatology, 437; diagnosis, 438; prognosis, 
 438; treatment, 438; endolaryngeal operation, 439: laryngec- 
 tomy by Solis-Cohen operation, 440; Delavan's rules for guid- 
 ance, 440; Aliddlemas Hunt's case, 441. 
 
 Chapter LXXXII. — Foreigx Bodies ix the Laryxx 442 
 
 Symptomatologv. 443 : diagnosis, 443 : prognosis. 444 : treatment, 
 445. 
 
 Chapter LXXXIII. — Roextgex Rays ix Laryxgeal Surgery 447 
 
 Chapter LXXXIV. — Operatioxs for Xasal Deformities 449 
 
 Annandale's operation, 450; Ellet's operation, 450; Roe's subcuta- 
 neous operations, 451. 
 
 Chapter LXXXY.— Operatioxs for Cleft Palate 454 
 
 Staphylorrhaphy. 455; Mac-Donald's operation, 455. Lranoplasty, 
 456: Ferguson's operation, 456; Mason Warren's method, 456; 
 Brophy's method. 457 : before operation. 457 : operation, 458 ; 
 after operation. 458: Owens's opinion, 459. 
 
 Ixdex to Literary Referexces 461 
 
 Gexeral Ixdex 464 
 
LIST OF ILLUSTRATIONS. 
 
 CTG. PAGE 
 
 1. Cartilages of the nose seen in profile 4 
 
 2. Sagittal section of skull, just to the right of the septum, showing 
 
 right nasal fossa \ 5 
 
 3. Anterior section of the nostrils 6 
 
 4. The posterior rhinoscopic image 7 
 
 5. Frozen section of head of adult (color-cut) 9 
 
 C. Phillips's electric photophone, with adjustment for focusing light. . 15 
 
 7. Head-mirror 16 
 
 ~a. Head-mirror in position 16 
 
 8. Laryngoscope, gas-stand, mirror, condenser, and tubing 17 
 
 9. Bosworth's large and small nasal specula 18 
 
 10. Goodwillie's nasal speculum 18 
 
 11. Myles's nasal speculum 18 
 
 12. Sincrock's nasal speculum 18 
 
 13. Sincrock's nasal speculum, with handle 18 
 
 14. Bosworth's nasal speculum, with shield for cautery-work 19 
 
 15. Shurly's nasal speculum 19 
 
 1 6. Post-rhinal mirror 19 
 
 17. Post-rhinal mirror 19 
 
 18. White's self-retaining palate-retractor 19 
 
 19. Applicators 20 
 
 "20. Tongue-depressor 20 
 
 21. Tongue- depressor 21 
 
 22. Tongue-depressor 21 
 
 23. Sass's tongue-depressor 21 
 
 24. Turck's tongue-depressor 22 
 
 25. Davidson's atomizers, to be used by compressed air or hand-bulb .... 22 
 
 26. Burgess's metal-tube atomizers: straight, up, and down 22 
 
 26a. Bosworth's atomizer 23 
 
 27. Compressed-air apparatus 23 
 
 28. Powder-blower with mouth-piece and tube 24 
 
 28a. Powder-blower with bulb 24 
 
 "28&. Powder-blower with tubing and bulb 24 
 
 28c. Powder-blower with scoop 24 
 
 29. Bosworth's nasal saws 25 
 
 30. Mial's reversible saw 25 
 
 31. Hartmann's nasal chisels 25 
 
 32. Freeman's drill . 26 
 
 33. Bosworth's nasal polypus-snare 26 
 
 34. Sajous's nasal polypus-snare 26 
 
 35. Hall's nasal polypus-snare 27 
 
 36. Dench's nasal polypus-snare 27 
 
 37. Universal cautery and snare-handle, with cannula and snare 27 
 
 '38. Cautery-electrodes 27 
 
 39. Nasal burrs 28 
 
 40. Nasal trephines 28 
 
 41. Beren's and Nichols's spokeshaves 28 
 
 (xvii) 
 
XV111 LIST OF ILLUSTRATIONS. 
 
 FIG. PAGE 
 
 42. Anterior rhinoscopy, position of the head for inspecting the -wall of 
 
 the pharynx through the nasal passages 29 
 
 43. Posterior rhinoscopic image 30 
 
 44. Hypertrophy of middle and inferior turbinals 45 
 
 45. Section of inferior turbinated (25 diameters) 46 
 
 46. Large masses of hypertrophied membrane on the posterior termina- 
 
 tion of the lower turbinated bones, more or less completely 
 
 filling the posterior nares 47 
 
 46a. Anterior portion of inferior turbinal (VVmch objective) 48 
 
 46&. Posterior portion of inferior turbinal (1-inch objective) 48 
 
 47. Ballard galvanocautery-battery, with cord, handle, and knife 53 
 
 48. Knight's nasal scissors 56 
 
 49. Shurly's nasal forceps 57 
 
 50. Post-nasal syringe 63 
 
 50a. Post-nasal syringe 63 
 
 51. Frozen section of the head of a child aged 5 years (color-cut) 77 
 
 51«. Frozen section of same child, taken two centimetres anterior to Fig. 
 
 51 (color-cut) 79 
 
 52. Section of cartilaginous spur from the nasal septum (25 diameters). 84 
 
 53. Silver tubes for septal deformity 85 
 
 54. Silver tubes for septal deformity 85 
 
 55. Bellocq's cannula 108 
 
 56. Rhinolith removed from the left nasal passage of a lady, aged 28, 
 
 nineteen years after the insertion of the button into the nostril. Ill 
 
 57. Spoon 113 
 
 58. Bosworth's nasal forceps 113 
 
 59. Alligator-forceps 113 
 
 60. Hartmann's forceps 114 
 
 61. Nasal polypi 116 
 
 62. Microscopical section of nasal polypus (200 diameters) 118 
 
 63. Microscopical section of nasal polypus from a child 7 years old. .. . 120 
 
 64. Blake's ear-polypus snare 122 
 
 65. Caseous mass washed out of antrum through ostium maxillare 162 
 
 66. Lateral frozen section through the middle region of the nose (color- 
 
 cut) 163 
 
 67. Electric illuminator with flexible shank and cords 167 
 
 68. Coronal section of the maxillary sinus, the subject of cystic disease. 173 
 
 69. Inflammation of the ethmoid cells, showing glands to right quite 
 
 normal and those to lower left hand more or less altered 176 
 
 70. Sectional view of the pharynx 186 
 
 71. Frozen section. Side-view of nose, pharynx, and larynx of child, 
 
 aged 3 years (color-cut) 187 
 
 72. The muscles of the soft palate and pharynx: the pharynx laid open 
 
 from behind 189 
 
 73. Infantile adenoids 204 
 
 73ff. Infantile adenoids (represents a growth quite common) 204 
 
 74. Stalactite forms 205 
 
 75. Microscopical section of hypertrophied pharyngeal tonsil with lym- 
 
 phoid infiltration (20 diameters) 206 
 
 76. Adenoid forceps 213 
 
 77. Adenoid curettes 215 
 
 78. Dr. Grant's case of post-nasal polypus 217 
 
 79. Uvula-scissors 255 
 
 80. Excision of uvula 256 
 
 81. Simple hypertrophy of faucial tonsil (57 diameters) 263 
 
 82. Mathieu's tonsillotomes 268 
 
 83. Pharyngomycosis (color-cut) 277 
 
 84. Leptothrix. Adventitious follicle to left side (color-cut) 278 
 
LIST OF ILLUSTRATIONS. XIX 
 
 FIG. ' PAGE 
 
 S5. Leptothrix in situ ( 1 / 8 -inch objective; color-cut) 278 
 
 86. Keratosis of tonsil with leptothrix (Winch objective; color-cut) . . . 279 
 
 87. Hypertrophy of the left lingual tonsil 284 
 
 87a. Bilateral hypertrophy of lingual tonsil 284 
 
 88. Lingual varix (color-cut) 285 
 
 89. Microscopical section of lobe of lingual tonsil 286 
 
 90. Roe's lingual tonsillotomy 288 
 
 91. Lupus. Palatal appearance 297 
 
 92. Lupus of lingual tonsil (Winch objective; Ehrlich-Biondi stain; 
 
 color-cut) 298 
 
 93. Lupus of lingual tonsil (Winch objective; Ehrlich-Biondi stain; 
 
 color-cut) 299 
 
 94. Malignant epithelioma, extending from right tonsil to base of 
 
 tongue 311 
 
 95. Stratified epithelioma of tonsils (Winch objective) 312 
 
 95a. Epithelioma showing cell-nests (V 6 -rnch objective) 313 
 
 96. Robertson's calculus from right tonsil 322 
 
 97. The cartilaginous frame of the larynx, with the hyoid bone and 
 
 ligamentous attachments 328 
 
 98. The cricoid, seen anteriorly 329 
 
 99. The cricoid, upper surface 329 
 
 100. The cricothyroid muscle, viewed anteriorly 330 
 
 100a. The voice-box, or larynx, seen from behind 331 
 
 100&. View of the voice-box, or larynx, cut open from behind 331 
 
 101. The arytenoid and posterior cricoarytenoid muscles 332 
 
 102. Side-view of tne larynx, showing the interior, the right plate of the 
 
 thyroid being removed 334 
 
 103. The laryngoscopic image during respiration 338 
 
 104. The laryngoscopic image during phonation 338 
 
 105. Laryngeal and post-rhinoscopic mirrors 340 
 
 106. The laryngeal mirror in position (Cohen) when held by the left 
 
 hand 341 
 
 107. Position for autoscopy 345 
 
 108. Autoscope with plate instead of hood 346 
 
 109. Autoscopic operation 347 
 
 110. Tongue-depressor for pharyngoscopy and direct laryngo-tracheoscopy. 348 
 
 111. O'Dwyer's intubation-set . 350 
 
 112. Instruments for intubation 351 
 
 113. Plated tracheotomy-tube 354 
 
 114. Hard-rubber tracheotomy- tube 355 
 
 115. Elsberg's tracheotomy-tube 355 
 
 115a. Hank's tracheotomy-tube 356 
 
 116. Low tracheotomy (color-cut) 359 
 
 117. Thyrotomy (color-cut) 359 
 
 118. Bosworth's laryngeal knives 373 
 
 119. American nebulizer 382 
 
 120. Multiple comminutor 383 
 
 121. Abscess of cricoid. Larynx opened from behind 395 
 
 122. Lupus. Laryngoscopic appearance 406 
 
 123. Lupus of the epiglottis (V 6 -inch objective; Ehrlich-Biondi stain; 
 
 color-cut) 407 
 
 124. Lupus of the epiglottis (Winch objective; Ehrlich-Biondi stain: 
 
 color-cut) , 408 
 
 125. Leprosy of the tongue and epiglottis 413 
 
 126. Destruction of epiglottis from syphilitic ulceration 415 
 
 127. Cicatricial stenosis of larynx, the result of syphilitic ulceration. . . . 416 
 
 128. Lennox Browne's hollow laryngeal dilator with cutting-blade 419 
 
 129. Papilloma of cord during respiration 429 
 
XX LIST OF ILLUSTRATIONS. 
 
 FIG. PAGE 
 
 130. Same during phonation 429 
 
 131. Fibroma situated beneath the right vocal cord 430 
 
 132. Chondroma of the epiglottis 431 
 
 133. Angioma of the left aryepiglottic fold 431 
 
 134. Extirpation instruments 433 
 
 135. Sarcoma of the larynx, as seen from behind 436 
 
 136. Tooth-plate in glottis 442 
 
 137. Tooth-plate removed 443 
 
 138. Laryngeal polypus-forceps, Mackenzie's, revolving, with three attach- 
 
 ments 444 
 
 139. Laryngeal polypus-forceps, Wax-ham's 444 
 
 140. Laryngeal polypus-forceps, Fraenkel's, cutting-jaw 445 
 
 141. Laryngeal polypus-forceps, Mackenzie's, articulated 445 
 
 142. Lead plate for nasal arch 449 
 
 143. Steel pin for nasal transfixion 449 
 
 144. Nasal appliance in position 451 
 
SECTION I. 
 
 Diseases of the Nasal Passages. 
 
CHAPTEE I. 
 
 ANATOMY OF THE EXTERNAL NOSE, NASAL PASSAGES, 
 AND ACCESSORY SINUSES. 
 
 The outer nose consists of the visible portion of that organ, 
 composed of bones, cartilages, fibrous tissue, muscles, integument, 
 and mucous membrane. It contains, within, the two vestibular sepa- 
 rated from each other perpendicularly by the anterior portion of the 
 triangular cartilage (Fig. 1) and the internal union of the lower lateral 
 cartilages. 
 
 The lateral walls are formed by the nasal bones, and the nasal 
 processes of the superior maxillary bones, together with the upper 
 and lower lateral and sesamoid cartilages. 
 
 The septum dividing the two nasal cavities from each other is 
 formed directly below the triangular cartilage, already mentioned, by 
 an additional narrow slip of cartilage at the entrance of the nostrils, 
 termed the "columnar cartilage." 
 
 The openings of the anterior nares are usually on a lower level 
 than the floor of the nose; and they are also protected by a number 
 of stiff hairs, or vibrissa?, which line the nostrils and the vestibule. 
 
 The various muscles of the nose are attached to the external walls 
 and are for the purpose of dilation and contraction of the nostrils 
 and for the elevation and depression of the or^am 
 
 The nasal fossae are two cavities about equal in size, extending 
 from the nostrils, or anterior nares, directly backward to the naso- 
 pharynx, and entering it by the posterior nares, or choanal, as they are 
 sometimes called. These cavities vary very much in size, the average 
 depth from before backward in the adult being about 5 centimetres, 
 and the height 3.5 centimetres in the centre of the fossa?. The sum- 
 mit of the vault on each side is only a narrow chink, arching from 
 the front to the back; while the floor runs almost horizontally back- 
 ward, with a surface varying between 1 and 1 1 / 2 centimetres in width. 
 The external walls of the passages slant irregularly outward and 
 downward (Fig. 2). 
 
 (3) 
 
4 DISEASES OE THE XASAL PASSAGES. 
 
 The septum divides the fossae from each other from front to 
 back. It is formed of the triangular cartilage in front, the perpen- 
 dicular plate of the ethmoid in the upper portion behind, with the 
 vomer immediately beneath it. In early life the septum usually oc- 
 cupies its natural central position; during youth and commencing 
 maturity it very frequently becomes deflected in some part of its course. 
 
 ( 
 V 
 
 3Wk 
 
 &< 
 
 Wm 
 
 Fig. 1. — Cartilages of the nose, seen in profile (Sappey). I, Eight 
 lateral cartilage. 2, Its anterior border. 3, An accessory cartilaginous 
 nucleus attached to the inferior border of the same cartilage. 4, Anterior 
 accessory cartilages remarkable for their ovoidal form and the constancy 
 of their existence. 5, External branch of the alar cartilage. 6. Union of 
 this branch with the internal branch. 7, 8, 9, Secondary cartilaginous 
 branches added to the external branch of the alar cartilage. 10, Accessory 
 cartilage not constantly found. (After Bosworth.) 
 
 The outer walls of the nasal fossae are formed from before back- 
 ward by the nasal, the superior maxillary, the lacrymal, the ethmoid, 
 the palate, and the internal pterygoid plate of the sphenoid. At- 
 tached horizontally to this bony wall, arranged from above downward, 
 are three scroll-like bones: the superior, the middle, and the in- 
 
ANATOMY OF THE NOSE. 
 
 ferior turbinateds. The superior turbinated, descending vertically 
 from the cribriform plate of the ethmoid, is only rudimentary in form. 
 The middle turbinated is larger, and has its origin in the lateral mass 
 of the ethmoid. The inferior turbinated, much larger than the middle 
 
 Fig. 2. — Sagittal section of skull, just to the right of the septum, 
 showing right nasal fossa. 1, Incisor canal. 2, Hard palate. 3, 4, Parts 
 of median crus of the cartilage of the aperture. 5, Anterior part of the 
 same cartilage. 6, Cartilage of the septum. 7, Groove leading to middle 
 meatus. 8, Aagger nasi. 9, Frontal sinus. 10, Inferior ethmoid concha. 
 11, Superior ethmoid concha, llfl, Superior meatus or ethmoid fissure. 12, 
 Recess of upper meatus. 13, Entrance to sphenoid sinus. 14, Pituitary 
 fossa. 15, Sphenoid sinus. 16, Inferior turbinal (maxillary concha). 17. 
 Eod passed into Eustachian tube. 18, Salpingopharyngeal fold. 10, Soft 
 palate. 20, Uvula. 21, Tongue. (After Lennox Browne, 1890.) 
 
6 DISEASES OF THE NASAL PASSAGES. 
 
 one, extends right through the nasal cavity from front to hack along 
 the bony wall, and is attached to the ethmoid, the superior maxillary, 
 the lacrymal, and the palate bones. The space between the superior 
 turbinated and the middle one is called the superior meatus; that be- 
 tween the middle and inferior turbinateds, the middle meatus; and the 
 floor of the passage below the inferior turbinated, the inferior meatus. 
 The roof is formed by the upper portion of the nasal bones in front, and 
 the cribriform plate of the ethmoid behind; the floor by the hori- 
 
 Fig. 3. — Anterior section of the nostrils (Luschka). 1, Septum of the 
 nares at position of tubercle. 2, Middle turbinated body. 3, Inferior tur- 
 binated body. 4, Superior turbinated body. 5, Superior meatus. 6, Middle 
 meatus. 7, Inferior meatus. ,8, Respiratory portion of the nares. 9, Olfac- 
 tory portion.- 10, Floor of the nares. 11, Cavity of right antrum. 12, 
 Opening from antrum to nostril. 13, Ethmoid cells. 14, Roof of the nasal 
 fossae. 15, Floor of the nasal fossse. 16, Cavity of orbit. (After Lennox 
 Browne, 1899.) 
 
 zontal processes of the superior maxillary and palate bones (Figs. 
 3 and 4). 
 
 The accessory cavities or sinuses are the frontal sinuses, the 
 sphenoid sinus, the ethmoid cells, and the antra of Highmore, all 
 opening into the nasal cavities. 
 
 Each frontal sinus opens into the corresponding middle meatus 
 by a narrow canal called the infundibulum. 
 
ANATOMY OF THE NOSE. 7 
 
 The sphenoid sinus is divided into two irregularly-shaped cavities, 
 situated in the body of the sphenoid; they are separated from each 
 other by a thin septum of bone. The canal into each communicates 
 with the superior meatus of the corresponding side. The opening is 
 usually not more than a millimetre in diameter; and the roof, sepa- 
 rating the sinus from the brain, not more than two millimetres in 
 thickness (Fig. 5). 
 
 This sinus stands alone; and, while it is more difficult to reach, 
 its isolation, fortunately, renders it less liable to disease. The two 
 divisions of the sinus are rarely equal in size; and the septum is 
 frequently to one side of the centre. The ostium on each side is 
 high, although less elevated relatively than the ostium maxillare. 
 
 An important feature to remember about the sphenoid sinus is 
 
 Fig. 4. — The posterior rhinoscopie image. 1, Septum. 2, Middle tur- 
 binated bone. 3, Inferior turbinated bone. 4, Superior turbinated bone. 
 5, Superior meatus. 6, Middle meatus. 7, Inferior meatus. 8, Main 
 passage of nostrils. 9, Vault of pharynx and pharyngeal tonsil. 10, 
 Cushion of soft palate. 11, Posterior surface of uvula. 12, Ridge formed 
 by levator palati. 13, Salpingo-pharyngeal fold. 14, Salpingo-palatine fold. 
 15, Eustachian prominence or cushion. 16, Fossa of Rosenmliller. 17, 
 Eustachian orifice. (After Lennox Browne, 1899.) 
 
 its near relation to the cavernous sinus and nerves passing into the 
 orbit. 
 
 The ethmoid cells, situated in the lateral mass of the ethmoid, 
 are irregularly divided into the anterior and posterior, the former 
 opening by minute orifices in the neighborhood of the hiatus semi- 
 lunaris and the latter into the back part of the superior meatus. 
 These delicate bony cells, strung together like a chain, are distin- 
 guished by their thin, paper-like walls, which become more attenu- 
 
8 DISEASES OF THE NASAL PASSAGES. 
 
 ated with advancing years. They form a species of labyrinth, and 
 are almost in direct communication with the orbit, the partition being 
 sometimes perforated from incomplete ossification. The lining mem- 
 brane is exceedingly thin and practically free from glands (Fig. 3). 
 
 The maxillary sinus, or antrum of Highmore, is situated in the 
 body of the superior maxillary bone. It is pyramidal in shape and 
 the largest of the accessory cavities — often large enough to hold 
 many grammes of fluid. Each antrum has one opening, situated on 
 the upper portion of the internal or nasal wall, called the ostium 
 maxillare, and located in the middle meatus (Figs. 3 and 5). 
 
 This sinus is lined throughout with mucous membrane, closely 
 adherent to the periosteum. This is of the columnar ciliated 'and 
 chalice epithelium type. Although the antral mucosa is about twice 
 the thickness of that in the other sinuses, yet, like them, it is almost 
 free from glands. What there are, histological examination has proved 
 to be of the tubular variety. The two antra frequently differ in size. 
 Zuckerkandl has found supernumerary apertures in a number of antra; 
 but these are too small to be of physiological importance. 
 
 The maxillary antrum differs from the other sinuses in several 
 important particulars: 1. It is very much larger in size. 2. The 
 only opening into it is in the upper portion of the sinus, whereas 
 in the other sinuses the openings are always upon a lower level. 3. 
 It is more prone to early disease, owing to the frequent encroach- 
 ment of dental caries and also to the absence of dependent drainage. 
 
 The lacrymal duct opens into the inferior meatus below the front 
 end of the inferior turbinated. 
 
 The mucous membrane of the nasal cavities is continuous with 
 that of the pharynx and the Eustachian tubes, and extends, in turn, 
 to all the accessory sinuses. It is formed in three layers: First, the 
 surface-epithelium, composed of epithelial cells of the columnar 
 variety, extending over the upper half of the septum, and the supe- 
 rior turbinated and part of the middle turbinated bones; and of 
 ciliated cells over the lower part of the septum and the remainder 
 of the turbinal surfaces. Second, the true mucous membrane, com- 
 posed of white, fibrous, elastic, connective tissue, inclosing within it 
 blood-vessels, smooth muscular fibres, serous and mucous glands, with 
 tubular orifices opening upon the epithelial surface. Third, a sub- 
 mucous layer of connective tissue, very loose in form, and lying 
 directly upon the periosteum and perichondrium of the nasal frame- 
 work. It is composed largely of venous sinuses studded with tu- 
 
Fig. 5. — Frozen section of head of adult. 1, Eight and left optic 
 nerves. 2, Sphenoid sinus with posterior wall removed. 3, Sphenoid sinus 
 with posterior wall in position. 4, Left nasal fossa. 5, Nasal septum. 6, 
 Right inferior turbinated bone. (From Primrose's Anatomical Museum, 
 University of Toronto.) 
 
AX ATOMY OF THE NOSE. 11 
 
 bular mucous glands, and lias its highest development over the tur- 
 binated bones, particularly upon the middle and posterior portions 
 of them — forming, with the middle layer, the so-called corpora 
 cavernosa nasi. The mucous membrane of the middle and inferior 
 turbinateds differs from the remaining surfaces in this respect: the 
 rich endowment of blood-vessels and muciparous glands enabling 
 them to perform so freely their physiological function. The color 
 of the columnar epithelium, in the mucous membrane of the upper 
 portion of the nose, is yellowish pink; that of the lower, or ciliated, 
 region, from its richer blood-supply, is reddish pink; while the pos- 
 terior ends of the inferior turbinateds, particularly when much 
 swelled, are of a whitish or purplish hue. 
 
 Tlie Nerves. — The innervation of the nose is of a double char- 
 acter: the one consisting of the special sense of smell, the other of 
 ordinary sensibility. The former is supplied by the olfactory nerve, 
 which passes by many minute filaments through the cribriform plate 
 of the ethmoid, and is distributed over the upper third of the septum, 
 the superior turbinated, and the upper half of the middle turbinated, 
 terminating in the rod, or olfactory, cells of Schultze, which are con- 
 sidered to be the special terminals of the olfactory nerve-fibres. The 
 latter is abundantly supplied by superior maxillary branches of the 
 trigeminus and the nasal branch of the ophthalmic and some fila- 
 ments from Meckel's ganglion. 
 
 Blood-vessels. — The vascular supply to the frontal sinuses, eth- 
 moid cells, and roof of the nose is derived from the anterior and 
 posterior ethmoidal branches of the ophthalmic. The spheno-palatine 
 branch of the internal maxillary artery supplies the mucous mem- 
 brane of the turbinateds and septum, while the alveolar branch of 
 the internal maxillary supplies the antrum. 
 
 Glands. — The upper, or olfactory, area of the nose is said to be 
 relatively more richly glandular than the lower, or respiratory, area; 
 and one function of the exosmosis being merely to keep the sensory 
 nerve-filaments in a constantly moist condition, these glands are almost 
 solely of a serous character. 
 
CHAPTER II. 
 
 PHYSIOLOGY OF THE NOSE AND ACCESSORY SINUSES. 
 
 Within the last half -century it was the general impression, even 
 among medical men, that the nose had only one important function 
 to perform, and that was to preside over the sense of smell. Now 
 it is known to perform three important functions, of which olfaction 
 is, perhaps, the least. The others are to give beauty and resonance 
 to the voice and to perform a complex duty in reference to respira- 
 tion. 
 
 The Sense of Smell. 
 
 The sense of smell is produced by infinitesimal particles of 
 odorous bodies being drawn into the nasal cavities during inspiration. 
 They are there dissolved by the nasal mucus and, coming in con- 
 tact with the terminal filaments of the olfactory nerves, a sense of 
 their presence is at once transmitted to the nerve-centre and their 
 odorous qualities recognized. Dry particles on dry membrane are not 
 perceived by the nerve. Hence the importance of the nasal mucosa 
 being in a healthy moist condition. In the same way the presence 
 of crusts or tumors or foreign bodies within the nasal cavities, by 
 preventing the contact of odorous particles with the sensitive mucosa, 
 mars the full observance of this important function. In order to 
 insure a perfect sense of smell, the nerve itself must be in a healthy 
 condition. 
 
 Frequently in prolonged and chronic nasal disease the terminal 
 filaments lose their normal sensibility, and this loss of functional 
 power affects, to a marked degree, the sense of taste, as well. 
 
 The Nose in Phonation. 
 
 This organ, in conjunction with the naso-pharynx, has a very 
 
 important influence upon the formation of the voice. Combinedly 
 
 they act as a resonance-chamber in which the voice, after passing 
 
 through the vocal cords, receives its final tone. All vocal sound is 
 
 (12) 
 
PHYSIOLOGY OF THE NOSE. 13 
 
 produced by vibrations of a column of air issuing through the glottis. 
 The pitch of tone is regulated by the tension of the cords; the volume, 
 by the force with which the column of air is driven through them; 
 while the character or individuality of the voice itself is dependent 
 largely upon the mouth, pharynx, and the formation of the nasal 
 chambers. 
 
 The soft palate has a great deal to do with correct phonation, 
 and, to perform its duties well, should be perfectly free from ob- 
 structive lesions, either in the naso-pharynx above or the tonsillar 
 region beneath. 
 
 The Nose in Kespiration. 
 
 The triple function of saturating, cleansing, and heating the 
 air of respiration, as it passes through the nasal fossae to the throat, 
 is probably the most important of all the duties which Nature has 
 assigned to this organ. It has been proved by experiment, over 
 and over again, that ordinary dry air, containing only a minimum 
 of moisture, becomes saturated as it passes through the nose during 
 inspiration. This added moisture is obtained from the serous exuda- 
 tion of the mucous membrane of the turbinateds. This fluid exudes 
 from the cavernous sinuses, caused by the stimulation of the air as 
 it passes over them, and is slightly diluted by the mucus from the 
 tubular glands. These venous plexuses, which perform so important 
 a function, are named by Zuckerkandl SchweWcorper, or swell bodies. 
 In a healthy condition they are fully surcharged with blood, and the 
 serum passes out by transudation, to be absorbed by the air during 
 inspiration. 
 
 The amount of moisture thus given off by the healthy nose in 
 twenty-four hours is estimated at about one-third of a litre and, as 
 can readily be seen, plays an important part in the phenomena of 
 normal breathing. To insure this supply of serum, the sinuses of 
 the turbinateds are always filled with blood, yet this hypersemic con- 
 dition, normally, is not sufficient to produce stenosis of any part. 
 Everywhere throughout the nose, however tortuous, these narrow 
 passages are open; and the air of respiration becomes saturated while 
 passing through them. 
 
 At the same time the air becomes elevated in temperature by 
 contact with the hot, moist walls, being many degrees nearer blood- 
 heat by the time it reaches the pharynx than it was on entering the 
 anterior nares. 
 
14 DISEASES OF THE NASAL PASSAGES. 
 
 Then, also, the air is purified as it passes through the nasal 
 passages. Insects, heavy dust, and minute foreign "bodies are largely 
 kept out by the fringe of vibrissa?, which stands guard over the en- 
 trance to each nostril. It is, however, the moist nasal mucosa which 
 does the chief part of the cleansing, the myriads of leucocytes and 
 mucous cells acting as phagocytes and destroying the invading hosts 
 of noxious germs as they advance backward from the vestibule. H. L. 
 Wagner says: "The action of these leucocytes does not consist in 
 their total destruction, but in greatly diminishing their activity." 
 Whether the normal mucous secretion is a germ-destroyer or not is 
 still, in some degrees, an open question, pathologists differing upon 
 the subject. Still, one thing is certain, that, whereas the mucus of 
 the vestibule is always loaded with microscopical germs, that in the 
 back parts of the normal nasal passages is almost, if not entirely, free 
 from them. It is possible that a great deal of the cleansing process 
 is due, however, to the oft-repeated efforts of Nature to eject, by 
 forcible expulsion, anything that irritates the nasal passages. 
 
 The special function of the large antra of Highmore is probably 
 one of phonation. Filled, as they are, by air when in a healthy con- 
 dition, with free openings into the nasal chambers, they may give 
 additional vibration and tone to the voice, whether in vocal exercise 
 or ordinary use. 
 
CHAPTER III. 
 
 INSTRUMENTS USED FOR THE EXAMINATION AND TREAT- 
 MENT OF DISEASES OF THE NOSE 
 AND THROAT. 
 
 For the successful examination and treatment of nasal diseases 
 we require the aid of artificial light, either reflected from an electric 
 lamp placed on the forehead of the surgeon (Fig. 6) or from bright 
 
 Fig. 6. — Phillips's electric photophone, with adjustment for 
 focusing light. 
 
 light of some kind placed on either side of the patient and reflected, 
 from the head-mirror of the operator, upon the part to be examined 
 (Figs. 7 and 7a). 
 
 The ordinary plan, and the one largely adopted by specialists 
 up to the present date, is the latter one. The light should be on a 
 level with the patient's nose, and on a plane a little posterior to it. 
 The surgeon sits immediately in front of the patient, and by adjust- 
 ed 
 
16 
 
 DISEASES OF THE NASAL PASSAGES. 
 
 Fig. 7. — Head-mirror. 
 
 Fig. 7a. — Head-mirror in position. 
 
 ing the head-mirror the focus of light is thrown directly upon the 
 spot to be observed. The advantage of this arrangement is that, by 
 
INSTRUMENTS AND THEIR USES. 
 
 17 
 
 looking with one eye through the hole in the mirror and with the 
 other past its edge, he entirely escapes any direct rays of the light 
 from falling upon his own retina. The character of the light used 
 is of some importance. An inclosed light in a dark corner of the 
 room is best. The light itself should be bright, clear, and steady, 
 placed, if possible, in a MacKenzie concentrator or one of the more 
 modern forms (Fig. 8). It may be by electricity, gas, or oil. Even a 
 
 Fig. 8. — Laryngoscope, gas-stand, mirror, condenser, and tubing. 
 (After MacKenzie.) 
 
 tallow candle, if nothing better can be obtained, may be of good 
 service. 
 
 For anterior rhinoscopy the nasal speculum is required, the ob- 
 ject being to open the nostril painlessly to its widest capacity for 
 the admittance of light. Of this instrument there are many varieties, 
 of which Figs. 9 to 13 are samples. Each surgeon must make his own 
 choice. I have found those of an ovoid, cylindrical form much the 
 most convenient, protecting the nostril and admitting abundance of 
 
18 
 
 DISEASES OF THE NASAL PASSAGES. 
 
 light. Some like a spring-wire instrument. Sliurly considers a spe- 
 cial protection to the nasal wall opposite to the side operated on to 
 
 Fig. 9. — Bosworth's large and small nasal specula. 
 
 Fig. 10. — Good willie's nasal speculum. Fig. 11. — Myles's nasal speculum. 
 
 Fig. 12. — Sincrock's nasal speculum. 
 
 Fig. 13. — Sincrock's nasal speculum, with handle. 
 
 be an essential, and has devised the instrument shown in Fig. 15 for 
 this purpose. Bosworth's Fig. 14 is formed in a somewhat similar 
 manner. 
 
INSTRUMENTS AND THEIR USES. 
 
 19 
 
 Fig. 14. — Bos worth's nasal speculum, with shield 
 for cautery-work. 
 
 Fig. 15. — Shurly's nasal speculum. 
 
 Fig. 16. — Post-rhinal mirror. 
 
 Fig. 17. — Post-rhinal mirror. 
 
 Fig. 18. — White's self-retaining palate-retractor. 
 
20 
 
 DISEASES OF THE NASAL PASSAGES. 
 
 For posterior rhinoscopy posterior rhinal mirrors of small sizes 
 are required (Figs. 16 and 17), and, to facilitate post-pharyngeal ex- 
 amination, various palate-retractors have also been introduced (Fig. 
 
 Fig. 19. — Applicators. 
 
 18). The latter are rarely necessary, as by a little practice on the 
 part of the operator and training on the part of the patient most 
 pharyngeal and post-rhinal cavities can be examined without their 
 aid. 
 
 To these might be added cotton-applicators or probes for the 
 
 Tongue-depressor. 
 
 application of solutions and cleansing of the passages (Fig. 19), and 
 tongue-depressors to facilitate examination of the post-nasal region 
 (Figs. 20 to 24). 
 
INSTRUMENTS AND THEIR USES. 
 
 21 
 
 These instruments are all required for operation as well as ex- 
 amination, and to them might be added the following: — 
 
 1. Atomizers to throw spray within the nasal cavities, anteriorly 
 
 Fig. 21. — Tongue-depressor. 
 
 23. — Sass's tongue-depressor. 
 
 and posteriorly. These may be simple hand-atomizers (Figs. 25 to 27) 
 or they may be driven by compressed air from tanks specially devised 
 for the purpose (Fig. 28). 
 
22 
 
 DISEASES OF THE NASAL PASSAGES. 
 
 Fig. 24. — Tiirck's tongue-depressor. 
 
 Fig. 25. — Davidson's atomizers, to be used by compressed air 
 or hand-bulb. 
 
 Fig. 26. — Burgess's metal-tube atomizers: straight, up, and down. 
 
INSTRUMENTS AND THEIR USES. 
 
 23 
 
 Fig. 26ff. — Bos worth's atomizer. 
 
 Fig. 27. — Compressed-air apparatus. 
 
 2. Insufflators, or powder-blowers, of which also there are many 
 in the market (Figs. 28, 28a, 28&, and 28c). The name is indicative 
 of their utility. Also post-nasal syringes. 
 
24 
 
 DISEASES OE THE NASAL PASSAGES. 
 
 Fig. 28. — Powder-blower with mouth-piece and tube. 
 
 Fig. 28a. — Powder-blower with bulb. 
 
 Fig. 286. — Powder-blower with tubing and bulb. 
 
 Fig. 28c. — Powder-blower with scoop. 
 
 3. Nasal saws, of which Bosworth's is the model upon which 
 most of the others are founded (Figs. 29 and 30). They are used 
 
INSTRUMENTS AND THEIR USES. 
 
 25 
 
 to remove segments or sections from the nasal septum. Roe's is an 
 excellent instrument for certain well-defined cartilaginous enlarge- 
 ments. 
 
 Fig. 29. — Bosworth's nasal saws. 
 
 Fig. 30. — Mial's reversible saw. 
 
 Fig. 31. — Hartmann's nasal chisels. 
 
 4. Chisels for the same purpose (Fig. 31); also drills (Fig. 32) 
 and more complicated instruments. 
 
2G 
 
 DISEASES OF THE NASAL PASSAGES. 
 
 Fig. 32. — Freeman's drill. 
 
 Fig. 33. — Bosworth's nasal polypus-snare. 
 
 Fig. 34. — Sajous's nasal polypus-snare. 
 
 5. Cold-wire snares of many varieties are exceedingly valuable 
 for removal of polypi, as well as other growths within the nasal 
 cavities (Figs. 33 to 36). 
 
INSTRUMENTS AND THEIR USES, 
 
 27 
 
 Fig. 35. — Hall's nasal polypus-snare. 
 
 Fig. 36. — Dench's nasal polypus-snare. 
 
 Fig. 37. — Universal cautery and snare-handle, with cannula and snare. 
 
 II 
 
 Fig. 38. — Cautery-electrodes. 
 
 6. The galvanocautery-snare is also received with favor in some 
 quarters (Fig. 37), though much more reliance is placed upon the 
 galvanocautery-knife or trephine for turbinal work (Figs. 38 and 40). 
 
28 
 
 DISEASES OF THE NASAL PASSAGES. 
 
 For the latter, Carmault Jones's spokeshave, with various modifica- 
 tions of it, has been received with marked favor in England, while 
 on this continent it has usually not been valued so highly (Fig. 41). 
 
 • 
 
 i i D 
 
 Fig. 39. — Nasal burrs. 
 
 
 Fig. 40. — Xasal trephines. (Curtiss.) 
 
 Fig. 41. — Beren's (1) and Nichols's (2) spokeshaves. 
 
 To the above might be added punches and curettes, curved scis- 
 sors and knives, forceps and clamps, as well as other instruments spe- 
 
ANTERIOR RHINOSCOPY. 29 
 
 daily devised for use in particular cases. Nasal burrs for antral as 
 well as septal work may also be mentioned (Fig. 39). 
 
 Anterior Ehinoscopy. 
 
 The view obtained by means of the rhinoscope, including as it 
 does, the head-mirror (Fig. 7), the reflected light, and the nasal specu- 
 lum (Fig. 12) is only limited, when confined to one position; but by 
 moying the head in different directions, a greater part of the nasal 
 cavity can be brought successively into view. By looking directly 
 in, the floor of the nose and the inferior turbinated, as well as the 
 
 Fig. 42. — Anterior rhinoscopy, position of the head for inspecting the wall 
 of the pharynx through the nasal passages. (After Bos worth.) 
 
 lower part of the septum, can be seen. The septum is very rarely 
 perfectly central in position, being deflected to one side or the other. 
 In these cases the whole length of the inferior turbinated can fre- 
 quently be seen, as well as the post-pharyngeal wall, through the 
 wider passage; and if the person examined be requested to count 
 1, 2, 3, the movements of the palate can also be distinctly observed 
 through the inferior meatus (Fig. 42). 
 
 When, owing to the turgid condition of the mucous membrane 
 the passages are too narrow to admit of examination, this can always 
 be aided by spraying the nasal fossas with a 1-per-cent. solution of 
 cocaine. In a few moments its astringent effect upon the mucous 
 
30 
 
 DISEASES OF THE NASAL PASSAGES. 
 
 membrane drives away the blood, and, shrinking the tissues, a better 
 view can be obtained. 
 
 In the normal state the middle and inferior turbinateds and 
 septum are of a pinkish hue, while the roof of the nose and the 
 superior turbinateds are yellowish pink. 
 
 Fig. 43. — Posterior rhinoscopic image. (After Bishop.) 
 
 Posterior Ehinoscopy. 
 
 To accomplish this, the head-mirror, reflected light, tongue-de- 
 pressor, and post-rhinal mirror are always required; and sometimes 
 the palate-retractor also (Fig. 18). Fig. 43 illustrates the method of 
 taking a view. Before entering the throat-mirror it is first gently 
 heated to a blood-temperature over a gass-jet or spirit-lamp, to avoid 
 the condensation of moisture upon its surface. Care should be taken,. 
 
POSTERIOR RHINOSCOPY. 31 
 
 after depressing the tongue, not to touch the soft parts while passing 
 in the instrument. 
 
 To obtain a good view of the posterior nares and vault of the 
 pharynx it is always necessary that the palate should hang straight 
 down. By a little training this can usually be accomplished, although 
 on first efforts the patient is very likely to retract the palate against 
 the post-pharyngeal wall, thus effectually cutting off all view of the 
 vault above. By directing the patient to breathe through his nose 
 the desired result may sometimes be obtained. Of course, when the 
 mouth is opened and the tongue held down by a depressor, it is im- 
 possible to breathe alone through the nose; but the attempt drops 
 the palate and gives the required view. 
 
 This method failing, a solution of cocaine applied to the palate 
 may remove irritation and produce the desired result. At all events, 
 it will enable a retractor to be applied, and, the velum being drawn 
 forward, a vision is obtained. 
 
 In the little post-rhinal mirror we first have the upper surface 
 of the soft palate, then the posterior nares, with the dividing septum; 
 to the two sides, the mouths of the Eustachian tubes and the lateral 
 walls of the naso-pharynx; above the vault, and behind the post- 
 pharyngeal wall, over the two latter we may have the pharyngeal ton- 
 sil, or, as it is usually called when in an hypertrophied condition, the 
 adenoids. Between the post-pharyngeal wall, on each side, and the 
 mouth of the Eustachian tube, is the fossa of Rosenmuller. 
 
 All these parts cannot be seen at once; and it will require a 
 little care and patience, both on the part of the observer and the 
 observed, with different adjustments of the instrument, to obtain an 
 entire view. The color of the vault is often a dark pink, with lighter 
 hue at the sides and lower portions, while the posterior nares are 
 inclined to be a yellowish pink. 
 
DISEASES OF THE NOSE. 
 
 CHAPTEE IV. 
 
 ACUTE RHINITIS. 
 
 This is an acute inflammation of the mucous membrane of the 
 nasal passages. It usually affects both sides alike and is attended by 
 coryza or discharge. Frequently the inflammatory action extends to 
 the pharynx; and sometimes, though not very often, to the various 
 accessory cavities and the lacrymal duct. 
 
 Pathology. — The commencement of the disease is the period of 
 congestion, with arrest of secretion, and is common, during the first 
 stage, to all inflammations of mucous membrane. This is followed 
 by transudation from the gorged venous sinuses and increased secre- 
 tion of mucus from the glandular structures. These together urge 
 on the exfoliative processes of the membrane, and leucocytes, as well 
 as epithelial cells, are thrown off in vast numbers, producing muco- 
 purulent discharge during the latter stage of the disease. 
 
 Etiology. — The most common cause is exposure to cold. This 
 is particularly the case with susceptible persons. In these the sudden 
 impression of a fall in temperature seems to paralyze the vasomotor 
 nerves of the naso-mucosa; and, the control of the capillary circula- 
 tion being lost, the membranes become congested. The extent to 
 which this congestion occurs before the inhibitory power is restored 
 would indicate the severity of the disease. In some cases acute rhinitis 
 is caused by exposure to acrid vapors and irritants of one form or 
 another; while in not a few instances it is primarily due to the pre- 
 existence of chronic rhinal disease. It is also one of the early indica- 
 tions of certain of the exanthemata, particularly in the case of measles. 
 Acute rhinitis is more prevalent among children than among adults. 
 Wagner believes that it is often produced by migrations of micro- 
 organisms from diseased tonsils into the nasal cavities. 
 
 Symptomatology. — The first symptom is usually that of dryness 
 (32) 
 
ACUTE KHINITIS. 33 
 
 of the nostrils, accompanied by more or less frontal oppression and 
 sneezing. There may be chilliness, lassitude, and slight febrile action. 
 The tingling sensation within the nostrils is quickly followed by sero- 
 mucous discharge. The flux may be serous at first, then sero-mucous, 
 and finally muco-pus before the discharge ceases. Usually a certain 
 amount of febrile action takes place. 
 
 If the frontal sinuses are affected, frontal oppression and head- 
 ache are the result, while the extension to the Eustachian tubes and 
 pharynx render symptoms in connection with these organs apparent. 
 Irritation of the conjunctiva, with discharge of tears over the cheek, 
 would indicate that the lacrymal duct was suffering from temporary 
 occlusion. 
 
 Sometimes the nasal stenosis is very distressing, necessitating 
 oral breathing. Excoriations of the lips and alae, by the discharge of 
 acrid secretions, are likewise often productive of much discomfort. 
 
 The sense of smell may also be affected during the severity of 
 the attack. 
 
 Diagnosis. — The group of symptoms described are so character- 
 istic that diagnosis should be easy. The mucous membrane is at first 
 swelled and red; then bathed in serum; and gradually, as the color 
 becomes lighter, muco-pus takes its place. The posterior choanse, 
 examined by the rhinoscope, reveal the middle and inferior tur- 
 binateds swelled, bathed in discharge, and practically filling up the 
 nares. Other mucous membranes involved in the inflammatory action 
 all present a similar pink and swelled condition. 
 
 Prognosis. — Favorable in a large majority of cases. It involves 
 no danger to life, and usually disappears in about a week. The real 
 danger lies in allowing colds to follow each other in such quick suc- 
 cession as to prevent the nasal mucosa from resuming its normal 
 tone. Permewan and Carter have also recently drawn attention to 
 the possibility of severe systemic infection being induced by this 
 disease, cases being reported in which prolonged illness and continued 
 fever, otherwise unaccountable, were entirely removed by antiseptic 
 intranasal treatment. • 
 
 Prophylaxis. — To those inclined to the disease regular habits of 
 life are important. Daily cold bathing either by plunge or sponge, 
 when followed by prompt reaction, is an important preventive. 
 Clothing should be comfortable and equally divided over the body. 
 
 Heavy neck wrappings are always objectionable. Heavy furs 
 worn by the ladies while calling and left on in hot rooms often have 
 
34 DISEASES OF THE NASAL PASSAGES 
 
 the effect of producing cold on returning to the street. "Wearing of 
 wet garments, which the exigencies of weather or occupation so fre- 
 quently render necessary for the time, will rarely during active exer- 
 cise produce injurious effects, but it is the continued wearing after 
 the exercise is over that does the harm. In short, if people would 
 systematically use good -common sense in their daily walk of life, the 
 colds from which so many people suffer would be very much rarer 
 than they are. 
 
 Treatment. — Nothing seems to check the general feeling of 
 malaise, attendant upon acute rhinitis, so quickly as quinine in 1 / 2 - 
 gramme doses. I prefer to give it in capsule form, repeating the dose 
 each morning while the disease lasts. In strong vigorous adults a 
 gramme might be given to commence with, taking the smaller amount 
 after the first day or two. In young children 1 / i or 1 / 8 gramme, ac- 
 cording to age and bodily habits. 
 
 A saline cathartic is also beneficial; and the feet put in hot water 
 at bed-time, followed by a stimulating drink of ginger-tea or hot 
 lemonade. The object aimed at is diaphoresis and restoration of the 
 natural equilibrium of the whole body. If there is unrest and wake- 
 fulness, with flushed face, acetanilid in 1 / 4 -gramme doses might be 
 repeated once or twice during the night-time. For the same purpose 
 minute doses of morphia and atropia in tablet form are often given; 
 the combination has the advantage of the astringent effect of the 
 atropia upon the mucous membrane: — 
 
 1. B Atropia sulph 10013 
 
 Morph. sulph 1065 
 
 M. Fiat in pil. x dividenda. 
 
 Sig.: One to be taken every four or six hours if required. 
 
 For Local Treatment. — 
 
 2. $ Menthol 
 
 Albolene 60 
 
 M. Sig.: To be used with an atomizer to the nostrils several 
 times a day. 
 
 1. I£ Atropia sulph gr. 1 / 50 . 
 
 Morphia sulph gr. j. 
 
 M. Fiat in pil. x dividenda. 
 
 2. R Menthol gr. x. 
 
 Albolene §ij. 
 
 M. 
 
ACUTE RHINITIS. 35 
 
 Or 
 
 1. n Thymol 12 
 
 Menthol 3 
 
 Albolene GO 
 
 M. Sig.: To be used with an atomizer to the nostrils several 
 times a day. 
 
 Either of these will be found an excellent remedy in this disease. 
 
 Bishop, in his recent work on "Ear, Nose, and Throat," strongly 
 recommends 3 per cent, of camphor-menthol in lavolin as a spray 
 in acute rhinitis. It has a similar action upon the inflamed mucosa 
 to the ones just referred to. 
 
 Lennox Browne, in the new edition of his valuable book on 
 "Diseases of the Nose and Throat," speaks emphatically of the value 
 of menthol in the treatment of diseases of these organs. Speaking 
 of this "remarkable drug," he says: "1. It stimulates to contraction 
 the capillary blood-vessels of the passages of the nose and throat, 
 always dilated in the early stages of the head-cold and influenza. 2. 
 It arrests sneezing and rhinal flow. 3. It relieves pain and fullness 
 of the head by its pain-killing properties. 4. It is powerfully germi- 
 cide and antiseptic." 
 
 All these statements, with the exception of the one referring to 
 sneezing, I have agreed with for years. The sternutatory effort is 
 frequently produced by the first applications of the menthol-spray 
 to the nose; but the mucous membrane soon becomes accustomed to 
 the slight irritation, and subsequent applications will be borne with- 
 out difficulty. 
 
 When the symptoms show tardiness in abating, recovery may 
 often be hastened by using stronger solutions of the stearoptenes in 
 the hydrocarbon menstruum. For instance, the menthol may be 
 doubled or tripled to the same quantity of albolene, and the same 
 may be said of thymol. In this case, however, they should be inhaled 
 directly into the mouth from the atomizer, and, the mouth being 
 closed, exhaled through the nose. 
 
 When there is much nasal stenosis, there is sometimes a tempta- 
 tion to use cocaine, owing to its power as an astringent in producing 
 immediate relief. It is unwise, however, ever to place this remedy 
 
 1. I£ Thymol gr. ij. 
 
 Menthol gr* v. 
 
 Albolene oij. 
 
 M. 
 
 3 
 
36 DISEASES OF THE NASAL PASSAGES. 
 
 in the patient's hands. The relief it affords is only temporary, and 
 the more frequently it is used, the more rapidly does reaction take 
 place, with return of the swelling. The danger of forming the co- 
 caine-habit makes it imperative to confine the nse of this drug to the 
 doctor's office. 
 
 After the vascular plethora has passed away and the exudation 
 diminished Bosworth recommends the application of chromic acid 
 to the still swelled membrane. After coeainization he applies minute 
 crystals of the acid to the prominent portions of the inferior turbi- 
 nateds, with the view of pinning down the parts and so securing con- 
 traction. Wherever I have found cautery treatment necessary, it 
 has always been in cases in which some previously existing hyper- 
 trophy demanded the operative treatment. 
 
 Dry heat applied to the forehead is sometimes of benefit in the 
 later stages, relieving the frontal headache and taking away the full- 
 ness which so often is felt over the root of the nose. 
 
CHAPTEE V. 
 
 CHRONIC RHINITIS. 
 
 This is a chronic inflammation of the nasal mucosa bearing ai 
 direct relation to the acute disease. Some observers believe it to be 
 the cause of the oft-repeated occurrences of the latter, while others 
 look upon it as the effect. The last mentioned is probably nearer the 
 truth. The entire mucous membrane may be involved, and the dis- 
 ease may extend to the Eustachian tubes, the lacrymal ducts, and, as 
 in the acute disease, to the accessory sinuses. 
 
 Pathology. — The mucous membrane is thickened and puffy, 
 while the venous sinuses are chronically relaxed. Interstitial infil- 
 tration is the result, but of a changeable character. Frequently will 
 one nasal fossa be affected, closing it sufficiently by oedema to pro- 
 duce complete nasal stenosis, while for the time the other is free 
 enough to carry on respiration. Lying for a short period on the 
 open side will reverse the condition, simply by hydrostatic gravita- 
 tion. Hydrorrhcea from the venous sinuses, together with the dis- 
 charge of leucocytes and pus-cells from the chronically-irritated 
 glands, becomes a leading feature. 
 
 Etiology. — Continued exposure to inclemencies of the weather 
 — with insufficient clothing, wet feet, etc., producing oft-repeated 
 colds — is a frequent cause. Inhalation of irritating dust and gases, 
 during ordinary occupation, when prolonged, will induce the disease. 
 The presence of a strumous diathesis may be a predisposing cause; 
 as also may be the presence of structural lesions and hypertrophies. 
 
 Symptomatology. — The most prominent symptom is a constant 
 nasal discharge, chiefly of a muco-purulent character, which induces 
 oft-repeatecl efforts at blowing and hawking. In aggravated cases the 
 nares are filled with a pasty, yellow matter; and the constant efforts 
 to void the discharge, in some cases, produce swelling and redness of 
 the nose, as well as eczema or ulceration of the anterior nares. Owing 
 tn the limited proportion of serum exuded, the secretion often be- 
 comes dry, resulting in crust-formation about the nostrils. To 
 liberate this, picking is resorted to, with gradual destruction of the 
 
 (37) 
 
38 DISEASES OF THE XASAL PASSAGES. 
 
 mucous membrane; and; in some cases, the septal cartilage eventu- 
 ally becomes perforated by this digital irritation. The disease occurs 
 most frequently between childhood and early maturity. 
 
 Diagnosis. — There is sometimes a nice distinction to be made be- 
 tween chronic rhinitis and Bosworth/s purulent rhinitis of children. 
 In the former the disease may occur any time after early childhood, 
 but rarely during that period, while in the latter it always occurs 
 •during early life. In the former there is less purulent discharge 
 than in the latter, while, owing to the shorter period of its exist- 
 ence, there is less likelihood of its culminating in atrophy. The 
 diagnosis between this and hypertrophic rhinitis is more easily made. 
 The application of a 4-per-cent, solution of cocaine for the time 
 will shrink away the infiltration of chronic disease, which it cannot 
 do with the enlargements arising from hypertrophy. On the other 
 hand, when of long duration, it may resemble and even be the 
 initiatory stage of atrophic rhinitis. 
 
 Prognosis. — In the region of the great lakes of this continent 
 chronic rhinitis is very prevalent, owing to the humidity of the at- 
 mosphere and the variability of temperature. As these cannot be 
 avoided, the prognosis as to permanent result is not very encouraging. 
 If proper means are adopted, however, a cure can be accomplished, 
 though the tendency to return may still exist. When long continued, 
 the disease is likely to culminate in chronic hypertrophic rhinitis. 
 Consequently a guarded prognosis as to ultimate results should always 
 be given. 
 
 Treatment. — Eegulation of the primes vice and toning up the 
 general system are in many cases necessary and can be done on the 
 principles of general medicine. 
 
 Locally, the nasal passages will require systematic cleansing. For 
 this, alkaline sprays will be required; and, of these, what is called 
 DobelPs may be considered the best type. All modern English 
 writers on disease of nose and throat acknowledge the utility of 
 DobelPs solution, and give credit to Dobell for introducing it to the 
 world, yet scarcely two of them agree upon its formula. I have be- 
 fore me the most recent works of Sajous, Bosworth, and Bishop; 
 and in giving the formula of DobelPs solution, while they all agree 
 as to ingredients,- they all differ as to quantities. Here, I think, lies 
 the intrinsic value of the preparation as a type, the combination re- 
 maining intact, while the proportions are varied, according to the 
 judgment of the physician in charge. 
 
CHRONIC RHINITIS. 39 
 
 My own rendering of DobelPs solution is the following: — 
 
 1. R Sodii bicarb 2 
 
 Sodii bibor 2 
 
 Acidi earbol 1 
 
 Glycerin 15 
 
 Aquaru ad 250 
 
 M. Sig. : To be used with the atomizer to the nose, as re- 
 quired, several times a day. 
 
 The advantage of this and similar preparations, used freely as 
 sprays to the nose, is that they are both alkaline and disinfectant, 
 acting as solvents to the muco-purulent secretions, which require to 
 be removed. 
 
 After cleansing, oleaginous sprays are indicated for their sooth- 
 ing, protective influence upon the mucous membrane. The oil used 
 as a menstruum should be one of the recently-discovered hydrocarbons, 
 as from their mineral origin and chemical composition they can never 
 become foul or rancid. It matters not whether it be liquid vaselin, 
 lavolin, glycolin, albolene, or any other of the many that are in the 
 market, so long as it is pure, colorless, inodorous, and unirritating; 
 but these requirements are essential. The one I have generally used 
 is albolene. The medicament dissolved in the oil should be of a 
 slightly stimulating and antiseptic character. For instance, 1 to 2 
 per cent, of menthol in albolene, 1 / 2 -per-cent, thymol in albolene, 1 
 to 2 per cent, of eucalyptol in albolene, 1 per cent, of creasote in 
 albolene, or 1 to 2 per cent, of camphor-menthol in albolene. The 
 first and second of these I have used more extensively than the others, 
 the treatments being repeated from one to three times a day. 
 
 The treatment of atrophic rhinitis by massage, introduced several 
 years ago by Braun, of Italy, induced me to try it also in simple 
 chronic rhinitis. He used probes with olive-shaped tips; and, passing 
 one into the nostril, guided by head-mirror and nasal speculum, 
 would, by tremulous pressure of the hand, produce vibration over the 
 diseased tissue. The method I have followed, though copied from 
 Braun, has been of a simpler nature, and would be practiced on each 
 visit of the patient for treatment. 
 
 1. ft Sodii bicarb gr. xxx. 
 
 Sodii bibor gr. xxx. 
 
 Acidi earbol gtt. xv. 
 
 Glycerin 3iv. 
 
 Aquam ad $viij. 
 
 M. 
 
AO DISEASES OF THE NASAL PASSAGES. 
 
 The end of an ordinary nasal cotton-carrier would be wrapped 
 firmly with a small pledget of cotton, the thickness of the temporary 
 tip being made to accord with the width of the crevice in the nasal 
 passage to which it was to be applied. Then the tip would be dipped 
 in albolene, and, after insertion into the nostril, manipulated in 
 accordance with Brainrs method. By proper care, combined with 
 gentleness of touch, massage of the whole mucous membrane can be 
 done without the use of cocaine, and with very little discomfort to the 
 patient. With each application the used pledget is stripped off and a 
 new one applied almost in a moment — three or four being required 
 for each nostril at one sitting. After massage a spray of albolene or 
 similar oil is all that is needed. 
 
 In a large number of cases this treatment has been attended with 
 very satisfactory results. The usual office-formula has been: 1. 
 Cleansing the nasal fossae by a free spray of Dob ell's solution. 2. 
 Massage of both passages. 3. Application of a spray of albolene to 
 each. For home-treatment the patient has been instructed to use 
 simple cleansing sprays, as required, between the visits to the office 
 for massage — the latter being repeated every second or third day, a 
 few treatments only being required. 
 
 Of the two methods, I have looked upon the massage treatment 
 as more effectual than that of simple medication. 
 
 In the posterior thickening of the. septum, which so frequently 
 occurs in the chronic rhinitis of adult life, we have a combination of 
 oedema with epithelial cell-proliferation. It is usually bilateral, and 
 exists in the form of a perpendicular ridge, a little in front and on 
 •each side of the posterior edge of the vomer. The hypertrophy is, 
 in some cases, so great as to seriously interfere with the nasal breath- 
 ing and to necessitate operative treatment. This is best done by the 
 galvanocautery. After cocainization the blade is passed into -the nostril 
 and, guided by the post-rhinoscopic mirror, the membrane is freely 
 singed. N~o special after-treatment is needed; and after a week or 
 so, by which time the surface will have healed, the operation can 
 be repeated if required. 
 
CHAPTEE VI. 
 
 PURULENT RHINITIS OF CHILDREN. 
 
 Bosworth was the first to clearly and definitely outline purulent 
 rhinitis and to place .it on the list of representative nasal diseases. 
 Other writers had spoken of it before, particularly MacKenzie, 
 Stoerck, Fraenkel, and Cohen, but it remained for Bosworth to recog- 
 nize its full importance and to intimate the position which he believed 
 it to occupy in the etiology of atrophic rhinitis. 
 
 Pathology. — As described by him, it is a disease peculiar to the 
 earlier years of childhood, its prominent feature being the chronic 
 discharge of purulent matter from the anterior nares. This discharge 
 is purely local, and not dependent on constitutional diathesis. In the 
 earlier stages there is increased secretion of mucus, with rapid des- 
 quamation of epithelial cells. The discharge gradually assumes a pu- 
 rulent form, and after lasting a number of years results in the shrink- 
 age of the turbinated bodies and the development of atrophic disease. 
 In support of this theory Bosworth says: "That in youth the epi- 
 thelial structures are especially liable to become the seat of diseased 
 action, whereas in adult life this tendency seems to disappear, and in 
 place of it there obtains a tendency to the involvement of the con- 
 nective-tissue structures. Thus, in the earlier years of life we notice 
 this tendency in the development of enlarged tonsils and follicular 
 disease of the upper air-tract, as well as in the vulnerability of the 
 lymphatic glands, whereas, in adult life, inflammatory changes in the 
 mucous membranes result in true connective-tissue hypertrophy." 
 
 "Wagner also expresses the same opinion when he says: "'During 
 childhood the skin and mucous membranes are more excitable; more 
 prone to disorders of the circulation. The function of the lymphatic 
 glands is prominent in childhood; the quantity of lymph is increased; 
 the lymphatic glands at this time have their greatest development." 
 Hence the tendency during childhood would appear to be toward 
 the abnormal development of glandular, adenoid, and lymphatic tis- 
 sues in the throat and naso-pharynx, and to proliferation and des- 
 quamation of epithelial cells in the nose itself. 
 
 (41) 
 
42 DISEASES OF THE NASAL PASSAGES. 
 
 Etiology. — The literature regarding the etiology is very scant; 
 but, as it occurs in otherwise healthy and rugged children, struma 
 and hereditary syphilis are not considered potent factors in its pro- 
 duction. Bosworth ascribes taking cold from unhygienic conditions, 
 and also neglect of the ordinary rules of health, as the only assignable 
 causes. 
 
 From my own experience, I believe we frequently have more direct 
 causes, and that the pathological tendencies already referred to as 
 incidental to childhood are sufficient to produce the disease. In many 
 cases that I have seen the purulent rhinitis has been associated with 
 hypertrophy of the faucial and pharyngeal tonsils. These bodies 
 have been so large as to interfere seriously with nasal respiration. 
 In these cases the adenoid enlargement and the epithelial desquama- 
 tion ran side by side; but, owing to the stenosis, it was impossible for 
 the purulent discharge to make its escape. Like a flowing well, it 
 ebbed out and over the surface, while the retained discharges produced 
 irritation and continued development, as a consequence. That the 
 adenoid enlargement was the real cause of the purulent rhinitis 
 seemed verified by the fact that the removal of the tonsils and ade- 
 noids would be followed by cessation of nasal discharge and restora- 
 tion of normal breathing. Some cases undoubtedly do occur with- 
 out the co-existence of tonsillar hypertrophy, but the majority that 
 I have seen have, at least, been associated with adenoids. This view 
 is borne out by the experience of Lennox Browne upon the same 
 subject. 
 
 Symptomatology. — The chief symptom is the continued discharge 
 of yellow muco-pus from both nostrils. During the night-time con- 
 siderable quantities flow out and are deposited upon the pillow. On 
 examining the pharynx, the like discharge, perhaps slightly grayer in 
 color, may frequently be seen trickling down behind the soft palate, 
 the yellower color as it exudes from the anterior nares being due to 
 freer oxidation. The blocking of the nostrils necessitates mouth- 
 breathing, which is still further aggravated when adenoids are present. 
 
 Fcetor is of rare occurrence, except late in the disease, when it is 
 gradually assuming the atrophic form. 
 
 Diagnosis. — The continued presence of the anterior nasal dis- 
 charge is a strong point in diagnosis. Another one is that it is bi- 
 lateral and odorless. In scrofula and syphilis the discharges are 
 offensive in odor and often are bloody, and accompanied by systemic 
 manifestations indicative of the disease. The presence of a foreign 
 
PURULENT RHINITIS OF CHILDREN. 43 
 
 body or rhinolith would be distinguished by being unilateral and the 
 discharge accompanied by malodor. Sometimes purulent nasal dis- 
 charges accompany the development of exanthematous diseases; but 
 in these cases the history proves the relationship, and the unpleasant 
 symptoms are short lived. 
 
 Ehinoscopic examination anteriorly, after the removal of the dis- 
 charge, will reveal a slightly swelled and reddish condition of the 
 turbinateds and septum, but without ulceration; while, posteriorly, 
 grayish or yellowish-green mucus will be observed in the naso-pharynx. 
 
 Prognosis. — Without appropriate treatment the prognosis is bad. 
 There is no danger to life, and it is a self -limited disease; but the 
 limit extends over so many years that serious results of a permanent 
 character follow, unless the limit be broken. When adenoids co- 
 exist, they naturally commence to shrink away about the tenth or 
 twelfth year; and with the shrinkage comes freer nasal breathing 
 and drying of the mucosa. But during the years of the purulent 
 rhinitis the epithelial layer has slowly wasted away, and the follicles 
 and mucous glands and venous sinuses have all been involved in the 
 shrinkage, while the relief from the adenoid absorption has come too 
 late to prevent the occurrence of the dreaded atrophy. 
 
 In the early stages, however, before the vitality of the mucous 
 membrane has become exhausted, a hopeful prognosis may be given, 
 provided proper treatment is instituted and carried out. 
 
 Treatment. — The first step in treatment is to ascertain whether 
 adenoids are present or not. If present, even if not very large, they 
 should be at once removed; as a limited post-nasal swelling, coupled 
 with the purulent inflammatory condition, will produce severe steno- 
 sis. The removal of these growths has a double effect: First, by 
 direct depletion of the parts by the haemorrhage resulting from the 
 operation, and, second, by the permanent removal of the obstruction; 
 both of which have the effect of checking the purulent inflammation. 
 Consequently the subsequent treatment which I have found most 
 effective has been of the mildest character, sprays of albolene alone, 
 or of 1 per cent, of menthol in albolene, or 1 / 2 per cent, of thymol 
 in albolene, two or three times a day, for a short while, to the 
 nostrils, being all that has been required to effect a cure. 
 
 In cases where it is inopportune to operate, or in which an 
 operation is not required, the nostrils should be thoroughly cleansed 
 by the use of a good atomizer several times a day, using either a mild 
 saline or alkaline solution. Dobell's solution to which has been added 
 
M DISEASES OF THE NASAL PASSAGES. 
 
 V 4 per cent, of thymol is an effective cleanser. Of others, 1 per cent, 
 of chloride of sodium in water, or 1 per cent, of chlorate of potassa 
 in water, will either of them do good service, a few drops of glycerin 
 being added to give softness to the solution. 
 
 The spraying of the nose should each time be followed by forcible 
 blowing to remove the pus. After this Bosworth recommends spray- 
 ing with mild astringent solutions for the purpose of controlling cell- 
 proliferations, and he instances the following among others: — 
 
 1. I£ Glycerol tannin 41 
 
 Aquam ad 30 
 
 M. 
 
 2. $ Argent, nitrat |2 
 
 Aquam ad 30| 
 
 M. 
 
 3. ~fy Ahimnis |65 
 
 Aquam ad 30| 
 
 M. 
 
 Although I have often tried them, I have never been favorably 
 impressed by the use of aqueous sprays in this disease. Young chil- 
 dren are exceedingly averse to the irritation produced by them. The 
 objection is frequently so great that to secure the successful use of 
 the atomizer the physician is obliged to apply it himself, which is 
 usually impracticable, when it requires to be used more than once 
 a day. 
 
 The sprays of hydrocarbons, on the other hand, are so fine and 
 unirritating that they can be borne by the child with impunity, and 
 the parents or guardians can apply them without any difficulty. They 
 possess this advantage, too, that a single preparation will answer all 
 purposes, thus simplifying the treatment. In some cases sprays of 
 albolene or glycolin alone, repeated several times a day, have been 
 sufficient, while in others 1 to 2 per cent, of menthol in the hydro- 
 carbon and 1 / 2 to 1 per cent, of thymol in the like menstruum have 
 been required. Other drugs as well — as eucalyptol, oil of caraway, 
 creasote, etc., in small quantities in the neighborhood of 1 per cent. 
 — could also be used to advantage in these only apparently intractable 
 cases. The use of these preparations, however, do not detract from 
 the importance of the removal of obstructive lesions when they exist. 
 
 1. I£ Glycerole of tannin 3i to %]. 
 
 2. B Argent, nitrat gr. iii to gj. 
 
 3. I£ Alumnus or. x to §j. 
 
CHAPTEE VII. 
 HYPERTROPHIC RHINITIS. 
 
 This is a chronic inflammation of the mucous membrane of the 
 nasal passages affecting chiefly the turbinated bodies and occurring 
 most frequently during the early years of maturity. 
 
 Pathology. — The mucous membrane of the middle and inferior 
 turbinateds, particularly the latter, is thickened and corrugated (Fig. 
 44). The surface-epithelium is hypertrophied, sometimes extending 
 
 Fig. 44. — Hypertrophy of middle and inferior turbinate. 
 (After Bos worth.) 
 
 in a stratified form into the connective-tissue layer beneath. This 
 second layer is likewise enlarged, owing to proliferation of new tis- 
 sue-elements, which frequently become fibrous in character. The 
 cavernous sinuses below, together with all the blood-vessels of the 
 mucosa, may become permanently dilated, the glandular elements 
 likewise being affected, the racemose glands having increased in num- 
 bers. With all this combined hypertrophy, there is little epithelial 
 desquamation. In advanced stages of the disease new connective 
 
 (45) 
 
46 
 
 DISEASES OF THE NASAL PASSAGES. 
 
 tissue is formed by proliferation from the old connective cells, produc- 
 ing the want of tendency of these hypertrophies to undergo spon- 
 
 Fig. 45. — Section of inferior turbinated (25 diameters), a, Stratified 
 ciliated epithelium. &, Glands of submucosa. c, Sinus of erectile tissue. 
 d, Artery, e, Vein, f, Hypertrophied turbinated bone. (Author's speci- 
 men by Bensley.) 
 
IIYPERTKOPHIC RHINITIS. 47 
 
 taneous resolution. In some cases the hypertrophy involves the tur- 
 binal bone also, as shown in microscopical section (Fig. 45). 
 
 Of the inferior turbinateds, all parts are about equally liable to 
 enlargement, with possibly a predominance of tendency in the pos- 
 terior end (Fig. 46), while in the middle turbinated it is the anterior 
 end that is usually involved. The Figs. 46a and 46& give histological 
 sections of portions of the anterior and posterior ends of the inferior 
 turbinated. 
 
 Etiology. — Anything which will produce continuous partial ste- 
 nosis in the anterior end of one nostril has a tendency to produce 
 
 Fig. 46. — Large masses of hypertrophied membrane on the posterior 
 termination of the lower turbinated bones, more or less completely filling 
 the posterior nares. (After Bosworth.) 
 
 turbinal hypertrophy on the same side. A little consideration will 
 make the reason of this plain. Inspiration of air through the nar- 
 rowed inlet immediately produces rarefaction behind the obstruction, 
 owing to the forcible manner in which the air is drawn through the 
 passage. This rarefaction means diminished atmospheric pressure, 
 repeated with each inspiration, and, acting on the soft tissues of the 
 turbinateds, it produces a tendency to abnormal congestion. 
 
 Consequently any malformation of the front end of the septum, 
 whether of traumatic origin or not, which has the effect of making 
 one nasal passage materially narrower than the other, is likely to 
 cause a gradual, but permanent, enlargement of the turbinal tissues 
 behind it. If, on the other hand, the closure of the passage from septal 
 
48 
 
 DISEASES OF THE NASAL PASSAGES. 
 
 deformity is so complete as to produce actual stenosis, there can be no 
 hypertrophy on the affected side; but there may be on the opposite 
 one, owing to the extra labor of inspiration through the single channel. 
 
 Fig. 46(7. — Anterior portion of inferior turbinal (V 2 -inch objective), 
 (After Lennox Browne.) 
 
 Fig. 46&. — Posterior portion of inferior turbinal (1-inch objective). 
 (After Lennox Browne.) 
 
 Narrowing of the anterior nares by displacement of the columnar 
 cartilage may also produce turbinal hypertrophy in the same way. 
 
HYPERTROPHIC RHINITIS. 49 
 
 There is another cause of this disease which I have not seen 
 mentioned by any author upon the subject, but which I believe is not 
 by any means infrequent, and that is the habit which many a mother 
 has of always laying her child on the same side while sleeping. It is 
 a well-known fact, which any observer can verify for himself, that 
 lying on one side will, in a very few minutes, produce turgescence of 
 the turbinateds of that side, accompanied by comparative anaemia of 
 those in the upper nasal cavity. This is simply the result of gravita- 
 tion. The turbinal tissues are naturally so lax that the dependent 
 ones, other things being equal, are always congested at the expense of 
 those that are above. By closing the lower nostril the upper one 
 will be found to be doing nearly all the breathing, while closure of 
 the upper one will reveal the fact that little air passes through the 
 one beneath. Reversing the position to the opposite side will further 
 substantiate the same law. 
 
 The consequence is that, by persistently placing the child on the 
 one side while sleeping, the mother is continually producing con- 
 gestion of the same set of turbinateds, forcing the infant to do the 
 greater part of its respiration through the upper nostril. It is only 
 reasonable to conclude that, in a healthy, rapidly-growing child, con- 
 tinual hyperemia of one set of turbinateds would lead to their hyper- 
 trophy. But this is not all; the rarefaction of the air upon the lower 
 side of the soft cartilaginous septum of the infant, with the full 
 pressure of fifteen pounds to the inch on the upper side, will have a 
 tendency to slowly, but surely, deflect it toward the least resistance, 
 thus permanently narrowing the nostril and tending to hypertrophic 
 enlargement. 
 
 Quite frequently, hypertrophic rhinitis owes its origin to other 
 causes. Strumous habit may produce it, particularly when attended 
 by injudicious exposure. Sudden changes of temperature oft re- 
 peated, particularly when the patient is unwisely or inefficiently 
 clothed, may also give rise to it. Long-continued chronic rhinitis may 
 also, in certain cases, culminate in hypertrophic disease. 
 
 Symptomatology. — The most prominent symptom in hyper- 
 trophic rhinitis is the obstruction to nasal respiration produced by 
 the enlarged turbinal tissues. Together with this, there will be a 
 change in the normal secretion and its retention to a more or less 
 extent within the nasal cavity. The discharges are thicker and 
 more opaque, owing to lessened exudation of serum and increased 
 secretion of muco-pus. The difficulty in nasal respiration and the 
 
50 DISEASES OF THE NASAL PASSAGES. 
 
 amount of discharge are both variable, being controlled, to a certain 
 extent, by the temperature and humidity of the atmosphere. In warm 
 dry weather the nasal passages are freer, with less abnormal secretion, 
 while in damp and cold seasons of the year there is greater swelling, 
 increased stenosis, and more profuse muco-purulent discharge. When 
 this occurs, the pharynx also becomes involved, becoming dry and 
 irritable, on account of the oral breathing which has become necessary. 
 
 Crusts do not form in this disease, except occasionally around the 
 anterior nares and the front ends of the inferior turbinateds. When 
 they do occur, it is due to the drying effect of the atmosphere, com- 
 bined with deficient serous effusion from the affected membrane. 
 
 There is rarely any odor with this disease. When, however, the 
 dense secretion is retained among the deep crevices for an unusual 
 length of time, mild putrefaction may set in; but the odor is very 
 different from the more offensive one of atrophic rhinitis. 
 
 The sense of smell is often notably impaired, owing to occlusion 
 of the nasal chambers. The voice becomes thickened and nasal, while 
 impaired hearing and occlusion of the lacrymal duct may occur as 
 results of the disease. 
 
 Headaches may arise from hypertrophy of the middle turbinateds, 
 and in these cases the enlargement is likely to press upon the septum. 
 
 Hay fever and asthma are also, in some cases, attributed to it. 
 
 Diagnosis. — For this, rhinoscopic examination is necessary. 
 Symptoms may indicate in a general way, but they cannot alone give 
 a positive diagnosis. On examination, the turbinateds will be found 
 to be more or less swelled, and the mucous membrane covering them 
 of a bright-reddish color. A certain amount of muco-pus will always 
 be present. The lower turbinated is usually the most swelled, some- 
 times almost filling the inferior meatus. The anterior end is the 
 reddest, the color gradually assuming a grayer hue toward the middle 
 and posterior end of the body. The enlargement of the turbinateds 
 is usually somewhat irregular, nodules often standing out promi- 
 nently in different parts. Occasionally the hypertrophic masses have 
 become united to the septum by bridges or synechias of fibrous tissue. 
 This is more likely to occur in hypertrophy of the middle turbinated 
 than of the inferior, owing to its closer proximity to the septum and 
 the greater tendency to enlargement of the anterior end. 
 
 The nasal speculum, aided by reflected light and the use of 
 the head-mirror, is always essential to examination. In posterior 
 hypertrophies the post-rhinal mirror reveals the condition, the end 
 
HYPERTROPHIC RHINITIS. 51 
 
 of the inferior turbinated assuming a corrugated, swelled appearance, 
 almost like a white strawberry, and in some cases entirely filling the 
 posterior choana (Fig. 46). 
 
 In a few instances the posterior hypertrophy has a reddish hue. 
 
 Sometimes an cedematous congestion, as in rhinitis cedematosa, 
 might be mistaken for a true hypertrophy; but the application of a 
 5-per-cent. solution of cocaine will soon remove the doubt. In either 
 case the swelling will be reduced; but in true hypertrophy the re- 
 duction will be limited, the abnormal fibrous tissue of the body still 
 leaving it in a swelled condition, while, in the other, the cocaine will 
 soon shrink the cedematous tissue down to even a subnormal state. 
 
 Prognosis. — Under proper surgical treatment, when the disease is 
 one of simple hypertrophy, the prognosis is always favorable. Without 
 surgical treatment it is a prolonged disease, the ultimate result in 
 many cases being exceedingly unsatisfactory. Not a few writers believe 
 that it is the forerunner of atrophic rhinitis, laying the majority of 
 cases that occur at the door of uncured hypertrophy. 
 
 Bishop says that: "After middle age the hypertrophies generally 
 are absorbed and disappear, when this form often becomes merged 
 into atrophic catarrh." 
 
 I seriously doubt the correctness of this statement, particularly 
 with regard to age, as the large majority of cases of atrophic disease 
 that have come under my observation have been many years under 
 the period of middle age. It is also generally accepted by rhinologists 
 that atrophic rhinitis has reached its term by middle life, and from 
 that time gradually disappears, or, at least, the distressing symptoms 
 pass away. 
 
 Treatment. — The kind of treatment required depends largely 
 upon the extent and severity of the disease. If the hypertrophy be of 
 a mild character, producing only slight stenosis, alkaline sprays, fol- 
 lowed by mild astringents, may be all that shall be required. The 
 solutions referred to in the treatment of purulent rhinitis would also 
 be suitable, to which list might be added: — - 
 
 1. B Zinci sulphat 12 
 
 Glycerini 2j 
 
 Aquam ad 301 
 
 M. 
 
 1. $ Zinci sulphat gr. iij. 
 
 Glycerini raxxx. 
 
 Aquam ad Sj. 
 
 4 
 
52 DISEASES OF THE NASAL PASSAGES. 
 
 1. IJ Camphor-menthol 1 
 
 Albolene 30 
 
 M. 
 
 The number of cases, however, in which simple spray-treatment 
 will effect a cure is very limited. Patients usually delay seeking 
 advice until permanent hypertrophy has taken place, to remove which 
 operative treatment of one kind or another is required. 
 
 For this, two methods of operating are largely in vogue. One 
 is by the application of chromic acid; the other by the use of the gal- 
 vanocautery. The first has the advantage of cheapness and simplicity 
 of management. The nasal fossa is first sprayed with a 2-per-cent. so- 
 lution of cocaine. This, in three or four minutes, will produce general 
 shrinkage of the mucous membrane, with the result of widening the 
 fossa. Then a stronger solution — say, 8 to 10 per cent. — may be 
 applied to the turbinated, on a cotton-holder, to remove the remain- 
 ing sensibility. To apply the chromic acid, first dip the end of a 
 slender bent probe into mucilage; then pick up with it two or three 
 crystals of chromic acid, and hold them in the flame of a gas-jet, 
 until they fuse into a bead on the end of the probe. This cools in a 
 moment and can be applied to the hypertrophic tissue. A small 
 eschar is formed, which in a few- days separates, reducing the swelling. 
 The operation can be repeated several times, at intervals, until the 
 required amount of reduction has been accomplished. The chief 
 thing to guard against in using the chromic acid is the possibility 
 of touching other parts while carrying it to and from the diseased 
 tissue. Care in application should prevent any accident of this kind. 
 
 The second method, by the use of the galyanocautery, is much 
 more generally followed, particularly by specialists. The chief diffi- 
 culty is the cost of expensive apparatus; but the advantage lies in 
 the thoroughness of treatment and the nicety and precision with 
 which the operative work can be done. For this purpose the various 
 forms of storage-batteries are usually employed. These can be 
 charged with electricity, at any works where electric light is manu- 
 factured, as frequently as the expenditure of the current may require. 
 In towns and cities lit by electricity, transformers can be constructed 
 in connection with the plant, and, when furnished with the requisite 
 resistance-coil, are always ready for use. In urban sections, where 
 storage-batteries cannot be regularly charged, the plunge-batteries- 
 
 1. I£ Camphor-menthol gr. xv. 
 
 Albolene £j. 
 
HYPERTROPHIC RHINITIS. 
 
 53 
 
 answer a very good purpose. I have latterly used a cautery-trans- 
 former connected with the alternating current from the city electric 
 works. It does excellent service, being constantly controllable as well 
 as easily regulated. 
 
 In Fig. 47 is shown a Ballard, 4- volt, two-celled storage-battery 
 that I used for years. On the top the metal bars comprise the adjust- 
 able volt-selector, by which the current may be made of 2- or 4-volt 
 power. For cautery-work only 2 volts are required; for electric light 
 4 volts are needed. In front of the battery is seen the rheostat by which 
 the cautery can be regulated from a dull-red to a white heat. Fig. 47 
 
 Fig. 47. — Ballard galvanocautery-battery, with cord, 
 handle, and knife. 
 
 also gives a galvanocautery-handle with knife and also shows electric 
 cord. In this case the two cords, for convenience sake, after separate 
 coating, are wrapped together in a single web. As will be noticed, 
 the two ends for attachment to the cautery-handle are separately 
 covered with rubber tubing. This is to positively prevent their touch- 
 ing each other when attached to the battery in circuit, as, should 
 this occur, the instrument might be destroyed by short circuit. 
 
 To operate with the cautery-knife successfully requires both care 
 and skill on the part of the operator. The parts should first be 
 thoroughly cocainized and the nostril opened and protected by a 
 
51 DISEASES OF THE NASAL PASSAGES. 
 
 large-sized speculum (Fig. 13). Shurly's, with its ivory septal pro- 
 tector, is an admirable one for this purpose (Fig. 15). Of others, I 
 like the ovoid the best, as they slip into the nostril and protect the 
 whole circumference. The speculum in position, the cautery-knife 
 is passed into the naris and directly back to the posterior end of 
 the enlargement to be operated upon. The current is then turned 
 on at a bright-red heat and an incision made into it from behind 
 forward. When the turbinal hypertrophy is very large, presenting a 
 round projecting surface, I have usually applied the flat side of the 
 instrument, cutting in pretty deeply. I know this is contrary to the 
 ordinary teaching, but I have found, after the slough has separated, 
 that there has still been abundance of myxomatous tissue and epi- 
 thelial coating to heal perfectly, without leaving a scar. In doing 
 this care must be taken not to have too wide a blade, and to confine 
 the application to the one width of the flattened surface of the elec- 
 trode. 
 
 On the other hand, when the hypertrophy is less prominent and 
 less enlarged, a slight knife-edge cauterization will produce the best 
 result. It is well in either case not to operate too extensively at one 
 sitting; and we should always be as conservative in our operations as 
 the nature of the case will allow. After operation the passage should 
 be sprayed out with albolene or glycolin, for its cleansing and pro- 
 tective effect; and a tampon dipped in the same hydrocarbon should 
 be inserted between the cauterized surface and the septum. This will 
 prevent any possibility of adhesion, and it should be left in situ for 
 thirty-six to forty-eight hours. 
 
 The best method of operating upon large hypertrophy of the 
 posterior end of the inferior turbinated is sometimes a vexed question. 
 Many authorities advise removing the hypertrophy with the cold 
 snare. This done by the slow turning of a Jarvis snare is a tedious 
 and painful process, even after free cocainization, particularly as it 
 may take from half an hour to an hour to separate the mass. Any 
 severe traction or pulling upon the parts is likely to do serious harm, 
 as, if resorted to, it may loosen the attachment of the turbinated bone 
 itself. 
 
 Other authorities advise the galvanocautery-snare as being speedy 
 and effectual. The objection may be urged that the large surface 
 exposed during the operation to the action of the heated wire contains 
 a considerable element of danger, particularly when we remember the 
 close proximity of the growth to the Eustachian tube. When resorted 
 
HYPERTROPHIC RHINITIS. 00 
 
 to, the finger should invariably be passed behind the palate, to adjust 
 the wire and insure the safety of the tube itself. 
 
 In my own experience, I have had better results in the treat- 
 ment of ordinary posterior turbinal hypertrophies by operation with 
 the flat electrode than by any other method. After applying a 10- 
 or 15-per-cent. solution of cocaine freely, I have passed the electrode 
 back through the nostril to the growth, guiding the application of 
 the cautery by the post-rhinal mirror. This sometimes required a 
 little training of the patient; but I would not venture to operate 
 without I could see the point of the instrument clearly reflected in 
 the glass. This being recognized, a firm hand, guided by a knowledge 
 of the anatomy of the parts, should perform the operation without 
 risk. The growth is large and vascular, and, pressing the electrode 
 flatly upon the centre of its inner side, you can burn down deeply 
 into it without producing pain. The one cauterization is all that 
 should be done at one sitting. In this case tamponage is not neces- 
 sary. It may be followed by swelling, but scarcely enough to touch 
 the septum; and a daily spray of weak solution of cocaine, followed 
 by albolene, will help to keep it open. In three or four days the 
 mass will slough away, and the operation can be repeated carefully at 
 intervals until the turbinated returns to its normal size; but one or 
 two repetitions are all that are ever required, and in some cases a 
 second burning is not needed. 
 
 I have never known middle-ear disease to arise from this method 
 of treatment, but I have seen several instances in which tinnitus 
 aurium and slight deafness have been removed by it. 
 
 Of course, this method of reducing the hypertrophy should not 
 be attempted by the inexperienced operator. What may be one mams 
 food may be another man's bane, and any individual, by constant 
 practice, may become so skillful in the use of a single instrument as 
 to prefer it to all others in the performance of certain operations. 
 
 Helot, of Eouen, recommends the use of electrolysis by the bi- 
 polar method for the treatment of posterior hypertrophy. The parts 
 are first cocainized, and then the electrodes are passed through the 
 anterior naris and inserted side by side into the enlargement. The 
 seances last five minutes or more, and are repeated at intervals of 
 several days until the hypertrophic tissue shrinks away. 
 
 During the last two years a new method of treating severe eases 
 of this disease has been discussed and practiced by many English and 
 European rhinologists. On this side of the ocean the plan, although 
 
56 DISEASES OE THE NASAL PASSAGES. 
 
 accepted in a modified degree, lias not been practiced in its entirety 
 to any great extent. This is operation by turbinectomy, or removal 
 of the turbinated body. The term "turbinotomy" has also been ap- 
 plied indiscriminately to this operation; but as this term, from its 
 derivation, really means simple incision of the turbinated, its use is 
 scarcely appropriate, and consequently should not be applied to the 
 operation at all. 
 
 Turbinectomy may be partial or complete, and it is the latter 
 that has been so strongly advocated in certain cases by Carmalt Jones, 
 Dundas Grant, Baber, and others. For this a special instrument has 
 been made: Carmalt Jones's spokeshave, modifications of which are 
 represented in Fig. 41. After cocainization the entire turbinated can 
 be removed by it. Its use is only advocated in extreme cases, where 
 milder operative measures have failed to give the required relief. 
 This severe and radical operation is opposed by many surgeons, par- 
 
 Fig. 48. — Knight's nasal scissors. 
 
 ticularly in iimerica, on account of the important position which the 
 inferior turbinated occupies in normal respiration. 
 
 Modified turbinectomy, on the other hand, is accepted by all 
 rhinologists, and, in appropriate cases, is constantly being done. Fre- 
 quently the anterior end of the middle turbinated, bulging and press- 
 ing upon the septum, can be better excised than burned away. And 
 can be removed effectually by means of serrated scissors (Fig. 48). 
 The anterior end of the inferior turbinated, likewise curled upon itself 
 and filling the whole of the inferior meatus, can often be best removed 
 by cutting instruments; and partial turbinectomy in either case would 
 be unattended by the inflammatory swelling which might be expected 
 from extensive cautery, operation. The same applies, though in a 
 modified degree, to the posterior end of the inferior turbinated. Fig. 
 49 shows forceps specially designed for nasal work, the spring closing 
 the instrument, and pressure opening it. 
 
HYPERTROPHIC RHINITIS. 57 
 
 These various operations can be performed under cocaine anaes- 
 thesia by means of various instruments, such as curved scissors, 
 knives, punch-forceps, Griinwald's typical method, or even saws 
 properly guarded. I have frequently used the last-named instrument 
 in excising the much-curved anterior end of the inferior turbinated. 
 In Grlinwald's operation a notch is cut in the neck of the middle tur- 
 binated, or near the central part of the lower turbinated, and the 
 part thus marked off is removed by hot or cold snare. 
 
 However well complete or extensive turbinectomy may suit the 
 moist and saline atmosphere of Great Britain, in the drier climate of 
 the United States and Canada it can rarely, if ever, be required. It 
 is quite possible that entire removal would leave such an atrophic 
 condition that the cure would be worse than the disease. 
 
 A method of treatment has been advanced by Lennox Browne 
 during the last year which is worthy of more extensive trial. It is 
 
 Fig. 49. — Shurly's nasal forceps. 
 
 by electrocautery-puncture of the hypertrophic tissues. After co- 
 cainization a sharp needle is passed deeply into the enlargement, 
 parallel with the wall of the fossa, It is left in situ at a red heat 
 for a few moments and then removed. By this means, while the 
 mucous membrane is saved, the hypertrophic tissue shrinks. The 
 method I would consider particularly applicable to posterior hyper- 
 trophies, special care being taken not to puncture the Eustachian tube. 
 Still another method of treatment has been proposed by Bryson 
 Delavan, somewhat similar to the last mentioned, the difference being 
 that, instead of cautery-puncture,, we have submucous knife-incision. 
 After cocainization a small bladed ophthalmic knife is passed into 
 the hypertrophic tissue without perforating the opposite side. A 
 slight sweeping movement is made as the knife is brought out of the 
 same opening. Relief is usually prompt and followed by no un- 
 pleasant results. 
 
CHAPTER VIII. 
 ATROPHIC RHINITIS. 
 
 This disease has been known for generations by the name of 
 catarrh, being considered as significant of nasal discharge accom- 
 panied by foul odor. Catarrh, however, is not a disease, but a symp- 
 tom, and as a symptom it differs widely, both in character and degree, 
 according to the pathological conditions to which it owes its origin. 
 
 Among the many definitions of atrophic rhinitis given by lead- 
 ing authors, I know of none more terse and comprehensive than that 
 of "Wyatt Wingrave, who says: "It may be defined as a progressive 
 and persistent form of dry rhinitis, characterized by a shrinkage of 
 the mucous membrane, which tends to invade contiguous chambers, 
 and is accompanied by the formation of crusts, with more or less 
 fcetor of a special character." 
 
 Pathology. — In the atrophic state the normal cilia lining the 
 mucous membrane of the lower half of the nasal fossas are gradually 
 destroyed. In severe cases this loss of the ciliated epithelium becomes 
 complete and permanent, their place being taken by a layer of flat, 
 squamous, epithelial cells in a state of constant desquamation. Below 
 this the cuboidal epithelium, the adenoid or hyaloid layer, the acinus 
 glands, the blood-vessels, and cavernous sinuses, all gradually shrink 
 away, losing their power of physiological engorgement and collapse, 
 so essential to the proper performance of the respiratory functions. 
 This atrophy of all the special tissues of the mucous membrane is ac- 
 companied by formation of abnormal connective tissue, though in a 
 minor degree than when the result of hypertrophic disease. 
 
 Notwithstanding the shrinkage of the turbinated tissues, Win- 
 grave, on microscopical examination, found imbedded in the inter- 
 lobular tissues of the glands, in the lymphoid tissues, and sometimes 
 in the stratified epithelium, small, round, refractive cells which he 
 called hyaloid bodies. They varied in size from one-eightieth to 
 one-thirtieth of a millimetre. These bodies increase in numbers as 
 the disease advances. Finally they break up into minute refractive 
 bodies, resembling spores. The question of the nature of these bodies 
 (58) 
 
ATROPHIC RHINITIS. 59 
 
 is still undecided. Some biologists believe them to be the bacteria of 
 atrophic rhinitis. 
 
 Klebs-Loerner bacilli and also staphylococci have been found in 
 large numbers in certain cases of atrophic rhinitis without develop- 
 ing either diphtheria or general suppuration. 
 
 Microscopically, multinucleated lymphocytes are found in the 
 atrophic discharges as well as the bacillus fcetidus and bacillus of 
 Friedlander. According to Lennox Browne, the crusts consist of 
 mucin, cell-globulin, and serum-albumin, with traces of sulphur and 
 phosphorus. 
 
 Fraenkel and Loewenburg have discovered a diplococcus which 
 they claim to have an influence in the etiology of the disease. 
 
 Noland Mackenzie maintains that atrophic rhinitis is a sclerosis 
 — a chronic inflammation in which there is an atrophy of specialized 
 tissue, accompanied by mild hypertrophy of connective tissue; that 
 this condition is present in hypertrophic as well as atrophic disease; 
 that the two differ not in kind but in degree, the one being hyper- 
 trophic sclerosis, the other atrophic sclerosis. 
 
 E. L. Shurly believes the disease to be a pure neurosis of central 
 origin. 
 
 Incidental pathological changes occur in a majority of cases. 
 Out of 60 recorded, the pharyngeal and faucial tonsils had entirely 
 disappeared in 56; while in the remaining 4 they were small, thus 
 indicating a direct relationship between the surrounding lymphoid 
 structures and the atrophic disease. 
 
 Perforation of the cartilaginous septum is of frequent occurrence. 
 It is, however, generally believed to be, not so much the direct result 
 of the disease itself, as of digital picking. In my own experience, I 
 do not remember a case of perforated septum co-existent with atrophic 
 rhinitis in which I could not trace the origin of perforation to the 
 period of childhood. When it comes under the notice of the physician, 
 the margin of the perforation will usually be found coated with 
 tenacious mucus, overlying a layer of proliferated epithelium. The 
 whole history of these cases of perforation would appear to support 
 Bosworth's theory, that purulent rhinitis in children was the fore- 
 runner of the subsequent atrophic disease. 
 
 Etiology. — Perhaps there are few subjects in medical science 
 upon which there exist so many differences of opinion as upon the 
 origin of atrophic rhinitis. Fraenkel was the originator of the idea 
 that it was a sequel of hypertrophic rhinitis, and a large number of 
 
CO DISEASES 0¥ THE NASAL PASSAGES. 
 
 observers are still of the same opinion. Seiler says that, while it may 
 be the result of hypertrophy, it may also be atrophy from the start. 
 Drake claims chronic purulent inflammation of the accessory sinuses 
 as the cause. Gottstein holds that defective development of the tur- 
 binated bodies may be responsible for the disease. Mayo Collier has 
 thrown out the suggestion that it may yet be discovered that the 
 initial disease was degeneration of the nerve-ganglion and nerve-fibres 
 supplying the parts. E. L. Shurly somewhat favors Collier's idea, for 
 he has long been of the opinion that it was essentially a trophic 
 neurosis of central origin. Bosworth, on the other hand, in his recent 
 issue of 1896, expresses as emphatically as ever the belief that the 
 disease is the result of a previous attack of infantile purulent rhinitis. 
 Gelli also favors this theory. 
 
 Personally I have seen a great many cases in young people which 
 could be traced back directly to purulent rhinitis of childhood. In 
 examining these cases there was no history whatever of previous 
 hypertrophic disease; but there was the history of chronic purulent 
 discharge, dating back as far as memory could reach. I believe, too, 
 that it is possible for atrophy tc be a sequel to hypertrophy, for I 
 have seen cases in which the relationship appeared to exist; but I do 
 not believe that it is, by any means, the rule. 
 
 "We rarely meet with hypertrophy of the turbinateds during 
 childhood; as a rule, it is a disease of early adult life; and it is 
 well to remember that the majority of cases of atrophic disease like- 
 wise occur in young men and women. It would seem impossible for 
 a slow hypertrophic process to have time for development, and that 
 to be followed by sufficient shrinkage to produce atrophy at the time 
 of life when we are usually called in to treat these cases. 
 
 Quite frequently atrophic rhinitis is unilateral, entirely confined 
 to the one nasal cavity, and that one the widest, with a curved sep- 
 tum, the convex surface within the narrow nostril. There may have 
 been no previous purulent disease; and the conclusion seems reason- 
 able that the great width of the fossa had allowed free breathing, 
 while permitting the retention of discharge. The retained secre- 
 tions would, in time, become purulent. Crust-formation would fol- 
 low, which eventually, by its repeated presence and pressure, would 
 produce greater shrinkage of tissue. 
 
 Symptomatology. — The symptoms are characteristic and too well 
 known to require a careful delineation. They consist of dryness of 
 nose and throat, the latter in consequence of the former, accompanied 
 
ATEOPHIC BHIXIT1S. CI 
 
 "by formation of crusts within the nasal cavities. These are often 
 difficult to blow out; and, as the disease advances, it becomes im- 
 possible, by Nature's effort alone, to thoroughly remove them. 
 
 On rhinoscopic examination the fossae will prove to be enlarged 
 to a greater or less extent, according to the severity of the disease, 
 the enlargement being due to the shrinkage of the middle and in- 
 ferior turbinated bodies. Greenish-yellow crusts, with a character- 
 istic, offensive odor, will partially fill the passages; and on the re- 
 moval of these the mucous membrane, although unbroken by ulcera- 
 tion, will present an unwontedly shrunken and pallid appearance. 
 
 In this disease the normal serous discharge becomes limited, and 
 finally almost ceases, leaving the air dry and foul by the time it 
 reaches the throat. With diminution of serous fluid there is increased 
 exfoliation of epithelial and pus- cells. These together incrust and 
 clog up the passages. In long-standing cases anosmia is of frequent 
 occurrence, while in many the sense of taste is likewise impaired. 
 
 Dryness of throat, or pharyngitis sicca, is always a result in ad- 
 vanced cases; and, as collateral events, the faucial and pharyngeal 
 tonsils usually become atrophic; the contiguous sinuses not infre- 
 quently become involved, and the Eustachian tubes may also be 
 affected. 
 
 While the offensive fcetor peculiar to atrophic rhinitis is usually 
 believed to arise from putrefaction of the retained secretions, Win- 
 grave has advanced a new and somewhat plausible theory: He says 
 that, as the mucous membrane is a transformed epidermal structure, 
 having with its glands a common origin with the skin; so in this dis- 
 ease we have a structural reversion, in the stratification of the surface 
 epithelium, to the primitive type; and in the glands there is estab- 
 lished a perverted function, the mucous membrane being converted 
 into cutaneous structure, with a corresponding change in secretion. 
 Following out this line of argument, he speaks of the various odors 
 produced by different portions of the skin, such as the feet, the 
 axillae, the prepuce, etc., and claims that the odor of atrophic rhinitis 
 has a direct kinship with these. 
 
 Diagnosis. — Except in its earliest stage, a careful and thorough 
 examination should, with little difficulty, exclude every other disease. 
 There is one remarkable fact, that, after the crusts have been carefully 
 and thoroughly removed, no matter how attenuated the turbinated 
 tissues may have become, ulceration will always be an absent quan- 
 tity. Of course, where septal perforation exists, there may be ulcera- 
 
62 DISEASES OF THE NASAL PASSAGES. 
 
 tion around its margin; but the perforation dates back to an earlier 
 date than the atrophic disease. Syphilis, on the other hand, is often 
 the cause of extensive ulceration of the bone as well as soft tissues; 
 but the odor of atrophic rhinitis, while disgusting enough, is still 
 distinct from that of syphilitic necrosis. 
 
 Prognosis. — Without treatment, prognosis is bad. With treat- 
 ment, relief can be obtained, and the condition very much improved, 
 and in a few cases cured. But this can only be accomplished by care- 
 ful and thorough treatment, carried out for years in many cases. 
 
 Fraenkel, of Berlin, says, referring to atrophic rhinitis: "A cured 
 case of ozama is unknown to me." Bosworth, in his last edition, says: 
 "In the early stages of the disease, before the foetid symptoms set in, 
 I have seen cases recover. In the advanced stages characterized by 
 fcetor, and in which the turbinated bones have almost entirely disap- 
 peared, I have not seen a case cured, if by cure is meant a condition 
 secured in which there remains no necessity for any measure of local 
 treatment." Sajous says: "Atrophic rhinitis is, perhaps, the most un- 
 satisfactory of the nasal affections to treat successfully." 
 
 All, however, agree that much can be done to ameliorate the 
 symptoms and make life comfortable 
 
 Treatment. — The initial step is always to thoroughly cleanse the 
 nasal and naso-pharyngeal cavities, removing completely all incrusta- 
 tions wherever located. This is best accomplished by the use of 
 aqueous alkaline sprays, such as Dobell's solution, to the anterior 
 nares; and the use of the post-nasal spray-syringe, by which water 
 at the temperature of 100° F. can be thrown forcibly through the 
 nostrils from behind. For the latter purpose a Davidson syringe 
 with a curved spray-tube attached is an admirable instrument. The 
 tube being passed up behind the palate and the patient's head tipped 
 well forward over a receiving-bowl, a constant stream of a pint or 
 more may be readily thrown through. This not only loosens the 
 concretions within the nasal passages, but also those behind the 
 palate; and, even if it does not bring them all away, it materially 
 softens them and facilitates their removal. Other instruments (Figs. 
 50 and 50a) act upon the same principle, although less effectively. 
 
 The method of using the nasal douche, and instructing the pa- 
 tient to pass 1 or 2 quarts of hot, medicated fluid daily through the 
 nose, up one nostril and down the other, which is often recommended, 
 only accomplishes part of the object in view. It floods the nasal 
 passages, but not the naso-pharynx: and in this disease it is as im- 
 
ATROPHIC RHINITIS. 
 
 G3 
 
 portant to cleanse the one as the other. If the nose during the douch- 
 ing is elevated enough to allow the fluid to pass beyond the soft 
 palate, there is serious risk of flooding the Eustachian tubes, an 
 accident involving much danger to the inner ear. The use of the 
 post-nasal syringe, carefully adjusted well up behind the soft palate, 
 with the head tipped forward, is devoid of this danger, while, as 
 
 Fig. 50. — Post-nasal syringe. 
 
 already stated, it cleanses the combined nasal and post-nasal region, 
 and consequently is preferable to the former method. It also simpli- 
 fies the treatment, as patients can be taught to practice the one as 
 readily as the other. 
 
 The anterior nasal spray from a good atomizer is a good adjunct 
 to the post-nasal treatment. Still, when the disease is severe, the two 
 
 Fig. 50<z. — Post-nasal syringe. 
 
 together will not effectually cleanse the parts from crusts. To com- 
 plete the removal, the nasal cotton-carrier by the anterior nares, and 
 the curved cotton-carrier by the naso-pharynx, will both be required. 
 In first treatments especially this should be done in a painstaking 
 and thorough manner, and always by the aid of anterior and posterior 
 rhinoscopy with a good reflected light. 
 
64 DISEASES OF THE NASAL PASSAGES. 
 
 This step having been accomplished, it is generally conceded 
 that the next one is to stimulate the atrophic membrane to a better 
 performance of its natural function of secretion. To this end Gott- 
 stein recommends plugging the nostrils for twenty-four hours with 
 cotton tampons. When they are removed a flow of mucus follows the 
 stimulation. When the flow subsides, the cavities are cleansed again 
 and fresh tampons inserted. The whole procedure is repeated as fre- 
 quently and for as long a period as required. 
 
 Woakes uses Gottstein's plugs for the purpose of applying pow- 
 ders of a stimulating character to the diseased membrane. Sajous 
 advises the use of the galvanocautery passed rapidly over the surfaces, 
 and Lennox Browne favors the same plan with subsequent insufflation 
 of iodol or iodoform. Shurly and Bryson Delevan recommend the 
 galvanic current, the positive electrode being placed on the nape of 
 the neck, and the negative, wrapped in absorbent cotton, to the in- 
 terior of the nose. Delevan uses from 4 to 7 milliamperes with a 
 duration of from seven to fifteen minutes at each sitting, until serous 
 discharge occurs. 
 
 Other methods of treatment are the use of stimulating sprays 
 after the cleansing, such as solutions of thymol, creasote, argent 
 nitrate, etc., of varying strengths; but these are of doubtful value. 
 
 Another method of treatment originated by Braun, of Trieste, 
 several years ago, and which from its enthusiastic acceptance by his 
 countr}mien, might be called the Italian method, is that of vibratory 
 massage of the mucous membrane. Outside of Italy either in Europe 
 or America it has not been received with any marked favor; but I 
 am glad to see that Bishop, in his recent work, speaks favorably of 
 massage. Personally, from my own experience, I indorse his views, 
 though each of us has modified his practice to suit his own individual 
 cases. As recommended by Braun, an olive-pointed probe is passed 
 within the nostril. It is held between thumb and finger like a pen, 
 and the vibrations are produced by the clonic rhythmical movements 
 of the hand and forearm of the operator as he presses the olive point 
 against the mucous membrane. By practice these contractions are 
 said to number about four hundred per minute. 
 
 The mucous membrane of each nasal fossa covers between thirty 
 and forty square centimetres, and the space operated on will be about 
 one square centimetre at a time. Braun says he makes the time of 
 each vibratory application about five minutes to each nostril. He also 
 precedes the treatment by the application of cocaine. 
 
ATEOPHIC KHIXITIS. (35 
 
 To relieve the fatigue of the operator, as well as to make the 
 vibrations more rapid and uniform, electromotor instruments have 
 been made, from which their originators claim to have -produced even 
 better results than by manual vibration. 
 
 Bishop's modification is by using an ordinary cotton-holder, or 
 probe. He wraps the end with a loose wad of cotton, and, passing it 
 into the nostril, by hand-vibration combines the double purpose of 
 cleansing and massage. 
 
 My own method, and from which I have seen excellent results, 
 is somewhat different. I have practiced it now for several years. 
 After thoroughly cleansing the fossa, I wrap a pledget of absorbent 
 cotton firmly and closely round the end of the holder, in the form 
 of an olive-shaped tip. This is dipped in albolene and used by hand- 
 vibration according to Braun's method. After each vibratory move- 
 ment the cotton is slipped off; and with a few twirls between thumb 
 and finger another one applied. One advantage of this method is 
 that the firm cotton tip can be made of any shape and size to suit 
 the various crevices within the nasal cavity. I may also add that, 
 for massage so applied, I never find it necessary to use cocaine. 
 
 Sometimes after removing the incrustations as thoroughly as 
 possible, even with the after-treatment of massage, a thick layer of 
 tenacious epithelium, projecting from the lower border of the middle 
 or inferior turbinated s, will still defy all efforts at cleansing. To 
 remove this the application of a 10-per-cent. solution of nitrate of 
 silver to the spot will sometimes be sufficient; but I have usually ob- 
 tained the best results by singeing the proliferation with the galvano- 
 cautery. This should never be carried to the extent of destruction 
 of the whole epithelial coating. As a result, the pale, bloodless, stringy 
 membrane would give place to a pinkish one of more healthy color. 
 
 One peculiarity of formation I have observed in several instances. 
 In each case it was confined to the side affected by the more marked 
 atrophy. This was the attachment, by a cicatricial band, of part of 
 the inferior border of the middle turbinated, either to the upper 
 part of the lower one or to the external wall of the middle meatus. 
 These special instances seemed to owe their origin to a previous 
 hypertrophic condition. In treating them, after applying cocaine. I 
 have separated the attachment by the galvanocautery with advantage 
 to the progress of the case. One thing more I may add: that for 
 years now, after cleansing and massage, instead of completing each 
 treatment by the use of some stimulating spray, I have obtained the 
 
66 DISEASES OF THE NASAL PASSAGES. 
 
 most satisfactory results to my patients by simply finishing with a 
 spray of one of the hydrocarbons. As said before, these bland, in- 
 odorous, aseptic preparations are soothing and grateful to the patient, 
 and act as protectives to the whole lining of the mucosa. 
 
 For home-treatment the patients are directed to use the post- 
 nasal syringe first, at least once a day; and follow this up with sprays 
 of albolene or glycolin at intervals of several hours, until they return 
 to the office again for more thorough treatment. 
 
 The solutions used in the post-nasal syringe may consist of 1 per 
 cent, of any of the following, in water at a temperature of 100 
 degrees: — 
 
 Muriate of ammonia. 
 Chlorate of potassa. 
 Chloride of sodium. 
 Boric acid. 
 Eesorcin. 
 Or 2 per cent, of 
 Biborate of soda or 
 Bicarbonate of soda. 
 Or a 5-per-cent. solution of peroxide of hydrogen. 
 These answer very well for a time, until the patients have be- 
 come familiar with the post-nasal method of treatment. I have sub- 
 sequently obtained better results by having them use simple clear 
 water at as high a temperature as they could comfortably bear. 
 
CHAPTEK IX. 
 (EDEMATOUS RHINITIS. 
 
 The earliest mention I can find of this disease is in the report 
 of the American Laryngological Association for 1893. In his paper 
 J. C. Mulhall describes it as a serons infiltration of the middle or in- 
 ferior tnrbinateds. It is remittent in character and may be unilateral 
 or bilateral. It may also be migratory and either acute or chronic. 
 When punctured, serum slowly exudes. He says cocaine has little or 
 no influence over it. It may be associated with bronchial asthma, 
 but only in a minority of cases. It is considered to be a neurotic 
 affection, yet distinct from the neurotic diseases which are caused by 
 extrinsic excitants. 
 
 In treatment Mulhall says that sprays are contra-indicated, and 
 that the best results are obtained by scarification. If nasal deformi- 
 ties are present they should be removed. In treatment the alimentary 
 canal and the general system should be carefully attended to. 
 
 This is a rare disease, and I have only seen one well-marked case. 
 The patient is a young man, aged 26 years, of sedentary occupation. 
 A number of years ago I removed a large spur for him, and also 
 cleared the naso-pharynx of adenoids, to remove the stenosis from 
 which he was suffering. For a couple of years he was free from any 
 difficulty in nasal respiration. Then the stenosis commenced to recur 
 again, sometimes very suddenly. Previous to the attack the septum 
 and turbinateds would appear perfectly normal, and there would be 
 no difficulty whatever in breathing through either side. Then from 
 cold taken from exposure, or sudden dropping of office-temperature, 
 one nostril, within an hour or so, would become completely blocked. 
 Examination would reveal one fossa quite clear, the other absolutely 
 closed, a pale, serous-looking oedema distending the mucosa of both 
 the septum and inferior turbinated of the affected side, and the parts 
 bathed in muco-serum. On examining the throat, the posterior rhino- 
 scope would reveal the corresponding choana filled by the gray. 
 swollen, inferior turbinated body. 
 
 * (67) 
 
68 " DISEASES OF THE NASAL PASSAGES. 
 
 Unlike Mulhall, I found the application of a 4-per-cent. solution 
 of cocaine, passed slowly through the nostril upon a cotton-carrier 
 and applied freely to the whole length of the turbinated, would, on 
 each occasion, give speedy relief. The charging of a good-sized 
 pledget would be all that would be required, and in five minutes 
 respiration through the passage would be restored. I found, also, 
 after repeated trials, that the relief obtained would be very much 
 prolonged and in some cases would continue for days, if the cocaine 
 treatment was supplemented, as soon as the passage became clear, by 
 a spray of thymo-menthol of the following strength: — 
 
 1. R Thymol 13 
 
 Menthol 1 
 
 Albolene 30 
 
 M. 
 
 The preparation appeared to prolong the astringent effect of the 
 cocaine and to stimulate the tissues to more effectual control of the 
 vasomotor vessels. 
 
 Quite frequently the oedema, after occurring for two or three suc- 
 cessive days on one side, would suddenly cease and appear again in 
 the adjoining cavity in just as severe a form, disappearing for the day, 
 after treatment, to occur again perhaps twenty-four hours later. 
 
 In this case there was no hypertrophy whatever, either of septum 
 or turbinateds, and, when the attack passed off, the parts seemed to 
 be in a perfectly normal condition. Sometimes months would pass 
 without any trouble. In every other way the young man was in a 
 strong, healthy condition. 
 
 During the fall and winter, however, he has for years had a num- 
 ber of seizures; and the present year the symptoms, particularly 
 on the left side, were particularly severe, threatening to remain 
 throughout the summer months as well. Consequently I decided to 
 make a deep galvanocautery incision along the full length of the 
 lower turbinated on that side. For a day or two there were no signs 
 of haemorrhage. Then it came on profusely, and plugging with kite- 
 tail tampons had to be resorted to. They were worn nearly a week 
 and then extracted piecemeal for several days longer, the fossa being 
 washed daily by sprays of 2-per-cent. cocaine and 1 / 2 per cent, of 
 
 I£ Thymol gr. ij. 
 
 Menthol gr. xv. 
 
 Albolene ' Sj • 
 
 M. 
 
(EDEMATOUS RHINITIS. 69 
 
 thymol in glycolin. The tissues seem to be again under control, and 
 for weeks now the oedema has ceased to occur. Whether the advent 
 of the changeable autumnal season will bring it back again remains 
 to be seen. 
 
CHAPTER X. 
 FIBRINOUS RHINITIS. 
 
 This is an acute inflammation of the mucous membrane of the 
 nasal passages, attended by a deposit of fibrinous exudation upon its 
 surfaces. It presents the pathological features of false membrane 
 imposed upon the epithelium without involving the deeper tissues. 
 
 As most of the cases of membranous rhinitis that have occurred 
 -and been examined have been simply an extension of diphtheria de- 
 posit upward into the nasal cavities, many observers still believe that 
 it is always of diphtheritic origin and the result of the presence of the 
 Klebs-Loefner bacillus. 
 
 Recent experiences accompanied by careful clinical and patho- 
 logical examinations have proved, however, that this is not the case. 
 Fibrinous exudate within the nasal passages of non-diphtheritic origin 
 does sometimes occur, and it is of this I now speak. 
 
 In 1893 the "Transactions of the Pathological Society of Lon- 
 don" contained an exhaustive article upon the subject. In it Abbott, 
 while leaning toward the idea that all cases were of a mildly- 
 diphtheritic character, states positively that: "It cannot be too often 
 insisted upon that the true nature of all membranous deposits upon 
 the mucous membrane of the air-passages (referring to the nose) can 
 only be definitely revealed by bacteriological research": a tacit ad- 
 mission that non-diphtheritic membrane might exist. 
 
 In 1894: Brun Murdoch, at the laryngological section of the 
 British Medical Association, reported a case of recurrent membranous 
 rhinitis which occurred in a female aged 33 years. During a little 
 more than a year she suffered from six different attacks without any 
 indications of true diphtheria. A number of bacteriological exami- 
 nations of the false membrane were. made; but all failed to show any 
 Klebs-Loeffler bacilli, although a number of micrococci of no special 
 moment were present. 
 
 The symptoms were at first those of slight head-cold, rapidly 
 getting worse and continuing for several days, with complete occlu- 
 sion of nostrils. About the fifth day white membrane would appear 
 In the anterior nares. This would scale off, leaving the parts some- 
 (70) 
 
FIBRINOUS RHINITIS. ?1 
 
 what raw and the nose swollen. There was no rise of temperature, 
 but severe sneezing. The whole attack would last about a fortnight. 
 
 Hot bathing, iodoform, menthol in fluid vaselin, cocaine, etc., 
 only slightly relieved the symptoms. At one time galvanocautery- 
 singeing produced partial relief. 
 
 In the same year Schiffer read before the Belgian Society of 
 Otology and Laryngology a paper on the "Pathogenesis of Non-in- 
 fectious Croup of the Nasal Mucous Membrane," with the history of a 
 case. The membrane was confined to the nasal cavities. The general 
 symptoms were slight, save for the nasal membranous obstruction. 
 Microscopical examination proved the absence of the Klebs-Loeffler 
 bacillus. There was no sign of the disease being infectious. 
 
 In 1898 Middlemas Hunt, in a paper on "The Eelation of Fibri- 
 nous Ehinitis in Diphtheria," reported four cases of fibrinous rhinitis. 
 In two of these there were no indications of Klebs-Loeffler bacilli. In 
 the other two, although none was discovered at the time, diphtheria 
 followed in the one patient two weeks later, and in the family of the 
 other after a similar interval. In concluding his article Hunt uses 
 these words: "I am afraid there are no clinical characters on which we 
 can rely in distinguishing the two diseases, and our one method is to 
 turn for help to the skilled bacteriologist." 
 
 Eichard Lake, of still later date, gives the history of a case of 
 chronic pseudomembranous rhinitis, occurring on the right side, in a 
 man aged 54. He was a hay-fever subject. Treatment had only a 
 temporary effect; and when he returned for examination, ten months 
 later, the membranous disease had increased in severity. Microscopical 
 examination revealed the staprrylococcus pyogenes aureus in abun- 
 dance, but no Klebs-Loeffler bacilli. 
 
 In March, 1898, I reported an idiopathic case of membranous 
 rhinitis to the Toronto Medical Society. It occurred in a young lady, 
 aged 17 years, an abstract account of which appeared in the Journal 
 of Laryngology, May, 1899. This was unilateral, affecting and closing, 
 for the time, the left nasal fossa. The membrane was whitish-yellow 
 and inodorous throughout.. It extended to the posterior naris, but 
 not into the naso-pharynx. The treatment consisted of applications 
 of cocaine, solutions of nitrate of silver, and albolene. There was 
 no fever. Microscopical examination discovered no Klebs-Loeffler 
 bacilli, but a large and pure culture of staphylococci was made from 
 the membrane. The cure was completed in about three weeks of 
 regular treatment. 
 
iZ DISEASES OE THE NASAL PASSAGES. 
 
 With reference to the statement that a similar false membrane is 
 always produced by the application of the galvanocautery to the mu- 
 cous surface, it must be remembered that the protective covering is 
 only formed upon the spots cauterized, whereas, in fibrinous rhinitis, 
 the whole mucous lining may be affected. Sometimes, however, the 
 effect of cauterization is not so limited, and the burning of a single 
 spot within the nasal cavity may induce the formation of false mem- 
 brane throughout the fossa. Although this fact is well known, the 
 literature upon the subject is so meagre that the report of a case may 
 not be without interest. 
 
 In September, 1895, a young lady, aged 25, a farmer's daughter, 
 came to me for treatment for hay fever. On examination there was 
 nothing unusual in the appearance except that the inferior tur- 
 binateds were very much enlarged. Otherwise they had the ordinary 
 pale hue usually present when hay fever exists. Under cocaine, I 
 burned both the inferior bodies through the centre from behind for- 
 ward. Twenty hours later, on her return for treatment, both nares 
 were stenosed and the whole lining mucosa of each passage, so far as 
 it could be seen, was covered with false membrane. All that I 
 could do for her relief was the application of cocaine followed by 
 vaselin. The membrane became thicker, but retained its clear, white 
 color without odor. In two days it commenced to loosen, and I re- 
 moved it gently in large flakes with the forceps. The recovery was 
 rapid and the relief of the hay fever complete. 
 
 Tw r o years later, in September, 1897, she returned again for 
 treatment for hay fever. She said she had none the previous year. 
 On examination, the inferior turbinateds were all right, but the middle 
 ones were enlarged and pressing on each side against the septum. 
 These I also cauterized, though much less extensively than the in- 
 ferior ones on the former occasion. I also took the precaution to in- 
 sert a small pledget of cotton on each side between the septum and 
 the middle body. 
 
 When she returned to the office on the following day the old con- 
 dition was repeated. The whole mucous membrane on each side was 
 coated with white, fibrinous membrane, and the treatment and history 
 was but a repetition of what occurred two years before. On both 
 occasions it was undoubtedly traumatic pseudomembranous rhinitis, 
 but it was unaccompanied by fever. I regret that no bacteriological 
 examination was made on either occasion. Other writers have re- 
 ported similar cases resulting from cautery-work. 
 
FIBRINOUS RHINITIS. 73 
 
 In closing this chapter I ma}', perhaps, venture to draw the follow- 
 ing conclusions: — 
 
 1. That non-diphtheritic pseudomembranous rhinitis does some- 
 times occur, and, though a very rare disease, it is probably as frequent 
 as primary nasal diphtheria. 
 
 2. That on clinical grounds alone it is possible, in a majority of 
 cases, to distinguish it from genuine diphtheritic disease. 
 
 3. That, owing to a possible mistake in diagnosis, isolation in all 
 cases should be imperative, until a reliable bacteriological examination 
 can be made. 
 
 Since writing the above an able article has appeared upon 
 "Fibrinous Khinitis" from the pen of Gibb Wishart, in the Septem- 
 ber issue of the Laryngoscope. In it he gives the history of seven 
 cases, two of which were benign, while five exhibited the Klebs- 
 Loeffler bacillus. He also sums up all the cases of which he can find 
 a record, totalling 98: 69 with Klebs-Loeffler bacilli and 29 without. 
 
 In conclusion, while he recognizes that many observers consider 
 fibrinous rhinitis a distinct disease, he believes that the accumulated 
 evidence proves the following points: — 
 
 1. Fibrinous rhinitis and diphtheria are not distinct diseases. 
 
 2. All cases of fibrinous rhinitis need the same precautions as 
 to isolation that diphtheria requires. 
 
CHAPTEK XL 
 
 DEFORMITIES OF THE NASAL SEPTUM. 
 
 In adult life septal deformities are the most frequent cause, not 
 only of catarrhal affections of the nasal passages, but also of defective 
 and unequal nasal breathing. "What seems strange is that these 
 deviations from the normal in symmetry should be confined so largely 
 to the civilized races of men. This is borne out by examinations of 
 the skulls of civilized and aboriginal races. In the museum of the 
 Royal College of Surgeons, London, out of 2152 skulls, it is reported, 
 on reliable authority, that over TO per cent, have irregularities of the 
 septum. On the other hand. Sir Morel Mackenzie and ZuckerkandL 
 after carefully examining a large number of the skulls of the 
 aborigines of America, Africa, and Australia, found only 20 per 
 cent, of the nasal cavities presenting osseous abnormalities. Allen 
 examined the skulls of 93 negroes, and found deflections and irregu- 
 larities in only 21 per cent. 
 
 Recently, in Toronto, at the Archaeological Museum of Ontario, 
 which contains the most exhaustive collection in Canada, I examined 
 220 Indian skulls, by far the largest number of them being Hurons 
 and Iroquois. One hundred and eight were all in which the septa 
 were sufficiently well marked to base a judgment upon. The result, 
 however, was different to that of the observers already mentioned. 
 Of the 108, 54 had deviated septa and 54 had straight ones, or 50 per 
 cent, of each. Of the number 4 were Flatlieads from British Colum- 
 bia; 2 had deviated septa, 2 had straight. Two others were Mound- 
 builders from Arkansas, of pre-Columbian history; 1 had deviated 
 septum and 1 straight. 
 
 I might add, as a curiosity, that, among a number of skulls of 
 Egyptian mummies, only one was sufficiently unwrapped to admit of 
 examination. In this the septum was straight: but the left inferior 
 turbinated was wedged against the posterior end of the vomer. This 
 archaeological specimen, three thousand years old, was an extreme 
 exception to the general rule: for almost invariably when the septum 
 was straight and centrally situated there was nothing abnormal in 
 the condition of the turbinated bones. 
 
 (74) 
 
DEFORMITIES OF THE NASAL SEPTUM. 75 
 
 To turn to the conditions in actual life, Collier reports that, out 
 of 1050 adult patients examined indiscriminately at the Northwest- 
 London Hospital, only 110, or about 10 per cent., had normal noses, 
 a large proportion being affected by septal deviations. In children up 
 to the age of eight or ten years the septa as well as turbinateds were 
 generally normal or almost so — any obstruction at that early age being 
 usually caused by lesions other than bony. Figs. 51 and 51a, taken 
 from a frozen section of a child aged 5 years, is a striking exception 
 to this rule, the deviation and the spur to the left being strongly 
 marked. 
 
 In the normal nose the septum is simply a bony and cartilaginous 
 wall, dividing it equally into two symmetrical fossae. In all the lower 
 animals, in young children, and in the lower untutored races of men, 
 this is still, in large measure, the case. But, as you approach adult 
 life among the civilized races, septal deformities appear in large num- 
 bers, until, as reported by so many observers, the percentage of these 
 inequalities becomes exceedingly great. 
 
 A jn-oper classification of these deviations would be difficult to 
 make. Quite frequently the septum is not thickened, but the car- 
 tilaginous portion makes a full convex curve into one or other nasal 
 fossa. In other cases with the curve there will also be a marked 
 projection or spur on the convex side. Again, spurs or conical 
 projections may appear on one or both sides of the lower end of the 
 triangular cartilage without any curvature of the upper septal wall. 
 In other instances a longitudinal ridge will appear in one fossa, ex- 
 tending backward along the base of the cartilage and involving also 
 the lower part of the vomer, while the upper part of the septum 
 retains its integral position. Some septa have a double curvature, or 
 concavo-convex form, from before backward; and still others have a 
 sharp longitudinal notch on one side, like the niche of an open book, 
 with a projecting perpendicular ridge on the opposite side of the sep- 
 tum. Synechia?, or bridges connecting the bony septum with the 
 middle or lower turbinated of the same side, are not infrequent. 
 There is often, too, a combination of several irregularities in the one 
 nose; while last, but not least, almost any deformity on the one side 
 of the septum is attended by some deviation from the normal on the 
 other. 
 
 Etiology. — This is a many-sided question, and many diverse 
 views are held upon it. Some authorities, Bosworth among the num- 
 ber, believe that the large majority of cases owe their origin to trau- 
 
Yb DISEASES OF THE NASAL PASSAGES. 
 
 matism. This author says: "The point on which I lay special 
 emphasis is that the deformity is primarily the result of traumatism, 
 and, secondarily, of a slow inflammatory process which results there- 
 from." Zuckerkandl has pointed out that in many instances a narrow 
 strip of cartilage lies between the perpendicular plate of the ethmoid 
 and the vomer, due to defective ossification, and in cases of septal 
 injury this might readily give rise to ridges found in this region. 
 
 Eoe draws attention to the fact that in early life the vomer is 
 divided into two laminae, separated from each other by a thin layer 
 of cartilage, which is prolonged forward to form the cartilaginous por- 
 tion of the septum. Ossification begins in the second week of infantile 
 life in each plate, but is not complete until puberty. About the 
 third year union commences between the plates from behind forward. 
 In this case, too, it is not complete until adult life, and sometimes 
 never. Hence many of the deformities may arise from overgrowth 
 of the anterior or free portions of the plates. This would also account 
 for the rarity with which we meet this deformity of the posterior end. 
 
 Trendelenburg believes that many cases arise from the upward 
 pressure of a highly-arched palate. Other writers believe that the 
 deformity. is produced by overgrowth of the septum in a confined 
 space. Jarvis affirms that many cases owe their origin to heredity, 
 and reports four cases occurring in one family in support of his 
 view. It is easy to believe heredity to be an important factor in 
 producing intranasal deformity, just as it is a potent element in pro- 
 ducing types of feature and of form. As an instance, I might men- 
 tion that one of my patients, a boy of 10 years, has developing a 
 curvature of the septum to the left. His father had a curvature to 
 the left, also, large enough to produce almost complete stenosis on 
 that side. On further inquiry, I was informed that the grandfather 
 had been a great snuff-taker, but that he always took it through the 
 one nostril. The conclusion is obvious: the grandfather had trans- 
 mitted the tendency to the son and grandson. 
 
 With all this multiplicity of views as to causation, it is possible 
 that Mayo Collier's researches, founded upon Zeinrs experiments on 
 young animals, may have struck the key-note. He claims that these 
 deformities are largely due to to the effects of atmospheric pressure, 
 badly equalized within the nasal cavities. In his investigations 
 Zeim would completely block one nostril of a young animal with 
 some soft substance, effectually stopping the respiration on that side. 
 This would be left in for a long time. The result in every instance, 
 
Fig. 51. — Frozen section of the head of a child aged 5 years. 1, Sec- 
 tion through back part of eye. 2, Posterior ethmoid cells. 3, Superior tur- 
 binated bone. 4, Middle turbinated bone. 5, Antrum of Highmore. 6, Sep- 
 tum curved to the left. 7, Inferior turbinated. 8, Superior meatus. 9, 
 Middle meatus. 10, Inferior meatus. (From Primrose's Anatomical 
 Museum, University of Toronto.) 
 
Fig. 51a. — Frozen section of same child, taken two centimetres an- 
 terior to Fig. 51. 1, Anterior ethmoid cells. 2, Middle turbinated bone. 
 3, Septum curved to the left. 4, Inferior turbinated bone. 5. Antrum of 
 Highmore 6, Hard palate. 7, Vault of mouth. (From Primrose's An- 
 atomical Museum, University of Toronto.) 
 
DEFORMITIES OF THE XASAL SEPTUM. 81 
 
 and he tried it in a great many, was the arrest of the development 
 on that side, with deflection of the septum, the palate, the intermaxil- 
 lary and frontal bones, all toward the blocked cavity. At the same 
 time, the unobstructed cavity would be larger than natural and more 
 fully developed. The reason is the rarefaction of the air in the closed 
 nostril during inspiration, caused by the rush of air through the open 
 one, with the consequent atmospheric pressure upon all sides of the 
 closed cavity. 
 
 Collier applies the same principle in unilateral nasal obstruction 
 occurring in men as Zeim does in his experiments on animals. Of 
 course, before the effects of rarefaction could occur, there must arise 
 from some cause partial stenosis of one nasal fossa. Then, in due 
 time, though it might take years to develop, the results indicated 
 would be likely to follow. In children, and many of the cases have 
 their origin in early life, the obstruction might arise from neglected 
 colds, particularly when the child was allowed to lie too consecutively 
 on one side. 
 
 Symptomatology. — The principal symptom is that of more or less 
 unilateral nasal stenosis. The secondary effect is a changed condi- 
 tion of the mucous membrane, which usually culminates in a chronic 
 nasal catarrh. It is often the catarrhal condition, with its attendant 
 throat-dropping, which chiefly attracts the patient's attention; and 
 he will frequently present himself for treatment without any per- 
 sonal knowledge of the existence of the stenosis, owing to its very 
 gradual development. 
 
 Septal deformity will frequently give rise to epistaxis. The pro- 
 jecting surfaces are exposed to the dust with which the air of respira- 
 tion is often loaded; and the contact of these particles on the walls 
 of the capillaries produce minute lacerations and consequent haemor- 
 rhage. And it must be remembered that it is from the septum that 
 the nose usually bleeds. 
 
 The voice also becomes affected, particularly when the deformity 
 is very marked; but this symptom is common to nasal obstruction 
 from any cause. 
 
 Dullness of hearing is not an infrequent symptom, arising from 
 the extension of the catarrhal condition to the Eustachian tube. In 
 these cases straightening the septum may be expected to be followed 
 by improvement in hearing. 
 
 Diagnosis. — This can only be made positive by direct examina- 
 tion, for which reflected light, head-mirror, nasal speculum, ami post- 
 
82 DISEASES OF THE XASAL PASSAGES. 
 
 rliinal mirror may all be required. A practical knowledge of the 
 parts should then remove all doubt. Sometimes a mistake may be 
 made by the anterior end of the middle turbinated being on a line 
 with the septum. At this spot a group of projecting glands may hide 
 the point of separation. Creswell Baker calls this spot "tubercuhim 
 septi." Careful examination, however, will easily remove the doubt. 
 Xasal polypus and fibroma of the septum are both movable, while 
 the septum is not. The former, too, is lighter in color and softer, 
 while the latter is darker and subject to haemorrhage on the slightest 
 touch. 
 
 Prognosis. — Left to itself, no septal deviation or deformity will 
 improve, and the symptoms produced by it are likely to remain un- 
 relieved. 
 
 In cases where the symptoms are mostly catarrhal, with partial 
 stenosis on the affected side, removal of the obstruction should be 
 attended by good results. In ear disease, too, arising from this cause, 
 benefit may be expected from similar treatment. Pharyngeal catarrh 
 is also greatly benefited by restoration of normal breathing. In hay 
 fever and asthma, these diseases being so frequently reflex in origin, 
 improvement will often follow operation, though the prognosis should 
 always be guarded. 
 
 Treatment. — The removal of the stenosis produced by the de- 
 formity is. the most essential feature of treatment, and the methods 
 to accomplish this vary materialky, according to the character of the 
 lesion. 
 
 Although fractures and displacements of the septum are of fre- 
 quent occurrence, they are unfortunately rarely presented for treat- 
 ment until after irregular union and healing has occurred, and the 
 after-effects noticed. When, however, the fracture is fresh, the frag- 
 ments can be pressed back into position, and retained in place by 
 suitable rubber or cork splints, cut to the required shape and placed 
 within the nasal passages. It has been said that splints are not re- 
 quired in these cases, as there is no muscular action to displace the 
 structures, once placed in position. This is a mistaken conclusion. 
 After fracture there is always swelling or cedema, and this itself may 
 separate the newly-adjusted parts. Blowing, to free the nose from 
 discharges, may also interfere with the proper union. On the other 
 hand, a carefully-adjusted splint inserted on the side of depression 
 will support the fragments without producing distress; and a week 
 or ten days' immobility will suffice to effect the desired union. Thick 
 
DEFOEMITIES OF THE NASAL SEPTUM. 8 3 
 
 rubber splints of medium softness, carefully adjusted to suit the size 
 and condition of the parts, are also in many cases of curvature of the 
 septum exceedingly useful. If worn for a number of weeks, the con- 
 stant support they effect will restore the passage to an almost nor- 
 mal condition. Their usefulness is highly appreciated by Lake and 
 other writers. 
 
 Consolidated deformities of the septum are treated in various 
 ways by different authors. Where projecting spurs and ridges pro- 
 duce obstruction, all agree that the exostoses and hyperchondria 
 should be removed. Many believe, with Bosworth, that they should 
 be excised by means of saws. The intention is to leave a smooth, 
 plane surface over which mucous membrane will quickly form with 
 little or no cicatrix. 
 
 When the distortion presents itself in the form of an hyper- 
 trophied ridge or spur upon the cartilaginous portion of the septum, 
 this can frequently be removed by means of a sharp, narrow-bladed 
 knife, leaving, as a result, a smooth surface and an open passage. A 
 recoating of new mucous membrane quickly follows. The accom- 
 panying microscopical section was taken from a spur removed in this 
 way from a gentleman, aged 58, who had been suffering from nasal 
 obstruction for thirty years. Calcification had commenced in the 
 hypertrophied cartilage (Fig. 52). 
 
 Other operators advocate the use of burrs operated by a dental 
 engine or electromotor. Holbrook Curtiss has invented a series of 
 small trephines adapted for the removal of this septal outgrowth. 
 These are ingenious, but unless very skillfully used they may fail to 
 leave the perfectly smooth surface which is so desirable and which 
 can be secured by the use of the saw. The latter instrument is 
 usually operated by hand, but can also be attached to an electromotor 
 machine. 
 
 To save the mucous membrane, Fletcher Ingals makes an in- 
 cision along the lower margin of the spur, dissects up the mucosa. 
 and, retracting it to free operation, excises the projecting cartilage. 
 The mucous membrane is then drawn down and sutured to its former 
 attachment. By this means the original mucosa is retained in its 
 entirety. Kyle follows a similar plan in curvature of the septum. 
 
 Loeb advocates the use of sharp, highly-tempered curettes, par- 
 ticularly in cases where saws cannot be used. 
 
 Cheval, Ballinger, Casselberry, and other recent writers have 
 used electrolysis with good results in removing cartilaginous spurs. 
 
84 
 
 DISEASES OF THE NASAL PASSAGES. 
 
 The latter found electromotor force of 11 to 14 volts necessary, with 
 a current-strength of from 15 to 40 milliamperes, according to the 
 amount of resistance found in the spur operated upon. The time 
 for each sitting was from five to eight minutes, to be repeated two 
 or three times at intervals of several days. 
 
 In some cases after removing a spur or ridge, at the base of a 
 
 Fig. 52. — Section of cartilaginous spur from the nasal septum (25 
 diameters), a, Stratified ciliated epithelium. &, Stratified squamous epi- 
 thelium, c, Glands, d, Connective-tissue layer, e, Cartilaginous spur, the 
 lower, shaded portion undergoing calcification. (Author's specimen by 
 Bensley.) 
 
 convex curvature, I have corrected the curve above by the use of a 
 silver tube. If the instrument is worn for a few weeks or months, 
 the cartilage, being pressed by it into the normal position, will re- 
 main so with but little subsequent deflection, the adjustment being 
 
DEFORMITIES OF THE NASAL SEPTUM. 8.3 
 
 rendered easy by the cutting away of the spur or ridge base. The 
 advantage of silver tubes lies in their lightness, aseptic character, 
 smooth surface inside and out, and the fact that a silversmith can 
 form one to suit each special case. The open tube enables the patient 
 to breathe through it. A small bulge placed on the outer wall will 
 secure its retention, and the patient can. soon learn to remove it daily 
 for cleansing purposes and return it to its position (Figs. 53 and 54). 
 Tubes of this kind are also useful in cases of severe traumation, 
 in which either of the anterior nasal passages has been destroyed. 
 In one case which I reported to the laryngological section of the 
 American Medical Association at San Francisco several years ago, the 
 
 Lateral view 
 
 Seen from above. 
 
 Fig. 53. 
 
 Lateral view. Seen from above. 
 
 Fig. 54. 
 
 Silver tubes for septal deformity. 
 
 mucous membrane of the cartilaginous portion of the left nasal pas- 
 sage had been entirely destroyed, the anterior ends of the middle and 
 inferior turbinateds being firmly united to the septum. I cut a new 
 opening through the fibrous cicatricial tissue and had the tube (Fig. 
 53) made to be passed into it. The front end was half a centimetre 
 from the anterior naris and invisible. The arch being upward pre- 
 vented mucus from gravitating into the tube, and it enabled the 
 patient to breathe freely through it. The bulge kept it in position. 
 The wearer takes it out every morning as a matter of toilet, and at 
 once returns it. He has worn it now for five years. Since the opera- 
 tion he has resumed his position as leading tenor in a large church. 
 
86 DISEASES OE THE NASAL PASSAGES. 
 
 which he had been compelled previously to resign, on account of 
 post-nasal catarrh caused by the unilateral stenosis. I expect in time 
 the artificial opening will remain permanent, without the use of the 
 instrument. 
 
 In a somewhat similar case, in which traumatic adhesions had 
 formed from the floor to the middle meatus, Myles succeeded in a 
 different way.- He trephined along the floor of the nose, and then 
 inserted a rubber tube. This was retained until a new passage had 
 formed. The subsequent operation was the removal of the cicatricial 
 tissues between the superior meatus and the new opening. 
 
 "When the enlargement would indicate increased length or height 
 of septum, Arthur Watson advocates removing an elliptical or wedge- 
 shaped portion, as the case might require, cutting through the sep- 
 tum, but leaving the mucous membrane on the opposite side entire. 
 Cutting forceps could be used if required. The parts are then pressed 
 into position and held by pins, the ends of the pins being padded to 
 prevent ulceration. They may be left in position for three weeks, 
 when union will be accomplished with cure of the deformity. The 
 spokeshave is also used for the removal of projecting nodules and 
 spurs upon the septum, giving, in many instances, a satisfactory re- 
 sult. 
 
 As a rule, I think the most widely useful of all is the saw opera- 
 tion. It will fulfill the requirements of the majority of cases. In the 
 first place, a 2- or -i-per-cent. solution of cocaine should be thrown 
 into the nostril by an atomizer. Then a stronger solution, of 10 or 
 15 per cent, should be applied by a curved cotton-holder to the sep- 
 tum. This may be repeated two or three times. In five to eight 
 minutes the parts are ready for operation. Two saws are required; 
 one with teeth on the upper edge, the other with teeth on the lower. 
 It is always better also to have the handle of the saw at an angle of 
 forty-five degrees to the central line of the shaft. The lower blade 
 is inserted first and the cutting is always done parallel to the axis 
 of the septum. Then the cut downward with the upper saw is made 
 to meet exactly with the inferior incision. To perform the opera- 
 tion requires a good speculum and a good reflected light. The word- 
 ing of the operation is simple, but, to do it successfully, care and 
 patience are required. "When the exostosis is large and hard, the 
 operation may be tedious, necessitating several stoppages before com- 
 pletion, in order to arrest or remove the blood. There is also danger 
 from faintness, due to the action of the cocaine combined with the 
 
DEFOKMITIES OF THE NASAL SEPTUM. 87 
 
 shock of the operation. There is likewise danger of cutting through 
 the septum, and, although this was the approved method of treat- 
 ment at one time for the relief of one-sided stenosis, it is something 
 which the careful surgeon wishes to avoid now. With judicious 
 management, it is an accident of exceedingly rare occurrence. 
 
 Little after-treatment is necessary. If haemorrhage arising from 
 the operation does not at once subside, it is better to pack the bleed- 
 ing-spot with cotton tampons. These may be left in for one, two, 
 or even three days without producing any evil effect. They may 
 be renewed entirely or in part at any time, as the tendency to bleed- 
 ing may direct. One of the main objects after operation is to pre- 
 vent the anterior part of the cut surface from becoming dry, as any 
 hard crust forming upon it would retard the process of healing. 
 To avoid this the patient should be directed to apply vaselin to the 
 septum several times a day. This should be done particularly before 
 retiring for the night. 
 
 In the majority of cases a few weeks will suffice to recoat the 
 raw surface with mucous membrane. It gradually forms from the 
 border-line, usually covering the wound without leaving any cicatrix 
 to mark the site of the operation. 
 
 Occasionally unpleasant sequels follow operations upon the nasal 
 septum: such as severe haemorrhage, which may recur at intervals 
 for several days before it entirely ceases; formation of synechiae 
 between the septum and the inferior turbinated; and the production 
 of excessive granulations. Careful treatment will avoid or at least 
 overcome all these difficulties. Very rarely even a septal abscess has 
 been the result of septal operation. Lederman recently reported a 
 case of this kind. It occurred in a young woman aged 22. Ordi- 
 nary antiseptic precautions were taken. The first saw operation upon 
 an extensive ecchondrosis gave some relief and healed well in two 
 weeks. A second operation to complete the removal of a remaining 
 exostosis was then done. In four days an abscess of the septum com- 
 menced to form and had to be lanced several times before it entirely 
 healed. 
 
 In dealing with these cases it is not the operative, but the post- 
 operative, treatment that I have usually found the most troublesome. 
 By saw or knife, drill or scissors, or curette, single or combined, the 
 projecting spur or ridge might be removed; synechiae connecting the 
 turbinated with the septum could be excised; or a partial turbinectomy 
 when necessary might be performed; but to procure smooth equable 
 
88 DISEASES OF THE NASAL PASSAGES. 
 
 support for the incised tissues during the process of healing has been 
 a much harder matter. 
 
 I think that rubber splints, made as Lake advises, from thick 
 rubber sheeting, do better work than anything else we have at our com- 
 mand for many of these cases. Their surfaces are smooth, compressible, 
 and elastic; they can be readily cut to the required shape, and they can 
 be obtained of any thickness we desire. 
 
 After cocainizing the parts and coating the plug with vaselin it 
 can readily be placed in position. Once in, it will not only retain its 
 place, but by elastic pressure give a smooth and even support to the 
 •raw surface to which it is applied, as well as prevent that profuse 
 granulation which otherwise would sometimes occur. At the same 
 time it does not retard the gradual extension of the new mucous mem- 
 brane, while it molds the tissues into a smooth and regular form. 
 
 The stiff pliable rubber, although not so hard on the surface, nor 
 possessing the polish of the vulcanite, is probably just as impervious 
 to bacterial invasion. Sometimes, however, after prolonged use it will 
 acquire a peculiar, unpleasant odor, in part arising from the rubber 
 itself. In these cases new splints or tampons should be substituted for 
 the old ones. 
 
 The length of time during which the splint will require to be 
 worn will depend upon the particular condition of each case. On 
 placing it in position it may usually be allowed to remain in from two 
 or three days to a week without removal. The chink above the splint 
 can be washed out each day with a weak spray of cocaine, followed 
 by one of albolene; so that there is no danger of retention of septic 
 secretions. Quite frequently, too, when once removed, there will be 
 no necessity for a replacement of the tampon. 
 
CHAPTEK XII. 
 
 DISTORTION OF THE COLUMNAR CARTILAGE. 
 
 Bosworth was the first to draw attention to the dislocation of 
 this body. In both the cases of which he gave a detailed report the 
 displacement was extreme, seriously interfering with respiration 
 through the corresponding naris; and in each, in order to give ade- 
 quate relief, complete removal of the cartilage became necessary. A 
 small incision was made along the axis of the cartilage and the car- 
 tilage itself removed through the opening. Then the redundant por- 
 tion of the mucous membrane was excised and the edges united with 
 fine sutures. The result was satisfactory in each case. 
 
 Although extreme cases are rare, displacement of the columnar 
 cartilage, to a more or less degree, is not by any means infrequent. 
 
 The columnar cartilage is a little column of cartilage placed 
 directly anterior and inferior to the triangular cartilage of the sep- 
 .tum. It is loosely attached to it by connective tissue in the centre 
 and mucous membrane on the two sides. It is very movable, covered 
 by integument, and forms the septal division of the two anterior 
 nares. 
 
 The anterior end, placed just beneath the tip of the nose, is 
 almost invariably in position. It is the lower, or posterior, end that 
 so frequently becomes distorted; and, being displaced to one side, 
 may have the effect of almost completely closing that nostril. 
 
 The cause of the distortion is somewhat obscure; as displace- 
 ment of the septum in infancy is almost unknown, displacement of 
 the cartilage at that early age would be even more rare. The prob- 
 ability is that the distortion is in every instance acquired. It may 
 owe its origin to picking the opposite nostril or placing the finger 
 in the wider cavity, to which some children are addicted. From 
 personal observation I believe, too, that it sometimes arises from the 
 habit, acquired during childhood and practiced on through life, of 
 invariably twisting the nose over to one side when using the pocket- 
 handkerchief. 
 
 One of my earliest cases was a gentleman of 40 years. He had 
 
 (89) 
 
90 DISEASES OF THE NASAL PASSAGES. 
 
 a good deal of septal deformity, but the columnar cartilage was the 
 worst of all. It was doubled on itself and almost filled the right 
 naris. I observed his use of the handkerchief, and he informed me 
 that he had always pulled the nose over to the right when wiping 
 that organ. 
 
 Treatment. — In extreme cases Bosworth's method would prob- 
 ably be the best that could be followed. In milder cases, however, 
 the treatment might be materially modified, and, although I have 
 operated on a number of cases, I have never found entire removal 
 of the cartilage necessary. 
 
 The treatment consisted, first, in producing local anaesthesia by 
 injecting a few drops of 5-per-cent. solution of cocaine beneath the 
 cuticle of the septum, followed by the local application of a stronger 
 solution to the mucous membrane. Then, by pressing the skin of 
 the septum toward the opposite nostril the cuticle of the cartilage 
 was put on the stretch. Thereupon, with a sharp, narrow-bladed 
 knife, the prominent portion, membrane and cartilage together, was 
 split off from end to end. By this means a portion of the cartilage 
 was in each case saved. There was no redundant mucous membrane 
 left, and that portion which had been pressed on the stretch over to 
 the opposite nostril slipped back, in great measure, over the raw 
 surface and covered it. Sutures were not required, and in a few 
 days by simple vaselin dressing the wound healed, leaving the nos- 
 tril patulous and the naris almost in a normal condition. 
 
CHAPTEE XIII. 
 PERFORATIONS OF THE SEPTUM. 
 
 This usually occurs through the triangular cartilage; sometimes, 
 though rarely, through the vomer. When in the latter situation, it 
 is believed to be the result of syphilis, scrofula, or malignant disease, 
 or else of traumation. Perforations of the cartilage are usually of 
 local origin; and, as the majority of cases occur during the later 
 years of childhood, they are probably the result of digital erosions, 
 made during that period, when purulent rhinitis is being gradually 
 transformed into atrophic disease. I look upon this as probable from 
 the fact that the majority of cases that have come under my obser- 
 vation have been atrophic cases, and yet in which the patients could 
 not tell when the perforation had taken place. 
 
 Another cause in the scrofulous subject is the projection of the 
 triangular cartilage into one nostril. In this case dust-laden air re- 
 peatedly inhaled impinges upon the prominent spot, gradually pro- 
 ducing erosion of the mucous membrane and cartilage. By and by 
 crusts form; and the removal of these crusts leaves an ulcerated sur- 
 face which continues to develop until perforation is the result. 
 
 Bosworth looks upon the erosion and perforation as an effect of 
 Nature to remove the obstructive lesion, and the result as beneficial 
 rather than injurious to the health of the patient. 
 
 Treatment. — In this matter very little is required. The main 
 point is to keep the perforation free from accumulation of secretions, 
 and not to allow crusts to form upon its margins. If the outline is 
 irregular and jagged, this can be trimmed to produce an even sur- 
 face, and, as Bishop says, if the perforation produces a whistling 
 sound in breathing, the shape can be altered to allow the air to 
 pass through the opening less noisily. Sometimes the posterior half 
 of the opening will become thick and granular, rendering that part 
 of the septum unusually thick and with a tendency to bleed upon 
 pressure. In this case the parts can be reduced by knife or cautery 
 operation to the respiratory advantage of the patient. 
 
 Accidental perforation of the bony septum during operation for 
 the removal of spurs, etc., will sometimes produce severe shock; but 
 
 (91) 
 
92 DISEASES OP THE NASAL PASSAGES. 
 
 the after-effects are not very serious. Still, it is the duty of every sur- 
 geon to do all that he can to avoid an accident of this kind. French 
 perforates the septum to improve the breathing-space when necessary. 
 Wright insists upon proper antiseptic treatment before and after all 
 operative work upon the nose, with which all surgeons, no doubt, 
 agree. 
 
 Abscess of the septum is an exceedingly rare disease, but when 
 it does occur it is usually the result of traumatism, and should be 
 treated upon ordinary, antiseptic, surgical principles. 
 
 Ulceration of the septum, apart from its occurrence as a prelude 
 to perforation, is also a very rare disease. Still, in scrofulous and syph- 
 ilitic subjects it does sometimes occur. Likewise in young children, 
 victims of Ascaris vermicular is, itching of the nose may be produced 
 by reflex irritation, leading to picking and scratching of that organ 
 until septal ulceration is the result. In all these cases systemic as well 
 as local treatment may be required to cure the disease. 
 
CHAPTER XIV. 
 HAY FEVER, OR VASOMOTOR RHINITIS. 
 
 Bostock, of London, in 1819 was the first among modern writers 
 to draw attention to this disease, although it had been recognized in 
 an indefinite manner by physicians for the previous two centuries. 
 It was observed by him to occur during the summer months among 
 persons working in the vicinity of new-mown hay. From this fact 
 it derived the name which it still bears. That there are two varieties 
 of this disease, one occurring in June and the other in August, and 
 that the symptoms may be provoked by emanations from a multitude 
 of substances, have not militated against the title, inasmuch as the 
 symptoms are in all cases alike. 
 
 Hay fever may be defined as a periodic disease occurring an- 
 nually at a fixed period of the year, and attended by intense hyper- 
 sensitiveness and hypersecretion from the mucous membrane of the 
 nose, eyes, and throat. 
 
 Pathology. — The pathological changes occurring in this disease 
 have long been the subject of careful investigation. During the 
 most aggravated exacerbation there is little, if any, rise in tempera- 
 ture. There is no previous chill. There is no febrile action, and yet 
 the whole system is affected by the violence and suddenness of the 
 explosion. Suddenly, and without warning, a vasomotor paresis is 
 induced. The blood-vessels and venous sinuses of the turbinateds 
 become relaxed and surcharged with blood. There is complete pa- 
 ralysis of the nerves which control exosmosis, and the serum is tran- 
 suded freely from all the pores of the mucosa. 
 
 The length of time during which the veins remain in this state 
 of dilatation depends, according to some writers, upon the quantity 
 of irritant present within the nasal passages. The exciting cause being 
 over, the vessels contract, the exudation ceases, and the parts return 
 to their normal condition, the mucosa retaining only an anaemic 
 appearance. 
 
 It is generally believed now that this disease is essentially a neu- 
 rosis. It affects chiefly persons of a nervous temperament. The 
 
 (93) 
 
94 DISEASES OF THE NASAL PASSAGES. 
 
 nerves affected are the sympathetic and trigeminus, which control the 
 vasomotor system of the nose. John MacKenzie believes it to be: "A 
 disordered functional activity of the nervous centres''; Joal, Leflaive, 
 and others that it is a reflex neurosis; Delavan that underlying that 
 neurosis there are general or diathetic conditions which tend to the 
 production of the disease. Hence it is pretty generally looked upon 
 as a functional neurosis, but, like other functional neuroses, it never 
 destroys life, and the neuropathologist in consequence is deprived of 
 the opportunity of post-mortem investigation. 
 
 Etiology. — Bishop presents the following as a summary of our 
 present knowledge upon this branch of the subject: "Thus, it ap- 
 pears, from the manner in which paroxysms of hay fever are started 
 and developed, that there are three conditions upon which the ex- 
 istence of the disease depends: 1. Abnormally-susceptible nerve- 
 centres. 2. Hyperesthesia of the peripheral termini of the sensory 
 nerves. 3. The presence of one of a large variety of irritating agents. 
 Exclude one of these conditions, and the paroxysms are prevented. 
 Allay the susceptibility of the nervous centres by certain central 
 sedatives and an attack is averted or arrested; anaesthetize the nerv- 
 ous supply of the oversensitive areas and the result is the same. Re- 
 move the patient beyond the reach of exciting causes and he is as 
 comfortable as any mortal." 
 
 Bosworth also gives three conditions as essential to the produc- 
 tion of an attack of hay fever, but they differ somewhat from 
 Bishop's, and they are given in an inverse order. They are: "1. The 
 presence of pollen in the air. 2. A neurotic habit. 3. A morbid con- 
 dition of the nasal mucous membrane." 
 
 1. "Abnormally-susceptible nerve-centres" and the "neurotic 
 habit" may be taken as essentially the same thing, and is probably 
 the primary cause of the disease. Without its presence, to commence 
 with, hay fever would be an impossible thing. What the essential 
 pathological condition is that we term the neurotic element would 
 be difficult to explain. Still, it is well known from extensive clinical 
 examination of hay-fever subjects that the family history, in a 
 majority of instances, justifies the opinion of the presence of ab- 
 normally-sensitive nerve-centres in other members of the family like- 
 wise, though it may not have been manifested in the same way. 
 
 2. Hyperesthesia of the peripheral termini of the sensory nerves 
 may arise from different causes: such as a morbid condition of cer- 
 tain parts of the nasal mucosa, hypersensitive areas, obstructive 
 
HAY FEVER, OR VASOMOTOR RHINITIS. 95 
 
 lesions of the septum or turbinateds, or the pressure of overgrowth 
 upon adjoining tissues. 
 
 3. The presence of an irritating agent will include Bosworth's 
 first cause: the pollen-in-the-air theory, based on Blackley's investi- 
 gations. This gentleman was himself the subject of hay fever, 
 usually coming on in June. With the idea that pollen, floating in 
 the atmosphere, might be the cause of it, he undertook a series of 
 experiments to ascertain the truth of his theory. His most success- 
 ful" experiments were by the use of a small disk of glass, coated with 
 glycerin and suspended in the air. He found that in twenty-four 
 hours, in the beginning of June, but a small number of grains of 
 pollen would become attached to the disk. By about the tenth they 
 would have increased about tenfold, and the hay fever would have 
 commenced. Inside the next three weeks the grains of pollen would 
 again be tripled, with marked increase in the severity of the symp- 
 toms. From this time forward the pollen, and with it the hay fever, 
 would subside, until by August 1st both would disappear. If heavy 
 rains occurred during the prevalence of pollen, they would tempo- 
 rarily diminish in number, and the symptoms for the time being 
 would also subside, while both would return as soon as there was a 
 chance for the grains to rise again in the air. 
 
 Experience, however, does not confine the local irritant by any 
 means to pollen. We find many of our cases residents of our large 
 cities, where little pollen can be possible in the air of respiration; no 
 doubt the coincidence of the prevalence of hay fever at the period of 
 the year when the atmosphere is most loaded with it would indicate 
 a causative relation as existing between the two. But there are many 
 irritants, physical and even mental, which may induce an attack. 
 The presence of feathers, odor of animals, perfumes; hot, impure air; 
 sudden change of temperature, mental worry, even exposure of the 
 spinal column to the air have all induced exacerbations of the dis- 
 ease. So true is this that a violent attack has been known to be in- 
 duced in an old hay-fever patient by merely gazing upon a picture of 
 a field of new-mown hay. 
 
 Although we can understand the presence of an irritant to be 
 the original exciting cause of the first attack, yet it is difficult to be- 
 lieve that each exacerbation is dependent upon the same exciting 
 cause. For instance, a patient, after a paroxysm of sneezing, and 
 profuse flow of serum from the nostrils, and profound tickling irri- 
 tation of the palate, will retire to bed under a sense of complete relief. 
 
96 DISEASES OF THE NASAL PASSAGES. 
 
 Everything is done to render the air of the room pure and free from 
 irritants. The night is hot and he can bear nothing but a sheet over 
 him. I am speaking of a case with which I am perfectly familiar. 
 That patient knows by experience that if he lies perfectly still upon 
 his back, with all his body, hands, and feet covered with the sheet, 
 he will be able to lie for hours, and even to sleep, before another ex- 
 acerbation will appear. But, warm as it is, if he exposes a foot or 
 a hand from beneath the covering, he knows that another attack 
 of sneezing will come on at once, and that he will saturate two or 
 three more handkerchiefs before it subsides. 
 
 What has pollen, or dust, or foul air, or feathers, or animal odor 
 to do with this? 
 
 I know a case, also, of a gentleman who has a periodic attack 
 of hay fever for a month every year, commencing near the end of 
 August. His worst exacerbations occur during the night-time; but 
 he can go daily and sit to read in a large public garden, filled with 
 flower-beds and exotics, without feeling any inconvenience from the 
 pollen rising from them. 
 
 I do not wish in any way to deprecate the importance of pollen 
 or any other irritant as exciting causes of this disease, but I do wish 
 to emphasize the fact, that there must be something inherent in the 
 system, when the disease has once developed, which itself produces 
 these periodic explosions, from which hay-fever patients so severely 
 suffer. 
 
 Shaw Tyrrell, of Toronto, and Bishop, of Chicago, have for 
 years, independently of each other, been advocating a new theory as 
 to the cause of hay fever. They believe that to some extent it is 
 caused by the presence of an abnormal amount of uric acid in the 
 blood. According to this theory, the formation and retention of uric 
 acid in the tissues does not produce hay fever, but the presence of 
 uric acid in the blood does. 
 
 The majority of cases of -this disease occur between the ages of 
 ten and forty years, and, in accordance with Bosworth's statistics, the 
 majority, in the ratio of two to one, are males. 
 
 Another important point, upon which all writers agree, is that it 
 is a disease incident to the educated classes and sedentary life. This 
 is what we might expect when we remember that hay fever is so 
 largely a neurosis. 
 
 Symptomatology. — Slight premonitory symptoms in the form of 
 tingling or itching of the eyelids, nasal passages, or soft palate may 
 
HAY FEVER, OR VASOMOTOR RHINITIS. 97 
 
 present themselves for days before the disease fully develops. Theu 
 spasmodic fullness of the nose will occur, sneezing will come on, and 
 the congestion will find relief in profuse watery discharge. The eye- 
 lids and eyeballs become congested, and copious lacrymation adds to 
 the general distress. The discharges are often profuse and the sneez- 
 ing very violent and continuous. Another symptom, often present, 
 is an intense tickling irritation of the soft palate, inducing an irre- 
 sistible desire to scratch it with the tongue, even when the patient 
 knows from experience that the very friction of the tongue on the 
 soft palate will increase the rapidity of the sneezing. 
 
 The hydrostatic condition of the turbinateds is particularly mani- 
 fest during an attack of hay fever, the paresis having deprived the 
 tissues of their normal power of resistance. Let the patient lie on 
 one side, in a very few moments the corresponding nostril will be 
 completely stenosed. Let him turn to the other, and the condition 
 will be at once reversed. Let him lie on his back, and the posterior 
 ends of the two inferior turbinateds will become so swollen that they 
 will fill both posterior choanal, and breathing through the nose will 
 be an impossibility. 
 
 Many cases of hay fever, after the first few years, also take on 
 the element of asthma, to increase the sufferer's misery. This comes 
 on two or three weeks after the commencement of the symptoms; and 
 in some cases will last for weeks after the hay fever proper has 
 subsided. 
 
 It is a question whether the asthma owes its origin to hay fever, 
 or whether they are not both the products of the one cause, pro- 
 ducing vasomotor rhinitis in the upper region and vasomotor bron- 
 chitis in the lower. 
 
 One remarkable peculiarity of hay fever is its exact periodicity. 
 Quite frequently it will come on year after year almost to the very day, 
 usually about the 20th of August, and last for four or six weeks, or 
 until the advent of cold weather, and then disappear almost as sud- 
 denly as it came. 
 
 Examination of the nasal passages during an attack reveals the 
 turbinated bodies swollen and water-soaked and of a gray or pur- 
 plish hue. The mucous membrane is painful and sensitive, while 
 the necessity, which so often exists, of sleeping with the mouth open 
 renders the throat dry and parched. 
 
 Throughout the United States and Canada the usual period of 
 attack is during the latter half of August; but with some people, 
 
98 DISEASES OF THE NASAL PASSAGES. 
 
 though they are greatly in the minority, the attack comes on in June, 
 bearing the name of "rose-cold/' from the fact of roses blooming at 
 that time. 
 
 In other instances, though these are likewise rare, the attack 
 comes on semi-annually. I have one lady patient who for years had a 
 light attack in March, to be followed by a severe one in August. The 
 latter still continues, followed or accompanied by asthma, while the 
 former has during recent years disappeared. 
 
 With regard to geographical area, it is found on this continent 
 over almost all parts of the United States and Canada. There are cer- 
 tain regions, however, said to be exempt, such as the White Mount- 
 ains, the Adirondacks, Manitoulin Island, parts of Muskoka, the 
 vicinity of Quebec, etc. But it is said, also, that, as urban life ex- 
 tends into these regions, their former immunity may gradually pass 
 away. 
 
 Diagnosis. — Perhaps acute rhinitis is the only disease that it is 
 likely to be mistaken for. In this, however, the chances of error 
 are slight. In acute rhinitis the mucous membrane is bright and red, 
 with no great amount of swelling. In hay fever the color is a grayish 
 or purplish red, and the swelling a leading feature. The discharge in 
 acute rhinitis is muco-pus of a yellowish color; in hay fever it is 
 little but colorless serum. 
 
 Prognosis. — Hay fever rarely, if ever, produces a fatal result. 
 Still, while it lasts it causes much intense suffering. In some cases 
 during the process of years the attacks of themselves become gradually 
 lighter and finally disappear; but in the majority, if unrelieved by 
 treatment, they culminate in asthma of a severe and continued form. 
 The disease is, however, more or less amenable to treatment, and a 
 large percentage of cases have been reported cured. 
 
 Preventive Measures. — As a preventive measure, nothing occu- 
 pies so prominent a position as the removal from home-surroundings 
 to a locality where hay fever is said not to exist. Of such regions 
 those already named bear a high reputation, particularly the White 
 Mountains. Bethlehem seems to be a favored spot in these mount- 
 ains. The elevation is less than 2000 feet, but large numbers of 
 people annually spend the whole of the hay-fever season there, and 
 claim, during their sojourn, almost complete immunity. 
 
 The Muskoka islands and lakes have also during recent years re- 
 ceived a good deal of attention as a hay-fever resort. The elevation 
 of 1000 feet above the sea, the purity of the waters, the rocky and 
 
HAY EEVEE, OE VASOMOTOE EHINITIS. 99 
 
 sandy nature of the soil, the abundance of woodland, and the teem- 
 ing variety of the innumerable islands have all helped to make it an 
 ideal region for the prevention, as well as treatment, of this disease. 
 
 The upper waters of the Saguenay, though lower in elevation, 
 is also gaining in reputation, particularly among sufferers directly 
 to the south of this romantic region; as also is Georgian Bay, with its 
 pure, dry atmosphere, and thousands of rocky islands. 
 
 The most important fact to be considered, in connection with 
 this view of prevention, is the advisability of moving to the chosen 
 spot before the commencement of the annual attack. The object is 
 to get the entire benefit of the climatic change; to prevent the dis- 
 ease from developing, not to break it up after it has made its appear- 
 ance. Another point which cannot be too strongly emphasized: if 
 the patient goes by railroad to the favored resort, before the time of 
 the annual attack, even if that period is only a few days, the symptoms 
 will not develop during the journey; but if the trip is made after 
 the hay-fever symptoms have commenced, they will be materially 
 aggravated by the time he reaches his destination. 
 
 The results arising from this method of prevention differ ma- 
 terially. In some cases the occurrence of the disease for the season 
 is broken entirely; in others the severity is weakened and the period 
 of the attack shortened; while in others little or no salutary effect 
 is produced. They may go the round of all the resorts they can hear 
 of, and yet the hay fever will exhibit itself with its old-time force 
 and duration. 
 
 Treatment. — This will frequently require to be of a threefold 
 character. 1. Constitutional treatment, for the correction of the neu- 
 rotic habit. 2. Treatment of the diseased condition of the nasal pas- 
 sages. 3. Treatment of the spasmodic attack. 
 
 1. Constitutional treatment. In this, regulation of the ali- 
 mentary canal and the urinary system may be of prime importance, 
 and should be followed by the administration of nerve and systemic 
 tonics, such as iron, quinine, strychnine, arsenic, and phosphide of' 
 zinc. Cold bathing practiced daily is an excellent adjuvant, as is 
 also systematized exercise. 
 
 Bishop, basing his conclusions upon his own theory of the pres- 
 ence of uric acid in the blood as the real cause of the disease, ad- 
 ministers systemic treatment under the title of preventive treatment. 
 In the first place, he reduces as much as possible the supply of foods 
 that increase the formation of uric acid, such as meats, sugar, beer, 
 
 L. «f c. 
 
100 DISEASES OF THE NASAL PASSAGES. 
 
 wine, etc.; and limits the diet largely to fruits, vegetables, milk, fats, 
 etc.; and at the same time administers salicylates for several weeks 
 prior to the onset of the disease, in order to diminish the uric acid 
 as it forms. 
 
 The moment, however, that symptoms of hay fever show them- 
 selves, he drops the salicylates and reverts to acid treatment. After 
 numerons experiments, he prefers Horsford's acid phosphates, which 
 he gives in 4-gramme doses two or three times a day. He claims 
 that this prevents the solution of uric acid in the blood, and at once 
 checks the disease, while, on the other hand, if alkaline treatment 
 were resorted to at this time it would produce uricacidsemia and pre- 
 cipitate an attack of the trouble he is trying to prevent. 
 
 2. Treatment of the diseased condition of the nasal passages. In 
 many cases the hyperassthetic condition of the mucosa depends upon 
 intranasal lesions of one form or another. It is self-evident that this 
 diseased condition should be removed and the passages rendered nor- 
 mal if possible. Deflections of the septum, hypertrophic rhinitis, 
 nasal polypi, pressure of the middle turbinated upon the septum may 
 any of them require operative interference; and the treatment should 
 be directed toward the removal of these conditions when present, ac- 
 cording to the methods already indicated in previous chapters. 
 
 As regards the period best suited to operation, it would, without 
 doubt, be better to remove all obstructive lesions prior to the annual 
 onset of the disease. As a rule, however, the patient does not present 
 himself for treatment until the severity of the exacerbations impel 
 him to seek relief. When he does come, his case should be examined 
 into thoroughly, with the aid of the necessary rhinoscopic instru- 
 ments. This can always be accomplished, even in the most sensitive 
 cases, after applying a 4-per-cent. solution of cocaine. The essential 
 theory is, first, to render each nasal passage free enough to allow of 
 normal respiration through it, and, second, to remove any pressure 
 upon the septum arising from turbinal Irypertrophy. At the same 
 time it is always well to be guarded against too extensive operative 
 interference, and, except in extreme cases, it would be better not to 
 operate during the actual presence of this periodic disease. 
 
 Sajous and MacKenzie believe that there are sensitive areas, in- 
 dependent of hypertrophy, and that slight galvanocautery operations 
 upon them will destroy the terminal filaments of the nerves for the 
 time being and thus check the exacerbations. 
 
 3. Treatment of the spasmodic attack. No treatment while the 
 
HAY FEVER, OR VASOMOTOR RHINITIS. 101 
 
 exacerbation is actually on will give such prompt relief as a spray of 
 a solution of cocaine. At the same time no drug is more dangerous 
 to the patient, if he becomes addicted to its indiscriminate use. 
 Wherever there is vascular turgescence of the nasal mucosa, from any 
 cause, the application of a solution of cocaine will at once remove 
 it; and in hay fever the attendant symptoms are, for the time, re- 
 lieved likewise. In most cases the following prescription will be quite 
 strong enough: — 
 
 1. I£ Cocaine hydrochlor 3 
 
 Amnion, chlorid 13 
 
 Aqua 30 
 
 M. Sig. : Spray each nostril with a small quantity and allow 
 it to be retained. Any good atomizer (as Figs. 25, 
 26, and 27) would answer for spray-treatment. 
 
 One difficulty, apart from the danger of acquiring the cocaine 
 habit, which can only be slight in the use of so weak a solution, is 
 the fact that its action is only temporary, and, after being used a 
 number of times in succession, the reaction from the condition of 
 the vessels produced by it becomes rapid and noticeable. That is, the 
 tissues swell up again even more quickly than they did before its use. 
 Here, again, to prolong the efficacy of the cocaine, good results can 
 be obtained from a 2-per-cent. solution of menthol in albolene, 
 thrown up the nostrils by a second atomizer, as soon as the cocaine 
 has been absorbed. 
 
 There is another method of treatment I have found very satis- 
 factory, in which cocaine has not been used at all, except for the 
 purposes of examination. This is by using a much stronger solution 
 of menthol in albolene as spray to the throat only — inhaling it 
 forcibly during a full inspiration, and then closing the mouth and 
 breathing out through the nose. This is repeated over and over again 
 until relief is obtained. The strength of the solution might be 3, 
 4, or 5 per cent, as the case might require, repeated, irrespective of 
 time, night or day, upon the approach of each threatened exacer- 
 bation. 
 
 There are a number of menthol-inhalers in the market, but 
 usually the use of the spray is attended by better results. 
 
 Bishop advocates the use of a 1-per-cent. solution of camphor- 
 
 1. B Cocaine hydrochlor gr. v. 
 
 Ammon. chlorid gr. ij. 
 
 Aqua 5j. 
 
 M. 
 
102 DISEASES OE THE NASAL PASSAGES. 
 
 menthol in lavolin as a spray to the nose in this disease, gradually 
 increasing the strength to 3 per cent, if required. He claims it to be 
 blander and more soothing than menthol alone. I have used it on 
 many occasions, but still prefer the menthol and thymol-menthol 
 preparations. Of the latter the following is a good formula: — 
 
 $ Thymol 
 
 Menthol 1 
 
 Albolene 30 
 
 M. 
 
 This should be used as a spray to the throat and diminished to 
 one-half strength when used to the nose. 
 
 Lennox Browne has more faith in the local application of men- 
 thol than of any other drug in the relief of this disease. 
 
 E. L. Slmrly has found snuff of daturine in starch a very effi- 
 cient remedy; while Fletcher Ingals, after cauterization, administers 
 tonics, together with the local application of cocaine, to relieve the 
 exacerbations. 
 
 In severe cases, when, from business engagements or other cir- 
 cumstances, it is impossible to use spray-treatment of any kind to 
 relieve the exacerbations, minute crystals of menthol dissolved in the 
 mouth will efficiently keep the symptoms under control. 
 
 As direct sedatives to the mucous membrane administered in- 
 ternally perhaps none are better than a combination of atropia and 
 morphia in minute doses. They have a quieting effect upon the nerv- 
 ous system, as well as an astringent effect upon the mucous membranes. 
 The following is a good formula: — 
 
 2. I£ Atropia sulph 1013 
 
 Morphia sulph |65 
 
 M. Make into 100 tablets. 
 
 Sig. : One to be taken every two, three, four, or six hours as 
 required. 
 
 Still, as with all narcotic sedatives, cocaine included, considering 
 the danger that is always present of forming a habit, the less of 
 these medicines that are given to the patient, the better. When 
 
 1. B Thymol gr. ij. 
 
 Menthol gr. xxij . 
 
 Albolene Ij. 
 
 M. 
 
 2. 3 Atropia sulph gr. V«- 
 
 Morph. sulph gr. x. 
 
 M. Make into 100 tablets. 
 
HAY FEVER, OR VASOMOTOR RHINITIS. 103 
 
 absolutely necessary the drug should be prepared in the doctor's 
 office, and not in the way of prescription. 
 
 Solis-Cohen and Wagner speak highly of suprarenal-capsule ex- 
 tract in the treatment of this disease. Solis-Cohen administers the ex- 
 tract in 5-gramme doses five times a day, insuring thereby a "sneeze- 
 less, coryzaless" night. Wagner favors its local application to the 
 turbinal tissues, with or without cocaine, obtaining excellent results. 
 
 Nasal Hydrorrhea. 
 
 This is an affection somewhat resembling hay fever, particularly 
 in the abundance of the serous discharge. It is very rare and occurs 
 at irregular intervals, the name indicates the nature and symptoms 
 of the disease. The discharges, however, are more of a passive char- 
 acter than in hay fever, and unaccompanied by the severe sneezing 
 and palate-irritation which attend that disease. It seems to arise from 
 idiosyncrasy of constitution. Sometimes it is a forerunner of nasal 
 polypi. How far it may stand in a causative relation to it at present 
 it is impossible to say. Treatment similar to that of hay fever is 
 called for; electrolysis under cocaine anaesthesia may be useful, and 
 operative treatment for removal of obstructions may sometimes be 
 required. 
 
 A case of "vasomotor rhinitis" reported by Howard Straight, 
 although accompanied by severe sneezing, I think should really come 
 under this head. The attacks were similar to those of hay fever 
 only for the facts that they come on more frequently during wet 
 weather than dry, and, lasting a day or two, occurred about every 
 two weeks all the year round. A number of handkerchiefs would be 
 saturated with each attack, and all ordinary treatment failed to give 
 relief. Finally the doctor, finding the entire nasal passage, tur- 
 binateds included, in a normal condition when the attack was off, 
 singed the inferior turbinateds lightly with the flat galvanocautery 
 electrode. The result was a great improvement of the condition, with 
 almost complete subsidence of the attacks. 
 
 St. Clair Thomson has very recently drawn attention to the pos- 
 sibility of mistaking escape of cerebro-spinal fluid for nasal hydror- 
 rhoea, the symptoms being somewhat alike. A number of cases are 
 recorded in which, in otherwise perfectly healthy subjects, cerebro- 
 spinal fluid would escape almost continuously from the one nostril, the 
 intermissions being rare. In true nasal hydrorrhcea the discharge is 
 more irregular and at the same time bilateral. 
 
CHAPTER XV. 
 
 ANOSMIA; PAROSMIA; FURUNCULOSIS. 
 
 Anosmia. 
 
 This disease, indicating loss of the sense of smell, may owe its 
 origin to either central or peripheral lesions or to mere functional 
 disturbance of the nerve-centres. When of central origin it may arise 
 from the pressure of a tumor on the double nerve-centre, or upon the* 
 nerves themselves, as in Loder^s case, in which the pressure arose from 
 scirrhus of the pituitary body. Appert's case also arose from press- 
 ure upon the olfactory nerves by abscess of the pituitary. Bonet's 
 case was caused by pus-formation within the olfactory bulbs. It may 
 arise also from atrophy of the bulb or trunk of the nerve as a func- 
 tional result of insanity and as the result of lesion caused by fracture 
 of the bone of the base of the skull. 
 
 By far the larger number of cases arise from peripheral com- 
 pression or lesion, or from causes that will prevent the contact of 
 odoriferous particles with the olfactory area of the nose. The causa- 
 tive effect of lesion of the terminal nerve-filaments is well illustrated 
 in cases of atrophic rhinitis and malignant disease. Here the nerve- 
 endings are destroyed, in the one case by atrophy, in the other by the 
 substitution of neoplasm. In all cases of anosmia the sense of taste is 
 likely to be impaired. Excessive tobacco-smoking will sometimes im- 
 pair the sense of smell. The pressure of nasal polypi not infrequently 
 will destroy the sense also. 
 
 When the anosmia is the result of atrophic rhinitis, a thorough 
 and systematic treatment of the latter is not infrequently followed in 
 the end by restoration of the olfactory sense. Joal records two cases 
 as cured by douches of carbonic acid. He applied it through a caout- 
 chouc tube, the effect being first, irritant and then resolvent. 
 
 When the cause is central, there is little hope of cure. Still, the 
 galvanic current may be useful and also courses of treatment by 
 nerve-tonics such as strychnine, arsenic, iron, and phosphorus. 
 
 In cases associated with hysteria and insanity the affection is of 
 (104) 
 
PAROSMIA. FURUNCULOSIS. 105 
 
 minor moment, and, as a neurosis, may disappear with the restoration 
 of the mind to a normal condition. 
 
 Parosmia. 
 
 This disease, although very rare, may manifest itself in various 
 ways. One of the most common ^s that of hyperesthesia of the olfac- 
 tory nerve, hy which the patient perceives natural odors with exag- 
 gerated intensity. This occurs chiefly in hysterical subjects. An- 
 other way is by perversion of the natural function. The olfactory 
 impressions in cases of this kind are usually of an unpleasant char- 
 acter. The odors complained of are disagreeable, such as carrion, 
 kerosene, greasy rags, etc. It is said that this perverted olfactory 
 ^function is not infrequently found among epileptics and the insane. 
 
 Treatment. — This should be on similar lines to those required 
 in the treatment of anosmia. Still, as its origin is more likely to be 
 central, the prognosis is not so favorable. 
 
 Furunculosis. 
 
 Small boils within the anterior nares are not by any means in- 
 frequent. They produce soreness, redness, and swelling of the end 
 of the nose. They occur most frequently at the outer margin of the 
 vestibule or the inner side of the ala, having their origin in diseased 
 hair-follicles. The most notable symptom is general soreness of the 
 part, with sharp pain produced by blowing or handling the nostril. 
 
 Treatment. — Systemic and local treatment, based on general 
 principles, is recommended. A local application of a 20-per-cent. 
 solution of camphor-menthol in lavolin is recommended by Bishop; 
 also a 12-per-cent. solution of carbolic acid in glycerin. When pus 
 is found, he recommends evacuation, followed by application of 
 yellow-oxide-of-mercury ointment. 
 
 I have found a simpler treatment speedily efficacious. When 
 the little boil, or furuncle, is forming, before pus can have developed 
 at all, a sharp needle should be pressed deeply into its centre. This 
 can be done by the patient without the aid of the surgeon. Then, 
 by vigorously blowing, blood is freely evacuated. This blowing- 
 should be repeated a number of times in quick succession. If blood 
 does not appear, the little operation should be repeated until it does. 
 The evacuation will have relieved the congestion, and healing takes 
 place at once without after-treatment. 
 
CHAPTER XYI. 
 EPISTAXIS. 
 
 This term is applied to all cases of nasal haemorrhage whatever 
 the origin may be. It is of frequent occurrence in childhood; but 
 much rarer in adult life. 
 
 Pathology. — The bleeding usually arises from erosion or rupture 
 of the minute blood-vessels, and in the majority of cases comes from 
 the lower portion of the cartilaginous septum. Chiari believes the 
 majority of cases, particularly in adult life, are tubercular. He gives 
 a record of six, in all of which the microscope proved the tubercular 
 nature of the disease. Hard granulations or tumors had formed on 
 the septum and from these the bleeding had occurred. In malignant 
 •disease haemorrhage may be severe, from any part of the neoplasm, 
 and the same is true of fibroma, only that in the latter spontaneous 
 haemorrhage is more rare, owing to the density of the fibrous tissue. 
 Undoubtedly many cases occur without the system in any way being 
 involved. 
 
 Etiology. — In children the most frequent causes are falls and 
 blows upon the nose. Picking the nose and the insertion of foreign 
 bodies also give rise to it. In deviation of the septum the erosion 
 of the prominent point of the cartilage by particles of dust may 
 produce bleeding, as also may fractures of the nose or the base of 
 the skull. 
 
 Sometimes the haemorrhage may be vicarious in place of sus- 
 pended menstruation. When occurring after the menopause, it may 
 he considered an effort to relieve the distended blood-vessels. 
 
 At other times it may arise from constitutional cachexia, such 
 as pernicious anaemia or purpura haemorrhagica, or again from organic 
 disease of the heart or kidneys, as a premonitory sign of typhoid, and, 
 as already said, as the result of septal tuberculosis. 
 
 Symptomatology. — It often occurs without premonitory symp- 
 toms. In other cases prodromic symptoms of vertigo, headache, 
 throbbing of the temples, etc., precede the venous discharge. Pro- 
 fuse arterial bleeding rarely occurs, except from malignant disease, 
 (106) 
 
EPISTAXIS. 107 
 
 fibroma, or tranmation. As a rule, the haemorrhage occurs only from 
 one nostril. 
 
 Diagnosis. — In this there should be no difficulty if the bleeding 
 occurs while the patient is in a. conscious condition. Frequently, 
 however, slight haemorrhage will occur in the night. If the patient 
 is asleep in the supine position no discharge may escape from the 
 anterior nares. Posterior rhinoscopy even in these cases should re- 
 move the doubt. 
 
 Prognosis. — In minor bleeding the prognosis is always favorable. 
 In diphtheria and the latter stages of typhoid it is not so hopeful, 
 while haemorrhage occurring in malignant disease and purpura may 
 be considered as unfavorable indications. 
 
 Treatment. — If the attack is mild, sitting quietly in a chair with 
 the head tilted slightly backward will often arrest the bleeding. If 
 the patient bends his head forward to cleanse the nostrils of the 
 clotted blood, haemorrhage will commence again; but, let him blow 
 out the accumulations and at once resume the former position, it 
 will be likely to soon cease. 
 
 Cold to the spine, hot applications to the external nose, hot- 
 water douches to the nostril, pledgets of cotton soaked in glycero- 
 tannin or tincture of iron have all been recommended. It is rare, 
 however, that active treatment will be necessary. 
 
 When bleeding threatens to be severe, it is well by means of 
 the nasal speculum and reflected light to search for the bleeding- 
 point and to pack the spot firmly with cotton pledgets alone or 
 saturated with astringents already mentioned. In these cases kite- 
 tailed tampons answer an excellent purpose. Small pieces of aseptic 
 absorbent cotton are tied together by a string at intervals of one inch 
 and a half from each other/ They are all then, after cocainizing the 
 mucous membrane, packed one after another into the bleeding nostril 
 by means of cotton-holder or small curved forceps, until by pressure 
 the haemorrhage ceases. The plug is retained for twenty-four or 
 forty-eight hours. After that the whole or part of the pieces may be 
 withdrawn by gentle traction, a portion being retained to the third 
 day if the return of haemorrhage appeared to be probable. 
 
 In anticipation of the latter, Ingals suggests the use of a strip of 
 iodoform gauze as less likely to become offensive during a prolonged 
 retention. 
 
 For deep packing Gleason also uses a long strip of gauze, soaked 
 in one of the hydrocarbon oils and packed, fold after fold, back as 
 
108 DISEASES OF THE NASAL PASSAGES. 
 
 far as the posterior choanae. Another method, which he considers 
 equally efficacious, in the checking of deep haemorrhage, is to soak 
 a loose piece of absorbent cotton in a 15-volnme solution of peroxide 
 of hydrogen, and to press it along the inferior meatus to the pos- 
 terior naris, as in the first method. He claims that by this means 
 posterior packing can be avoided. 
 
 In post-rhinal haemorrhage from' malignant or fibroid diseases 
 these methods may all fail; then Belloccr's cannula (Fig. 55) will do 
 excellent service. The objection to this instrument when first intro- 
 duced was on account of the curve in the tube. That, however, has 
 vanished, as the instrument now in use is almost straight. The ob- 
 ject aimed at is to plug the posterior naris of the bleeding side first 
 and the anterior naris afterward. The cannula is threaded with a 
 strong cord through the eye of the spring. The thumb-screw is next 
 
 
 HtVJ ' .-. lll RJUL.;jJBl 
 
 Fig. 55. — Bellocq's cannula. 
 
 adjusted so that it will retain the spring within the cannula. Then 
 the instrument is passed along the floor of the inferior meatus until 
 the end projects beyond the velum. The spring is now touched and 
 the cord is at once seen within the mouth. To this cord is fastened a 
 pledget of wool large enough to fit the posterior naris. Then the 
 cannula is withdrawn, the wool pulled through the nostril into posi- 
 tion, and cut loose. In drawing the cotton through the naso-pharynx 
 it can be guided in its course by the finger of the left hand of the 
 operator. 
 
 It is claimed that the cotton plug should be large enough to fill 
 both posterior nares, as otherwise the haemorrhage might continue 
 from the free side. This looks like false logic, as there is no natural 
 communication between the two passages. 
 
 In a case of a severe haemorrhage from nasal fibroma, the only 
 occasion in which I have ever required to use this instrument, I 
 
EPISTAXIS. 109 
 
 plugged the one side only, followed by immediate cessation of the 
 ha?morrhage. 
 
 Another plan of treatment worthy of mention is the insertion of 
 a soft-rubber bag deeply within the nasal cavity, and distending it 
 with compressed air. 
 
 Continuous haemorrhage from ulcerated nodule of the cartilagi- 
 nous septum is best controlled by careful singeing down of the nodule 
 with the galvanocautery. The spot should then be constantly anointed 
 with yaselin until healing takes place. There should be no recurrence. 
 
CHAPTEK XVII. 
 
 RHINOLITHS; FOREIGN BODIES; PARASITES. 
 
 Ehinoliths. 
 
 A ehinolith is a nasal calculus. It is formed by the gradual 
 deposit of the mineral constituents of the normal nasal secretions 
 upon the surface of some foreign body, located within the nose and 
 acting as a nucleus. 
 
 The earliest record of one being removed was reported by Gardi 
 in 1502. It was indefinitely described as being as large as a fir-cone. 
 During the four centuries from then until now more than a hundred 
 have been chronicled. Still, rhinoliths are of rare occurrence and 
 they occur so infrequently that each individual case is usually con- 
 sidered worthy of a record by itself. 
 
 In the matter of history, they follow the same law that governs 
 the formation of calculi in the bladder and other organs of the body, 
 and in most instances some trace of nucleus can be found. It usually 
 takes many years from the insertion of the original foreign body in 
 the nasal cavity to the full development of the rhinolith, as seen 
 when the patient applies to the surgeon for relief. 
 
 Symptomatology. — Sometimes from their size and position they 
 give rise to great deformity. In Hendley's case' the nose was swollen 
 and there was an external sinus from which pus exuded; in BovnTs 
 case facial paralysis and destruction of the hard palate. In Hill's 
 case the rhinolith was very large and had caused extensive rhinitis 
 caseosa. In Marsh's case there was marked deviation of the septal 
 cartilage to the left, behind which the calculus lay concealed. One 
 of the writer's cases, a girl of 19 years, was similarly affected, but in 
 her case it was on the right side. On removing a portion of the 
 hypertrophied and deviated cartilage the stone was discovered be- 
 hind. It was broken in fragments and removed. The nucleus had 
 been a cherry-stone pushed into the nose when the patient was six 
 years of age. In the other case of which an illustration of fragments 
 of exact size is given (Fig. 56) the stone was exceedingly large. It 
 (110) 
 
RHIXOLITHS. Ill 
 
 filled the whole of the inferior meatus and had to be broken up before 
 it could be removed. The nucleus was a button, as shown in the upper 
 right end of the figure. 
 
 One prominent symptom attending all cases of long standing 
 is a sanious, muco-purulent discharge of peculiarly unpleasant odor. 
 It is almost characteristic of the disease and quite different from 
 that produced by atrophic rhinitis. 
 
 Diagnosis. — As the development of rhinoliths is a slow process, 
 they rarely come under observation until adult life. By this time, 
 from their size, the symptoms become severe. In childhood any hard 
 substance found within the nose is likely to be a foreign body, 
 without the calcareous deposit, although both Clark and Baber report 
 cases occurring in children. 
 
 In direct examination the gritty sensation produced by the touch 
 of the probe is indicative of calculus. When curvature of the septum, 
 as in the two cases related, hides the stone from observation, the im- 
 
 Fig. 56.— Rhinolith removed from the left nasal passage of a lady, aged 28, 
 nineteen years after the insertion of the button into the nostril. 
 
 pediment may require to be removed before the diagnosis can be made 
 sure. 
 
 Prognosis. — The enlarged calculus can never be removed except 
 by operation. Surgical relief by one means or other is always possible. 
 
 Treatment. — This is simply the removal of the rhinolith like any 
 other foreign body. This can rarely be accomplished without the 
 crushing or breaking-up process. Fortunately they are not often 
 dense enough to resist the force of compression-forceps, and when 
 that density does exist small lithotrites may be used instead. 
 
 Some operators have found it necessary to enlarge the nasal ori- 
 fice by incision. Others have cut through the soft palate or perforated 
 the hard palate to facilitate removal. But these cases occurred in 
 earlier years; and, with the improved facilities of cocainization, ex- 
 amination, and surgical treatment of the present time, the surgeon 
 should not require to resort to any efforts save per vias natu rales. 
 
 After removal of the rhinolith there may be some haemorrhage 
 
112 DISEASES OF THE NASAL PASSAGES. 
 
 caused by contusion of the soft tissues, but healing is always rapid. 
 Odor entirely disappears and the catarrh almost at once ceases. 
 
 Foreign Bodies. 
 
 Foreign bodies are put in the nose by children, sometimes by 
 hysterical females, and occasionally by insane persons. They have 
 been known also to enter the nose during sudden inspiration, and to 
 have got there by accident of one form or another. In the act of 
 vomiting masses of undigested food have been thrown up behind the 
 palate and into the nasal fossae. Bosworth relates an instance in 
 which he removed a deciduous tooth from a gentleman's nose, which 
 had loosened and been swallowed when a lad. It had probably been 
 vomited and thrown into the naris, causing purulent rhinitis for 
 twenty-five years before the doctor was called to remove it. Lowndes 
 tells of a ring being impacted in the posterior nares of a child of 
 15 months. It was too large to have got there through the nostril. 
 Cotton tampons have been removed after remaining in the nose for 
 years. Young children frequently put buttons, peas, pebbles, etc., 
 into the nose. 
 
 Sometimes if they give little trouble nothing is said about them. 
 If discovered within a year or two they may be found unchanged. 
 But, as is mentioned in the first part of this chapter, if retained, they, 
 in course of time, become the nuclei of rhinoliths. 
 
 Symptomatology. — Profuse sero-mucous discharge accompanied 
 by sneezing are the earliest symptoms. There may also be pain, par- 
 ticularly if the object is rough, angular, or large. Subsequently the 
 discharge from pressure may become muco-purulent and of offensive 
 odor. Obstruction is also a prominent symptom, arising partly from 
 the pressure of the foreign body and partly from swelling produced 
 by the irritation. Toleration, however, in many instances soon occurs, 
 as the body usually lodges in the inferior, or largest, meatus — a region 
 less liable to irritation than the olfactory areas above. The sense of 
 smell is rarely affected. 
 
 Diagnosis. — This can only be made by direct inspection when 
 the patient is either ignorant of the fact or unwilling to tell what he 
 knows. Cocaine should always be used during examination, as it per- 
 forms the double duty of shrinking the tissues and at the same time 
 relieving their sensibility. With the use of a probe aided by re- 
 flected light and nasal speculum, there should not be much difficulty 
 
FOREIGN BODIES. PARASITES. 113 
 
 in diagnosis. In young children a general anaesthetic might be re- 
 quired. The touch of the probe should distinguish it from calculus, 
 while thorough examination should remove all neoplasms by exclusion. 
 Treatment. — An anaesthetic will be required during removal in 
 
 Fig. 57. — Spoon. 
 
 most cases occurring in young children, but in some complete anaes- 
 thesia may not be necessary. The application of a drop or two of 
 solution of cocaine to the mucous membrane will shrink the tissues 
 and facilitate extraction. 
 
 Fig. 58. — Bosworth's nasal forceps. 
 
 A nasal spoon (Fig. 57) in the majority of instances will readily 
 Temove the object, though sometimes mouse-toothed or curved nasal 
 forceps may be required (Figs. 58 to 60). When these fail a snare 
 
 Fig. 59. — Alligator-forceps. 
 
 may possibly be slipped over some projecting point, and render the 
 extraction easier than by any other method. 
 
 Parasites. 
 
 The presence of extraneous or parasitic life within the nasal 
 cavities is very rare in temperate climates, so rare that many rhinolo- 
 
114 DISEASES OF THE XASAL PASSAGES. 
 
 gists have never seen a case, while in tropical countries it is compara- 
 tively frequent. In India alone Lahory collated 91 cases, 2 of which 
 were fatal. In Cloquef s case, a man, after sleeping in an open field, 
 was seized with severe pains in the forehead and with swelling of the 
 face. He was taken to a hospital. Worms commenced to crawl about 
 his nostrils and ears; and on lancing the swollen tissues several 
 plat ef uls are said to have been taken away (Bosworth). The patient 
 recovered with the loss of his eyes. 
 
 Fraenkel says that in temperate climates the presence of ozgena 
 is favorable to the growth of parasites, and that the most active enti- 
 ties in producing the malady are the Musca vomitoria, the Musca 
 carnaria, and the gadfly. 
 
 Goldstein, in the Laryngoscope for December, 1897, graphically 
 
 Fig. 60. — Hartmann's forceps. 
 
 introduces a new insect to the notice of his professional brethren. 
 This is the Compsomyia mac cellar ia, or Texas screwworm-fly. Pro- 
 fessor Williston, of Yale, says that it prevails everywhere from Canada 
 to Patagonia. 
 
 This pest usually confines its ravages to cattle, but sometimes it 
 invades the nasal passages of human beings. Several deaths have 
 been recorded from its effects. In all the known instances, how- 
 ever, in which the eggs of the screwworm have been deposited in the 
 nose or ear there has been either pre-existing ozaena or otorrhoea. 
 The fly deposits its eggs upon decaying animal or vegetable matter, 
 and upon this the fly feeds voraciously. 
 
 Symptomatology. — The symptoms in all cases are pretty nearly 
 alike. These are excessive irritation, excruciating pains, formication, 
 and the appearance of the maggots crawling within the nasal cavities. 
 
PARASITES. 115 
 
 They are very tenacious of life, and will .stick to the walls of the 
 passages with great tenacity. Mnco-purulent and bloody discharges 
 soon follow, accompanied by headache, fever, and other constitutional 
 symptoms. When death occurs it is probably dne to the supervention 
 of cerebral meningitis, possibly aided by the development of septi- 
 caemia, from the extensive suppurations which sometimes occur. 
 
 Treatment. — The best treatment is to curette and pick out the 
 larvae. The screwworm is said to be so tenacious of life that it will 
 live for several minutes in pure carbolic acid. The vapor of chloro- 
 form, if concentrated, will kill them; but care would be required lest 
 in zeal to destroy the parasite the patient should be sacrificed. Ordi- 
 nary washes and sprays are useless. Eigid watchfulness, with oft- 
 repeated extractions of the grubs, aided by cocaine and reflected light, 
 would appear to be the best treatment. 
 
 Schappegrell advises the use of warm oil. He says it destroys 
 the larvae by occluding their respiratory organs. He places the pa- 
 tient in the horizontal position, and fills the nostril with the fluid: 
 olive-oil, albolene, glycolin, etc., and claims to eradicate the worm 
 by careful and painstaking use of this means. 
 
CHAPTEE XVIII. 
 
 NASAL POLYPI. 
 
 These are tumors of the nose, presenting several marked char- 
 acteristics. They have smooth surfaces, are lobulated, but usually 
 are regular in form, each being attached by its own broad or narrow 
 pedicle. The color is grayish blue, sometimes slightly pink. They 
 are tense and elastic to the touch, and are of jelly-like consistency. 
 
 Fig. 61. — Nasal polypi. (After Bosworth.) 
 
 They rarely appear simultaneously for the first time in both nasal 
 fossae, but attack one nostril first. Sometimes, through a long course 
 of years, the other one is never invaded. In other instances the de- 
 velopment of polypi on one side is quickly followed by their forma- 
 tion on the other (Fig. 61). 
 
 Pathology. — This is a subject in which there exists, particularly 
 among recent writers, a considerable difference of opinion. 
 
 Bilbroth classes nasal polypi with the adenomata; Bosworth, 
 (116) 
 
NASAL POLYPI. 117 
 
 Erichsen, and Butler consider them to he myxoma; while J. N. Mac- 
 kenzie says that the change from the normal is not myxomatous, hnt 
 that of simple inflammation. He says that the ordinary mucous poly- 
 pus is an oedematons fibroma, not a myxoma. Jonathan Wright also, 
 after extensive microscopical examinations, has arrived at the con- 
 clusion that true myxomata are never found within the nasal cham- 
 bers, and that the growths usually called by this name are simply 
 the results of chronic inflammation. He finds that, in addition to 
 the degeneration of the stroma and the cedematous infiltration so 
 generally present in nasal polypi, there are also occasionally hyaline 
 bodies or berries. They are confined almost entirely to the stroma, 
 and vary in size from that of a round, white blood-cell to three or 
 four times that diameter. "These bodies are divided symmetrically 
 by sulci, which refracted the light strongly into lobules, compressed 
 into polygonal shapes, apparently by a limiting membrane" (Jonathan 
 Wright). 
 
 Swain has proved histologically that polypi having surface cor- 
 rugations contained a large amount of fibrous tissue, and that, whether 
 in their origin they had a purulent basic foundation or not, no bacilli, 
 cocci, or parasitic bodies seemed to be present in their tissue. Swain's 
 observations seem to have brought out an additional fact: that the 
 histological character of the polyp bears a direct relation to the 
 density of the tissue upon which it grows. He also believes their 
 origin to be inflammatory, involving the pre-existence of an hyper- 
 trophic condition of the mucous membrane. 
 
 Notwithstanding differences of opinion upon fundamental prin- 
 ciples, there are certain pathological conditions in which all agree. 
 The external surface of the polypus is composed of an epithelial layer 
 similar to that of the ordinary mucosa; it may be mixed in character, 
 or either squamous or ciliated, according to circumstances and situa- 
 tion. Within this there is hypertrophy of the structural elements 
 of the mucous membrane and connective tissue, giving a fine reticular 
 frame-work, the meshes of which are filled with semifluid mucin 
 and leucocytes. Glandular tissue may be present, but there is usually 
 a minimum of vascular elements (Fig. 62). 
 
 The site of attachment is usually the internal surface of the 
 middle turbinated. It may be around the margin of the ostium 
 maxillare or along the whole of the lower border of the bone. Some- 
 times they are attached to the inferior turbinated and occasionally to 
 the septum; but these instances are rare. 
 
118 
 
 DISEASES OF THE NASAL PASSAGES. 
 
 Etiology. — Although this subject has engaged the attention of 
 so many keen observers, as has already been said, they do not all 
 agree. The probability is that there are many causes which may lead 
 to the development of this disease. The fact that the mucous mem- 
 
 m¥&^^m^^^§mm^^M 
 
 Fig. 62. — Microscopical section of nasal polypus (200 diameters). 
 a, Stratified ciliated epithelium, h, Reticular frame-work, c, Polynuclear 
 leucocyte, d, Vascular centre, e, Radiating blood-vessels. (Author's 
 specimen by Bensley.) 
 
 brane of the middle turbinated is of softer and more delicate con- 
 sistency than that of the lower, and composed of a finer reticular tis- 
 sue, may make it more liable to this so-called myxomatous hyper- 
 trophy. In a normal condition the tissues of the middle turbinateds 
 
NASAL POLYPI. li ( J 
 
 are in constant condition of serous exosmosis. The membrane in 
 some cases may be easily overdistended, and, if from any cause in- 
 hibition is lost at a given point, there is nothing to prevent the dis- 
 tension increasing, with proliferation of cell-elements. 
 
 TToakes believes the large majority of cases to be the result of 
 necrosing ethmoiditis, while Griinwald considers the formation of 
 polypi to be secondary to empyema of the accessory cavities. Mc- 
 Bride considers them to be simply cedematous fibromata, to be dis- 
 tinguished from papillomata by their density, color, and site of origin, 
 but to be the same in character and cause. Zuckerkandl suggests that 
 they originate as adenomata, but that during development some of 
 the ducts become occluded, resulting in myxomatous degeneration of 
 glandular tissue. Somewhat in opposition to all these views, Jonathan 
 "Wright and Swain, of this continent, maintain that the disease is, in 
 all cases, a result of chronic inflammation of the mucous membrane. 
 
 My own conviction, based on personal clinical experience, is that 
 the etiology cannot be confined to any one cause. In the large ma- 
 jority of cases that I have seen, where the polypi were large and 
 numerous, there was no sinous disease. On the other hand, cases of 
 antral disease that I have attended were usually affected also with 
 polypi of the adjoining middle turbinated; but these polypi were 
 always small, and after the healing of the sinus the polypi ceased to 
 return. Hence they were purely secondary results, quite different 
 from multiple myomatous disease. 
 
 Nasal polypi are said to occur more frequently among males than 
 females. They rarely occur in early life, although one of the most 
 severe cases I ever saw occurred in a little girl aged 7 years, from 
 whom I removed about twenty from the two nostrils; Fig. 63 gives 
 a microscopical section. Her mother stated that she had been 
 troubled with them from the age of two and a half years; and that 
 for more than a year after that she was under the constant care of 
 a specialist, who removed them as rapidly as they appeared. This 
 case, I think, was undoubtedly congenital. The rarity of these cases 
 is evident from Moure's statistics, for, out of 10,520 cases of nasal 
 polypi, only 5 occurred among children. This is strikingly brought 
 out by Dunbar Eoy in an able article reporting a case. 
 
 Symptomatology. — Two noted authors give directly opposite 
 statements as to first symptoms. Bosworth says: "The first and 
 earliest symptom is tense irritation in the upper air-passages of the 
 cavity, manifesting itself in more or less violent attacks of sneezing. 
 
120 
 
 DISEASES OF THE NASAL PASSAGES. 
 
 accompanied with watery discharge/' Lennox Browne says: "Sneez- 
 ing is seldom exhibited, immunity from this disagreeable symptom 
 being doubtless due to a blunting of the sensibility of the nerve- 
 endings." 
 
 I think the fact is that we so rarely see cases of nasal polypi 
 when they commence to form that we cannot tell whether they are 
 accompanied by sneezing or not. When the patient first presents 
 himself for treatment, it is usually for the relief of unilateral catarrh, 
 associated with more or less nasal stenosis and frontal compression. 
 In some instances we are astonished at the small amount of apparent 
 
 ±% 
 
 ;r 
 
 m 
 
 %^ i t" 
 
 Fig. 63. — Microscopical section of nasal polypus from a child 7 years old. 
 (Author's specimen by Bensley.) 
 
 distress which large masses of polypi will produce. The reason of 
 this is obvious: they always form in the middle turbinated region 
 and by their presence and pressure expand the upper portions of the 
 nasal fossae. By this means the lower turbinal regiou is also ex- 
 panded, giving compensatory space; and it is not until they are 
 large enough to drop downward that breathing is interfered with. 
 
 The sense of smell is likewise seriously affected in the majority 
 of cases. 
 
 Not infrequently nasal polypi give rise to reflex disturbances. 
 This is particularly the case with hay fever and asthma; and the 
 truth of the statement is proved by the history of numerous cases 
 
NASAL POLYPI. 121 
 
 in which these affections have been relieved by the removal of the 
 offending cause. Aprosexia, or lack of power of concentration, is also 
 sometimes a result. 
 
 The ocular and aural disturbances induced by the pressure of 
 nasal polypi are not so much of a reflex character as owing to direct 
 pressure upon contiguous structures in the case of the eye and inter- 
 ference with the normal condition of the Eustachian tube in that of 
 the ear. 
 
 Diagnosis. — This can only be made by direct inspection; and,, 
 no matter how easily seen the growth may be, it is better to make a 
 thorough examination by reflected light. To the experienced observer 
 scarcely anything else can be mistaken for polypus. To the inexperi- 
 enced it is widely different. Sometimes the polypi are deeply seated 
 and may be hidden by a deformed septum, or the inferior turbinated 
 may be so enlarged as to hide them from view. The application of a 
 solution of cocaine will, in a few minutes, remove these difficulties 
 and facilitate examination. The bluish-gray color and shining sur- 
 faces of the polypi should easily be recognized. Then by using the 
 probe they can readily be moved and their surfaces indented. When 
 the polypi extend backward into the posterior choanae, they can always 
 be examined by aid of the post-rhinal mirror. Here, on account of the 
 color of the two being nearly the same, hypertrophy of the posterior 
 end of the inferior turbinated might be mistaken for polypus; the 
 corrugated surface of the former, however, as compared with the 
 smooth shining surfaces of the latter, should make the diagnosis 
 certain. 
 
 Prognosis. — Nasal polypi involve but little danger to life. They 
 produce, however, a great deal of physical distress, while they ex- 
 hibit little, if any, tendency toward spontaneous arrest of development. 
 "While a catarrhal condition of the mucous membranes is produced 
 by their presence, the most serious results that may be expected are 
 the development of hay fever and asthma by reflex nervous action. 
 To these might be added destruction of the sense of smell, and, also, 
 what is more serious, impairment of hearing caused by pressure of the 
 post-pharyngeal polypi on the Eustachian tubes. 
 
 The longer the disease is neglected, the larger, the more numer- 
 ous, and the more prolific do the growths become. It is also a disease 
 which has a strong tendency to return. Let the polypi be removed 
 as perfectly as seems possible, and in many instances a few months 
 will suffice to have a new crop appear, like young grapes in an old 
 
122 DISEASES OE THE XASAL PASSAGES. 
 
 vineyard. The only wise plan is to keep these cases under constant 
 observation, and by careful operative treatment to remove the polyps 
 as fast as they form. In this way many cures in the end can be 
 accomplished. 
 
 Treatment. — Complete removal of the neoplasms is the only 
 proper treatment, whether accomplished by ablation or destruction, 
 or both. Formerly the application of astringents in the form of 
 powders and sprays to the surfaces of the polypi was largely prac- 
 ticed, but, being practically useless, it has been abandoned. 
 
 Kemoval by cold snare or forceps, and to destroy them by gal- 
 yanocautery or electrolysis are the methods now in use. Of these the 
 cold snare has in every way the preference. It is more widely used 
 than any other instrument, and it produces the best and most lasting 
 results; it is indorsed by such men as Moure, Lennox Browne, Bos- 
 worth, Shurly, Delavan, Schech, MacKenzie, and a host of others 
 (Figs. 33, 34,' 35, 36). 
 
 Fig. 64. — Blake's ear-polypus snare. 
 
 Jarvis was the first to introduce ablation by this instrument. 
 Since then the steel-wire snare has undergone many modifications, 
 and at the present time there are many varieties in the market. 
 
 The simpler the instrument is, the shorter its shaft and handle, 
 and the more easily it can be manipulated, the better. The chief 
 points in selection are to have the instrument light and strong; with 
 the handle placed at an angle with the shaft, so as not to obscure 
 the vision of the parts while operating; and to have it so hung that 
 in the large majority of cases it can be manipulated for the removal 
 of the polypus entirely by the one hand. 
 
 Personally I have in my armamentarium a number of expensive 
 instruments highly recommended. They are handsome, highly 
 polished, and indicative of scientific knowledge and skill on the part 
 of their inventors. But I rarely use them. I have tried them over 
 and over again on different occasions; but they are all so cumbersome 
 rnd unsatisfactory that they lie in the case, simply to be looked at; 
 
NASAL POLYPI. 123 
 
 and I do all my work now with two or three ear-polypus snares of 
 almost the same pattern. I find them quite capable of grasping and 
 removing the largest nasal polypus even when filling the posterior 
 ehoana. They are almost identical in form and size with Blake's 
 ear-polypus snare (Fig. 64). 
 
 In operating cocaine should always be used, not only to anaes- 
 thetize the parts fully, but also to shrink the tissues and render the 
 vision of the fossa as perfect as possible. It is best to throw in a 
 ■i-per-cent. solution first, and then apply a 10- or 15-per-cent. solution 
 by means of a cotton-holder. 
 
 In adjusting the snare care should be taken not to have the 
 loop much larger than the circumference of the polyp to be inclosed. 
 Then, as the attachment is always on the external, and not in the 
 septal, side, the lower rim of the loop should be outward as it is 
 passed into the nasal cavity and slipped under the lower margin of 
 the polypus. By a gentle back-and-forward movement and gradual 
 tightening of the loop, it can usually be slipped up to the neck of 
 the polypus; then the wire is drawn home and by traction the body 
 removed. 
 
 This is only a general rule of operation, and must be modified in 
 detail according to the number and positions of the different polypi 
 and the experience of the operator. After cleansing the fossa of dis- 
 charges that may occur, the routine may be repeated over and over 
 again at the one sitting, until all that are visible are removed, or until 
 it seems advisable to postpone the conclusion of the work. As a 
 rule, the hamiorhage is slight, but occasionally it may be more severe; 
 and in some cases tampons might require to be inserted to hasten 
 its control. I have never, however, seen a case where this was neces- 
 sary. 
 
 How thoroughly the removal of the visible polypi from one or 
 both nostrils at the one sitting may be accomplished depends a good 
 deal on the ability of the patient to stand the combined effects of the 
 cocaine and the operative treatment. In any case I believe it is 
 better to have the patient return at intervals of two or three days regu- 
 larly until all the polypi are extracted. I have frequently seen cases 
 where I have taken away all that I could see on the one day, and on 
 the reappearance of the patient, forty-eight hours later, another series 
 were visible in the lower part of the middle meatus. These were 
 not of new formation; but had merely availed themselves of the open 
 space produced by the previous evulsion and by gravitation and press- 
 
124 DISEASES OF THE NASAL PASSAGES. 
 
 lire from above had made themselves visible. Some authorities advise 
 to wait a week before operating the second time. Why should this 
 be done? The patient often comes fifty or one hundred miles to be 
 relieved of his nasal trouble. Time is precious to him; and it would 
 seem to be our duty to relieve him as thoroughly as possible during 
 the limited period at his disposal; and we may be able to do this by 
 operating on alternate days until the work be accomplished, provided 
 that the reaction from each operation has subsided before the next 
 one is done. During the intervals between operations I have found 
 my patients rendered much more comfortable by the repeated use of 
 a spray of simple albolene. 
 
 When the nostrils are pretty thoroughly cleansed of polypi, it 
 is advisable to again apply cocaine; and, upon drying the parts, little 
 fragments and stumps of polypi may still be visible. These should 
 be touched with the galvanocautery; and it can be done with but 
 slight injury to the surrounding mucosa. The healing is rapid and 
 attended by little or no discomfort. 
 
 Bosworth says that: "If we thoroughly extirpate the growths 
 they do not recur." This is contrary to my own experience and to 
 that of a large number of rhinologists. Some operators are more 
 skillful and more successful than others; but, as a rule, you may re- 
 move every vestige of polypus that can be found, you may ablate 
 completely and watch the case for weeks or months without the 
 slightest apparent return, but let two or three years pass by, particu- 
 larly in young people, without any treatment, and in a large number 
 of cases, upon examination, you will find a reformation of the 
 growths. This may not be on account of incomplete extirpation; 
 but from the fact that, although you can eradicate the disease, you 
 may not be able to eradicate the innate tendency to its development. 
 
 Casselberry strongly favors removal of the anterior end of the 
 middle turbinated by scissors, forceps, and curette, when the polypi 
 form, as they frequently do, directly around the hiatus semilunaris. 
 This gives much greater freedom of access to the bases of the polypi, 
 and permits of more thorough eradication. 
 
 I do not mean to say that this disease cannot be cured, for I 
 believe it can; but that, to thoroughly destroy the tendency, each 
 case should be seen often enough to nip the buds as they form, and 
 by this means eventually to break up the habit. 
 
 The difficulty is that patients experience such complete and 
 gratifyiug relief after thorough operative treatment that they do not 
 
NASAL POLYPI. 125 
 
 take cognizance of the slow return, and frequently put off the visit 
 to the surgeon until a large number of polypi have again developed. 
 
 The second method of treatment, that of evulsion by forceps, is 
 the oldest method of operative procedure, and is still largely prac- 
 ticed. Many forms of this instrument have been devised. The blades 
 should be narrow and strong, as well as serrated, or toothed, and set 
 at a similar angle to the nasal saw and polypus-snare and for the 
 same reasons. Seilers tube-forceps are also said to serve a good pur- 
 pose. 
 
 The chief objection to the forceps operation is the injury so likely 
 to be inflicted upon the mucous membrane by its use: a consider- 
 ation so largely absent in the careful use of the snare. If the surgeon 
 decides to operate with the forceps, it becomes his imperative duty 
 to exercise the greatest care in order to produce a minimum of injury. 
 
 In operating, after cocainization, aided by speculum and mirror, 
 the forceps should be closed and gently inserted until the neck of 
 the polypus is reached and carefully seized. Then by a twisting rotary 
 motion it is detached and withdrawn. The operation is to be re- 
 peated until all the polypi are removed. There is more tearing in 
 this operation than with the snare and consequently more bleeding. 
 So that, as a rule, a smaller number can be removed at one sitting. 
 
 The galvanocautery-snare had numerous advocates among the 
 earlier writers for the effectual removal of nasal polypi, Yoltolini, 
 Michel, Brims, and others being earnest advocates of the method. 
 Later writers, however, do not approve of it, the chief objection being 
 the difficulty of adjusting the soft and pliable platinum wire to the 
 neck of the polypus. In place of it the elastic spring of the cold-steel 
 wire has found almost universal favor. 
 
 One other method of treatment must be mentioned which has 
 been received with some favor by several recent writers; this is treat- 
 ment by electrolysis. Two methods of application are advocated: one 
 is to attach the positive pole of the battery to a needle to be inserted 
 into the polypus, while the negative pole with sponge electrode is 
 placed over the nose; the other is to pass both needles into the poly- 
 pus side by side. The current in each case should be continued for 
 ten or fifteen minutes at each sitting. The process is a very tedious 
 one, and for this disease of doubtful utility. 
 
CHAPTER XIX. 
 PAPILLOMA. 
 
 As already stated iii the preceding chapter, the pathological 
 difference in the construction of nasal polypus and nasal papilloma 
 is very slight. The elementary tissues are the same in each, the dif- 
 ference, according to McBride, being dependent very much upon 
 density of construction and site of attachment, their microscopical 
 characters being very much alike. The papilloma is the result of pro- 
 liferation of epithelial and connective-tissue elements. When found 
 near the entrance of the nostril, the growth is firm and dense in 
 structure and covered with squamous epithelial cells. When deeper 
 within the cavity, the covering is of columnar cells and the papilloma 
 is of softer texture (Hopmann). 
 
 The usual site is the anterior portion of the nostril, either upon 
 the inferior turbinated, the septum, or the floor of the nose. They 
 are supposed to be caused by irritation of one form or another. Still, 
 as they resemble cutaneous warts in method of growth, as well as 
 structure, it is difficult to trace the etiology. 
 
 They are not of frequent occurrence, although much has been 
 written about them. Their growth is slow and painless, and fre- 
 quently the only knowledge the patient has of their existence is 
 from digital examination. The annoyance which the discovery has 
 produced may induce the patient to have them removed. Sometimes, 
 like their congeners, warts on the hands or face, they may appear in 
 numbers: and produce a certain amount of stenosis, with local irrita- 
 tion and muco-purulent discharge. 
 
 In regard to prognosis, operation is said to have been followed 
 by death in two cases. In Ward's case the patient died of pneumonia 
 twelve days later, though what connection existed between the two 
 phenomena we are left to conjecture. In YerneiuTs case death 
 seemed to have resulted from an extension of the tumor. With these 
 exceptions, the results of operative treatment have apparently always 
 been successful. 
 
 Treatment. — This is simply removal of the growth, either by 
 (126) 
 
PAPILLOMA. 127 
 
 snare, scissors, or knife. The main object is to remove the neoplasm 
 in its entirety and with as little irritation to the surrounding mucosa 
 as possible. In the majority of instances this can be accomplished by 
 means of the cold-wire snare. As a rale, no after-treatment is re- 
 quired. If, after ablation, any prominent tissue is left or the removal 
 is incomplete, the base should be touched with the galvanocautery. 
 "When near the margin of the nostril, it would be well to apply vaselin 
 occasionally for a day or two to allay irritation. 
 
 In my own practice I have seen but one case. This occurred in 
 a lady aged 35 years. It was located on the floor of the right inferior 
 meatus, and would occasionally bleed. It was clipped off with scis- 
 sors and without using cocaine, and healed without further treatment. 
 
 In the majority of cases it would be better to use a local anaes- 
 thetic before operating. 
 
 Bilateral Tumors of the Septum. 
 
 Pegler (Journal of Laryngology, Rhinology, and Otology, October, 
 1898) divides these growths into two varieties: the lymphoid and the 
 erectile. Their chief interest lies in their etiological relationship to 
 nasal obstruction, paresis of the soft palate, and sigmatic dyslalia, or 
 affections of speech. 
 
 Of the lymphoid variety the author reports one case. This con- 
 sisted of a growth on each side of the septum, about three millimetres 
 from the posterior border. The tumors were attached by a broad, 
 tough pedicle, and projected into the naso-pharynx. They were oval 
 in shape, pale in color, and mammillated on the surface. Microscop- 
 ically they consisted solely of lymphoid tissue, incapsuled by ciliated 
 epithelium. There were no adenoids, but large hypertrophies of the 
 middle and inferior turbinateds were present. 
 
 The erectile variety appeared as parallel longitudinal ridges, ex- 
 tending along the septum from before backward at the level of the 
 tubercle. They, too, are broad-based, pink in color, and sometimes 
 lobulated. Microscopically they are composed of erectile tissue, min- 
 gled with masses of lymphoid cells. 
 
 The treatment of the lymphoid tumors was removal by cold snare 
 and spokeshave, aided by the finger in the naso-pharynx. The erectile 
 growths were excised by means of a curved, probe-pointed tonsil-knife, 
 the snare being used to engage what had escaped abscission. 
 
CHAPTEE XX. 
 
 FIBROMA. 
 
 The majority of cases of fibroma affecting the air-passages are 
 to be found in the naso-pharynx. Still, an examination of the liter- 
 ature upon the subject will prove that it sometimes does occur 
 within the nasal cavities, and the reports of something like fifty cases 
 have been published. 
 
 Pathology. — Fibroma, wherever found, presents the same essen- 
 tial pathological features. Its chief constituents consist of close- 
 grained fibrous tissue, with stellate cells scattered between the bundles. 
 The fibrous tissue is chiefly white, with yellow, elastic fibres inter- 
 lacing through it. Bilbroth has shown that the starting-point of 
 development is in the nerve-sheaths and walls of the small arteries. 
 As the growth develops, the nerves shrink away, while the arteries 
 become enlarged. This will account for the comparative insensibility 
 of nasal fibroma, together with its tendency to repeated haemorrhages. 
 Sometimes myxofibroma appears from the first, and the excessive 
 arterial supply may, in others, lead to formation of angiofibroma. 
 
 Etiology. — The rich supply of nerves and blood-vessels within 
 the nose may have a causative relation in the etiology of this disease, 
 particularly as it is in the nerve-sheaths and adventitia of the arteries 
 that it makes its first manifestation. Traumatism is, in some cases, 
 the exciting cause. It occurs more frequently among males than 
 females, and it is most prevalent during the earlier years of life, — 
 say, between the ages of 15 and 40 years, — though no period of life 
 is exempt. In Jobson Home's case the patient was a woman aged 
 70 years, while Sikkel's case was congenital, being present at the birth 
 of the child. 
 
 Symptomatology. — The chief symptoms are gradually-increasing 
 stenosis of one nasal fossa, attended by frequent haemorrhages, and 
 occurring during the earlier years of life. The closure of the nasal 
 cavity increases as a result of the growth of the neoplasm. The 
 attacks of bleeding are sometimes very frequent as well as persistent. 
 The slightest touch upon the tumor may give rise to it. 
 
 Other symptoms, the result of pressure, are observed as the dis- 
 (128) 
 
FIBROMA. 129 
 
 ease advances. Such as anosmia, from compression of the olfactory 
 nerve-filaments; deafness, from closure of the Eustachian tube; or 
 epiphora, from pressure upon the lacrymal duct. Facial and palatal 
 deformity are also frequently present from the same cause. 
 
 Diagnosis. — Examination with the nasal speculum should reveal 
 the front surface of the tumor. Application of cocaine will shrink 
 the surrounding tissues, and after removal of secretions by the cotton- 
 holder a good vision should be obtained. The color should be a pale- 
 reddish pink, some parts brighter in color and ready to burst with 
 the contained blood. When in a state of quiescence and unirritated, 
 the white, fibrous tissue may, in some cases, be seen beneath the 
 glistening surface. The growth is usually smooth, lobulated, and 
 irregular in form, its limits well defined, and its attachment sessile. 
 The body of the growth is firm and not easily moved, though touch- 
 ing by the probe may not infrequently produce haemorrhage. The 
 posterior side of the tumor can usually be examined by aid of the 
 rhinoscopic mirror, when displacement of the normal tissues may 
 be observed, as a result of the enlargement of the neoplasm. 
 
 The relentless growth of fibroma is one of its characteristics, 
 and in this it resembles sarcoma. The more irregular contour, with 
 the presence of greater pain and a larger amount of surface-sloughing, 
 should distinguish the latter; but it will require microscopical exami- 
 nation to complete the diagnosis. 
 
 Prognosis. — Without successful operation the result will always 
 be unfavorable. The steady advancement of the growth upon all the 
 surrounding tissues, muscles, cartilages, and bones, and its nearness 
 to the vital points, — arteries, nerves, and brain, — render a fatal re- 
 sult inevitable. 
 
 With operative treatment many cases have permanently recov- 
 ered; and when the fibroma can be entirely removed the prognosis 
 is hopeful. The operation itself, however, is not without danger. 
 A number of cases are recorded in which death was directly the 
 result, and in most of them from the haemorrhage itself, at the time 
 of the operation. 
 
 Treatment. — Local treatment by way of sprays and powders is 
 useless in this disease. Electrolysis, however, as reported of one case 
 by Ingals and another by the writer, has been used with advantage in 
 reducing the size of the growth and in facilitating more radical meas- 
 ures. Wnether or not it can be made available for complete removal 
 remains to be seen. 
 
130 DISEASES OF THE NASAL PASSAGES. 
 
 When the tumor can be embraced by a cold-wire snare or the 
 galvanoeantery-ecraseur (Fig. 37), there are no better means of oper- 
 ating at our disposal. Of the two, as in the case of nasal polypi, 
 the steel wire is more readily adjusted than the pliable platinum, and 
 in the use of the one or the other each case must be judged upon its 
 merits. The slow compression of the steel wire will probably do 
 more for the prevention of haemorrhage than the more rapid adjust- 
 ment of the cautery-snare, although the latter might have a better 
 effect in destroying the base of the tumor. 
 
 Owing to the broad, sessile base which so often occurs, Cassel- 
 berry's device, of notching the base of the fibroma at each side by 
 the galvanocautery-knife (Fig. 38), and then adjusting the steel 
 snare into the notches and round the growth, may suit some of these 
 cases. 
 
 In some cases the neoplasms have been so large and difficult to 
 reach that the surgeon has resorted to direct dissection by operating 
 upon the nose or through the palate in order to reach the seat of the 
 disease. 
 
 Still, in all cases, no matter how operated on, the great danger 
 of haemorrhage at the time has to be met. In Gerdy^s case and in 
 Seilers both died on the table from this cause. 
 
 In a case the history of which I read before the laryngological section 
 of the American Medical Association at Baltimore, in 1895, the patient almost 
 bled to death in my office at the commencement of operation from galvano- 
 cautery incision into the growth. The man, aged 22, had been treated by a 
 surgeon for a bleeding growth in his nose five years previously. Several at- 
 tempts were made at that time to remove it, but each time there was excessive 
 haemorrhage, followed by rapid growth of the tumor. A section was removed 
 for microscopical examination and it was pronounced sarcoma. Subsequently 
 he went to a hospital in one of the Atlantic cities to have it removed. This 
 would appear to have been successfully accomplished, for it did not recur again 
 until about a year before he came to me for treatment. 
 
 On examination I found the posterior half of the right nasal fossa filled 
 with a grayish-red growth. In front of it was a wide cavity with complete 
 absence of inferior turbinated bone: probably removed at the former opera- 
 tion. The attachment was widely sessile, extending over the upper part of 
 septum, vault above, and middle turbinated. Posteriorly it pressed the palate 
 downward, the septum to the left, and the Eustachian tube backward. 
 
 As it was impossible to snare it, owing to its wide attachment, I con- 
 cluded to try successive operations with the galvanocautery. The first opera- 
 tion was at the lower septal attachment, incising upward. There was little 
 bleeding. Two days later the operation was repeated at the outer margin. 
 This time the bleeding was severe, and I inserted kite-tailed tampons to control 
 
FIBROMA. 131 
 
 it. One week later I incised the central portion between the two former cuts. 
 In a "few seconds, while the instrument was still in position, arterial blood 
 commenced to jet vigorously from the nose; kite-tailed tampons were resorted 
 to again, without avail. Dr. Reeve kindly came to my assistance and we 
 plugged the nostril from behind with Bellocq's cannula (Fig. 55). The patient 
 was in a collapsed condition, and was confined to bed for several days, at the 
 end of which time I removed the plugs and commenced the use of bipolar 
 electrolysis. The needles were inserted a quarter of an inch apart through the 
 anterior naris into the growth. This was repeated at several sittings, produc- 
 ing pallor of the growth and slight shrinkage. Then the current was changed, 
 one straight needle being inserted through the anterior naris into the growth 
 and a curved needle passed behind the palate and into the tumor from behind. 
 The seance in each case was from three to five minutes, all the patient could 
 endure, although 20-per-eent. solution of cocaine had been applied. 
 
 I then returned to the use of the galvanocautery-knife, and little by little 
 destroyed the whole of the growth without further accident. -There were six- 
 teen operations in all, covering a period of two months. One-half the opera- 
 tions were through the anterior naris; the other half, though performed 
 through the anterior naris, were guided by light reflected from the post-rhinal 
 mirror. 
 
 Twice over microscopical sections were made, and they proved the growth 
 to be a close-grained fibroma. 
 
 This is now four years after the operation, and there has been no return. 
 
 It is but rarely that fibroma of the nose is quite pure in its for- 
 mation. Frequently there is a combination with myxoma, sarcoma, 
 or angioma, or else the so-called soft fibroma of Stoker or Victor 
 Lange, composed of vascular papillary growths of the middle and 
 inferior turbinateds. 
 
 Probably one of the most characteristic cases of pure fibroma 
 that has occurred was the one reported by Charles Knight. It was 
 composed of dense fibrous tissue, with collections of small, round 
 cells of inflammatory origin near certain points of its surface, and 
 it was noted by its absence of vascularity. It was pedunculated and 
 its removal easily accomplished by cold-wire snare. There was no 
 recurrence. 
 
CHAPTEE XXI. 
 
 ADENOMA; ANGIOMA. 
 
 Adenoma. 
 
 Adenoma of the nasal passages is so exceedingly rare that any- 
 thing more than an allusion to it will not be necessary here. The 
 name indicates that it is a growth of glandular character; and, as 
 the glands within the nasal cavity are few in number and only limited 
 in action, it can readily be seen that tumors of a glandular nature in 
 this region must of a necessity be infrequent. 
 
 Still, that they do occur is verified by several instances that 
 have been recorded; and as one reported by Gosselin gives the his- 
 tory, pathology, and treatment of the case, I will repeat it as de- 
 scribed by him : — 
 
 "A man, aged 43, presented with the following history: Early 
 in 1857 he developed nasal stenosis, for which he sought relief at 
 the hospital, early in the April following, when a number of polypi 
 were removed. A second operation of the same character was done 
 in October. In February, 1858, he was seen by Gosselin, who found 
 the right nasal passage completely closed by a tumor which presented 
 at the nostril and also projected into the pharynx. It was of firm 
 consistency and grayish in color, the surface being soft and pul- 
 taceous. It was attached in front and above. An operation being 
 decided upon, access to the cavity was obtained by external incision, 
 and the growth extracted by means of forceps and manipulation. 
 The operation was attended by but slight haemorrhage. Microscop- 
 ical examination showed the growth to be composed of 'abundant 
 epithelial cells with glandular cul-de-sacs,' on which the diagnosis 
 of a glandular tumor was based. The operation was successful and 
 the patient left the hospital apparently cured." 
 
 Angioma. 
 
 When we consider the exceedingly vascular nature of the nasal 
 mucosa, we would naturally be of the opinion that it would be prone 
 to the development of angiomatous tumors. Still, very few cases have 
 (132) 
 
ANGIOMA. 133 
 
 been recorded, probably not more than 20 in all. Among the most 
 recent is the one reported to the Laryngological Society of London 
 in March, 1896, by St. Clair Thomson. It was removed from the 
 right middle meatus of a man aged 29. The growth was the size of 
 a hazel-nut, irregularly ovoid, and lobulated. It was attached by a 
 bluish pedicle to the right cartilaginous septum and removed by snare. 
 There was free haemorrhage, checked by the galvanocautery. Eecur- 
 rence took place. This was also removed. Microscopical sections 
 were made, proving the tumor to be an angioma. 
 
 Pathologically these sections were almost completely surrounded 
 by normal columnar epithelium. In some parts immediately beneath 
 the epithelium there was loose connective and myxomatous tissue; 
 while in other parts the epithelium lay directly on the new growth. 
 This was composed almost entirely of blood-vessels of very different 
 sizes whose walls were formed of cells, and did not contain either elastic 
 or muscular tissue. The stroma between the vessels consisted of loose 
 fibrous tissue, with oval and spindle cells, which were of uniform char- 
 acter throughout, and arranged around the vessels, among which was a 
 good deal of extravasated blood. 
 
 This account of the histological conditions of Thomson's case 
 does not differ materially from the pathology of the disease described 
 by Bosworth years ago. 
 
 The etiology is doubtful, it being difficult to assign a definite 
 cause, either active or predisposing. Bosworth suggests that it may 
 arise from disturbed nutrition of the vascular walls. It occurs during 
 all ages of life. 
 
 The symptoms are similar to those attending nasal fibroma, ex- 
 cept that the softer character of the growth will prevent nasal de- 
 formity by pressure. Angioma differs also from fibroma in not being 
 dangerous to life and in being more readily amenable to treatment. 
 
 Treatment. — About the only treatment recommended is removal 
 either by the steel wire or galvanocautery-snare. The former is con- 
 sidered the best, as by slowly tightening the wire haemorrhage may 
 be avoided. Jarvis's snare, with its nut-screw, is believed to be the 
 best adapted to the treatment of these cases, placing the wire as high 
 as possible upon the pedicle. 
 
CHAPTEE XXII. 
 CYSTOMA OF THE NOSE. 
 
 Delavan reported in 1895 three cases of this somewhat rare 
 affection. They were all cases which had been for years affected with 
 nasal polypi and in which, after repeated operations for their re- 
 moval, cystoma had eventually developed. In one case the growtli 
 hung out of the nasal fossa into the post-pharyngeal space. It was 
 round, and about an inch in diameter, and was removed by Jarvis's 
 snare. In the other two cases all efforts to remove them were un- 
 availing until the growths had been punctured. Then a large amount 
 of fluid drained away and, the walls collapsing, they were removed 
 by snare or polypus-forceps. Microscopical examination of the rem- 
 nants, made in each case by Dr. Hodenpyl, proved them to be com- 
 posed of columnar and ciliated epithelium, glandular matter, fibrin, 
 and cell detritus, diagnosing each case as loose fibroma. The fact 
 that each of them contained ciliated epithelium would prove their 
 origin from the middle or lower turbinateds. 
 
 The cases of Johnson, Watson, and Lefferts, as reported by Bos- 
 worth, were also of middle-turbinal origin (Fig. 61). 
 
 Brown Kelly (Journal of Laryngology, Rliinology, and Otology, 
 June, 1898) gives a report of an entirely different series of cases of 
 cystoma of the nose. The situation of development is the floor of 
 the fossa; and as no full account has heretofore been published, 
 together with the history of his cases, he gives a sketch of the disease. 
 
 It always occurs in females. At any rate, the twelve cases, up to 
 the present time reported, have all appeared in women, the ages 
 being between nineteen and fifty-eight years. The site of formation, 
 likewise, is always the same, being the outer floor of the nostril, 
 anterior to the inferior turbinated body, and just behind the union 
 of the skin with the nasal mucous membrane. The appearances within 
 the nose vary only in degree. When the cyst is small, it forms a gray- 
 ish hemispherical eminence, about the middle or outer half of the 
 floor. As the sac enlarges, it extends backward, and also downward 
 into the incisor fossa, but verv rarely toward the septum. 
 (134) 
 
CYSTOMA OF THE NOSE. 135 
 
 The views as to etiology are largely speculative, but it has usually 
 been considered as the development of a retention-cyst, probably the 
 result of inflammatory action. 
 
 As to treatment, when the cyst is small, incision or aspiration, 
 with or without the injection of an irritant, will suffice. If the dis- 
 charge continues, the application of caustics or the destruction of the 
 lining membrane of the cavity by galvanocautery may be called for. 
 When the cyst becomes large, its excision from the gingivo-labial fold 
 would be required to produce a cure. In two of the cases reported 
 by Brown Kelly simple incision was all that was needed. In the third 
 incision was followed by return, and the cyst was eventually excised. 
 
CHAPTER XXIII. 
 CHONDROMA; OSTEOMA. 
 
 Chondroma. 
 
 Most of the cases of cartilaginous enlargement within the nose 
 that come under observation are merely hypertrophies of the cartilag- 
 inous septum, and cannot be placed under this head. The t5rm 
 "chondroma" is confined to those cases of round nodulated tumor 
 occasionally met with which macroscopically resemble fibroma, but 
 which on closer examination are found to consist of cartilage. They 
 are usually found at the anterior, inferior angle of the cartilaginous 
 septum. 
 
 The etiology of these growths is still unknown. The period of 
 their development is during the adolescent years of life. The symp- 
 toms are similar to those produced by benign neoplasms. They differ, 
 however, from fibroma and angioma by being unattended by haemor- 
 rhage and by their yellowish color. To touch they are hard and 
 cartilaginous, but the pressure of a needle will distinguish them from 
 the still greater hardness of osteoma. In structure they are com- 
 posed of hyaline cartilage, combined with white fibrous and yellow 
 elastic tissue. 
 
 Simple surgical treatment is required, the object being removal 
 of the growth. Whether this is done by snare, scissors, curette, gouge, 
 or knife is immaterial, so long as the tumor is completely excised. 
 There appears after successful operation to be no tendency to return. 
 
 Osteoma. 
 
 Osteoma requires to be distinguished from exostosis, as the latter 
 term applies to bony outgrowths of the septum, at the sutural junct- 
 ure of the vomer with the perpendicular plate of the ethmoid, or 
 the palate, or maxillary bones, while the former is restricted to osseous 
 neoplasms, having their origin independent of sutural union. They 
 are usually located in the upper portion of the nose, having their 
 origin in the bones of one or other of the accessory sinuses. 
 (136) 
 
OSTEOMA. 137 
 
 Pathology. — In some cases the osteoma is made up entirely of 
 hard, compact tissue. In others the body of the bone is cancellous 
 and covered with a close and compact layer. In Adenot's case the 
 tumor was an osteogenic exostosis, with a chondromatous envelope. 
 In Coakley's it was exceedingly hard, springing from the inferior 
 turbinated, and of tertiary syphilitic formation. 
 
 Etiology. — The etiology is unknown. Possibly it may arise from 
 some constitutional dyscrasia. The period of its greatest frequency 
 is early life. The majority of cases are said to occur in males. 
 
 Symptomatology. — External deformity is one of the earliest 
 symptoms. This is owing to the situation of the growth, being in the 
 upper part of the nose. Hence, stenosis, one of the earliest symptoms 
 produced by the majority of benign nasal neoplasms, may be late in 
 appearing. Pain is likely to occur, owing to pressure upon the nerve- 
 filaments. In Adenot's case, epileptic seizures, produced by reflex 
 action of tumor, were relieved, after vertical osteotomy had been per- 
 formed. Epistaxis and nasal discharge are neither of them likely 
 to be troublesome. The point of origin is frequently in the neigh- 
 borhood of the ethmoid cells, and may be from little islands of car- 
 tilage or bone in the mucous membrane. 
 
 Osteomata are usually irregularly lobulated and covered with 
 mucous membrane. When the growth has space enough to develop 
 itself without infringing upon surrounding bony structures, it will 
 remain free and rounded. It is when its development becomes im- 
 peded by osseous resistance that it becomes lobulated or flattened. 
 If from any cause its attachment becomes fractured, it may remain 
 within the nasal cavity as a foreign body. 
 
 Treatment. — Osteomata differ from other nasal neoplasms in the 
 fact that they usually require external operations to accomplish their 
 removal. This is owing to the density and size of the growth and 
 the difficulty in reaching the site of attachment. The surgical oper- 
 ation required to reach the growth is sometimes more difficult than 
 the excision itself. This must be conducted upon ordinary surgical 
 principles. When the tumor is reached, the chisel, saw, or forceps, 
 may readily separate the neck from its attachment. Haemorrhage, 
 which is sometimes severe, requires to be guarded against. 
 
CHAPTEE XXIV. 
 
 SARCOMA. 
 
 Foktunately this malignant disease rarely occurs within the 
 nasal fossa. Although the majority of eases occur in mature life, the 
 average age of patients afflicted with it is less than in carcinoma, 
 while the younger the patient, the greater the malignancy and the 
 quicker the fatal result. The usual site is the septum, but it may 
 arise from the turbinateds or any other portion of the nasal cavity. 
 
 Pathology. — The pathological history of sarcoma of the nose does 
 not differ from that of other regions of the body. It originates from 
 the meshes of connective tissue and is filled with round, ovoid, and 
 fusiform cells, the round often prevailing. Myeloid and large granu- 
 lar cells are often present in large numbers. When the granular 
 structures of the mucous membrane have undergone proliferation in 
 connection with the development of round- or spindle- celled elements, 
 adenosarcoma may result. In other instances, proliferation of the 
 stellate mucous cells, together with the sarcomatous elements, would 
 indicate myxosarcoma; while in cases where the ordinary blood- 
 vessels are lost, and vascular spaces are found instead, in connection 
 with the sarcomatous development, angiosarcoma is the result. 
 
 Etiology. — The history of the forty-one cases collected by Bos- 
 worth, and another dozen that have been recorded since then, throw 
 little light upon the subject. Some were preceded by nasal polypi, 
 which might bear a causative relation to the development of the 
 malignant disease; but a very large number arose de novo, and with- 
 out assignable cause. Some writers believe that surgical traumatism, 
 in the way of galvanocautery and forceps operations, is, in some in- 
 stances, a cause. As an objection to this idea, it may be argued that 
 a large number of the severest cases of sarcoma occur in the earlier 
 years of life, when prior nasal operations have not been thought of. 
 Personally I have never seen a case of malignant disease of any kind 
 which could in any way be traced back to operative treatment. 
 
 Symptomatology. — The first and most prominent symptom is ob- 
 (138) 
 
SARCOMA. 139 
 
 struetion to nasal breathing. This is soon followed or accompanied 
 by a foetid mucous discharge. The color is often greenish and haemor- 
 rhage frequently occurs. This odor arises in part from decomposed 
 retained secretions. Pain, although not necessarily severe, is of fre- 
 quent occurrence and is due to pressure. When located in the an- 
 terior region of the nose, there may be great deformity. When in 
 the posterior, deafness and dysphagia may result. When in the upper 
 and middle turbinal region, destruction of the cribriform plate of 
 the ethmoid and extension of the disease to the brain may lead to a 
 fatal issue. 
 
 Sarcomata bleed easily when touched with a probe. They have 
 no resiliency, and have a reddish color, frequently assuming a bluish 
 or violet tinge. They occur singly and may be either pedunculated 
 or have a broad or sessile base. 
 
 Diagnosis. — The malignancy of the growth can scarcely escape 
 recognition after careful rhinoscopic examination. The soft pulta- 
 ceous tissues, with reddish-gray surfaces, foul odor, and offensive dis- 
 charge will, in many instances, at once stamp the nature of the dis- 
 ease. But, when occurring in mature years, nothing but microscop- 
 ical examination will positively distinguish it from carcinoma. 
 
 Prognosis. — It is a hopeless disease save for the relief that may 
 be obtained from operative treatment. When taken early and thor- 
 oughly removed by operation, there is a fair prospect of recovery. 
 One-half the cases reported up to the present time are said to have 
 been cured. This statement must be accepted with much reservation, 
 as many of the reports were obtained but a short time after operation 
 and before there could well be a recurrence of the disease. 
 
 Treatment. — Complete extirpation when the disease is not too 
 far advanced for operation is the only correct method of treatment. 
 Without there is good prospect of this being accomplished, it should 
 not be attempted at all. With regard to the nature of the operation, 
 each case must be a rule for itself. 
 
 When the removal can be made through the anterior nares, with- 
 out facial operation, it is much the better plan to follow, taking the 
 neoplasm away by snare, curette, spoon, cautery, etc., or all combined, 
 as the case may require, always guarding against the possibility of 
 excessive haemorrhage. This method can only be available in the 
 very earliest stages of the disease, the parts being anaesthetized by a 
 strong solution of cocaine. 
 
 In other instances, however, primary surgical operations through 
 
140 DISEASES OE THE XASAL PASSAGES. 
 
 the nose or soft palate will be required before the base of the growth 
 can be reached. Having eradicated the tumor, the parts are replaced 
 by regular surgical methods and the internal wound treated as the 
 conditions of the parts may require. 
 
CHAPTEK XXV. 
 
 CARCINOMA. 
 
 Babe as is sarcoma within the nasal cavity, still more rare is the 
 more malignant disease carcinoma. The average age of persons 
 afflicted with it is also somewhat greater, although, as in sarcoma, the 
 period of childhood is not entirely exempt. The thirty cases carefully 
 collected by Bosworth were all of primary origin, and the same may 
 be said of the cases of Hinde, Max Thorner, Haton, Dreyfuss, Flatan, 
 Domoe, Syne, Hopkins, and Lennox Browne which have occurred 
 since the issue of Bosworth's work. That is to say, in each of these 
 cases the epithelioma made its appearance first within the nasal cavity. 
 
 In all these cases the only elaboration of the carcinoma was by 
 extension, and not by formation of new foci in distant regions. As 
 secondary carcinoma of the nose, I have so far not been able to find 
 a case on record, although extension to the nose from the neighboring 
 organs might possibly occur. 
 
 Pathology. — As in sarcoma, the pathology of carcinoma is the 
 same wherever found. When near the cutaneous surface, the cancer 
 may be a squamous epithelioma (Verneuil). Deeper within the cavity 
 the adeno-epithelial type may be developed, as in the case recently 
 reported by Max Thorner. Throughout the growth an enormous 
 mass of tubuli or alveoli will be found surrounded by connective and 
 epithelial tissue and filled with colloid substance. 
 
 Etiology. — Hereditary influence is probably the most potent 
 primary cause in the development of cancer. Granting this, we know 
 that physical injury is frequently the exciting cause for its develop- 
 ment in other parts of the body. Possibly the reason of its extreme 
 rarity in the nose is the infrequency of severe traumatism in that 
 region. It is a disease which rarely occurs until after middle life. 
 The possibility, however, of the development of malignant disease 
 from either myxoma or fibroma of the nose is now an acknowledged 
 fact. 
 
 Symptomatology. — The symptoms are almost identical with 
 those produced by sarcoma of the nasal passages. The submaxillary 
 glands are more likely to be involved, the cachexia to be more 
 
 (141) 
 
142 DISEASES OF THE NASAL PASSAGES. 
 
 marked, and the progress of the disease more rapid, while the average 
 age of the patient is greater. But the stenosis, the offensive and fonl 
 discharges, the deformity, and the internal appearance of the growth 
 are very much alike in both diseases. 
 
 Diagnosis. — The diagnosis must depend materially on microscop- 
 ical examination, the resemblance to sarcoma being so great that the 
 distinctive cancer-cells would need to be discovered to insure a posi- 
 tive opinion. From tuberculosis and syphilis the clinical history 
 should be sufficiently positive to make the diagnosis certain, par- 
 ticularly with microscopical aid. 
 
 Prognosis. — The prognosis is the worst that can be expected, 
 except in exceedingly rare cases where the disease has been recognized 
 and promptly removed upon its earliest manifestations. Even in 
 these cases speedy recurrence is more than a possibility. 
 
 Treatment. — The majority of cases do not come under observa- 
 tion until after the disease has become thoroughly seated and the 
 deep-lying tissues involved. In such cases operation would be useless, 
 and would only induce more rapid development. All that could be 
 done reasonably would be in the way of soothing antiseptic applica- 
 tions, such as cocaine, aristol, iodoform, iodol, etc., together with 
 systemic support. 
 
 In early cases, when there is freedom from glandular enlarge- 
 ment and a fair prospect of complete eradication, it would be the duty 
 of the surgeon to extirpate at once, and by the most available means, 
 as already described in dealing with sarcoma, the main features of 
 the operation being to avoid undue injury to surrounding parts, bear- 
 ing in mind the possible evils of traumatism upon already-weakened 
 tissues. A large number of these cases occur in the ethmoid region, 
 and one can see how hopeless radical operation would be even in 
 the most initiatory stages. In very few instances has operation been 
 successful even in giving temporary relief, while in not a few it has 
 hastened the final issue. 
 
CHAPTEE XXVI. 
 TUBERCULOSIS. 
 
 As ax indication of the rarity with which tuberculosis attacks 
 the nasal passages, Willigk, out of 426 autopsies upon the bodies of 
 persons who had died of tuberculosis, found only 1 case in which the 
 disease had affected the nose; and Weichselbaum, out of 164 similar 
 autopsies, found only 2. On the other hand, rare as the disease is in 
 this region, Eeidel reported 2 cases in which primary tuberculosis of 
 the septum existed for years, without the lungs being in any way 
 affected by the disease; and William Hill in 1896 reported 1 of 
 tuberculosis of the inferior turbinated in which disease of the lung 
 was so slight that he mistook the nasal disease to be malignant, and 
 performed turbinectomy. The patient did well, although subsequent 
 microscopical examination proved it to be a case of tuberculosis. 
 Symonds, Watson, Williams, and Sach have all reported cases of 
 primary septal origin. 
 
 Pathology. — The exhaustive investigations of recent patholo- 
 gists, particularly of such men as St. Clair Thomson and Hewlett, 
 have thrown new light upon the subject of nasal pathology. These 
 gentlemen proved that about 500 litres of air, containing, on the 
 average, 1500 bacteria, are inspired every hour by each person. Thir- 
 teen healthy individuals were examined. As the vestibule of the nose 
 contains vibrissas and is lined by membrane, partly integumentary 
 and partly mucous, they made one series of cultures and cover-glass 
 preparations from the vestibule and another series taken from the 
 mucous membrane deeper within the fossa. The result was that, while 
 in the first series they found a large number of micro-organisms, in 
 the second they found very few, 80 per cent, of them being sterile, 
 having no micro-organisms at all. The natural conclusion is that 
 the comparative immunity of the nose from such diseases as tuber- 
 culosis, cancer, sarcoma, syphilis, etc., is due in some measure to the 
 bactericidal properties possessed by the phagocytes of the nasal 
 mucosa. 
 
 There are two forms in which tuberculosis of the mucous mem- 
 brane of the nose may present themselves. In the one ulceration 
 
 (143) 
 
144 DISEASES OF THE NASAL PASSAGES. 
 
 may take place, either on the septum or on the floor of the inferior 
 meatus. In the other, hyperplasia, with a sessile base, may appear 
 upon the septum, the inferior turbinated, or the outer wall. Ulcer- 
 ation follows, surrounded by pale granulations. There is usually 
 more or less round-celled infiltration, together with nucleated epi- 
 thelial cells. Tubercle bacilli are frequently few in number. 
 
 Etiology. — The disease usually occurs as a secondary deposit, 
 following pulmonary tuberculosis. In some cases the method of at- 
 tack is said to be by autoinfection, from contact of the sputum during 
 coughing with an excoriated septum. In others it occurs through 
 the lymphatics. One case is reported by Chiari to have been caused 
 by infection from the antrum of Highmore. In some cases the germs 
 must have come from without, dust, laden with bacilli, being de- 
 posited upon abraded mucous membrane near the anterior nares. 
 
 Symptomatology. — When hyperplasia has taken place, it is of a 
 grayish-red color, soft and protruding, bleeding easily, and of irregu- 
 lar outline. It is often covered with mucus or crusts, with a tend- 
 ency to ulceration. When ulceration takes place, crust-formation is 
 likely to be troublesome. Stenosis is often present, but there is no 
 pain. The usual discharge is that of grayish mucus, the amount 
 depending on the severity of the ulceration. 
 
 Diagnosis. — Tuberculous ulcers wherever found always present 
 similar appearances. The color is usually whitish gray. There is 
 little loss of tissue, the centre being only slightly depressed. The 
 border is irregular in outline. There is never any areola round the 
 ulcer, and the bruish-red tinge gradually blends imperceptibly with 
 the surrounding mucosa. The irregular crusting and bleeding of the 
 nose are produced by the drying and irritating effects of respiration. 
 The neoplastic form of tubercular disease, usually found in the in- 
 ferior turbinated, presents an appearance of little, grayish-red warts, 
 and must be distinguished from papilloma by being smaller, flatter, 
 and softer. Microscopical examination will usually discover tubercle 
 bacilli, though in small numbers. 
 
 Prognosis. — In a large majority of cases this is purely a second- 
 ary matter, depending upon the progress of the primary pulmonary 
 lesion. It is usually slow of development, and may continue for years 
 without serious results, the comparative fatality of pulmonary, laryn- 
 geal, and pharyngeal tuberculosis not applying to the protected cham- 
 bers of the nose. The local lesion can frequently be readily removed, 
 but is apt to return. 
 
TUBERCULOSIS. 145 
 
 Treatment. — When neoplasms and granulations have formed, 
 free operation by curetting and cauterization is advisable. For ulcer- 
 ation, applications of lactic acid in 25- or 50-per-cent. solutions are 
 useful, as also are chromic acid, sulphoricinate of phenol, formalin, 
 and trichloracetic acid after previous cocainization. 
 
 Supporting measures are also required. The aim should be to 
 supply as large an amount of nutriment to the system as the digestive 
 forces would have power to assimilate. Of medicines, codliver-oil, 
 iron, and strychnine are all useful. But perhaps, of all, carbonate of 
 creasote is the best for its systemic and antiscorbutic effects. It con- 
 tains 90 per cent, of creasote and, being almost inodorous and non- 
 irritant, can be readily taken. It is said not to be decomposed until 
 it reaches the duodenum, where it gradually splits up and is absorbed. 
 The dose is 1 to 2 grammes two or three times a day. It can be 
 taken readily in sugar or in codliver-oil, in doses of 10 or 15 grammes 
 of the latter. 
 
CHAPTER XXVII. 
 
 LUPUS; GLANDERS. 
 
 Lupus. 
 
 Sometimes, though rarely, lupus may occur primarily within 
 the nasal fossa; but usually the external nose or the palate is affected 
 first, and the disease extends backward or forward into the nasal 
 cavity. 
 
 Pathology. — The essential pathological change in this disease is 
 the deposit of round cells of granulation-tissue in the meshes of the 
 mucous membrane. This deposit, or infiltration, is gathered in little 
 masses or nodules, and seems to follow, in a measure, the course of 
 the blood-vessels. In addition to the characteristic round corpuscles 
 of lupus giant corpuscles also occur. As the nodules rise above the 
 surface they ulcerate; but the nodular reproduction beneath is more 
 rapid than the surface-desquamation; consequently, unless the dis- 
 ease is checked by medical or surgical treatment, the proliferation 
 of the neoplasm is in excess, and the nasal passages become blocked 
 by the development of the disease. Schuller has found irregular 
 chains of micrococci among the granular cells and extending into 
 the surrounding connective tissue. Neisse was the first to demon- 
 strate the presence of tubercle bacilli; and, as more recent investi- 
 gations have frequently discovered their presence, the theory that 
 lupus is a species of tuberculosis has been established. 
 
 Etiology. — There is no doubt that the disease arises from the 
 deposit of a specific virus which produces changes of an inflammatory 
 and ulcerative character in the membrane affected, and that a stru- 
 mous diathesis is a prominent factor in preparing the soil for the 
 germ. The majority of cases occur in the early years of maturity, 
 but quite a number even in youth. One is reported at the age of 
 six months, while Reed, Shurly, and Tresilian record cases at the 
 fourteenth year. Most nasal cases attack the cutaneous surface first, 
 and the mucous membrane afterward. 
 
 Symptomatology. — A certain amount of nasal stenosis is always 
 present. After ulceration brownish or greenish-brown crusts form, 
 accompanied by sanious discharges from beneath their edges. On 
 (146) 
 
lupus. 147 
 
 lifting the crusts, blood will exude from the central parts of the 
 nodules. Odor is not marked, but, when it does not occur from reten- 
 tion of the scabs, it is of a musty character. Pain is not a promi- 
 nent symptom, nor is the physical system materially affected. 
 
 Diagnosis. — The peculiar reddish, nodulated appearance of the 
 external nose, with the greenish-brown crusts and characteristic dis- 
 charge, should remove all difficulty in diagnosis when the external 
 organ is affected. Any intranasal lesion will only be an extension 
 of the external disease, the cartilages usually succumbing to its on- 
 ward march. When, however, the mucosa is the only part affected, 
 considerable difficulty may attend the diagnosis, and the truth may 
 only be reached by a process of exclusion. One point should be 
 remembered, however, and that is the peculiar softness of the lupoid 
 growth. It can be easily removed by the spoon and indented or 
 penetrated by the probe. 
 
 From syphilis it can be distinguished by constitutional treat- 
 ment, and from tuberculosis and malignant disease by the history of 
 the case and the general condition of the system. 
 
 Prognosis. — In all cases it is a slowly progressive disease, and in 
 a large measure amenable to treatment when taken early. Very 
 few cases confined entirely to the mucous membrane have been 
 reported as incurable, and they often heal without leaving a scar. 
 This is not so when the cuticle is the seat of the disease, as in these 
 cases cicatrices always are left after the healing process is over. 
 When the lesions are extensive, the prognosis is not so favorable, the 
 development being indicated by the growth of new nodules, in con- 
 tinuous succession into the surrounding tissue. 
 
 Treatment. — Among local applications lactic acid is received 
 with favor. The parts should be first cocainized, and then freely 
 rubbed with a 50-per-cent. solution. This can be gradually increased 
 to 75 or 100 per cent. Care should be taken to apply it to every 
 part thoroughly, the applications being repeated every second or 
 third day. In some cases this is said to destroy the growth. 
 
 Lake has had good results from the administration of thyroid 
 extract in doses of a little over 1 gramme per diem, the disease 
 almost disappearing under its use. 
 
 For years, too, tuberculin has been used with more or less favor 
 by a number of European writers. 
 
 Of directly surgical treatment, evulsion by Volkmann's spoon 
 or a sharp curette has many advocates — dusting the surfaces after- 
 
148 DISEASES OF THE NASAL PASSAGES. 
 
 ward with iodoform or brushing them with lactic acid. Burning the 
 nodules down with the galvano-cautery is advocated by Bresgen. 
 Tresilian successfully treated a case recently by scraping with a sharp 
 spoon, subsequently burning it with galvanocautery, and then brush- 
 ing with 50-per-cent. solution of lactic acid. Dundas Grant also, in 
 one of his latest cases, was equally successful by a similar line of 
 treatment. 
 
 Glanders. 
 
 This is a communicable disease, peculiar to higher animals, par- 
 ticularly horses, and liable to spread to man upon exposure to infec- 
 tion. It is also contagious among men. In its acute form it is very 
 virulent and uniformly fatal. When chronic there is a little more 
 hope of recovery. The usual site of attack is the mucous membrane 
 of the nose, from which it may spread to both pharynx and larynx. 
 The incubation-period is from three to six days. 
 
 Pathologically there is a low-grade inflammation, resulting in 
 formation of granulation-tissue containing large numbers of bacilli. 
 The characteristic germ of glanders is the bacillus Mallei. Rapidly- 
 spreading suppuration and ulceration follow along the line of the 
 lymphatics. Glands become swollen. Pyaemia, necrosis of bone and 
 cartilage, deep abscesses among the tissues, all follow. The discharges 
 are also profuse and offensive. The chronic form differs only from 
 the acute in being somewhat milder. (Kyle.) 
 
 Constitutionally there is marked fever and prostration. The dis- 
 ease may last from fifteen to twenty days, death taking place by coma 
 and collapse. Treatment, although practically useless in the majority 
 of cases, consists of supporting measures, together with antiseptic nose 
 and throat douches and sprays. (Lennox Browne.) 
 
CHAPTER XXVIII. 
 RHINOSCLEROMA. 
 
 This disease occurs but rarely. It is characterized by trie de- 
 posit in all the layers of the skin or miicons membrane of dense, hard 
 nodes, or plates. The first deposits are usually in the neighborhood 
 of the nostrils, gradually extending into the fossae. The progress, 
 from all records of the disease, appears to be steady, irresistible, and 
 almost, if not entirely, uninfluenced by treatment. 
 
 It is believed to owe its origin to the rhinoscleroma bacillus which 
 has been extracted and cultivated by Pawlowsky and Freudenthal. 
 The latter gives a complete history of a case treated by him in 
 1896. It occurred in a Galician Jew aged 45. The nose was of 
 immense size. The right side presented a tumor as large as a hen's 
 egg. It was dark-bluish red, with a few vessels coursing over it and 
 of ivory hardness. There was a separate nodule in the upper lip. 
 The right inferior turbinated was involved in its whole extent, 
 completely occluding the passage. The pharynx was a mass of scar- 
 tissue, the uvula destroyed, and the naso-pharynx and the glottis 
 almost entirely shut off, so that a tracheotomy-tube had to be inserted 
 to permit of respiration. 
 
 ■ There is little, if any, pain in this disease, except when the 
 extension of the growth is very great. Then the physical obstruction 
 to mouth and nose may produce great distress. There is no tendency 
 at any time to ulceration or softening of the tissues. 
 
 In Pean's case the nose was surrounded by dense lardaceous 
 neoplasm. The upper lip had degenerated and the rhinoscleroma 
 had extended through the maxillary and ethmoid sinuses. 
 
 The pathological condition is believed to be one of infiltration 
 into the affected tissue of masses of small, round cells. These cells 
 are gradually transformed into spindle cells, and then into dense 
 fibrous connective tissue. Corneil found a small, rod-like bacillus 
 inclosed in a hyaline capsule, the same that is spoken of by Freuden- 
 thal and Pawlowsky. 
 
 Treatment. — It is usually regarded as entirely incurable. Oper- 
 
 (149) 
 
150 DISEASES OF THE NASAL PASSAGES. 
 
 ative treatment has so little effect that it is considered useless, except 
 when required to restore the possibility of respiration. Internal medi- 
 cation is also useless. Notwithstanding this, Dontrelepont reports a 
 cure from the application of a l-per-cent.-corrosive-sublimate oint- 
 ment twice a day for three and one-half months. As Bosworth 
 remarks: "May this not have been a syphilitic case cured by mer- 
 curial inunction?" 
 
 Pawlowsky treated two cases by hypodermic injections of rhino- 
 sclerin, or the chemical extract of cultures of rhinoscleroma. The 
 injection of the extract in a patient 18 years old produced feverish 
 reaction and swelling of the affected nose. A month later, after 
 15 injections, the plaques were softened and there were signs of acute 
 inflammation. He treated this case for a year, and during that time 
 the disease had not advanced. In a second case treated the same 
 way, although it was not cured, there was during six months no 
 increased development. Hence the author believes, from the history 
 of these two cases, that he has found in rhinosclerin a diagnostic 
 and therapeutic agent for this disease. 
 
 Pean tried surgical treatment in the case of a woman aged 20. 
 By extensive operation he removed the nose and all the upper lip 
 and the turbinated bodies, resecting the ascending part of the maxil- 
 lary bone and curetting the antrum. He approximated the cutaneous 
 flaps. All that was left was a large hole in the middle of the face. 
 Subsequently cauterization of suspicious parts was performed with 
 Canquoin's paste. How long the patient lived we are not informed. 
 
CHAPTER XXIX. 
 
 SYPHILIS. 
 
 The indications of syphilis in the nasal passages are identical 
 with their local manifestations in the other organs of the body, and 
 need not be entered into minutely here. The primary lesion, or 
 hard chancre, is one of the rarest of intranasal lesions. Still, cases 
 are recorded of its occurrence. Its history and appearance, aided by 
 the process of exclusion, should render its recognition easy. 
 
 The mucous patch, although rare, is one of the most frequent 
 manifestations of early syphilis in this region. The tendency of the 
 disease to develop at the muco-cutaneous border-lines of the lip and 
 nostril exists here, as at the anus and vulva, although in the former 
 region the cases are very infrequent. Devasse and Deville, in re- 
 porting 186 females suffering from mucous patch, only found 8 in 
 which the patch affected the nose. 
 
 The superficial ulcer is believed by many to occur only in the 
 secondary stage, two or three years after the primary sore, and to 
 be caused by the softening and breaking down of a mucous patch. 
 Bosworth believes that it belongs to a later date of the disease, and 
 is the result of softening and erosion of superficial gummatous de- 
 posit; particularly as the latter gives so little indication of its pres- 
 ence that it may be overlooked until the attention is drawn to the 
 more notable features of the fully-developed ulcer. The site of super- 
 ficial ulcer is usually the septum or the floor of the nose; but this 
 is not invariably the case. At the present time I have a patient, a 
 married man, who has superficial ulcer of the left middle turbinated 
 and also of the post-pharyngeal wall. 
 
 Bony necrosis is a result of extension of deep ulceration, through 
 gummy deposit, and hence is of a tertiary nature. Among European 
 races it occurs ten or fifteen years after the primary disease. Among 
 some of the earlier races, particularly the Chinese, Arabs, and Mexi- 
 cans, the disease is more virulent and runs a more rapid course. 
 Most of these bony lesions occur upon the septum, the turbinateds 
 coming next; that is, when the muco-cutaneous surfaces are not 
 invaded first. 
 
 10 (151) 
 
152 DISEASES OF THE NASAL PASSAGES. 
 
 Pathology. — Syphilitic lesions, wherever found, are all of an in- 
 flammatory character, and the nasal passages are no exception to the 
 rule. In primary lesion of the nasal mucous membrane the febrile 
 action runs high, and the ulcer may present a large granular mass, 
 filling up the nostril and causing deformity, while the slightest press- 
 ure may produce bleeding. The mucous patch and the superficial 
 ulcer will differ little from their appearance in other regions. There 
 need be no great thickening without the ulceration arises from an 
 enlarged gumma, the chief stenosis being caused by the abundance of 
 muco-pns constantly secreted. 
 
 When the gummy tumor forms, it indicates an active condition 
 of the tertiary stage. There may be large deposit of gummatous 
 material with infiltration or tumefaction of the membrane. No part 
 of the nasal cavity may escape the deposit. The ulcerative process 
 early invades the gumma, and bone as well as cartilage may soon be 
 involved. 
 
 Sometimes surface-ulceration ends in resolution and culminates 
 in cicatrization; but in the majority of cases the underlying peri- 
 chondrium or periosteum partakes in the ulceration, and necrosis of 
 bone or cartilage follows. 
 
 Symptomatology. — When the disease is primary — that is, the re- 
 sult of direct contagion — the ordinary symptoms of chancre may be 
 expected, only in an aggravated degree. There will be inflammatory 
 swelling, pain, difficult nasal breathing, discharge, and considerable 
 fever. 
 
 In the secondary stages, as variously manifested, there will be 
 corvza from mild to purulent. The mucous membrane will be puffy, 
 red. and congested. Greenish-yellow pus will exude from the nos- 
 trils, and, after thorough cleansing, ashy-gray patches may sometimes 
 be seen. 
 
 In the tertiary type ulceration is deep and formidable, being sur- 
 rounded by ragged edges and an angry-looking areola. The cartilages 
 and bones being involved, foul, offensive pus, with shreds of necrosed 
 cartilaginous and osseous tissue, come away, until eventually both 
 cartilage arul bone may be destroyed, leaving unsightly facial de- 
 formity. In the severest cases the triangular cartilage, perpendicular 
 plate of the ethmoid, vomer, and even the turbinateds are all in- 
 volved in the ruin, nothing but Chinese "nose-holes" being left — 
 mere apertures in front of an irregularly-flattened face. 
 
 In one case that came under my observation the whole of the 
 
SYPHILIS. 153 
 
 internal nasal structures had become detached from their surround- 
 ings, and formed into a huge, foetid, movable mass. This occurred 
 in a married woman aged about 30 years. The condition, I was 
 informed, had existed for a number of years and she was not referred 
 for special treatment until a small perforation through the hard 
 palate had formed, allowing the foetid secretions to trickle through 
 into the mouth. The treatment consisted of breaking up the mass, 
 extracting the fragments through the anterior nares, and washing out 
 the cavity. Internally the syrup of the iodide of iron was adminis- 
 tered. 
 
 Diagnosis. — When all other diseases have been put aside by a 
 process of exclusion, a resort to constitutional treatment my help to 
 remove all remaining doubt as to the true nature of the disease. 
 
 Prognosis. — This depends largely upon the extent and severity 
 of the lesions. If the general health has not materially suffered, and 
 the lesions are of a superficial character, treatment should be fol- 
 lowed by the best results. Even when bone and cartilage have be- 
 come involved, when this destruction is merely local it may be 
 possible to arrest it in its progress. And, even in the worst cases, 
 some little good may be expected from judicious and careful treat- 
 ment. 
 
 Treatment. — This is one of the few nasal affections in which 
 systemic medication is absolutely essential to effect complete resolu- 
 tion. Specific treatment, aided by soothing, and cleansing lavage of 
 the nasal fossae, will in many cases effect a cure. The main thing 
 is to commence the internal treatment at once. Then the local treat- 
 ment, to be guided by the requirements of the case, after washing 
 out the nasal cavity with a solution of boric acid, by means of an 
 atomizer:— 
 
 1. I^ Acid, boric 
 
 Aqua 30 
 
 M. 
 
 Aristol or iodol might be thrown into the fossae by insufflators, 
 or the parts might be touched with tincture of iodine. Nitrate of 
 silver fused on the end of an aluminum applicator will frequently 
 control ulcerative action. Galvanocauterization is rarely necessary 
 
 1. Ifc Acid, boric gr. x. 
 
 Aqua I]. 
 
 M. 
 
154 DISEASES OF THE NASAL PASSAGES. 
 
 in this disease. In some cases of extensive ulceration light singeing 
 of the parts exercises a controlling influence. 
 
 As to internal medication, Sajous recommends red iodide of mer- 
 cury in doses of 4 milligrammes three times a day, particularly in 
 secondary affections. After ptyalism has occurred, he substitutes 
 iodide of potassa for the purpose of elimination. In the tertiary 
 form mercury is less effective than the iodide, which should be given 
 in full doses to produce the desired result. 
 
 When mercurials are required, it matters little what special form 
 is used. The main features are to choose the preparation least ob- 
 jectionable to the stomach, to give it in minute doses, and to watch 
 its effect, keeping its influence upon the system thoroughly under 
 control. 
 
 When osseous or cartilaginous necrosis takes place the breath 
 becomes horribly offensive, and operative procedure may become 
 necessary to save the patient from absorption of necrotic material. 
 The sharp spoon or curette in these cases will do the best service, 
 followed by thorough antiseptic and aseptic treatment. 
 
 Supporting measures in the way of tonics, codliver-oil, good 
 diet, daily baths, warm clothing, abundance of pure air, and thor- 
 oughly hygienic surroundings are all of essential benefit. 
 
CHAPTER XXX. 
 
 CONGENITAL SYPHILIS. 
 
 It is still an unsettled question whether a syphilitic father can 
 transmit the disease to his child without affecting the mother at the 
 same time. It is believed, however, that if either parent is affected 
 by the disease at the time of impregnation, the unfortunate offspring 
 will, as a consequence, be the sufferer. 
 
 Symptomatology. — Coryza, together with some diffuse form of 
 cutaneous eruption, is usually the earliest symptom. The coryza, as 
 a rule, is watery at first. There is also swelling of the nasal mucosa, 
 sufficient to impede or prevent nasal respiration. Gradually the dis- 
 charge becomes muco-purulent, producing irritation of the nostrils 
 and upper lip, with crust-formation. The discharge is more irritating 
 than that produced by an ordinary cold. Syphilitic children are apt 
 to be pale and cadaverous looking, and may have the withered look 
 of age even during the first year. This may be partly due to inability 
 to take a proper amount of nourishment, from the too-often careless 
 mother, owing to nasal stenosis produced by the disease. 
 
 Congenital syphilis of the nose usually runs a rapid course. In 
 many cases ulceration of the septum and nasal cartilages quickly 
 follow the coryza. Bone is laid bare, sloughing of tissues and ne- 
 crosis of bone may follow, with foetid catarrh and deformity as direct 
 results. The deformity of saddle-back nose, produced by destruction 
 of the septum and sinking in of the tissues, frequently has its origin 
 in inherited tertiary disease. of childhood. The course of the disease 
 is more rapid in infantile than in adult life, owing to the lessened 
 power of resistance which exists in young children. Among the 
 curious results of this disease is one reported by Gibb Wishart, in 
 which, together with great destruction of the bony frame-work of 
 the nose, there is also the development of a tooth within the nasal 
 fossa. 
 
 Diagnosis. — In the otherwise-healthy child, ordinary acute ca- 
 tarrh of the nasal passages speedily undergoes resolution. Syphilitic 
 rhinitis of childhood, on the other hand, is noted for its continuity 
 and the severity of its symptoms; also for the unhealthy cachexia of 
 
 (155) 
 
15G DISEASES OF THE XASAL PASSAGES. 
 
 its victims. The diagnosis from ordinary purulent rhinitis of child- 
 hood should not be difficult, as syphilitic rhinitis will be manifest 
 during early infancy, whereas purulent rhinitis does not usually ap-' 
 pear before the third year. The syphilitic cachexia, and the char- 
 acteristic cutaneous eruption, also, do not present themselves in the 
 milder disease. 
 
 Prognosis. — The earlier the positive symptoms appear in the life 
 of the infant, the more severe the disease and the less the prospect of 
 recovery. "When the symptoms are manifest at first nasal stenosis is 
 usually so great as to interfere with nursing. Malnutrition is the 
 result, with consequent decay in vitality. The nasal septum soon 
 ulcerates awa} r , and falling in of the bridge may be the result, if the 
 little patient survives long enough to experience the deformity. 
 
 On the other hand, if the disease is lighter, the symptoms ap- 
 pearing later, the nasal tissues may not be destroyed, and under 
 proper treatment there is hope of cure. 
 
 Treatment. — Cleansing and soothing treatment of the irritated 
 and inflamed mucous membrane is very important. To shrink the 
 swollen tissue, by diminishing turgescence, and at the same time to 
 lessen the sensibility of the nerve-filaments, the use of a weak solu- 
 tion of cocaine is advisable. In making the solution, however, it 
 should be remembered that muriate of cocaine and biborate of soda 
 are incompatible, an insoluble borate of cocaine being at once formed. 
 Bicarbonate of soda and muriate of cocaine are also incompatible, the 
 cocaine alkaloid being deposited, and chloride of sodium being left 
 in solution. 
 
 Either of the following prescriptions would, however, answer 
 the purpose: — 
 
 1. IJ Cocaine hydrochlor 12 
 
 Acid, boric |5 
 
 Aquam ad 30] 
 
 M. 
 
 Either of these might be used as a spray to the nares; but a 
 better plan, according to my experience with young children, would 
 be to apply it by means of a pledget of wool upon a cotton-holder. 
 With the child in the recumbent posture, it can be placed within 
 the nostril more effectually and will be received with less opposition. 
 
 1. I£ Cocaine hydrochlor gr. iij. 
 
 Acid, boric gr. vij . 
 
 Aquam ad 3j. 
 
 M. 
 
CONGENITAL SYPHILIS. 157 
 
 Or 
 
 1. B Cocaine hydrochlor 2 
 
 Amnion, hydrochlor 3 
 
 Aquam ad 30 
 
 M. 
 
 might be used in the same way. 
 
 Then, after the shrinkage of the nasal mucosa which a few 
 minutes' action of the cocaine would produce, the following or some 
 similar preparation might be applied in the same way: — 
 
 2. R Thymol 1 13 
 
 Menthol |3 
 
 Albolene 30| 
 
 M. 
 
 The parts by this time being anaesthetized, the child will prob- 
 ably submit to the use of the spray. If not, the cotton-holder can 
 be used with this solution as before, pressing it gently through the 
 nostril to better cleanse the passage. If sneezing is produced by it, 
 a good purpose will have been accomplished, as the sternutatory efforts 
 will involuntarily clear the nostrils of secretions. 
 
 As a local application to the upper lip and inflamed anterior 
 nares, the following has a soothing effect, applied as often as re- 
 quired : — 
 
 3. B Ung. zinci oxidi 
 
 Vaselin alba 
 
 M. 
 
 For ulcerative action within the nostrils aristol, iodol, iodoform, 
 etc., may any of them be used by insufflation after cleansing. 
 
 This treatment, while beneficial to the local manifestation of 
 the disease, can do nothing toward eradicating it from the system. 
 
 1^ Cocaine hydrochlor gr. iij. 
 
 Ammon. hydrochlor gr. v. 
 
 Aquam ad 5j. 
 
 M. 
 
 1$ Thymol gr. ij . 
 
 Menthol « r. v. 
 
 Albolene 31 . 
 
 M. 
 
 I£ Lfng. zinci oxidi 3ij. 
 
 Vaselin alba 3ij . 
 
 M. 
 
158 DISEASES OF THE NASAL PASSAGES. 
 
 This can only be accomplished by constitutional means, and the best 
 of these is the internal administration of mercury. This can usually 
 be accomplished by the stomach. Minute doses of any of the mer- 
 curicals may be given, governed by the fixed rules which guide the 
 administration of these drugs. If the stomach is disturbed by the 
 mercury, inunction may possibly yield better results. 
 
 General rules with regard to food and hygiene should, of course, 
 be enforced. 
 
DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 
 
 CHAPTER XXXI. 
 
 ACUTE SINUSITIS. 
 
 It is generally conceded, with regard to chronic inflammation 
 of different regions of the nose and throat, as well as other organs of 
 the body, that they must of necessity be preceded by acute inflam- 
 matory action of one form or another. Why diseases of the antrum, 
 ethmoid cells, and sphenoid sinus should be exceptions to this rule 
 it is difficult to say. 
 
 As Lennox Browne tersely says, "Acute sinusitis is frequent" 
 although the fact, for which abundant proof has been given, is not 
 as yet generally admitted. 
 
 Weichselbaum, of Vienna, performed autopsies upon the bodies 
 of a large number of patients who had died of influenza. In 90 
 per cent, of these he found evidences of inflammation of one or 
 other of the accessory sinuses. 
 
 Frankel, of Hamburg, likewise performed autopsies upon the 
 bodies of 146 patients, followed by bacteriological examinations of 
 the contents of the sinuses. They were found to be all subjects of 
 sinusitis without one of them being discovered during life. 
 
 Bacteriological examinations have proved that numerous bacilli 
 enter into the development of acute sinous disease. Among these are 
 the diplococcus lanceolatus in the pneumonic form of antral disease. 
 Streptococcus is sometimes found in pure culture. Staphylococcus 
 is usually associated with the other organisms. Bacillus pyogenes 
 fcetidus, bacterium coli, and Aspergillus fumigatus have all been dis- 
 covered in some cases. 
 
 Etiology. — Acute endorhinitis, or, as it is usually called, acute 
 rhinitis, is the most frequent cause of sinous disease. Next to this 
 may be considered the infectious diseases: scarlet fever, measles, 
 typhoid fever, and small-pox. Another cause not sufficiently appre- 
 ciated by the profession is the presence of tampons of absorbent 
 cotton within the nasal cavities, placed there by the surgeon, either 
 to check haemorrhage or as an after-treatment following operation. 
 
 (159) 
 
160 DISEASES OF THE NASAL PASSAGES. 
 
 A severe case of acute purulent sinusitis, arising from the first- 
 mentioned cause, came recently under my observation. It occurred 
 in a physician aged 40. The symptoms were fullness and heaviness 
 in the region of the antrum, with copious discharge through the 
 ostium, particularly upon bending forward. The antrum healed up 
 in a short time without any special treatment other than that re- 
 quired for an ordinary cold. 
 
 The maxillary antrum is the sinus usually affected in this dis- 
 ease, though sometimes the ethmoid cells may be the primary seat 
 of lesion. Sometimes the inflammation may attack the two success- 
 ively. 
 
 Symptomatology. — The subjective symptoms are usually those of 
 acute nasal catarrh, affecting the one side particularly. There may 
 be neuralgia in the region of the orbit, with photophobia and lacry- 
 mation, together with a general feeling of malaise. These symp- 
 toms appear to be amenable to treatment. 
 
 Physical examination without first applying cocaine to shrink 
 the tissues will usually be without avail, owing to the swollen con- 
 dition of the mucous membrane. After the shrinkage, however, if 
 suppuration has occurred, the middle turbinated of the affected side 
 will be seen more or less bathed in pus. There will likewise be 
 tenderness on pressure upon the affected side. 
 
 The majority of cases of acute sinusitis get well without treat- 
 ment, for the simple reason that they pass away without ever being 
 discovered. Still, it is very probable that a large number of cases 
 of chronic sinusitis have originated in the acute form, which by 
 timely treatment might have been arrested. 
 
 As Lermoyez has well said, acute sinusitis is almost invariably 
 amenable to cure without operation, while in chronic sinusitis no 
 remedies are available except the surgical. 
 
 Acute sinusitis is supposed to last about eight days, subacute is 
 extended to two or three weeks, while a longer existence merges it 
 into the chronic disease. 
 
 The proportionate danger arising from acute inflammation of 
 the antrum, ethmoid cells, and sphenoid sinus is in the inverse ratio 
 to their frequency. Acute disease of the antrum, although the most 
 frequent, is the mildest in type, owing to its greater distance from 
 the meningeal membranes. The ethmoiditis is more severe on ac- 
 count of danger of inducing basic meningitis and orbital complica- 
 tions, while acute inflammation of the sphenoid sinus, although so 
 
ACUTE SINUSITIS. 161 
 
 Tare as to be almost unknown, is supposed to be the gravest of all 
 when it does occur, owing to the possibility of inducing cavernous 
 thrombosis. 
 
 Treatment. — This should be along the lines already indicated 
 for the treatment of acute rhinitis. Mild catharsis in the commence- 
 ment of the disease, followed by x / 4 -gramme doses of quinine two 
 or three times a day, together with tablets for the night-time, com- 
 posed each of 1 / 2 centigramme of morphia and 1 / 10 milligramme of 
 atropia, repeated every two or three hours until sleep is induced, 
 may be considered an advisable course of systemic treatment. When 
 fever is present drop-doses of tincture of aconite every hour has a 
 good effect. 
 
 Local treatment by 2-per-cent. spray of cocaine will relieve the 
 intranasal congestion, the astringent effect of which may be prolonged 
 by following it with spray of 2 per cent, of menthol in albolene. This, 
 repeated as often as required, will favor freedom of discharge and 
 hasten the healing process as the slight fever abates. 
 
CHAPTER XXXII. 
 CHEONIC DISEASE OF THE ANTRUM OF HIGHMORE. 
 
 The antrum of Highmore, being the largest of the nasal acces- 
 sory sinuses, and the one most frequently affected with purulent dis- 
 ease, is worthy of the most careful consideration (Fig. 66). The term 
 indicates a chronic inflammatory condition of the mucous membrane 
 lining the superior maxillary sinus, attended by the formation of pus. 
 This gradually fills the cavity, and, having no other outlet, when 
 the purulent matter reaches the height of the ostium maxillare it 
 trickles over into the middle meatus, beneath the middle turbinated 
 body, and is discharged by the anterior and posterior nares. 
 
 Pathology. — At the commencement of the disease the mucous 
 membrane of the antrum is slightly swollen and hyperasmic. Some- 
 
 Fig. 65. — Caseous mass washed out of antrum through 
 ostium maxillare. 
 
 times the blood-vessels rupture in different places, causing little spots 
 of ecchymosis. As the disease advances, the membrane thickens, 
 in some cases becoming infiltrated and in others covered with granu- 
 lations. Not infrequently cedematous nodules form, which in time 
 take on 'the myxomatous aspect, until clusters of small polypi may 
 be found hanging round the internal border of the ostium. Kanthack 
 records a case of polypoid growth within the antrum. Symonds 
 found several in one antrum varying between, one and two centi- 
 metres in length. Both says antral polypi are scarce. In the Annals 
 of Ophthalmology and Otology for 1896 I reported a case in which 
 what seemed to be soft polypi were washed out through a large 
 hiatus semilunaris, the nozzle of the syringe being placed in one end 
 of the passage. The accompanying cut (Fig. 65) gives the exact size 
 of the largest, after being in alcohol over two years. Microscopical 
 (162) 
 
Fig. 66. — Lateral frozen section through the middle region of the nose. 
 1. Ethmoid cells. 2, Superior turbinated. 3, Middle turbinated. 4. 
 Antrum of Highmore. 5, Union, or synechia, between septum and inferior 
 turbinated. 6, Inferior turbinated bone. 7, Hard palate. 8, Tongue. 0. 
 Middle meatus. 10, Inferior meatus. (From Primrose's Anatomical 
 Museum. University of Toronto.) 
 
CHRONIC DISEASE OF THE ANTRUM OF HIGHMORE. 1G5 
 
 examination of the same at the present time proves it to be nothing 
 but a mass of caseous matter, composed of cell detritus and poly- 
 nnclear leucocytes. Cases occasionally occur in which the fluid of 
 the pus becomes absorbed and the cellular elements undergo fatty 
 degeneration. This is the caseous form of the disease, and it is ac- 
 companied by numerous bacteria, such as staphylococcus pyogenes 
 and sometimes Aspergillus fumigatus. 
 
 Sometimes in advanced cases the periosteum becomes unusually 
 active, and little juttings and spiculse of bone will grow and project 
 out into the antral cavity, even in rare cases bridging it across and 
 by formation of their lamellas dividing it into sections. In rare 
 cases, also, cysts form by distension of lymph-spaces or ducts within 
 the antrum (Fig. 68). 
 
 Etiology. — The old tradition handed down for generations, that 
 decayed teeth were the usual cause of antral empyema, is advocated 
 by Moldenhaur, Fraenkel, Beverly Eobinson, and others, while Zucker- 
 kandl, Chatellier, Demochowski, Schiffers, etc., believe in its intra- 
 nasal origin in a large majority of cases; and this accords largely 
 with my own experience. Bosworth doubts the probability of actual 
 extension of the disease from the nasal fossa into the maxillary sinus, 
 but is of the opinion that the majority of cases arise (1) from 
 closure of the ostium from pressure of nasal polypi, (2) from pressure 
 of enlarged middle turbinateds, and (3) from extension of disease 
 from carious teeth; while Nyles is of the opinion that the nose and 
 teeth are about equal as causal factors in grave forms of the disease. 
 
 M. Saint Hilaire reports two cases {Journal of Laryngology, 
 August, 1898) of empyema of the antrum of Highmore caused by 
 plugging the nasal fossae. One occurred in a lady, aged 52, who had 
 been suffering from albuminuria for two years. To check a severe 
 attack of epistaxis Bellocq^s cannula was used, plugging the anterior 
 and posterior ends of the passage. In two days severe pain occurred 
 in the suborbital region. The anterior plug was removed and two 
 days later the posterior one also, but the antrum was full of pus. 
 And three months later operation for its relief was performed. 
 
 The other was in a woman of 39. The nostril was plugged to 
 check violent epistaxis. This, owing to similar pain as that of the 
 first case, was removed two days later. Pain and oedema disappeared, 
 but in a few days the antrum filled with pus, which could be seen 
 in the middle meatus. 
 
 Symptomatology. — If the disease is caused bv inflammatory ac- 
 
166 DISEASES OF THE NASAL PASSAGES. 
 
 tion and secretion of pus induced by closure of the ostium, the cavity 
 will in time become full, and pain from the pressure of retained 
 secretions will result. When it arises from caries of the teeth, the 
 ostium not being closed, the discharge escapes through the outlet 
 and pain does not become so early or prominent a symptom. In 
 either case, however, the jaw may be tender on pressure, and the 
 teeth on the affected side may have a fullness and soreness on 
 closing. Sooner or later foetid, creamy-colored discharge makes its 
 escape, and flows from the nostril. The odor, one-sidedness, and 
 color are characteristic of sinus disease. The point is to ascertain 
 positively the source of its origin. 
 
 Diagnosis. — The diagnosis of antral disease is frequently obscure, 
 and consequently a positive conclusion can rarely be arrived at upon 
 the first examination. The presence in one nasal cavity of pus of a 
 creamy color, and possessing an unpleasantly aromatic odor, while 
 the other nasal cavity is free, is always sufficient to indicate that 
 suppurative disease exists in one or other of the accessory sinuses. 
 
 The question is whether the disease is frontal, ethmoidal, antral. 
 or sphenoidal? Sometimes, too, the muco-purulent discharge pro- 
 duced by the presence of nasal polypi, associated with atrophic dis- 
 ease, simulates the pus of antral suppuration. Foreign bodies and 
 rhinoliths may also give rise to a somewhat similar discharge. 
 
 After cleansing the nostril the application of cocaine to the 
 mucous membrane should materially aid in diagnosis. 
 
 Its astringent action upon the tissues will make the presence or 
 absence of polypi certain. The same may be said of foreign bodies. 
 These being excluded, the next question is: which sinus is affected? 
 After thorough cleansing and shrinkage, the presence of a drop of 
 creamy pus in the middle meatus, just external to the lower border 
 of the middle turbinated, is almost of diagnostic value. If the pus 
 is farther back and visible in the posterior nares, it may have come 
 from the diseased sphenoid sinus. If farther forward in the vicinity 
 of the infundibulum, from the ethmoid cells or frontal sinus; but 
 in both the latter the tissues of the orbit would be likely to be 
 affected. This rarely occurs in simple antral disease. When the 
 quantity of pus is large, even after cleansing, whatever its origin, it 
 may extend to all these locations, and the diagnosis becomes more 
 difficult. Sometimes by bending the head forward, the exit of the 
 pus from the ostium may be verified by examination with the nasal 
 speculum immediately afterward. 
 
CHROXIC DISEASE OF THE ANTRUM OF HIGHMORE. 167 
 
 The neuralgias which arise from sinusitis, wherever located, are 
 not of much diagnostic value. Still, there is an uncomfortable feel- 
 ing, a sensitiveness on pressure, and a tenderness of the affected jaw 
 in closing the teeth, any of which may be caused by antral disease, 
 but not by suppuration of -the other sinuses. 
 
 Moreau Brown gives one sign in diagnosis which in my experi- 
 ence has been of little value. He says that after cleansing the pus 
 away by a pledget of cotton, pressure upon the facial wall of the 
 maxillary sinus will produce its reappearance. The maxillary bone 
 seemed to be uninfluenced by any pressure which it seemed safe to 
 make. 
 
 Irrigation is also recommended as an aid to diagnosis. That is, 
 by passing the point of a Eustachian catheter attached to a syringe 
 into the ostium and washing out the cavity with warm water; the 
 
 Fig. 67. — Electric illuminator with flexible shank and cords. 
 
 pus discharged would indicate the presence of the disease. It may, 
 however, be remarked that when the passage is sufficiently open to 
 admit the introduction of the catheter the pus can usually be seen 
 issuing from the ostium without the use of the instrument. 
 
 Exploratory puncture as a method of diagnosis has always re- 
 ceived a certain amount of favor. . It is made either through the in- 
 ferior meatus, the canine fossa, or the oral cavity, between the second 
 bicuspid and the first molar teeth, and internal to them. With all 
 the present means of exploration at command, it is doubtful whether 
 puncture will ever be frequently required in the future. Chiari, in 
 giving the history of one hundred cases, says that the rhinoscopic 
 examination gave such excellent diagnostic results that he only re- 
 quired to puncture fourteen times through the inferior meatus, to 
 insure a correct diagnosis. 
 
 Of all the aids to diagnosis, probably transillumination, by 
 
168 DISEASES OF THE NASAL PASSAGES. 
 
 placing a guarded electric lamp in the back part of the closed mouth, 
 introduced by Voltolini, stands the first (Fig. 67). Although of un- 
 doubted value, the amount of weight attached to it by different 
 rhinologists varies very greatly. Gouguenheim says that transillumi- 
 nation is often embarrassing. On using it he has found well-marked 
 suborbital umbra, indicating pus, and upon opening the antrum found 
 none — the darkening being caused by a thickened mucosa. Grant, 
 on the other hand, thinks it may often be useful in a negative way. 
 In several suspicious cases, where pus was believed to be present, he 
 found on transillumination the translucency so clear that empyema 
 of the sinus could be positively excluded. 
 
 These are only exceptions, however; as a rule, the use of the 
 electric lamp in the mouth will produce an umbra, of more or less 
 density beneath the lower eyelid in each case of antral disease. 
 Milligan tells us he uses Voltolinfs lamp in every suspected case; and 
 wherever it failed to produce a light zone beneath the eyelid, and a 
 red and luminous pupil, on opening the antrum pus had been found. 
 
 Greville Macdonald lays great stress on the fact that where we 
 have suppuration with granulation-tissue or polypi in the middle 
 meatus, we can seldom be sure of the extent or severity of the disease. 
 He says he has frequently seen cases when the suppuration of the 
 antrum was supposed to be the whole trouble, but in which it was 
 afterward proved that the frontal sinus and ethmoid cells were just 
 as seriously involved, while, on the other hand, cases which had long 
 been treated for so-called necrosing ethmoiditis turned out to be 
 overlooked cases of profuse antral suppuration. 
 
 My own most recent case was of this double nature. I at first 
 took it to be pure ethmoid disease, as there was profuse granulation 
 and suppuration of the posterior ethmoid cells, accompanied by deep- 
 seated pain in the "eye of that side. Galvanocautery operation of the 
 hyperplasia and curettage of the cells failed to check the discharge. 
 Then I discovered that the corresponding antrum was involved. 
 Eemoval of a molar tooth, perforation of the alveolus, and daily wash- 
 ing out with hot boiled water in a few weeks, together with the previous 
 treatment, removed the whole of the double disease. 
 
 For several years I have used transillumination by the electric 
 lamp in all cases where I suspected antral suppuration; but I cannot 
 say that the result has been sufficiently marked to make the diagnosis 
 positive by it alone in a single case. I have not opened an antrum 
 without finding pus; but still the umbra from illumination was not 
 
CHEOXIC DISEASE OF THE ANTKUM OF HIGHMOEE. 1G9 
 
 decided enough, even with the darkened pupil added, to justify an 
 operation without the presence of other equally positive signs. 
 
 Prognosis. — These cases involve little danger to life; yet spon- 
 taneous recovery from chronic suppuration of the antrum rarely, if 
 ever, occurs. By careful and persistent treatment, however, all cases 
 can he relieved, and many of them cured. 
 
 Treatment. — Bosworth tells us: "The essential feature of the 
 treatment of a case of suppurative disease of the antrum consists in 
 opening the cavity for proper drainage, and subsequently its thorough 
 cleansing and disinfection. 77 
 
 In the latter clause all rhinologists agree. They agree also in 
 the former, while they differ widely in their methods of procedure. 
 Still, they unitedly accept as imperative the removal of any polypi, 
 granulation-tissue, or hypertrophy of the middle turbinated which 
 might be obstructing the ostium maxillare. 
 
 The direct treatment of the suppuration may be conducted in 
 one or other of the following ways: — 
 
 1. By direct irrigation through the ostium. Gavel, of Lyons, is 
 the great apostle of this method of treatment. He claims that it 
 can be accomplished in a large majority of cases, and that the antrum 
 can be washed out regularly and completely without any artificial 
 opening whatever. Out of 44 cases he succeeded by this method in 
 28, or 63 1 / 2 per cent.; and out of these had to resort to other treat- 
 ment in only 6 cases. The larger number were cured in a short time. 
 The fluid used was usually a warm solution of boric acid. The in- 
 strument used was a Heryng catheter, inserted, with the point turned 
 downward, between the middle turbinated and the outside wall. 
 Passing the instrument upward to a position above the ostium, he 
 turns the point outward and gently engages it in the mouth of the 
 cavity. This requires careful manipulation, as the point of the in- 
 strument is in close proximity to the orbit. 
 
 At the first washing the discharge is purulent, foetid, and some- 
 times caseous; but before the irrigation is over the fluid returns from 
 the naris perfectly clear. On each succeeding washing the pus de- 
 creases in quantity. After a few washings nothing comes away but 
 a mass of gelatinous muco-pus, the water itself being quite clear. 
 At each sitting the mass discharged becomes smaller and finally 
 ceases, the patient being cured. 
 
 2. By opening through the inferior meatus, or Jourdain's 
 method. Of this plan Dundas Grant is a very strong supporter. He 
 
170 DISEASES OF THE NASAL PASSAGES. 
 
 claims that as the antrum communicates with the respiratory pas- 
 sages, and not the digestive, the more natural opening will be by the 
 nose. After applying a 15-per-cent. solution of cocaine to the mucous 
 membrane, he uses Krause's trocar and cannula, penetrating the 
 antrum through the wall of the inferior meatus. Withdrawing the 
 trocar and leaving the cannula in situ, he attaches it to the point of 
 the syringe, and washes out the cavity with warm solution of boric 
 acid, the fluid escaping through the natural opening. After each 
 treatment the cannula is removed. At the next sitting cocaine is 
 again applied, the cannula reinserted, and the treatment repeated. 
 
 Grant claims that, although the treatment is somewhat difficult, 
 yet the number of irrigations required, being less than by other 
 methods, will justify its use. 
 
 Zeim, of Dantzic, criticizes this method severely. The difficulty 
 of operating in this region, the thickness of the naso-antral wall in 
 many cases, inefficiency in drainage, and the impossibility of personal 
 irrigation by the patient are among the points which he emphasizes; 
 and to these might be added the evil effects of successive applications 
 of cocaine. 
 
 3. By removing a molar tooth and opening the antrum through 
 the alveolus. This is Cooper's well-known method, and is warmly 
 supported by Zeim, Harrison, Milligan, and Bosworth. 
 
 When the teeth are sound, Zeim condemns removal, and suggests 
 perforating the antrum through the roof of the mouth in close prox- 
 imity to the teeth, either between the second bicuspid and the first 
 molar or between the first and second molars. The fact that the 
 opening into the alveolus, or floor of the antrum, and the ostium 
 maxillare are at opposite ends of the same cavity, must be conceded as 
 an advantage in irrigation, while the facility it affords for personal 
 treatment is also in its favor. 
 
 To keep the artificial opening clear, various silver and gold tubes 
 have been devised for permanent insertion, during the period re- 
 quired for treatment. The tubes are attached by silver wire to the 
 adjacent teeth, and plugged to prevent the entrance of food. 
 
 In many instances, however, when the treatment required is of 
 limited duration, these tubes can be entirely dispensed with, as, with 
 ordinary care, there is little if any danger of the food passing through 
 the opening into the antrum. 
 
 4. Desanlfs plan of opening the canine fossa appears to be 
 steadily gaining ground. It is claimed that the patient can treat 
 
CHKOXIC DISEASE OF THE ANTRUM OF HIGHMORE. 171 
 
 liimself equally well in this way as through the alveolus, and that it 
 will frequently prevent the sacrifice of a sound tooth. A tube with 
 a plate attached to fit against the jaw can be retained, even better 
 than in the alveolus, and without wiring. Plugging the tube is un- 
 necessary, as there is practically no danger of food entering the 
 antrum. 
 
 Some operators have invaded the canine fossa very extensively; 
 and without hesitation chiseled away enough of the external antral 
 wall to admit of digital exploration of the cavity. The antrum is 
 then curetted and washed out and packed with iodoform gauze. This 
 is changed regularly, the cavity being kept open until thorough heal- 
 ing takes place. Although revived recently, this plan of treatment is 
 not new, for we read of la Morier as early as 1760 treating a case 
 successfully in this way. 
 
 5. The Eobertson method of combining the chiseling of the 
 canine fossa with the perforation of the inferior -meatus, in one or two 
 places, has also a number of supporters. Scanes Spicer favors this 
 plan of treatment, as the only one securing thorough and effectual 
 drainage in many of the most difficult cases. He makes a large open- 
 ing in both the anterior and internal sides of the antrum. These 
 openings are intended to be permanent. He then irrigates thoroughly 
 with boric solution, and follows this by packing the cavity lightly 
 with creolin gauze. This is left in for forty-eight hours and then 
 removed. No form of tubage or mechanical drainage is used, but the 
 cavity is syringed out daily with a similar warm solution. The 
 patient is directed to blow out the cavity frequently, from the nose 
 to the mouth, and also from the mouth to the nose. He claims rapid 
 healing, and, although the perforations contract, they usually remain 
 permanently open to some slight extent, without inconvenience to 
 the patient. 
 
 This multitude of methods all practiced to-day by leading 
 rhinologists, each preferring his own special plan as the best, but 
 utilizing some other method in exceptional cases, seems to prove that 
 the results are not, on the whole, as satisfactory as we would like them 
 to be. A few cases are cured quickly. Others take a longer time. 
 All are relieved; but in many cases the treatment requires to be 
 carefully, systematically, and persistently followed out, and that for 
 a considerable time in order to secure a perfect cure. 
 
 It is undoubtedly true that many cases of antral disease come 
 under the domain of the dentist for treatment, and many dentists 
 
172 DISEASES OF THE NASAL PASSAGES. 
 
 claim to be particularly successful in dealing with these cases. But 
 this is not to be wondered at. The cases that come naturally under 
 their charge are those of dental origin, the region of the ostium not 
 being at all affected. And when the carious tooth is removed, the 
 antrum perforated through its alveolus, and the cavity antiseptic-ally 
 washed out for a few times, it is natural for the lining membrane to 
 heal. An entirely different state of things exists when the etiology 
 is nasal; and it is this class of cases that usually fall into the hands 
 of the rhinologist to deal with. 
 
 In my own practice the large majority of my cases have been 
 treated through the alveolus. Although in several of these it took many 
 months of treatment, yet they were all eventually cured. In one 
 ■case the treatment was confined to washing out the antrum through 
 the ostium maxillare with a warm solution of resorcin. This case 
 healed rapidly and without return. In three I tried perforation 
 through the canine fossa with insertion of a silver tube and followed 
 by regular irrigation. In the first of these it was successful. In the 
 second it failed. For three years the patient personally carried on the 
 cleansing treatment, but declined to have any other operative treat- 
 ment than the renewal of the tube as frequently as the old one wore 
 away. In the third, after trial for weeks, there Avas no prospect of 
 healing in the antrum, so a tooth was extracted, and a week or two 
 of regular irrigation with hot boiled water effected a cure. 
 
 The second of these eases is worthy of further consideration. The patient 
 was of a tubercular family, three brothers and his mother having died of pul- 
 monary tuberculosis. A few months ago. as there seemed to be no probability 
 of cessation of antral discharge, he finally consented to the extraction of the 
 first molar tooth, and perforation through the alveolus. 
 
 Instead of fitting a silver tube to the opening, as I had done in his case 
 in the canine fossa, I instructed him to make a hardwood plug to fit the passage, 
 the lower end being large enough to prevent its slipping wholly into the 
 antrum. This plan I had followed on previous occasions in the treatment of 
 other cases with uniformly good results, the plug being removed each time 
 irrigation was required, and replaced immediately afterward. After a few days, 
 as the patient managed the local treatment efficiently, the amount of pus at 
 the same time gradually diminishing in quantity, I told him that he need not 
 return to the office again for a number of days. He returned, however, sooner 
 than expected and, with a distressed expression of face informed me that the 
 last and largest plug he had used had gone up into the antrum, and he was 
 afraid that the previous one had slipped in also. It appeared that two nights 
 previously he had fitted the plug into the alveolus on going to bed. When he 
 awoke in the morning it was gone. He passed a probe into the hole, but could 
 not feel it. Thinking that possibly he might have swallowed it, he made a 
 
CHROXIC DISEASE OF THE ANTRUM OF HIGHMORE. 
 
 173 
 
 larger one and pushed it in tightly, after washing out the antrum. The next 
 evening it was all right, but when he awoke in the morning he could just 
 reach it with his tongue, and an hour later it had entirely disappeared. 
 
 On examining the antrum through the openings with the probe I could 
 not find either of the foreign bodies. There seemed to be an abundance of 
 space, and, washing through the alveolus, the fluid escaped freely from the 
 
 it 
 
 a<- 
 
 p x . 
 
 ci— 
 
 Fig. 08. — Coronal section of the maxillary sinus, the subject of cystic 
 disease, a, Cancellous spaces in bony wall. 6, Region of the crista tur- 
 binalis. c, Glands of nasal fossa, d, Glands of the maxillary sinus, e, De- 
 generating gland-tissue. The wavy lines around indicate the capsule of the 
 cyst. (From Lennox Browne, 1899.) 
 
 nose through the ostium maxillare. On the patient's assurance that at least 
 one of the plugs was in the antrum I had an anaesthetic administered, and, 
 after dissecting back the tissues, with hammer and chisel enlarged the opening 
 in the canine fossa to the diameter of a centimetre. Under the impression that 
 
174 DISEASES OF THE XASAL PASSAGES. 
 
 the foreign bodies, if there, would be on the floor of the antrum, I explored 
 that region first, but could not find anything. Then I passed the forceps 
 toward the ostium without success. After mopping out the cavity with ab- 
 sorbent cotton I again passed the forceps upward and backward. This time 
 something was seized, but it required a good deal of traction to dislodge it, 
 when out came a long and thick plug. Another attempt was made in the same 
 region, followed by the extraction of a still larger one. I suppose that after 
 they were engaged within the cavity, which was large, the force of gravitation, 
 while lying on the back, together with the inspiratory force in breathing 
 through the ostium, had drawn them upward and backward to the region in 
 which they had become impacted. The smallest plug was two centimetres in 
 length and half a centimetre in diameter, the larger one somewhat thicker, and 
 half a centimetre longer. They were both of them without the bulge on the 
 end that I had ordered. 
 
 Cyst of the Antrum. 
 
 Two years ago Charles H. Knight wrote a comprehensive review 
 of what was then known of this rare disease, closing with the history 
 of a case. His patient complained of no symptoms except the de- 
 formity in the left malar region and gingivo-labial fold caused by the 
 pressure of the tumor. On incising freely into the canine fossa the 
 bony wall was found to be almost completely absorbed. Sixty 
 grammes of thin, turbid fluid were drained away; the lining mem- 
 brane was found to be closely adherent to the bone. Digital exami- 
 nation disclosed nothing abnormal. After washing out the cavity 
 and packing it for three days with iodoform gauze the recovery and 
 healing were uneventful. A year later there was no return of the cyst. 
 
 Lennox Browne says that: "Cystic sinusitis may originate in two 
 wa}^s: T>y distension (1) of lymph-spaces, (2) of the gland- acini or 
 ducts. Fig. 68, from a preparation by Alexander, of Berlin, ex- 
 emplifies a condition due to the first-named cause. It is character- 
 ized by excessive cancellation of the bone, by distended gland-ducts, 
 some patches of round-cell infiltration, and a cyst-like inclusion of a 
 mass of disused glands and blood-vessels." 
 
CHAPTEE XXXIII. 
 ETHMOID DISEASE. 
 
 Catarrhal affections of the ethmoid regions are not of infre- 
 quent occurrence; and in acnte cases, when the inflamed cells are not 
 occluded by the swelling of the surrounding nasal mucosa, the dis- 
 ease may subside and disappear with the general decline of the 
 catarrhal condition. When the cells become blocked by pressure 
 from without or from enlargement of the middle turbinated body, 
 the inflamed conditions may take on suppurative action, even result- 
 ing in periosteal ulceration and ethmoid necrosis. 
 
 Pathology. — To Xoland Mackenzie belongs the honor of lifting 
 the veil that so densely obscured our knowledge of the pathology 
 of this region. By an extensive series of investigations he has arrived 
 at the conclusion that the so-called myxomatous degeneration of the 
 ethmoid is not due to mucous change at all, but to simple inflam- 
 matory action. In this view he is strongly supported by Jonathan 
 Wright. He believes that all the changes found in the ethmoid cells 
 represent merely successive stages of the- same affection; and that 
 therefore divisions and subdivisions of ethmoiditis tend to introduce 
 an element of confusion into our pathological conception of the dis- 
 ease (Fig. 69). 
 
 In opposition to Woakes's idea that all ethmoiditis is of the 
 nature of necrosis, Mackenzie states positively, and in this he is 
 supported by Hajek, that purulent ethmoiditis may endure for years, 
 without producing any bone-lesion, and that, therefore, the proposi- 
 tion that all ethmoiditis tends toward and usually develops into necro- 
 sis has no foundation in pathological fact, That it does so occasion- 
 ally, however, he freely admits. 
 
 Two other facts he dwells upon; the one, that the ethmoid 
 region affords a most excellent place for the study of the origin of 
 the so-called nasal polypi; the other, the very striking similarity that 
 exists between the young granulation-tissue found in the ethmoid 
 region and the structure of round-cell sarcoma, and hence the possi- 
 bility of error in diagnosis. 
 
 (175) 
 
176 DISEASES OF THE NASAL PASSAGES. 
 
 Myles accentuates two important facts in the pathology of eth- 
 moid disease. 
 
 1. In extreme polypoid cases the ethmoid is rather brittle, and 
 parts can easily be removed. 
 
 2. The bone is almost flinty hard in suppurative cases. 
 
 The pathology of ethmoid and antral disease resembles each 
 other in the existence of suppurative process and in the significance 
 of pressure in the origin of each. 
 
 Etiology. — The origin of the disease is frequently obscure. 
 
 
 
 •Ate,: * - -*?»<#?; 
 
 IP 
 
 
 Fig. 69. — Inflammation of the ethmoid cells, showing glands to right 
 quite normal and those to lower left hand more or less altered. In the 
 extreme lower left the nnely-nbrillated tissue is a false membrane composed 
 of hyaline fibrin with a few pus-cells. (After J. Xoland Mackenzie.) 
 
 Neglected catarrhal processes may produce permanent hyperemia, 
 resulting in retained secretions, with final suppurative action. It may 
 also arise from pressure of nasal polypi, though by many writers sup- 
 puration of the ethmoid cells is believed to be the cause of polypoid 
 disease. Not infrequently the cause is an extension of the suppura- 
 tive action from the other accessory cavities. According to Myles, 
 two-thirds of the cases are due to the presence of polypi in the region 
 
ETHMOID DISEASE. 177 
 
 of the ethmoid cells, while in other instances atrophic rhinitis is 
 sometimes the cause. 
 
 Constitutional debility — arising from tuberculosis, malignant dis- 
 ease, or syphilis — may also act as a predisposing cause. 
 
 Symptomatology. — Pain at the root of the nose and in the 
 orbital and temporal regions is one of the earliest symptoms. This 
 is associated usually with discharge of cream-colored pus, of a more 
 or less foetid odor, from the naris. In some cases there is promi- 
 nence or bulging at the side of the root of the nose. This, however, 
 is not frequent except as a result of pressure from polypi associated 
 with the ethmoid disease. When the anterior cells, which are two or 
 three in number and situated external to the anterior end of the 
 middle turbinated, are affected, exophthalmia may be present from 
 pressure upon the wall of the orbit, and pus-infiltration may occur, 
 through perforations of the orbital plate of the ethmoid. With the 
 posterior cells, which are the same in number, though longer, the 
 pain is not quite so severe. 
 
 Diagnosis. — After cleansing the nasal passage by the use of an 
 alkaline spray, and shrinking the tissues by the application of cocaine, 
 all other diseases but those of the accessory sinuses should be easily 
 excluded. In distinguishing ethmoid from antral disease the throat- 
 lamp should be of great service, as there is rarely, if ever, an umbra 
 in purely ethmoid affections, whereas in suppuration of the antrum 
 it is usually one of the distinguishing features. Ingals points out 
 that, after thorough cleansing, pus from the antrum may be noted 
 trickling down over the middle of the inferior turbinated, while in 
 issuing from the ethmoid cells it flows over the posterior end. The 
 deep-seated pain produced by ethmoid disease is also of diagnostic 
 value, distinguishing it from antral, in which this symptom is usually 
 wanting. The bulging of the eye forward does not occur as a result 
 of either antral or sphenoid disease. 
 
 Prognosis. — Simple catarrhal ethmoiditis undergoes resolution in 
 unison with the acute rhinitis to which it owes its origin. Woakes's 
 necrosing ethmoiditis, in which caries of the bone exists, is a much 
 more serious affair, and little likely to result in absolute cure. Sup- 
 purative ethmoiditis, occupying a medium position between the two, 
 should be amenable to treatment, and result in cure in the majority 
 of instances. 
 
 The disease is not dangerous to life unless it extends to the 
 cranial cavity. More frequently, owing to the thinness of the walls 
 
178 DISEASES OF THE NASAL PASSAGES. 
 
 and its proximity to the eye, the orbit becomes affected, sometimes 
 resulting in abscess. Operative treatment, combined with thorough 
 cleansing and drainage, is often productive of good results. 
 
 Treatment. — In mild cases, unattended by hypertrophy, shrink- 
 ing the parts with cocaine, and following this with sprays of solu- 
 tions of either 15-volume peroxide of hydrogen, boric acid, or resor- 
 cin, should relieve the disease and quickly result in cure. 
 
 Any of the above might be used as follows: — 
 
 1. I£ Peroxide of hydrogen 715 
 
 Aquam ad 301 
 
 M. 
 
 - 2. R. Acid, boric 21 
 
 Glycerini 4 
 
 Aquam ad 301 
 
 M. 
 
 3. R< Resorein 1 
 
 Aquam ad 30 
 
 M. 
 
 In severe cases where suppuration exists without necrosis, oper- 
 ative treatment will be necessary. Polypi, if present, should be re- 
 moved. Also any granulation-tissue that may appear in the neighbor- 
 hood of the cells. This may be done by curetting or cauterization, 
 and will clear the way for the antiseptic treatment already referred to. 
 Direct opening of the ethmoid cells above the middle turbinated is 
 a difficult operation. By removing the anterior end of this body it 
 can be better accomplished and the anterior ethmoid cells more easily 
 reached. This can be done by the use of the cold snare, curved scis- 
 sors, gouge, cutting-forceps, or Griinwald's forceps. The cells can 
 be reached by gouge and curette. The main features after operation 
 are antiseptic treatment and free drainage. The application of lactic 
 acid is sometimes followed by the best results. G-leitsmann favors 
 the application of strong solutions of nitrate of silver in many of 
 
 1. R Peroxide of hydrogen 3ij. 
 
 Aquam ad 3j • 
 
 M. 
 
 2. R. Acid, boric gr. xxx. 
 
 Glycerini 3j. 
 
 Aquam ad §j . 
 
 M. 
 
 3. B Resorein gr. xv. 
 
 Aquam ad §j. 
 
 M. 
 
ETHMOID DISEASE. 179 
 
 these eases, a cure being obtained by the combined surgical and local 
 treatment in some instances in one or two months. He also lays 
 stress on the importance of allowing the reaction of one curettement 
 to pass off before another is accomplished in cases where this oper- 
 ation is necessary. 
 
 Myles drills or gouges an opening through the floors of the an- 
 terior and posterior cells, and then with the antero-posterior and 
 lateral clippers cuts away as much of the floors as he considers neces- 
 sary. All his patients treated by this method were relieved and some 
 cured. 
 
CHAPTER XXXIV. 
 SPHEXOID DISEASE. 
 
 Simple catarrhal disease of the sphenoid sinuses is probably, like 
 the similar disease of the ethmoid cells, of frequent occurrence. The 
 symptoms, however, are so masked by the associated diseases of the 
 rhinal fossae that they are unobserved, and the course and recovery 
 become essentially uneventful. The situation of the sphenoid sinus 
 is seen in Fig. 5. 
 
 Suppuration of the sphenoid sinus, on the other hand, although 
 still very obscure, is a much more serious affection, and may lead to 
 dangerous results. The symptoms, unfortunately, are not by any 
 means distinctive, and it is difficult to diagnose it with any degree 
 of certainty from the ethmoid disease. The etiological and patho- 
 logical conditions are much the same; and the deep-seated pain of 
 the post-ethmoid cells is difficult to distinguish from the deep-seated 
 pain of the sphenoid. The discharge, similar to that from the other 
 accessory cavities, flows more naturally down the post-pharynx, though 
 a certain amount finds it way over the turbinated bodies. The eye 
 symptoms are also similar, inasmuch as a larger plane of the sphenoid 
 enters into the formation of the orbital cavity than can be said of 
 the ethmoid, although bulging of the eyeball is usually an absent 
 quantity. 
 
 In some cases after shrinkage by cocaine the probe can be passed 
 gently upward and backward over the lower part of the middle tur- 
 binated, between it and the septum into the sphenoid sinus, and, 
 after drying the passage, a small pledget of cotton passed in on a 
 holder would indicate whether pus was in the sinus or not. 
 
 Flateau reports, in the Journal of Laryngology, etc., for 1895, 
 having treated 26 cases of empyema of the sphenoid. Only once had 
 he seen it in connection with ozama; polypi were rarely present, ex- 
 cept in cases in which the ethmoid and sphenoid disease were asso- 
 ciated with each other. The most common complication found in 
 this large number was with disease of the ethmoid cells. In many 
 cases the etiology was doubtful, but in other cases it followed as a 
 sequel of exanthematous diseases. In treatment he found that per- 
 foration into the sinus, with subsequent cleansing and free discharge, 
 was necessary. Holbrook Curtiss has devised an instrument for 
 (180) 
 
SPHEXOID DISEASE. FRONTAL DISEASE. 181 
 
 irrigating the sinus after trephining, the patient being able to intro- 
 duce the tube of the irrigator into the sinus without difficulty. 
 HajeFs hook is said to be the best instrument for curetting the 
 cavity. 
 
 Eosenburg has furnished some interesting facts about this ob- 
 scure disease which are worthy of mention. He says that the age 
 of patients vary from 19 to 35 years, and that it never arises as the 
 result of syphilis or scrofula. The distance from the spina nasalis 
 anterior to the anterior wall of the sphenoid sinus is from 6 to 7.5 
 centimetres, averaging 6.8 centimetres; and to the posterior wall of 
 the same from 7 to 10 centimetres, averaging 8.5. The amount of 
 space in the two nasal fossse varies so much in certain cases that the 
 twisted septum will allow a probe to be passed through the one nasal 
 fossa into the sinus on the opposite side. He describes the subjective 
 symptoms to be: burning in the nose; pain at the root of the nose, 
 over the eye, and in the temporal region; shooting pains in the head, 
 and a feeling of stuffiness. In one of his cases, attended by severe 
 pain in the head, no pus could be seen, but, after the removal of the 
 hypertrophied middle turbinated, pus flowed down from the sinus 
 and the pain immediately disappeared. 
 
 In dealing with this subject, in a recent able article, Myles says: 
 "The sphenoid cells are not so difficult to open as some are inclined 
 to think. In cases where the septa are moderately straight and where 
 the posterior end of the middle turbinated bone has been removed, 
 the oozing pus can be easily detected at the point of the natural open- 
 ing, high up and near the septum. The probe will often enter after 
 careful use; a small, sharp, firm curette passed in and then pulled 
 outward will often tear away the sides of the opening sufficiently for 
 good drainage. I do not consider it safe to curette the upper and 
 external walls of these sinuses. Careful scraping of the anterior wall 
 and the floor often produces decidedly beneficial results." 
 
 Frontal-Sinus Disease. 
 
 Disease of the remaining accessory cavity, the frontal sinus, is a 
 very wide subject, and an exceedingly important one. It falls natu- 
 rally, however, under the domain of the oculist, and hence is usually 
 treated by him. This volume is a treatise upon the nose and throat 
 only, and, consequently, can leave frontal-sinus disease, without preju- 
 dice, within the limits of its own proper sphere (Fig. 2). 
 
SECTION II. 
 
 Diseases of the Pharynx. 
 
CHAPTEE XXXV. 
 
 ANATOMY OF THE PHARYNX. 
 
 The pharynx is a musculo-membranous sac, lying between the 
 back of the nose and the oesophagus. The base is upward beneath the 
 base of the skull, and the apex downward terminating in the oesoph- 
 agus, and on a level with the cricoid cartilage and fifth cervical 
 vertebra. It is situated behind the nose, mouth, and larynx. In 
 length it is between ten and eleven centimetres, and it is broader 
 laterally than before backward. Its greatest breadth is midway be- 
 tween the palate and the oesophagus, and its narrowest at the oesoph- 
 ageal termination (Figs. 70 and 71). 
 
 The boundaries of the pharynx are, as roof, the basilar process of 
 the occipital bone; and, as floor, the entrance to the oesophagus, the 
 right and left sinus pyriformis, and the arytenoid cartilages and com- 
 missure of the larynx. Posteriorly it is separated from the upper 
 four cervical vertebrae in the centre and the recti capitis antici and 
 longi colli muscles at the sides by loose areolar tissue. The promi- 
 nence of the arch of the atlas may often be recognized near the upper 
 extremity of this surface. The anterior boundary is formed by the 
 posterior nares, separated by the vomer, the internal pterygoid plates, 
 the soft palate, the tongue when the mouth is closed, the hyoid bone, 
 and the epiglottis. Each lateral wall is marked at its upper end by 
 the pharyngeal orifice of the Eustachian tube and the fossa of Eosen- 
 miiller, and is connected with the styloid processes and their muscles. 
 This wall is also in contact with the common and internal carotid 
 arteries and internal jugular veins and with the eighth, ninth, and 
 sympathetic nerves. 
 
 There are seven openings into the pharynx: the two posterior 
 nares, the two Eustachian tubes, the mouth, the larynx, and the 
 oesophagus. As described in dealing with the nose, the posterior 
 nares are the oval openings which enter the pharynx on the anterior 
 wall almost on a level with the vault. The two Eustachian tubes 
 open one on each side of the pharynx, almost directly behind the in- 
 ferior meatus. The mouths of these tubes are ovoid, or funnel- 
 shaped; Eoosa describes them as "trumpet-shaped orifices, nine milli- 
 metres high and five millimetres broad/' The opening of the tube 
 
 12 (185) 
 
186 
 
 DISEASES OE THE PHARYNX. 
 
 is partly surrounded by a cartilaginous ring, which is most prominent 
 posteriorly and above, lighter in front, and absent beneath. Behind 
 the Eustachian orifice, and between it and the posterior wall of the 
 pharynx is an elongated depression: the fossa of Eosenmtiller. While 
 at rest the Eustachian orifice is closed; but in the various motions of 
 
 Nasopharynx. 
 
 Oropharynx. 
 
 Laryngo-pharynx. 
 
 Fig. 70. — Sectional view of the pharynx. 1, Left Eustachian tube. 
 2, Left fossa of Eosenmtiller. 3, Palate and uvula. 4, Tongue. 5, Left 
 tonsil. 6, 6, Upper and lower boundary of larynx (epiglottis and cricoid 
 cartilage). 7, Cavity of nares. 8, Cavity of mouth. (After Lennox 
 Browne. ) 
 
 the fauces it is frequently opened by the contraction of the tensor- 
 palati muscles. 
 
 Directly behind and below the posterior nares lies the superior 
 surface of the soft palate, with the uvula in its centre. Below that the 
 mouth, then the base of the tongue, epiglottis, and larynx. The 
 oesophageal opening is the apex of the pharyngeal cavity. 
 
Fig. 71. — Frozen section. Side-view of nose, pharynx, and larynx of 
 child, aged 3 years. 1, Body of sphenoid. 2, Ethmoid cells and superior 
 meatus. 3, Middle turbinated bone. 4, Middle meatus. 5, Inferior tur- 
 binated bone. 6, Vestibule of the nose. 7, Superior maxillary bone. 8, 
 Soft palate. 9, Tongue. 10, Naso-pharynx. 11, Epiglottis. 12, Larynx. 
 (From Primrose's Anatomical Museum, University of Toronto.) 
 
ANATOMY OF THE PHARYNX. 
 
 189 
 
 The pharynx is composed of three coats: a mucous coat, a fibrous 
 coat, and a muscular layer beneath. The muscular coat consists of 
 the superior, middle, and inferior constrictors; the levatores palati, 
 and the tensores palati, together with the stylo-pharyngei and palato- 
 pharyngei and palato-glossi muscles, a fuller account of which will 
 be found in the standard works on anatomy (Fig. 72). 
 
 The fibrous coat is situated between the muscular and mucous 
 layers; and is termed the pharyngeal aponeurosis. It is thick above. 
 
 Cephalo- 
 or Xaso- pharynx. ^ 
 
 Hyo- or 
 Oro- pharynx. < 
 
 Laryngo- 
 pharynx. 
 
 Fig. 72. — The muscles of the soft palate and pharynx: the pharynx 
 laid open from behind (modified from Gray). 1, 1, Levatores palati, the 
 left being cut short near to its origin. 2, 2, Tensores palati, the left show- 
 ing its reflected tendon and relation to the hamular process (a). 3, 3. 
 Palato-glossi (anterior pillars of the fauces). 4, 4, Palato-pharyngei (pos- 
 terior pillars of the fauces). 5, 5, Tonsils. 6, Azygos uvulae. 7, Uvula. 
 8, 8, Eustachian tubes. 9, 9, Inferior constrictors (laryngo-pharyngei). 
 10, 10, Middle constrictors (hyo- or oro- pharyngei). 11, 11, Superior 
 constrictors (cephalo- or naso- pharyngei). 12, 12, Epiglottis and larynx 
 not laid open. (After Lennox Browne). 
 
190 DISEASES OF THE PHARYNX. 
 
 Here the muscular fibres are absent and the fibrous coat is attached 
 firmly to the basilar process of the occipital and the petrous portion 
 of the temporal bone. As it descends, it becomes gradually lost in 
 the true muscular coat beneath it. 
 
 The mucous layer is continuous with that of the nares, Eu- 
 stachian tubes, mouth, and larynx. The upper surface of the soft 
 palate, with, the vault of the pharynx down as low as the floor of the 
 nares, is covered with columnar ciliated epithelium, while in the oral 
 part of the pharynx, below the palate, the epithelium is of the 
 squamous variety. 
 
 The movements of the soft palate are controlled by the levator- 
 palati, palato-pharyngei, and azygos-uvulse muscles, of which this 
 flexible piece of mechanism is. composed. Several of these muscles 
 have also a direct relation to the Eustachian tubes by opening them 
 when necessary to admit the entrance of air. 
 
 The pharyngeal glands are of two kinds: the follicular, simple 
 and compound, scattered throughout the pharynx beneath the mucous 
 membrane; and the racemose, in the upper pharynx between the 
 Eustachian tubes. 
 
 The arteries are supplied from the ascending pharyngeal, the 
 palatal branch of the facial, together with branches of the internal 
 maxillary. 
 
 The veins enter into the internal jugular. 
 
 The nerves are derived from the second and third divisions of 
 the fifth, together with branches from the glossopharyngeal and the 
 vagus. 
 
 The pharynx, owing to its relation to the nose at the one end, 
 and the larynx and oesophagus at the other, together with the fact 
 that its posterior wall is an uninterrupted surface, may be considered 
 as a single division of the respiratory tract. For physiological as 
 well as pathological reasons, however, it is usually considered to be 
 divided into two sections by the soft palate, known as the naso- 
 pharynx and the oro-pharynx. 
 
 In the naso-pharynx, the tissue or pharyngeal tonsil situated on 
 the back wail and upon the base' of the occipital bone, and known 
 by the older anatomists as the racemose glands, frequently undergoes 
 enormous development (Figs. 73 and 74). In its natural state it pre- 
 sents a soft, cushion-like surface. It is sometimes covered with 
 rounded elevations. At others divided by deep fissures, running chiefly 
 in a perpendicular or longitudinal direction. This mass of glands is 
 
ANATOMY OF THE PHARYNX. 191 
 
 called the pharyngeal tonsil, or Luschka's tonsil, in honor of the man 
 who first gave a full anatomical description of it. In the lower part of 
 the tonsil in the medial line is sometimes found a small opening leading 
 into the sac, called the bursa pharyngea. This sac may be from one 
 to two centimetres long and from three to six millimetres wide. In 
 the natural state this pharyngeal cushion should never in any part 
 of it be more than four to six millimetres in thickness, gradually 
 thinning away toward its outer margins. 
 
 The Fattctal Tonsils. 
 
 These two round or almond-shaped bodies do not belong to the 
 pharynx proper, but are separated from it on each side by the palato- 
 pharyngeus muscle. They lie between the anterior and posterior pil- 
 lars of the fauces, and directly above the base of the tongue. Their 
 direct anatomical relations are thus described by Delavan: "The re- 
 lations of the tonsil to the internal carotid artery are not so intimate 
 as commonly supposed, for between the lateral wall of the pharynx, 
 the internal pterygoid, and the upper cervical vertebrae there is a 
 space filled with cellular tissue, the pharyngo-maxillary interspace, 
 in the posterior part of which are located the large vessels and nerves, 
 and which lies almost directly backward from the pharyngo-palatine 
 arch. The tonsil corresponds to the anterior part of this interspace, 
 so that both carotids are behind it, — the internal carotid one and 
 five-tenths centimetres, the external carotid two centimetres, distant 
 from its lateral periphery." 
 
 The tonsil may be described as composed of lymphoid tissue. It 
 presents on its outer surface a number of orifices varying from five 
 or six to a dozen in number, leading down to the deep crypts of the 
 tonsil. Besides these, from the researches of His, and during the past 
 year of D. N. Paterson, we have had drawn to our notice the existence 
 in the upper part of the tonsil of an anatomical space called the 
 supra tonsillar fossa. In the majority of instances careful examina- 
 tion will reveal a small recess in this situation, close to the anterior 
 palatal arch, having a different folding and being much larger in 
 every way than an ordinary crypt. 
 
 In young subjects, particularly, a web of membrane is frequently 
 attached to the border of the anterior pillar, extending downward 
 and backward over the tonsil. It is called the' plica triangularis: and 
 it is between this plica and the upper portion of the tonsil that the 
 supratonsillar fossa is found. 
 
192 DISEASES OF THE PHARYNX. 
 
 The lymphoid tissue consists of two kinds: lymph-pulp and 
 lymph-nodules. The pulp constitutes the greater part of the tonsil. 
 The nodules form ten or twelve oval or round masses, immediately 
 below the walls of the crypts, and situated within the lymph-pulp. 
 They differ from, while in some respects they resemble, the Mal- 
 pighian bodies of the spleen. They are surrounded by a dark zone of 
 reticular tissue. 
 
 The lymph-pulp consists of lymphocytes inclosed in a delicate 
 reticulum. The cells are larger and the reticulum coarser than in 
 the nodules. The reticulum is formed of elongated cells inclosing 
 lymph-spaces through whose walls lymph and migratory corpuscles 
 readily pass from the capillaries. (Lennox Browne.) 
 
 The Lingual Tonsils. 
 
 At the base of the tongue on either side of the glosso-epiglottic 
 fold are situated two irregular nodular masses, varying widely in 
 degree of development and of form. These are known as the lingual 
 tonsils. Histologically they are identical with the faucial tonsils. 
 The crypts are sometimes, however, lined with ciliated epithelium, 
 and the cellular, tissue is more dense than in the faucial region. 
 Another important point in regard to them: they frequently do not 
 commence to develop until adult life, — the period when the faucial 
 tonsils have commenced to disappear. 
 
CHAPTEE XXXVI. 
 
 PHYSIOLOGY OF THE PHARYNX. 
 
 The physiological functions of the naso-pharyngeal and oro- 
 pharyngeal divisions of the pharynx are in some respects very dis- 
 tinct from each other. 
 
 The former has largely respiratory functions to perform, and, 
 like the lower half of the nasal passages, is supplied with columnar 
 ciliated epithelium, to aid in keeping the passage free from any 
 secretions which might impede normal respiration. The naso-pharynx 
 is also richly endowed with the glands of the pharyngeal tonsil, whose 
 special function appears to be to secrete clear, colorless mucus for 
 the purpose of moistening and keeping pliable the surrounding tis- 
 sues and to help to lubricate the food ere it leaves the oro-pharynx 
 for the lower alimentary canal. 
 
 The soft palate, or velum pendulum palati, hanging in mid- 
 position in the pharynx, has several functional duties to perform. 
 By pressing tightly the post-pharyngeal wall during the act of 
 swallowing, it completely divides the pharynx into two parts, and 
 effectually prevents food whether solid or fluid from entering the 
 naso-pharynx. At the same time, by its pressure upward and back- 
 ward, it forces down into the oral cavity the mucous secretion already 
 spoken of. It also plays a very important part in the function of 
 voice-production, which will be spoken of more fully when dealing 
 with the larynx. 
 
 The tissues of the oro-pharynx are of harder and denser texture 
 than those of the naso-pharynx. This enables it to perform the 
 duties of deglutition without injury to its flexible surface. It has 
 fewer glands than the naso-pharynx, and depends largely for the 
 moisture and lubrication it requires upon the salivary glands and the 
 mucous discharge from the pharyngeal tonsil. 
 
 Deglutition is a complex movement. After mastication the food 
 is forced backward by the tongue pressing gradually from the tip 
 to the base against the hard palate. As it reaches the pharynx, the 
 faucial muscles come into play, forcing it still farther backward and 
 downward, while the palato-pharyngei and levator-palati muscles pre- 
 
 (1^3) 
 
194 DISEASES OF THE PHARYNX. 
 
 vent its passage into the upper pharynx. At the moment that the 
 faucial muscles contract, the muscles of the hyoid bone draw up the 
 larynx behind the base of the tongue. By means of this complex move- 
 ment the epiglottis is tilted backward, and the whole of the oro- 
 pharynx is transformed into a funnel, down which the food is forced 
 by muscular action into the oesophagus. 
 
 The physiological functions of the tonsils have long been an 
 object of investigation. Formerly it was the prevailing impression 
 that they were secreting bodies, the object of the secretion being to 
 prepare the food for deglutition. At a latter day it was claimed that, 
 like lymphatic structures generally, their mission was the production 
 of white corpuscles of the blood. Hingston Fox and Scanes Spicer 
 held this view, while the former gave them another mission: that 
 of reabsorption of the salivary secretions after deglutition had been 
 accomplished. Swain suggests that their real function may be to 
 destroy pathogenic germs entering the mouth with the food; thus, 
 the lymphatic cells or leucocytes of the tonsils would do the work of 
 scavengers or phagocytes. Bosworth believes that, whatever their 
 function, they are really absorbent organs, and that yet the crypts and 
 tubular glands of the tonsil would indicate a secretory power, how- 
 ever limited. Bruschke is of the opinion that the tonsil, without 
 being ulcerated or inflamed, may be the point of entrance for pyo- 
 genic micro-organisms. Semon also found evidence that the infect- 
 ing micro-organisms in septic inflammation of the pharynx gain 
 entrance through the tonsillar crypts; and Wagner, of San Francisco, 
 has shown that rheumatism may be due to migration of germs from 
 the tonsillar tissue. He has found the same micro-organisms in the 
 synovial fluid of the knee-joint in two instances, and in the urine of 
 nearly all his cases, as existed in their diseased tonsils, of which the 
 clinical history proved they were quite free, prior to the attack of 
 tonsillar disease. 
 
 These opinions would seem to be at variance with the somewhat 
 prevalent one, of the existence of physiological, tonsillar phagocytosis. 
 
DISEASES OF THE XASO-PHARYXX. 
 
 CHAPTER XXXVII. 
 XASO-PHARYNGEAL CATARRH. 
 
 This disease may appear in an acute or chronic form. It is 
 somewhat rare, however, for it to fall into the hands of the physician 
 in the acute stage. When it does, it is usually an extension of or 
 accompaniment to acute rhinitis, as the disease is more likely to ex- 
 tend from before backward than from the lower pharynx to the 
 vault above. When fortunately treated as an acute disease, it is at- 
 tended by similar symptoms to those of acute rhinitis, and, being 
 associated with it, is amenable to similar treatment. 
 
 The subacute, or chronic, form, however, requires distinct con- 
 sideration. 
 
 Pathology. — In this disease there is thickened haso-pharyngeal 
 mucosa affecting particularly the muciparous glands of the pharyn- 
 geal tonsil. Wherever these glands are clustered together in large 
 numbers, there is a predisposition to chronic inflammatory disease 
 and cell-desquamation. This is particularly so in the pharyngeal 
 vault; and, whenever a proximate cause exists, a muco-purulent dis- 
 charge from the evenly-distributed mass of glandular structures may 
 be the result. This chronic inflammatory action is usually attended 
 by more or less hyperplasia. Bosworth believes that the sac or cavity 
 called Luschka's or Tornwaldt's bursa is not a natural condition, but 
 the result of inflammatory action. By it, the two lateral lobes, into 
 which the pharyngeal tonsil is sometimes divided, are swollen and 
 crowded together, and the superficial layer of epithelium on the one 
 side unites w x ith the epithelial layer on the other, the interior being 
 left open, thus forming the so-called bursa. 
 
 In these cases, as well as those in which the hyperplasia is more 
 uniform and unattended by bursal development, the surface may 
 assume a mammillated or raspberry-like contour. This lymph-tissue 
 
 (195) 
 
 
196 DISEASES OF THE PHARYNX. 
 
 is well supplied with blood-vessels, but with, few acinous glands, and 
 hence is differently formed than ordinary gland-tissue. It is supposed 
 that the increased secretion, not having an acinous origin, must be 
 formed in the sulci or fissures which separate the hypertrophied lobules 
 from each other. When Tornwaldt's bursa exists, its lining mem- 
 brane may also produce much of the discharge which occurs in this 
 disease. 
 
 Etiology. — Meteorological changes in atmospheric conditions are 
 frequentty the exciting cause of this disease, particularly on the lower 
 levels and along the water-ways. Throughout the extensive lake- 
 region of North America this disease is very common. The cold, damp 
 winds that prevail so extensively along the lakes during the change- 
 able seasons of fall and spring, chilling the cutaneous surfaces, pro- 
 duce congestion of the naso-pharyngeal mucosa and lead to the chronic 
 inflammation which exists, so widely during these seasons of the year. 
 Inhaled dust may also be a factor in some cases, but can only be of 
 moment when the situation is dry and elevated and away from the 
 lake-region. 
 
 In mountainous districts, however, and on the extensive inland 
 prairies there may not be sufficient natural exosmosis from the tur- 
 binateds to saturate the air as it is inspired. In these cases dry, dusty 
 air may pass through the nares and strike against the post-pharyngeal 
 wall, inducing chronic inflammation and catarrh. 
 
 The consequence is that these two causes alone, from their varied 
 features of humidity and altitude, may produce two entirely different 
 varieties of post-nasal catarrh: the one hypertrophic, the other atro- 
 phic. Or, in other words, the "moist" catarrh prevails with the lake- 
 dwellers, while the "dry" catarrh holds sway upon the elevated plains. 
 
 The tendency among children to disease of lymphatic tissues 
 would lead us to look for naso-pharyngeal catarrh most frequently in 
 early life; Mouri says that it is even common among infants. 
 
 We are not sufficiently cognizant of the fact that unequal nasal 
 breathing bears, in many instances, a direct relation to it also. In a 
 large number of instances the comparative respiratory freedom of the 
 two nostrils bears the relation of one to two or one to three. What- 
 ever produces freedom of respiration in one nostril at the expense of 
 the other tends to accumulation of secretion behind the stenosed re- 
 gion, and that accumulation results in disorganization of tissue and 
 catarrhal disease. 
 
 Charles Knight has shown conclusively that exostosis of the sep- 
 
NASOPHARYNGEAL CATARRH. 197 
 
 turn is a frequent cause of chronic naso-pharyngeal disease. The 
 bon}' projection is usually in the form of a somewhat irregular ridge 
 running from before backward along the osseous septum, parallel with 
 the floor of the nose. Sometimes it is even adherent to the inferior 
 turbinated. Discharges are retained behind the obstruction, occa- 
 sioning putrefaction and consequent increased irritation. While con- 
 demning officious operative treatment in all cases, the indications are 
 clear to remove the obstructive lesion and by this means to produce 
 efficient drainage. 
 
 In atrophic rhinitis naso-pharyngeal catarrh is always the result. 
 The vault of the pharynx is in no way supplied with the venous sinuses 
 of the turbinateds; so when the air, on account of turbinal atrophy, 
 fails to reach the point of saturation in passing through the nasal 
 passages, it quickly dries up the scanty secretion of the pharyngeal 
 vault, leaving here the inspissated mucus, which it is so often difficult 
 to remove. 
 
 This disease is said to be more prevalent in America than in Eu- 
 rope. 
 
 Another cause, particularly in our large cities, owes its origin to 
 our supposed advanced civilization. Naso-pharyngeal catarrh among 
 the aborigines of the various continents is almost an unknown quan- 
 tity; but in our furnace-heated homes, with the intense dryness of 
 the air, it is among the commonest of catarrhal affections. 
 
 Let a man wearing spectacles enter a house in the winter-time 
 comfortably heated by stoves or fire-places, and immediately the moist- 
 ure of the atmosphere will condense upon the glasses, and make vision 
 through them impossible; and without he dries them, it will take sev- 
 eral minutes before the glass will acquire the temperature of the room, 
 and permit of drying by evaporation. Let the same man, on the other 
 hand, enter a house heated by a hot-air furnace, and the glass will re- 
 main perfectly dry, inasmuch as the air contains too little moisture to 
 permit of condensation. 
 
 The reason of this is that furnace manufacturers have too little 
 knowledge of pneumatics and hydrostatics to build furnaces correctly. 
 A water-pan for evaporation is supplied with each furnace; but it is 
 usually altogether too small and too remote from the fire to be of 
 material benefit. My own furnace is a case in point. It was consti- 
 tuted on the regular orthodox plan and the water-pan evaporated a 
 pailful of water per day. But the air was so dry as to be distressing 
 to the mucous membranes. This lasted one winter. The second season 
 
198 DISEASES OF THE PHARYNX. 
 
 I had the builder put in a large extra water-pan, right in the furnace- 
 wall and above the coal shute. This evaporated nearly three times 
 as much water per day as did the first one; and the two together 
 made the house a great deal more comfortable. Of course, care had 
 tc be taken against too abrupt changes of temperature in furnishing 
 the water-supply. 
 
 Symptomatology. — The earliest symptom of naso-pharyngeal 
 catarrh is the presence of something in the upper part of the throat, 
 accompanied by a desire or impulse to remove it. The discharge which 
 hawking brings away is of a more or less muco-purulent character, 
 yellow in color, and tenacious in consistence. It is felt by the patient 
 to be lodged behind the palate; and, when the disease is of long stand- 
 ing, quite frequently the most persistent efforts will fail to effect a 
 complete removal. 
 
 One of the common symptoms is the so-called "dropping" which 
 the patient feels in the throat. Of course, the term "dropping" is 
 largely a misnomer. The discharge is often too thick and tenacious 
 to drop. Another thing, it is not located so much upon the palate 
 as on the post-pharyngeal wall; and it is the constant desire to swallow, 
 which its presence produces, that gives rise to the mistaken idea. 
 
 In this disease the throat is easily fatigued. A feeling of con- 
 striction and even of aching is experienced. The discharge varies 
 much in density. Sometimes it consists almost entirely of sero-pus 
 and trickles down over the pharynx and off the palate easily. In others 
 it is so tenacious that it cannot even be washed away, but requires the 
 manipulation of a cotton-holder to remove it. 
 
 Although the discharge may be constant, day and night, the move- 
 ments of the pharynx, together with efforts to cleanse the throat, may 
 keep the parts free by day-time; but during the long hours of sleep 
 the deposit accumulates, to be removed with difficulty in the morning. 
 
 Sometimes the Eustachian cartilages are swollen and red, and the 
 orifices of the tubes blocked by secretion. If this extends deeply into 
 the tubes, catarrh of the middle ear and deafness may result. 
 
 In children, inflammatory thickening of the glands may induce 
 adenoid disease, with mouth-breathing and all the other symptoms 
 produced by nasal stenosis. 
 
 Perhaps no class of people feel the effects of this disease so se- 
 verely as voice-users; and of these probably clergymen are the most 
 numerous, as they speak for long periods at a stretch more regularly 
 than any other class of speakers. 
 
NASO-PHARYNGEAL CATARRH. 199 
 
 Diagnosis. — Although there is little difficulty in discovering the 
 presence of a post-rhinal discharge, either in the oro-pharynx or naso- 
 pharynx, yet there may be considerable difficulty in diagnosing the 
 cause of its occurrence. To be sure that it is purely naso-pharyngeal, 
 the exclusion of a nasal cause will be necessary. Many cases of pharyn- 
 geal discharge arise from nasal obstruction or lesion, even when the 
 pharyngeal tonsil is hypertrophic; and, when atrophic rhinitis exists, 
 the throat affection is, in nearly all cases, secondary. The same may 
 be said of nasal polypus. 
 
 If, however, we can exclude the various affections of the nose, and 
 find the glandular tissue in the throat coated with secretion, instead 
 of being clear, moist, and of its natural pinkish-red color, the case is 
 clearly one of pharyngeal origin. When Luschka's, or, as it is some- 
 times called, Tornwaldt's, bursitis has occurred, the discharge will be 
 more purulent than in other varieties of the disease; and in the centre 
 of the vault, above the prominence of the atlas, will be seen the pro- 
 jecting sac. 
 
 The possibility of mistaking syphilis of the naso-pharynx should 
 be avoided by exclusion. In doubtful cases a course of specific treat- 
 ment should be tried. 
 
 Prognosis. — When taken early and chronicity has not had time 
 to be thoroughly established, it is usually amenable to treatment; but 
 it is not a disease that has any tendency toward spontaneous cure. 
 When it has been long in existence, and has become essentially chronic, 
 although much can be done for it, positive and permanent cure need 
 not be expected. In cases, however, when it is purely a secondary 
 affection, the removal of the primary cause should always be followed 
 by cure. 
 
 One difficulty the physician has to contend with in dealing with 
 these cases is the general unwillingness of patients to submit to a 
 long course of treatment for what they often consider a comparatively 
 unimportant disease. 
 
 Treatment. — Whatever may have been the origin of the affection, 
 or the predisposing cause which tended toward its development, it is 
 essentially local in its manifestations. Hence the first object of treat- 
 ment should be to secure perfect cleanliness of the parts affected. This 
 can usually be accomplished by the use of certain alkaline washes 
 The temperature of the solution should always be about 100° F. 
 
 In order of merit the following will serve as illustrations: — 
 
200 DISEASES OF THE- PHARYNX. 
 
 1. ^ Sod. bicarb 8 
 
 Sod. bibor 8 
 
 Acid, carbol 2 
 
 Glycerin 15 
 
 Aquam ad 300 
 
 M. 
 
 R. Sod. chlorid. 
 
 Aquam ad 300j 
 
 M. 
 
 3. R Acidi borici 12 
 
 Glycerin 8 
 
 Aquam ad 300 
 
 M. 
 
 4. ~fy Pot. chlor . 81 
 
 Aquam bullient 300 1 
 
 M. 
 
 The best method of applying the solution is by the use of a post- 
 nasal spray-syringe (Fig. 50). In using the instrument, after insert- 
 ing the hard-rubber end behind the palate, the head should be bent 
 forward over a bowl. Then the fluid is forced through the naso- 
 pharynx and the nasal passages, coming out, in great measure, through 
 the anterior nares. By this method both the vault and the nasal 
 fossae are effectually cleansed. The position of the head referred to is 
 important, when a continuous stream is thrown through the passages, 
 as otherwise part of the fluid would find its way into the larynx. When, 
 however, the interrupted flow is used, the bulb being filled separately 
 each time, this precaution is not necessary. 
 
 This method of treatment should be followed twice a day at first. 
 When improvement has become marked, the interval between treat- 
 
 Ill Sod. bicarb 3ij. 
 
 Sod. bibor 3ij. 
 
 Ac. carbol 3ss. 
 
 Glycerin 3iv. 
 
 Aquam ad §x. 
 
 M. 
 
 B Sod. chlorid 3ij. 
 
 Aquam ad %x. 
 
 M. 
 
 I£ Acidi borici 3iij. 
 
 Glycerin 3ij. 
 
 Aquam ad £x. 
 
 M. 
 
 U Pot. chlor 3ij. 
 
 Aquam bullient §x. 
 
 M. 
 
NASO-PHARYNGEAL CATARRH. 201 
 
 ments may be lengthened to suit the requirements of each case. If 
 from acute sensitiveness of the parts the flitid nsed should prove to 
 be too irritating, it could be weakened to half-strength or even less. 
 In some cases during early treatments a weak solution of cocaine might 
 require to be applied, but only under the doctor's supervision. 
 
 Sometimes even this vigorous treatment may not effectually re- 
 move the tenacious coating; and a curved cotton-holder, passed up 
 behind the palate, guided by the post-rhinal mirror, may be required 
 to mop it away. 
 
 Having thoroughly cleansed the naso-pharynx, stimulating and 
 astringent treatment of the diseased mucosa is then required, and 
 probably for this purpose no application is so useful as that of 10- 
 per-cent. solution of nitrate of silver. It should be applied by means 
 of a curved cotton-holder. It has an astringent effect upon the dis- 
 eased surface-epithelium, and at the same time appears to check pus- 
 cell proliferation. 
 
 The following tannin pigment has also a good effect applied in 
 the same way: — 
 
 1. 1$. Acidi tannici 115 
 
 Glycerin 31 
 
 Aquam ad 30 
 
 M. 
 
 Of sprays, after office-treatment, to be used by the patient, I have 
 found nothing better than the following applied by atomizer through 
 the nose, and in suitable cases into the post-nasal pharynx, by means 
 of the curved tip, two or three times a day: — 
 
 2. $ Thymol 2 
 
 Menthol 6 
 
 Albolene 60 
 
 M. 
 
 Any of the following would also answer: — 
 
 1. Ifc Acidi tannici gr. xxij. 
 
 Glycerin mxlv. 
 
 Aquam ad Sj. 
 
 M. 
 
 2. 1$. Thymol gr. iij. 
 
 Menthol gr. x. 
 
 Albolene gij. 
 
 M. 
 
202 DISEASES OF THE PHARYNX. 
 
 1. I£ Eucalyptol 21 
 
 Menthol |o 
 
 Albolene 601 
 
 M. 
 
 2. I£ Creasote 16 
 
 01. mentli. pip 16 
 
 Albolene 60 1 
 
 M. 
 
 3. I£ Formalin 41 
 
 Aquam ad 60) 
 
 M. 
 
 4. I£ Hydrogen peroxide 121 
 
 Aquam ad 601 
 
 M. 
 
 When the naso-pharyngeal glands are enlarged, and continue 
 secreting pus with little prospect of improvement, the removal or de- 
 struction of gland-tissue becomes necessary. To accomplish this vari- 
 ous methods have been devised, xlmong the number is the use of the 
 galvanocautery. This can be done, after applying a 15-per-cent. solu- 
 tion of cocaine, by passing the electrode directly backward through 
 the nose, the operation being guided by the post-rhinal mirror. It 
 can also be accomplished by the curved post-rhinal electrode, passed 
 through the mouth and up behind the palate, guided, as before, by 
 the use of the mirror. In the latter method the protection of the soft 
 palate is an important consideration. 
 
 This can be accomplished in two ways: either by the use of a well- 
 chosen palate-retractor or by the use of rubber cords passed through 
 the nares and out through the mouth, the two ends being tied on each 
 side over the lip. 
 
 Cases occur in which it is impossible even to examine the post- 
 
 1. B Eucalyptol 3ss. 
 
 Menthol gr. viij. 
 
 Albolene §ij. 
 
 M. 
 
 2. I£ Creasote »tx. 
 
 01. menth. pip mx. 
 
 Albolene '. §ij. 
 
 M. 
 
 3. I£ Formalin 3j. 
 
 Aquam ad §ij. 
 
 M. 
 
 4. I£ Hydrogen peroxide 3iij. 
 
 Aquam ad Bij. 
 
 M. 
 
NASOPHARYNGEAL CATARRH. 203 
 
 pharynx without the use of a palate-retractor; but, fortunately, the 
 majority of patients can be trained to control the palate-muscles suf- 
 ficient for this purpose. 
 
 I believe, however, that the best method of removing these post- 
 tonsillar enlargements is by the use of G-ottstein's curettes. By two 
 or three sweeps of the instrument the diseased tissue can be removed 
 and a smooth surface left in its place. 
 
 Sometimes chromic acid is used as a caustic instead of the galvano- 
 cautery, but, like this instrument, it is likely to injure healthy tissue, 
 except under the most careful manipulation. Both, too, are tedious, 
 requiring a series of operations to effect the desired result. 
 
 As a distinct variety of naso-pharyngeal catarrh, the atrophic 
 type might be mentioned. It is doubtful, however, if it ever occurs 
 except as a result and continuation of atrophic rhinitis. It is produced 
 by the same cause, and has essentially the same pathology, diagnosis, 
 and prognosis. Left to itself, it is just as hopeless of amelioration or 
 cure, while it demands, and is equally amenable to, a similar line of 
 treatment — a speedy or positive cure being impossible, while ameliora- 
 tion of symptoms and a fair degree of comfort can always be obtained. 
 
 When Tornwaldt's disease or inflammation of the so-called pharyn- 
 geal bursa exists, free incision, with subsequent antiseptic treatment, 
 will often be followed by a good result. 
 
CHAPTER XXXVIII. 
 
 ADENOID GROWTHS OF THE NASOPHARYNX. 
 
 Post-ehaeyngeal adenoids are overgrowths or abnormal devel- 
 opments of the lymphoid tissues which exist naturally during early 
 life in the naso-pharynx. Wilhelm Meyer was the first to study the 
 history of these vegetations thoroughly; and he based his conclusions 
 upon the personal and careful investigation of over one hundred cases. 
 Numerous writers have written extensively upon the subject since 
 Meyer's first paper appeared, but they have added, comparatively 
 speaking, little to what he had already given us (Figs. 73 and 73a), 
 
 ,,nf!Hi:;;:. : :::::::i;i: 
 
 mmSm. 
 
 Illlltlii ml^BsMiMik . 
 
 Fig. 73. Fig. 73a. 
 
 Fig. 73. — Infantile adenoids. Fig. 73a represents a growth 
 
 quite common. (After Schadle.) 
 
 Adenoid growths are found in the upper and back part of the 
 naso-pharynx, on the site of the pharyngeal, or Luschka's, tonsil. The 
 situation is between the orifices of the Eustachian tubes, but behind 
 and above them. In some cases they grow so large as to press upon 
 these tubes, even overlapping their orifices, and preventing the proper 
 action of the tubal muscles (Fig. 74). 
 
 Pathology. — Between infantile and adult life, the pathological 
 conditions of adenoid disease vary very much. In the former the sur- 
 face of the adenoid enlargement presents a convoluted appearance, of 
 (204) 
 
NASO-PHARYNX. ADENOIDS. 205 
 
 strawberry-like contour, the nodules standing out over the whole sur- 
 face, except when Luschka's sac is present; then the central portion 
 will exhibit a marked projection. In the latter the lymphatic cell- 
 elements have given place, in some measure, to connective-tissue forma- 
 tion, and a denser and smoother development occupies the position of 
 the original adenoid structure. In the transition-period of life the 
 tonsillar hypertrophy will also indicate a blending of the two types. 
 In young children to the touch it is almost like the softness of cerebral 
 tissue. 
 
 Microscopically the surface is covered with columnar ciliated epi- 
 thelium, but the cilia are frequently broken and bent and in some in- 
 stances absent. Beneath this we have the myxomatous mucosa rilled 
 with lymph-corpuscles and the round lymph-follicles, separated from 
 
 Fig. 74.— Stalactite forms. (After Schadle.) 
 
 each other by interfollicular tracts (Fig. 75). It is essentially a lym- 
 phoid structure, copiously supplied with blood-vessels, the whole being 
 arranged in the form of lobules (and secreting mucus or lymph from 
 the crypts between the follicles). As the adenoid becomes old with 
 increasing years, the lymph-tissues become absorbed, often shrinking 
 away by the fifteenth or the twentieth year. In other instances hyper- 
 plasia takes the place of absorption, and fibrous connective tissue de- 
 velops among the follicles and lobules of the adenoid. 
 
 The general impression, founded on clinical experience, is that 
 the fibrous, connective-tissue element varies in direct ratio with the 
 age of the patient. McBride, in his recent work, takes issue with this 
 idea. Founding his opinion upon the examination of six hundred 
 cases of adenoid disease, he says: "That while in many cases there is 
 
206 
 
 DISEASES OF THE PHARYNX. 
 
 a tendency to increase of the fibrous element at the expense of the 
 cellular, yet it is a mistaken idea to believe that it tends to come on 
 at any given age, and that it is more common in the very young child 
 than in the adult." 
 
 Together with adenoid development, there are often, probably as 
 an effort of extension, chains or clusters of enlarged follicles extend- 
 ing down the sides of the oro-pharynx, and situated behind the poste- 
 
 Fig. 75. — Microscopical section of hypertrophied pharyngeal tonsil 
 with lymphoid infiltration (20 diameters), a, Lymphoid follicle. &, Strati- 
 fied squamous epithelium of tonsillar crypt, infiltrated with lymphoid cells. 
 c, Cavity of crypt filled with secretion and lymphoid cells. (Author's 
 specimen by Bensley.) 
 
 rior pillars of the fauces, while single ones may be scattered here and 
 there over the post-pharyngeal wall. 
 
 Etiology. — This is not believed to be a disease of early infantile 
 life. Very few cases occur during the first two years. The exanthem- 
 ata usually attack children after that age has been reached, and it 
 is to the effects of those diseases that manv cases can be traced. Bar- 
 
NASO-PHAKYNX. ADENOIDS. 207 
 
 rett and Webster, of Melbourne, believe that scarlet fever, measles, 
 diphtheria, and whooping-cough bear a directly-causal relation to 
 adenoid development, basing their theory upon the natural tendency 
 to lymphoid development manifested by children about the period of 
 the second dentition. 
 
 The largest percentage of cases occur between the ages of five and 
 fifteen years. 
 
 Greville Macdonald's idea that one prominent cause in young 
 children is the presence of anterior nasal stenosis, the effect being 
 to lower barometric pressure in the naso-pharynx and to produce hy- 
 peremia there, appears in America to be untenable. In my own ex- 
 perience, I have found nasal stenosis in young children per se exceed- 
 ingly rare. Where I have seen it the cause has almost invariably been 
 traumatic. Even where the nostrils have been blocked with mucus, 
 adenoids being present, clearing the passages has revealed patent nos- 
 trils: quite sufficiently open, after the adenoids had been removed, to 
 permit of normal respiration. Instead of obstruction and disease of 
 the nasal passages being the cause of adenoid enlargement in young 
 children, I believe the reverse to be the case, and that not infrequently 
 both purulent and atrophic rhinitis owe their origin directly to the 
 enlargement of the so-called Luschka tonsil. 
 
 Heredity is not without its influence in etiology, for frequently 
 several members of the same family will successively apply for treat- 
 ment for the same disease. 
 
 The comparative frequency in males and females varies little. 
 
 It is frequently associated with the presence of hypertrophied 
 faucial tonsils, probably indicating the existence of a strumous diathe- 
 sis, with a tendency to abnormal lymphoid development. 
 
 Symptomatology. — The symptoms may be divided into aural and 
 general. Of the two classes, the aural are the most important. This 
 importance lies in the fact that when aural symptoms do appear they 
 indicate no little danger to a very important organ. In the language 
 of Pynchon, "Deaf-mutism is probably more often due to adenoid 
 hypertrophy than to any other single cause, the l^pertrophy having 
 occurred before the child has learned to speak/' 
 
 The first s}anptom of ear trouble is the presence of more or less 
 deafness, caused by the closure or obstruction of the Eustachian tube. 
 This may be followed by tinnitus aurium, otitis media, and abscess, 
 resulting in perforation. Healing may then take place; but frequently 
 chronic otitis media purulenta remains for weeks or months and even 
 
208 DISEASES OF THE PHARYNX. 
 
 3'ears without healing, if the adenoids, the cause of the abscess, are not 
 removed. When healing of the otitis does occur without adenoid op- 
 eration, the continuance of pressure and the extension of catarrh to 
 the Eustachian tube, produced by the ever-present hypertrophy, may 
 lead to renewal of the inflammatory attack at any time. 
 
 If the development of the adenoids is uneven, the growth being 
 in juxtaposition with one tube and not the other, it is quite possible 
 for one-sided deafness to exist for years, and the hearing power to have 
 diminished one-half, without having been discovered. The evil effect 
 of the presence of adenoids upon hearing is chiefly produced in early 
 life, although the stenosis and general shrinkage which occur in ma- 
 turity ma} T remove all interference with the Eustachian tubes; yet the 
 evil ma} f already have been accomplished, and the sense of hearing may 
 have become permanently impaired. Still, many cases do occur in 
 which ear-symptoms are never developed. 
 
 General Symptoms. — In young children the most pronounced 
 s}unptom is continuous mouth-breathing, with discharge of yellowish 
 muco-pus from both anterior and posterior nares, the source of the 
 secretion being chiefly the crypts and follicles of the hypertrophied 
 adenoid tissue. The presence of the growth, together with the accu- 
 mulated secretion, seriously interferes with nasal respiration. The 
 child has neither the knowledge nor the ability to throw off the dis- 
 charge, and it simply trickles away. When the pharyngeal tonsil is 
 only moderately enlarged there is still room for nasal breathing during 
 the day. The anterior nares may be free from secretion; but the ropy 
 mucus still presents itself in the throat, and on going to sleep the 
 mouth drops open. The night passes with stertorous, disturbed breath- 
 ing, accompanied by fretfulness and dreaming, and in the morning the 
 little patient wakes up tired and unrefreshed. 
 
 One s} T mptom which is always present, when stenosis occurs as a 
 result of the obstruction, is what Meyer calls "the dead voice." The 
 tcne undergoes a change. The resonance of the voice is destroyed, by 
 leing cut off from the resonating chamber. Instead of what is com- 
 monly called the "nasal twang" being produced, it is abolished. The 
 vocal waves are interfered with, and the proper voice is, in a sense, 
 smothered, the power of correct singing being entirely destroyed. 
 
 When the nasal passages are free and the breathing normal, mas- 
 tication and deglutition do not interfere in any way with respiration; 
 but, when the naso-pharyngeal stenosis is severe, the act of eating be- 
 comes a distressing thino-. for the little sufferer. 
 
NASOPHARYNX. ADENOIDS. 209 
 
 External deformities of the face and chest are also the result of 
 prolonged adenoid disease. Gleitsmann has pointed out the influence 
 of adenoids upon the development and configuration of the nasal sep- 
 tum and upper maxilla. Many facial deformities, he says, are produced 
 by their interference with nasal respiration, such as high-arched palate, 
 V-shaped upper maxilla, with the lateral teeth turned inwardly, and 
 the molars outwardly. As a result, the upper jaw, being flattened, 
 projects pointedly forward. 
 
 De Havilland Hall lays emphasis upon the amount of chest-de- 
 formity produced by defective nasal respiration. This in early life, 
 he says, is almost always occasioned by the presence of adenoid vegeta- 
 tions. 
 
 The reflex influences of adenoid enlargements offer a wide field 
 for investigation. Even over the voluntary movements of the young 
 child their eifects have been noticed. Lennox Browne and Bryson 
 Delavan have each of them related the history of a case of masturbation 
 in a young child troubled with adenoid disease; and in each case re- 
 moval of the growth was followed, without any further interference, 
 by cessation of the habit. 
 
 Headache is often the result of adenoid pressure; and instances 
 of asthma, laryngeal cough, and hay fever have all been relieved by the 
 removal of the growth. 
 
 Otto gives the history of a remarkable case of a young lady, aged 
 18, who was completely cured of enuresis nocturna by extirpation of 
 a mass of adenoids located in her naso-pharynx. 
 
 One other point in reference to symptoms should be mentioned 
 here. In the most severe cases of adenoid enlargement a condition 
 termed aprosexia is frequently developed. In other words, the dull- 
 ness and mental apathy indicated by the open mouth and unnatural 
 expression of features has its counterpart in the mental condition of 
 the patient. This is evidenced by irritability of temper, incapacity of 
 concentration, and deficiency of memory. That the mental power of 
 the brain is not itself injured, except by temporary suspension, is 
 proved by the complete change of both facial expression and mental 
 activity which follows the removal of the growths. The sulky and 
 cross child with open mouth will be transformed into a bright and 
 cheery one with closed lips and an aptitude for study previously un- 
 known to it. The cause of this lack of mental grip is ascribed to the 
 condition of lymphatic stagnation at the base of the brain. Quaife 
 draws attention to the numerous minute foramina communicating be- 
 
210 DISEASES OF THE PHARYNX. 
 
 tween the nasal passages and the cranial cavity, and that a similar men- 
 tal condition is sometimes fonnd in severe cases of nasal polypus. 
 
 Diagnosis. — The fancial symptoms, nasal stenosis, open mouth, 
 flatness of voice, together with the early life of the patient are usually 
 sufficient to produce a correct diagnosis without a rhinoscopic or digital 
 examination. The use of the post-nasal mirror is often impossible in 
 children; but examination of the pharynx by either sunlight or re- 
 flected light will often reveal a fullness of the palate or the region 
 behind it diagnostic of the cause of obstruction. Digital examination 
 behind the palate, however, will at once render the diagnosis possible. 
 The soft, corrugated, brain-like tissue will be felt to present itself on 
 the posterior and upper wall of the naso-pharynx: a condition which 
 in early life could be produced by no other abnormal growth. Some- 
 times they may even descend into the oro-pharynx and be visible to 
 direct examination. 
 
 When it is possible to obtain a post-rhinal view, a rounded or 
 stalactite or flattened nodular tumor will be seen hanging down from 
 the roof of the vault and projecting forward from its posterior surface 
 (Fig. 73). Sometimes it hangs directly downward, hiding the upper 
 part of the posterior nares from view (Fig. 74). When very large, the 
 whole of the choanse may be covered. 
 
 In adult life, when the growth is present, it will have lost its 
 mammillated appearance, — at least, in a majority of instances. It is 
 then more hyperplastic in character, the fibrous, connective-tissue ele- 
 ments having, in large measure, taken the place of the lymphoid and 
 glandular. The consequence is that the tonsil is denser and firmer, 
 with a smoother surface and containing fewer crevices and indentures. 
 
 Prognosis. — In mild cases, insufficient to produce nasal stenosis 
 and Eustachian obstruction, the prognosis even without treatment is 
 favorable, as Xature favors absorption of the tonsillar hypertrophy, 
 when puberty and adult life are reached. 
 
 In many cases requiring operative treatment the prognosis after 
 removal is equally good, provided ear-lesions have not already oc- 
 curred. Even when serious ear-complications do exist in young chil- 
 dren, hope may be expressed of arresting the progressive deafness, to- 
 gether with expectation of a certain amount of improvement. When 
 the ear disease has stopped short of necrosis, we may safely predict 
 the arrest of chronic otitis media, both catarrhal and suppurative, at 
 least in a majority of cases. 
 
 Eecurrence of adenoids after removal rarelv occurs. The text- 
 
NASO-PHARYNX. ADENOIDS. 211 
 
 books speak very lightly upon the subject. Some even affirm that after 
 thorough ablation they never return. Although this is the rule, still 
 many instances have occurred in which, after thorough extirpation, 
 there has been a redevelopment of the growth. Delavan, Wright, 
 Butts, Meyer, and others have recorded cases; and Hopkins gives the 
 history of three in which, after complete removal, adenoids developed 
 again. I have personally attended two cases in which recurrence took 
 place after what I believed to be thorough removal. 
 
 Although the operations for the removal of adenoids are usually 
 attended with little danger, and at the same time productive of the 
 best results, yet in some instances a fatal issue has followed the opera- 
 tion. Sandford reports the death of a child six hours afterward from 
 convulsions; Mayo Collier reports a similar case. In both cocaine was 
 the local anaesthetic used. Death was attributed in each case to nerv- 
 ous explosion. 
 
 Treatment. — General treatment, so far as the regulation of the 
 alimentary canal and the toning up of the system are concerned, is 
 always advisable. At the same time it can have but little effect in con-. 
 trolling the development of the adenoid disease. Sprays and washes 
 are also of little efficacy in severe cases, and their use is likewise usu- 
 ally resisted by the little sufferer. "When the hypertrophy is not large, 
 but just sufficient to produce a certain amount of catarrhal discharge, 
 without much stenosis, this may be remedied by a slightly stimulating 
 or astringent spray, of which the following is a good example. It 
 should be thrown up behind the palate once or twice a day by an 
 atomizer: — 
 
 1. I£ Acid, tannic II 
 
 Sod. bibor 1| 
 
 Carbolic acid 3 
 
 Glycerin 6 
 
 Aquam ad 601 
 
 M. 
 
 The formula on the following page is another excellent spray for 
 the same purpose, being antiseptic and slightly stimulating. 
 
 One part of this alcoholic solution should be added to 7 parts of an 
 
 1. I£ Acid, tannic gr. xv. 
 
 Sod. bibor gr. xv. 
 
 Carbolic acid mv. 
 
 Glycerin ' 3iss. 
 
 Aquam ad oij. 
 
 M. 
 
212 DISEASES OF THE PHAHTNX. 
 
 aqueous 2-per-cent. solution of boric acid, and used with an atomizer 
 to the nose and throat. 
 
 1. B Eucalyptol 125 
 
 01. gaulther |2 
 
 Menthol 1 
 
 Thymol 3 
 
 Alcohol rect 30 
 
 M. 
 
 When from one cause or another an atomizer cannot be used, the 
 preparation already mentioned, of 1-per-cent. solution of menthol in 
 albolene, could be snuffed up the nostril. 
 
 Any of these could be used two or three times a day. 
 
 When the adenoids are large, removal by surgical operation be- 
 comes necessary. This may be done by the use of hot or cold snares, 
 galvanocautery-knife, cutting forceps,, or curettes. It is impossible to 
 completely destroy the sensibility of the parts by application of a local 
 anaesthetic; but after childhood and during adult life it will rarely 
 be necessary to administer a general anaesthetic, a 15- or 20-per-cent. 
 solution of cocaine, applied by means of a cotton-holder, being all that 
 should be required. 
 
 During infancy and early childhood the case is different; and my 
 own impression is that an anaesthetic should always be administered. 
 If the adenoids alone require to be removed, it need not be given to 
 the extent of complete anaesthesia; but the operation can be performed 
 so much more easily, rapidly, and painlessly under its influence that 
 the advisability of its use can scarcely be questioned. The choice of 
 the anaesthetic, however, is an exceedingly important matter, the safety 
 of the patient being always of the highest consideration. Owing to the 
 wide preference for ether, which has been displayed by surgeons for so 
 many years for general surgical work, many are tempted to use it for 
 throat-work also. There are serious objections to it, however. Not 
 only is it believed to produce more bronchial congestion and pharyn- 
 geal hypersecretion than chloroform, and also, according to Linde- 
 mann, acute pulmonary oedema during or after the narcosis; but what 
 is perhaps equally important is the fact that the vapor of ether is in- 
 
 1. I£ Eucalyptol miv. 
 
 01. gaulther "*iij- 
 
 Menthol gr. iss. 
 
 Thymol gr. v. 
 
 Alcohol rect Bj- 
 
 M. 
 
XASO-PHARYXX. ADEXOIDS. 
 
 213 
 
 flammable, and that it would be dangerous to use a cautery in any 
 form to the nose or throat while using ether as an anaesthetic. 
 
 Bromide of ethyl has recently been received with great favor for 
 these operations. Bishop considers it the ansesthetic par excellence for 
 throat-work in children. The little patient is placed in a sitting post- 
 ure on the assistant's lap, an ounce tube of bromide of ethyl is emptied 
 into the air-tight inhaler and administered, allowing no air to enter. 
 Anaesthesia is induced in about one minute and lasts about five. About 
 one-half the bromide is taken and consciousness quickly returns. 
 Nitrous oxide also during recent years has grown rapidly in favor as a 
 safe anaesthetic. For short operations it is admirably suited, and its 
 
 Fig. 76. — Gleitsmann's (a) and Lowenberg's {!)) adenoid forceps. 
 
 effect can be prolonged by combining it with oxygen. Lennox Browne 
 strongly favors its use. 
 
 The choice would seem to lie between bromide of ethyl and 
 nitrous oxide. The comparative safety of the two it is too early to 
 positively decide. One advantage of both of them, if advantage it is, 
 lies in the fact that they can be administered in a sitting posture. As 
 regards simplicity of management, however, chloroform would seem 
 to have the advantage. A clean, coarse towel is all the instrument re- 
 quired, and the drug should always be given per guftatim. Often a 
 very little is needed and in a few moments the operation is all over. 
 A few deaths have been recorded from its use in throat-work, out of 
 the tens of thousands of times in which it has been given; but many 
 
214 DISEASES OF THE PHAKYNX. 
 
 of these could be traced to careless administration; and we are not 
 sure of the perfect safety of any anaesthetic that has ever been used. 
 
 The galvanocautery operation would be performed as already de- 
 scribed in the chapter on "Naso-pharyngeal Catarrh/' the mouth-gag 
 being inserted and the palate retracted before the electrode is passed 
 into the naso-pharynx. The child should be recumbent, with the head 
 thrown back, the face being turned toward the operator and with sun- 
 light playing upon the open pharynx. The position should be the 
 same no matter what instrument is used in the operation, particularly 
 if chloroform is the anaesthetic chosen. In using the cautery the sense 
 of touch should be a sufficient guide for the instrument. 
 
 Snares, although used by some surgeons, are not generally con- 
 sidered satisfactory instruments for the removal of adenoids. When 
 they are used, whether hot or cold, the snare may be passed through 
 the nostril or up behind the palate, but it should be adjusted to the 
 growth by the forefinger of the left hand (Figs. 34 to 37). 
 
 Many operators use post-pharyngeal cutting forceps, such as those 
 of Lowenberg or Gleitsmann (Fig. 76 a, b), taking the adenoids away 
 piece by piece. In some cases the whole operation is completed at one 
 time. In others several operations are required before the adenoids 
 can be entirely removed. 
 
 The most satisfactory instrument, however, and the one most 
 extensively used by the profession at the present time, is Gottstein's 
 curette. Of this there are various sizes and several modifications since 
 Gottstein introduced the original design. It is a ring-instrument with 
 the cutting edge so placed that in the downward movement it will lie 
 in contact with the post-pharyngeal wall, excising completely all within 
 its grasp (Fig. 77 a, b, c, d). In using it, although the mouth-gag is 
 required, the palate-retractor is not. After anaesthesia in the upright 
 posture — in the case of bromide of ethyl or nitrous oxide and in the 
 recumbent in that of chloroform — the instrument is slipped up behind 
 the palate, to the front of the adenoid growth. It is then pressed 
 against the vault, and brought down with a sharp sweep, the shaft of 
 the instrument being elevated toward the nose as the blade descends 
 along the post-pharyngeal wall, the central part of the adenoid being 
 swept away. It may be at once reinserted, first for one lateral portion 
 and then for the other. To complete the operation and to avoid leav- 
 ing any loose fragments of tissue, it is better to pass up the sterilized 
 forefinger of one hand afterward and scrape the surface clean with 
 the finger-nail. 
 
NASO-PHARYNX. ADENOIDS. 
 
 215 
 
 In older patients the curettage can be done in the operating-chair 
 under cocaine anaesthesia, and without the use of the mouth-gag. 
 
 In my own experience, the large majority of my patients have 
 been children between the ages of 4 and 10 or 12 years, and I have 
 made it a rule to operate with the patient lying on the back with the 
 head low, and invariably to have the anaesthetic administered by a 
 qualified practitioner. In this class of cases I always operate digitally, 
 using the nail of the forefinger of either hand, whichever at the time 
 
 (d) 
 
 Fig. 77. — Adenoid curettes: (a) Gottstein's; (&) Bosworth's, rigid 
 shank; (c) Payne's; (d) Munger^s. 
 
 is the most convenient to use. The soft pulpy lymphoid tissue can 
 easily be stripped off at a single operation; and the educated digit can 
 apply itself more thoroughly and efficiently to the lateral regions, be- 
 tween the Eustachian tubes and the sides of the central promontory, 
 than it would be possible to do at one sitting with the curette alone. 
 When the tissue is too dense to be removed by the finger, the curette 
 can be used to complete the operation. 
 
 The objection sometimes made to this method of operating, that 
 
216 DISEASES OE THE PHARYNX. 
 
 particles of adenoid tissue are likely to drop into the larynx, is, I be- 
 lieve, groundless. The recumbent posture with the head on the same 
 level with the body, and with it turned somewhat toward the operator 
 and thrown back during the operation, and the quick reversal to the 
 side position to facilitate the haemorrhage through the nasal passages 
 into the bowl, will neutralize this tendency; and I have not seen a 
 single instance in which I had the slightest reason to suspect its oc- 
 currence. 
 
 In older youths and adults, as said before, the operation is per- 
 formed under cocaine anaesthesia and in the operating-chair, the in- 
 strument used being one form or other of Gottstein's curettes. It has 
 usually in these cases required two or three operations to secure a per- 
 fectly satisfactory result. My use of post-nasal forceps has never been 
 a success, although I have tried them variously modified in a number 
 of instances. 
 
 The operation is always more or less painful, the cocaine never 
 producing complete anaesthesia of the parts. Still, there is no doubt 
 that it materially modifies the sensibility. Cleansing sprays for a few 
 days after the operation are advisable; but they should not be com- 
 menced until thirt} T -six or forty-eight hours after the removal of the 
 growth. The hydrocarbon oils containing 1 / 2 to 1 per cent, of thymol 
 or menthol are among the best for this purpose. 
 
 Sometimes, though rarely, severe haemorrhage will follow the op- 
 eration for the removal of the adenoids. In July of the present year 
 Martin, of San Francisco, reported three cases of severe haemorrhage 
 after operation, though fortunately none of them were followed by 
 death. Schmiegelow, one year ago, gave the history of a case by which 
 the operation was followed immediately by a gush of arterial blood 
 from the mouth and nose; and in a few minutes the boy was dead. 
 Post-mortem examination proved that the internal carotid artery had 
 been pushed out of position by swollen glands, and was opened by the 
 curette. Several years earlier Xewcombe reported two or three other 
 cases, including one of his own, in which death occurred from general 
 haemorrhage from the vault. Fortunately these cases are very rare, 
 though not infrequently severe bleeding will occur without resulting 
 in a fatal issue. 
 
CHAPTER XXXIX. 
 
 MYXOFIBEOMA OF THE NASOPHARYNX. 
 
 Myxofibroma, or polypus, of the nasopharynx is of compara- 
 tively rare occurrence. It is less myxomatous in character than when 
 within the nose, and contains more fibrous connective tissue. Hence 
 it must be considered a distinct variety of the disease. The surface is 
 deeply congested, in contradistinction to the blue-gray of the nasal 
 
 Fig. 78. — Dr. Grant's case of post-nasal polypus. 
 
 polypus, while its freedom from pressure within the naso-pharynx 
 enables it to attain a much larger size (Fig. 78). 
 
 Pathology. — The site of origin of polypus influences its patho- 
 logical character. The ordinary mucous polypus has its origin usually 
 along the summit of the middle meatus between the middle turbi- 
 nated and the external wall, from a pure mucous membrane. As the 
 mucosa descends downward over the body of the inferior turbinated 
 and toward the post-rhinal choana, the fibrous, connective-tissue ele- 
 ments within it become more numerous. Hence, the polypus spring- 
 ing from the upper portion of one of the posterior nares, or the 
 
 (217) 
 
218 DISEASES OF THE PHARYNX. 
 
 junction of the nose and the naso-pharynx, is composed of a com- 
 bination of both elements, the fibrons preponderating over the 
 mucous. Like nasal polypus, the histological definition is that of 
 loose fibroma, the external wall being of denser texture and more 
 liberally supplied with blood-vessels. They do not always arise from 
 the choanas, however. Sicthoff reports a case in which the tumor filled 
 the whole of the post-nasal space, and the site of the attachment was 
 the posterior end of the middle turbinated body. Microscopically 
 it was an adenoid, connective-tissue growth, covered with stratified 
 and ciliated epithelium. R. A. Reeve, of Toronto, also reports a 
 peculiar case occurring in a man aged 20. The growth was long and 
 evenly thick throughout, visible in the pharynx below the soft palate 
 and attached to the summit of the vault. It was of a grayish-red 
 color. Tentatively iodid. pot. was given in large doses for a week. 
 By this time it had diminished in size; so that the drug was con- 
 tinued without operation, and in a few weeks complete absorption had 
 taken place. 
 
 Etiology. — This is still, in a measure, an unknown quantity. It 
 cannot be affirmed positively what the cause may be; but as the 
 post-nasal polypus bears some relation to the ordinary myxoma of the 
 nose, not infrequently occurring in the same individual, the causes 
 may be identical. They are said to occur more frequently in females 
 than males, and between the fifteenth and thirtieth years. They are 
 usually single. 
 
 Symptomatology. — The principal symptoms are those caused by 
 physical interference with respiration, vocalization, and deglutition. 
 As it hangs down from one posterior naris, it occludes the passage 
 on that side; and, the enlargement continuing, soon has the effect, 
 by its pressure, of closing the other. Consequently respiration, of 
 necessity, becomes oral, while vocal resonance incident to a normal 
 condition of the nasal chambers is destroyed by the presence of the 
 growth. Deglutition is interfered with, just to the extent that the 
 movements of the palate are limited by the pressure of the polypus. 
 Although there may be progressive discomfort, there is little pain. 
 As the growth increases in size it may project below the palate and 
 be visible in the pharynx. Like other nasal neoplasms, it occasion- 
 ally produces reflex symptoms. Bosworth reports a case in his own 
 practice in which spasmodic asthma was caused by the pressure of a 
 post-nasal myxofibroma, and in which removal was followed by com- 
 plete relief. 
 
NASO-PHARYNX. MYXOFIBROMA. 219 
 
 Diagnosis. — Posterior rliinoscopic examination should make the 
 round, smooth, pinkish tumor visible. From adenoids it is dis- 
 tinguished by its site of origin, lighter color, and pear-shaped ap- 
 pearance; from fibroma, by more regularity of outline, less redness, 
 and no tendency to haemorrhage on being touched. Post-turbinal 
 hypertrophy has a more corrugated surface, does not project far into 
 the post-rhinal cavity and is always pale in color. Among the strik- 
 ing characteristics of post-nasal polypus are the facts that it is easily 
 movable; and does not produce haemorrhage, erosion, or facial de- 
 formity; nor does it possess that tendency to malignant development 
 which true fibroma is supposed to do. 
 
 Prognosis. — While there is no probability of the tumor leading 
 to a fatal issue, its removal by sloughing or absorption are not very 
 promising. After complete removal, however, by operative measures 
 they rarely recur. 
 
 Treatment. — Evulsion by strong serrated forceps through the 
 mouth, when the tumor is sufficiently large to be grasped within the 
 naso-pharynx, is one of the best methods of operation. A 15-per-cent. 
 solution of cocaine should first be applied freely to the growth through 
 the nose. This can be done by means of a cotton-carrier. Then, by 
 grasping the tumor with the instrument, aided, if necessary, by the 
 post-rhinal mirror, it can be drawn down to obtain freedom of motion, 
 and twisted off its pedicle, care being taken not to use too much 
 force in extraction. 
 
 In other cases, the nasal passages having been cleared and the 
 tissues shrunken by cocaine, a snare may be passed through the nasal 
 fossa and the wire adjusted to the pedicle by a finger passed within 
 the naso-pharynx. This is a safe and in many cases an excellent 
 method of extraction, particularly when the polypus is not very large, 
 and may be done by either the cold-wire snare or galvanocautery-snare. 
 The spring of the former, however, renders it much more adjustable, 
 and, hence, it has a distinct preference over the pliable platinum w r ire. 
 When the cold wire is used,, the base of the growth should be cauter- 
 ized afterward, and the same may be said after the forceps operation. 
 In using the cautery-snare the Eustachian tube should be properly 
 guarded. 
 
 Some writers recommend, in certain cases, incision into the soft 
 palate, to increase the space and facilitate removal. With modern 
 appliances for intranasal work, this should rarely, if ever, be neces- 
 sary for removal of simple myxofibroma, however large. Under co- 
 
220 DISEASES OF THE PHARYNX. 
 
 came the growth can be taken away through the naso-pharynx with- 
 out resorting to cutting operations into the normal tissue. Later ex- 
 perience has proved that in many cases the cold-wire snare passed up 
 behind the palate is the best method of removal. 
 
 I have seen three cases. The first was a child aged 5 years. The 
 pinkish, soft growth was visible hanging down behind the palate. 
 Under chloroform I attempted to remove it with post-nasal forceps, 
 but the attachment would slip from the grasp of the instrument. 
 Failing this, I scraped it from the child's left posterior choana with 
 the nail of the right forefinger. This occurred four years ago and 
 there has been no return. 
 
 The second was in a man past middle life. The growth had 
 formed from a large sessile base, and was attached to the upper part 
 and on both sides of the posterior end of the septum. It partly filled 
 hoth posterior nasal fossae, and lay upon the upper surface of the soft 
 palate. I found it impossible to pass the snare around it. The 
 surface was smooth and glistening, and of a grayish-pink color. With 
 the posterior rhinoscope slipped behind the growth, the base could be 
 seen attached to the central part of both choanae. With posterior 
 nasal forceps part of it was removed. The galvano cautery-knife was 
 then passed through the anterior nares, first on one side and then 
 on the other, an incision being made in each case through the at- 
 tachment close to the septum. Several days later, the attachment 
 having loosened, the bulk of the growth was removed by the forceps 
 from behind. The extended base was then singed by a curved elec- 
 trode passed through the nares. Spray-treatment for cleansing pur- 
 poses was subsequently used. Three years later, at the age of 60, 
 there was no return. 
 
 E. A. Eeeve, of Toronto, has reported another case of myxo- 
 fibroma of the naso-pharynx. Unlike the one already referred to, this 
 one had reached an immense size. It occurred in a woman aged 
 49. On examining the nose anteriorly something resembling myx- 
 omatous tissue seemed to fill the lower portion of both nasal fossae. 
 The masses, however, were not attached to the turbinateds as they 
 usually are in ordinary cases of nasal polypi. On examining the 
 throat the growth was found to fill the whole naso-pharynx. In 
 order to remove it, a vulsellum-forceps was bent to a suitable angle 
 and the teeth blunted. The instrument was carefully passed up be- 
 hind the palate and the body of the growth seized near its attach- 
 ment to one of the posterior choanae. With comparatively slight 
 
XASO-PHARYNX. MYXOFIBROMA. 221 
 
 traction the whole mass was removed in one piece. The projecting 
 tentacles lying in the inferior meati were but overgrowths of a huge 
 polypus, and slipped backward and out without severing their con- 
 nection. On examination the attachment proved to be by a compara- 
 tively small pedicle, which was severed by the traction of the vulsel- 
 lum. As a result, the patient received entire and permanent relief. 
 
 Since writing the above the following cases have been recorded: — 
 
 Weil {Werner medicinische Wochensclirift, January, 1899) reports 
 one case. It was attached all along the posterior edge of the vomer. 
 Two hemispherical processes filled the naso-pharynx and caused com- 
 plete nasal obstruction. One large branch of the polypus filled the 
 right nasal cavity as far as the anterior naris, while a pear-shaped por- 
 tion, whose lower extremity could only be seen by strongly depressing 
 the tongue, covered the whole post-pharyngeal wall. Weil removed 
 it through the post-pharynx in one piece. Its weight was forty-five 
 grammes. 
 
 Max Thorner (Laryngoscope, April, 1899) reports another, which 
 was even larger. Hearing was much diminished, there was complete 
 nasal stenosis, and the voice had the characteristic nasal twang. The 
 left nasal fossa was free, but the right one, posteriorly, was filled with 
 the mass. The attachment was at the posterior portion of the right 
 nasal fossa. It was removed en masse by means of a cold-wire snare 
 passed up behind the palate and around the growth. It was composed 
 of many large and small nodules, some of them of the size of a small 
 hen's egg. The pedicle was slender, not larger than a lead-pencil. 
 The weight was fifty -grammes. The patient was a man aged 30 years. 
 
 The author might likewise refer to one which he removed from 
 the naso-pharynx of a woman aged 31, on April 24, 1899. The phy- 
 sician who brought this case for treatment had already removed a 
 polypus from the left nostril. The probability, however, is that this 
 was only a projection forward of the original growth into the naris 
 from the naso-pharynx. On the left side there was complete stenosis. 
 Post-nasal examination revealed a large lobulated, firm, and pinkish 
 tumor, filling the post-nasal pharynx. A cold snare was passed up 
 behind the soft palate, and was adjusted over the growth by the index 
 finger of the left hand. The whole was removed in one mass. Al- 
 though much smaller than the two already recorded, its weight was 
 sixteen grammes. 
 
 The author would also like to make one remark, which so far he 
 has not observed in reading up the literature upon this subject, and 
 
222 DISEASES OF THE PHAEYNX. 
 
 that is: whenever a true fibroma oedematosa, or naso-pharyngeal 
 polypus, is successfully removed, it is usually taken away in a single 
 piece. It is difficult enough, and requires care and patience to adjust 
 the snare well up around the body of the tumor; but it is next to 
 impossible to press the wire closely upon all sides of the mass so as 
 to grasp only the pedicle. Still, when the snare is tightened, it does 
 not sever a piece, but removes the whole. The reason is obvious on 
 examining the structure of the polypus. The body has often been 
 years in growing, and is dense and fibrous and massive in character, 
 while the pedicle is formed largely of blood-vessels and mucous mem- 
 brane, and contains comparatively little fibrous tissue; and hence 
 yields more readily to the traction placed upon it than does the body 
 of the tumor. 
 
CHAPTEE XL. 
 
 FIBROMA OF THE NASOPHARYNX. 
 
 This disease differs materially from the one recorded in the pre- 
 vious chapter, being composed almost entirely of fibrous tissue and 
 having its origin, many authorities say, from the base of the occipital 
 bone, near its junction with the sphenoid, instead of in the choanal 
 region. It differs, too, in its slow, steady, and relentless growth, 
 crowding its way onward irrespective of the nature of the invaded 
 tissue, and producing absorption of bone as well as other tissues if 
 its way is impeded. With regard to origin, however, Capart says that 
 in history of fifty cases he has usually found the tumor to arise from 
 the internal surface and base of the pterygoid apophysis, and always 
 on the right side. 
 
 Pathology. — These tumors always occur singly. The attachment 
 is by a broad surface or pedicle, and sometimes the surface-attach- 
 ment expands with the growth of the neoplasm. In color they are 
 a dark red, though sometimes of a brighter or pinkish hue. They 
 have a hard or dense texture, and at first a rounded form and smooth 
 surface. The latter changes, and irregularity occurs as the disease 
 advances. They are formed of close-grained, white, fibrous tissue 
 plentifully supplied with blood-vessels. Scattered through the fibres, 
 which often interlace, are found the arteries and veins, and around 
 these are numbers of fusiform cells. The whole tumor is inclosed 
 in a capsule derived from the mucous membrane. In addition to the 
 vessels that permeate the growth, there are numerous blood-spaces, 
 some of them lying directly below the outside coating of the fibrous 
 neoplasm. 
 
 Etiology. — In Bishop's pithy words: "Their cause remains in 
 obscurity." This is true in regard to many diseases. Notwithstand- 
 ing the rapid progress medical science has made during recent years, 
 we are still, in reference to etiology, groping in the dark; and how 
 far bacteriological research will, in the near future, enable us to place 
 this division of the science upon a sound basis yet remains to be seen. 
 The majority of cases occur in males, and during the years of early 
 maturity, the disease rarely commencing after the age of twenty-five 
 
 (223) 
 
224 DISEASES OF THE PHARYNX. 
 
 years. The surface blood-vessels of the growth are larger than those 
 of the interior; hence the tendency to haemorrhage from mere sur- 
 face-abrasion. 
 
 Symptomatology. — The most prominent symptom, apart from 
 those of nasal stenosis, which have already been more than once de- 
 scribed, is that of frequently-recurring epistaxis arising from the 
 bursting of some of the numerous venous spaces on the surface. This 
 is possibly caused by friction with the soft palate. The amount of 
 bleeding differs from a few drops to copious and even dangerous 
 haemorrhage. As the growth increases in size it will press the palate 
 downward, often causing serious deformity. In the same way it may 
 extend anteriorly into the nasal fossae, displacing the nasal bones and 
 producing deformity even of the face itself. There is usually con- 
 siderable muco-purulent or muco-sanguineous discharge. The inter- 
 ference with nasal respiration and the pressure of the palate down- 
 ward will affect deglutition and induce pharyngeal and laryngeal com- 
 plications. The stenosis produced by naso-pharyngeal fibroma, al- 
 though unilateral at first, soon becomes bilateral, gradually filling up 
 the whole post-nasal cavity. 
 
 Diagnosis. — Post-rhinal examination should distinguish it from 
 any other disease, even at an early date. Naso-pharyngeal fibroma is 
 less regular in outline than myxofibroma and of a redder hue. The 
 former is hard, the latter soft; it will also bleed on touching, while 
 the naso-pharyngeal polypus will not. Beneath the reddish-pink sur- 
 face of the fibroma the white fibrous tissue may sometimes be seen. 
 While the tumor is hard to touch, it can easily be distinguished from 
 the still-harder texture of osteoma. One other characteristic which 
 distinguishes it from all other neoplasms, except those of a malignant 
 character, is the tendency to oft-repeated haemorrhage. 
 
 The points of difference between fibroma and the malignant dis- 
 eases, sarcoma and carcinoma, will be dwelt upon when dealing with 
 these subjects. 
 
 Prognosis. — If unremoved by operative measures the tendency 
 is toward a fatal result, partly owing to the repeated haemorrhages 
 which so frequently occur. These growths, however, rarely develop 
 after puberty; and, that age being reached without a fatal issue, 
 development may sometimes be arrested and gradual shrinkage of 
 the tumor ensue. Several cases have been recorded in which this has 
 occurred. Still, it is not wise to postpone treatment with the hope 
 of such an issue, for, if unarrested, the surrounding structures, no 
 
NASO-PHARYNX. FIBROMA. 
 
 9.9A 
 
 matter liow vital their character, are likely to be invaded by the 
 disease. 
 
 Treatment. — These growths should invariably be removed, if 
 there is any prospect of this being accomplished without incurring 
 risk of life. When at all possible, too, the operation should be per- 
 formed per vias naturales. There are few instances requiring the 
 radical method, proposed by some writers, of removing the upper 
 maxilla. If necessary, it would be better to divide the soft palate in 
 order to reach the base of the growth. The palate is not affected 
 except by pressure, having no attachment to the tumor itself. 
 
 Operation by galvanocautery-eeraseur is considered one of the 
 best methods now adapted, as by the slow action of the cautery 
 haemorrhage may be prevented. After passing the snare through the 
 nasal fossa the platinum wire is adjusted to the base of the growth in 
 the vault by the finger. Then the wire is drawn so as to grasp the 
 tissue, and the electric current turned on at a red heat, and slowly 
 tightened until the growth is excised. This operation is easy to 
 describe, but difficult to accomplish, especially with the instruments 
 that are now in use. The platinum wire, when drawn tightly, will 
 often break, particularly when at a dull-red heat, and the part to 
 which it has to be adjusted is difficult to manipulate with so soft a 
 wire. 
 
 Still, 14 cases are reported by Lincoln as treated in this way. 
 Of these, 11 were cured, while in the other 3 recurrence took place; 
 whereas in 38 operations in which the superior maxilla was resected 
 10 were cured, 8 died from the operation, 11 recurred, and 9 were 
 incomplete. In 7 operated on through the palate 2 recovered, 2 re- 
 curred, 1 died, and 2 were incomplete. 
 
 In some cases, where the galvano-ecraseur is unavailable or does 
 the work incompletely, the galvanocautery-knife may do better serv- 
 ice. It will require great care in manipulation to prevent haemor- 
 rhage. 
 
 Operations by cutting forceps and the curettes in the early stages 
 have been tried, but the same care against excessive bleeding requires 
 to be taken. 
 
 Bosworth prefers the cold steel-wire snare, applied in the same 
 way, the instrument being a stronger one than those ordinarily in 
 use and made of the Jarvis type, with a bar to tighten the screw in- 
 stead of a wheel. 
 
 Capart and Ingals favor electrolysis in the treatment of this dis- 
 
226 DISEASES OF THE PHAKTXX. 
 
 ease. It has the advantage over all others of being unattended by 
 haemorrhage, and when the parts are freely cocainized it is not very 
 painful. It may be practiced either by the bipolar or monopolar 
 method. In the former the positive and negative needles, properly 
 protected, are passed side by side directly into the tumor at the dis- 
 tance of half a centimetre from each other. This can be done either 
 through the cocainized nasal fossa or by curved needles into the 
 growth from behind the palate. The current should be between 15 
 and 25 milliamperes and the time at each sitting ten to twenty min- 
 utes. By the monopolar method, the right pole might be a large flat 
 electrode applied to the cervical spine, and the left pole a needle in- 
 serted into the tissue as before. The number of treatments required 
 would vary materiall}', some requiring a large number and others 
 comparatively few. When the electrolysis is not destructive of the 
 tumor, it may have a contracting effect upon the calibre of the blood- 
 vessels, thus limiting the arterial supply and rendering subsequent 
 radical operation less dangerous. The frequency of treatment would 
 be every two or three days. 
 
 Whatever plan is followed, the parts can be kept as aseptic as 
 possible by the use of cleansing, antiseptic sprays. 
 
CHAPTER XLI. 
 
 MALIGNANT DISEASES OF THE NASOPHARYNX: 
 SARCOMA AND CARCINOMA. 
 
 Saecom A . 
 
 Malignant diseases of this region are very rare, but of the two 
 — sarcoma and carcinoma — sarcoma is much more frequent. 
 
 Pathology. — The origin of sarcoma of the naso-pharynx, like 
 fibroma, is usually from the neighborhood of the union of the basilar 
 process of the occipital bone with the sphenoid. The tumor is more 
 sessile in its attachment than fibroma. It starts in the deeper layers 
 of the mucosa, and, while the base is expanding, the growth develops 
 downward, with a lobular surface, rapidly filling the post-pharynx, 
 and sometimes extending forward through the post-nares into the 
 nasal cavities. Histologically it presents the usual characteristic feat- 
 ures of sarcoma, with large and small round cells and dense fibrous 
 connective tissue. The growths are of softer texture than fibroma, 
 and, hence, are less likely to displace the dense osseous tissues. 
 
 Etiology. — The bacillus of sarcoma has so far not been dis- 
 covered, but it is more than probable that it is, in all cases, of bacil- 
 lary origin. It usually occurs in early life, in this way differing from 
 the rarer disease, carcinoma. Still, it does occur occasionally even 
 in extreme age. It is more frequent in males than females. 
 
 Symptomatology. — In the early stages the symptoms do not differ 
 materially from those of the diseases already described which impede 
 nasal breathing. There is, however, somewhat early in its history a 
 characteristic discharge of offensive malodorous sero-pus. Haemor- 
 rhage sometimes occurs, though less frequently and less severely than 
 in the milder disease, fibroma. The general health likewise suffers. 
 When the sarcoma grows large, it interferes with the normal condi- 
 tion of the adjacent organs, pressure on the Eustachian tubes pro- 
 ducing deafness to a more or less degree, and invasion of the pharynx 
 inducing difficult deglutition and vocalization. Shooting pains to the 
 ears sometimes occur. 
 
 Diagnosis. — Sarcoma of the naso-pharynx is to be distinguished 
 from carcinoma, fibroma, tuberculosis, and tertiary syphilis. Its soft, 
 grayish, pultaceous appearance should distinguish it from the harder 
 
 (227) 
 
228 DISEASES OF THE PHAKYNX. 
 
 and pinker fibroma. From carcinoma, the age of the patient should 
 help in the diagnosis. The exceeding rarity of carcinoma, also, to- 
 gether with its more marked cachexia and greater tendency to be 
 associated with glandular enlargement, should help in this matter. 
 As to tuberculosis and syphilis, the general constitutional symptoms 
 and personal history should materially aid in forming a correct con- 
 clusion. 
 
 Prognosis. — The younger the patient, the more rapid the progress 
 of the disease. This is never toward resolution, but always toward a 
 fatal issue. Small-celled sarcoma is said to be more rapidly fatal than 
 the large round-celled or the spindle-celled varieties. Fibrosarcoma, 
 which is merely a combination of the fibrous with the malignant dis- 
 ease, is slower in development, although more likely to be attended 
 during its course by attacks of severe haemorrhage. Even after suc- 
 cessful removal by operations, in the majority of instances, recurrence 
 takes place, a very small percentage of recoveries having been 
 recorded, while a large number of patients have died on the operating- 
 table. 
 
 Treatment. — As a rule, palliative measures, with mild cleansing 
 washes to the parts affected, are the only justifiable means of treat- 
 ment. The general system should be supported by tonics and good 
 digestible food, while hygienic conditions should be carefully at- 
 tended to. 
 
 The results of operative treatment are usually very unfavor- 
 able. The old method of splitting the palate and dissecting out the 
 growth; and the larger one, of removing a portion of the upper 
 maxilla, to get at the pedicle of the disease, have been attended almost 
 uniformly by a fatal result. Bryson Delavan, however, reports a case 
 which seems to be an exception. After the sarcoma had developed, 
 until it partly filled the naso-pharynx, and almost entirely the left 
 nasal cavity, electrolysis was resorted to and carried on for a year. 
 Under its use, haemorrhage ceased, the growth shrank, and health 
 improved. By that time it lost its efficacy, and operation was per- 
 formed, removing the growth as thoroughly as possible. Eecurrence 
 was soon very marked, and operation was again performed. This 
 time the upper part of the left superior maxilla was removed, and 
 the growth found to be attached to the sphenoid sinus. It was ex- 
 cised thoroughly. An opening was left in the hard palate by which 
 the site could be watched. It recurred slightly several times and was 
 each time burned away with galvanocautery. On recording this case 
 
NASO-PHARYNX. CARCINOMA. 229 
 
 four months had elapsed without any return, and the youth, aged 
 17, was well. 
 
 Bosworth reports a case cured in a gentleman aged 42. This was 
 done "by repeated snaring of small portions of the growth, carried on 
 daily for several weeks, and followed by a series of galvanocautery 
 operations, conducted in like manner. After a time the sarcoma was 
 entirely removed, and seven years later there had been no return. 
 
 Logan, in 1894, reported a somewhat similar case. In this a num- 
 ber of snare operations had been performed, but all were followed by 
 rapid recurrence of the disease. Finally the case fell into his hands. 
 He tied the palate forward and found the growth attached to the roof 
 of the naso-pharynx. He divided the growth into several sections 
 and removed each section by a galvanocautery operation. Six years 
 later the sarcoma had not returned and the man was in perfect health. 
 
 In all these cases microscopical examinations proved the correct- 
 ness of the diagnosis. 
 
 In Bosworth's case as well as Logan's it will be noticed that the 
 final successful work was done by the galvanocautery: a clear indica- 
 tion of the value of this instrument in dealing with malignant disease. 
 
 If the tumor is taken early, and can be removed piece by piece 
 by means of the galvanocautery, which can be so controlled as to 
 occasion but little haemorrhage, we are certainly justified in making 
 the attempt. By this means we also save the possibility of autoinfec- 
 tion, which might occur through knife operation upon unaffected 
 tissues. 
 
 Carcinoma. 
 
 The literature upon this subject is confined to the history of a 
 few reported cases. The disease resembles sarcoma in many ways, and 
 is so invariably fatal that little need be said of it here. Bare as is 
 sarcoma, carcinoma, the more malignant of the two, is still more rare. 
 A few important points are worthy of notice, however: It is a dis- 
 ease that almost always occurs late in life. Unlike sarcoma, it is also 
 attended by profuse glandular enlargement and a general appearance 
 of malignant cachexia. Microscopically the presence of epithelial 
 cells distinguish it from sarcoma. 
 
 The prognosis is uniformly unfavorable. Operative treatment is 
 useless, mild cleansing and supporting measures being all that can be 
 of any avail. Opiates internally and the local application of cocaine 
 may, in the latter stages, afford a certain measure of relief. 
 
230 diseases of the pharynx. 
 
 Chondroma of the Naso-pharynx. 
 
 This non-malignant disease is so exceedingly rare that only mere 
 mention of it will he necessary. The symptoms are those of ordinary 
 stenosis. There may also he occasional' attacks of headache and also 
 of syncope. Post-nasal examination reveals the presence of a hard, 
 dense, whitish growth. Microscopical examination of segments show 
 the cartilaginous character of the neoplasm. There is no tendency 
 to malignancy. Surgical operation will he required for removal. 
 There should he no return of the disease. 
 
 Foeeigx Bodies. 
 
 Sometimes, though rarely, foreign hodies "become lodged in the 
 naso-pharynx. Although they produce symptoms, they may remain 
 for years hef ore they are discovered. The two following are interesting 
 cases and worthy of note: — 
 
 E. Patterson (Journal of Laryngology, May, 1899) reports a for- 
 eign body impacted in the naso-pharynx for four years. This was a 
 metal regulator of an infant's feeding-bottle. It was removed from a 
 child, aged 6 years, suffering from otorrhcea of the left side, with foetid 
 discharge from left nostril. There was also complete nasal stenosis, 
 and something could be distinguished in the post-pharynx on looking 
 through the left nasal passage. Tnder anaesthesia a hard mass was 
 discovered and removed from the naso-pharynx, and was found to be 
 the body mentioned, thickly coated with phosphates. 
 
 The history obtained was that, when the child was fifteen months 
 old, while playing with a regulator it suddenly showed difficulty of 
 breathing. This was relieved by suspending the head downward. 
 From that time nasal breathing became obstructed, and the child's 
 health suffered. At various times subsequently bougies had been 
 passed into the oesophagus by medical men, to prove to the parents 
 that the foreign body was not still in the throat. 
 
 H. S. Birkett (Montreal Medical Journal, June, 1899) reports a 
 foreign body in the naso-pharynx for eighteen years and gives the his- 
 tory of this peculiar case. It occurred in a woman aged 23 years. She 
 had had profuse muco-purulent discharge from both nostrils for many 
 years. The odor was characteristic of a foreign body. 
 
 When five years old she accidentally slipped a thimble into her 
 throat. This was followed by a violent fit of coughing, which suddenly 
 ceased upon her being thumped upon the back. 
 
DISEASES OF THE OKO-PHAKYNX. 
 
 CHAPTER XLII. 
 
 ACUTE PHARYNGITIS. 
 
 Acute sore throat, the common name of this disease, is of fre- 
 quent occurrence. It affects the whole fancial region, including the 
 soft palate, with the uvula, faucial pillars, and tonsils. The spot first 
 attacked, and from which it spreads to the surrounding tissues, varies 
 in different cases. In persons subject to the disease, the plan of attack 
 and extension often follows an almost invariable course. 
 
 One patient will always feel at the onset an uncomfortable prick- 
 ing soreness in the one tonsil, from which it will extend to the whole 
 pharyngeal cavity. Another will perceive the first symptoms on the 
 htack wall of the pharynx, while a third will declare that the primary 
 irritation is always felt in the back part of the nostrils or the post- 
 nasal space. Still another will state positively that, while the acute 
 cold will always commence in the throat, it invariably extends upward 
 to the nose before it disappears. 
 
 Pathology. — The mucous membrane of the fauces is but scantily 
 supplied with glands. Consequently in the first stage of acute inflam- 
 mation the squamous epithelial lining shows marked hyperemia, ac- 
 companied with arrest of secretion and dryness of the surface. The 
 condition may last twenty-four hours or so, and is followed by ex- 
 osmosis of serum and intermixture of muco-pus and epithelial cells. 
 Micrococci are present in large numbers, of which streptococci in 
 many cases predominate. 
 
 Etiology. — While sudden exposure to a greatly lowered tempera- 
 ture, particularly when that exposure is confined to certain parts of 
 ihe body, will often be the immediate cause, yet it is pretty generally 
 conceded that this rarely occurs without the presence of a prior or 
 latent cause for the production of the disease. So many people are 
 exposed in a similar manner without acquiring acute phalangitis that 
 we are forced to believe in a special tendency toward its development 
 in the case of those who habitually become victims. 
 
 Whether that tendency is produced by the constant presence of 
 
 (231) 
 
232 DISEASES OF THE PHARYNX. 
 
 chronic faucial disease, tonsillar hyperplasia, naso-pharyngeal steno- 
 sis, general dyscrasia, or deranged digestion or not, one of these, at all 
 events, becomes in many instances a potent factor in the etiology, and 
 if possible should be removed. 
 
 The attack may be brought on by exposure of the back of the 
 neck or chest to a cold wind, particularly when the system is over- 
 heated or perspiring. In the same way, sudden changes of under- 
 garments from heavy to light, without due regard to atmospheric 
 temperature, may chill the surface and increase the blood-pressure in 
 a weakened pharyngeal mucous membrane. The disease is often 
 caused by a vitiated atmosphere, inhaled by persons employed in over- 
 heated, ill-ventilated rooms. These unfortunates frequently become 
 the victims. 
 
 It is more apt to occur in adult life than among children, as in 
 the latter the lymphatic and glandular elements are more prone to 
 inflammatory action than are the connective-tissue structures. 
 
 Symptomatology. — Slight chilliness and general malaise, accom- 
 panied by a sense of discomfort and soreness of throat, are usually 
 the first symptoms. The rise in temperature is slight, rarely more 
 than one or two degrees. Frontal headache is sometimes present, and 
 when the inflammation extends to the Eustachian tubes, producing 
 temporary stenosis, there may be ringing or deafness. 
 
 For the first hours the throat will feel dry and irritable, and on 
 inspection will reveal an hypergemic condition, with diffused redness 
 pervading all the visible parts of the pharynx. After this the blood- 
 vessels and small glands commence to relieve themselves, by pouring 
 out upon the surface a copious effusion of sero-mucus ; pus-corpuscles 
 may also develop, and the inflamed pharynx, coated with secretion, 
 may in some places be almost hidden from view, particularly when 
 the vault is involved. 
 
 In some cases considerable oedema of the soft palate takes place, 
 and the mucous membrane of the mouth and tongue become flabby 
 and heavily coated and the breath itself unpleasant. When the inflam- 
 matory condition extends downward to the larynx, an irritable cough 
 is induced. This, although it occurs comparatively early in the dis- 
 ease, rarely extends to the bronchial tubes. 
 
 The duration of acute pharyngitis may be from two or three 
 days to a week. By prompt treatment it can often be shortened and 
 the temperature reduced to the normal, followed by rapid disappear- 
 ance of symptoms. 
 
ORO-PHARYNX. ACUTE PHAEYNGITIS. 233 
 
 Diagnosis. — Sore throats occur in connection with exanthematons 
 diseases, and in these cases the diagnosis may not be certain nntil the 
 surface eruption appears. Still, close examination should distinguish 
 the even hyperemia of simple sore throat from the submucous efflores- 
 cence of the eruptive fevers. In commencing tonsillitis the pain of 
 the tonsil affected is more severe than in simple acute pharyngitis, 
 while the redness of the surrounding mucosa is less evenly distributed. 
 In rheumatic sore throat there is usually less oedema than in the 
 second stage of this disease, while the faucial muscles are more pain- 
 ful. 
 
 Prognosis. — Unless the inflammatory action extends to the 
 larynx, it usually subsides within a week. Some writers have reported 
 cases followed by systemic paralysis, but it is doubtful whether the 
 toxic effect of the disease could be severe enough to produce paresis. 
 Other writers believe that these must have been cases of masked 
 diphtheria, in which the Klebs-Loeffler bacillus, although present, 
 could not be found. 
 
 Treatment. — Before entering upon the treatment of acute phar- 
 yngitis a word or two might be said here in reference to eucaine, 
 introduced a couple of years ago as a collateral drug which might 
 in some cases take the place of cocaine in the treatment of nose 
 and throat diseases. I have not spoken of eucaine before, because 
 from the writings of authors and my own personal experience I did 
 not think it could be used with advantage in nasal work, and in this 
 field would be far inferior in utility to cocaine as a local anaesthetic. 
 In the pharynx, where we have ample space for vision, and do not 
 require to contract the tissues in order to obtain a view, the case 
 may be different, and I will here give the views of several leading 
 writers upon the comparative merits of the two drugs. 
 
 Somers {Therapeutic Gazette) says cocaine produces local anaes- 
 thesia in from 3 to 5 minutes, lasting from 20 to 30 minutes; eucaine 
 produces local anaesthesia in from 8 to 10 minutes lasting only 20 
 minutes. Cocaine produces anaemia of mucous membrane. Eucaine 
 produces hyperaemia. This action of eucaine, he says, strongly mili- 
 tates against its use in operations upon hypertrophic tissues. The 
 advantages, however, which it has over cocaine are the following: 
 It produces less pharyngeal disturbance, is less harmful to the system, 
 keeps better in solution, and the efficiency of the drug is not injured 
 by boiling. 
 
 Pouchet {La Semaine Medicate), reporting to the Societe Thera- 
 
234 DISEASES OF THE PHAEYNX. 
 
 peutique, said that he had investigated the physiological action of 
 encaine. He found the toxic equivalent almost equal to that of co- 
 caine. He says encaine may produce toxic effects, which may even 
 ]3rove fatal without any prodromic stage. Its action on the heart is 
 as intense as that of cocaine. Eucaine must therefore be looked upon 
 as a dangerous drug. 
 
 Keclus (British Medical Journal Epitome) says that in equal doses 
 its anaesthetic power is less than that of cocaine. He thinks, there- 
 fore, that it should not be used in serious operations. 
 
 J. S. Gibb (Philadelphia Polyclinic) has used eucaine in diseases 
 of nose and throat, and sums up as follows: 1. Eucaine is equally 
 efficient with cocaine as an anaesthetic in ordinary examinations. 2. 
 It possesses equal anaesthetic power with cocaine, and hence is as use- 
 ful in operations on nose, throat, and larynx. 3. Eucaine is nearly 
 if not quite as effective as cocaine in reducing the engorged turbinated 
 bodies. 4. Eucaine is superior to cocaine, in that it is less likely to 
 produce toxic symptoms and also unpleasant subjective symptoms, 
 particularly as regards the pharynx. 
 
 Lastly, Jobson Home and MacLeod Yearsly (British Medical 
 Journal), after a long article upon the subject, close with the follow- 
 ing statement: "Several points remain for further experience to 
 decide, but we consider that our results, so far, justify us in con- 
 tinuing the investigation. Eucaine cannot, however, wholly replace 
 cocaine, since the effect of the latter, in reducing the size of the tur- 
 binated bodies, gives it a value as an aid to diagnosis which eucaine 
 does not appear to possess." 
 
 These combined remarks seemingly would justify our exclusion 
 of eucaine in dealing with diseases of the nose; while they indicate 
 a probable utility in regard to the treatment of pharyngeal disease. 
 
 To return to the treatment of acute pharyngitis. Much can be 
 done in the way of abortive treatment in the physician's office. It 
 can frequently be arrested by prompt local treatment. First, cleanse 
 the pharynx with a spray of Dobell's solution. Then spray it at once 
 with a 2-per-cent. solution of cocaine. Possibly a similar solution of 
 eucaine would answer equally as well. This will, in a few moments, 
 deaden the terminal nerve-filaments and prepare the mucous mem- 
 brane for the important part of the treatment, which is simply to 
 brush the pharynx with a 5-per-cent. solution of nitrate of silver, 
 applying the pigment most thoroughly upon the parts affected. The 
 treatment is to be repeated in twenty-four hours if required. In the 
 
ORO-PHARYNX. ACUTE PHARYNGITIS. 235 
 
 meantime, and subsequent to the brushing, either of the following 
 solutions, applied with an atomizer every three or four hours, will 
 act as an antiseptic to the throat and aid in keeping it clear of 
 catarrhal secretions: — 
 
 1. I£ Resorcin 1 
 
 Glycerin 6 
 
 Aquam ad 60 
 
 M. 
 
 2. $ Thymol 
 
 Boric acid 2 
 
 Glycerin 3 
 
 Aquam ad 60 
 
 M. 
 
 Although by this method slightly increased tenderness of the 
 throat may be experienced, as soon as the effect of the cocaine or 
 eucaine has passed away, yet the course of the disease will be short- 
 ened. In a day or two the increased redness of the mucous membrane 
 will have disappeared, and, instead of the pultaceous infiltration and 
 muco-purulent discharge that sometimes occurs, it will have resumed 
 an almost normal appearance. 
 
 To accomplish the same object in a different way Bishop advises 
 the administration of pellets each containing 1 / 6 milligramme 3 of 
 atropia and 8 milligrammes 4 of morphia, repeated every few hours 
 as required, to act by their combined anodyne and drying effect upon 
 the mucous membrane. 
 
 Quinine might be administered in either case and a brisk cathar- 
 tic if required. 
 
 Among the older methods of treatment, one that has often been 
 very effective in checking the disease is the giving of drop doses of 
 tincture of aconite every hour until the throat symptoms commence 
 to abate, after which the interval should be lengthened. This would 
 
 1. R. Resorcin gr. xviij. 
 
 Glycerin 3iss. 
 
 Aquam ad 3ij- 
 
 M. 
 
 2. $ Thymol gr. j. 
 
 Boric acid gr. xxx. 
 
 Glycerin m-K.lv. 
 
 Aquam ad 5ij. 
 
 M. 
 
 3 1 
 
 Aoo grain. 4 l / 8 grain. 
 
 15 
 
236 DISEASES OF THE PHARYNX. 
 
 usually occur before the first twenty-four doses had been given. 
 Tincture of belladonna might be prescribed in the same way, in 3- 
 drop doses every two hours. Both are arterial sedatives, with an 
 astringent effect upon the fauces. 
 
 Gargles of alkaline solutions, such as DobelFs, chlorate of potassa, 
 etc., have long been advised in the treatment of this disease. Gargles 
 are, however, as a rule, only imperfectly applied, the solution not 
 being allowed to enter the lower pharynx at all. Consequently, even 
 when using the same solution, a good atomizer is much to be pre- 
 ferred. 
 
 If the improvement seems tardy, the alkaline spray might be fol- 
 lowed by an astringent, my own preference being for the hydrocarbon 
 compound, used, of course, with an atomizer. 
 
 1. I£ Acid, tannic 2 
 
 Glycerin , 3 
 
 Aquam ad 60 
 
 M. 
 
 2. U Thymol 13 
 
 Menthol 13 
 
 Albolene 60 
 
 M. 
 
 As regards external applications to the neck, I do not believe 
 they are of much value. Sometimes a cold wet flannel applied to the 
 front of the throat, and kept in position by a rubber bandage around 
 the neck, will reduce the irritation by its sedative effect. When 
 counter-irritation is needed, equal parts of spirit of turpentine and 
 sweet oil form a good application, the throat being covered with a 
 layer of cotton-wool. 
 
 As said before, persons subject to this disease are frequently 
 sufferers from some obstructive lesion, which is the primary cause. 
 Hence, after recovery, it is the duty of the physician to see to it that 
 the lesion if present be removed, and that the entire naso-pharyngeal 
 mucosa be placed in as sound a condition as possible. 
 
 1. I£ Acid, tannic gr. xxx. 
 
 Glycerin mxlv. 
 
 Aquam ad §ij. 
 
 M. 
 
 2. $ Thymol gr. ij. 
 
 Menthol gr. xx. 
 
 Albolene |ij. 
 
 M. 
 
CHAPTER XLIII. 
 
 CHRONIC PHARYNGITIS. 
 
 This disease is confined largely to the pharyngeal mucous mem- 
 brane, the soft palate and the uvula being rarely affected, except in 
 cases which have a nasal origin. As it occurs chiefly in adult life, 
 the glandular system is but little affected. The tonsils, however, if 
 in an hyperplastic condition, not infrequently become affected by the 
 disease. 
 
 Pathology. — Successive repetition of attacks of sore throat, from 
 whatever cause, is likely to produce permanent hyperemia and relaxa- 
 tion of the blood-vessels. A species of pharyngeal paresis takes place 
 — the continued congestion resulting in surface-infiltration and struct- 
 ural thickening of the mucosa. The lymph-follicles and muciparous 
 glands are also affected, sometimes being marked by distinct hyper- 
 trophy in the lines of the salpingo-pharyngeal folds. 
 
 Etiology. — There are many causes for this disease, and writers 
 in tracing out the etiology are apt to be influenced by special features 
 coming under their personal observation. In my own experience, 
 chronic nasal disease, deviations of the septum, the presence of neo- 
 plasms, or post-nasal adenoids have been the prevailing causes. The 
 result of any of these would be oral breathing, particularly at night, 
 and the direct contact, repeated every night for a prolonged period, 
 of dry air upon the post-pharynx, for reasons already explained, 
 would be sufficient to induce- the disease. 
 
 Some writers believe that the most common cause is the occur- 
 rence of the oft-repeated attacks of acute pharyngitis, while others 
 assert that this is never the cause, but that the chronic disease is the 
 etiological factor of the acute. 
 
 Bosworth traces the disease to chronic gastritis of one form or 
 another, basing the belief on the theory that the oro-pharynx is a part 
 of the food-tract, and consequently more in sympathy, physiologically 
 and pathologically, with the digestive than the respiratory organs. 
 Gastric disturbances of a chronic character almost invariably affect 
 the pharynx, possibly by reflex influence. This is particularly the 
 case in chronic alcoholism. The tobacco habit, too, is not unattended 
 
 (237) 
 
238 DISEASES OF THE PHARYNX. 
 
 by evil results, though whether they arise from nicotine absorption 
 or the direct effect of the hot, dry air upon the throat is still an 
 undecided question. Persons whose occupations keep them exposed 
 to constant respiration of foul air or irritating gases are also subject 
 to the disease. It is also frequently caused by improper or prolonged 
 use of the voice. 
 
 Symptomatology. — A sensation of throat discomfort, accom- 
 panied by a desire to swallow, in order to relieve the })arts of sup- 
 posed accumulations, is one of the commonest symptoms, particularly 
 when the disease has a nasal origin. "When it arises from chronic 
 gastric disturbance, the throat is more irritable, and on examination 
 with the tongue-depressor retching may be produced, while the raw, 
 inflamed condition of the lower pharynx will be observed. The 
 voice, too, is often altered in tone. There may be a rasping screatus 
 to clear the lower pharynx, and a jerky hoarseness, sometimes lapsing 
 momentarily into aphonia. A voluntary cough to free the arytenoids 
 from mucus may be present. In certain cases the palate becomes 
 relaxed, hanging down like a flabby curtain, and even the uvula may 
 become cedematous and elongated, though these conditions can only 
 occur, I believe, when the primary cause lies in the upper air-passages. 
 
 Diagnosis. — The symptoms described, together with the sensa- 
 tions experienced by the patient, should easily distinguish this from 
 any other disease. The chief difficulty in diagnosis should not be as 
 to existence of chronic pharyngitis, but as to the cause which pro- 
 duced it, whether it arose from gastric or nasal disturbance or from 
 some purely external source. One broad distinction lies between the 
 first two. In the former the lower throat will be deeply congested and 
 the tongue will be irritable, with red papillae standing over its base, 
 the palate being but slightly affected. In the latter the redness and 
 irritability will be slighter, the post-pharynx be more deeply coated, 
 and the palate affected more or less by the disease. When both 
 these causes can be excluded, the history of the case per se may 
 indicate the origin. 
 
 Prognosis. — This is not an alarming disease; but, as the cause 
 producing it is usually of a chronic character, both chronic condi- 
 tions require to be removed, and it may take careful treatment for 
 .a long time to accomplish the end in view. Still, much relief even 
 from the commencement can be given, and it is worth the patient's 
 -while to submit to the necessary treatment. 
 
 Treatment. — When the disease is secondary it becomes important, 
 
ORO-PHARYNX. CHRONIC PHARYNGITIS. 239 
 
 if possible, to remove the primary cause, whether that be by surgical 
 removal of obstructive lesions of nose or naso-pharynx or systemic 
 treatment of chronic gastric disease. It may be necessary to break 
 or check the liquor habit or to interdict the use of tobacco. Difficult 
 as either of the latter may seem to be, the patient who appreciates 
 the throat affection sufficiently to seek professional relief will usually 
 do his best to carry out the physician's advice. 
 
 Direct treatment to the throat will also be required. The first 
 should be thorough cleansing with alkaline sprays. If there is much 
 thickening and infiltration of the mucosa, this should be followed by 
 the application of a 10-per-cent. solution of nitrate of silver. The 
 best way of applying it is by means of a cotton-holder. Sometimes 
 the throat is so irritable that the pressure of the tongue-depressor 
 upon the back of the tongue will immediately produce contraction 
 of the pillars, shutting off almost the whole of the post-pharyngeal 
 wall from view. To obviate this a weak solution of cocaine, 1 or 2 
 per cent., may be applied to the fauces. Then, in applying the silver 
 solution, the end of the holder, after brushing the part of the post- 
 pharynx in view, should be bent to an angle of 100 degrees or so, and 
 slipped behind the posterior pillar on one side, and glided up and 
 down to the full depth of the fold, the other side being treated in 
 the same way. This treatment need not be repeated oftener than 
 once or twice a week at the physician's office. 
 
 Other astringents — such as sulphate of copper, chloride of zinc, 
 glycero-tannin, etc. — might be used instead, but for directly removing 
 the outside coating of the mucous membrane, and stimulating normal 
 action of the capillaries, no application appears to act as efficiently as 
 nitrate of silver. 
 
 For home-treatment the patient should spray the throat freely 
 twice a day with an alkaline solution, and follow this each time by one 
 of the hydrocarbon preparations already mentioned, such as: — 
 
 3-per-cent. camphor-menthol in albolene. 
 5-per-cent. eucalyptol in albolene. 
 3-per-cent. menthol in albolene, etc. 
 
 The general system should also be regulated, the alimentary canal 
 attended to,. and appropriate tonics prescribed if necessary. 
 
CHAPTEE XLIV. 
 
 FOLLICULAR PHARYNGITIS. 
 
 This disease, as its name implies, is confined to the follicles of 
 the pharynx, particularly to those of the post-pharyngeal wall. The 
 inflammatory process, without extending to the whole mucous surface, 
 produces hyperplasia in a number of isolated spots, scattered over the 
 membrane, the abundance and location of the affected follicles vary- 
 ing in different cases. 
 
 Pathology. — The lymph-follicles involved in this disease are en- 
 larged and stand out prominently above the surrounding mucosa. 
 While the muciparous glands are few upon the pharyngeal wall and 
 the lymph-follicles widely scattered, yet it appears to be those situ- 
 ated in the immediate vicinity of the glands that have the greatest 
 tendency to hypertrophy. The morbid process consists of abnormal 
 deposits of lymph-elements accompanied by epithelial growth. In 
 the exudative form, instead of the latter development, the follicular 
 tubules are distended by a cheesy secretion, which exudes, and may 
 crust upon the surface. In some cases the inflammation becomes 
 more diffuse. A number of follicles will be united by connecting 
 submucous hyperplasia, and plaques are found varying in size rising 
 above the mucous membrane. When the disease occurs in early life, 
 the granulations are soft and sometimes large; but as they rarely 
 disappear of themselves, they undergo a change as the patient gets 
 older, becoming smaller and more dense in texture. Sometimes the 
 hypertrophy of the follicle is associated with atrophy of the surround- 
 ing mucosa. In others there are not only the isolated granulations of 
 the central wall, but also strings of thickly-studded lateral granula- 
 tions extending upward into the naso-pharynx, behind the posterior 
 pillars of the fauces. 
 
 Etiology. — Except in the two extremes of life, during which 
 periods the disease is almost unknown, age has little influence in pro- 
 ducing it. It occurs from childhood all the way up to middle age. 
 In early life when adenoids are present we would naturally expect 
 these granulations to occur in conjunction with them, the adenoids 
 being the cause, not by direct extension, but by producing throat 
 
 (240) 
 
OROPHARYNX. FOLLICULAR PHARYNGITIS. 241 
 
 irritation consequent to oral breathing. The formation of adenoids 
 and follicular disease are both influenced in many cases by the pres- 
 ence of scrofulous diathesis. In adult life it frequently occurs as a 
 result:: or- complication of previously-existing nasal disease. 
 
 It is said to occur more frequently among women than men, 
 probably owing to the more sedentary occupations of the former, and 
 the consequent greater tendency to the development of disease of the 
 mucous membrane. We should remember, also, how much the phar- 
 yngeal mucosa is influenced by the gynaecological condition of the sex. 
 
 Granting a tendency toward the disease, breathing a dusty at- 
 mosphere, excessive use of the voice, continued nasal obstruction, the 
 occurrence of acute or chronic pharyngitis, or any other conditions 
 which may induce continuous throat irritation may result in the 
 development of pharyngeal granulations. 
 
 Symptomatology. — When occurring in children, the symptoms 
 are rarely noticeable, being thrown entirely into the shade by the 
 existing primary disease. In adult life this is different. The sub- 
 jective sensations are more intelligently realized. The nasal stenosis 
 or post-pharyngeal discomfort may have been relieved, but the dry- 
 ness and pricking sensations, and hacking cough produced by the 
 presence of the granulations are still there, producing annoyance and 
 discomfort to the patient. The voice loses its full and rounded tone 
 and is easily fatigued. ■ 
 
 When the disease is associated with post-nasal catarrh, the pos- 
 terior wall of the pharynx may be covered with a grayish, stringy 
 coatiug of mucus-pus, often hiding the granulations from view until 
 it is removed. Then the surface will be seen more or less covered 
 with prominent little hypertrophies. They vary from one to five 
 millimetres in diameter, and, when plaques are present, they some- 
 times cover from one-half to one square centimetre in area. 
 
 Although strings of granulations may sometimes be observed 
 running upward behind the pillars into the naso-pharynx, it is com- 
 paratively rare to find the posterior pillars affected. When they do 
 form on the pillars or the margin of the velum or uvula, the granu- 
 lations are very small and hard, like little, red seeds, standing out 
 upon the mucous membrane. 
 
 Stiffness of the throat, painful deglutition, and soreness after 
 prolonged speaking are frequent symptoms, and have given rise to the 
 term "clergyman's sore throat" which has often been applied to it. 
 The application seems to be an unfortunate one, as the sore throat 
 
242 DISEASES OF THE PHARYNX. 
 
 by which so many clergymen are affected is almost always due to other 
 causes. This was particularly exemplified in a paper which I read 
 before the Canadian Medical Association in Montreal in August, 1896, 
 giving the history of 10 cases of so-called clergyman's sore throat. 
 Although it is a slight digression, yet it has a bearing upon the 
 subject, and the quotation of the last few sentences will not be out 
 of place: — 
 
 "In conclusion, according to old parlance, the 10 cases I have 
 reported might all be called 'clergyman's sore throat,' while in 
 reality only 2 had follicular pharyngitis. All had soreness and hoarse- 
 ness in a more or less degree; but these symptoms arose from widely 
 different causes, and in several instances hypertrophies of different 
 kinds were found to exist in the one case. 
 "Briefly to epitomize: — 
 
 In 1 there was a large nasal polypus. 
 
 In 1 a dislocated columnar cartilage. 
 
 In 1 hypertrophy of the faucial tonsils. 
 
 In 1 ulceration of the hyoid fossa. 
 
 In 2 there were septal ridges. 
 
 In 2 septal spurs. 
 
 In 2 catarrhal hypertrophies of the post-septum. 
 
 In 2 elongation of the uvula. 
 
 In 2 pharyngeal granulations. 
 
 In 3 turbinal hypertrophies. 
 "While in only one, 1 and that the most serious case of all, was 
 there uncomplicated laryngeal disease." 
 
 Whether a name which will cover such a variety of diseases, merely 
 because one or two symptoms may be present in all, is worthy of a 
 place in medical literature is at least doubtful. 
 
 Diagnosis. — Careful examination by means of the head-mirror 
 and reflected light should at once exclude every other disease. The 
 little, round, red or grayish-red spots, shining brightly upon a paler 
 background, could not be mistaken for anything else. When the sur- 
 face is coated from post-pharyngeal catarrh the spots may be hid, 
 but clearing this away by the use of an alkaline spray will soon render 
 them visible, together with any plaques or lateral granulations that 
 may be present. 
 
 Prognosis. — This is usually a chronic disease, and rarely subject 
 
 1 Eighteen months later this gentleman died of malignant disease of the 
 larynx. 
 
OROPHARYNX. FOLLICULAR .PHARYNGITIS. 243 
 
 to spontaneous cure, except as incidental to the lymphatic atrophy, 
 common in old age. Besides the annoyance it causes, in persons who 
 do not require to use the voice unusually, its presence may be of little 
 moment. In voice-users, however, whether public speakers or singers, 
 the presence of follicular pharyngitis becomes a serious matter, as 
 it interferes with the tone and quality, as well as the endurance, of 
 the voice itself. Fortunately, however, it is amenable to treatment 
 in a large majority of cases. 
 
 Treatment. — This consists, after cleansing the pharynx of all se- 
 cretions by the free use of sprays, in destruction of the hypertrophic 
 follicles one by one. For this purpose many methods have been ad- 
 vised, the object being to destroy the overgrowth without injuring 
 the surrounding healthy tissue. London paste and chromic acid are 
 both used for this purpose. The chief objection to each is the possi- 
 bility of the extension of the effects of the agent to the adjoining 
 mucous membrane. The galvanocautery-point carefully used is en- 
 tirely free from this objectionable tendency. 
 
 Although the operations are slight, and the pain of burning re- 
 duced to a minimum, it is always better to precede the operation by 
 the application of a solution of cocaine to the pharynx. Some oper- 
 ators consider this unnecessary. Still, the fact that the deadening of 
 the pharyngeal wall prevents the reflex contraction of the posterior 
 pillars during the operation makes it almost imperative to use it. At 
 the first sitting three or four or half a dozen granules may be touched. 
 The operations should be repeated at intervals of three or four days 
 until all have been removed. A mild spray of 1 / 2 -per-cent. solution 
 of thymol in albolene used several times a day by the patient will 
 have a soothing influence during the course of treatment. If ca- 
 tarrhal secretions interfere, they can be removed by an alkaline spray 
 instead. The kind of electric point used should depend on the size 
 and shape of the granulations, and the heat should not be so great 
 as to produce haemorrhage. The small-pointed hypertrophies would 
 require the needle-pointed electrode, the larger ones a thicker tip, 
 and the plaques may be incised at a dull heat from side to side with 
 parallel cuts — the whole surface not being destroyed at one time. 
 There is always more or less inflammatory action afterward, and it is 
 always better so to operate as to keep reaction at a minimum point. 
 
 If the granulations are very numerous the treatment should be 
 prolonged and sometimes intervals of weeks might be allowed to pass 
 between the cauterizations. 
 
244 DISEASES OF THE PHAKYNX. 
 
 Of course, if the disease owes its origin to neoplasms or over- 
 growths in the upper respiratory passages, these should be removed 
 before the patient is dismissed from treatment. Any derangement 
 of the system should also be rectified by judicious medication, to- 
 gether with attention to diet and hygiene. 
 
CHAPTER XLV. 
 
 ACUTE TONSILLITIS, OR QUINSY. 
 
 The close observation with which this disease has been observed 
 during recent years has established the fact that although the tonsil 
 partakes in the acute inflammation which is developed, in a large 
 proportion of cases the disease originates, not in the tonsil itself, but 
 in the areolar tissue surrounding it. Still there can be little doubt 
 that many cases occur in which the inflammatory action, if not 
 virtually confined to the tonsil, at least has its origin there. 
 
 Bosworth believes that all cases of quinsy are peritonsillar inflam- 
 mations of areolar tissue; Casselberry equally favors this view. The 
 older writers, and Bishop among the new ones, claim the condition 
 as one of amygdalitis, or abscess of the tonsil itself, and any peri- 
 tonsillar extension to be of a secondary character. In Lennox 
 Browne's experience 55 per cent, of cases occur in the lacunae of the 
 tonsil, 28 per cent, in the parenchyma, and only 13 per cent, in the 
 peritonsillar tissue. 
 
 From my own experience, I believe the origin may be either 
 extratonsillar or intratonsillar. The deep phlegmonous abscess, in- 
 volving all the peritonsillar tissues, with the whole lateral wall stand- 
 ing out, and pressing the tonsil itself directly across the faucial cavity, 
 may in every instance be peritonsillar in its origin; but others, which 
 are oft-recurring, definitely localized, and acutely painful, in which 
 the most marked ocular signs are in the tonsils themselves, are likely 
 to be tonsillar in their origin, any extension into the surrounding 
 tissues being of a secondary character. 
 
 If not, it might be asked, how is it that in the latter class of 
 cases the tonsils themselves steadily increase in size, becoming larger 
 and larger with each successive attack, while, so far as can be seen, 
 the surrounding tissues remain unchanged? And how is it, also, that 
 the removal of a large segment of the hypertrophied tonsil will, in 
 most cases, effectually check the recurrence of quinsy? 
 
 Pathology. — Although acute tonsillitis, as a rule, results in sup- 
 puration, yet in some instances it extends no farther than acute in- 
 flammation, becoming red and shiny: according to Leland, the paren- 
 
 (245) 
 
246 DISEASES OF THE PHARYNX. 
 
 chymatous variety. There may be infiltration with increased cell and 
 lymphoid development, together with the presence of pathological 
 germs within the crypts of the tonsil. Streptococcus pyogenes and 
 pnenmococci may be present; but so long as they are all on the sur- 
 face or within the crypts only, and not within the deeper tonsillar 
 or areolar tissues, phlegmonous abscess does not occur. In a large 
 proportion of cases, however, the infectious process does not stop here. 
 The lacunae of the tonsils may become blocked. Pathogenic germs 
 may already have found an entrance, and, the crypts being closed, 
 exposure to the surface cold may produce hyperemia of a rheumatic 
 throat, and inflammatory action be developed in all its intensity. In 
 a rheumatic diathesis the peritonsillar tissue, particularly when pressed 
 by a hard, hypertrophied tonsil, will be prone to inflammatory action, 
 and having commenced may soon spread to the surrounding tissue 
 and the tonsil itself. Pus-corpuscles are formed, a phlegmonous 
 abscess results, and streptococci pyogenes may be found in large num- 
 bers. Sometimes pnenmococci and staphylococci will also be present. 
 
 The site of the abscess varies greatly, sometimes it is in front 
 of the juncture of the anterior and posterior pillars. At others deeply 
 seated behind the lower part of the anterior fold, pressing the tonsil 
 inward almost to the opposite wall of the pharynx. Again, it may be 
 at the posterior side of the tonsil, deeply engaging the soft palate 
 and uvula in inflammatory infiltration, while not infrequently the 
 whole body of the tonsil itself may be the subject of phlegmonous 
 enlargement. 
 
 When the pus forms, the soft character of the surrounding tis- 
 sues do not tend to limitation. Fortunately it spreads equally in all 
 directions, and, there being no dense membrane between it and the 
 surface, spontaneous evacuation usually soon occurs. When the sup- 
 puration is deeply seated, behind a dense hyperplastic tonsil, progress 
 toward the mucous surface is more tardy and the pus may burrow 
 extensively into the surrounding tissues. Yelpeau reports a case in 
 which the pus made its way into the cellular tissues of the neck as- 
 low down as the clavicle. Beid reports another in which the pus 
 burrowed along the course of the great vessels into the pleural cavity, 
 resulting in death from empyema. 
 
 In some cases the tonsillitis is confined entirely to the tonsil, and 
 is deeply ulcerative in character. Lake reports a case of this nature. 
 The ulcer was as large as a shilling and covered with a tenacious 
 gray slough. He removed the tonsil and in five days the young man 
 
OKO-PHARYNX. QUINSY. 247 
 
 was well. Tlie microscope revealed large masses of beaded bacilli on 
 the advanced edge of the slough. 
 
 Pakes reports three cases of acute tonsillitis in which the ton- 
 sils themselves were the seat of the disease, being in each case red 
 and swollen. On microscopical examination of the blood-serum a 
 pure culture of Friedlander's bacillus was found in each, in one of 
 them being associated with staphylococcus aureus. 
 
 Etiology. — The period of life during which this disease is most 
 prevalent is between the ages of 15 and 40 years, the larger number 
 being near the centre of that period. Still, some occur even in child- 
 hood, while a very few are reported among the fifties and sixties. 
 The rheumatic diathesis is a predisposing cause, and in many cases 
 acute rheumatism of the joints is a prelude to rheumatic tonsillitis, 
 while in other instances the quinsy precedes the general rheumatism. 
 Successive attacks of tonsillitis tend to produce hypertrophy of the 
 tonsil, while the increasing hypertrophy promotes susceptibility to 
 inflammatory action. The disease occurs more frequently among 
 males than females, owing to the greater exposure as well as climatic 
 privations to which men are subject. There is also in some cases a 
 marked hereditary tendency. This occurs chiefly in strumous cases, 
 hypertrophied tonsils being a prominent feature of development. One 
 fact is readily observed, that quinsy rarely occurs when the tonsils are 
 of normal size. 
 
 The usual exciting cause is sudden and unequal exposure of the 
 body to cold. The chilling of the surface, and the consequent con- 
 gestion of any weak internal organ, will in many instances tend to 
 the development of the disease. There is another point, which I do 
 not remember to have seen referred to, but which I have observed 
 in practice, and that is. that the majority of cases of quinsy occur in 
 mouth-breathers. The constant oral respiration exposes the throat 
 to a variety of changes, both of temperature and purity of air, which 
 the normal breather escapes. 
 
 Symptomatology. — The depressing effect which this disease has 
 upon the nervous system is indicated by the feeling of weariness ac- 
 companied by chilliness and exhaustion, with which it is often ush- 
 ered in. For the first day or two general febrile action takes place, 
 rising to 102° or 103°, in some cases even higher. 
 
 These symptoms are accompanied by pain in the affected tonsil, 
 swelling soon takes place, and in two or three days it may become 
 so great as to materially interfere with deglutition. When the disease 
 
248 DISEASES OF THE PHARYNX. 
 
 is peritonsillar the tissues become very brawny and painful, the 
 muscles swollen, and the movements of the inferior maxilla are ma- 
 terially interfered with. The efforts to swallow even fluids are some- 
 times almost unavailing, and, owing to the imperfect action of the 
 swollen palate, they may escape through the nose in the effort of 
 swallowing. The voice becomes muffled and indistinct, and sleep al- 
 most impossible. At first the pain is sharp and lancinating. Later 
 on swelling occurs, and the pain becomes of an oppressive, aching 
 character. As the swelling in the throat becomes greater, saliva 
 dribbles from the mouth and the jaws become almost immovable. 
 The temperature goes down, the body may be bathed in cold sweats, 
 and even respiration . may be stertorous and impeded. Little or no 
 nourishment can be taken, and the recumbent posture becomes almost 
 impossible. This condition may continue several days without relief 
 is given by surgical means. Finally the pus, aiming at some point 
 within the pharynx or back part of the mouth, gradually softens the 
 surface-membrane; the mucosa gives way, and, the pus being dis- 
 charged freely, the patient obtains immediate relief. 
 
 When the disease attacks both tonsils, it is rarely exactly at the 
 same time, but in quick succession, the one being invaded within 
 two or three days of the other. They then run their course almost 
 together, the main difference between single and double tonsillitis 
 being in severity of symptoms. 
 
 Diagnosis. — The acuteness of the inflammation, with its rapid 
 development, and high fever, should distinguish it in all cases from 
 syphilis, tuberculosis, or malignant disease. With reference to other 
 acute affections, the characteristic symptoms of quinsy should render 
 the diagnosis plain. The sudden onset of high fever, accompanied by 
 sharp unilateral pain in the tonsil, bright redness and swelling in 
 one side of. the throat, the difficulty in swallowing, the immobility of 
 the jaws, the difficulty of bending the neck, and the peculiar dis- 
 tressing look of the face point to this disease in contradistinction to 
 all others. When the disease is double, the intensity of the symptoms 
 should render the diagnosis more certain. From phlegmonous abscess 
 of the post-pharynx it must be distinguished by the position of the 
 enlargement, and the greater impediment to respiration which the 
 disease induces. Palpation is always a material aid in diagnosis. In 
 the early stages the brawny feeling of the abscess, wherever located, 
 may be outlined, and, as the suppuration advances, the point of soften- 
 ing can be readily discovered. 
 
ORO-PHARYNX. QUINSY. 249 
 
 In the commencenient there is a possibility of confounding this 
 disease with diphtheria and acute lacunar tonsillitis, but attentive 
 observation should remove all difficulty. The onset is more sthenic 
 than in diphtheria, but there is less enlargement of the glands, no 
 albuminuria, no development of false membrane. As to lacunar ton- 
 sillitis, the presence of tonsillar exudation, unaccompanied by much 
 enlargement or by deep-seated pains, should distinguish it at once from 
 the more serious malady of tonsillar abscess. 
 
 Prognosis. — Acute, painful, and exceedingly distressing, as the 
 disease always is, it very rarely proves fatal per se. When it does do so, 
 it occurs either from oedema of the air-passages or extension of the 
 abscess into the surrounding tissues. It is a self-limited disease, and 
 runs its course in from one to two weeks. After free evacuation of 
 the pus-cavity, whether by necrosis of the surface-tissue or by surgical 
 operation, recovery is usually very rapid. 
 
 The possibility and even probability of the recurrence of the 
 disease should always be borne in mind. 
 
 Treatment. — Unfortunately in this, as in many other affections, 
 the patient, as a rule, does not seek treatment until the disease is well 
 established; and by that time it is too late to abort it. Prompt treat- 
 ment on the first appearance of the throat symptoms would in many 
 instances check its progress. For this object a saline cathartic, such 
 as sulphate of magnesia or Eochelle salts, may be given, followed at 
 once by a dose of 1 / 2 to 1 gramme of quinine. Prompt treatment 
 of the throat, also, should be attended to. First wash it thoroughly 
 with a spray of DobelFs solution. Then apply a 10-per-cent. solu- 
 tion of cocaine freely to the affected tonsil, and follow this by brush- 
 ing it with a 10-per-cent. solution of nitrate of silver. The cocaine 
 temporarily drives away the blood from the congested tissues, while 
 the cathartic is attempting to prove its efficiency. The astringent 
 and antiseptic effect of the silver will remove a good deal of the super- 
 ficial irritation, as well as destroy the surface and lacunar bacteria, 
 thus producing a general sedative effect upon the inflamed gland. 
 
 Other astringents — such as solutions of sulphate of copper, alum, 
 or tannic acid — might be tried, but they lack the effectiveness of the 
 silver nitrate. 
 
 If the tonsillitis is of rheumatic origin, full doses of salicylates 
 should be given. 
 
 Failing the abortive treatment, other measures will be required. 
 As the disease advances, it becomes very difficult to open the mouth; 
 
250 DISEASES OF THE PHAKYNX. 
 
 and, while examinations may be necessary, in order to keep cognizant 
 of the location and progress of the disease, frequent digital exami- 
 nations are inadvisable. The touch of the finger in the early brawny 
 condition may help to clear up the diagnosis; but even then it is 
 scarcely necessary. Subsequent to that, the touch of the cotton- 
 holder with its thin, firm stem and little pledget of cotton-wool on 
 the end, aided by reflected light, should be sufficient to indicate the 
 condition of the parts. 
 
 When pointing is indicated, from the grayish color and softened 
 condition of any spot, it is best to open the abscess freely at once 
 and liberate the contained pus. The question often arises: Should 
 we lance the inflamed tissues earlier, or before we are absolutely sure 
 of the presence of purulent matter? In many instances I believe we 
 should. I have seen instances where a deep incision into the tonsil 
 itself, producing free venous haemorrhage, without the outlet of pus 
 at all, has been followed at once by relief of the most urgent symp- 
 toms and gradually recession of the disease. -Another instance I can 
 well remember, in the case of a rheumatic patient, in which the 
 pharynx was almost filled with an intensely-painful right-sided phleg- 
 mon. The teeth could not be opened more than half an inch; but, 
 inserting a tongue-depressor, a deep and long incision was made 
 parallel with the edge of the anterior pillar. Bleeding was very free, 
 but there was no pus. Eelief from the severe tension was marked, 
 and twelve hours later pus commenced to flow from the wound. 
 
 While incisions to give relief require to be free, the proximity 
 of important vessels should always be borne in mind. The internal 
 carotid artery is in near proximity to the posterior and external 
 border of the tonsil, and if wounded death might result before the 
 vessel could be cut down upon and tied. As a rule, however, it is 
 better not to lance until we are morally certain of the formation of 
 pus; and, without the operator is perfectly sure of his bearings, this 
 should be the law in all cases. Sometimes the pus-cavity is not a 
 single sac, and several openings may require to be made before all 
 the pus can be discharged. 
 
 Frequent gargling of the throat with hot water, before and after 
 operation, will usually have a grateful effect upon the patient; and 
 the same may be said of steaming the pharynx by means of a rubber 
 tube attached to a kettle of hot water. 
 
 With regard to external applications, many believe in hot poul- 
 tices to the neck; while others recommend the application of crushed 
 
OROPHARYNX. QUINSY. 251 
 
 ice in the same way. In my own experience a simple method has 
 sufficed, giving equal comfort with less trouble. Warm spirit of tur- 
 pentine and olive-oil in equal parts were rubbed freely over the region 
 of the tonsils and then a thick narrow layer of surgeon's absorbent 
 cotton was applied from side to side and fastened in position by a 
 neck-bandage. This was repeated twice a day, securing a sensation 
 of warmth and support. 
 
 During the progress of the disease, light and nourishing diet will 
 be required, the amount to be controlled by the power of deglutition 
 of the patient. 
 
 After recovery I do not know any systemic treatment that will 
 remove the tendency to recurrence. The ordinary rules regulating 
 diet, clothing, and hygiene should, of course, be followed. The one 
 thing, however, of all others, where there is either hypertrophy or 
 hyperplasia of the tonsils which will prevent the return of the quinsy, 
 is the removal of the diseased glands. 
 
CHAPTEE XLVI. 
 DISEASES OF THE UVULA : (EDEMA; ELONGATION. 
 
 (Edema. 
 
 This is a simple serous exudation into the deeper layers of the 
 mucous membrane. When severe and prolonged, the fibres of the 
 azygos uvula? may be involved, also the soft palate and pillars of the 
 fauces. It is the second stage of inflammatory action in the softened 
 and relaxed tissues. 
 
 Etiology. — (Edema of the uvula is almost always of a secondary 
 nature, having its origin in acute or chronic inflammation of some 
 portion of the nose or naso-pharynx. Occasionally it is a reflex 
 traumatism from surgical operation upon the turbinateds or faucial 
 tonsils. Sometimes it is idiopathic. 
 
 In one patient I was struck with the peculiar fact that on several 
 occasions the application of 10-per-cent. solution of cocaine to the 
 nasal cavity preparatory to operation was followed, in less than half 
 an hour, by oedema of the uvula, which in a couple of hours spon- 
 taneously subsided. 
 
 It may, in a few cases, be the result of pharyngeal tuberculosis 
 and also of general anasarca. 
 
 Symptomatology. — A tickling sensation in the middle of the 
 throat, with a feeling of fullness as if from the presence of a foreign 
 body, accompanied by constant efforts to clear the pharynx by hawk- 
 ing and swallowing, are the leading symptoms. Physical examination 
 will at once reveal the condition. The palate will be relaxed and the 
 uvula — elongated, thickened, and baggy — will have lost its normal 
 pink hue, and assumed that of a transparent bag of serum. 
 
 Prognosis. — When it arises from traumatism, the subsidence will 
 be spontaneous, usually within a few hours. When from acute or 
 chronic disease, the swelling may not so soon abate. Each case, even 
 without treatment, should, in time, subside, unless it owes its origin 
 to general dropsical effusion. No fatal case has been recorded. 
 
 Treatment. — As a rule, the treatment for the removal of the 
 primary cause is all that will be required. When the symptoms are 
 (252) 
 
OROPHARYNX. ELONGATION OF THE UVULA. 253 
 
 very distressing, astringent gargles of tannic acid, subacetate of lead, 
 alum, etc., might be used. In others the surface of the uvula might 
 be brushed with a solution of cocaine, and then the mucous membrane 
 could be punctured in a number of places with the point of a lance, 
 to allow the effusion to escape. Subsequently the throat could be 
 steamed, or astringent gargles used. 
 
 Elongation of the Uvula. 
 
 This is frequently associated with hypertrophy of the organ. 
 ISTormally the uvula should hang down freely within the fauces, with- 
 out touching the tongue, and of a length varying from eight to twelve 
 millimetres. The mucous membraue should fit closely to the muscle 
 beneath, and the surface should be firm and of a clear, pink color. 
 
 When elongation takes place, the length may be even three centi- 
 metres or more, and unless the increase in length arises purely from 
 cedematous thickening of the mucous membrane there is usually 
 present hypertrophy likewise. 
 
 Pathology. — As a rule, the condition of chronic irritation which 
 eventuates in elongation confines itself to producing hyperplasia of 
 the mucous membrane, the white fibrous and elastic tissue of the 
 muscle remaining unaffected. Consequently the elongation is purely 
 below the azygos. Still, cases occur in which the whole organ is of 
 abnormal thickness as well as length; of a red, deeply-congested 
 color; and in which even the free application of 10-per-cent. solution 
 of cocaine will produce very limited shrinkage. In these cases the 
 azygos muscle extends down decidedly below the centimetre-line, and 
 the whole organ has the appearance of a large fleshy mass. The 
 permanent congestion seems to result in granular hyperplasia of the 
 fibrous-tissue elements, situated below the true mucosa. 
 
 Etiology. — Elongation of the uvula is so frequent an attendant 
 upon chronic nasal and naso-pharyngeal disease that it would seem, in 
 the majority of cases, to owe its origin to their presence. The per- 
 petual movements of the palate to clear the naso-pharynx keep it in 
 a state of constant irritation, resulting successively in relaxation, 
 elongation, and hypertrophy. A weakened condition of the system 
 or loss of muscular tone may accentuate the trouble, allowing a re- 
 laxed palate to drop the uvula upon the tongue. The constant effort 
 of the patient to dislodge or swallow the seeming foreign body has 
 the effect of keeping the uvula in a congested and irritable condition. 
 
 In some instances the elongation is congenital. In these cases. 
 
254 DISEASES OF THE PHARYNX. 
 
 where there is no naso-pharyngeal irritation to aggravate the trouble, 
 there is little likelihood of hypertrophic development, the simple 
 elongated, (Edematous uvula being all that is likely to occur. 
 
 Symptomatology. — The symptoms come on so gradually and 
 painlessly that elongation frequently is not recognized until investi- 
 gation for some other disease reveals its presence. The symptoms are 
 those of ordinary throat irritation similar to those of oedema of the 
 uvula, but of minor degree. 
 
 Deglutition is not much interfered with, but phonation, when 
 there is hypertrophy as well as elongation, is frequently affected. 
 This is particularly the case with public speakers and singers. In 
 these it gives the voice a muffled, throaty character, as if the intona- 
 tion issued from the pharynx without the clear control of the muscles 
 of the tongue and mouth. 
 
 The cough produced by elongation of the uvula is of an irritable, 
 nervous character and unaccompanied by expectoration, save that 
 which can be hawked up from an ordinarily catarrhal pharynx. 
 When the uvula is very long, the supine position will cause it to lie 
 on the post-pharyngeal wall. While the upright position, if the 
 larynx is situated high in the throat, will make it touch the epi- 
 glottis, in either case producing temporary irritation and cough. 
 Asthma is recorded as one of its reflex results. 
 
 Diagnosis. — This can only be a matter of simple examination. 
 Whether thick or thin, if long and pendulous, and accompanied by 
 throat catarrh and nervous cough, it may be concluded that the con- 
 dition of this organ is abnormal. 
 
 Prognosis. — To life it involves no danger. To general health 
 very little. To the speaker or singer the presence of the elongation 
 is not a good omen, as, without operation, the difficulty is likely to 
 be permanent. Hence in these cases, and in all where it is accom- 
 panied by throat irritation, the prognosis should point to ablation 
 of a portion of the offending member. 
 
 Treatment. — In mild cases devoid of annoying symptoms the use 
 of astringent gargles may be of benefit. Perhaps the best of these 
 would be glycero-tannic or sulphate of iron. Touching the end of 
 the uvula also with a 10-per-cent. solution of nitrate of silver might 
 be of service. When the elongation is produced entirely by hyper- 
 trophy of the mucosa, brushing with tincture of iodine may be 
 attended by good results. 
 
 In most cases, however, a slight operation will be found neces- 
 
OEO-PHARYXX. ELONGATION OF THE UVULA: 255 
 
 sary, the redundant portion of the uvula requiring to be removed. 
 In doing this there is always danger of cutting off too large a portion. 
 If we desire to establish a simple rule that might govern all cases 
 in which operations was absolutely required, it might be this: Never 
 to cut off more than one-lialf from the length of the uvula. 
 
 As indicated, from what has already been said, the excision 
 should only be that of the hypertrophied mucous membrane at the 
 end of the uvula, in cases unattended by muscular hypertrophy. 
 
 There are several methods by which the little operation can be 
 performed, each method requiring different instruments. Macken- 
 zie's uvulotome might be mentioned, constructed on the principle of 
 the faucial tonsillotome. Bosworth's serrated scissors is also praised 
 as a good instrument, inasmuch as the serrated blades prevent any 
 possibility of slipping (Fig. 79). De Blois's galvanocautery-guillo- 
 tine is an ingenious instrument, preventing any haemorrhage at the 
 
 Fig. 79. — Uvula-scissors. (After Bos worth.) 
 
 time of operation. Kyle, uses a sharp bistoury, cutting out a wedge- 
 shaped piece from the end of the uvula and thus avoiding a club- 
 shaped stump. 
 
 My own preference lies with the long and curved scissors to- 
 gether with long, mouse-toothed forceps. 
 
 In operating I invariably secure the patient's assistance. (I have 
 only seen one case in childhood, and in this the uvula was removed 
 under chloroform.) A 10-per-eent. solution of cocaine is first applied 
 on a pledget of cotton to the uvula. The patient then holds the 
 tongue down with a tongue-depressor. With the left hand the oper- 
 ator seizes the uvula near the extremity with the forceps, and draws 
 it gently forward without putting it on the stretch; and with the 
 right applies the scissors, leaning upward and backward, so as to cut 
 the uvula with an acute angle to the front. By this means the heal- 
 ing is mostly on the posterior surface, the anterior mucous membrane 
 being, left almost entire (Fig. 80). 
 
256 
 
 DISEASES OF THE PHARYNX. 
 
 No further treatment is required except to insist upon light, soft 
 diet of a cool temperature for a day or two. No condiments or hot 
 fluids or irritants of any kind should be taken during that period, 
 on account of the acute pain they might produce. 
 
 Severe haemorrhage after uvulotomy is exceedingly rare. One or 
 two deaths have been reported following the operation, but it is 
 doubtful if the death really occurred as a result. A few cases of 
 severe haemorrhage after the operation, some of them difficult to con- 
 trol, have also been recorded. In a number of these many hours 
 elapsed before the bleeding could be stopped; and in half of them 
 
 Fig. 80.- — Excision of uvula. (After Bosworth.) 
 
 the whole organ had been removed. If the uvula itself was hyper- 
 trophied as well as elongated, and the large fleshy mass was excised 
 entirely on a line with the arches of the soft palate, one would not 
 wonder at haemorrhage being severe. If, on the other hand, it was 
 accepted as a fixed principle never to remove more than one-half the 
 length of the organ, the haemorrhage should always be easily con- 
 trollable. I never saw a case which bled severely, and invariably what 
 little bleeding did occur was over in a few minutes. 
 
 If cocaine has been freely applied before operating, there will 
 rarely be any bleeding at all for several seconds after the piece is 
 
0K0-PHARYNX. ELONGATION" OF THE UVULA. 257 
 
 snipped off, owing to the blood being driven out by the astringent 
 action of the cocaine; then slight bleeding only will occur. 
 
 I have not seen a case recorded of return of abnormal growth of 
 the uvula after it had been once excised. Some years ago, however, 
 a clergyman, aged 59, came to me for treatment. I found that he 
 had nasal polypus, relaxed palate, and a very long uvula, the central 
 muscular portion extending almost to the end of the organ. He in- 
 formed me that a throat specialist had performed uvulotomy several 
 years before, but that it had grown again and he desired to have it 
 removed. This time I reduced it to the length, of about one centi- 
 metre. It has given no further trouble. 
 
 Occasionally we meet with cases of congenital bifurcation of the 
 uvula. One branch is usually smaller than the other and planted to 
 one side. If no symptoms arise as a consequence, they should not be 
 interfered with. Sometimes for aesthetic purposes the smaller may 
 be removed. When the bifurcation is even, extending into the palate, 
 the edges should be pared and the cleft closed by fine sutures. 
 
CHAPTER XLVIL 
 RETROPHARYNGEAL ABSCESS. 
 
 This disease resembles tonsillar abscess, except that instead of 
 occurring in the tonsillar region it has its origin in the postpharyn- 
 geal wall. Qnite possibly aggravated cases of peritonsillar abscess 
 might extend by submucous infiltration into the deeper pharyngeal 
 tissues and result in extensive pus-sac formation. 
 
 Pathology. — The pathological condition of retropharyngeal ab- 
 scess occurring in childhood differs from that occurring in mature 
 years. In early life the lymphatic tissues are in a state of active 
 development, and in their immature condition are more prone to dis- 
 ease, whereas, when maturity is reached, this development has been 
 completed; permanent shrinkage has already commenced, and there 
 is little tendency to suppurative action in them. In adult life it is 
 the cellular tissues rather than the lymphatic that are liable to in- 
 flammatory action; but there is probably no greater tendency to 
 abscess-development at this period in the throat than in other regions 
 of the body. 
 
 The development of abscess in cellular tissue is usually rapid; 
 and, just as quinsy will run its course in a very few days, so will 
 retropharyngeal abscess in the adult result in pus-formation and ex- 
 tension into the surrounding tissues in a similar length of time. 
 
 In childhood, however, the suppuration takes place in strumous 
 lymphatic glands which have previously been swollen, and the de- 
 velopment of the disease is a slow and tedious process. 
 
 Etiology. — As in the pathology, so in the etiology, the disease 
 differs according to the period of life in which it occurs. In childhood 
 the presence of the lymphatic diathesis renders the tissues of the post- 
 pharynx more ready to take on suppurative action. The consequence 
 is that during this period the primary cause in a majority of cases 
 is the same: the presence of a strumous habit. In these cases any 
 cause which may excite glandular inflammation on either side of the 
 post-pharyngeal wall may result in suppuration. 
 
 In older persons the causes are more idiopathic in their character, 
 
 (258) 
 
ORO-PHARYXX. RETROPHARYXGEAL ABSCESS. 259 
 
 each individual case being dependent upon some special cause of its 
 own. Some cases arise from caries of the vertebras, although the per- 
 centage is very small; some as sequelae of exanthemata, particularly 
 scarlatina, equally small in number; and occasionally one from trau- 
 matism. Perhaps cold, acting upon a sensitive throat, the physical 
 health being at the time below par, may in adult life be the most 
 frequent cause. Sex has no special influence. In old age it rarely, 
 if ever, occurs. 
 
 Symptomatology. — In children the symptoms are those attending 
 the slow suppuration of the lymphatic glands. There is rarely any 
 chill, but the feeling of malaise, loss of appetite, and languor. The 
 fever is very slight and accompanied by gradual loss of flesh. Days 
 may elapse before attention is drawn to the throat. Deglutition 
 gradually becomes difficult, and may finally become impossible, while 
 the voice assumes a peculiar quacking tone. 
 
 On examination of the throat the post-pharynx will be found to 
 be swollen as if by oedema, particularly on one side, filling up the 
 pharynx and pressing upon the tongue. D»yspncea also becomes, in 
 many cases, a serious symptom, owing to the pressure of the phleg- 
 monous sac upon the larynx, producing defective aeration of blood 
 and more or less cyanosis. The child's head may become fixed: bent 
 forward slightly if the disease is bilateral and toward the unaffected 
 side if unilateral. 
 
 In adults there are no long-continued premonitory symptoms. 
 There is no glandular affection; but coming on suddenly are the 
 direct symptoms of severe faucial lesion. This is in the form of 
 acute inflammation in a localized spot, resulting in early suppuration, 
 with rapid extension into the surrounding tissues. 
 
 There is pain in the pharynx from the first, aggravated by any 
 attempt at deglutition. The disease is sthenic, usually ushered in 
 by a chill, and marked by a rise of several degrees in temperature; 
 whereas in children the fever is of a low asthenic type. 
 
 Another notable difference is that in adult life, while degluti- 
 tion may be exceedingly painful and almost impossible, dyspnoea 
 rarely occurs. 
 
 Diagnosis. — On examination the post-pharynx will be dark and 
 swollen, and in due time the point of nearest approach of pus to the 
 surface will be noted by its grayish, dead appearance. These, with 
 the general phlegmonous condition, either across the whole of the 
 posterior Avail or limited partially to one side, should indicate pretty 
 
260 DISEASES OF THE PHARYNX. 
 
 well the nature of the disease. - Palpation would indicate the presence 
 of pus or the brawny condition preceding it. The same might be 
 said of the careful use of the cotton-holder, the elastic sensation at 
 the point of softening being recognizable by either means. 
 
 In the asthenic abscess of childhood there is less localized in- 
 flammatory action, and perhaps more of an cedematous appearance. 
 The disease is also more likely to be unilateral. Hence, from the 
 one-sided fullness, together with the indications from touch, the diag- 
 nosis should not be difficult. Its chronicity in child-life should not 
 be forgotten. In all cases, both in children and adults, the peculiar 
 character of voice, fixation of the head, absence of cough, and freedom 
 from tonsillar complication should help to exclude all other diseases. 
 
 The possibility of mistaking aneurism for post-pharyngeal abscess 
 seems almost incredible. The strong regular pulsation of the one, 
 free from all inflammatory action, should, by sight as well as touch, 
 distinguish it positively from abscess of the pharynx. 
 
 Prognosis. — The phlegmonous abscess of adult life runs its course 
 in something like a week. Then, in favorable cases it will open 
 spontaneously, and in a few days heal. When lanced earlier, the 
 course is shorter. It is rarely a dangerous disease, even if let to find 
 its own outlet, although both painful and distressing. 
 
 In childhood its course is much more prolonged, extending over a 
 number of weeks, and not unattended by danger. Unsuccessful diag- 
 nosis may prolong the disease and endanger life from suffocation, 
 rupture of abscess into the air-passages, or prolonged anaemia and de- 
 bility. (Edema, also, might lead to stenosis and death. 
 
 When the disease arises from spinal caries the prognosis is not 
 good, inasmuch as the cause cannot be removed. 
 
 In very severe cases, when unrelieved by surgical interference, 
 there is serious danger of general septicaemia, to be followed by a 
 fatal issue. 
 
 Treatment. — In adults the treatment is almost identical with 
 that of quinsy. The abscess should be opened as soon as the presence 
 of pus becomes certain, and the swollen and inflamed tissues may be 
 scarified even before the existence of pus is discovered. 
 
 In young children, considering that the phlegmonous inflam- 
 matory condition is absent, scarification would be contra-indicated, 
 but opening of the abscess as soon as discovered should certainly be 
 done. As a rule, the opening should be made in the most dependent 
 part of the abscess, and into the pharynx. Cases, however, do occur 
 
ORO-PHARYNX. RETROPHARYNGEAL ABSCESS. 2G1 
 
 in which, an external incision is the best; but this can only be when 
 the suppurative lymphatic glands can best be reached in that way. 
 
 Poulticing in this disease can be of little avail. In juveniles the 
 condition is too asthenic to require their application. In adults they 
 cannot reach the affected parts, and hence are useless. If applications 
 to the neck are required at all, the warm cotton-w r ool rolls already 
 referred to in treating of quinsy are all that would be required. In 
 children after evacuation the application of tincture of iodine to the 
 swollen glands might be productive of good. 
 
 Supporting measures and nourishing diet in children are always 
 in place, and regulation of the primcu vice in adults, with antiperiodic 
 treatment, might be of service. 
 
 Acute infectious phlegmon of the pharynx is an exceedingly 
 rare and fatal disease. It is specific in character and differs from 
 retropharyngeal abscess in being more virulent, but not unattended 
 by development of pus-sacs. Treatment is said to be supporting, but 
 unavailing;. 
 
CHAPTEE XLVIIL 
 HYPERTROPHY OF THE FAUCIAL TONSILS. 
 
 In early life this disease is essentially an enlargement or pro- 
 liferation of the lymphatic tissues of which the normal tonsil is com- 
 posed. All the elements of the tonsil are engaged in the process, but 
 it is the lymphatic cell-development which is chiefly stimulated. 
 
 In adult life any hypertrophy occurring in the tonsil usually 
 means hypertrophy of the connective-tissue elements, and not so much 
 of the adenoid, producing permanent thickening of the fibrous and 
 parenchymatous tissue of the tonsil. Hence arises the hard, smooth 
 hyperplasia so often seen in men and women in contradistinction to 
 the soft, lymphoid hypertrophy of childhood. There is also the 
 lacunar variety, not infrequently met with, in which the lacuna? 
 become greatly distended with caseous matter, making clefts and 
 sinuous passages in the tonsil, ultimately involving the parenchyma. 
 
 There is likewise what Pynchon has recently described as the 
 "Submerged Tonsil," being a condition in which, notwithstanding a 
 general fullness of the throat, no distinct tonsillar enlargement can at 
 first be seen. Closer inspection, however, will reveal the true condi- 
 tion. In some cases the faucial pillars are greatly enlarged, causing" 
 an even lateral fullness with the tonsillar thickening. In others the 
 enlarged tonsil is hidden by the plica triangularis, already described, 
 which sometimes extends downward and backward from the margin of 
 the anterior pillar. 
 
 Pathology. — In early life there is in the tonsils an active pro- 
 liferation of lymphoid elements. The crypts are widened and can be 
 seen studding the surface. The enlarged tonsil fills in the cavity 
 between the anterior and posterior pillars on each side, standing cut 
 prominently and projecting toward the mesial line. The mucous 
 membrane is unchanged, dipping down within the folds of the crypts 
 much as in health. The papilla? are enlarged and flattened by the 
 distension of the organ. The lymphatic bodies are notably enlarged 
 and the blood-vessels increased in size and number, while the con- 
 nective-tissue fibres, even in childhood, may be increased, interlacing 
 and binding together the lymph-bodies as a whole (Fig. 81). 
 
 (262) 
 
ORO-PHARYNX. HYPERTROPHY OF THE TONSILS. 263 
 
 In adult life the natural tendency toward shrinkage of the lymph- 
 tissues is usually apparent, even in eases of extensive hypertrophy. 
 These bodies may have been enlarged, but they are bound down 
 by the connective-tissue growth. Proliferation continues; the crypts 
 themselves are invaded until they are obstructed; and, instead of the 
 open follicles which are found in the normal or even in the hyper- 
 trophied tonsil, the smooth, rounded, hyperplastic surface is left in 
 its place. This hyperplastic tonsil thus consists of bundles of con- 
 
 
 HmHh 
 
 8#i 
 
 Wp- 
 
 
 ~m\. ■... ... ". f 
 
 Fig. 81. — Simple hypertrophy of faucial tonsil (57 diameters), a, 
 Stratified squamous epithelium. b, Connective-tissue layer containing 
 blood-vessels, c, Mucus-secreting glands, d, Lymphoid tissue containing 
 four nodules, e, Epithelium of crypt, f, Cavity of crypt, (Author's speci- 
 men by Bensley.) 
 
 nective-tissue elements, containing blood-vessels, nerves, and shrunken 
 lymphatic bodies. In this form, from the supply of blood being- 
 limited, the surface is sometimes of a paler hue than natural. "When 
 the lacunas have become distended by the secretion of caseous matter, 
 this can be squeezed out readily by pressure. 
 
 In other instances, the hypertrophic form of childhood does not 
 materially change as mature years are reached, any connective-tissue 
 
26-i DISEASES OF THE PHARYNX. 
 
 development only increasing the general enlargement of the mass. De 
 Simoni speaks of the development of vegetable parasites, or blas- 
 tomycetes, as an interesting histological feature associated with chronic 
 tonsillitis in the light of etiology. 
 
 As a rule, whatever the form of hypertrophy, it is bilateral, 
 though it is rare that the two sides are equally enlarged. The bi- 
 lateral condition is considered to be an indication of the diathetic 
 nature of the disease. This, however, does not end here; but, where 
 we have double tonsillar hypertrophy, there is usually enlargement 
 of the pharyngeal tonsil likewise. 
 
 Etiology. — This not infrequently is a congenital condition, the 
 enlargement having commenced prior to birth, as a manifestation of 
 a lymphatic or strumous diathesis. As a rule, the hypertrophy com- 
 mences during childhood, a large percentage of the cases being de- 
 veloped earlier than the tenth year. Bishop places the largest num- 
 ber of cases between the tenth and twentieth years. Probably all 
 cases occurring after the latter age are of either hyperplastic or lacunar 
 form. 
 
 The diathetic habit would naturally involve the hereditary in- 
 fluence, and, given this tendency, frequent exposures to cold would 
 keep the throat constantly liable to attacks of inflammatory disease, 
 while each attack would leave additional enlargement. 
 
 In the same way the exanthematous diseases — scarlet fever, 
 measles, diphtheria, etc. — all of them frequently leave in their trail 
 the commencement of deep-seated tonsillar hypertrophies. Congenital 
 syphilis, too, is said to be a potent element in the production of this 
 disease, while the rheumatic habit, leading so frequently to pharyn- 
 geal rheumatism in adult life, is the direct cause of many cases of 
 severe hyperplasia. 
 
 Symptomatology. — In childhood the external appearance of the 
 face, without examination of the throat at all, is almost sufficient to 
 indicate the presence of the disease, at least sufficient to divide the 
 cause with adenoid enlargement. The facial symptoms are those 
 spoken of in connection with that disease, although they are probably 
 exaggerated more in pharyngeal than in faucial hypertrophy. Avhen 
 the tonsils alone or in combination with adenoid enlargement are 
 sufficiently hypertrophied to produce nasal stenosis, the facial symp- 
 toms become very apparent. The vacant look, the open mouth, the 
 pinched nostrils, the oral breathing, may all be present; while ster- 
 torous respiration and restlessness are regular, nocturnal symptoms. 
 
ORO-PHARYXX. HYPERTROPHY OF THE TONSILS. 265 
 
 These symptoms are all of a mechanical character. The tonsils 
 act like foreign bodies obstructing the throat and naso-pharynx and 
 preventing normal nasal breathing. This forced and continned sus- 
 pension of natural respiration tends to produce pharyngeal conges- 
 tion, resulting in increased hypertrophy with each inflammatory attack. 
 
 Embarrassed respiration is another result which often occurs, 
 particularly in early life, and in rachitic or scrofulous subjects is likely 
 to be followed by chest-deformity. The voice also becomes affected, 
 not only with the so-called nasal twang, but also from 'a thick, muffled 
 tone, resulting from unnatural pharyngeal fullness. 
 
 Deglutition is not much interfered with, except in young infants, 
 when, as in the case of adenoids, the impossibility of normal nasal 
 breathing prevents the child from nursing with any comfort. 
 
 It is doubtful whether enlargement of the faucial tonsils has the 
 effect upon the Eustachian tubes usually assigned to it. There are 
 undoubtedly many cases of deafness and chronic ear disease asso- 
 ciated with tonsillar hypertrophy; but it must be conceded that, 
 almost invariably, notable hypertrophy of the faucial tonsils is accom- 
 panied by enlargement of the pharyngeal tonsil; and that it is to the 
 latter that the pressure upon the Eustachian tube is due. 
 
 Excessive tonsillar secretion is not a characteristic of this disease. 
 Cheesy concretions, however, are deposited in some cases within the 
 lacunae, producing soreness by their presence and an offensive odor 
 from long retention. 
 
 Diagnosis. — Thorough examination with or without reflected 
 light should in all cases be sufficient to establish a correct diagnosis. 
 To insure this the tonsil should be examined in two positions: 1. 
 With the posterior faucial pillars in their natural relaxed position; 
 that is when the mouth is wide open, the anterior and posterior pil- 
 lars standing parallel with each other. This can usually be accom- 
 plished by gently depressing the tongue. If enlarged, the tonsils will 
 stand out prominently beyond the pillars projecting toward the medial 
 line. 2. With the posterior pillars drawn tightly and the tongue well 
 depressed. By this means the tonsils are thrown face forward and all 
 the inequalities and irregularities of outline become distinctly visible. 
 They are not only turned forward, but, in a measure, inside out a? 
 well, the deep sulci and wide clefts which so often occur, and which 
 remain unnoticed in the normal position, being brought into view. 
 
 It is said that there is sometimes danger of mistaking an enlarged 
 tonsil for a tonsillar abscess. The latter is attended by fever, pain. 
 
266 DISEASES OF THE PHAEYXX. 
 
 and peritonsillar fullness, which are all absent in the former condi- 
 tion. Digital examination should remove any remaining doubt. 
 
 In after-life unilateral enlargement between the pillars might 
 arise from malignant disease, but the distinguishing features of 
 cachexia, acute pain, and rapid enlargement, with ichorous discharge 
 which distinguish cancer, would prevent a wrong diagnosis. 
 
 I have seen one case where left tonsillar fibroma developed in a 
 lawyer, aged 47, some time after an hyperplastic tonsil had been 
 removed, but for which fact it might have been taken for a simple 
 tonsillar enlargement. It was also distinguished by its white, fibrous 
 character and the shooting pains which passed in different directions 
 from it. It was sessile and prominent and interfered with the use 
 of the voice. It was removed by repeated galvanocautery operations 
 and did not return. 
 
 Occasionally a tonsillith, buried within the gland, will cause in- 
 convenience by its size and may be mistaken for sinrple hypertrophic 
 lesion. 
 
 Prognosis. — The natural tendency is for the tonsils, when not 
 seriously enlarged, to shrink away gradually and be absorbed during 
 the earlier years of maturity, so that a mere semblance of the tonsil- 
 lar tissue remains. And when hearing is unaffected, when respiration 
 is normal, and there is no tendency to soreness of the throat, even 
 if the tonsils are hypertrophic, Nature should be allowed to do her 
 own prescribing, and the tonsils left severely alone. 
 
 On the other hand, when they are seriously enlarged, oral breath- 
 ing being one of the results, there is serious risk to the health of the 
 patient in several ways. Not only does the nasal stenosis deprive the 
 air of respiration of the advantages of saturation, cleansing, and heat- 
 ing, which nasal breathing provides, but the open mouth makes the 
 enlarged tonsils still more susceptible to irritation. The germs of 
 disease floating in the air find a ready nidus for development in the 
 open sulci of the tonsils. These large bodies are particularly sus- 
 ceptible to infection, and it is well known that children having ton- 
 sillar hypertrophies are more prone to the diseases of childhood than 
 those who do not possess them. . Hypertrophied tonsils are also liable 
 to attacks of quinsy; and when children grow up to adult age, with 
 hypertrophy giving way to hyperplasia, the periodic attacks of quinsy 
 often continue for years, constantly increasing the connective-tissue 
 development. 
 
 Treatment. — Medical treatment for enlarged tonsils, both inter- 
 
OROPHARYNX. HYPERTROPHY OF THE TONSILS. 267 
 
 nal and local, lias so frequently been tried, and with such uniformly 
 unsatisfactory results, that it is almost useless to speak of it here. It 
 is possible that in mild cases the local application of iodine, or, where 
 there is atony of system, the administration of iodide of iron inter- 
 nally may be of some use. So also astringent gargles of tincture of 
 iron in solution, or the local application of nitrate of silver, might be 
 tried in cases in which for various reasons operative treatment would 
 be inapplicable; but, when serious symptoms arise from the presence 
 of the hypertrophied masses, extirpation is the only reasonable treat- 
 ment. 
 
 Of course, before operating, it is always best to secure the con- 
 sent of the patient, or, in the case of children, the consent of the 
 guardian in charge. 
 
 The various methods of operation, by excision with curved scis- 
 sors, bistoury, galvanocautery-knife, cold-wire snare, galvanocautery- 
 snare, or by the various tonsillotomes, all have their advocates. But 
 the last method, in all cases where the tonsillotome or guillotine can 
 be used, is the one most generally adopted (Fig. 82). 
 
 In all cases, before operating the throat should be thoroughly 
 cleansed by the use of an alkaline spray or disinfectant throat-wash. 
 And it is best, when a general anaesthetic is not used, to paint the 
 tonsils freely with a 15-per-cent. solution of cocaine or eucaine. I 
 see no reason for inducing unnecessary pain in any patient, and, as 
 the drug is entirely under the control of the operating surgeon, there 
 need be no risk whatever of forming the narcotic habit, by its judi- 
 cious application. The cocaine may not make the use of instruments 
 entirely painless, but it will materially lessen the suffering. 
 
 As the majority of patients requiring tonsillotomy are children, 
 I have, as a rule, found it the best plan to administer a general 
 anaesthetic to them. While it may be quite possible to adjust the 
 instrument to the first tonsil without exciting the child's alarm, the 
 second adjustment would be impossible without provoking terror as 
 well as resistance. By using an anaesthetic both of these are avoided. 
 
 For performing tonsillotomy many varieties of tonsillotome are 
 in the market. I think, on the whole, however, that Mathieu's is 
 to be preferred, particularly with its most recent modification; that 
 is, with smooth spear-points, the barbs near the ends being removed. 
 They are intended to hold the tonsil for extraction, after it has been 
 excised. This would seem to be unnecessary; as in using the newer 
 instrument, the tonsil, in my experience, has always remained upon 
 
268 
 
 DISEASES OF THE PHARYNX. 
 
 the points during extraction, notwithstanding the absence of the 
 barbs; and could be slipped off more readily afterward. One beauty 
 of this instrument is the power of adjusting the exact amount of 
 traction you desire to make upon the tonsil by means of the screw 
 in the spear-blade. The only fault with the instrument is the fact 
 
 82. — Mathieu's tonsillotomies. 
 
 that it is composed of distinct segments, and requires to be taken to 
 pieces to be disinfected and cleansed, after each operation. Still, 
 this only takes a minute or two, and can be attended to easily by 
 any nurse or assistant. 
 
 In applying the tonsillotome, the patient holding the tongue- 
 
0R0-PHARYNX. HYPERTROPHY OF THE TONSILS. 209 
 
 down at the time with the depressor, it is important to pass the in- 
 strument well over the lower part of the tonsil, as this portion is often 
 pendulous, and, being situated low down in the pharynx, may escape 
 observation, unless due care is taken. The right hand will hold the 
 instrument, whichever side is operated upon; and the tonsil can be 
 held firmly in toward the pharynx by outside pressure of the left 
 hand. There is thus, under cocaine anaesthesia, no necessity for the 
 presence of an assistant. 
 
 Although the tonsils can often be removed without the aid of 
 reflected light, yet when it is available it is always better to use it. 
 The operator, seated directly in front of the patient, can by its 
 reflection see the parts much more clearly and adjust his instrument 
 with more precision than he otherwise could. 
 
 In cases among children, in which general anaesthesia is required, 
 ethyl-bromide or nitrous oxide may be administered in the method 
 already mentioned. And in view of the experience of other men, and 
 in the light of history, I earnestly recommend one of these drugs to 
 be used. 
 
 Still, in my own practice I have heretofore used chloroform in 
 these cases, the method being to have it administered per guttatim, 
 and not to give sufficient to produce very profound anaesthesia. 
 
 The child, when ready, is turned over on its side, with its face 
 toward a good light and the tonsils removed in quick succession. The 
 body is then rolled to nearly a prone position, the head being held 
 over the side of the couch to allow for the escape of blood into the 
 bowl beneath. In defence of my position I may say that in a pro- 
 fessional experience of thirty years, and covering thousands of cases 
 in which general anaesthesia has been required, for one operation or 
 another, I have not seen a death occur from its use, either in my own 
 practice or in that of any of my professional brethren. 
 
 Bleeding after tonsillotomy, although usually free, is rarely 
 severe, lasting only a few minutes and gradually ceasing. A good 
 many cases, however, have been recorded in which the haemorrhage was 
 alarming. This has almost invariably occurred in adults. Out of TO 
 recorded cases only 4 or 5 were younger than 10 years. With some 
 exceptions, the bleeding occurred immediately after or within a few 
 hours of the operation. Two of the former were in my own practice. 
 One, a strong, plethoric, medical student, was attacked by secondary 
 haemorrhage on the fifth day, after overexertion. The other was the 
 little 5-year-old sou of a physician. In his case the bleeding came 
 
.270 DISEASES OF THE PHARYNX. 
 
 on while sleeping in the carl}' morning, four and one-half days after 
 operation. In both cases the haemorrhage was stopped with little 
 difficulty. 
 
 It is fortunate that, with all these cases of bleeding, I have so far 
 been unable to find a case recorded in which haemorrhage from tonsil- 
 lotomy has proved fatal. 
 
 Excision by means of curved scissors or bistoury is applicable to 
 irregularly-shaped tonsils. Some operators go so far as to recommend 
 the method for all cases. After cocainization, the tongue being de- 
 pressed, the tonsil is seized by a vulsellum or toothed forceps, and 
 aided by reflected light the growth is cut away. This method is most 
 suitable to cases presenting irregular projections, to which the tonsil- 
 lotome could not be applied. 
 
 The use of the cold-wire snare and also the galvanocautery-snare 
 have each had tbeir advocates, particularly on the ground that by 
 this means haemorrhage would be avoided. Whether on account of 
 the difficulty in applying the wire, the pain of the operation itself, 
 or the conical stump the operation is apt to leave, or all combined, 
 this method has not been received with general favor. 
 
 One other method, operation by galvanocautery-knife, remains 
 to be considered. In suitable cases, properly selected, no other in- 
 strument that I know of can do as efficient work. It is particularly 
 suited to those irregularly-cloven tonsils which we often meet with. 
 Foul secretions, loaded with pathogenic germs, form within the clefts; 
 and oft-repeated attacks of sore throat, result in hypertrophy of 
 irregular, parenchymatous masses. In the hard, hyperplastic tonsils 
 of adult life the gaivanocantery treatment can also be used to ad- 
 vantage. Cheesy masses are constantly forming within the deep and 
 narrow crypts. By their presence they produce a good deal of irrita- 
 tion: and they can only be removed by direct pressure. Xeither of 
 these varieties are of a form to be seized effectually by the tonsillo- 
 tome. They are probably also too hard or too fibrous to yield readily 
 to either bistoury or scissors. 
 
 The ordinary method advised in such cases, when the gaivano- 
 cantery is considered to be the proper instrument, is to make a num- 
 ber of punctures with the cautery-needle into the face of the tonsil, 
 and after an interval of several days to repeat the operation. When 
 the growths are very large, this method is said to take about twenty 
 operations to effect a cure: no doubt a tedious and painful process 
 to the patient. 
 
OROPHARYNX. HYPERTROPHY OF THE TONSILS. 271 
 
 It would seem reasonable to limit' materially the number of oper- 
 ations and also the time required for the work. After thorough co- 
 eainization each time the cautery-knife instead of needle might be 
 used. The tip being bent at right angles to the blade, and then care- 
 fully avoiding the pillars and their union at the upper angle, the 
 knife is passed at a bright-red or white heat from top to bottom of 
 the structure to be removed. This is repeated several times, making- 
 parallel incisions as widely and deeply as the operator in his judg- 
 ment believes advisable for the one operation. It is best in every case 
 for the surgeon unaccustomed to this method of cauterization to com- 
 mence cautiously until experience becomes his guide. It is not neces- 
 sary, however, to limit the first operation to one tonsil. Both can be 
 treated at each sitting. For several days mild sprays and light diet 
 will be required. Then the operation can be repeated, and so on until 
 the work is done. As a rule, three or four operations will suffice for 
 complete removal of the offending tissue. The pillars of the fauces 
 must remain uninjured, and a smooth tonsillar stump be left on each 
 side as a result. In the submerged tonsil a similar method may be 
 followed. The plica triangularis can also more readily be removed by 
 electrocautery than by any other method; and it is advocated strongly 
 by Pynchon, with the one addition: that he draws out the offending 
 tissue with a tenaculum each time before operating. 
 
 In performing necessary operations upon either nose or throat, 
 it should never be the aim merely to give relief. While this is un- 
 doubtedly the most important object, the cosmetic effect should also 
 be kept religiously in view. When Nature in her highest and most 
 normal development leaves a symmetrical surface, the surgeon should 
 endeavor to do so likewise, and the nearer we can restore the various 
 organs we have to treat to the normal form and condition, the more 
 surely we have performed our duty to our patient. 
 
CHAPTEK XLIX. 
 
 LACUNAR TONSILLITIS. 
 
 This disease, as its name implies, is an acute inflammation of 
 the lacunae, or crypts, of the tonsils, attended by the deposit of 
 whitish-yellow exudate at their orifices. 
 
 Pathology. — The morbid lesion consists of a catarrhal inflamma- 
 tion of the parenchyma of the tonsil, accompanied by a fibrinous exu- 
 dation from the lining membrane of the lacunae, filling them with 
 little, pearly-white masses composed of leucocytes, fibrinous fibrillar 
 (Sokolowski), and epithelial cells, which appear visible at the openings 
 of the crypts. As they increase in size they spread out over the 
 mucous membrane, surrounding the mouths of the lacuna?, and, being 
 soft and friable, are easily brushed away. 
 
 Regarding the possibility of mistaking this disease for diphtheria, 
 Sendziak in 1896 investigated the subject very fully. In thirty cases 
 which were histologically examined, all were found free from Klebs- 
 Loeffler bacilli; four had Loeffler's pseudodiphtheria bacilli, but they 
 were mixed with other pathogenic germs; while all had staphylococci, 
 streptococci, or pneumococci, either single or combined, staphylococci 
 being usually in excess. His concluding words are: — 
 
 "Relying on the clinical picture of the disease, and the results 
 obtained by bacteriological investigations in my thirty cases, I main- 
 tain that the so-called follicular angina, or, better, lacunar tonsillitis, 
 is clinically and histologically an independent pathological process, 
 having nothing in common with true diphtheria. It is no doubt in- 
 fectious, but we unfortunately do not know its specific virus." 
 
 The common title, "follicular tonsillitis," usually applied to this 
 disease is not only discarded by Sendziak, but also by YTolfenden, 
 Lennox Browne, and others. Wolfenden says: "The very term 'fol- 
 licular' is really erroneous, since it is not the follicles of the tonsils 
 which are affected, except in a very secondary manner and in a few 
 cases. It is the tonsillar crypts, or lacuna?, which are the chief seat of 
 the disease.'' 
 
 As a rule, both tonsils are affected simultaneously. The catar- 
 rhal affection extends to the pillars, palate, and pharynx also, and oc- 
 (272) 
 
OROPHARYNX. LACUNAR TONSILLITIS. 273 
 
 casionally spots of exudation occur on these parts. The cervical 
 glands likewise become sensitive and in some cases enlarged. 
 
 Etiology. — It is generally believed to be a specific disease, de- 
 pendent upon the access of micro-organisms to the tonsils in certain 
 conditions of the system. While in some respects it resembles the ex- 
 anthemata, it differs from them in being in no way protective against 
 the possibility of future attacks. 
 
 Although the germ itself and its origin are still unknown, it is 
 believed frequently to arise from the elements of putrefaction in de- 
 fective sewers. This idea has originated from the fact of its preva- 
 lence in old houses where drainage has been defective. 
 
 Sensitive inflamed throats with enlarged tonsils are fit subjects 
 for infection. The spongy tissue with open crypts offer free lodgment 
 for the invading bacteria; and, as a similar tonsillar hypertrophy fre- 
 quently affects all the children of a family, all may be affected suc- 
 cessively by the endemic infection. 
 
 Although more prevalent in childhood than in maturer years, 
 it frequently occurs during the latter period. Sex has no special in- 
 fluence over it. As might be expected, it is more prevalent in the 
 spring and fall than during other seasons of the year. 
 
 One peculiar feature that has been observed by rhinologists is 
 the development of lacunar tonsillitis in from twenty-four to forty- 
 eight hours after nasal operation, particularly when performed by 
 galvanocautery. The theory has been advanced that the absorption 
 of the germ might take place through the nasal wound, and the near 
 proximity to the tonsils would facilitate its transition and the de- 
 velopment of lacunar disease. 
 
 If the disease occurred equally after knife and saw operations, the 
 theory would seem more feasible. As the galvanocautery, when it 
 does not produce haemorrhage, hermetically seals the wound, may it 
 not arise from the fact that galvanocautery operations upon the nose 
 are temporarily followed by oedema and more or less stenosis, result- 
 ing in mouth-breathing? The impact of the germs upon the crypts 
 during the depressed vitality resulting from the shock of operation 
 would naturally tend to inflammatory action in the organ so affected. 
 
 Symptomatology. — The onset of the disease is noted by a general 
 feeling of chilliness, which may last for several hours, to be followed 
 by febrile action, the temperature in some cases rising as much as 
 three or four degrees. Pain in the back usually accompanies the 
 development of fever. Together with the fever and pain, the throat 
 
274 DISEASES OF THE PHARYNX. 
 
 symptoms manifest themselves. There is dryness and irritation, fol- 
 lowed by the formation of the lacunar deposit, accompanied by pain, 
 upon movement of the tonsils, particularly in deglutition. In young 
 children the systemic disturbance is sometimes very severe, the tem- 
 perature rising, even though rarely, as high as 105° and ushered in 
 by convulsions. With the high temperature there will be acceleration 
 of pulse and also of respiration. 
 
 By the second or third day the febrile symptoms subside, and 
 pursue a very modified course until the disease disappears, between 
 the fifth and seventh days from its commencement. The throat symp- 
 toms persist until near the close of the attack, unless modified By 
 treatment. 
 
 In severe cases albuminuria is not by any means a rare symp- 
 tom. Formerly the presence of this complication, in exudative throat 
 disease of any kind, was considered a positive indication that the 
 disease was diphtheritic. This idea is now discarded, and, although 
 albuminuria is more prevalent in diphtheria, the only positive evi- 
 dence now acknowledged in favor of that disease is the presence of 
 the Klebs-Loeffler bacillus. In regard to albuminuria, Wolfenden 
 states positively: "That it is rarely absent in cases of acute ton- 
 sillitis." 
 
 Pneumonia and nephritis have supervened in rare instances, 
 while orchitis and enlarged spleen are occurrences which have been 
 known to immediately follow the tonsillar disease. 
 
 Diagnosis. — The only other disease it is likely to be confounded 
 with is diphtheria. Some cases may so resemble mild diphtheritic 
 disease that in simple clinical examination an error in diagnosis might 
 occur, and, in fact, has frequently been made. 
 
 To examine the fauces thoroughly, reflected light, head-mirror, 
 and tongue-depressor are all necessary. In lacunar tonsillitis the 
 gland is red and swollen, while, at the mouths of the lacunae, clear, 
 white, pearly spots will be seen, adhering closely to the mucous mem- 
 brane beneath. These spots, as they develop, grow somewhat larger 
 and extend outwardly around the mouths of the crypts, and can be 
 brushed off with the cotton-holder without injuring the surface. 
 They always retain their original color of bluish or yellowish white 
 and are non-odorous. 
 
 In diphtheria the tonsil, although somewhat swollen, instead of 
 being bright red is of a bluish, turgid color. The exudation forms 
 an even flake, varying in thickness and covering the tonsil. In color 
 
OROPHARYNX. LACUNAR TONSILLITIS. 275 
 
 it is yellow or yellowish gray, and cannot be brushed off without 
 leaving a raw surface beneath. On the second or third day instead of 
 retaining its color, the margins assume a grayish-black tinge, and 
 malodor is distinctly perceptible. 
 
 One other point in clinical history is of considerable importance: 
 Acute lacunar tonsillitis is a sthenic disease with high febrile action, 
 whereas diphtheria, the graver disease of the two, is asthenic and 
 marked by a lower temperature. Both are infectious, but diphtheria 
 is the more virulent of the two. Still, in all cases, where there is the 
 slightest doubt in diagnosis it is better to submit the exude to micro- 
 scopical examination. The history of the case should distinguish it 
 from the throat eruption of the exanthematous diseases, also from 
 cancer and syphilis. 
 
 Prognosis. — This is usually favorable. The disease runs a regular 
 course of four or five days or a week, and, although it may be attended 
 by considerable pain and fever, it is not likely to leave any serious 
 complication after it subsides. The albuminuria which occurs is 
 usually mild and of short duration. Paralysis of the palate has in a 
 few instances followed the disease, lasting at the longest only a few 
 weeks. Quinsy has also been developed as a result of the tonsillar 
 irritation. 
 
 Treatment. — Attention to hygienic rules, abundance of light diet, 
 and regulation of the alimentary canal are all that seem to be re- 
 quired in many of these cases. While the fever is high and the bowels 
 constipated, saline cathartics are indicated. Upon the hot and irri- 
 table throat alkaline sprays have a grateful effect. Among the in- 
 ternal remedies none have a better reputation than tr. fer. mur., 20 
 per cent, in glycerin, in doses of 1 to 2 grammes every one or two 
 hours. It is given undiluted, its efficacy as a systemic tonic being 
 aided by the direct contact of the iron upon the tonsillar exudation. 
 
 In my own cases I have not administered the iron in this way, but 
 have diluted it very freely, in order to avoid any injurious effect the 
 chloric acid might have upon the teeth of the patient. To free the 
 tonsils the ferric glyceride was applied twice a day to them by means 
 of a cotton-holder. 
 
 In many of these cases I have seen advantage from the sedative 
 and astringent effect of nitrate of silver, applied in the early stage of 
 exudation. The tonsils were first brushed with a 4-per-cent. solution 
 of cocaine, followed in three or four minutes by the application of a 
 10-per-cent. solution of the nitrate. For the first hour the patient 
 
 17a 
 
276 DISEASES OF THE PHARYNX. 
 
 would scarcely perceive any effect from the application. Then the 
 sensation of soreness would only be slight. By the following day the 
 deposit would be more than half of it gone and a second similar 
 treatment would complete the removal. The diluted iron solution 
 would be regularly administered internally, during the whole period 
 of treatment; and, by the combined methods, the course of the dis- 
 ease would, in many instances, be materially shortened. 
 
 I have found the nitrate of silver particularly useful in that 
 traumatic class of cases, the result of nasal operations, already re- 
 ferred to, quite frequently only a single brushing with the silver being- 
 required. 
 
 When there is much headache and insomnia 1 / 4 - to 1 / 2 -gramme 
 doses of phenetidin or acetanilid, given at bed-time, will often secure 
 quiet and refreshing rest for the night; smaller doses to be given to 
 children in proportion to age, of this as well as any other medicines 
 required. 
 
 If there is much depression after the first two or three clays, 
 quinine may be resorted to, in Y 4 -gramme doses once or twice a day. 
 
 The question of isolation in lacunar tonsillitis is one of no little 
 moment. Whenever there is the slightest doubt as to the identity of 
 the disease, there should be no hesitation upon the matter, and the 
 patient should at once be placed out of reach of affecting others. 
 When sure that we have not diphtheria to contend with, we may 
 somewhat relax our vigils, while care is taken to keep the patient 
 aloof from those who would be most susceptible to the disease, know- 
 ing that the chief danger is from its endemic character, and not from 
 the slightly-infectious nature of the exudation-deposit. 
 
 In treatment of acute lacunar tonsillitis I do not think the lance 
 can ever be required. After the subsidence of the disease, however, 
 if the tonsils are hypertrophied, tonsillotomy should be performed. 
 This, in a large measure, would prevent the recurrence of the disease. 
 
 As an external application, camphorated oil, or a combination 
 of spirit of turpentine and olive-oil, rubbed over the region of the 
 tonsils, and the surface covered at once with a layer of absorbent 
 cotton, always answers a good purpose. 
 
CHAPTER L. 
 
 PHARYNGEAL MYCOSIS. 
 
 Mycosis fungoides, a comparatively rare disease, when it does 
 occur usually affects some portion of the fauces. It is termed "myco- 
 cis pharyngeus," "mycosis tonsillaris/' "mycosis lingualis," etc., ac- 
 cording to the mucous membrane affected. But as it extends, in most 
 instances, to all these localities, being rarely confined exclusively to 
 one site, the title at the head of this chapter may be considered the 
 best (Fig. 83). 
 
 Fig. 83. — Pharyngomycosis. (Author's specimen by Wrinch.) 
 
 Pathology. — The term mycosis, from the Greek word uvxr/g. sig- 
 nifying fungus, indicates the character of the plant. This is a para- 
 sitic disease, composed of small, whitish-yellow growths, dense in 
 structure, and projecting above the mucous membrane upon which 
 they have grown. It belongs to the schizomycetes group of fungi; and 
 the species is called leptothrix, from the cylindrical, or thread-like, 
 shape of the cells. The term is applied to a variety of vegetable 
 organisms found in drains, garbage, bogs, etc. They may also be 
 found in milk, urine, and foul watery solutions, after prolonged ex- 
 posure to the air. The microscope reveals the thread, or rod-like, 
 cells of the leptothrix imbedded in amorphous granules, streptococci, 
 
 (277) 
 
278 DISEASES OF THE PHARYNX. 
 
 etc. (Figs. 84 and 85). If treated with. Lugol's solution, these "bodies 
 assume a bluish tinge, indicating the presence of starch. The cells 
 
 Fig. 84. — Leptothrix. Adventitious follicle to left side. 
 (Author's specimen by Bensley.) 
 
 Fig. 85. — Leptothrix in situ (Vs-ineh objective). 
 (After Lennox Browne.) 
 
 vary in form according to the anatomical region from which they are 
 removed. When the fungus appears on the surface of the mucous 
 
ORO-PHARYNX. PHARYNGEAL MYCOSIS. 
 
 279 
 
 membrane, it may be purely superficial, or be inserted in a wedge- 
 shaped manner in the parenchyma. In the one it is simply attached 
 en masse to the flattened epithelium, and is homogeneously striated 
 in appearance (Bosworth). In the other, when it penetrates deeply 
 into the epithelium, the growth is denser and more granular, and 
 the microscope sometimes fails to demonstrate the rod-like cells. 
 Heryng believes that this obliteration is caused by the pressure. 
 \Yhen the mycosis enters still deeper into the crypts, the latter be- 
 come dilated and filled with fungous growth, degenerated epithelium, 
 and amorphous matter. Sometimes a horny hypertrophy of the epi- 
 
 Fig. 86. — Keratosis of tonsil with leptothrix (V G -inch objective). 
 (After Lennox Browne.) 
 
 thelial cells, instead of simple catarrh of the crypts, acts as a base for 
 the leptothrix, forming a keratosis of the tonsil (Fig. 86). 
 
 Etiology. — The original source of the fungus is still a matter 
 of question. The microscopical examinations of Toeplitz, Wagner, 
 Damaschino, Colin, and others have proved, however, that the lepto- 
 thrix is frequently found in the mouth, abiding there, like many 
 other germs, innocuously, but that a condition of impaired health, 
 together with idiosyncrasy of constitution, would appear to be re- 
 quired to secure the attachment and growth of the fungus within 
 the pharynx. The peculiar feature is that, although the bacteria may 
 be present in such large numbers within the oral cavity, they should 
 so rarely find a nidus for development there, and should prefer the 
 
280 DISEASES OF THE PHARYNX. 
 
 faucial region. Perhaps the intense muscular activity of the mouth 
 itself may act as a deterrent to leptothrix attachment. Sex has little, 
 if any, influence. It rarely occurs before early maturity, and not 
 very often in old age. Colin says the period of life liable to attacks 
 is between the ages of 20 and 30 years. 
 
 Siebenmann (Arcliiv fur Lanjngologie und JRhinologie. 1895) has 
 a long article upon this subject. On histological grounds he strongly 
 combats the theory that pharyngomycosis owes its origin to the pres- 
 ence of the leptothrix. He first describes the microscopical appearance 
 of a single quill of the disease and then a section of the tonsil with 
 quill in situ. The examination shows the mass to be made up of a 
 cyst, or sack, composed of a central narrow lumen surrounded by an 
 epithelial wall. He compares it with the human hair in structure. 
 The wall of the quill is partially composed of hardened unnucleated 
 epithelial cells, and partially of homogeneous horny substance. The 
 central lumen is narrow and filled with detritus, bacteria, and mucus. 
 The outer surface of the quill as it projects from the crypt is covered 
 with bundles of leptothrix. He says that in the neighborhood of the 
 crypt there is no evidence of inflammation, such as hypertrophy of con- 
 nective tissue and small, round-celled infiltration. 
 
 As the result of his investigations he concludes that the process 
 is an unusually intense cornification of the lacunar epithelium, termi- 
 nating in quill-formation. He also says that keratosis of the tonsil- 
 crypts in a mild form is not an uncommon condition, and that the 
 presence of the leptothrix is purely incidental, and bears no relation to 
 the disease as a causative factor. 
 
 The Leptothrix buccalis is a saprophyte, or fungus, found in almost 
 every mouth — the more richly where the epithelial cells are thickest. 
 Basing this theory on the absolute demonstration of the epithelial 
 formation of the quills, with the manifestation of the leptothrix-spores 
 only on the outer surfaces, Siebenmann considers his case clearly dem- 
 onstrated, and desires the name of the condition to be changed to that 
 of "Hyperkeratosis Lacunaria.' 7 
 
 Eichardson, of "Washington, from pathological examination and 
 clinical experience, also strongly favors Siebenmanms view. 
 
 The ages of all the cases I have seen are the following: IT, 19, 
 22, 26, 28, 30, 40, 55, and 60 years. The last two occurred in the 
 same gentleman, with an interval of between four and five years of 
 entire freedom from the disease. The second case was that of a 
 girl working in a brush factory. She stated that the dust from a cer- 
 
ORO-PHARYXX. PHARYXGEAL MYCOSIS. 281 
 
 tain kind of bristles always produced soreness of the throat, which 
 eventually developed into this disease. The sixth case is also worthy 
 of mention. The patient was a young farmer. Two years before I 
 saw him with the mycosis he came from a distant town to be treated 
 for antral disease. After some weeks' treatment a complete cure was 
 accomplished and he returned home. One year and a half later he 
 spent the winter polishing cow-horns, during which time his throat 
 became sore. In the spring he came again for treatment. On exami- 
 nation I found the whole of the tonsils, lower pharyngeal wall, and 
 base of the tongue covered with the leptothrix fungi. There was no 
 return whatever of the antral disease. In the fifth case the first indi- 
 cations occurred during the fourth week of an attack of typhoid 
 fever. 
 
 Symptomatology. — When situated in any portion of the fauces, 
 mycosis presents very few subjective symptoms. It produces no in- 
 flammatory action, and is causative of stiffness more than soreness. 
 When the eruption is very abundant, a feeling of irritation may, how- 
 ever be developed. As the plants increase in number, and become 
 scattered over a larger area, the movements of the pharynx become 
 somewhat restrained, and the muscles slightly stiffened, partial 
 dysphagia being the result. Occasionally, too, a slight irritable cough 
 may be produced; but these symptoms are never marked. 
 
 The most frequent site, and where it presents the largest de- 
 velopment, is in and between the crypts of the faucial tonsils, uext 
 on the lingual tonsil, on the walls of the pharynx, and last upon the 
 pharyngeal tonsil itself. Siebenmann and Schubert both recite cases 
 in the latter region; but the growth in these was aspergillus instead 
 of leptothrix. I have only seen one case of development in the naso- 
 pharynx, and that was an extension upward from the faucial region. 
 
 Mycosis, when examined, presents small, milk-white opaque 
 masses projecting above the mucous membrane. They are soft and 
 moist in appearance, but are not easily moved. Colin describes three 
 forms of development: 1. Small isolated spots. 2. Larger spots like 
 a cock's comb. 3. Small, smooth, yellow-white plaques. Whatever 
 form they take or wherever they are located, particularly in the kera- 
 tosic variety, they will stand a large amount of friction without sepa- 
 rating their attachment. Usually a large number of the plants are 
 scattered over the area affected, varying in size from a millet-seed 
 to a shelled oat-seed or larger. Sometimes they exist for years, pre- 
 senting few symptoms of a distressing character. 
 
282 DISEASES OE THE PHARYNX. 
 
 Diagnosis. — On a casual inspection it might possibly be mistaken 
 for diphtheria; but a careful examination should at once remove 
 doubt in this direction. 
 
 The only disease to which pharyngeal mycosis bears any resem- 
 blance is lacunar tonsillitis, but in distinguishing it there should be 
 no difficulty. The one is a sthenic inflammatory disease of limited 
 duration; the other, non-inflammatory, asthenic, and essentially 
 chronic. In the one the cryptal deposit is soft and pultaceous and 
 easily removed. In the other the firm leptothrix development adheres 
 tenaciously to any part of the tonsil or pharynx upon which it may 
 have grown. 
 
 Possibly, too, that chronic condition of the tonsil in which 
 cheesy deposits form within the lacunae and protrude above the sur- 
 face might be mistaken for mycosis. Here both the diseases are 
 chronic and non-imflammatory; but the cheesy masses only appear at 
 the mouth of the crypts, never anywhere else; and they are easily 
 pressed out, while the mycosis is scattered in every direction and can- 
 not be so easily moved. 
 
 Prognosis. — In pharyngeal mycosis there is nothing dangerous to 
 life; and a number of cases, after existing for years, have been known 
 to disappear spontaneously, without treatment. It is only in excep- 
 tional cases that the disease is very distressing; still, as a rule, it is 
 interminable in continuity, and if left to itself might last throughout 
 a life-time. This long continuance undoubtedly has a depressing 
 effect upon the vital forces, and may render the subject more sus- 
 ceptible to the influence of other diseases. 
 
 Treatment. — The treatment consists in the eradication of the 
 plant. In a few recorded cases this has been done with facility; but, 
 in the majority, careful, vigorous, and persistent treatment has been 
 required for a prolonged period before complete cure has been ob- 
 tained. Tincture of iodine, tannic acid, nitrate of silver, solution of 
 bichloride, calomel insufflations, have all been used with more or less 
 efficacy. Chromic-acid cauterization has its advocates, and also curet- 
 tage. 
 
 But, of all methods, the galvanocautery needle, carefully in- 
 serted directly into each fungoid deposit, is generally acknowledged 
 to be more positive in its results than any of the other methods of 
 treatment. This will probably necessitate a large number of 
 sittings, the use of cocaine or eucaine being in each required. Like 
 all other methods of treatment, the cure will be tedious; but it has the 
 
OROPHARYNX. PHARYNGEAL MYCOSIS. 283 
 
 advantage of permanency in results. A cure can be accomplished, 
 and, once cured, the disease rarely returns. During the intervals be- 
 tween operations the throat should be treated by antiseptic sprays, 
 two or three times a day. Of all that I have tried, nothing seems to 
 have so effective an influence in controlling the development of the 
 new spores as a solution of izal. This is a coal-product, one of the new 
 hydrocarbons, and said to be much stronger than carbolic acid in its 
 germ-destroying influence. The preparation I have used is a 10-per- 
 cent, aqueous solution. 
 
CHAPTEE LI. 
 
 HYPERTROPHY OF THE LINGUAL TONSIL. 
 
 Hypertrophy of the lymphatic tissue, situated at the base of the 
 tongue, in the glosso-epiglottie fossa, is not of infrequent occurrence. 
 This mass of muciparous glands, called the lingual tonsil from its 
 
 Fig. 87. — Hypertrophy of left lingual tonsil. 
 (After Lennox Browne.) 
 
 similarity in structure to the faucial and pharyngeal tonsils, is in 
 many instances abnormally developed, giving rise to a morbid fullness 
 and irritation, which are both distressing and somewhat painful to the 
 
 Fig. 87a. — Bilateral hypertrophy of lingual tonsil. 
 (Author's specimen.) 
 
 patient. The condition may be either unilateral or bilateral (Figs. 
 87 and 87a). 
 
 Pathology. — This mass of glands extends from the circumvallate 
 papillae to the epiglottis. It is divided into two halves by the medio- 
 (284) 
 
OBO-PHABYXX. HYPEBTBOPHY OF THE LINGUAL TOXSIL. 285 
 
 glosso-epiglottic ligament. AYhen in a state of hypertrophy, the 
 glands may grow to an enormous size, and become packed closely to- 
 gether from side to side, over the base of the tongue. They are fre- 
 quently accompanied by the development of large veins, coursing be- 
 tween the lymphoid tissue and the papillae, forming the lingual varix. 
 Singers are somewhat subject to this disease, women particularly 
 (Fig. 88). 
 
 The main difference between hypertrophy of the lingual tonsil 
 and of those already mentioned is that, while the latter are largely 
 
 Fig. 88. — Lingual varix. (Author's specimen by Wrinch.) 
 
 incidental to childhood, the enlargement of the former rarely de- 
 velops before maturity. The growth is in the form of a broad layer 
 of crypts or follicles over the base of the tongue; beneath and be- 
 tween these large blind lymphatic bodies are developed, inclosed in 
 fibrous capsules (Fig. 89). The combined tissues enlarge until the 
 sulcus between the tongue and the epiglottis is, in some instances, 
 completely filled. 
 
 Etiology. — This hypertrophic condition occurs more frequently 
 in females than males: the reverse of the history of faucial tonsillar 
 
286 
 
 DISEASES OF THE PHAKYNX. 
 
 hypertrophy. Bosworth suggests that it occurs much more frequently 
 in young children than is generally supposed, not heing recognized 
 from the fact of the comparative insensitiveness of the throat dur- 
 ing early life. Constitutional dyscrasia may in this, as in other 
 hypertrophies, have much to do with its primary development. Not 
 infrequently it occurs as a sequel to diphtheria, scarlet fever, etc. 
 People addicted to the excessive use of spices, condiments, alcohol, 
 etc., are also prone to the disease, owing to the hyperemia produced 
 by their irritative action upon the post-lingual region. According to 
 Eay, the disease is of frequent occurrence among singers. 
 
 Symptomatology. — Lennox Browne describes three forms of 
 chronic inflammatory disease of the tonsils: 1. As simple lymphoid 
 or catarrhal inflammation. 2. Lacunar inflammation. 3. Parenchy- 
 
 ~1 > v ; , 
 
 Fig. 
 
 -Microscopical section of lobe of lingual tonsil. 
 (Author's specimen.) 
 
 matous inflammation, sometimes ending in abscess, but usually in 
 hypertrophy. 
 
 Whatever the form may be, the disease is almost invariably 
 chronic, and of a secondary character. 
 
 Not infrequently chronic hypertrophy and lingual varix are asso- 
 ciated together, while in not a few varicose veins will be present, 
 without lymphoid enlargement. The prominent symptoms are the 
 sensation of a foreign body in the throat, unrelieved by swallowing, 
 and, when the growth is large, accompanied by a feeling of constric- 
 tion of the lower pharynx. There is often a reflex irritable cough, 
 a constant endeavor to clear the throat, laryngeal fatigue, and also 
 occasional hoarseness. In speakers and singers the voice soon tires 
 and loses volume. In many instances the lingual is associated with 
 
OEO-PHAEYXX. HYPERTROrilY OF THE LINGUAL TOXSIL. 287 
 
 faucial liypertropliy. When varicose veins are present haemorrhage is 
 often a prominent symptom, occurring usually in the morning. 
 
 Diagnosis. — So many throat diseases produce symptoms similar 
 to those of hypertrophy of the lingual tonsil that to insure a correct 
 diagnosis a thorough throat examination should always be made. In 
 some cases this can be accomplished by the use of the tongue-depres- 
 sor without further aid. But these cases are rare, reflected light and 
 throat-mirror being, in most instances, required. 
 
 A mass of mammillated tissue will be seen on the base of the 
 tongue, stretching from side to side and divided in the centre by a 
 longitudinal depression, indicating the position of the glosso-epiglot- 
 tic ligament. Sometimes the hypertrophy of tissue is so great that 
 it fills in the glosso-epiglottic notch completely, even overlapping the 
 epiglottis itself, when in the upright position (Figs. 87 and 87a). 
 
 Prognosis. — This disease involves no danger to life and but little 
 to the general health. Still, having once developed, there is little 
 likelihood of amelioration of symptoms, as the growth is slowly 
 progressive, remaining for years without any tendency to shrinkage 
 or change. In the case of varix, the condition is more serious, as the 
 frequent haemorrhages which are occasioned by it are debilitating to 
 the constitution. 
 
 Treatment. — Topical applications of iodine, glycero-iodide, solu- 
 tion of acetic acid, chromic acid, etc., have all been used with more 
 or less effect. Still, it must be remembered that the growth is essen- 
 tially one of mature years, and the firmness of its texture renders it 
 little amenable to mild methods of treatment. 
 
 The object aimed at should be removal of the hypertrophied 
 tissue, whether lymphoid or varicose or both. This can be clone in 
 various ways. Some authorities advise excision by curved scissors or 
 bistoury. Others by the galvanocautery-ecraseur or the cold-wire 
 snare. The operation, however, which has been received with the 
 greatest favor and is the most largely practiced, is by the galvano- 
 cautery-knife or electrocautery-knife. 
 
 In any case, the parts should be thoroughly cocainized, and the 
 operation should be performed by aid of reflected light. The objec- 
 tion to either of the cutting operations is the possibility of inducing 
 severe haemorrhage and the difficulty of controlling it in such an 
 obscure situation. When the surgeon decides to operate by either 
 bistoury or scissors, it is better to commence tentatively, and not to 
 expose too large a surface of raw tissue at one operation. 
 
288 
 
 DISEASES OF THE PHAEYXX. 
 
 Operation by the hot platinum snare I have had no experience 
 with, but would expect the same difficulty in applying it to the broad 
 base of the growth in this as in other situations. I have used the 
 cold-wire snare on two occasions only, for removal of hypertrophied 
 lingnal tonsil. In the first the operation and result were both satis- 
 factory. In the second, the patient was a young man aged 30. The 
 growth had been developing for a good many years: a fact that I 
 did not know until the snare was tightly drawn around it. Then the 
 closest traction I could put upon the wire failed to sever the tonsil. 
 Fortunately for the patient the parts were well cocainized. After 
 trying ineffectually for a quarter of an hour to tighten the wire 
 
 Fig. 90. — Eoe's lingual tonsillotome. 
 
 enough to cut through the tissue, I was obliged to sever it beneath 
 the snare-ring by means of curved scissors. This is a difficulty in 
 using the cold snare which, perhaps, is not sufficiently realized. As 
 in the nose, so in the throat, we should make sure that we do not 
 grasp in the guillotine any tissue, bony or fibrous, that the wire cannot 
 readily sever. 
 
 The galvanocautery operation, for both operator and patient, I 
 have found in many cases to be the best. The electrode should be 
 curved to escape touching the body of the tongue, and, the parts 
 having been cocainized, a number of the larger nodules may be 
 touched freely at the first sitting, the patient grasping his tongue and 
 
ORO-PHARYXX. HYPERTROPHY OF THE LIXGUAL TOXSIL. 289 
 
 holding it by means of a napkin, held by the fingers of one hand. 
 After an interval of several days the operation may be repeated, and 
 so on until the hypertrophy is all removed. Healing quickly takes 
 place. There is no haemorrhage. The suffering is not severe, and, as 
 a rule, a very few treatments will suffice to restore the parts to a 
 normal condition. Food should be bland and light. Demulcents are 
 grateful, and mild antiseptic alkaline sprays are soothing during the 
 process of healing. 
 
 Some years ago Eoe, of Eochester, invented an instrument spe- 
 cially adapted for the removal of enlarged lingual tonsils (Fig. 90), 
 and since then various modifications of his original design have been 
 brought out bv different writers. 
 
CHAPTEK LII. 
 
 BENIGN TUMORS OF THE PHARYNX. 
 
 Papilloma. 
 
 Neoplasms of several kinds occasionally affect the different por- 
 tions of the pharynx. Still, they are all comparatively rare. Prob- 
 ably papillomata are of the most frequent occurrence. The nsnal 
 site is on some part of the soft palate, particularly the uvula. 
 Occasionally they may be found on one of the pillars of the fauces, 
 but rarely on the pharyngeal walls. 
 
 They are little, firm, warty growths. Sometimes, though rarely, 
 they develop to the diameter of a centimetre, and present a cauliflower 
 or mammillated surface. They are whitish and glistening in color, 
 and microscopically exhibit the- usual characteristics. They are com- 
 posed of connective tissue, each papilla being supplied with its own 
 blood-vessel and coated over with epithelium. 
 
 No special symptoms are produced by them. They are always 
 painless and rarely give any discomfort. When very large, particu- 
 larly if attached to the uvula, they may produce cough and irritation 
 to some slight extent. Still, they are rarely looked for, and almost 
 invariably are discovered by accident. 
 
 Treatment is simple. It is merely to snip them off close to the 
 surface by scissors or to seize them by the forceps and cut them off 
 at the base by a small, sharp-pointed bistoury. When properly re- 
 moved they evince no tendency to return. 
 
 Fibroma. 
 
 Fibroma of the pharynx is much rarer than papilloma. Occa- 
 sionally this growth may develop on the soft palate or tonsils. It 
 consists of similar fibrous tissue to fibroma in other parts, and fol- 
 lows a similar history in development. The disease occurs most fre- 
 quently in the tonsil. 
 
 Fibrous neoplasms usually occur in adult life. They give rise to 
 few symptoms, the main features being those attending obstruction, 
 (290) 
 
ORO-PHARYNX. FIBROMA. 291 
 
 when the growth has attained any large size. Xot infrequently the 
 discovery of the fibroid tumor has been accidental, the use of the 
 throat-mirror, when applied for some other purpose, rendering its 
 presence apparent. The pinkish-white color, rounded or nodulated 
 form, and dense resisting consistency are prominent features, and 
 should render the diagnosis certain. They are also less liable to be 
 attended by haemorrhage than fibromata of the naso-pharynx. 
 
 Operative treatment is the only method worth speaking of. If 
 the growth is once thoroughly eradicated, it is not likely to return. 
 If it is not removed, it will go on growing, displacing surrounding 
 tissues and promoting their absorption; and there is possibility of its 
 ultimately degenerating into malignant disease. 
 
 Treatment should be by evulsion. Sometimes the guillotine may 
 be passed round its base; and, as fibrous tumors are liable to be 
 attended by hemorrhage, this is an excellent plan of removal, when 
 possible. In others, the tumor may be seized by tenaculum or for- 
 ceps, and, having been drawn out to the tension-point, the attach- 
 ment may be severed by scissors or bistoury. 
 
 I have seen one case only. The patient was a barrister 48 years 
 of age. The growth was sessile and located in the left tonsil. It was 
 whitish pink in color and accompanied by occasional shooting pains 
 up. to the ear and down to the larynx. It gradually increased in 
 size and commenced to interfere with speech, causing weariness and 
 pain after a long address. In this case I removed it by repeated 
 galvanocauterizations. The treatment was completed three years ago, 
 and there has been no return. 
 
 Besides pure fibroma, other varieties of neoplasms of a combined 
 character are sometimes found in the pharynx. Such as fibrolipoma, 
 a combination of fibrous and fatty tissue; fibrochondroma, a union 
 of fibrous and cartilaginous; fibrolymphadenoma, containing the 
 fibrous and lymphatic elements combined. But they are all exceed- 
 ingly rare, and their history and treatment differs little from that of 
 fibroma in its simple form. 
 
 Mention should also be made of adenoma of the palate, which 
 somewhat resembles fibroma in history and appearance, though much 
 slower in development; and also of angioma, which in rare instances 
 has been known to affect the palate as well as the base of the tongue. 
 In the latter removal may be by the means already mentioned, the 
 chief danger in operation being from haemorrhage. This may be con- 
 trolled by galvanocauterization at a dull-red heat. 
 
292 diseases of the phaeyxx. 
 
 Desmoid Tumoes. 
 
 One other variety of tumors, the dermoid, is occasionally found 
 in the pharynx. They are the remains of defective or superfluous de- 
 velopment in embryonic life. Arnold has gathered a list of thirty- 
 eight dermoid tumors of the fauces. Seventeen of these occurred in 
 premature still-born infants, while a large proportion of the remain- 
 ing ones died within a day or two of birth. Still, a number of cases 
 have been recorded in which children have lived for a length of time 
 with the dermoid tissue still present, and several have arrived at adult 
 age without having it removed. 
 
 The tumor is formed of ordinary integument, is attached by 
 pedicle, and contains sweat and sebaceous glands, as well as hair- 
 follicles. In it there is nothing dangerous to life; and the large mor- 
 tality incident to its development has been due to vital insufficiency 
 independent of the growth. Only mechanical symptoms are produced 
 by it. The surface is soft and white. Sometimes hair is visible, and 
 the appearance is that of ordinary skin moistened by the secretions of 
 the throat. 
 
 The treatment is simple removal by scissors or whatever other 
 instrument appears most suitable for the case. There is no tendency 
 to reformation after complete excision. 
 
CHAPTER LIIL 
 
 TUBERCULOSIS OF THE PHARYNX. 
 
 Of all forms of miliary tubercle, that of the pharynx is the rarest. 
 While one-seventh of the population of civilized countries die of pul- 
 monary tuberculosis, it is roughly estimated that not more than 1 
 per cent, of these are ever affected by pharyngeal tubercular disease. 
 One noticeable feature about it, however, is its peculiar virulency 
 when developed in the faucial region. When in the pharynx, al- 
 though usually considered an asthenic disease, it is, in the majority 
 of instances, sthenic, severe, and rapidly fatal. 
 
 Pathology. — Whether in the larynx or pharynx, the pathological 
 changes very much resemble each other. At the commencement and 
 throughout the disease there is a peculiar pallor of the surface. The 
 first deposit of gray nodules is usually in the soft palate, upon an ab- 
 normally-gray mucosa. With this there may be infiltration and the 
 presence of tubercle bacilli. By and by the nodules break down, and 
 shallow, irregular ulcerations, with ragged edges, take place, which 
 may coalesce and form extensive surfaces of tubercular disease. The 
 tonsils are more rarely affected. The larynx is usually invaded almost 
 synchronously with the pharynx. 
 
 Etiology. — Pharyngeal tuberculosis is very rarely a primary dis- 
 ease. At all events, it is recognized, as a rule, to be a secondary de- 
 velopment, following the manifestation of tuberculosis in some other 
 organ or organs. Unlike the disease in the lungs, or even in the 
 larynx, it is assumed by its presence to indicate the existence of gen- 
 eral tuberculosis in other organs of the body. Its rapid clinical his- 
 tory would seem to bear out this view. As a rule, it is a secondary 
 development to pulmonary disease. Abercrombie and Gee reported 
 cases following tubercular enteritis; and, even though not primarily 
 recognized in other organs, it is doubtful if it is not present, though in 
 a latent form. Still, there appears to be no reason why a primary de- 
 posit of tubercle is not possible in the fauces as well as in any other 
 region of the body, and a number of cases have been recorded in 
 which this seems to have been the case. Lennox Browne has reported 
 
294 DISEASES OF THE PHARYNX. 
 
 two cases in which the mouth and fauces were affected with tubercu- 
 losis between two and three years before there was any manifestation 
 in the lungs. 
 
 Symptomatology. — Apart from the general constitutional dys- 
 crasia, which would indicate the presence of tuberculosis, perhaps the 
 first directh'-pharyngeal symptom which would be noticed would be 
 pain in the act of swallowing or speaking. This is of a sharp, lan- 
 cinating character, and is accompanied by chilliness and increased 
 temperature, often rising to 103° and 104°. The cedematous condi- 
 tion of the palate interferes seriously with deglutition. Food will pass 
 up into the nose, and secretions will accumulate within the pharynx, 
 owing to the stiffness and incompetence of the palatal muscles. 
 Cough is always feeble and accumulations difficult to void. The 
 voice, although muffled, does not lose its tone, unless the tongue is 
 affected: a condition which frequently takes place. Difficulty and 
 pain in deglutition materially interfere with the proper nourishment 
 of the body. Examination of the throat reveals the pallid condition 
 of the surfaces, and the presence of granulation, infiltration, or ulcer- 
 ation variously combined, according to the condition of the parts 
 affected. 
 
 Diagnosis. — This should not admit of any great difficulty. There 
 are two well-recognized stages in the history of faucial tuberculosis. 
 In the first the mucous membrane is unbroken, but beneath its sur- 
 face, on close inspection, minute grayish-white spots may be observed. 
 They are about the size of mustard-seed, and may be scattered pretty 
 extensively over the parts affected. There is also slight infiltration 
 as well as anamiia of the mucosa. The spots are greenish or muddy 
 colored, quite different from the clear, white spots of lacunar tonsil- 
 litis. In the second these nodular spots of tubercular deposit in a 
 very few days break down into true ulceration, of the type peculiarly 
 characteristic of tuberculosis. 
 
 There is probably only one disease with which tuberculosis of the 
 pharynx is likely to be confounded, and that is the ulceration of 
 syphilis. Still, the local conditions manifested by the two diseases 
 are strikingly different. In syphilis the ulcers are clear cut, deeply 
 excavated, with bright-red irritable areola, and bathed copiously in 
 yellow pus. In tuberculosis the ulcers are shallow without any well- 
 defined margins, without areola, slowly progressive, and with limited 
 discharge of grayish mucus. In syphilitic ulceration there is no fever; 
 in tubercular ulceration fever is well marked. Tuberculous granula- 
 
ORO-PHARYNX. TUBERCULOSIS. 295 
 
 tions are indolent and pallid, while syphilitic granulations are larger 
 and inflammatory. 
 
 Lupus, being essentially a chronic, non-febrile disease, could 
 scarcely be mistaken tor tuberculosis. It is also more nodular, less 
 painful, and given to vigorous cicatrization, to which tuberculosis is 
 unknown. 
 
 Bowlby relates a case of extensiye pharyngeal tuberculosis in 
 which the membrane was so extensive and thick and gray as to sug- 
 gest the possibility of diphtheria, while Walton reports one in which 
 the hard palate was perforated into the antrum of Highmore, render- 
 ing a possibility of mistaking it for malignant disease. 
 
 Prognosis. — This might be pronounced a hopeless disease were it 
 not for the fact that a very few recoveries under favorable circum- 
 stances have been reported. It is one of the most acute of all tuber- 
 cular affections, usually terminating in a fatal result in a compara- 
 tively short space of time. As it rarely occurs except as secondary 
 to extensive tubercular disease elsewhere, it only adds fuel to the 
 existing fire. Still, when the nodules were limited to a small area, or 
 a small ulceration existed without surrounding nodular deposit, cases 
 have occurred in which prompt treatment has removed the local dis- 
 ease and healing has taken place. These patients might ultimately 
 die of tuberculosis, but they were cured of the pharyngeal disease. 
 
 Treatment. — On general principles, it is better to keep the parts 
 free from discharges by the use of cleansing sprays. These should be 
 of a mild character to prevent irritation; 20-per-cent. solution of 
 peroxide of hydrogen answers this purpose very well. As does also 
 a 5-per-cent. solution of resorcin. Dobell's solution answers a good 
 purpose likewise, without possessing as much antiseptic power as 
 those already named. After cleansing, cocaine might be applied, and 
 the ulcers rubbed with a 50-per-cent. solution of lactic acid. This 
 is after Krause's method of treatment of laryngeal tuberculosis. The 
 application may be repeated at intervals of two or three days, and 
 may be carried out in buccal as well as pharyngeal tuberculosis. In 
 regard to the latter, I have seen excellent results in a case of extensiye 
 sublingual tubercular ulceration. This occurred in a man, aged 35, 
 
 O 7 O 
 
 suffering from severe apical disease. The treatment extended over six 
 months and the ulceration healed, leaving the tongue somewhat 
 limited in projectile movement. The pulmonary tuberculosis stead ily 
 advanced, resulting fatally the following year. 
 
 Of newer remedies, the application of guaiacol to the ulcerations 
 
296 DISEASES OF THE PHARYNX. 
 
 lias been productive of good results. The same may be said of sulplio- 
 ricinate of phenol, parachlorophenol, and enzymol. The latter is 
 recommended by Murray as acting in like manner with lactic acid. 
 
 A 5- to 10-per-cent. spray of menthol in albolene, or a similar 
 preparation used by an oro-inhaler, would have a soothing and cleans- 
 ing effect upon the diseased tissues. 
 
 Another method of treatment of pharyngeal tuberculosis is by 
 curettement and lactic-acid treatment combined, as advocated by 
 Heryng. If the physical strength of the patient is not too much im- 
 paired, destruction of the ulcerative tissues by galvanocautery may, 
 in some cases, check the progress of the disease. 
 
 After cleansing or operation frequent dusting by iodoform has 
 also been found of benefit. 
 
 Internal medication may also be of benefit for the general tuber- 
 culous condition. For this no remedy at the present time possesses 
 a higher reputation than creasote and its derivatives. Of the latter, 
 carbonate of creasote, or creosotal, probably takes the first place, in- 
 asmuch as it can be taken in larger doses than any of the others 
 without injury to the digestive tract; doses of 1 or 2 grammes can 
 readily be taken two or three times a day, either in codliver-oil or on 
 sugar. Other systemic tonics and ferruginous medicines may also be 
 prescribed in suitable cases, while the dietetic, hygienic, climatic, and 
 other conditions of the patient are carefully attended to. 
 
CHAPTER LIV. 
 
 LUPUS OF THE PHAKYNX. 
 
 Lupus of this region, as well as lupus of the skin, nose, or larynx, 
 is a very chronic disease. It is a rare disease, slowly progressive in 
 character, and marked by nodular development and infiltration. Al- 
 though in the large majority of instances, lupus attacks the skin in 
 preference to the mucous membrane, cases do occur, occasionally, in 
 which the latter is the primary seat of the disease. 
 
 Pathology. — Lupus differs widely both in clinical history and 
 appearance from local tuberculosis; yet the presence of the tubercle 
 bacilli in each proves that a close relationship exists between them, 
 and a close investigation will reveal the fact of a tuberculous con- 
 
 Fig. 91. — Lupus. Palatal appearance. (After Lennox Browne.) 
 
 nection in the majority of cases. The soft palate or one of the faucial 
 pillars is usually the part affected first; and from this it slowly 
 spreads to the soft tissues of the pharyngeal walls (Fig. 91). The 
 development is that of nodular thickening, accompanied by slow 
 ulceration, the peculiar feature of the ulceration being that, while 
 there is destruction of normal tissue, there is little change of color 
 and but scanty discharge of pus and debris. 
 
 The process of ulceration is accompanied by the compensatory 
 formation of cicatricial tissue, which, when developed, twists and con- 
 torts the pharynx out of its natural shape. 
 
 This disease is rarely symmetrical, the lesions being more ex- 
 tensive on one side of the pharynx than the other; and the nodular 
 infiltration always presents a characteristic, vascular, knobbed, and 
 
 (297) 
 
298 
 
 DISEASES OF THE PHARYXX. 
 
 irregular appearance. Though sometimes associated with tubercular 
 disease in the other organs of the body, it most frequently occurs as 
 an independent pathological condition (Figs. 92 and 93). 
 
 Etiology. — It occurs more frequently in females than in males. 
 Why this is the case is difficult to understand — the reverse being the 
 case in tuberculosis, its kindred disease. The period of life most 
 subject to it is between the ages of ten and thirty years. 
 
 A susceptibility to tuberculous invasion may possibly be one 
 cause why the deposit of the bacillus tuberculosis within the pharynx 
 
 Fig. 92. — Lupus of lingual tonsil (Vc-inch objective; Ehrlich-Biondi 
 stain). (After Lennox Browne.) 
 
 may lead to its proliferation there as lupus; but why it should take 
 on that form instead of that of the more prevalent disease, tuberculo- 
 sis, is the question. 
 
 What special conditions are causative of its development in any 
 given case are still unknown. - 
 
 Symptomatology. — It is rare for lupus of the pharynx to be recog- 
 nized in the initiatory stage, as it always develops slowly and almost 
 without symptoms. Semon recently reported a case of extensive 
 lupus of the pharynx and larynx in which there had never been the 
 slightest pain, although the voice had been destroyed for months. 
 
OEO-PHARYNX. LUPUS. 299 
 
 Stiffness of the throat and sluggish motion of the parts are among 
 the earliest symptoms. Later an ulceration develops, together with 
 nodular enlargement and cicatrization. Deglutition and phonation 
 may both be interfered with. When the palate is seriously involved, 
 food can pass into the naso-pharynx and the nose during the effort 
 of swallowing. Still, with painstaking effort, sufficient food can 
 always be taken to sustain life. 
 
 Unlike syphilis, when the palate is affected, the buccal instead 
 of the pharyngeal surface is usually the seat of the lesion when first 
 observed. The appearance of lupus of the uvula is also peculiar. As 
 
 ■#$*■> 
 
 Fig. 93. — Lupus of lingual tonsil (V 2 -inch objective; Ehrlich-Biondi 
 stain). (After Lennox Browne.) 
 
 Lennox Browne describes it, the end of the organ is swollen, with 
 solid infiltration, and club-shaped in appearance. 
 
 Diagnosis. — One of the notable features of this disease is its pro- 
 longed, chronic, non-febrile character: the direct antithesis of its fel- 
 low, tubercular pharyngitis. The deposit is in the form of small 
 nodules irregularly distributed, destroying the smooth regularity of 
 the mucous membrane. When ulceration commences, it is always 
 limited arid accompanied by little discharge. The surface of the 
 nodules, as well as the ulcerations, is of a red color. As the destruc- 
 tive process advances, cicatricial bands form, which are readily seen 
 upon examination. 
 
 The pale-gray color of tuberculous ulceration should not be con- 
 
300 DISEASES OF THE PHARYNX. 
 
 founded with lupus. The color and objective form of the two diseases' 
 are entirely dissimilar, while the tenacious muco-pus of the tubercular 
 process is quite distinct from the scarcely-noticeable discharge of 
 lupus. The cachexia and fever of the one is also in striking contrast 
 to the non-febrile, non-cachectic condition of the other. 
 
 From tertiary syphilis, with its broad, deep ulcer, sharp outlines, 
 and copious purulent discharge, it should readily be distinguished. 
 
 With malignant disease likewise it has little in common. The 
 pale, mottled surface of cancer, with its necrosis of tissue, frequent 
 haemorrhages, offensive discharges, etc., are characteristic of malig- 
 nant, but not of lupoid, disease. 
 
 Prognosis. — Serious and unfavorable as this disease always is, it 
 is rarely of itself fatal. It is usually, however, only a complication of 
 lupus of the head or face, and is sometimes only a prelude to the more 
 serious affection of lupus of the larynx. Still, in all cases life may 
 be prolonged indefinitely without apparent abbreviation by its 
 j^resence. 
 
 Spontaneous cures rarely, if ever, occur. Yet there are some- 
 times, under favorable circumstances, quiescent periods in which for 
 years little progress will be made, and in which there may be some 
 improvement in symptoms, to be followed by a return of the onward 
 march of the disease. 
 
 Treatment. — As there is little secretion and likewise little pain, 
 neither cleansing nor anodyne treatment is required in the majority 
 of cases. The only treatment of any use is radical, either to remove 
 it altogether or at least to check its progress. 
 
 The plan usually adopted is to scrape away as much of the dis- 
 eased tissue as possible with a sharp spoon or curette, and then to 
 brush the basic surface freely with lactic acid, the operation or brush- 
 ing, or both, to be repeated at intervals of several days while required. 
 Another method of treatment which has been received with a good 
 deal of favor is by the use of the galvanocautery. Excision, too, is 
 not without its advocates. Free cocainization in any case would be 
 necessary prior to operation. 
 
 Internal treatment by arsenic, codliver-oil, iron, etc., is also a 
 useful adjunct to the operative procedure. 
 
 Hypodermic injections of Koch's lymph have frequently been 
 tried, and the results received with more or less enthusiasm, in the 
 history of many cases; though whether permanently good results have 
 been accomplished in any of them is a matter of grave doubt. 
 
CHAPTEE LV. 
 SYPHILIS OF THE PHARYNX. 
 
 Syphilis of the pharynx is not by any means an infrequent event, 
 and occurs during some portion of the history of the majority of cases 
 of syphilitic disease. In rare instances it is primary, in a very large 
 number secondary, and in a certain proportion of cases it occurs in 
 the tertiary form. 
 
 Pathology. — Lesions, whether superficial or deep, are all of an 
 inflammatory character, and partake largely of the nature of those 
 that occur on the mucous membrane of the genital organs, modified 
 only by the structure and functions of the special tissue upon which 
 they occur. 
 
 When the primary disease, or hard chancre, appears in the 
 pharynx, its usual site is in the tonsil, presenting similar pathological 
 lesions to those manifested when it appears on the penis, only that 
 they are of an aggravated character. 
 
 The secondary manifestations of syphilis which appear in the 
 pharynx may be of different forms: 1. Erythema or passive hyper- 
 emia. This is of venous character, as if the parts were congested by 
 dark, sluggish blood. It does not occur until two or three months 
 after the primary lesion. 2. Mucous patches. These are the most 
 frequent of the secondary lesions; and appear about the same period 
 after the initial disease. In the mucous patches there is dilatation 
 of the blood-vessels over symmetrical areas upon each side of the soft 
 palate, with effusion of serum and embryonic cells. There is increase 
 of cell-proliferation, with exudation upon the surface, giving the 
 peculiar whitish appearance which is so noticeable a feature of the 
 mucous patch. 3. The superficial ulcer. This is another secondary 
 manifestation of the presence of syphilis; but, as it is frequently the 
 result of necrosis of mucous patch, it is not always a distinct mani- 
 festation. 
 
 The tertiary period of syphilis is marked by the development of 
 gnmmata, which rarely appear before the fourth or fifth and some- 
 times as late even as the twentieth year of the disease. When they 
 
 (301) 
 
302 DISEASES OF THE PHAEYNX. 
 
 occur in the pharynx the deeper tissues become involved. The growth 
 forms rapidly, and, having limited vitality, breaks down quickly. 
 Pathologically it resembles gumma wherever found, but, being situ- 
 ated in soft tissues, necrosis occurs earlier than when it is situated on 
 cutaneous surfaces. Softening quickly and involving the deeper tis- 
 sues, it forms the deep ulcer of tertiary disease, the depth of ulcera- 
 tion being always limited by the extent of the pre-existing gummy 
 deposit. 
 
 The only other pathological conditions which need be mentioned 
 here are those produced by cicatrization of the superficial and deep 
 ulcers of syphilis. In the superficial the cicatrices are small, but 
 characteristic, being stellate in outline, the fibres radiating from a 
 central mass. 
 
 In the deep the cicatrices produce extensive deformity. They 
 are formed of dense, inelastic bands of fibrous connective tissue. 
 These bands undergo continual contraction, as though Nature were 
 trying to draw the distant normal surfaces together. Not only do 
 cicatrices form across the fields of ulceration, but abraded surfaces, 
 as between the palate and post-pharynx or between the uvula and one 
 of the faucial pillars, will come in contact and unite, resulting in per- 
 manent destruction of mucous membrane and more or less stenosis of 
 the naso-pharynx. 
 
 Etiology. — Syphilis of the pharynx may arise from direct con- 
 tamination, or as the result of secondary or tertiary disease in the 
 system. It may occur as a primary lesion from direct contact of an 
 infected subject by kissing or biting; from using towels, utensils, etc., 
 infected by a syphilitic person; or from certain loathsome practices. 
 Max Thorn er recently reported a case of this nature, occurring in a 
 married woman, the infection being directly produced by her wretch 
 of a husband. 
 
 Secondary syphilis of the throat occurs in the majority of cases 
 of constitutional syphilis, following the general trend of development 
 of this disease in the marginal mucous membranes, or membranes 
 near the physical outlets. 
 
 Tertiary lesions are produced- by the constitutional disease. They 
 are of frequent occurrence in long-standing cases and may arise from 
 five to twenty years after the original primary disease. Secondary and 
 tertiary lesions may also be hereditary. 
 
 Symptomatology. — The symptoms vary materially according to 
 the stage of the disease in which they are manifested. 
 
OROPHARYNX. SYPHILIS. 303 
 
 In the primary the chancre appears most frequently upon the 
 tonsil. It is usually unilateral, but sometimes may occur on both 
 sides. Jullien reports a recent case in which bilateral chancres of the 
 tonsil occurred in a girl aged 17. They were caused from sucking 
 the nipples of a syphilitic parent, recently delivered. The spongy, 
 open condition of the lacunae of the tonsils may be the reason for the 
 more ready deposit of the virus in this region, but other parts of the 
 mouth, the under surface of the tongue and the lip, sometimes become 
 the site of the disease. 
 
 The first s} T mptoms are those of severe sore throat, with pain in 
 swallowing. The tonsil becomes swollen and red, and a white abrasion 
 forms, with slightly-elevated edges. In a few days the glands of the 
 throat swell and become painful. 
 
 Secondary lesions, whether as erythema or mucous patch, are 
 usually symmetrical. Both eruptions confine themselves to the soft 
 palate and pillars, and both show a sharp line of demarkation. In 
 ooth there is stiffness of the throat and soreness. When the mucous 
 patch is present there is acute sensibility, particularly in swallowing. 
 Condiments, acids, and hot drinks produce sharply-distressing pain. 
 
 Tertiary lesions. The symptoms attending the development of 
 gumma in the pharynx are largely mechanical, owing to interference 
 in deglutition and phonation. Although the pain may be severe, it is 
 not so lancinating as in certain forms of secondary disease. It is un- 
 like the secondary, too, in being unilateral at its commencement, 
 usually attacking one tonsil with the adjacent pillars or one side of 
 the post-pharyngeal wall. Deep ulceration quickly follows the de- 
 velopment of the gumma. It is speedy and extensive in its destructive 
 action, presenting prominent and ragged edges around the margin of 
 the ulcer. 
 
 When it remains unarrested, the destruction may be very ex- 
 tensive, involving the integrity of the palate and destroying the 
 power of normal deglutition, food and drink finding an entrance into 
 the nasal passages as a consequence. Haemorrhage of a severe char- 
 acter rarely occurs. Perforation frequently takes place. 
 
 The symptoms arising from cicatricial deformity are almost 
 purely of a mechanical character. Nasal stenosis, from closure of the 
 faucial isthmus or adhesion of the palate to the post-pharyngeal wall, 
 sometimes occurs. Cases are on record in which the cicatricial con- 
 tractions were so severe that the naso-pharynx was entirely cut off 
 from the oro-pharynx, and others in which the palate from side to 
 
304 DISEASES OF THE PHARYNX. 
 
 side became attached to the post-pharyngeal wall. In other instances 
 the palate itself has been lost, giving the food an equal tendency to 
 pass into the naso-pharynx as the oesophagus. Most of these deformi- 
 ties are irregular and of a one-sided character. They rarely affect the 
 respiration when confined to the pharynx; but frequently the voice is 
 changed from the normal. 
 
 Diagnosis. — Chancre of the tonsil presents the ordinary appear- 
 ance of chancre of the penis, with the exception that it covers a wider 
 area, involving the whole of the surface of the tonsil. The margin 
 of the nicer is indurated and the submaxillary and cervical glands 
 of the affected side become enlarged and tender to pressure. The 
 surface of the ulcer is granular, gray, and coated with mucus. Some- 
 times, though rarely, the lesion is small; it may then resemble more 
 fully an ordinary chancre. It differs from gummatous ulceration in 
 not being excavated. 
 
 In syphilitic erythema the chief diagnostic marks are the sharp 
 line of separation from the healthy tissue, and the dark, diffused con- 
 gestion of the mucous membrane affected by the disease. The soft 
 palate and the faucial pillars are the parts usually involved, the post- 
 pharynx not being touched by the lesion. 
 
 The mucous patch is of a bluish-white color, scattered evenly over 
 the right and left sides of the palate and faucial pillars. Its line of 
 demarkation is as closely drawn as that of erythema, and is one of the 
 leading diagnostic features. The thickening at first is very slight; 
 but, if the disease remains long without control, the patch becomes 
 raised above the surface, the color more even and opaque, and the 
 margin develops a ring of hyperemia not before noticed. In some 
 cases it becomes fissured, scaly, and haemorrhagic, resulting in super- 
 ficial ulceration. Superficial ulcers are, as the name implies, shallow. 
 They are usually ovoid in form, are sharply defined, and have little 
 tendency to extend. 
 
 Gummy tumors are hard and often large. They are paler, than 
 the surrounding mucosa and not very painful. The diagnosis is often 
 very difficult, as they may be mistaken for fibromatous or malignant 
 neoplasms. In these cases specific medication should effectually 
 establish the diagnosis. 
 
 Deep ulcers of syphilis are much more readily recognized than 
 gummata. The edges are sharply cut, the ulcers deep and depressed, 
 sometimes undercutting the surrounding mucous membrane. The 
 marginal areola is very distinct. Pus is profusely discharged, and 
 
ORO-PHARYXX. SYPHILIS. 305 
 
 necroses of the ulcerated tissues is a prominent feature. As in super- 
 ficial ulcer, there is little tendency to spreading beyond denned limits, 
 while at the same time, except under specific treatment, repair is 
 exceedingly slow. 
 
 The cicatricial tissues are recognized by the stellate and super- 
 ficial character of the former, and the irregular, extensive, and deep- 
 seated pharyngeal deformities produced by the latter. 
 
 Prognosis. — So far as life is concerned, it is only in the tertiary 
 form that there is any tendency toward a fatal issue. It is, however, 
 one of the most loathsome diseases and also one of the most con- 
 tagious, and, if not relieved, productive of almost life-long misery of 
 one form or another. The liability of the development of gummata 
 and deep ulcerative processes throughout the different tissues of the 
 body should never be lost sight of. 
 
 Treatment. — Constitutional treatment is an important factor in 
 dealing with this disease, and should be carefully carried out in deal- 
 ing with its various forms, particularly the two later ones. 
 
 In local treatment, whether primary, secondary, or tertiary, 
 thorough and systematic cleansing is of the greatest value. This can 
 be done by alkaline gargles or sprays. The latter w T hen applied are 
 the more effectual. When chancre of the throat exists, different lines 
 of treatment are recommended by different authors, subsequent to the 
 regular throat- wash, but their main objects are alike. Solutions of 
 permanganate of potash, nitrate of silver, acetate of lead, chloride of 
 zinc may any of them be applied to the ulcer by means of the cotton- 
 holder; or the various forms of iodine powders — such as iodoform, 
 iodol, aristol, etc. — may be dusted on the surface. 
 
 The question of removal of the chancre by excision, or of the 
 hypertrophied tonsil upon which it may be located, is rarely seriously 
 thought of how. The virus is already in the system when the chancre 
 is found, and the production of a large raw surface in the syphilitic 
 throat would produce serious danger of autoinfection. 
 
 Mucous Patch. — In this it is highly important to treat most 
 thoroughly, the object being to destroy the mucous infiltration as early 
 as possible. While the primary chancre is a self-limited disease, the 
 mucous patch, unless removed, will go on indefinitely and may pro- 
 duce chronic throat-lesion. For this there is no better remedy than 
 the application of nitrate of silver in strong solution, repeated on alter- 
 nate days as long as the disease lasts, cleansing sprays being used 
 during the intervals. Of other remedies that might be tried, iodoform 
 
306 DISEASES OF THE PHARYNX. 
 
 and glycero-tannin have both clone good work, also tinct. fer. mur. in 
 glycerin, 1 part to 4. painted on the surface three times a day. 
 
 In the ulcerations, superficial and deep, as well as the gummy 
 tumor, besides the local cleansing and the application of the iodine 
 compounds, already mentioned, the main thing is to get the system 
 under constitutional control as quickly as possible, by the adminis- 
 tration of the iodides. This treatment should be pursued with zeal, 
 in every instance where a gumma is discovered, with the object of its 
 resolution, before ulceration — with all its destructive results — can take 
 place. 
 
 The successful treatment of deformities of the pharynx arising 
 from tertiary syphilis is a very difficult matter. The most common de- 
 formity is adhesion, all or in part, of the soft palate to the post- 
 pharyngeal wall. Although these adhesions may be severed, they are 
 followed by renewal of the cicatrix, without special means are devised 
 to keep the parts open by the use of suitable dilators; and, as the 
 cases all differ from each other, each one must be judged and treated 
 upon its own merits. When extensive perforations of the palate have 
 taken place, obturators have sometimes been used to prevent the 
 passage of food into the nose or naso-pharynx. 
 
 Actinomycosis. 
 
 This disease, like glanders, is peculiar to the higher animals; but, 
 instead of selecting the horse as its habitat, it has chosen the bovine 
 race. Like glanders, too, it is communicable to man. In cattle the dis- 
 ease is known as "lumpy- jaw/' and owes its origin to the "ray-fungus." 
 It may be transmitted to man by contagion through an abraded sur- 
 face, and from there carried by the lymph-vessels to the pharynx and 
 tonsils. 
 
 The implantation of the ray-fungus leads to development of 
 granulation-tumors, which result in inflammation, chronic suppura- 
 tion, and formation of ill-conditioned sinuses. The symptoms are those 
 of local tumefaction and persistent purulent discharge. Pain is vari- 
 able and is of a heavy, aching character. Sometimes the disease might 
 be mistaken for sarcoma. The prognosis is bad, although early treat- 
 ment might be of some avail. Large doses of iodide of potassium are 
 said to have cured some cases. Nitrate of silver given internally has 
 also been attended with good results. In suitable cases extirpation 
 of diseased tissue should be accomplished. (Kyle.) 
 
CHAPTER LVI. 
 
 SARCOMA OF THE FAUCES. 
 
 This is a comparatively rare disease. It occurs more frequently 
 in the tonsil than in the soft palate or post-pharyngeal wall, fully one- 
 half of the cases, reported having occurred in the tonsillar region. 
 
 Pathology. — Sarcoma differs little in physical characteristics 
 wherever found. It has a greater tendency to localize itself than car- 
 cinoma, and when it develops in the tonsil it grows more rapidly than 
 in the palate or post-pharynx. When located in the palate it extends 
 somewhat slowly and, as a rule, in a backward direction. In the 
 tonsil the spongy nature of the lymphatic tissues favors more rapid 
 growth. Infiltration becomes extensive and the disease progresses 
 toward the oro-pharynx and into the deeper tissues of the neck. Be- 
 sides the greater rapidity of its development, in one other feature 
 does sarcoma of the tonsil differ from sarcoma commencing in the 
 faucial regions, and that is in its tendency to extend through the neck 
 to the outside. There is no fixed rule of development, however, 
 wherever the disease may be located. Chiari points out that frequently 
 large tumors are formed in the pharynx, mouth, and upper jaw, and 
 the malignant growth may even extend to the larynx, orbit, and 
 cranial cavity, accompanied by deep and wide-spread ulceration. 
 
 Several varieties of this growth occur in the pharynx and soft 
 palate, though perhaps the most frequent are what are called the 
 round- and spindle- celled sarcomas. Cases of myxosarcoma, adeno- 
 sarcoma, lymphosarcoma, fibrosarcoma, and giant-celled sarcoma are 
 also reported. 
 
 It is the small, round-celled sarcoma which occurs most fre- 
 quently in the tonsil. The cells are similar to those of the lymphatic 
 glands, but their nuclei, while round, are larger. The spindle-celled 
 sarcomas occur very rarely in the tonsil, and the large, round-celled 
 Tarely, if ever. 
 
 Etiology. — There is no definite cause known, up to the present, 
 for the development of this disease, no method of ascertaining before- 
 hand why it should arise in one person and not in another, no means 
 
 10a (307) 
 
308 • DISEASES OF THE PHARYNX. 
 
 of analyzing the special conditions essential to its formation, and 
 prophesying definitely the coming result. Certain premises, are, how- 
 ever, known. For instance, it occurs much more frequently in men 
 than women. Unlike carcinoma it frequently affects childhood, while 
 it is known to occur during all the ages of matured life. If there is 
 any preference in this matter, sarcoma of the tonsil exhibits a greater 
 tendency to develop during the two extremes: childhood and old age. 
 
 Symptomatology. — The development of sarcoma varies greatly 
 according to the situation and virulence of the disease. In the palate 
 it may come on insidiously, and give little indication of its presence, 
 until deglutition and phonation is interfered with. There may be 
 little cachexia and no glandular enlargement; but, when the growth 
 is attached by pedicle, the mechanical presence of the dependent body 
 may give rise to laryngeal symptoms. 
 
 In the tonsil the symptoms may come on more rapidly and be 
 earlier felt. At first it might be taken for quinsy, but the latter is 
 more rapid and accompanied by febrile action. As ulceration de- 
 velops, haemorrhage not infrequently occurs, accompanied by offensive 
 discharges of pus and debris. In tonsillar sarcoma the deep extension 
 may pass quickly through to the outer wall of the neck, where it be- 
 comes hard and nodular. Swelling of the neighboring glands occurs, 
 and the cachexia of malignant disease is more readily noticeable. 
 
 Sarcoma of the pharyngeal walls, like sarcoma of the palate, 
 seems to have less malignancy in detail than that of the tonsils. 
 There may be less pain, less haemorrhage, and slower development. 
 The glands are less involved and the cachexia less marked. Still, the 
 general symptoms are present in all, and each case, no matter where 
 situated, is bound by no fast rules of clinical history. 
 
 Diagnosis. — The chief diseases from which sarcoma of the fauces 
 has to be distinguished are adenoma, fibroma, and carcinoma. In the 
 palate sarcoma has a light-reddish color and is rounded or nodulated 
 in form. In the tonsil it may be of. a darker red, while in the pharynx 
 it may be of a still more purplish hue and mottled in outline. From 
 carcinoma it is distinguished by the harder, almost-cartilaginous out- 
 lines, as well as lighter color, of the more malignant disease. The 
 latter also spreads with greater facility, and is accompanied by more 
 extensive glandular enlargement. Sarcoma extends backward and 
 outward in its growth, while carcinoma usually has a forward develop- 
 ment. 
 
 Fibroma of the pharynx is a very rare disease, slower in develop- 
 
OROPHARYNX. SARCOMA. 309 
 
 ment, and unattended by glandular sympathy. Adenoma, too, is 
 slower in formation and less likely to ulcerate. 
 
 The possibility of mistaking at first sight sarcoma of the tonsil 
 for quinsy has already been referred to, but the fact that the latter is 
 an acute inflammatory disease, with the attending symptoms so easy 
 to recognize, should at once remove all donbt. 
 
 The bacillus of sarcoma has so far not been discovered; bnt in 
 each case, if possible, a microscopical examination of a minute section 
 of the neoplasm should be made, to demonstrate the presence of the 
 cells indicative of the disease. 
 
 Prognosis. — Although a very grave disease, it appears to be much 
 more amenable to treatment, when situated in the palate or pharynx 
 than when located in the tonsil. In any situation there is no tendency 
 to spontaneous cure, but in the two former successful removal has 
 been accomplished more frequently than in the latter, with a certain 
 amount of immunity from future return. In the pharynx the growth 
 is often pedunculated and removable. In the tonsil the attachment 
 is broad and deep, owing to the mixed character of the tissue in- 
 volved. The lymphatics of the tonsil have also intimate connection 
 with the underlying lymphatics of the neck; this may possibly ac- 
 count for the greater malignancy when situated in this region. 
 
 In the palate enucleation from the surrounding tissues has in a 
 number of instances been attended with the best results. The dura- 
 tion of the disease may be between six months and two or three years. 
 
 Treatment. — This may be divided into palliative and operative. 
 Of the former, cleansing washes of an unirritating and aseptic char- 
 acter may be required to keep the parts free from purulent secretions. 
 This with supporting measures is all that can be done. Of internal 
 remedies, the administration of arsenic seems to be held in the highest 
 favor. 
 
 Of operative treatment, there is no fixed rule for the guidance of 
 the surgeon, except the necessity for the removal of the entire neo- 
 plasm when at all possible. If the growth is pedunculated, ablation 
 by the snare is the best method at our command. This may be either 
 by the cold wire or the galvanocautery-ecraseur, and particularly ap- 
 plicable when the disease occupies the pharyngeal wall. When sessile 
 or nucleated, excision may be necessary. It is always better to operate 
 directly through the mouth when possible. At other times, when the 
 external wall is affected, the tonsil being deeply involved, lateral 
 pharyngotomy may require to be resorted to. The main thing in all 
 
310 DISEASES OE THE PHARYNX. 
 
 cases is to make the diagnosis positive as early as possible; and then, 
 if there is any probability of a good result, to operate as thoroughly 
 as possible and without delay. As to the method required, or the 
 instruments to be used, each ease must be carefully considered upon 
 its own merits. The operator should be guided by the best judgment, 
 either singly or in consultation, always remembering the possibility of 
 severe haemorrhage, which operations in this locality are liable to 
 produce. 
 
 Leukoplakia Palati. 
 
 This is a condition which sometimes, though rarely, affects the 
 anterior border of the soft palate. Although not carcinomatous, it is 
 said to bear an intimate relation to cancerous disease; and, if not re- 
 moved, desquamation may set in, with the final result of the develop- 
 ment of malignancy. As its name implies, it is distinguished by the 
 development of little, white plaques, ranging from one or two milli- 
 metres to a centimetre in diameter, due to fatty degeneration of the 
 surface-epithelium. 
 
 Treatment should be local applications of nitrate of silver, chromic 
 acid, or electrocautery, together with the use of mild antiseptic sprays. 
 Systemic treatment should be of a supporting character. 
 
CHAPTER LVII. 
 
 CARCINOMA OF THE FAUCES. 
 
 Sir Morele Mackenzie defined carcinoma in this region as 
 "primary malignant disease of the pharynx, generally causing death 
 by starvation, but sometimes by haemorrhage" (Fig. 94). At the 
 present time, while this definition might be considered largely cor- 
 rect, a good deal of weight would be placed upon the influence of the 
 toxins, evolved from cancerous growth, in hastening the fatal result. 
 
 Fig. 94. — Malignant epithelioma, extending from right tonsil to base 
 of tongue. (After Lennox Browne.) 
 
 Pathology. — The prevailing type of cancer of the fauces, whether 
 in the tonsils, soft palate, or pharyngeal walls, is epithelioma. When 
 located in the soft palate, the history of the cases reported seems to 
 indicate a tendency not to spread very widely beyond the muscles of 
 that organ. Whatever extension does occur is usually toward the 
 pillars and tongue, rather than the pharyngeal tissues as in sarcoma. 
 It has been noticed, in reference to this disease, that when it com- 
 mences in muscular structures it appears to avoid lymphatic tissues 
 
 (311) 
 
312 DISEASES OE THE PHARYNX. 
 
 in its extension, whereas when it has its origin in lymphatic bodies, 
 as in the tonsil, it spreads indiscriminately to the surrounding tissues, 
 no matter what their structure may be. 
 
 Opinions are divided as to the comparative frequency of sarcoma 
 and carcinoma of the fauces. Perhaps the weight of opinion is with 
 the latter. There is this difference, however, that, while sarcoma of 
 the throat occurs frequently during early life, carcinoma prevails 
 during the middle and later periods. During mature years the lym- 
 phatic structures of the throat undergo shrinkage and diminished 
 activity, while the epithelial and connective-tissue elements retain 
 
 Fig. 95. — Stratified epithelioma of tonsils (Yo-inch objective) 
 (After Lennox Browne.) 
 
 their aptitude for increased development. If from any cause this epi- 
 thelial proliferation becomes stimulated to an abnormal degree, we 
 have a condition favorable to the formation of cancerous tissue, which, 
 forming first superficially, penetrates deeper, displacing and invading 
 normal tissue as the epithelial deposit increases. 
 
 In all parts of the fauces the development of cancer follows the 
 ordinary course: rapid formation of the tumor, followed by peripheral 
 ulceration and hsemorrhagic discharges. When located in the lower 
 pharynx, the tendency of the disease is to spread downward, involving 
 the oesophagus and larynx; when in the tonsil, outward and forward 
 as well as toward the pillars: while, as said before, its first develop- 
 
ORO-PHARYXX. CARCINOMA. 
 
 313 
 
 ment among the muscles of the soft palate is followed by a tendency 
 to self -limitation. 
 
 Histologically epithelioma of the tonsils appears in two forms: 
 
 1. That of stratified epithelioma with fimbriated processes (Fig. 95). 
 
 2. That of cell-nest development along the track of the lymph-vessels 
 (Fig. 95a). 
 
 Etiology. — The average age of persons afflicted with carcinoma 
 of the pharynx is somewhat above fifty years. This in males and 
 females is about alike; but one curious fact is noticeable relative to 
 the cases so far recorded, and that is: while twice as many males 
 have cancer of the palate and tonsils as females, the reverse holds 
 
 Fig. 95a. — Epithelioma showing cell-nests ( 1 / 6 -inch objective) 
 (After Lennox Browne.) 
 
 good in reference to cancer of the lower pharynx, — more than two- 
 thirds of the cases reported have occurred in women. 
 
 Of the various regions of the throat, it occurs most frequently in 
 the tonsils, the largest number occurring between the ages of forty and 
 fifty years. 
 
 Hereditary tendency has something to do with its development, 
 but how much, it is difficult to say. Exposure to vicissitudes of out- 
 door life is also said to be a cause, as also the excessive use of alcohol 
 and tobacco. 
 
 Symptomatology. — When confined to the palate, and also when it 
 has its origin in the pharyngeal wall, the early symptoms are chiefly 
 
314 DISEASES OF THE PHARYNX. 
 
 those of a mechanical character. There may be difficulty of swallow- 
 ing and also muffled voice; but there is no fever, no hypersecretion 
 of mucus, and but little pain. On the other hand, when the tonsils 
 are the seat of the disease, sharp and lancinating pains are among 
 the earliest symptoms. These are felt chiefly in deglutition, and as 
 the disease advances increase in severity. They radiate in different 
 directions from the part affected, but chiefly toward the ear. As the 
 tumor develops either in the palate or the pharynx, the pains also 
 become more severe, though they are probably never so excruciating 
 as in tonsillar carcinoma. Ulceration is usually a comparatively 
 early symptom, and in the tonsils as well as the pharynx is more 
 likely to be followed by haemorrhage than in the palatal disease. 
 
 Increased flow of saliva is also an early symptom, the salivary 
 glands being stimulated to hypersecretion; hence drilling is often 
 present. 
 
 The cervical glands become enlarged, particularly in tonsillar or 
 pharyngeal disease, and the early development of cancerous cachexia 
 is of frequent occurrence. 
 
 When the disease is situated in the lower pharynx, its extension 
 to the oesophagus and larynx interfere decidedly with both deglutition 
 and phonation, and also, as the disease becomes more severe, with 
 normal breathing. 
 
 Diagnosis. — The diseases of the fauces from which carcinoma 
 must be distinguished are chiefly those of sarcoma and fibroma. The 
 latter is more rare in this region than carcinoma. It is slower in 
 growth, is unattended by constitutional cachexia, is productive of less 
 pain, and is usually pedunculated and consequently movable. On 
 the first appearance of the neoplasm, however, before serious symp- 
 toms have had time to develop, there may in some cases be room for 
 doubt; but these will soon vanish by a careful observance of the 
 progress of the disease. 
 
 From sarcoma the distinguishing lines are less clearly drawn, ex- 
 cept in typical cases; and it should be remembered that in many 
 cases the indications of the two diseases so overlap each other that 
 without microscopical examination it is almost impossible to arrive 
 at a positive conclusion. 
 
 The typical sarcoma is a soft, red, fleshy tumor, not much given 
 to ulceration and slow in forming, while typical carcinoma is harder 
 even than fibroma, cartilaginous to the touch, and of a whitish-red 
 color and nodulated. The cervical elands become involved earlv in 
 
ORO-PHARYNX. CARCINOMA. 315 
 
 carcinoma, while in sarcoma they are late in becoming affected. In 
 the same way the malignant cachexia is much more early in its mani- 
 festations in the former than the latter. 
 
 Carcinoma of the tonsil, which is usually seirrhus, is harder, 
 whiter, and denser than sarcoma, much more painful, more given to 
 deep ulceration, and more likely to extend, as it progresses toward a 
 fatal result, into the oral region. Both are likely to be attended by 
 haemorrhage; but that from sarcoma is superficial, while the bleeding 
 from carcinoma is more likely to be arterial. 
 
 Carcinoma of the walls of the pharynx differs from sarcoma, even 
 more definitely than in the other regions of the throat. The former 
 has the ordinary appearance of epithelioma, with broad, flattened, 
 grayish, hard infiltration; the latter, dark red or purplish and 
 pedunculated, as well as soft. Then when ulceration commences, 
 which it does quite early in the disease, the appearance is almost 
 diagnostic. The centre of the gray, elevated mass is depressed and 
 covered with yellowish-red serum. 
 
 From adenoma, angioma, etc., there should be little difficulty in 
 the matter of diagnosis, as, besides the difference in clinical symp- 
 toms and appearances, these diseases are free from ulceration and 
 the general cachexia indicative of the graver affection. 
 
 The use of the microscope should in any event render the diag- 
 nosis more certain. Kroulein, in a history of sixty-one cases, says 
 that they were all flat-celled epitheliomata, and, of these, fifty-six 
 occurred in men and only five in women. No bacillus of cancer has 
 so far been discovered. 
 
 Prognosis. — This is always unfavorable in- carcinomatous disease 
 of the throat, whether situated in the palate, tonsils, or pharyngeal 
 walls. It is, in fact, a uniformly-fatal disease. The length of time 
 the patient may live will vary from a few months to one or two years. 
 In a few cases if operated on early the neoplasm may be removed and 
 temporary relief secured for the patient; but recurrence almost in- 
 variably takes place, and sooner or later the result will be fatal. 
 
 Treatment. — Palliative treatment is about all that is advisable 
 in these cases: mild washes to the throat and the application of 
 sprays of cocaine to relieve the pain of swallowing. The spray of 
 menthol in albolene, 2 to 5 per cent., will also produce a grateful and 
 soothing effect upon the pharynx and help to relieve the excruciating 
 pain which sometimes attends the disease. This is particularly the 
 case if the menthol-spray is applied directly after the cocaine solu- 
 
316 DISEASES OF THE PHARYNX. 
 
 tion. It seems to have the effect of prolonging the action of the 
 latter, and at the same time of preventing the depressing effect which 
 the cocaine sometimes produces. Supporting measures in the most 
 palatable form are also required, for the days of the patient frequently 
 depend upon the length of time during which he can partake of food 
 sufficient to sustain life. 
 
 With regard to operative treatment, to he effectual at all it must 
 be radical as well as early: and many cases, even if taken at the 
 very commencement, would not be fit subjects for operation. The 
 question of excision in any case is a serious one, and upon it the sur- 
 geon must use his wisest judgment. Still, cases are on record in 
 which the cancerous growth has been entirely removed, the wound 
 has healed, and for a prolonged period there has been no return. 
 Mickulicz's case, a woman, aged 65, who had been suffering for six- 
 teen months, was operated on successfully by an external lateral 
 operation; two and a half years later there was no return. Dupage, 
 following Mickulicz's method of lateral pharyngotomy, operated suc- 
 cessfully upon three cases, which are all said to have been cured, 
 although the intervals between the operations and the report are not 
 given. In Ferrard's case, aged 74, the growth was removed from the 
 palate by knife operation, and five years later there had been no re- 
 turn. These are exceptions to the general rule. 
 
 It may be laid down as a reasonable conclusion that in all cases 
 where the cancerous cachexia has become developed, radical oper- 
 ations should not be undertaken. Cases may occur, however, in which, 
 although a speedily fatal result is certain, the malignant mass may so 
 obstruct respiration or deglutition that a removal of part of it may 
 give temporary ease. Menzes, of Amsterdam, reports a case of this 
 kind. A large cancerous mass was growing from the right pharyngeal 
 wall, producing complete nasal stenosis. He removed it by Gott- 
 stein's curette, affording, for a time, complete relief to the patient. 
 In cases of this kind operation would be both justifiable and laudable. 
 
 When, on the other hand, cachexia is not noticeable, the growth 
 is accessible, and there is a fair prospect of eradicating the tumor in 
 its entirety, it is usually advisable to operate. The method must be 
 governed by the circumstances of the case, together with the apti- 
 tude and experience of the operator. 
 
 If the intrapharyngeal operation can be accomplished success- 
 fully, either by snare, galvanocautery, or knife, it is to be preferred 
 to the larger operation by external excision. Still, each case must 
 
ORO-PHARYXX. CARCINOMA. 317 
 
 be judged on its own merits, the work being accomplished in accord- 
 ance with the well-established rules of surgical procedure. 
 
 Kyle, our most recent authority, in his work just published dwells 
 upon the differentiation which exists in this rare disease. He says: 
 "If the carcinoma be of the epithelial variety, the growth is soft and 
 spongy in character; or, if of the scirrhus variety, it begins as a hard 
 irregularly-outlined mass. In either form, early in the growth the 
 mucous-membrane surface is fairly normal in appearance; but with 
 ulceration this is entirely lost. The cervical glands are involved, and 
 in the scirrhus variety this involvement takes place early. If the 
 growth occurs low down in the pharynx and is limited to the posterior 
 surface it is more often of the fungoid character. It is very irregular 
 in outline, and the surrounding structures are swollen almost to the 
 point of being cedematous. In low involvement of the pharynx there 
 is not such marked implication of the cervical glands." 
 
CHAPTER LVIII. 
 
 NEUROSES OF THE FAUCES. 
 
 Disordered sensibility of the terminal filaments of the nerves 
 of the pharynx are not of infrequent occurrence. They may be 
 divided into neurosis of sensation and neurosis of motion. 
 
 Neuroses of Sensation. 
 
 Neurosis of sensation may be present in the form of anaesthesia, 
 hyperesthesia, or paresthesia, and occasionally as neuralgia. The first 
 is of little moment, without it is associated with paralysis, of which it 
 may be a symptom. When occurring alone it rarely calls for treat- 
 ment. Possibly the administration of strychnine and the application 
 of galvanism may be of benefit. 
 
 Hyperesthesia and paresthesia of the pharynx are practically 
 synonymous terms, and indicate oversensitiveness of the mucous mem- 
 brane, though the former is usually applied to touch, and the latter 
 to the feeling of pricking and irritation which sometimes exists with- 
 out apparently adequate cause. This is particularly liable to occur 
 in hysterical women. As a rule, the palate is more sensitive than any 
 other part of the throat. I have one male patient, however, aged 35, 
 who has for years been under treatment, off and on, for atrophic 
 rhinitis; but in his case the sensitive part is the base of the tongue. 
 He cannot bear the slightest pressure upon it, without producing 
 retching, although any other part of the throat can be touched with 
 impunity. Even the application of cocaine is without controlling 
 effect; the consequence is that in his case the use of a tongue- 
 depressor is always out of the question. In the majority of instances 
 pharyngeal hyperesthesia owes its origin to some local lesion the 
 removal of which would relieve the annoying symptoms. 
 
 Neuralgia of the pharynx is usually unilateral and may owe its 
 ■origin either to a local morbid condition or to some form of anemia. 
 It is not, as a rule, associated with hysteria. Removal of any exist- 
 ing local lesion or tonsillar concretion, together with the adminis- 
 tration of systemic tonics, such as quinine, iron, arsenic, or strychnine, 
 would seem to be the best treatment. 
 (318) 
 
oro-pharynx. paralysis of the fauces. 319 
 
 Neuroses of Motion. 
 
 Spasm of the pharynx is not of infrequent occurrence. It may 
 arise from elongation or oedema of the uvula, acute pharyngitis, ap- 
 plication of local irritants, etc. Courmont and Magnan relate cases 
 arising from tabes, which were at once cured by suspension. They 
 believe that the pharyngeal spasms are influenced by central or pe- 
 ripheral lesions. Spasm of the pharynx is produced by hydrophobia 
 and also by tetanus, being in each case a symptom of systemic disease. 
 The part usually affected is the soft palate, the levator palati being 
 the muscle ordinarily involved in cases of chorea affected by pharyn- 
 geal spasm. In some cases the constrictor muscles are all equally 
 involved. 
 
 PARALYSIS OF THE FAUCES. 
 
 One of the most common forms of throat paralysis is that in 
 which it occurs as a sequel to diphtheria. It has been known also 
 to follow acute lacunar tonsillitis. In these cases there is little doubt 
 that the disease is of central origin, arising from the effects of the 
 toxins of diphtheria upon the nerve-centres. In this affection the 
 voice assumes a quacking or nasal twang. It becomes impossible in 
 some cases to render tense the levator palati muscles so as to close the 
 naso-pharynx from the oro-phar}<nx. Consequently, in attempting to 
 swallow, the food will frequently pass into the vault above. In other 
 instances, the pharyngeal constrictors having lost their power of con- 
 traction, ordinary deglutition becomes impossible, and the patient is 
 obliged to force the food downward out of the oro-pharynx by filling 
 his mouth with fluid and then aiding the process by the compression 
 of the oral muscles. 
 
 In these cases, similar treatment to that prescribed for anaes- 
 thesia of the pharynx, the use of nerve-tonics, and the application of 
 electricity may be tried; but they are often unavailing. Weeks pass 
 away without apparent improvement; then the recuperative power 
 of Nature slowly asserts itself, and the normal function is gradually 
 restored. 
 
 Sometimes paralysis of the palate accompanies facial paralysis. 
 It is then unilateral. No special treatment is required. 
 
 Myopathic paralysis occurs in some morbid conditions of the 
 muscular fibres. Whether this is really the seat of the lesion, or 
 whether the paralysis of certain muscles arises from an abnormal 
 
320 DISEASES OF THE PHARYNX. 
 
 condition of the smaller nerves or nerve-filaments, is still a matter of 
 question . Sometimes one group of muscles may be affected, some- 
 times another; the affection may be either unilateral or bilateral. 
 
 Palato-glosso-pharyngeal paralysis is one of the symptoms of 
 progressive bulbar paralysis. It arises from an anaemic condition of 
 the medulla. It is rarely met with before the age of forty years. All 
 the nerves supplying the muscles of deglutition and articulation may 
 be involved. The glossopharyngeal, hypoglossal, facial, spinal ac- 
 cessory, and trigeminus, all having their origin in the medulla, may 
 be affected in this disease. As a rule, the malady affects the tongue 
 first, then the lips, palate, and pharynx. 
 
 As its name implies, it is progressive, slowly but steadily ad- 
 vancing toward a fatal issue. Early in the disease there is indistinct- 
 ness of speech: dysphagia. also is an early symptom. These steadily 
 advance until articulation becomes unintelligible and deglutition im- 
 possible. Wasting and misery become extreme and the patient suc- 
 cumbs. 
 
 Acute bulbar paralysis may also occur. It is exceedingly rare, 
 and differs little from the preceding, except in the rapidity of the 
 progress of the symptoms and the speedy termination of life. 
 
 In treatment of either little can be done; and that little is con- 
 fined to the relief of concurrent symptoms, based on the general 
 principles of therapeutics. 
 
CHAPTER LIX. 
 
 FOREIGN BODIES IN THE FAUCES. 
 
 TONSILLITHS. 
 
 In connection with this subject a word might be said about the 
 concretions or calcareous deposits which are sometimes formed within 
 the lacunae, or crypts, of the tonsils. In certain inflammatory condi- 
 tions, which during middle age tend to produce connective-tissue 
 hyperplasia, the mouths of the crypts may become closed, and the re- 
 tained secretion inspissated, until in time calculus is formed. It is 
 doubtful, however, whether this can occur without the previous de- 
 posit within the crypt of some small foreign body, which, as in the 
 case of the rhinolith, becomes the nucleus around which the con- 
 cretion gradually forms. These calculi were at one time considered 
 to arise from a gouty affection of the pharynx. This theory has 
 latterly been discarded, as repeated examinations of the tonsillar cal- 
 culi have always proved them to consist of phosphate and carbonate 
 of lime instead of urates. The symptoms are similar to those of com- 
 mencing quinsy. Sometimes the diagnosis is a little difficult, owing 
 to the completeness with which the foreign body is covered. Palpa- 
 tion and probe examination should remove all doubt. Still, instances 
 have occurred in which the concretion was not suspected, until it 
 was grasped by the tonsillotome. Treatment consists in removing 
 the calculus by means of the forceps, or, when necessary, incision 
 with bistoury in order to make extraction possible, and then removal 
 with forceps or spoon. The use of a cleansing wash would be all the 
 after-treatment required. 
 
 In the issue for January 7, 1899, of the British Medical Journal, 
 Aitchison Robertson gives the history of the largest tonsillar calculus 
 on record. It was shaped somewhat like an egg. Its greatest length 
 was 4.4 centimetres and greatest breadth 3.8 centimetres. The weight 
 was 26.8 grammes. The age of the patient was 50 years, and its 
 presence was never discovered until it was expelled by violent cough- 
 ing during a suffocative attack which occurred about the middle of 
 
 (321) 
 
322 DISEASES OF THE PHAKYNX. 
 
 the night. It came from the right tonsil. There was no haemorrhage, 
 but a large cavity marked the site of its formation. It was pale yel- 
 low in color, had a worm-eaten appearance, and while fresh had a 
 strong odor (Fig. 96). 
 
 Fokeign Bodies. 
 
 Foreign bodies are often lodged in the pharynx from without. 
 They are very diverse in character, consisting of such substances as 
 pieces of meat, fragments of bone, false teeth, buttons, coins, pins, 
 needles, etc. Small, pointed bodies are apt to become fixed in the 
 tonsils or pharyngeal walls or about the top of the larynx. Larger 
 bodies, round or square in outline, are more likely to be lodged in 
 the lower pharynx or in one of the pyriform sinuses or between the 
 tongue and epiglottis. Occasionally the effect of Nature to expel the 
 foreign body by spasmodic coughing results in throwing it forcibly 
 into the naso-pharynx, where it may either remain lodged or be again 
 expelled. 
 
 Fig. 96. — Robertson's calculus from right tonsil; weight, 
 26.8 grammes. Actual size. 
 
 The symptoms produced by foreign bodies in the pharynx are 
 frequently distressing. Deglutition may be seriously interfered with 
 or even suspended. Several years ago I removed a needle from the 
 lower part of a woman's pharynx which had been lodged there trans- 
 versely for twelve hours, during which time she had been entirely 
 unable to swallow anything, not even fluids. There is no doubt in 
 this case that the inability was partly voluntary, owing to the pain 
 which the effort produced. Hard substances may lodge in the pyri- 
 
OROPHARYNX. FOREIGN BODIES. 323 
 
 form sinus, and produce pain in the lateral regions of the lower 
 pharynx, as well as interfere with swallowing. 
 
 When the foreign body is located in the oro-pharynx, it may be 
 observed in many cases by direct light; but, in the majority of in- 
 stances, the use of reflected light and a throat-mirror will be required. 
 In all doubtful cases the examination should be as thorough as pos- 
 sible, and, if the mirror fails to reveal anything, digital exploration 
 may be resorted to, to make the diagnosis certain. 
 
 The history of the case, together with the symptoms and thorough 
 inspection, will usually make the nature and position of the object 
 clear. When still in doubt, the use of the sciagraph should remove 
 all remaining uncertainty. It must be remembered, however, that 
 not only may the presence of a foreign body in the pharynx be im- 
 aginary, but also that even the removal or expulsion of the foreign 
 body may be followed for weeks or even months afterward with the 
 impression in the mind of the patient that it is still in the old posi- 
 tion. This is particularly likely to occur when the subjects are 
 hysterical women. 
 
 Prognosis. — This varies according to the nature and position of 
 the object. Sharp pieces of metal or bone may do serious harm. 
 They have been known to penetrate the blood-vessels of the neck 
 and produce death by haemorrhage. In other instances they have fre- 
 quently found their way into the tissues of the neck, and been ex- 
 tracted from situations far removed from the point of entry. Large 
 bodies have become impacted, and have produced a fatal result, by 
 ulcerating through the pharyngeal walls and inducing pyaamia. 
 
 In the majority of cases, -however, they may be removed with 
 more or less facility, and without leaving any serious effect upon the 
 pharyngeal walls. 
 
 Treatment. — This consists simply in removing the foreign body 
 as gently as possible, and with a minimum of injury to the surround- 
 ing tissues. To accomplish this, as a rule, we need a good reflected 
 light, the throat-mirror, and forceps to suit the position and nature 
 of the object. The finger, in exploration as well as removal, is often 
 of great assistance. Some objects, such as pins, may be grasped be- 
 tween the finger and the nail, in not a few instances, and their removal 
 effected. In some cases the curette will be of service, and in others 
 the snare; while in still another class the careful insertion of the 
 coin-catcher or the umbrella-bougie into the upper part of the oesoph- 
 agus will result in lifting the object directly into the outer air. 
 
324 DISEASES OF THE PHARYNX. 
 
 After the removal no other treatment is required, except the 
 warning to the patient that for some time the impression may remain 
 that the foreign body is still within the pharynx. 
 
 When the obstruction seriously interferes with respiration, and 
 cannot at the time be removed, tracheotomy may be called for, resort 
 being made to further efforts after the artificial breathing has been 
 established. 
 
SECTION III. 
 
 Diseases of the Larynx. 
 
CHAPTER LX. 
 ANATOMY OF THE LARYNX. 
 
 For the minute anatomy of the larynx the reader must be re- 
 ferred to the descriptions of more elaborate text-books. Enough, 
 however, of the general anatomy may be given to indicate important 
 points, without the knowledge of which it would be impossible to treat 
 effectually diseases of this organ. 
 
 This complicated organ may be considered as an expansion of 
 the trachea. It lies between the hyoid bone above and the trachea 
 below. The lower pharynx and the entrance to the oesophagus lie 
 behind it, and the skin and superficial tissues cover it in front. On 
 each side are the great vessels and nerves and it is connected with 
 the adjacent parts by muscles and ligaments. 
 
 Behind the larynx, from the tip of the epiglottis to the lower bor- 
 der of the cricoid, lie the third, fourth, fifth, and sometimes the sixth 
 cervical vertebrae; that is, when the organ is in a stationary position. 
 During phonation and deglutition, particularly the latter, it makes 
 notable excursions in an upward direction. 
 
 The larynx is the entrance-door to the lungs, and allows the freest 
 passage of air during the acts of inspiration and expiration. The other 
 chief function of the larynx is that of phonation. 
 
 The larynx is composed of five principal cartilages: the thyroid, 
 the cricoid, the epiglottis, and the two arytenoids. There are also four 
 supplementary cartilages: the two of Santorini and the two of Wris- 
 berg (Fig. 97). 
 
 The cricoid, or ring, cartilage is the foundation of the larynx. 
 It rests directly upon the trachea. It is formed like a seal ring, the 
 small, rounded, curved portion being in front, and the enlarged, thick- 
 ened, seal division being behind. On the upper surface of the back 
 part are two large facets for articulation with the arytenoids, and on 
 the outer portions of the same surface two smaller depressions for 
 articulation with the inferior cornua of the thyroid cartilage (Figs. 
 98 and 99). 
 
 The under surface is attached by fibrous tissue to the upper ring 
 of the trachea. 
 
 (327) 
 
328 
 
 DISEASES OF THE LARYNX. 
 
 The thyroid cartilage is shield-shaped, and forms the largest por- 
 tion of the laryngeal frame-work. It is composed of two symmetrical, 
 
 Fig. 97. — The cartilaginous frame of the larynx, with the hyoid bone 
 and ligamentous attachments (Broca). A, Hyoid bone. B, B, The greater 
 cornua of the hyoid. G, C, The lesser cornua of the hyoid. D, Epiglottis. 
 E, Thyroid cartilage. F, F, The superior cornua of the thyroid. G, The 
 lesser cornu of the thyroid. H. Cricoid cartilage. 1, Thyroepiglottic liga- 
 ment. 2, Hyo- epiglottic ligament, 3, Lateral thyrohyoid ligament. 4, 
 Median cricothyroid ligament. 5, Lateral cricothyroid ligament. (After 
 Bosworth.) 
 
ANATOMY. 329 
 
 four-sided plates, united together in front, at an angle of about ninety 
 degrees (Fig. 100). They form the front and lateral walls of the 
 larynx, and, owing to their stability, are a direct protection to the deli- 
 cate structures contained within the organ. The union of the two 
 plates serves for the attachment of the cricothyroid membrane at the 
 
 4- 
 
 4 
 
 Fig. 98. — The cricoid, seen anteriorly (Broca). 1, Anterior portion. 
 2, Posterior portion. 3, Internal surface. 4, Superior circumference. 5, In- 
 ferior border. (After Bosworth.) 
 
 lower margin. At the upper margin of union there is a deep acute 
 angle, called the thyroid notch, into which is attached the petiolus of 
 the epiglottis. Projecting perpendicularly from the posterior margin 
 of each plate, one downward and the other upward, are two horns, or 
 
 Fig. 99. — The cricoid, upper surface. 1, 1, Articular facets for the 
 arytenoid cartilages. (After Bosworth.) 
 
 cornua, the upper one on each side being attached to the hyoid bone, 
 and the lower one on each side to the cricoid cartilage. 
 
 The arytenoids are little, cone-shaped, movable bodies, standing 
 erect upon the lateral facets of the cricoid already described. Their 
 internal faces are nearly parallel with each other. At their summits 
 are attached the two little cartilages of Santorini. External to and 
 
330 
 
 DISEASES OF THE LARYNX. 
 
 in front of the latter, and situated at the commencement of the ary- 
 epiglottic fold are the little, stem-like cartilages of Wrisberg (Figs. 
 100a and 100&). 
 
 The epiglottis is a fibrocartilage and said to be shaped like a leaf. 
 
 c_ 
 
 J.. 
 
 Fig. 100. — The cricothyroid muscle, viewed anteriorly (Broca). A, 
 'Hyoid bone. B, Thyroid cartilage. C, Thyrohyoid membrane. D, Cricoid 
 cartilage. E, Cricothyroid membrane. F, Trachea. 1, 1, Cricothyroid 
 muscle. 2, 2, Origin of the muscle from the anterior portion and side of 
 the cricoid. 3, 3, Insertion into the lower border of the thyroid. (After 
 Bos worth.) 
 
ANATOMY. 
 
 331 
 
 It varies more in form than any other organ of the body, not even 
 excluding the nose. It stands immediately above the thyroid, with 
 its open face backward, and is attached by its pedicle or petiolus to 
 the superior notch of the thyroid. 
 
 As a rule, the epiglottis occupies more or less of a vertical posi- 
 tion. The anterior surface is convex, or somewhat saddle-shaped from 
 side to side, and concave from above downward. These outlines vary 
 in different cases, and in extreme cases may even be the reverse of the 
 ordinary rule. The posterior surface is slightly concave from side to 
 
 Fig. 100a. 
 
 Fig. 1006. 
 
 Fig. 100a.— The voice-box, or larynx, seen from behind. 1, 2, Ring 
 cartilage. 3, 4, Pyramid muscle. 5 and 6, Shield. 7 and 8, Tongue-bone. 
 9 and 12, Cartilages of Santorini. 10 and 13, Cartilages of Wrisberg. 11, 
 14, 15, Lid. 16, Windpipe. 17, Cushion of the lid. 18 and 19, Back ring- 
 pyramid muscles. 20, 21 and 22, 23, Constrictors of the vestibule. (After 
 Lennox Browne.) 
 
 Fig. 100&. — View of the voice-box, or larynx, cut open from behind. 
 1, 2, Ring cartilage. 3, 4, Pyramid muscle. 5 and 6, Vocal ligaments. 
 5, 6, 7, 8, Entrances to the pockets. 7 and 8, Pocket ligaments. 9, 10, 
 Cartilages of Santorini. 11 and 12, Cartilages of Wrisberg. 11, 12 and 
 13, 14, Aryepiglottic folds. 15, Lid. 16, Windpipe. 17, Cushion of the 
 lid. 18 and 19, Prop cartilages. (After Lennox Browne.) 
 
 21 
 
332 DISEASES OE THE LARYNX. 
 
 side, and in some instances deeply concave, like the long diameter of 
 the half-section of a flattened tube. Between these two every variety 
 of formation may be found, the two sides in each case being, of course, 
 symmetrical (Fig. 101). 
 
 The epiglottis is attached to the inner surface of the notch of the 
 
 •E 
 
 H' - ■ e 
 
 ■r. 
 
 ' --V:^^- - ; 
 
 1 
 
 •c 
 
 f 
 
 4 
 
 
 L<_ 
 
 J 
 
 Fig. 101. — The arytenoid and posterior cricoarytenoid muscles 
 (Broca). A. Hyoid bone. B, B, Posterior border of the thyroid. G, Pos- 
 terior face of cricoid. D, D, Posterior border of the arytenoid. E, Epi- 
 glottis. F, F, Ary epiglottic folds. G, Trachea. 1, Arytenoid muscle. 2, 3, 
 Oblique fibres of same. 4, 4, Cricoarytenoid posterior muscles. 5, 5, Their 
 insertion in the outer angle of the base of the arytenoid cartilage. (After 
 Bos worth.) 
 
ANATOMY. 333 
 
 thyroid by a firm band of elastic tissue; when prominent, it is called 
 the cushion of the epiglottis. The upper margin of this organ rises 
 above the base of the tongue, to which it is attached in the front and 
 the two sides by the glosso-epiglottic folds of mucous membrane. 
 
 In structure the thyroid, cricoid, and arytenoid cartilages are 
 hyaline, and in old age have a tendency to calcify. The epiglottis and 
 the cartilages of Santorini and Wrisberg are formed of fibrocartilage, 
 and show no tendency to calcification. 
 
 The ligaments of the larynx are (1) extrinsic, (2) intrinsic, (3) 
 mixed. There are three thyrohyoid ligaments: the median and the 
 two lateral. The median one is a membrane of elastic tissue, attached 
 to the posterior border of the hyoid bone above and the upper margin 
 of the thyroid cartilage below. The two lateral thyrohyoid ligaments 
 are cylindrical masses of fibro-elastic tissue, connecting the superior 
 cornua of the thyroid cartilage with the greater cornua of the hyoid 
 bone. Between these ligaments and the central membrane there is a 
 thin layer of fibrous tissue. The cricotracheal ligament is a band of 
 fibro-elastic tissue connecting the lower border of the cricoid to the 
 upper ring of the trachea. 
 
 The intrinsic ligaments are the cricothyroid, the cricoarytenoid, 
 the superior thyroarytenoid, and the inferior thyroarytenoid or vocal 
 cords. 
 
 The cricothyroid is a band of elastic membrane connecting the 
 two cartilages at the cricothyroid notch, and can be felt in front of 
 the neck just below the prominence known as Adam's apple. 
 
 The cricoarytenoid ligaments are capsular, surrounding the crico- 
 arytenoid joints on either side. 
 
 The superior thyroarytenoid ligaments form the ventricular bands, 
 or false cords. 
 
 The inferior thyroarytenoid ligaments, or true vocal cords, are 
 the most essential and important structures of the larynx. They are 
 formed of strong bands of yellow, elastic tissue. They extend from 
 the inner surface of the thyroid angle directly backward to the pro- 
 cessus vocalis, or the projecting angles of the arytenoids. Each vocal 
 cord is inserted as a single band at its anterior extremity. This splits 
 up into three bands as it extends backward. The first is inserted into 
 the vocal process of the arytenoid, the second is inserted into the ante- 
 rior face of the same cartilage as high up as the ventricular band, and 
 the third is inserted into the cricoarytenoid capsular ligament. A 
 cross-section of the vocal cord shows that it is triangular, the apex, or 
 
334 DISEASES OF THE LARYNX. 
 
 border-line, being turned toward its fellow of the opposite side (Fig. 
 102). 
 
 In the adult male the vocal cord has an average length of 2 1 / 2 
 centimetres and in the adult female 1 3 / 4 centimetres. The vocal cords 
 -are covered with mucous membrane, and the fibres of the thyro- 
 arytenoid muscle unite with their outer margins, making a large por- 
 tion of their substance. 
 
 The only mixed ligament is the epiglottic, consisting of two por- 
 tions, the outer and the inner. The outer connects the epiglottis with 
 the root of the tongue and the hyoid bone. The inner, or thyroepi- 
 
 Fig. 102. — Side-view of the larynx, showing the interior, the right 
 plate of the thyroid being removed. 1, 2, Arytenoid cartilages. 3, 3, 
 Processi vocales of the arytenoids. 4, Processus musculus of the right aryt- 
 enoid. 5, Upper border of cricoid. 3, 3, 6, Vocal cords. 7, Facet for 
 articulation of the thyroid with the cricoid. 8, Left plate of the thyroid. 
 9, Left superior cornu of thyroid. 10, Cricoid cartilage. 11, Trachea. 
 (After Lennox Browne.) 
 
 glottic, ligament connects the lower end of the epiglottis with the 
 thyroid. 
 
 Between the cartilages and the mucous membrane there is a con- 
 tinuous layer of elastic tissue, giving resiliency as well as smoothness 
 to the motions of the various parts. 
 
 The articulations of the larynx are the cricothyroid, cricoaryte- 
 
ANATOMY. 335 
 
 noid, and the Santorini arytenoid. These joints are provided with 
 articular cartilages, synovial membranes, and capsular ligaments, and 
 the movements present are those of flexion and extension. 
 
 The larynx is supplied with three sets of muscles. 1. The crico- 
 thyroidei in front, connecting the lower border of the thyroid with the 
 cricoid. 2. The cricoarytenoidei postici, or abductors of the vocal 
 cords. 3. The cricoarytenoidei laterales, or adductors of the cords, — 
 the thyroarytenoidei and the arytenoidens. Of the latter group the 
 cricoarytenoidei laterales and the arytenoidens are the adductors. The 
 cricothyroid^ make tense and elongate the vocal cords, while the thyro- 
 arytenoidei relax and shorten them. Besides these, there are a num- 
 ber of smaller muscles which help to adjust the glottis to the various 
 positions required in the act of vocalization (Fig. 101). 
 
 Above and external to the true vocal cords and between them 
 and the ventricular bands there is situated on each side an elliptical 
 fossa, or fissure, extending nearly the whole length of the cords. These 
 are called the ventricles of the larynx, or ventricles of Morgagni, after 
 their discoverer. In the anterior end of each there is found a little 
 pouch-like cavity, called the sacculus laryngis. 
 
 The arteries of the larynx are derived from branches of the supe- 
 rior and inferior thyroid arteries. These lar}mgeal branches are divided 
 into two sets, the anterior and the posterior, the former consisting of 
 branches from the thyroid only. The veins are similar in their ar- 
 rangement to the arteries. They anastomose with the veins of the thy- 
 roid, the tongue, and the trachea, and they terminate in the internal 
 jugular. 
 
 The lymphatics are supplied abundantly to the mucous mem- 
 brane, arranged as a thick net-work. The lymphatic capillaries unite 
 to form trunks on either side of the larynx: two above the ventricular 
 bands and two below the cricoid. At the interarytenoid commissure 
 the lymphatics are so abundant as to form a distinct thickening, called 
 the laryngeal tonsil. Although the lymphatic supply to the mucous 
 membrane of the larynx is so abundant, the cartilages, muscles, and 
 ligaments are said to be entirely without lymphatic vessels. 
 
 The nervous supply is derived from the superior and inferior, or 
 recurrent laryngeal nerves. The former is the sensory nerve of the 
 larynx, derived from the pneumogastic, the latter is exclusively motor. 
 
 The mucous membrane of the larynx is supplied with both tes- 
 sellated and ciliated epithelium. It is continuous with the pharynx 
 above and the trachea below. The lower larynx up to the ventricular 
 
336 DISEASES OF THE LARYNX. 
 
 bands, with the exception of the vocal cords, is covered with columnar 
 ciliated epithelium. This extends upward over the interarytenoid com- 
 missure, and also over the lower half of the posterior surface of the 
 epiglottis. All the rest of the laryngeal mucous membrane is supplied 
 with tessellated or squamous epithelium. 
 
 The lining membrane is also richly supplied with muciparous 
 glands, particularly the posterior surface of the epiglottis and the ary- 
 epiglottic folds. 
 
 The inner larynx is sometimes divided into three sections: the 
 upper, or tubular, from the epiglottis to the ventricular bands; the 
 central, bounded by the ventricular bands above and the vocal cords 
 below; and the inferior laryngeal, from the cords to the lower margin 
 to the cricoid. 
 
CHAPTER LXI. 
 PHYSIOLOGY OF THE LARYNX. 
 
 The larynx possesses two functions: one in respiration; the other 
 in phonation. 
 
 The function of the larynx in respiration is to permit the free 
 passage of air into the lungs during inspiration. The theory generally 
 accepted has been that, during expiration, the air passing out through 
 the glottis forces the vocal cords open without any muscular effort of 
 the larynx being required, but that, during inspiration, the vocal cords 
 act like a valve and would close but for the posterior cricoarytenoid 
 muscles — the abductors, which open the gateway and permit the air 
 to enter. The consequence is that the position of the cords in expira- 
 tion is simply passive, while in inspiration it is active, being controlled 
 by an impulse from the respiratory centre, the chink during the latter 
 act being always the wider of the two. 
 
 Eecent extensive investigations by Sir Felix Semon have thrown 
 doubt upon the correctness of this theory. He claims that, in a large 
 number of personal examinations of larynges during the act of breath- 
 ing, he has found absolutely no change in the position of the cords 
 during that act. He affirms that they simply occupy the position of 
 complete muscular rest, the width of the chink of the larynx being 
 precisely the same during inspiration as expiration. 
 
 My own examinations of larynges made since Semon so clearly 
 expressed his views have vindicated his position, and I believe that the 
 conclusion he arrived at is physiologically correct. The difficulty is 
 that almost any one, while having his larynx examined, will uncon- 
 sciously use undue effort during the act of inspiration. But let the 
 observer wait until respiration has become passive, and he will find 
 that the vocal cords remain motionless during both inspiration and 
 expiration. The slightest inspiratory effort, however, will produce con- 
 traction of the abductor muscles, and, in my experience, the greater 
 the effort, invariably, the wider will become the chink. 
 
 If this is the true condition, the valve-theory of the position of 
 the vocal cords during inspiration must be erroneous, while the seem- 
 
 {66 . ) 
 
338 
 
 DISEASES OF THE LARYNX. 
 
 ingly more reasonable one, that the position of these bodies during 
 inspiration as well as expiration is of a purely passive character, is 
 probably correct (Fig. 103). 
 
 The proper performance of the function of the larynx during 
 phonation depends on the extent and accuracy of the voluntary con- 
 trol of the vocal cords during expiration. These organs are drawn 
 into the position of a narrow chink by the adductor and the tensor 
 muscles, and then thrown into sonorous vibrations by forcing the air 
 of expiration through them. It is thus seen that the function of 
 respiration is really one of inspiration, while phonation is purely one 
 of expiration (Fig. 104). 
 
 As said before, the only abductor muscles of the larynx^ or those 
 which expand the glottis, are the posterior cricoarytenoid. 
 
 Fig. 103.— The laryngoscopic im- 
 age during respiration. (After Bos- 
 worth.) 
 
 Fig. 104. — The laryngoscopic im- 
 age during phonation. (After Bos- 
 worth.) 
 
 On the other hand, the muscles whose special duty it is to adduct 
 the vocal cords, or close the glottis for purposes of phonation, are the 
 lateral cricoarytenoid and the interarytenoid. The former pulls for- 
 ward the outer angle of the base of the arytenoid cartilage, rotating 
 inward the vocal process to which the vocal cord is attached, while the 
 interarytenoideus pulls into apposition the arytenoid cartilages. For 
 finer adjustment of the cords, the thyroarytenoid, being attached as it 
 is to the whole length of the outer border of the cord, by its bodily pres- 
 ence gives firmness as well as increased tension, the latter being aided 
 by the action of the cricothyroid. 
 
PHYSIOLOGY. 339 
 
 In the lower tones the larynx moves downward to a lower level in 
 the throat, and in the higher tones to a higher level. 
 
 The attributes of the voice are pitch, intensity, and quality. 
 
 The pitch depends npon the number of vibrations of the vocal 
 cords, during a given time, in producing the tone. The tighter the 
 tension, the greater the number of vibrations and the higher the pitch. 
 
 The intensity depends upon the force of the expiratory effort. 
 
 The quality depends upon the combined influences of the whole 
 vocal apparatus, including larynx, pharynx, nose, and accessory sinuses. 
 
 For a further account of the physiology of the larynx, particularly 
 in regard to phonation and vocalization, the reader is again referred to 
 more elaborate works upon the subject. 
 
 To perform these functions normally the vocal cords, as well as 
 the muscles, must be in a healthy condition. Even slight congestion 
 of the mucous membrane, particularly of the cords, may impair their 
 vibration and produce weakness as well hoarseness of the voice. When 
 the symptoms are more severe, the cause, of necessity, must be more 
 serious, and, when neoplasms occur, respiration may be very seriously 
 interfered with, and the voice in many instances destroyed. 
 
CHAPTER LXII. 
 LARYNGOSCOPY. 
 
 The principles of laryngoscopie examination are the same as those 
 of examination of the post-pharynx. The uses of the head-mirror and 
 reflected light are the same, while the difference in the throat-mirror 
 is merely one of diameter, the circular face of the laryngeal mirror 
 being much larger than the one required for post-rhinal examinations 
 (Fig. 105). The reflected light should be placed in a dark corner, with 
 as little as possible of the ordinary sunlight present. 
 
 In examining the larynx, after warming the mirror to a blood- 
 temperature in the manner and for the reasons already described, the 
 patient is directed to take hold of the tongue with a napkin and draw 
 
 Fig. 105. — Laryngeal and post-rhinoscopic mirrors. 
 
 it gently out. The mirror is placed against the soft palate, pressing 
 the uvula lightly in an upward and backward direction, and, other 
 things being equal, the vision of the larynx is at once obtained (Fig. 
 106). 
 
 Although the directions are simple, it usually requires a little 
 practice, as well as training of the patient to the use of the instrument 
 to accomplish the end in view. 
 
 First with regard to holding the tongue. It is usually taught that 
 the laryngologist should hold it himself with his left hand, while he 
 holds the mirror lightly between the fingers of his right, but that in 
 some cases the patient may be allowed to hold it himself. Personally, 
 I believe the opposite should be the rule. Practically, I never hold 
 the patient's tongue, but invariably direct the patient to do it. He can 
 do it just as well as the operator, who then always has his other hand 
 (340) 
 
LARYNGOSCOPY. 
 
 341 
 
 at liberty; at the same time it increases the confidence of the patient, 
 who feels that he himself is helping to do the work. 
 
 Sometimes, however, notwithstanding the training we give the 
 patient, the ball of the tongue rises so high that it directly intervenes 
 
 Fig. 106. — The laryngeal mirror in position (Cohen) when held by 
 the left hand. (From Bos worth.) 
 
 and prevents a proper vision of the larynx. In these cases, while the 
 patient grasps the tongue, the examiner can hold it down with the 
 depressor held in one hand, while he uses the throat-mirror with the 
 other. 
 
 Not infrequently the palate is sensitive to pressure, and retching 
 
342 DISEASES OF THE LARYNX. 
 
 occurs on attempting to use the mirror. Patient perseverance will 
 usually overcome this. If not, a solution of cocaine or eucaine applied 
 to the fauces will often allay the hypersensitiveness of the parts. 
 
 By instructing the patient to hold the head backward and to 
 breathe quietly, the vocal cords will be seen midway between abduc- 
 tion and adduction. Below the glottis the rings of the trachea can be 
 observed, and, in some instances, the whole length of the anterior wall 
 of the wind-pipe, down to the bifurcation of the bronchial tubes, is 
 brought into view. 
 
 For the observer to see the vocal cords distinctly, and to bring 
 them in line parallel with each other, the patient should slowly sound 
 the word "ah." To obtain a still better view, the tone "ee" having 
 a higher pitch, should be attempted. The epiglottis will then be more 
 erect, as the larynx has attained by the effort a slightly-higher posi- 
 tion; but, in this instance, as the base of the tongue rises with it, the 
 use of the tongue-depressor, as well as traction, may possibly be re- 
 quired. 
 
 The position of the epiglottis sometimes seriously interferes with 
 a good view of the larynx. Instead of standing erect, it may lean per- 
 manently backward, obstructing the vision, or it may be curled upon 
 itself so as to prevent direct light from being thrown upon the vocal 
 cords. Even these difficulties may in most instances be overcome by 
 the combined efforts of throwing the head back, using a very high tone 
 of "ee," drawing out the tongue, and at the same time depressing it. 
 
 Instruments have been devised to draw forward the epiglottis in 
 extreme cases, but they will very rarely be required. 
 
 In one extreme case 1 I found the epiglottis long and narrow, pro- 
 jecting horizontally backward and pressing against the post-pharynx, 
 the patient breathing up through the narrow slits at the sides. To 
 relieve the catarrhal and hoarse condition it produced, I removed a 
 quarter of an inch from the end of the organ and so left a permanent 
 chink. Even then, however, the vocal cords could not be distinctly 
 seen. 
 
 When the tonsils are very large vision may be obstructed; but 
 the use of a small mirror may still render the larynx visible. An 
 elongated uvula, while it may seriously interfere with the post-nasal 
 examination, does not affect examination of the larynx. 
 
 On examining the larynx with the la^ngeal mirror, the picture 
 
 1 Transactions of the Pan-American Medical Congress, Washington, 1893. 
 Section of Laryngology. 
 
LARYNGOSCOPY. 343 
 
 will naturally be in a reversed position; that is, the tongue will be in 
 a posterior portion of the mirror, and the posterior wall of the pharynx 
 in the anterior. The right and left sides will also be reversed. Be- 
 ginning, then, at the upper margin of the image, the first thing seen 
 is the base of the tongue, and in front of it the notch which separates 
 it from the epiglottis. This organ comes next, arched in most cases 
 like a bow, with the concavity in front. On either side of it are the 
 pharyngo-epiglottic folds. The color of the epiglottis is yellowish 
 pink. Usually blood-vessels may be seen scattered over it. Beneath 
 the concave surface of the organ, if the vocal cords are open, will be 
 seen a triangular opening with its apex under the epiglottis and its 
 base toward the front, of pink color, with whitish cross-bars. This is 
 the internal surface of the trachea, already mentioned. Directly to 
 the right and left, forming the arms of the triangle, are the broad, 
 white vocal bands forming the glottis. When the vocal cords are 
 closed the trachea will not be seen, but the two white cords will stretch 
 from front to back parallel with each other. External to the true cords 
 are two triangular surfaces of a much darker hue, their bases beneath 
 the epiglottis and their apices stretching to the front almost the full 
 length of the vocal cords. These are the ventricular bands. They oc- 
 cupy a higher plane than the vocal cords, being directly above and ex- 
 ternal to them. Between the two on each side lies the ventricle of 
 Morgagni. Still farther to the right and left, and having their origin 
 at the limits of the epiglottis, we have the right and left aryepiglottic 
 folds, connecting the epiglottis with the arytenoid cartilages. As they 
 approach the latter they converge and near their extremities are en- 
 larged by two little, round, projecting bulges. The first is the carti- 
 lage of Wrisberg, the second the capitulum Santorini. Across the 
 anterior side of the laryngeal mirror, connecting the two aryepiglottic 
 folds, is the interarytenoid commissure, thus completing the circle of 
 the internal larynx. Outside the aryepiglottic folds are two pyramidal 
 cavities, called the pyriform sinuses, while still further in the front 
 part of the image is the compressed opening to the oesophagus, lying 
 slightly to the right side of the picture, meaning individually to the 
 left. This is hidden mostly by the extensive folds of the postpharyn- 
 geal wall. 
 
 Eeturning to the interior of the larynx, in certain positions, and 
 in some larynges much more clearly than in others, directly below the 
 epiglottis and above the angle of the vocal cords, we find the cushion 
 of the epiglottis. 
 
34-i DISEASES OE THE LARYNX. 
 
 The mucous membrane of the larynx, as observed by aid of the 
 laiyngoscope, is of a light-pink color. There should be no accumula- 
 tion of mucus anywhere, and in vocalization the vocal cords should 
 come freely together, without any interference from a thickened 
 mucosa between the arytenoids. 
 
 "With regard to the position of the patient for laryngological ex- 
 amination, it is well for the operator to accustom himself to the use by 
 the patient of any stool or chair which at the time happens to be con- 
 venient. Still, in his own office it is better to have an operating-chair 
 specially suited for the treatment of the majority of his cases. 
 
 In laryngological work the patient should sit either perfectly up- 
 right or leaning forward in order to bring his head near to that of 
 the operator, and in the line of perfect vision. 
 
 In order to accomplish this, I had my operating-chair made with 
 a straight back and leaning slightly forward. The back itself reaches 
 above the head of the tallest patient, and has down its centre a deep 
 and wide groove, to fit the back of the head of any patient, young or 
 old. This prevents any backward jerking when the head is rested 
 against it. The concave surface likewise militates against any side- 
 ward movement, while it enables the patient to slide the head upward 
 or downward, and to adjust a view of the parts to the requirements of 
 the operator. 
 
CHAPTER LXIII. 
 
 AUTOSCOPY. 
 
 In 1895, Alfred Kirstein, of Berlin, introduced to the- medical 
 profession a new method of examining the larynx and trachea which 
 he styled "autoscopy." By this he meant direct linear inspection 
 through the mouth of the lower pharynx, larynx, and trachea without 
 the aid of a laryngeal mirror. In the following year, Max Thorner, 
 of Cincinnati, gave an excellent translation into the English language 
 
 Fig. 107. — Position for autoscopy. 
 
 aph was taken from 
 
 a partly-stripped patient in order to show distinctly the position of head 
 and neck during examination. (After Kirstein-Thorner.) 
 
 of Kirstein's monograph, with added improvements as the method 
 became more complete. 
 
 The necessary conditions of a complete linear inspection are: — 
 
 1. "The body must be placed in such a position that an imaginary 
 continuation of the laryngo-tracheal tube would fall within the open- 
 ing of the mouth (Fig. 107). 
 
 2. "This imaginary straight line must be cleared of those parts 
 of the body (epiglottis and the base of the tongue) which obstruct it/' 
 
 (345) 
 
346 DISEASES OF THE LARYNX. 
 
 The first condition, it is said, will be obtained by gently tilting 
 the head backward so that the axis of vision, instead of being at an 
 angle of ninety degrees to the axis of the trunk, will be at an angle of 
 about one hundred and thirty-five degrees. 
 
 The second condition can only be obtained by drawing the base 
 of the tongue forward and downward. To secure this position a spe- 
 cial tongue-depressor is required, which must be slipped directly over 
 the circumvallate papillae to the root of the tongue. Pressure forward 
 now upon that organ will remove it out of the way of vision, and at 
 the same time, by compressing the median glosso-epiglottic ligament, 
 elevate the epiglottis and so dispose of the remaining obstruction to the 
 view. In some cases it may be necessary to slip the instrument over 
 the epiglottis itself, and draw it forward, before the required view can 
 be obtained; in these the use of cocaine will be required. 
 
 Fig. 108. — Autoscope with plate (P) instead of hood. 
 (After Kirstein-Thorner.) 
 
 Owing to the position which the examiner has to assume in prac- 
 ticing autoscopy, the ordinary stationary light required for laryn- 
 goscopy is useless, and he must either have an electric lamp fastened 
 to his own forehead or, what Kirstein considers better, a species of 
 electroscope attached to his special tongue-depressor. This transmits 
 the light along the groove of the spatula, into the larynx of the pa- 
 tient, without its origin being seen by the operator (Fig. 108). 
 
 The autoscope consists of three parts: a spatula, a hood, and a 
 handle. 
 
 The spatula for adults is 14 centimetres long; 2 centimetres wide 
 at the tip, which is thickened and rounded to avoid injury to mucous 
 membranes, and notched to receive the median glosso-epiglottidean 
 ligament; and 1 1 / 2 centimetres wide where it passes over the convex- 
 ity of the tongue; this portion should be grooved longitudinally, to 
 
AUTOSCorr. 
 
 34? 
 
 fit into the natural groove which the tongue exhibits on central de- 
 pression. The tip of the spatula is bent downward, 1 centimetre lower 
 than the ordinary grooved portion; so that it can press upon the base 
 of the tongue, and by this means raise the epiglottis. The instrument 
 is made of nickel-plate. 
 
 The hood, which is made of the same material, is, for the adult, 
 6 centimetres long and 3 centimetres wide. It fits upon the front end 
 of the spatula, and serves to keep the passage clear for light and. vision. 
 It is inserted within the mouth, and is adjustable, preventing obstruc- 
 
 Fig. 109. — Autoscopic operation. (After Kirstein-Thorner.) 
 
 tion from the upper teeth, upper lip, or mustache. The medium 
 height of Kirstein's standard hood is about 6 millimetres, the slit being 
 amply wide for examination purposes. When instruments require to 
 be used the hood should be of greater height. The handle is set at 
 right angles to the spatula, and to it is attached by special contrivance, 
 the electroscope. 
 
 Kirstein says: "Autoscopy is a difficult act, until one has acquired 
 a certain hard-to-define knack in introducing the spatula." The pa- 
 tient should bend the upper part of his body slightly forward, as in 
 
348 DISEASES OF THE LARYNX. 
 
 Figs. 107 and 109, making the air-passage in a somewhat direct line. 
 This gives the additional advantage of relaxing the muscles of the 
 neck. 
 
 While autoscopy has the great advantage of direct vision, it is 
 accompanied by several inconveniences. The chief ones are: 1. The 
 expense of the required armamentarium, for operative instruments 
 would require to be specially suited for autoscopic work. 2. The 
 trouble of acquiring the technique. 3. The close proximity of the sur- 
 geon to the direct breath of the patient, with all that this involves. 
 
 Still, in the words of Kirstein: "For the purposes of scientific 
 demonstration autoscopy is just the thing; a number of spectators can 
 look, one after another, through the autoscope and note the condi- 
 
 Fig. 110. — Tongue-depressor for pharyngoscopy and direct laryngo- 
 tracheoscopy. Side-view and surface-view of the anterior portion. In some 
 cases an instrument with a larger curve of the anterior portion is more 
 practicable. (After Kirstein-Thorner.) 
 
 tions. In persons well adapted to autoscopy it is easy to demonstrate 
 to any layman the movements of the vocal cord, the physiological pulsa- 
 tion of the wall of the trachea, the systolic beating of the bifurcation- 
 spur, and quite as easily a carcinoma of the larynx. " 
 
 In many cases the throat is so formed that even the skilled ex- 
 aminer can derive no advantage from the use of the autoscope; but 
 the triumph of autoscopy lies in the incomparable view which it gives. 
 in many others, of the posterior wall of the larynx and the entire inner 
 surface of the trachea even to the entrance of the bronchi. 
 
 As autoscopy can be practiced with facility while the patient is 
 under the influence of an anaesthetic, it is probable that it will be re- 
 ceived with much favor for the examination of young children, with 
 whom laryngoscopy is usually such a difficult matter. 
 
AUTOSCOPY. 349 
 
 The instruments for autoscopic operations are shaped like nasal 
 instruments, with longer shafts. They should measure about 20 centi- 
 metres from the knee to the tip. Other things being equal, autoscopic 
 operations should be easier than laryngoscopic ones (Fig. 109). 
 
 Since introducing this new method of examining the laryngeal 
 cavity, Kirstein, for ordinary purposes, has somewhat simplified his 
 technique. Many cases occur in which the hood is unnecessary, and 
 in which the groove can likewise be dispensed with. If anything, the 
 tip should have a longer curve, while the width remains the same as 
 in the original depressor (Fig. 110). Instead of the electroscope at- 
 tached to the spatula, the forehead-light of the operator would answer 
 equally well. 
 
 With regard to the practical application of this method of opera- 
 tion, Max Thorner has reported a case in which he removed a piece of 
 bone, four centimetres long, from the supraglottic portion of the 
 larynx of a young man aged 24. The operation was done by the aid 
 of the autoscope without the use of cocaine, the time required being 
 only a few seconds. 
 
CHAPTER LXIY. 
 
 INTUBATION. 
 
 This method of relieving laryngeal stenosis has long been a 
 theory, crude instruments being used to obtain the object in view. 
 They were not of much value, however, and it remained for O'Dwyer 
 to introduce to the profession the method itself, with a full set of in- 
 struments capable of accomplishing intubation. His own record in 
 
 O'Dwver's intubation-set. 
 
 the use of these instruments has been brilliant indeed, the regret- 
 table feature being that, at the moment when O'Dwyer's tubes had 
 obtained a world-wide reputation, and the advantages which his re- 
 searches had given to science were being fully realized, he should be 
 called from his labors and the glory which was the product of his 
 genius. The saddest feature of all is that, notwithstanding this crown- 
 ing effort for the good of humanity, he died a poor man. 
 (350) 
 
INTUBATION. 
 
 351 
 
 O'Dwyer's tubes consist of a series of instruments of different 
 lengths and sizes, to suit the various ages of patients. Besides these, 
 there is an introducer and an extractor that will fit all the tubes. Add 
 to these a mouth-gag and a scale to regulate the size of the tube in 
 accordance with the age of the patient, and the outfit is complete (Figs. 
 Ill and 112). 
 
 The tube is a flattened cylinder bulging toward the centre. The 
 head is rounded and flanging, to rest on the ventricular bands, and 
 through one side of the head is a perforation for the insertion of a 
 cord. 
 
 Fig. 112. — Instruments for intubation: (a) introducer; (6) tube; 
 (c) scale; {d) extractor; (e) mouth-gag. 
 
 The introducer consists of a slender rod fitted with a handle. On 
 it is a sliding tube. At the distal end of the introducer is the obturator, 
 a thin, jointed piece of metal which is screwed on to the introducer 
 at right angles. This passes through the tube. 
 
 The extractor is for the purpose of removing the tube when de* 
 sired. It is shaped with a right angle somewhat like the introducer. 
 
 The mouth-gag is to keep the jaws apart during the operation. 
 
 To perform intubation during infancy or childhood, the patient 
 should be wrapped in a sheet from the neck downward, so as to se- 
 curely hold the arms and hands. He should then be held from behind 
 in the upright position either in the lap of a nurse or standing on a 
 
352 DISEASES OF THE LARYNX. 
 
 chair. The assisting surgeon should hold the gag, placed in the- left 
 side of the mouth of the patient, taking care to press the handles lightly 
 against the cheek, to prevent the slipping of the instrument. 
 
 The operator stands immediately in front. The introducer is 
 held in the right hand. The left forefinger, disinfected and oiled, is 
 then passed into the pharynx, the epiglottis found, and, slipping the 
 finger over it, the cavity between it and the arytenoids is detected. 
 Immediately the end of the tube attached to the introducer, and armed 
 with a strong thread, is passed along the palmar surface of the finger 
 already touching the larynx, and, guided by it, is slipped over the 
 epiglottis. The handle of the introducer is now raised so as to direct 
 the tip of the instrument directly into the larynx. If this is not done, 
 the tube slips over the commissure into the oesophagus. 
 
 The tube having entered the larynx, of which the operator may 
 be sure by feeling the soft tissue all around the tube, the thumb is 
 pressed on the button of the slide and the tube separated. In remov- 
 ing the introducer the left forefinger should be kept on top of the tube 
 to secure its retention. 
 
 A finger-guard is recommended by some operators. It is a cum- 
 bersome contrivance, and in young children there is little enough space 
 for the finger alone. I have never used one, and, although I have had 
 the finger bitten once or twice, in each case it has been caused by de- 
 fective holding of the mouth-gag: something which could always be 
 avoided. 
 
 If failure of insertion occur on the first attempt, the child should 
 be allowed to rest a few minutes before a second attempt is made. 
 
 When the tube becomes blocked by false membrane, during or 
 immediately after its introduction, so as to produce threatened suffoca- 
 tion, it should at once be removed; and after a little while another 
 trial made. In case of failure of effecting intubation, tracheotomy may 
 in some cases be required in the attempt to save life. 
 
 In adults, and youths possessed of sufficient self-control, intuba- 
 tion may readily be accomplished without the use of the left forefinger, 
 but by means of the laryngeal mirror. 
 
 The thread should not be removed until we are sure that the tube 
 is not only in position, but also that there is no danger of its being- 
 occluded by membrane. Then it can be slipped out, care being taken 
 not to remove the tube while doing so. 
 
 To remove the tube, the patient is again placed in the attitude 
 required for its introduction. The extractor is carried down along the 
 
INTUBATION. 353 
 
 left index finger as in the primary operation. The mouth of the tube 
 is felt below the epiglottis and the closed tips of the extractor inserted 
 into the open tube. By pressing the spring the blades are opened, and, 
 grasping the inside walls of the tube tightly, the latter is at once with- 
 drawn. The removal is often a more difficult operation than the intro- 
 duction; and to render this part of the work easier, Max Thorner, of 
 Cincinnati, brought before the profession, at the last meeting of the 
 American Laryngological, Ehinological, and Otological Society, a de- 
 sign believed to be an improvement upon O'Dwyer's extractor and 
 tube. The formation of the tube is the same, with the exception that 
 the head is more widely and more deeply concave; so that when the 
 extractor touches the cavity it will glide more readily into it. The ex- 
 tractor itself is likewise simpler in form, and serves the double purpose 
 of introducer as well as extractor. 
 
 Sometimes the tube is coughed out and will require reinsertion. 
 
 One of the main difficulties in connection with intubation is the 
 difficulty in deglutition which attends it, particularly in reference to 
 fluids. Soft foods can usually be swallowed if given slowly and with 
 care; but fluids are likely to get through the tube into the larynx and 
 trachea. By adopting Gary's method of placing the patient on his 
 back with the hips well elevated swallowing is said to be easier; and 
 in some cases small quantities, even, of fluid can be given in this way. 
 In any case fluid nourishment can always be administered by enemata, 
 the chief part of it being readily absorbed. 
 
 Intubation is largely used in cases of laryngeal diphtheria occur- 
 ring in children : and since the introduction of antitoxin into the treat- 
 ment of this disease, the fatal issues, when the two are combined, have 
 greatly diminished in numbers, while there is no doubt whatever, even 
 when used alone, that it has saved many lives. The fact of intubation 
 being accomplished without the use of the knife has caused it to be 
 received with much favor by parents and friends of patients requiring 
 operation; and for this reason it is frequently preferred to the seem- 
 ingly more serious operation of tracheotomy. Casselberry relates the 
 history of four cases also, occurring in adults, in which intubation re- 
 sulted in the cure of this disease. 
 
 O'Dwyer has found intubation serviceable in a number of cases of 
 stricture from tertiary syphilis in the adult. Other observers, too, fol- 
 lowing his example, have attained a measure of success in the same 
 wa}^. Deglutition in these cases is said to be comparatively easy, after 
 the first dav or two. 
 
CHAPTER LXV. 
 
 TRACHEOTOMY; THYROTOMY. 
 
 Tracheotomy. 
 
 Up to the time of Q'Dwyers discovery of intubation this was the 
 only operation known for the relief of suffocation arising from laryn- 
 geal stenosis. Since then intubation has in many instances taken its 
 place. With the general public this has also been received with more 
 favor, inasmuch as it is a bloodless operation. Still, there are many 
 occasions in which tracheotomv stands alone in its utilitv and in which 
 
 Fig. 113. — Plated tracheotomy- tube. 
 
 intubation would be worse than useless, while there are others in which 
 the choice of operation must depend upon the surgeon's judgment of 
 the case presented to him for relief. Further than this, numerous 
 eases have occurred in which intubation, having been performed with 
 unsuccessful results, tracheotomy as a dernier ressort has been required. 
 The diseases for which the operation may be required are oedema 
 of the larynx, abscess of the larynx; syphilitic, tuberculous, or malig- 
 nant laryngitis; the presence of neoplasms or foreign bodies, paralysis, 
 pseudomembranous laryngitis, etc. 
 
 Instruments required are scalpel, retractors, tenaculum, grooved 
 (354) 
 
TRACHEOTOMY 
 
 355 
 
 director, thumb-forceps, etc., besides the necessary tracheotomy-tube 
 suitable to the age of the patient (Figs. 113, 114, 115, 115a). Also, 
 to make the outfit complete, should be added needles, ligatures, tapes, 
 scissors, and artery-clamps. 
 
 As a rule, an anaesthetic should be used, either general or local. 
 
 Fig. 114. — Hard-rubber tracheotomy-tube. 
 
 Until recently the former was always administered, either ether or 
 chloroform. In childhood this is an important matter, as it is difficult 
 to hold the child still enough to perform the operation when at all 
 sensible to pain. In cases where the danger to life by delay is im- 
 
 Fig. 115. — Elsberg's tracheotomy- tube. 
 
 minent or when, owing to carbonic asph} 7 xiation, the sensibility to pain 
 is materially diminished, the operation may be done at once, without 
 attempting anaesthesia. In children of larger growth and in adults, 
 hypodermic injection of a solution of cocaine in the region of the larynx 
 
356 DISEASES OF THE LARYNX. 
 
 or upper trachea will answer as good a purpose as the administration of 
 a general anaesthetic. 
 
 In the Berliner hlinische Wochenschift of June, 1898, Fraenkel 
 speaks strongly in favor of local anaesthesia in these cases. He has 
 performed tracheotomy twenty-three times during the last three years, 
 the patients in every instance being under cocaine anaesthesia. Many 
 of these operations would have been dangerous under a general anaes- 
 thetic. His plan is to inject hypodermically a few drops of a 20- 
 per-cent. solution in two places near the site of operation, or of a 
 10-per-cent. solution in four places. In children he always uses the 
 10-per-cent. solution. In adults the amount injected is about 4 
 centigrammes of cocaine. He says that the patients dread the cocaine 
 less than the chloroform. One of the advantages of operation under 
 local anaesthesia is the removal of all necessitv of undue haste. N"o 
 
 o 
 
 Fig. 115a. — Hank's tracheotomy-tube. 
 
 matter how anaesthesia is produced, it is always better to have one or 
 more assistants, to aid in the various duties of the operation. 
 
 Tracheotomy may be either high or low. In high tracheotomy 
 the incision into the trachea is above the isthmus of the thyroid; in 
 low it is below the isthmus. 
 
 The former is the one usually performed, inasmuch as it involves 
 fewer blood-vessels, and, being nearer the external surface, it is easier 
 of accomplishment. 
 
 In preparation for the operation, the patient is placed upon the 
 back with the head tilted backward by means of a roller or hard pillow 
 placed beneath the neck, the object being to place the trachea and 
 larynx in a prominent position. The neck is then thoroughly and 
 quickly washed with a solution of corrosive sublimate, carbolic acid, or 
 other disinfectant. 
 
TRACHEOTOMY. 357 
 
 For the high operation the incision by the scalpel should be from 
 four to six centimetres long, and directly in the median line, extend- 
 ing from the opposite cricothyroid membrane directly downward. The 
 two ends of the incision should be beveled gradually in from the ex- 
 ternal surface at either end, making the longest part of the cut the 
 external one. After the first or skin cut, together with that of the 
 superficial fascia has been made, the dissection inward should be care- 
 fully done by means of the scalpel-handle, more than the blade. 
 
 The sternohyoid muscles are now brought into view. The areolar 
 tissue is pushed aside by the handle of the scalpel, and the muscles are 
 held apart on either side by retractors. These can be held by an as- 
 sistant. The deep fascia is now in view, with the thyroid isthmus at 
 the lower end of the cut. The parts are cleared of areolar tissue, ex- 
 posing the two layers of fascia, one extending in front of the isthmus, 
 the other behind it. The isthmus itself is a little pink body over the 
 second and third rings of the trachea. 
 
 If on examination there seems to be room enough to insert the 
 tube above the isthmus, the deep fascia is incised from the cricoid 
 downward and drawn aside by retractors. If the space appears to be 
 too small, a transverse cut is made through the deep fascia over the 
 cricoid cartilage. It must be long enough to admit the scalpel-handle 
 or grooved director, which is at once inserted and slid down between 
 the deep fascia and the trachea, and tilted up so as to expose the two 
 upper tracheal rings. In either case the tissues are drawn aside by 
 retractors, the trachea seized by a tenaculum, and the first two or three 
 rings cut in the medial line, care being taken not to incise the posterior 
 wall of the trachea. The final cut into the trachea should not be made 
 until the haemorrhage from the previous incisions have abated or been 
 controlled. Expulsive coughing usually follows after the trachea has 
 been opened, relieving the passage of any secretions or false membrane 
 that may be loose. In diphtheritic cases the surgeon should protect 
 himself, as in intubation, from the contagion of particles of membrane 
 expelled. 
 
 As soon as respiration is free through the artificial opening, as 
 large a tube as will freely enter should be inserted. This should be 
 watched for a few minutes, and when coughing is over, and breathing 
 through it has become natural, the tapes, which had been previously 
 attached to the rings, should be fastened round the neck to hold it in 
 position. A thin piece of antiseptic absorbent cotton should be placed 
 around the instrument between the shield and the skin of the patient. 
 
358 DISEASES OE THE LARYXX. 
 
 The low operation is performed in a similar manner to the high 
 one. The cutting is necessarily deeper, and consequently the incision 
 should be longer, extending from the cricoid almost to the sternum. 
 The muscles to be held aside by retractors are thS sternothyroid, in- 
 stead of the sternohyoid. There is more danger of haemorrhage, as 
 the plexus of veins over the trachea is larger and more copiously sup- 
 plied with blood. Greater care is needed in dissection; and sometimes 
 the thyroid artery, extending to the mesial line of the trachea, seri- 
 ously interferes with the operation. When the neck of the patient is 
 short and thick, the operation is much more difficult. This, however, 
 is, in some cases, counterbalanced by the fact that the lower operation 
 places a greater distance between the wound itself and the laryngeal 
 disease than is possible in the high operation, and, other things being 
 equal, would give the patient a greater chance for life (Fig. 116). 
 
 With reference to after-treatment, it is essential, in either case, 
 that the tube should be carefully watched. Any obstruction that might 
 occur in it should be at once removed, either by forceps or cotton- 
 holder, or by taking out the inside tube, cleansing, and returning it. 
 The mouth of the tracheotomy-tube should be covered with loose moist 
 antiseptic gauze. This should be changed repeatedly and regularly. 
 The air of the room should have a uniform temperature and humidity, 
 being constantly charged with moisture in order to make the air of 
 respiration as nearly the saturation point as possible. 
 
 The length of time the tube is worn will differ in each case, ac- 
 cording to the circumstances relating to it and the nature of the dis- 
 ease for the relief of which it was inserted. The charge of the case 
 should always be placed in the hands of a competent nurse, and directly 
 under the surgeon's or physician's control. 
 
 Thyrotomy. 
 
 Fig. 117 represents the completed operation for thyrotomy, taken, 
 together with Fig. 116, by permission, from Bosworth's recent work. 
 The operation resembles somewhat that of tracheotomy. The incision 
 is made through the integument along the mesial line, extending 
 from above the trryroid notch to the cricoid ring. The integument 
 being retracted, the areolar tissue is pressed aside by the handle of the 
 scalpel, revealing the thyroid cartilage; and then with a strong sharp 
 knife an incision is made in the mesial line from top to bottom. This 
 incision should be gradually and carefully deepened by successive cuts 
 
THYHOTOMY. 3G1 
 
 until the mucous membrane is reached. In later adult life the thyroid 
 cartilage is frequently the seat of calcification and will require the use 
 of the saw or cutting-forceps to separate it into segments. 
 
 It is important to sever the cartilage and also to control the haem- 
 orrhage before penetrating the mucous membrane; otherwise a trouble- 
 some cough may render the completion of the operation more difficult. 
 
 In order to have the operation exactly in the centre, and at the 
 same time to save the vocal cords from injury, it is well to incise the 
 mucous membrane from below upward, the severed cartilages being 
 held apart, while the position of the cords is exposed to view. By this 
 means they become a guide to the completion of the operation. 
 
 It is always best, if possible, to leave a small portion of the carti- 
 lage directly beneath the notch unsevered. This will provide for more 
 perfect union during the process of healing. In operating, the posi- 
 tion of the cricothyroid artery crossing the cricothyroid membrane 
 should likewise be remembered. 
 
 When the thyroid cartilage has thus been opened, it is often diffi- 
 cult to distinguish correctly the tissues within the larynx. Careful 
 observation of the exposed arytenoids, however, in their to and fro 
 movements, will sometimes remove the difficulty. 
 
 After removal of the growth, for which the preliminary thyrotomy 
 has been performed, and haemorrhage has been controlled, the carti- 
 lages are brought together again in as perfect apposition as possible 
 and secured by sutures. In a child these should be of silk-worm gut 
 and left in situ. The skin is then sutured in the ordinary way. (Bos- 
 worth.) 
 
 The question of preliminary tracheotomy and when it should be 
 done must be decided in each case upon its own individual merits. 
 
CHAPTER LXYI. 
 ACUTE LARYNGITIS. 
 
 This is a common, but not a dangerous, disease. It is unattended 
 by sanguineous infiltration, the inflammatory process being confined to 
 the mucous membrane without involving the deeper tissues. Its chief 
 interest lies in the impairment or even loss of voice which usually at- 
 tends its development. 
 
 Pathology. — The first changes are the abnormal dilatation of the 
 laryngeal blood-vessels, with arrest of glandular secretion. This is 
 quickly followed by exudation of serum and return of mucous secre- 
 tion. The loose folds of mucous membrane become ens-oro-ed with 
 blood, as well as bathed in sero-mucous discharge. The parts most 
 affected are where these folds are abundant as well as loosely attached, 
 as in the arytenoid commissure and ventricular bands. As the vocal 
 cords are not supplied with muciparous glands, their blood-vessels 
 become dilated without discharge of mucus. The inflammatory action 
 rarely extends below the vocal cords, and the epiglottis is likewise 
 rarely a participant in the disease. 
 
 Etiology. — Without the existence of some predisposing cause, 
 acute laryngitis does not often occur. This usually takes the form of 
 obstructive interference with normal respiration, either from intra- 
 nasal lesion or post-pharyngeal disease. What these pathological con- 
 ditions are have already been dwelt upon. It will suffice to say that 
 hypertrophic conditions of the upper breathing-passages, when suffi- 
 cient to produce oral respiration, may become a predisposing cause. 
 The same may be said of chronic catarrh of the pharynx, and also of 
 atrophic rhinitis, inasmuch as it deprives the air of respiration of its 
 necessary moisture. 
 
 The immediate cause of the disease is frequently exposure to cold, 
 getting the feet wet, sudden changes of temperature, too hasty cooling 
 of the body during perspiration, etc. 
 
 It occurs at any age of life, but in men more than women, owing 
 to the greater exposure incidental to their lives. 
 
 Inhalation of irritating vapors, such as chlorine, ammonia, etc., or 
 excessive smoking may give rise to it. The internal administration of 
 (362) 
 
ACUTE LARYNGITIS. 363 
 
 tod. pot. in large doses will also in certain cases produce laryngeal in- 
 flammation. 
 
 Another cause quite common among yoice-users is overstrain of 
 the voice in singing, public speaking, etc. 
 
 Symptomatology. — The most noticeable symptom is hoarseness in 
 various degrees. It is rare, however, for complete aphonia to occur, 
 for the simple reason that it requires more or less infiltration of the 
 arytenoids or vocal cords to produce absolute loss of voice; and this 
 would place it under the heading of laryngitis gravior instead of laryn- 
 gitis mitior, or simple laryngitis. Without infiltration really exists, 
 the voice can always be sounded by making extra effort, save in those 
 cases Avhere the nervous element has entered largely into the history, 
 and in these the use of the laryngoscope should materially aid in the 
 diagnosis. 
 
 Discomfort is usually in the form of soreness rather than pain, and 
 partakes of the dry and slightly-burning character. There is no diffi- 
 culty in respiration, but frequently a harsh, irritating throat-cough in- 
 creases the general malaise. The cough, too, is out of proportion to 
 the small amount of expectoration which is at first discharged from 
 the inflamed throat. This secretion increases somewhat as the disease 
 advances. There may be slight difficulty in swallowing solid food, 
 while bland diet will slip down without effort. 
 
 Of fever there is but little. No distress of the general system and 
 practically the disease resolves itself into temporary hoarseness accom- 
 panied by more or less irritation. 
 
 Diagnosis. — Frequently the abrupt onset of the disease, with the 
 characteristic voice, is quite sufficient to establish the diagnosis. Still, 
 there are many things which may produce hoarseness, and it is better 
 when possible to make the opinion sure by the use of the laryngoscope. 
 The chief aim in using it should be to examine the vocal cords. If 
 they are smooth, although reddened, opening and closing evenly, and 
 are without thickenings or indentations upon their borders, the diag- 
 nosis may be tolerably sure. The blood-vessels upon their surfaces may 
 be higher colored and more prominent than usual, with the cords still 
 white and glistening; or the whole surfaces of the cords in aggravated 
 cases may be hyperaemic. At the same time, the mucous lining of the 
 larynx will have a bright, congested hue, which in some cases may 
 culminate in thickening of the interarytenoid commissure, preventing 
 entire closure of the cords. 
 
 A red or pink color of the vocal cords, however, is not always a 
 
364 DISEASES OF THE LARYNX. 
 
 diagnostic indication of laryngitis, nor either is a pearly-white condi- 
 tion a sure sign of a normal larynx. 
 
 This was brought out prominently by Heryng at the recent Med- 
 ical Congress at Warsaw. He said that not infrequently the pearly 
 whiteness was caused by layers of thickened epithelium, and that 
 owners of vocal cords of this color would come to the laryngologist for 
 treatment for vocal troubles, while, on the other hand, some of the 
 best singers had red, catarrhal-looking cords. One of the finest lady- 
 soloists he knew of had slightly-red cords before singing, and very red 
 ones after. In these cases all the symptoms and signs available must 
 aid the laryngologist in arriving at a correct diagnosis. 
 
 In comparing hoarseness from this disease with that produced by 
 other throat affections it should be remembered that the hoarseness 
 of laryngeal tuberculosis is soft and weak, and that of syphilis is harsh 
 and grating, while that from acute inflammation is even and firm, al- 
 though it may be rasping in tone. In both the former, as well as in 
 malignant disease, and when neoplasms are present, the hoarseness 
 comes on gradually and slowly, without tendency to improvement, 
 while the disease under consideration is self-limited in history. 
 
 Prognosis. — It is not dangerous to life, and it runs a course vary- 
 ing from a few days to a couple of weeks. The impairment of the 
 function of voice-production, particularly in singers and public speak- 
 ers, is the most important consideration in regard to it; another point 
 is the probability of its recurrence, owing to the presence of the pre- 
 disposing causes already named. Any tendency to extension of the 
 disease down into the trachea or bronchial tubes must also owe its 
 origin to the impaired naso-pharyngeal respiration rather than to laryn- 
 geal inflammation. These should all point to the importance of re- 
 moving any stenosis that may occur in any part of the upper respira- 
 tory passages. 
 
 Treatment. — As this is a local disease, attended by so little febrile 
 disturbance, I believe largely in relying upon local treatment. This 
 should not, however, be confined to the larynx, but should commence 
 with the nose and naso-pharynx. Whatever is the immediate cause of 
 the disease, examination, as a rule, will find more or less nasal stenosis 
 in one or both passages. In these, if treated at his office by the sur- 
 geon, a 1-per-cent. solution of cocaine should be thrown up each nostril 
 by an atomizer. A small quantity will suffice; and in two or three 
 minutes the astringent effect of the cocaine will be noticeable. The 
 patulous condition of the passages will be increased and the patient 
 
ACUTE LARYNGITIS. 365 
 
 can blow out freely airy accumulations which hypertrophic engorge- 
 ment may have allowed to gather. An important end now to be aimed 
 at is to keep the passages open as long as possible, thus restoring nor- 
 mal respiration and facilitating laryngeal recovery. Speaking entirely 
 from my own experience, I would again refer to the efficiency in pro- 
 longing the astringent affect of cocaine, which I have found the ap- 
 plication of 1-per-cent. solution of menthol in albolene to possess. 
 When thrown into the nasal passages by an atomizer immediately after 
 the absorption of the cocaine, it not only stimulates the secreting cells, 
 thus relieving the engorgement, but also counteracts the depressing 
 effect which the cocaine itself produces. 
 
 Xext, the pharynx should be sprayed out freely with an alkaline 
 solution, such as DobelPs. This will relieve both pharynx and larynx 
 of any hypersecretion that may be present. If the larynx is found to 
 be very much congested, a 1-per-cent. solution of cocaine should also 
 be thrown into it through the down tip of the atomizer. The congested 
 condition in a very few moments is somewhat relieved. The treat- 
 ment immediately following this depends upon the length of time dur- 
 ing which the disease has been in existence. If advice is sought near 
 the onset of the symptoms a similar 1-per-cent. solution of menthol 
 in albolene as that already applied to the nose will have a good effect, 
 and a spray of: — 
 
 $ Thymol 
 
 Menthol 
 
 Albolene 60 
 
 M. 
 
 applied by the patient to the larynx every two or three hours until he 
 again requires to see the physician, may be prescribed. 
 
 If the inflammatory condition is of longer standing and well 
 established, the cocaine solution may be thrown into the larynx a lit- 
 tle more freely, and followed immediately by the application of a 2-per- 
 cent, solution of nitrate of silver by means of the laryngeal cotton- 
 holder. A similar solution of the nitrate could be applied by atomizer, 
 and Bosworth recommends it in this way. After the application of 
 the silver the patient should carry out the home-treatment as already 
 described, returning every second day to have the application renewed. 
 
 In cases in which upon examination we find some hypertrophic 
 
 I£ Thymol gr. iij . 
 
 Menthol gr. x. 
 
 Albolene § ij. 
 
 M. 
 
 23 
 
366 DISEASES OF THE LAEYNX. 
 
 nasal or pharyngeal tissue occupying a primary causative relation to 
 the laryngitis, the question of advisability of operation arises. Some 
 laryngologists believe in waiting until the laryngeal difficulty has sub- 
 sided before operating. Others believe in operating as soon as the 
 lesion is observed, believing that this itself will produce a cure. In my 
 own mind, if there is little or no fever in consequence of the laryn- 
 gitis, the latter is the plan that I prefer to follow; and I have never 
 known it to be productive of evil results. Some nasal and pharyngeal 
 operations are attended by more or less bleeding; and it is well to 
 remember that this hemorrhage may "have a sedative effect upon the 
 inflamed larynx. When, however, there is much febrile action or the 
 laryngitis is severe, it is always better to postpone operative measures 
 until abatement has taken place. In the same way galvanocautery 
 operations within the nose should be postponed, on account of the 
 oedema and stenosis which they sometimes temporarily produce. 
 
 When the inflammatory action is attended by much fever, and 
 the laryngeal irritation is very great, a cure can be expedited by steam- 
 inhalation frequently repeated, or by confining the patient to a warm 
 room, surcharged with moisture evaporated from antiseptic solutions 
 of one form or another. With this the administration of tincture of 
 aconite, 1 drop per hour, is still a favorite remedy with many. 
 
 When confinement to the house becomes necessary, I prefer the 
 application to the neck of equal parts of olive-oil and oil of turpentine, 
 with an outside wrapping of absorbent cotton, to the old-fashioned 
 method of poulticing. Cold packing to the neck is also productive of 
 a sedative effect upon the inflamed larynx. 
 
 It is doubtful if benefit can be derived from the use of ordinary 
 astringent lozenges in these cases. They do not come in contact with 
 the interlaryngeal mucous membrane, and how a slightly astringent 
 effect upon the pharynx can benefit the former is doubtful. When the 
 chief ingredient of the lozenge is of a volatile nature the case is dif- 
 ferent. This may be said of menthol lozenges. They not only have 
 a local influence upon the pharyngeal walls, but the vapor of the men- 
 thol is continually brought in contact with the mucous membrane of 
 the larynx, producing a cooling, as well as astringent, effect. 
 
 One important point during treatment is to insist upon as little 
 use of the voice as possible. The primce vice should also be regulated, 
 and judicious efforts made to avoid any repetition of exposure to cold. 
 The importance of absolute and continued nasal respiration should 
 likewise be impressed upon the mind of the patient. 
 
CHAPTER LXVIL 
 
 ACUTE LARYNGITIS OF CHILDREN. 
 
 In early life acute laryngitis is more frequent than during adult 
 years, owing to the generally loose attachment of the mucous mem- 
 brane and to its increased vascularity. The inflammation, which is 
 frequently pharyngeal in its origin, may extend merely to the upper 
 portion of the larynx or may pass downward, affecting the infraglottic 
 region. The loose attachment of the mucosa permits of a certain 
 amount of infiltration without penetrating deeply into the submucous 
 tissue, causing the croupous symptoms which so often occur in young 
 children. The cases differ in severity, the milder ones being distin- 
 guished merely by a harsh cough, the more severe ones by a strident 
 spasmodic closure of the glottis during the acts of coughing and breath- 
 ing. 
 
 Pathology. — In this disease we have hyperemia of the laryngeal 
 mucosa, the minute vessels being gorged with blood and the loosely 
 attached membrane being swollen to a more or less extent by lymphatic 
 pressure. When confined to the supraglottic portion, the tumefaction 
 is limited; when infraglottic it may be severe as well as extensive, 
 almost closing the lumen of the cricoid region and producing severe 
 laryngeal stenosis. The swelling of the parts is always confined to the 
 mucous membrane itself, and does not involve the submucous tissue as 
 in acute oedema, and is probably due to the presence of the lymphatic 
 vessels, which in early years bears so important a part in the anatomy 
 of the throat. 
 
 Etiology. — The presence of hypertrophy of the lymphatic tissues 
 of the throat is frequently a predisposing cause, not only from the tend- 
 ency to lymphatic inflammation incidental to early life, but also from 
 the nasal stenosis which enlarged faucial or pharyngeal tonsils so fre- 
 quently cause. The mouth-breathing which follows aids in producing 
 laryngeal irritation. 
 
 The disease is probably more common among ill-nourished, 
 neglected, ill-clothed children. Still, it frequently occurs in appar- 
 ently strong and vigorous ones. Probably in these a careful examina- 
 tion would reveal a lymphatic tendency not at first noticed. 
 
 (367) 
 
368 DISEASES OF THE LARYNX. 
 
 The exciting cause is usually cold or exposure to changeable and 
 uneven temperatures. Children often get overheated while playing 
 and will sit down, cooling the body unequally while the skin is still 
 perspiring. The consequence is that the blood is driven from the sur- 
 face to the internal organs, and the throat, liable as it is to catarrhal 
 affections, is the organ most likely to be affected. 
 
 Boys suffer more frequently from this disease than girls, prob- 
 ably owing to greater exposure. 
 
 Symptomatology. — The milder forms of acute laryngitis in chil- 
 dren usually commence in acute rhinitis, the inflammatory action ex- 
 tending down to the pharynx and the supraglottic portion of the 
 larynx. There will be dryness and irritation of the throat, with slight 
 hoarseness and stridulous cough. The more severe cases, those to 
 which the term spasmodic croup is so commonly applied, are more 
 likely to arise in cases of tonsillar enlargement, the laryngeal symp- 
 toms arising from direct irritation. The constitutional disturbance 
 is greater in the latter than in the former; and the fever, which is 
 slight when the upper larynx is affected, is likely to become severe 
 when the subglottic region is the seat of the disease. It is only in the 
 latter that laryngeal stenosis is likely to be at all severe. Hoarseness 
 will be of a shrill, metallic character at first, gradually assuming a 
 harsher tone and in some instances ending in aphonia. Cough attends 
 this disease from the first and is stridulous and croupy, with nocturnal 
 exacerbations. The attack usually comes on in the night-time, and the 
 child may cough for a quarter of an hour before it can obtain relief 
 by the expectoration of a little mucus. Sometimes the exacerbations 
 are repeated several times during the night. 
 
 The disease is more prevalent during the cold and damp months 
 of the year, and, having once occurred in any child, is liable to recur 
 again, unless the obstructive lesions, which may have given rise to the 
 first attack, have been removed. 
 
 Diagnosis. — Laiyngoscopical examination in young children is 
 usually very difficult. Still, in some instances it can be accomplished, 
 and will reveal the hyperaBmic and infiltrated condition of the inner 
 larynx. In these cases Kirstein's aiitoscope in skillful hands should do 
 good service, and under chloroform should be particularly easy. Ac- 
 cording to Kirstein, it can be done without the use of the anaesthetic, 
 but is necessarily difficult and somewhat dangerous, owing to the 
 struggles of the child. 
 
 When visual examination of the larynx cannot be made by either 
 
ACUTE LARYNGITIS OF CHILDREN. 369 
 
 method, it makes the diagnosis more difficult, as the ordinary symptoms 
 bear some resemblance to those of membranous croup or laryngeal 
 diphtheria. Still, the severer disease is attended by much severer 
 symptoms, such as higher temperature, more complete aphonia, more 
 noiseless cough, and greater physical prostration. Most writers, at the 
 present time, agree with the idea of the identity of pseudomembranous 
 croup with laryngeal diphtheria; and it must be remembered, in the 
 way of diagnosis, that in the latter the exudative disease is strictly 
 progressive, while in the so-called spasmodic croup the nocturnal ex- 
 acerbations are the most important feature. 
 
 Prognosis. — This disease is not usually dangerous to life. The 
 nocturnal exacerbations are the only indications which should cause 
 alarm. Usually they increase in severity for two or three nights. 
 Then they abate and soon disappear, the harshness of tone and throat- 
 irritation gradually passing away. The disease may be extended out to 
 two or three weeks, but usually it is of shorter duration. Occasionally, 
 though rarely, death may result from the subglottic oedema. 
 
 Treatment. — As soon as the decided hoarseness or croupy cough 
 occurs in a child, indicating the presence of acute laryngitis, he should 
 be placed and kept continually in a temperature of about 70°- F. It 
 would be advisable to have moisture continually evaporated in the 
 room. The bowels should be moved by a laxative, and mild soft nour- 
 ishment should be given. 
 
 For internal administration minute doses of aconite, with car- 
 bonate or muriate of ammonia, do excellent service, as they relax the 
 pores of the skin and stimulate the throat to mild secretion. The fol- 
 lowing are suitable preparations; either of these might answer for a 
 child four or five vears old: — 
 
 I£ Mur. amnion 15 
 
 Tr. aconite 125 
 
 Glycerin 4| 
 
 Aquam ad 301 
 
 M. Sig. : One teaspoonful every one or two hours. 
 
 Mur. amnion gr. viij. 
 
 Tr. aconite gtt. iv. 
 
 Glycerin 3j. 
 
 Aquam ad Sj- 
 
 M. 
 
370 DISEASES OF THE LARYNX. 
 
 1. 3. Carbon, ammon 14 
 
 Tr. aconite 25 
 
 Glycerin 4 
 
 Aquam ad 301 
 
 M. Sig. : One teaspoonful every one or two hours. 
 
 For external treatment I like nothing better than a stimulating 
 emollient application to the neck of camphor liniment and olive-oil, 
 equal parts, or oil of turpentine and olive-oil in like proportions. This 
 should be applied with the warm hand to the neck, then a snug layer 
 of absorbent cotton wrapped over it from ear to ear. By its warmth 
 it promotes gentle perspiration, and thus depletes from the part, while 
 it affords ease and comfort to the inflamed throat. The nocturnal at- 
 tacks may be relieved by a hot steam-inhalation, and, when this fails, 
 the inhalation of a few drops of chloroform will sometimes check the 
 exacerbation. 
 
 As the child improves, the thickness of the throat dressing should 
 be made gradually less, and care should be taken against too early an 
 exposure to cold. 
 
 When in severe cases all other measures fail to give relief to the 
 little patient, resort may he had to intubation. Prolonged use of the 
 tube will not be required, as it is so frequently in cases of diphtheria, 
 the insertion of the tube for a few hours, or a day or two in extreme 
 cases, being all that would be needed. In so mild a disease, intubation 
 is undoubtedly preferable to the more serious operation of tracheotomy. 
 
 After the recovery of the child, when the disease owes its primary 
 origin to lymphatic hypertrophy, this should be treated according to 
 rules already laid down, and by this means an end put to any tendency 
 to recurrence. 
 
 R. Carbon, ammon gr. vj. 
 
 Tr. aconite gtt. iv. 
 
 Glycerin 3j. 
 
 Aquam ad 5j- 
 
 M. 
 
CHAPTER LXVIII. 
 ACUTE (EDEMATOUS LARYNGITIS. 
 
 Acute inflammation of the larynx, attended by oedema, has long 
 been described by writers under a diversity of names. The facts that 
 it is an exceedingly acute inflammation, that the inflammation goes 
 deeper than the mucous membrane, and that it is attended by sub- 
 mucous infiltration are sufficient to make the above title, chosen out 
 of the many it bears, one that at least is applicable to the disease. 
 
 Pathology. — The morbid changes are indicative of acute vascular 
 turgescence, more rapid in formation than in simple acute laryngitis, 
 and attended by extension to the submucous tissues, with almost im- 
 mediate serous infiltration. This occurs most extensively where the 
 mucous membrane is loosely attached, as in the region of the ven- 
 tricular bands, the aryepiglottic folds, and the posterior surface of the 
 epiglottis. The arytenoids are almost as readily swollen, while the 
 vocal cords and the infraglottic region, with a more closely attached 
 mucosa, are less liable to the disease. 
 
 As a rule, the affection is bilateral, and, if unchecked, staphylo- 
 cocci, streptococci, and other organisms make their appearance in the 
 infiltration-fluid, and the disease may pass through from the serous 
 stage into the purulent. These changes occur more rapidly when the 
 disease is unilateral. The condition in any case is one of acute cellu- 
 litis. 
 
 Etiology. — Sudden and unequal exposure of the body to cold is 
 the apparent cause of a majority of cases. It is generally believed, 
 however, to owe its origin to micro-organisms; and that the unequal 
 temperature to which the patient might be exposed, is only the match 
 which kindles the fire, the fuel for which has already been prepared 
 for ignition. What would seem to give color to this belief is the fact 
 that, while exposure in one case may produce simple acute laryngitis, 
 in another similar exposure may result in intense cedematous disease. 
 
 Eecent observers, as Levi and Lameres, believe the oedema to be 
 of infectious origin, while Liaras believes that it may be even a trau- 
 matic oedema, immediately dependent upon local vasomotor disturb- 
 ance the result of cold. 
 
 (371) 
 
372 DISEASES OF THE LARYNX. 
 
 It occurs more frequently in males than females, and in early adult 
 life than in later or earlier years. It is a rare disease, sympathetic 
 oedema of the larynx being much more frequent in occurrence. 
 
 Voice-straining has been an apparent cause in some cases, and 
 facial erysipelas has sometimes been followed immediately by oedema 
 of the larynx, which, in all probability, was an extension, if not a 
 metastasis, of the erysipelas itself. 
 
 Traumatic causes will produce acute oedema, as from inhalation 
 of hot steam or swallowing of boiling water, etc. As a secondary affec- 
 tion, it may arise as a complication of the various exanthemata, though 
 the cases are exceedingly rare. 
 
 Symptomatology. — The throat symptoms occur so quickly and are 
 of such distressing character that the ordinary premonitory symptoms 
 of chilliness and fever are sometimes overlooked, although they may 
 be present in every case. In the most severe one that I have ever 
 seen no premonitory symptoms of any kind were observed, save a slight 
 feeling of weariness. Without warning, the patient, a strong young 
 man of 25, was seized with dyspnoea, and in six hours it became so 
 severe that respiration became stertorous and the face cyanotic. 
 
 The voice soon becomes lost in a soft hoarseness. Inspiration and 
 expiration both become labored. At first the face is flushed, and, as 
 difficulty in breathing increases, the purplish hue of cyanosis takes its 
 place. 
 
 These symptoms may become fully developed in from ten to 
 twent}'-four hours, or, as in the case referred to, in a shorter period. 
 In severe cases the result will be fatal in from one to three days, with- 
 out surgical relief of one form or another is secured. In milder forms 
 of oedematous laryngitis the course may result in spontaneous resolu- 
 tion or the development of abscess in some particular spot, with abate- 
 ment of the general disease. 
 
 In the severer forms, if the patient does not succumb quickly to 
 the progressive stenosis, abscess may become diffused, speedily bringing- 
 about a fatal issue. 
 
 Diagnosis. — Many things will produce laryngeal dyspnoea; and 
 to distinguish acute oedematous laiwngitis from all of these a careful 
 laryngoscopic examination is absolutely necessary. Digital examina- 
 tion may be of some value, revealing the soft tumefaction of the epi- 
 glottis and aryepiglottic folds, but it must be remembered that, with- 
 out the explorer is familiar with the touch of the laryngeal region, it 
 cannot be of much service. On the other hand, in this progressive age 
 
ACUTE (EDEMATOUS LARYNGITIS. 
 
 373 
 
 it should be the duty of every physician to familiarize himself with all 
 the methods used in the exploration of the affected parts. 
 
 By the use of the laryngoscope the mucous membrane of the 
 larynx will be seen greatly distended. The epiglottis will be thick- 
 ened, particularly upon its border and posterior surface. The lateral 
 folds of the inner larynx will be rolled out behind and to the sides of 
 the epiglottis, the three forming a triangular chink in the glottic re- 
 gion. 
 
 Although the color is that of increased redness, there is a watery 
 and transparent cast to the tumefaction, the extent of which depends 
 upon the severity of the disease. When pus has commenced to form, 
 the spot of its development will be marked by increased swelling or 
 pointing, as well as the assumption of a lighter color. 
 
 Fig. 118. — Bos worth's laryngeal knives. 
 
 Prognosis. — This is always exceedingly grave. In some cases, 
 without surgical treatment, a rapidly fatal result may be expected, 
 arising from serous stenosis, before the disease has existed long enough 
 to give rise to the development of pus. Milder cases may undergo reso- 
 lution without pus-formation, but usually they end in localized devel- 
 opment of abscess, with discharge and recovery. The danger lies in 
 suffocation; hence the cases should be watched with the greatest care. 
 
 Treatment. — Mere local applications of any kind may be consid- 
 ered as useless in promoting the main object of treatment: the reduc- 
 tion of swelling. This can be accomplished, however, by free scarifica- 
 tion of the inflamed and infiltrated tissues with a curved laryngeal 
 knife, such as Boswortlr's or Tobold's, guided by the laryngeal mirror 
 (Fig. 118). Free exudation of sero-sanguineous fluid follows. This can 
 
374 DISEASES OE THE LARYNX. 
 
 be aided by hot steam-inhalations, which, while promoting discharge, 
 have a grateful effect upon the inflamed tissues. The scarification may 
 be repeated every few hours until the urgent symptoms abate. In the 
 case already referred to, this plan of treatment was rewarded by a suc- 
 cessful issue. 
 
 Pry or reports a case cured by external leeching, aided by hot foot- 
 baths and hot lemonade. Levi also reports one cured by applying six 
 leeches to the laryngeal region. Both were cyanotic; the stress was 
 laid on the fact that scarification was in these cases unnecessary. 
 Tiarus in 1897 cured a case by removing a piece of the infiltrated mem- 
 brane by punch-forceps, thus promoting free secretion. 
 
 In cases where suffocation becomes imminent, any of these means 
 cannot be relied on, and tracheotomy will require to be done. There 
 is no doubt that this operation is preferable to intubation in this dis- 
 ease, as the laryngeal swelling is usually on a higher plane than the cap 
 of the intubation-tube, when placed within the larynx. • Consequently, 
 if it were inserted, the oedema might continue to produce stenosis, not- 
 withstanding the presence of the tube. When abscesses point, no 
 matter where located, they should be promptly opened. 
 
 Supporting measures during treatment are required; and care 
 should always be exercised against avoidable changes of temperature. 
 
CHAPTER LXIX. 
 
 SIMPLE CEDEMA OF THE LARYNX. 
 
 Simple oedema of the larynx, unconnected with any inflammatory 
 condition of that organ, not infrequently occurs. It is rarely, how- 
 ever, of merely local origin, but is a result of severe systemic disease 
 and is of a secondary nature. It occurs during all periods of life, 
 but rarely in extreme age. The majority of cases occur in males. 
 
 Pathology. — In this disease there is simply effusion of serum into 
 the loosely-attached submucous tissues of the larynx, the infiltrations 
 being largest in the aryepiglottic folds and the posterior surface of the 
 epiglottis. Still, all parts are liable to tumefaction, and in some cases 
 the ventricular bands have been the only parts affected. The vocal 
 cords and subglottic region are not often involved. Whenever ob- 
 struction to the blood-current is an element of the disease, the slight 
 resistance which the larynx offers to infiltration renders it more liable 
 than other regions to immediate dropsical effusion. 
 
 Etiology. — As it is a secondary disease, the cause must be looked 
 for in general affections of the system which have a deteriorating in- 
 fluence upon the vital powers. Any systemic disease which may pro- 
 duce dropsy in other parts of the body, other things being equal, may 
 give rise to it here. Bright's disease, tuberculosis, syphilis, and car- 
 cinoma are among its causes. Obstruction of venous circulation from 
 the head, as by pressure from thoracic or aortic aneurism, may also be 
 a cause. 
 
 Symptomatology. — The onset of the attack may be sudden, but 
 usually it comes on gradually. Instead of hoarseness there is very soon 
 complete aphonia. Dyspnoea is the prominent symptom. Inspiration 
 becomes exceedingly difficult owing to the swollen aryepiglottic folds 
 rolling in and closing the glottis. Expiration, on the other hand, is 
 not so difficult, as the swollen bodies by the effort roll out again. Still, 
 the cords are kept so wide apart by the tumefaction that vocalization 
 often becomes impossible. Cyanosis soon occurs, with all the other 
 symptoms of impending suffocation. 
 
 Diagnosis. — This is best made by the use of the laryngoscope. 
 
 (3(5) 
 
376 DISEASES OF THE LARYNX. 
 
 The existence of laryngeal stenosis is so self-evident from the symp- 
 toms that the only difficulty is to be sure of the variety of the laryn- 
 geal disease. The autoscope, too, particularly in young subjects, should 
 serve an excellent purpose in giving direct vision of the infiltrated tis- 
 sues. The resemblance to phlegmonous disease may in some cases be 
 striking. Still, the swelling in oedema is likely to be more diffused 
 and the color of the mucous membrane paler, while the presence of 
 systemic disease as the direct cause should rule out the phlegmonous- 
 or acute cedematous laryngitis. The shining, grayish-white, trans- 
 lucent appearance of the swollen masses in the larynx should distin- 
 guish the oedema from any other lesion. 
 
 Prognosis. — As an indication of serious organic disease, the pres- 
 ence of oedema of the larynx is of the greatest importance, and is usu- 
 ally the prelude to speedy dissolution; and, although the primary dis- 
 ease may be necessarily fatal, the laryngeal stenosis itself, if not re- 
 lieved, may terminate the case in a few hours. 
 
 Treatment. — If the oedema is severe, with threatened stenosis,, 
 the first effort should be to relieve the swelling by free scarification. 
 The room should be warm and the atmosphere charged with moisture 
 from an evaporating-kettle. When it arises from tuberculosis or 
 malignant disease this treatment will often be of service for the time- 
 being, even when constitutional treatment can be of no avail. In 
 syphilis the local scarification may relieve the breathing while mer- 
 curials and iodides are producing a systemic effect. When general 
 anasarca exists from heart or kidney disease or cirrhosis of the liver,, 
 heart-tonics and drastic cathartics would seem to be indicated in addi- 
 tion to the surgical treatment of the larynx, though the relief at best 
 could only be of a very temporary character. 
 
 In malignant disease tracheotomy may be required. Intubation,, 
 owing to the chief effusion being supraglottis would in most if not 
 all cases be practically useless. 
 
CHAPTER LXX. 
 CHRONIC LARYNGITIS . 
 
 This is a chronic inflammation of the mucous membrane of the 
 larynx. It is usually supraglottis but may extend through the vocal 
 cords to the infraglottic region. It is always of a catarrhal character, 
 -and does not include affections of the larynx arising from tuberculosis, 
 syphilis, or malignant disease. 
 
 Pathology. — There is thickening of the mucosa, with hyperemia, 
 the blood-vessels being permanently dilated; also cell-proliferation, 
 with increased secretion. When the disease is of long standing there 
 is increase of lymphoid tissue as well as of the surface-epithelium and 
 tubular glands. The whole of the lining membrane of the larynx may 
 be affected, or the disease may be confined largely to the arytenoids, 
 interarytenoid commissure, and the ventricular bands. Sometimes the 
 vocal cords are involved in the inflammatory action. Finally, the con- 
 dition may extend downward, producing cell-proliferation and dis- 
 charge from the infraglottic region and the trachea itself. In simple 
 chronic laryngitis erosions are rarely present. When they do occur, 
 they arise from the breaking of the epithelial coating from the pressure 
 of the thickened connective tissue beneath, and can only be found in 
 •cases of long standing. 
 
 Etiology. — The usual cause is some diseased condition of the nose 
 •01 naso-pharynx producing nasal stenosis. Anything that will produce 
 chronic naso-pharyngeal catarrh has a tendency to induce a similar 
 condition in the larynx. Whether this arises from direct continuity 
 of the diseased mucous membrane, or from irritation caused by the 
 presence of catarrhal secretion in the region of the epiglottis and aryte- 
 noids, opinions are divided; but where the condition exists, in many 
 instances, chronic laryngitis is the result. In other individuals, nasal 
 stenosis, accompanied by catarrhal pharyngitis, will directly induce 
 chronic laryngitis by enforcing the inspiration of unwarmed, unfiltered, 
 unsaturated air, the constant breathing of which will have an irritating 
 effect upon the laryngeal mucous membrane. 
 
 Atrophic rhinitis is also a frequent cause, particularly in cases 
 
 "(377) 
 
378 DISEASES OF THE LAKYNX. 
 
 where it lias already produced pharyngitis sicca. In these instances 
 the turbinateds have already lost the function of transudation, and 
 the air passes over them to the larynx unmoistened and loaded with 
 putrescent emanations. Crusts and foul catarrhal debris often impede 
 the entrance to the laryngeal cavity, and everything directly favors the 
 development of a chronic catarrhal condition. 
 
 In many instances, particularly in voice-users, the nasopharyn- 
 geal condition is not sufficient per se to induce the disease, but merely 
 acts as a predisposing cause; and any excessive strain, either in sing- 
 ing or speaking, particularly when frequently repeated, will result in 
 the development of the disease. 
 
 Many speakers who breathe correctly when in a passive condition 
 entirely ignore correct respiration while speaking. "What is called the 
 "recovery" in inspiration is made by them through the mouth, and 
 not through the nose. This is a fault which, if properly attended to, 
 could, as a rule, be avoided, and, if the nasal recovery was insisted upon 
 by the speaker, it would not only insure the saturation of the respira- 
 tory air, but would also make the utterances more leisurely, and by 
 this means save the voice. For singers to inspire naturally while carry- 
 ing on their vocation is much more difficult. It is well to remember, 
 however, that there is some compensation for the loss of turbinal secre- 
 tion in these cases in the profuse salivation which voice-using produces. 
 
 Elongated uvula and hypertrophic tonsils may also, by the pharyn- 
 geal irritation they produce, lead to chronic laryngeal disease. 
 
 Males are more subject to chronic laryngitis than females, owing 
 to the more frequent exposure, and, in public speakers, to more ex- 
 cessive use of the voice. 
 
 The disease occurs most frequently during early adult and middle 
 life. 
 
 Symptomatology. — Slight irritation of the larynx, with tendency 
 to repeated hawking, are among the earliest symptoms. Sometimes 
 there is a sense of dryness, accompanied by spasmodic efforts to clear 
 the throat. These symptoms are, however, of a minor character, and 
 are marked, in a measure, by the gradual development of hoarseness. 
 This may not be noticed much during ordinary conversation, but in 
 singing or public speaking becomes annoying both to speaker and 
 hearer. Any extra exertion of true voice in either of these ways may 
 produce burning and tickling sensations in the larynx, with the effect 
 of producing a dry, spasmodic cough. 
 
 The use of the voice by persons affected by chronic laryngitis is 
 
CHEONIC LARYNGITIS. 379 
 
 followed by different results in different persons. In some huskiness 
 will develop into hoarseness, and, if the voice continues to be used, 
 into complete aphonia, while, in others, even hoarseness will gradually 
 disappear as the speaking or singing continues, and the voice become 
 clear before the end is reached. In the first the laryngeal glandular 
 secretion becomes exhausted, while in the second the secretory follicles 
 have retained their power, and, being stimulated to extra secretion by 
 the action of the laryngeal muscles, have lubricated the vocal cords 
 and enabled them to perform their increased duty. 
 
 The discharges from the larynx are usually of a grayish color and 
 scanty, without the inflammatory action extends to the infraglottic 
 region. Then they become more copious and of a yellowish color, the_ 
 voice becoming more easily fatigued. 
 
 Diagnosis. — The oft-repeated efforts to clear the throat, with the 
 hoarseness upon using the voice, indicate, to some extent, the nature 
 of the disease. -This hoarseness is likely to increase as the day advances, 
 and is often relieved by a night's sleep. Still, there are other laryngeal 
 troubles which will produce similar symptoms, and the use of the 
 laryngoscope is required to make the diagnosis sure. 
 
 By its use the mucous membrane of the larynx will present the 
 ordinary appearances of chronic inflammation. The arytenoids and 
 ventricular bands will be slightly swollen and hyperagmic. The vocal 
 cords may be somewhat congested, but there will be no great swelling 
 or tumefaction, no irregularity of motion, little or no surface-lesion; 
 but there may be slight bathing of the parts in muco-pus. Sometimes 
 the minute laryngeal vessels may be swollen and tortuous, particularly 
 on the posterior surface of the epiglottis; and, in severe cases, they 
 may be distinctly seen on the vocal cords. Minute granulations may 
 also appear on the vocal cords and intralaryngeal walls. 
 
 Prognosis. — As this disease so frequently owes its origin to lesions 
 in the upper air-passages, the prognosis is usually good, when these 
 are removed; when the cause is chiefly voice-abuse, let this cease and 
 the disease will likewise. A large number of cases, however, are of a 
 very chronic character, when they come under the physician's notice. 
 The laryngeal mucosa is thickened; the secretions, although not 
 copious, have become habitual; and cure can only be accomplished by 
 slow process. When the voice is not an important factor in the voca- 
 tion of the patient, the disease may remain stationary in many cases 
 without producing serious harm. Still, the fact that every fresh cold 
 may result in an acute or subacute attack of laryngitis in the alreadv 
 
380 DISEASES OF THE LARYNX. 
 
 diseased organ, would indicate that amelioration should be aimed at 
 in all cases. 
 
 Treatment. — As chronic laryngitis occurs, as a rule, in persons 
 otherwise enjo}dng robust health, little is required in the way of sys- 
 temic treatment. If the liver is torpid a cholagogue may be given, and 
 saline cathartics may be administered when the plethora of the system 
 demands it. 
 
 In cases where naso-pharyngeal lesions have produced stenosis or 
 catarrhal disease in the upper air-tract it becomes the imperative duty 
 of the medical attendant to aim at their removal. The only question 
 is: Should this be accomplished at the time when the laryngeal symp- 
 toms are most urgent or at a later date? The answer to that depends 
 upon whether we are called to treat the larynx in its chronic condition 
 or in one of the acute exacerbations with which it is so often attacked. 
 In the former, operation upon the turbinateds, septum, nasal polypi, 
 adenoids, or tonsils, when required, should be done at once. In the 
 latter, while we may alleviate the stenotic symptoms by lavage, etc., 
 it should be the aim to reduce the acute laryngeal condition before 
 completing the naso-pha^ngeal treatment. 
 
 For local treatment of the larynx I believe there is no instrument 
 so generally useful as the atomizer. When properly constructed and 
 carefully used, the fluid contained in it can be applied thoroughly to 
 the intricate foldings of the larynx. To accomplish this object the 
 atomizer should have a curved tip at right angles to the shaft of the 
 instrument. When using it the tongue of the patient should be pro- 
 truded to its full extent, and, if necessary, held in position by the pa- 
 tient grasping it lightly in the folds of a doilet. If we desire the 
 application to reach the infraglottic region, the patient should be in- 
 structed to inhale steadily and forcibly while the spray is thrown in. 
 If the solution is intended to come in contact with the entire upper 
 surfaces of the vocal cords, or to wash out the ventricles of Morgagni, 
 or both of these, the patient should articulate the sound "ah," prolong- 
 ing out the note while the spray is thrown in. 
 
 As there is always more or less mucous or muco-purulent secre- 
 tion in the pharynx as well as the- larynx, the first solution used by 
 the atomizer should be one of the alkaline preparations already men- 
 tioned. With this the throat should be thoroughly washed. Then, 
 if the condition is temporarily of an acute character, a 1-per-cent. solu- 
 tion of cocaine may follow. This will relieve the immediate tender- 
 ness and enable an astringent spray to be used without producing sore- 
 
CHRONIC LARYNGITIS. 381 
 
 Bess. If it is simply the chronic condition that requires to be treated, 
 the cocaine may be omitted. 
 
 Of the astringents now to be applied, the following may be con- 
 sidered in order of merit: — 
 
 Argent, nit. in solution, 1 to 3 per cent. 
 
 Zinci chloridi in solution, 1 / 2 to 1 per cent. 
 
 Cnpri sulphas in solution, 1 to 3 per cent. 
 
 Tannic acid, 2 to 5 per cent., with glycerin, 10 per cent., in water. 
 
 Any of these may be thrown into the larynx and retained as long 
 as possible, the patient returning daily to the office for treatment, or 
 at longer intervals as may seem advisable. 
 
 For the interim treatment to be carried on at the patient's home, 
 I have always obtained better results from the stearoptene preparations 
 dissolved in one of the hydrocarbons than from the use of aqueous 
 solutions. Among the advantages of the oil sprays over the water ones 
 are the fineness of atomization, the softness of the touch upon the in- 
 flamed tissues, and the consequent greater penetrability within the 
 folds of the organ, owing to the absence of the resistance which the 
 coarser spray produces. 
 
 The preparations are much the same as those already mentioned 
 in speaking of the treatment of pharyngeal disease, but to save the 
 trouble of reference may be spoken of again here. Albolene is only 
 taken as a good example of the hydrocarbons. 
 
 Menthol in albolene, 1 to 3 per cent. 
 
 Thymol in albolene, 1 / 2 to 1 per cent. 
 
 ft Menthol 
 
 01. caryoph 
 
 Albolene 30 
 
 2. 
 
 ft Thymol |0G7 
 
 Menthol 135 
 
 01. anisi |67 
 
 Albolene 301 
 
 1. ft Menthol gr. v. 
 
 01. caryoph nix. 
 
 Albolene %]. 
 
 M. 
 
 2. ft Thymol gr. j. 
 
 Menthol gr. v. 
 
 01. anisi »ix. 
 
 Albolene oj. 
 
 M. 
 
382 DISEASES OF THE LAEYNX. 
 
 For finer atomization to the throat, stronger solutions can be used 
 by means either of the nebulizer or the comminutor. The American 
 nebulizer is well adapted for home-use by the patient. As seen in Fig. 
 119, the heavier oil-globules are thrown against the wall of the bottle, 
 and flow back into the fluid, while only the vaporous particles pass out 
 of the mouth of the tube in a mist, to be inhaled by the patient. 
 
 The multiple comminutor is a more elaborate development of the 
 same principle. By its use several vapors can be combined at one time 
 for inhalation, if considered desirable. Its use is specially designed for 
 the physician's office (Fig. 120). 
 
 Any of these can be used by the patient to the throat with a good 
 atomizer or nebulizer two or three times a day. To have the best 
 
 Fig. 119. — American nebulizer. 
 
 effect he should be instructed to inhale deeply while using the instru- 
 ment. In any case the oil solution should not be too strong at first, 
 the proportion of the drug within the menstruum being easily increased 
 to suit the susceptibility of the patient, and also the kind of instrument 
 by which it is to be applied. 
 
 Any of these preparations have the additional advantages of being 
 antiseptic and cooling, as well as astringent. 
 
 In using nitrate of silver I prefer to apply it with the laryngeal 
 cotton-holder after cocainization, guiding it to the part to which it 
 is applied by the use of the throat-mirror, and using care to avoid 
 abrasion of the surface by the manipulation. The use of the laryngeal 
 brush in these cases, while more easily applied, is always more diffuse 
 in its application. 
 
CHRONIC LARYNGITIS. 
 
 383 
 
 Some operators advise the application of astringents in a dry form 
 by means of insufflators, but the method is generally conceded not to 
 be as efficacious as the one already referred to. 
 
 Counter-irritation over the larynx may also be of benefit; also 
 
 Fig. 120. — Multiple comminutor. 
 
 painting the surface with iodine. In some cases, where there is actual 
 doubt in diagnosis, the administration of iodide of potassium may help 
 to clear up the difficulty. 
 
 Care in the use of the voice is imperative. 
 
CHAPTER LXXI. 
 ATROPHIC LARYNGITIS. 
 
 This is a variety of chronic laryngitis occasionally met with. 
 Like ordinary chronic laryngitis, it is a sequel or result of disease of 
 the upper air-passages. As also chronic laryngitis is usually the thick- 
 ening of the mucosa of the larynx, resulting indirectly from thicken- 
 ing or hypertrophy of the nasal and pharyngeal tissues, so, likewise, 
 atrophic laryngitis, like pharyngitis sicca, is ah indirect result, if not 
 extension, of a similar disease from the nose and naso-pharynx. 
 
 Like atrophic rhinitis, it is characterized by diminished secretions 
 and crust-formation over the surfaces of the laryngeal mucous mem- 
 brane. There is also pallor and shrinkage of the normal tissues of the 
 parts affected. 
 
 Pathologically it is identical with the disease of the nose from 
 which it originated, and is accompanied by similar pathological 
 changes. Loewenberg's ozsena diplococcus has also been found within 
 the crusts of the larynx; and, if the microbic origin of the disease may 
 be granted, the like spores will be present wherever the disease may be 
 located. 
 
 Symptomatology. — Crust-formation is much more severe during 
 the night-time than the day, owing to the quietude of the larynx dur- 
 ing the hours of sleep. In the morning, particularly, there is a sense 
 of harshness in the larynx, with considerable difficulty of clearing away 
 the accumulated discharges. The masses expectorated come directly 
 from the larynx, and are usually of a greenish color, and possess, though 
 in a minor degree, the heavy earthy odor characteristic of atrophic 
 rhinal disease. On examination of the laryngeal mucosa the surfaces 
 may be found abraded or even ulcerated and the expectoration may be 
 tinged with blood. It is not unusual in atrophic laryngitis for ulcera- 
 tions to be extensive, particularly when the disease has extended to 
 the infraglottic region. In this respect atrophic disease of the larynx 
 differs materially from atrophic rhinitis, in which ulceration so rarely 
 occurs; this is, probably, due to the greater mobility, thinner tissue- 
 covering, and less vascularity of the larynx itself. I have seen one 
 
 (384) 
 
ATROPHIC LARYNGITIS. 385 
 
 ease in which the front portions of several of the upper rings of the 
 trachea were completely destroyed hy the erosion, only minute side- 
 fragments of the rings being left. When the vocal cords become in- 
 volved in the disease, or when crusts form over the interarytenoid re- 
 gion, the voice is not only hoarse, but often aphonic. 
 
 Diagnosis should not be difficult. Presence of atrophic rhinitis 
 and pharyngitis sicca would lead to the impression that any serious 
 laryngeal trouble partook of the same nature. When, added to these, 
 are foul, oral breathing, irritation of lower throat, sensitive hyoicl, 
 cough with expectoration of greenish crusts, hoarseness, and great dif- 
 ficulty in clearing the laryngeal cavity, there is little likelihood of 
 mistaken diagnosis. Examination with the laryngoscope should re- 
 move any remaining doubt. Unless there has been thorough cleans- 
 ing of the larynx, immediately before examination, the peculiar green- 
 ish crusts of the disease will be seen in position, above or below the 
 glottis, or both. If they have already been removed, the flattened and 
 shrunken and perhaps ulcerated mucosa will be seen, generally pallid 
 in color, and perhaps streaked with blood, if haemorrhage has taken 
 place. When the disease is extensive, the crusts adhere to the infra- 
 glottic region more tenaciously than the supraglottis owing to the 
 more abundant supply of glandular secretions above the vocal cords. 
 
 Prognosis. — If taken early in its history, cure may be possible; 
 but it must be remembered that it owes its origin to long-standing 
 nasal disease, which may be incurable by the time that the laryngeal 
 atrophy has developed. In these cases amelioration is all that can be 
 expected. If, on the other hand, the atrophic rhinal condition can be 
 removed by treatment, the laryngitis sicca should likewise, as a conse- 
 quence, be arrested. There is another thing to be remembered: that 
 as atrophic rhinitis under proper care ceases to present severe symp- 
 toms in old age, the like result may be expected in the history of the 
 laryngeal disease. 
 
 Treatment. — The first and most important element in treatment 
 is to place the nose and naso-pharynx in as healthy a condition as pos- 
 sible; the treatment required has already been described when dealing 
 with these organs. This having been done at each sitting first, the 
 like procedure should at once be applied to the larynx as well. 
 
 For first cleansing nothing is better than a free spray of Dobell's 
 solution, thrown forcibly into the larynx with the down tip of the 
 atomizer. If the crusts are difficult to remove, the coarser spray of a 
 curved laryngeal syringe may accomplish their loosening more effect- 
 
386 DISEASES OF THE LARYNX. 
 
 ually. With the aid of compressed air and a Davidson atomizer, there 
 should never be any difficulty. 
 
 In rare cases the use of the laryngeal brush or cotton-holder may 
 be required to detach the crusts. I never saw a case, however, in which 
 this was necessary. 
 
 As second treatment to be applied each time after the use of the 
 cleansing spray, the application of the various metallic solutions are 
 recommended. From my own experience, I again prefer, for their 
 mild protective influence, the use of the various hydrocarbons: al- 
 bolene, glycolin, etc. With the oil may be combined from 1 / 2 to 1 
 per cent, of carbolic acid, creasote, or thymol. This should be used 
 several times a day by the patient, with instructions to inhale deeply 
 while using the atomizer. 
 
 When the case is severe, the home use of the steam-inhaler con- 
 taining a weak solution of any of the drugs mentioned will have a 
 beneficial effect. 
 
CHAPTER LXXIL 
 
 PACHYDERMIA LARYNGIS. 
 
 This is a disease which may occur: (1) in the region of the vocal 
 processes of the cords; (2) over the internal surface of the interaryte- 
 noid commissure. The first is' the verrucous form of pachydermia; 
 the second the diffuse. Both indicate a thickening of tissue: the 
 former circumscribed, the latter irregularly hypertrophic. 
 
 Pathology. — Histological sections taken from the vocal processes 
 are oval in form, grayish in color, and, according to Damieno, are com- 
 posed of pavement-epithelium, being changed into epidermoidal layers 
 of flattened cells without nucleus, the mucous membrane at the point 
 affected being apparently transformed into tissue resembling strati- 
 fied skin. In this variety the epithelial tissues thicken at the expense 
 of the submucous connective tissue, which in some cases is almost 
 absent. 
 
 In the interarytenoid pachydermia there seems to be a local over- 
 growth of all the tissues, the connective tissue as well as the epithelial 
 elements being affected. The overgrowth is usually fissured deeply 
 from above downward. 
 
 While the one class of cases has its origin in the pavement-epithe- 
 lium of the cords, the other arises from the ciliated epithelium of the 
 commissure. 
 
 Etiology. — The cause is supposed to be the presence of chronic 
 laryngitis, whether occurring upon the cords or between the arytenoids. 
 In singers and speakers overuse of the voice undoubtedly has an in- 
 fluence in the development; naso-pharyngeal hypertrophy is also in 
 some cases a factor in the etiology of the disease. One well-marked 
 case of interarytenoid pachydermia, occurring in a lady-vocalist, I 
 traced to the presence of adenoid vegetation, and another in a gentle- 
 man to throat catarrh occasioned by the total removal of the uvula. 
 In the former, ablation of the adenoids, together with brushing the 
 pachydermia with solution of nitrate of silver, resulted in complete 
 cure without return. In the latter a change to a more equable climate 
 had a favorable result. 
 
 (387) 
 
388 DISEASES OE THE LARYNX. 
 
 Symptomatology. — When the nodes occur upon the cords, general 
 symptoms are very slightly developed. There may he- weakness of the 
 voice, however, attended by huskiness or hoarseness, owing to the pro- 
 jection of the hypertrophied nodules from the margin of the cords; 
 but there is little, if any, soreness and no coughing or expectoration. 
 
 When the diffuse condition exists, there is more secretion, more 
 soreness, and laryngeal distress, owing to the fact that the projecting 
 growth between the arytenoids may prevent the complete closure of 
 the cords; the voice becomes affected, and the patients complain of 
 aching and general fatigue of the larynx. 
 
 Diagnosis. — As pachydermia of the cords is largely an epithelial 
 development, there is some danger of mistaking it for epithelioma; 
 and in some instances it has been asserted that the pachydermia really 
 developed into cancer. Damieno declares that these were cases in 
 which the epithelioma really existed prior to or in combination with 
 the pachydermia, not as a result. The essential difference between 
 the two diseases exists in the fact that in cancer there is true prolifera- 
 tion of epithelial cells, the cellular nuclei being most active, and the 
 epithelial products penetrating everywhere among the lymphatics and 
 blood-vessels, while in pachydermia there is no true proliferation, but 
 hypertrophy of the epithelium as it takes place in a corn, the cellular 
 nuclei becoming atrophied and disappearing. 
 
 In diffuse pachydermia there is danger of its being confounded 
 with laryngeal tuberculosis in the stage of hypertrophy and infiltra- 
 tion, prior to ulceration. The general condition and absence of other 
 tubercular symptoms, together with microscopical examination of the 
 secretions from the larynx, however, should render the diagnosis 
 tolerably certain. 
 
 Verrucous pachydermia, or pachydermia conscripta, as it is some- 
 times called, is in the form of little, hard nodules situated on or near 
 the vocal processes. In rare instances they are found at the junction 
 of the anterior and middle thirds of the cord. They are white or 
 slightly pink in color and about a pin's head in size. In the typical 
 form the nodule may be single. During vocal effort it comes in con- 
 tact with the opposite cord. This at first produces an indentation, 
 which by and by gives way to proliferation and the development of 
 another node. Then the two, coming in contact, prevent proper clos- 
 ing during vocal effort. 
 
 Prognosis. — Nodes of the vocal cords of speakers and singers 
 would frequently disappear of themselves, if prolonged and complete 
 
PACHYDERMIA LARYXGIS. 389 
 
 rest of the voice were practiced. It is rare, however, that this can be 
 accomplished. Treatment alone, without rest, is of little avail, but 
 the two combined should in all cases produce a good result. 
 
 In the diffuse interarytenoid pachydermia, fissured thickening 
 having occurred, spontaneous absorption is exceedingly rare. 
 
 Treatment. — In the pachydermia couscripta, as said before, some 
 cases will get well of themselves if the voice is given sufficient rest. 
 In mild cases, where the nodules are small, brushing with 25- to 50- 
 per-cent. solutions of lactic acid or 10-per-cent. solution of nitrate of 
 silver will result in their removal. Before the brushing a spray of 4- 
 per-cent. solution of cocaine would be required, to still the larynx, so 
 as to enable the application to be confined as much as possible to the 
 diseased parts. The treatment may be repeated at intervals of one or 
 two days while required. 
 
 In severe cases authors differ greatly in the treatment they advise. 
 Professor Chiari recommends the use of electrolysis. Heryng, when 
 the nodes are any size, advocates thorough cocainization and then the 
 snipping off of the projecting nodules. Some recommend the use of 
 a fine snare, and Gottstein advises the use of the galvanocautery point. 
 
 In diffuse pachydermia, consisting of so much hypertrophic tis- 
 sue, the treatment may require to be more vigorous to effect a removal. 
 Under cocaine a 50-per-cent. solution of lactic acid, applied by means 
 of a laryngeal cotton-holder at intervals of two or three days, will in 
 some cases promote absorption, while in others a 15- or 20-per-cent. 
 solution of nitrate of silver used in a similar way will effect a like re- 
 sult. It usually takes weeks or months of careful treatment to accom- 
 plish this. 
 
 In severe cases scraping the hypertrophic tissue with Krause's 
 curette, as in the treatment of tubercular infiltration, has been found 
 of service. This is done after thorough cocainization, and is followed 
 up by rubbing the raw surface freely with the lactic-acid solution, the 
 operation to be repeated if required. 
 
 Personally I have seen four cases of the diffused variety (British 
 Medical Journal, November, 1897). Two were treated by brushing 
 with solution of nitrate of silver and two by brushing with solution 
 of lactic acid. All recovered, although one required treatment for a 
 year and a half. Another had threatened return as the fall of the year 
 approached, and was obliged to seek residence in a milder clime. 
 
 One case of node of right cord, occurring in a minister, finally 
 disappeared under repeated sprays of -i-per-cent. of menthol in al- 
 
390 DISEASES OF THE LARYNX. 
 
 bolene, together with complete rest of the voice for a number of weeks. 
 In a second case, the patient being a lecturer, applications of solution 
 of nitrate of silver after cocainization, together with spray treatment, 
 resulted in cure. 
 
 Subglottic chronic laryngitis, which Gehrardt terms "chor- 
 ditis inferior hypertrophica," owing to the fact that it is attended with 
 local subglottic hypertrophies, sometimes occurs, and is likely to be 
 productive of a serious degree of laryngeal stenosis. The "chronic 
 blennorrhcea of Stoerck" likewise produces hypertrophies and cica- 
 trices, but on the vocal cords, instead of between them. Klebs says 
 that histologically the elements in blennorrhcea resemble those of rhi- 
 noscleroma. It is a question whether both conditions are not of the 
 nature of pachydermia. (Lennox Browne.) 
 
 Treatment would consist of dilatation, with or without trache- 
 otomy, as the indications of each case might call for. 
 
CHAPTER LXXIII. 
 PSEUDOMEMBRANOUS LARYNGITIS. 
 
 As true or pseudomembranous croup is believed by the majority 
 of physicians to be laryngeal diphtheria, it will not be treated of in this 
 volume, inasmuch as it is fully discussed in works upon general medi- 
 cine. 
 
 There are cases, however, of traumatic pseudomembranous laryn- 
 gitis to which a brief reference might be made. It is reasonable to 
 suppose, also, that if pseudomembranous rhinitis does occasionally 
 occur, of a purely idiopathic character, with the total absence of the 
 Klebs-Loeffler bacillus, so also might a similar disease occur in the 
 larynx under favorable conditions. 
 
 Of traumatic origin, I have had one case which occurred in Au- 
 gust, 1892, that of a young lady aged 25. Galvanocautery operation 
 upon the tonsils was followed three days later by intralaryngeal mem- 
 branous laryngitis. In this there was no continuation of membrane 
 from the tonsillar operation. The epiglottis was unaffected and the 
 membrane was formed upon the ventricular bands down to the vocal 
 cords, the latter being slightly involved in the coating. There was 
 some laryngeal stenosis and complete aphonia, with temperature of 
 100°. Treatment was by steam-inhalation and iron and glycerin in- 
 ternally. In four or five days the membrane had gradually disap- 
 ])eared. There was no recurrence. The case had no connection what- 
 ever with diphtheria, as there were no cases either before or afterward 
 in that neighborhood. The probability is that it was a pure fibrinous 
 deposit of staphylococcic origin. 
 
 At the Laryngological Society of Paris, January, 1894, Courtade 
 reported a case of "recurrent subglottic pseudomembranous laryngitis" 
 in a female aged 25 years. For eight days the patient had suffocative 
 attacks after meals and at night. Two years before she had a similar 
 illness lasting fifteen days. Laryngoscopic examination revealed a 
 whitish-gray plaque- beneath the cords. Antispasmodic remedies re- 
 lieved the symptoms, and coughing expelled four grayish flakes the 
 size of the little finger-nail and the thickness of a ten-cent piece. The 
 
 ' (391) 
 
392 DISEASES OF THE LARYNX. 
 
 aphonic voice then became normal, and laryngoscopic examination re- 
 vealed the mucous membrane of the ventricular bands, the arytenoids, 
 and the subglottic region of a deep-red color, but without trace of ex- 
 udation. 
 
 At the Laryngological Section of the International Medical Con- 
 gress held in Moscow, in 189 7, Rosenberg reported a case of laryngitis 
 fibrinosa in a man aged 67. Xo infection could be traced. The dis- 
 ease lasted eight days, and was marked by patches of membrane upon 
 the epiglottis and inner walls of the larynx, the zones surrounding the 
 affected spots being quite red and inflamed. The mucous membrane 
 and plaques were examined microscopically. Xo diphtheria bacilli 
 were found, but staphylococci and streptococci were, and the false 
 membrane was fibrinous. 
 
 Middlemas Hunt also reports a case of recurrent membranous 
 laryngitis which had existed off and on, in a middle-aged lady, for 19 
 years. The membrane would form, accompanied by acute sore throat, 
 and would last for a week or two, and then disappear for a similar 
 period, to be followed by another attack. It was always located to the 
 left side. Staphylococci and streptococci would be found, but no 
 Klebs-Loeffler bacilli. 
 
CHAPTER LXXIV. 
 
 LARYNGEAL PERICHONDRITIS. 
 
 This is a rare disease, occurring sometimes as a result of syphilis, 
 tuberculosis, or cancer of the larynx. In a few instances, as in the cases 
 of Newman and Jurasz, it develops as an acute idiopathic affection; 
 occasionally it occurs as a sequence to one of the exanthemata. It 
 comes on very suddenly, is attended by the gravest symptoms, and is 
 sometimes so obscure in its manifestations that a positive diagnosis 
 becomes exceedingly difficult. 
 
 Pathology. — There is at first increased vascularity in the peri- 
 chondrium of the cartilage. This gradually extends to the cartilage 
 itself, with increased cell-formation and swelling. This may be fol- 
 lowed by formation of pus beneath the perichondrium, separating it 
 from the chondrium and involving the latter in necrosis, or, by slower 
 process, cell-organization and hypertrophy may take place. 
 
 Of all the cartilages the cricoid is most frequently affected in the 
 acute idiopathic disease, and, as a rule, the inflammation confines itself 
 to the cartilage primarily involved. In tuberculous cases the aryte- 
 noids are the most frequent seat, and in these the inflammatory action 
 usually extends also to the cricoid. As regards frequency of develop- 
 ment, Bosworth, out of 33 cases collated, found that 23 involved the 
 cricoid, 3 the thyroid, 4 the arytenoid, 1 the cricoid and thyroid, and 
 in 2 cases all the cartilages were involved. Liming, out of 55 cases 
 collated, found disease of the cricoid in 22, of the cricoid and arytenoid 
 in 14, of arytenoid in 9, of thyroid and cricoid in 5, of thyroid, cricoid, 
 and arytenoid in 3, and of thyroid in 2. 
 
 Etiology. — As a single cause, perhaps exposure to cold may claim 
 the greatest number. It is likely, however, that some acquired or in- 
 herited weakness of constitution has in each case been a predisposing 
 factor. Typhoid fever, scarlatina, diphtheria, tuberculosis, syphilis, 
 etc., are also exciting causes, as also is traumatism. The majority of 
 cases occur in males, and the period is during adult life. 
 
 Symptomatology. — In very acute cases the disease is likely to be 
 ushered in by a well-marked chill and localized pain. As a rule, how- 
 ever, as there has been some previous indisposition, the chilliness may 
 be mild or even absent. Fever follows of two or three degrees, with 
 
 * (393) 
 
394 DISEASES OF THE LARYNX. 
 
 pain in the bones and general distress of the system, arising from the 
 approaching difficulty of respiration and deglutition. 
 
 When the cricoid is affected, the swelling on the inner surface of 
 the cartilage seriously interferes with breathing, both inspiration and 
 expiration being prolonged and difficult. • The tumefaction and sore- 
 ness will also interfere with deglutition. When the arytenoids are in- 
 volved, the closing of the glottis cannot be completed, and breathing- 
 may be easier than with cricoid stenosis, while odynphagia and dys- 
 phagia will both be more severe. Perichondritis of the thyroid carti- 
 lage is usually on the inner surface and unilateral. In this case the 
 voice, although hoarse, may not be entirely lost; when bilateral it 
 usually is. The epiglottis being composed of fibrocartilage instead of 
 simple cartilage, possesses more power of resistance, and is rarely, if 
 ever, attacked by idiopathic disease. 
 
 In acute cases the symptoms may reach their utmost severity in 
 a very few days, while in chronic ones they may exist a much longer 
 time without producing severe stenosis. 
 
 Diagnosis. — The suddenness of the attack, accompanied by steno- 
 sis and fever, with the absence of diphtheritic symptoms, may give 
 some idea of the nature of the disease. Still, it may not be easy to 
 arrive at a correct conclusion, even with the aid of the laryngoscope. 
 With the development of abscess, there is more or less oedema; and, 
 although the attending fever may distinguish it from simple oedema, 
 yet the laryngeal images of the two are sometimes so much alike that 
 doubt may be occasioned. When the swelling is not great enough to 
 obliterate the view of the infraglottic region, the unilateral character 
 of the perichondritis, with the swelling on the one side and the conse- 
 quent visible distortion of the larynx, will aid in diagnosis. This is 
 particularly the case with the supraglottic cartilages, but with the 
 cricoid, the disease being almost centrally situated and the swelling 
 widely diffused, it is often impossible for the laryngoscope to reveal 
 anything but general oedema of the parts. 
 
 This was particularly the case in a man, aged 50, whom I saw 
 in consultation some years ago. Acute laryngitis of some sort, ac- 
 companied by difficult respiration, came on suddenly. In forty-eight 
 hours from the supposed commencement of the attack I was sum- 
 moned. The man was ansemic; breathing was stertorous, inspiration 
 was more difficult than expiration. He had no pains and could walk 
 about with ease; temperature, 100°. By the laryngoscope the larynx 
 was found to be oedematous. Both arytenoids and epiglottis were 
 
LARYNGEAL PERICHONDRITIS. 395 
 
 swollen. Vocal cords could not be seen. By using spray of cocaine 
 and menthol in solution breathing became slightly easier. It did not 
 seem advisable to perform tracheotomy immediately, particularly as 
 the patient wanted any operation postponed as long as possible. I did 
 not see him again alive, as the following day he was thought to be 
 easier. The succeeding night the stertor became more severe. The 
 doctor was summoned. When he arrived half an hour later the pa- 
 tient was dead. 
 
 At the post-mortem we discovered an extensive perichondria! ab- 
 scess, extending more than half-way round the inner surface of the 
 cricoid. A portion was to the right side, but, after extending over the 
 anterior surface of the posterior half of the ring, it largely filled in the 
 
 Fig. 121. — Abscess of cricoid. Larynx opened from behind. The dark 
 spot below the centre and to the left side indicates the larger opening; the 
 lighter spot to the right, the smaller one. 
 
 left side, the cartilage itself being denuded and disorganized. The 
 other cartilages were in no way affected (Fig. 121). 
 
 I was informed by a member of the family that a brother of the 
 deceased died of the same trouble several years previously. 
 
 Prognosis. — The immediate danger is from laryngeal stenosis. 
 In chronic cases this comes on so gradually that there is time for con- 
 sideration before operation is. required. As disease of the cricoid pro- 
 duces the most extensive swelling, it is usually attended by the most 
 danger. When several cartilages are involved, the prognosis is most 
 unfavorable. In nearly all cases, however, life might be prolonged if 
 tracheotomy were performed comparatively early in the disease. The 
 presence of the purulent sac within the larynx would preclude the 
 advisability of intubation. 
 
396 DISEASES OF THE EARYXX. 
 
 Treatment. — When the progress of the disease is slow enough, to 
 allow of systemic treatment, this may be tried in the way of antiphlo- 
 gistic and diuretic measures. In cases in which the oedema is not too 
 great to permit of laryngeal observation, the point of protrusion may 
 be freely opened by the laryngeal lancet, after which inhalations of 
 steam will favor a free discharge. When pointing externally, it should 
 be opened early and discharge encouraged. 
 
 In cases of severe stenosis, however, whether from the oedema of 
 the parts or the pressure of the pus-sac, tracheotomy is always advis- 
 able. Artificial respiration once established, efforts can be made to 
 more thoroughly treat the perichondrial inflammation, and when re- 
 quired it is possible that the diseased cartilage itself might be removed, 
 in the absence of systemic disease. 
 
 Supporting treatment, when there is any prospect of prolonging 
 life, is always called for, and, owing to difficulty in deglutition, recourse 
 may be had to enemata. 
 
 The case I referred to is one in which I believe tracheotomy should 
 have been done at the time of my first and only visit. There is little 
 doubt but that it would have prolonged the patient's life; and I have 
 often regretted since that I did not insist at the time upon giving him 
 the required relief. 
 
 Affectioxs of the Cricoarytenoid Articelatiox. 
 
 De la Sota was the first to describe primary inflammation of this 
 joint due to exposure to cold, and Debrousses, in 1861, was the first to 
 express the opinion that such a trouble might be rheumatic in char- 
 acter. 
 
 When it is remembered that the cricoarytenoid articulation is sup- 
 plied, like the other joints of the body, with capsule and ligaments and 
 a true synovial membrane, besides possessing slight rotatory and lateral 
 movements, it is but natural to believe that it may be subject to the 
 usual run of joint diseases. The investigations of more recent observ- 
 ers have borne out this idea. 
 
 In 1880 Archambault wrote that acute laryngeal manifestations 
 of rheumatism were more common than was generally supposed, and 
 that one of its manifestations was in the articulations. 
 
 In 1887 George W. Major, of Montreal, drew attention to several 
 affections b}' which the cricoarytenoid articulation was sometimes in- 
 vaded. These were sprain, dislocation, direct local injury, acute in- 
 
AFFECTIONS OF THE CEICO ARYTENOID ARTICULATION. 397 
 
 flammation, and ankylosis. Of these, he gave instances, ankylosis of 
 the joint being the most common. The chief causes mentioned are 
 perichondritis, rheumatism, gout, the exanthems, and catarrhal affec- 
 tions; the chief of these is rheumatic inflammation of the joint. 
 
 The leading symptom is embarrassed breathing. The voice is not 
 much interfered with and swallowing, as a rule, is not difficult. En- 
 largement of the joint may be present, but there may be, in advanced 
 cases, atrophy instead. Other symptoms are external tenderness and 
 friction-sounds on manipulation. 
 
 Six years later, in an elaborate and valuable paper, bearing the 
 title of "Arthritis Deformans of the Larynx," Casselberry gave the his- 
 tory of an exceedingly interesting case. This occurred in a lady aged 
 58. She was a subject of general arthritis deformans, the joints of 
 both sides of the body being affected alike. The hands and wrists 
 were distorted, the fingers and thumbs dislocated, and the feet and 
 ankles similarly affected, though in a minor degree. 
 
 The cricoarytenoid joints were also ankylosed on each side alike. 
 The vocal processes of the arytenoids were similarly affected, the swell- 
 ing extending to the cords themselves. The posterior ends of the cords 
 Avere both thickened, projecting downward and upward and beyond the 
 natural line of the rima glottidis. The abductor muscles were so lim- 
 ited in their action as to prevent material opening of the glottis. 
 
 The history of this case proved that it was in no sense one of 
 paralysis, and, strange to say, neither did it seem to be one of gout or 
 rheumatism. This lady had never suffered from pain in any of the 
 joints during the development of the disease, and, what is more, medi- 
 cines administered for the relief of gout or rheumatism had not had 
 the slightest effect in arresting the progressive deformity. While un- 
 der Casselberry's care sprays and inhalents afforded temporary relief. 
 
 Newcomb has also written upon the "laryngeal manifestations of 
 rheumatism," dwelling particularly upon its development in the crico- 
 arytenoid joint, the symptoms being similar to those described by 
 Major. He speaks also of the deeper congestion which occurs along 
 the line of contact between the articular surfaces of the cartilages 
 affected. 
 
 Concerning treatment of the rheumatoid condition, nothing has 
 yet been found to take the place of the salicylates. Salol, or salicylate 
 of phenol, is a good addition to the group. Ingals has found much 
 relief in these cases from a combination of salol and extract of Phyto- 
 lacca in V 4 -gramme doses of each. Guaiac is also sometimes useful. 
 
CHAPTER LXXY. 
 TUBERCULOSIS OF THE LARYNX. 
 
 This disease is said to occur in from 10 to 20 per cent, of all cases 
 of pulmonary tuberculosis. In a large majority of cases it is secondary 
 to that affection, although in a certain proportion of cases it exists as 
 a primary disease. Bosworth takes the ground that the tubercular 
 process has added virulence as it occurs nearer the outer world, while 
 at the same time it occurs with less frequency, the ratio being inverted. 
 That is to say, that, while pharyngeal tuberculosis is the rarest of tuber- 
 cular manifestations, it is the most rapidly fatal. And laryngeal tuber- 
 culosis, occupying a medium position between the pharynx and lungs, 
 also occupies a median position, both with regard to severity and fre- 
 quency of the disease. Hence it is less frequent, but more rapidly 
 fatal, than simple pulmonary tuberculosis. 
 
 Pathology. — The morbid process of tuberculosis is essentially the 
 same, whatever part of the body it occurs in, being based upon the 
 presence of the tubercle bacilli in the affected tissue. In the large ma- 
 jority of cases the formation of tubercle within the larynx is secondary 
 to primary pulmonary disease. In rare instances it may arise in the 
 larynx de novo. 
 
 In the earliest stages of laryngeal tuberculosis there is infiltration 
 of the mucous membrane of the parts affected, with multiplication of 
 round embryonic cells, lymphocytes, and leucocytes. In the central 
 portion of the periphery these small cells may aggregate more densely, 
 resulting in necrosis and ulceration of the part, with deposit of cheesy 
 matter in the submucous layer. Quite frequently, although the tuber- 
 cle bacillus is considered the primary agent, it may be difficult to dis- 
 cover it microscopically. Usually the nodular or tubercular deposit is 
 at first subepithelial, gradually working toward the surface, and re- 
 sulting in ulceration. In nearly all" cases the disease is progressive, the 
 spots of disintegration multiplying as the tuberculosis extends 
 
 The amount of infiltration varies in different cases. In some it 
 is very superficial, and, according to Clifford Beale, this class of cases 
 is very much more amenable to treatment than when the disease ex- 
 tends to the submucous layer. 
 (398) 
 
TUBERCULOSIS. 399 
 
 When of recent development, the ulcers are shallow and super- 
 ficial, with jagged edges, the base being gray and smooth. On the 
 other hand, old ulcers are irregular, studded with hollows and small 
 cavities, around which the tissues are sclerosed. 
 
 The most frequent site is said to be the arytenoid commissure, 
 next the arytenoids, ventricular bands and cords, and perhaps last the 
 epiglottis, although authorities differ as to the frequency with which 
 the last mentioned is affected. 
 
 In some cases, although the arytenoids, commissure, and ven- 
 tricular bands may be involved, the cartilages being ulcerated and 
 eroded, the vocal cords may remain intact even to the last. In other 
 cases they are the chief seat of the disease, one or both being thick- 
 ened and jagged for the whole length of the border. When the peri- 
 chondrium is seriously invaded by necrosis, extensive oedema of the 
 submucous tissues is likely to ensue. 
 
 Etiology. — Tuberculosis of the larynx is usually a local manifesta- 
 tion of a systemic disease. It is rarely primary in origin, but dependent 
 upon a pulmonary tuberculosis already present. Granting, however, 
 a constitutional weakness, abrasion or relaxation of the laryngeal 
 mucosa may, in some cases, permit the invasion of the bacillus and 
 the primary development of the disease within the larynx. 
 
 Hereditary tendency has an undoubted influence in the etiology 
 of this disease. Catarrhal pharyngitis and laryngitis, as well as con- 
 tinued exposure to cold and wet, may also be classed as predisposing 
 causes. 
 
 As tuberculosis usually occurs in the lungs first, autoinfection is 
 believed by many to be the chief cause of its occurrence in the larynx, 
 any abrasion of the mucous membrane of that organ giving ready lodg- 
 ment to the tubercle bacilli, on their way outward in the act of cough- 
 ing; or invasion may occur through the medium of the lymphatic ves- 
 sels with which the larynx is so freely endowed. 
 
 Tubercular laryngitis occurs more frequently in males than 
 females. It is also a disease of adult life, by far the largest number 
 of cases occurring between the ages of twenty and forty years. 
 
 The percentage of cases- of pulmonary tuberculosis which are fol- 
 lowed by tuberculosis of the larynx is variously estimated by different 
 writers, the figures being between 10 and 30 per cent. Perhaps the 
 medium of 20 will be the nearest to the truth. 
 
 Symptomatology. — Impairment or softening of the voice is one of 
 the earliest symptoms. This is to be distinguished from the harsh 
 
400 DISEASES OF THE LARYNX. 
 
 voice, with lowered pitch, resulting from simple chronic laryngitis. 
 In this disease the muscles of the larynx are weakened and relaxed, 
 while the infiltration, which so frequently occurs at the arytenoid com- 
 missure, prevents the proper vocal adjustment of the cords, with con- 
 sequent loss of voice even to the extent of aphonia, as the disease 
 progresses. 
 
 When the disease is unilateral and situated entirely above the 
 vocal cords, or located in the epiglottis to the exclusion of other points, 
 impairment of voice may not be present. 
 
 Pain is a frequent symptom, especially during deglutition. When 
 the upper portions of the larynx, such as the arytenoids and epiglottis 
 are affected, the pain is usually more acute, and after ulceration has 
 commenced may be very severe. 
 
 Cough is probably present in all cases, the pulmonary cough being 
 notably increased by the laryngeal irritation. 
 
 There is also, particularly when oedema exists, a feeling of fullness 
 in the region of the larynx, which is very distressing to the patient. 
 
 The expectoration in the early stage as coming from the larynx 
 is limited. As the disease advances the secretion becomes more abun- 
 dant, and consists of gray, ropy mucus, as distinguished from the heavy, 
 muco-purulent matter, the product of pulmonary disease. 
 
 The ordinary systemic symptoms of tuberculosis will more rapidly 
 assume an aggravated form upon the addition of the laryngeal disease. 
 Emaciation comes on more quickly, mental anxiety is greater, and the 
 pain sustained by the patient is more severe than when pulmonary 
 tuberculosis exists alone. 
 
 Diagnosis. — When the examination of the lungs indicates tuber- 
 culosis, particularly if microscopical examination of the sputum dis- 
 covers the presence of tubercle bacilli, any decided softening of the 
 voice, together with laryngeal pain, will render the diagnosis of laryn- 
 geal tuberculosis almost certain. Lanmgoscopic examination, how- 
 ever, will always be necessary to make positive. the location and extent 
 of the disease. In cases, too, where the lungs are affected to only a 
 limited extent or not at all, the only certain way of arriving at the 
 truth may be by the use of the lanmgoscope. 
 
 In this disease the mucous membrane of the larynx and even the 
 pharynx will have lost to a large extent its accustomed pink color and 
 be more pallid in appearance. This will distinguish the tuberculosis 
 from the hyperemia of syphilitic and malignant disease. 
 
 This pallor, with swelling or infiltration, is the earliest local sign 
 
TUBERCULOSIS. 401 
 
 revealed by the laryngoscope. The swelling is confined to the spot 
 involved in the disease, the pallor being diffused over the surrounding 
 tissues. The infiltration is at first unilateral, but may soon extend to 
 the opposite side, assuming, in the case of the arytenoids, the club- 
 shape, and, in the epiglottis, the turban form. 
 
 Prior to ulceration the membrane of the swollen tissues is of a 
 dull-gray-yellowish tinge, smooth and moist, but without the semi- 
 transparent appearance of healthy mucous membrane. As the disease 
 advances, minute yellow spots of tubercle may be seen dotting the in- 
 filtrated tissue. They form on the mucosa beneath the epithelium. 
 As they enlarge, they project a little above the surface, and, gradually 
 breaking down, leave an ulcerated surface. These ulcerations are 
 shallow and differ little in color from the surrounding tissue. As they 
 extend, the surface assumes an irregular worm-eaten appearance, and, 
 although there is consequent loss of tissue, this is less apparent, owing 
 to infiltration which prevails beneath and around the ulcer. Any 
 granulations that occur are usually of a pale-pink color. 
 
 When the epiglottis is the seat of the disease, loss of tissue fre- 
 quently extends rapidly, the greater part or even the whole of the 
 organ being gradually eaten away by the ulceration. The pallor of the 
 tissues, the shallowness of ulceration, the results of microscopical anal- 
 ysis, together with the local and systemic symptoms, should render the 
 diagnosis certain. 
 
 Prognosis.— This is exceedingly grave. The large majority of 
 cases die, and, as it is usually a secondary manifestation, its presence 
 only adds speed to the coming fatal issue. Still, cases do recover, and 
 a number are on record in which the laryngeal tuberculosis has been 
 completely removed, although the patient has ultimately died of orig- 
 inal pulmonary disease. 
 
 After extensive personal observation, as well as investigation of 
 records, Bosworth has arrived at the conclusion that the average dura- 
 tion of life in pulmonary tuberculosis uncomplicated is three years: 
 complicated with laryngeal disease, two years; and duration of life 
 after larynx has become involved, one and one-half years. 
 
 Although pulmonary consumption is, in some instances, a curable 
 disease, the records of post-mortems proving that many people die of 
 diseases other than tubercular, although exhibiting cicatrices within 
 the lung-tissue arising from healed vomicae, yet, when complicated 
 with laryngeal tuberculosis, the former always eventually proves fatal. 
 
 Of late years, however, the cure of the laryngeal tuberculosis itself. 
 
402 DISEASES OF THE LARYNX. 
 
 if taken early, is by many laryngologists believed to be possible, at 
 least in numbers of cases, the life of the sufferer being thereby pro- 
 longed. 
 
 Treatment. — For general constitutional treatment, the demands 
 made in behalf of laryngeal tuberculosis do not differ from those re- 
 quired when the disease is located in other organs of the body. Our 
 province here, however, refers to the direct treatment of the local dis- 
 ease. In the early history of cases, and before operative measures can 
 be deemed advisable, probably no method of treatment is of equal value 
 to that of sprays, thrown by the atomizer directly into the larynx. Of 
 all the medicaments that can be applied in this manner, I have found 
 none so useful as different percentages of menthol in albolene. This 
 may vary from 2 to 10 or even 20 per cent, of the stearoptene in the 
 oil, commencing with the lower number, and gradually making the 
 proportion stronger as the patient is able to bear the application. Even 
 after ulceration has commenced and the tissues of the larynx are grad- 
 ually becoming disintegrated, the cleansing and soothing effects of the 
 drug thus applied are always grateful to the patient. Bishop prefers 
 camphor-menthol for this purpose, while others advise insufflations of 
 iodoform, iodol, aristol, etc. When the pain is severe, occurring so fre- 
 quently as it does in the advanced stages of the disease, solutions of 
 cocaine are recommended for local application, on account of the tem- 
 porary relief which they insure. In these cases, intrinsically hopeless, 
 it is undoubtedly our duty to do all that is possible for the comfort and 
 physical relief of the patient. Lennox Browne, Charles Knight, and 
 many others believe that much can be accomplished by spray-treat- 
 ment, and menthol in various proportions appears to be the drug that 
 they rely most upon in these cases. G-uaiacol in albolene or olive-oil 
 in 30- to 60-per-cent. solution acts in a similar manner to the menthol 
 and is worthy of trial. 
 
 Of direct local applications to be applied by means of the laryn- 
 geal cotton-holder, the one that is believed to be the most useful, and 
 receives the widest professional support at the present time, is lactic 
 acid. It was introduced in 1885 by Ivrause, and is used in various 
 strengths from 25- to 100-per-cent. solution. It may be applied to the 
 diseased tissue by brush or cotton-holder. 
 
 Parachlorphenol, 5 to 20 per cent., in glycerin is another remedy 
 recently advocated by Simonowsky, applied as a pigment, and enzymol 
 is spoken of by Murray as a most valuable adjunct to other treatment. 
 
 Intralaryngeal surgical treatment is the most modern and radical 
 
TUBEKCULOSIS. 403 
 
 means advocated for the relief and cure of this disease. Different lines 
 of procedure have been followed with more or less success. 
 
 First arid most prominent is cnrettement. Then follow submu- 
 cous injections, electrolysis, and galvanocautery operations. Together 
 with these methods, the regular throat treatment by lactic acid, brush- 
 ing, etc., may be associated, according to the judgment of the operator. 
 
 As pointed out by Gleitsmann, fifteen members of the Laryngeal 
 Section of the International Congress at Eome advocated cnrettement 
 in suitably-situated cases. This is particularly applicable to the aryte- 
 noid and commissural regions. In advocating this measure he does so 
 under the following conditions: — 
 
 1. In cases of primary tuberculous affections without pulmonary 
 complication. 
 
 2. In cases with circumscribed ulcerations and infiltrations. 
 
 3. In cases with dense, hard infiltrations of the arytenoid region, 
 the ventricular bands, and tuberculous tumors of the epiglottis. 
 
 4. In the incipient stage of pulmonary disease, with but little 
 fever and no hectic symptoms. 
 
 5. In advanced pulmonary disease with distressing dysphagia, re- 
 sulting from infiltration of arytenoids, as the quickest means to give 
 relief. 
 
 Gleitsmann gives the following as contra-indications of cnrette- 
 ment: — 
 
 1. Advanced pulmonary disease and hectic. 
 
 2. Disseminated tuberculosis of larynx. 
 
 3. Extensive infiltration, producing severe stenosis, when trache- 
 otomy is indicated or laryngotomy can be taken into consideration. 
 
 The operation should be done under the free use of cocaine, and 
 by means of Heryng's double curette. 
 
 Submucous injection of lactic acid has also its advocates. This 
 is introduced into the affected tissue by an appropriate curved syringe. 
 Creasote in the same manner is likewise advocated strongly by Chapelle. 
 
 Treatment by electrolysis, as taught by Scheppegrell, is too recent 
 to be worthy of strong advocacy yet. Galvanocautery operations have, 
 however, been used to advantage, with or without the addition of 
 cnrettement. 
 
 Tracheotomy and laryngotomy can only be considered advisable 
 as last resorts, indicated to relieve extreme stenosis and dyspnoea. 
 
 As said before, general constitutional treatment is alike whether 
 the disease be located in the larynx, lungs, or both, and should, me- 
 
404 DISEASES OF THE LARYXX. 
 
 dicinally and dietetically, be, in the highest degree, of a supporting 
 character. Codliver-oil, when purified and deodorized, is by no means 
 an unpalatable agent; and is still largely and wisely used. Creasote has 
 long been a favorite remedy in doses of 1 / i cubic centimetre two or 
 three times a day variously modified. Latterly, however, creosotal, 
 or, more correctly, carbonate of creasote, has largely taken its place, 
 inasmuch as doses containing several times this amount of creasote 
 can in many cases be taken without in any way injuring the digestive 
 system. 
 
 A very eligible way of administering the creosotal is in combina- 
 tion with purified codliver-oil, as: — 
 
 1. I£ Creasote carbonate 60 
 
 01. morrh. opt 360 
 
 M. Sig.: Eight to sixteen grammes three times a day after 
 meals. 
 
 With the best of treatment and care this class of cases, as already 
 stated, cannot, on the whole, be considered hopeful; yet much can be 
 done to relieve the sufferings, prolong the life, and in some way benefit 
 the unhappy victims of this disease. Guaiacol is sometimes of benefit. 
 Small doses of morphine and codeine may also be of advantage in allay- 
 ing distressing symptoms. 
 
 E. Lake (Journal of Laryngology, Rhinology, and Otology, Feb- 
 ruary, 1899) says that, while "general treatment is useless, one must 
 not lose sight of the enormous aid one derives from increasing the 
 powers of resistance in the body, and by increasing the numbers and 
 energy of phagocytes and white corpuscles." Local measures he divides 
 into surgical and non-surgical. The former consist in removing dis- 
 eased portions, curetting ulcers, and depleting cedematous tissues by 
 puncture, etc. The latter consist of insufflation of powders, painting 
 on or rubbing in of solutions, the injection into the tissues of hypo- 
 dermic remedies, and the injection into the trachea of oily solutions 
 by syringes and atomizers. In using any "paint" to the larynx a brush 
 should never be used, but always a cotton-wool mop, for the two reasons 
 of cleanliness and efficiency. Brisk and firm friction are required, and 
 all solutions should be as strong as possible. "When injections are given 
 the temperature should be about 80° F., the patient being instructed 
 
 1. I£ Creasote carbonate 3ij- 
 
 01. morrh. opt §xij. 
 
 M. Sig.: Two to four teaspoonfuls three times a day after meals. 
 
TUBEECULOSIS. 405 
 
 to inhale deeply, hold his breath immediately after the injection, and 
 not to cough. The conditions attending laryngeal tuberculosis are 
 divided into six clinical heads: 1. Granular condition of vocal cords. 
 2. Superficial excoriation or ulceration. 3. (Edema. 4. (Edema and 
 superficial ulceration. 5. Deep ulceration. 6. Mixed oedema and deep 
 ulceration. In ISTos. 1 and 2 no method of treatment has been so effi- 
 cacious as intratracheal injection. In Nos. 3 and 4 surgical treatment 
 is required as well as the application of paints. Cutting-forceps do the 
 most effective work. Formic aldehyde or lactic acid should be used 
 after every intralaryngeal operation on a tubercular subject, no matter 
 how small the operation. In Nos. 5 and 6 frictions and operations are 
 useless as well as intolerant to the patient. In such cases insufflations 
 of iodoform and orthoform will have a wonderfully soothing effect, par- 
 ticularly the latter, which is noted for its prolonged action. It is a 
 non-toxic anodyne, producing anaesthesia of the parts for nearly twenty- 
 four hours. The prognosis, under judicious treatment, is good under 
 the first two divisions, fairly good in some of the third and fourth varie- 
 ties, and universally bad in the other two. 
 
 25a 
 
CHAPTER LXXVI. 
 LUPUS OF THE LARYNX. 
 
 Primary lupus of the larynx is not so rare as primary tubercu- 
 losis of the larynx, although both are believed to owe their origin to 
 the presence of tubercle bacilli. As a rule, however, it is secondary 
 in its origin, being derived from lupus of the pharynx, which itself 
 had been an offshoot of lupus of the skin. In this, too, it differs from 
 tuberculosis of the larynx in being sequel to an external disease instead 
 of an internal one (Fig. 122). 
 
 To the comparatively long list of cases of primary origin already 
 published, Mayer, of New York, has recently added two more. On 
 
 Fig. 122. — Lupus. Laryngoscopy appearance. 
 (After Lennox Browne.) 
 
 examination of the report in the Journal of Laryngology in 1897, 
 however, only one of these could be called purely laryngeal, and the 
 other was a long-standing case under the care of Morris J. Asch, and 
 was more pharyngeal than laryngeal. In this case the skin was for 
 years unaffected, and the patient lived for eighteen years, finally dying 
 of apical tuberculosis. 
 
 For the pathology and etiology of laryngeal lupus, reference to 
 its history as occurring in the pharynx will cover the points of chief 
 interest. The only point that need be further mentioned here is the 
 one brought out by Lefferts many years ago, that the first pathological 
 element of this disease is essential hypertrophy of tissue. This is fol- 
 lowed by slow, but destructive, ulceration, to be succeeded by dense, 
 (406) 
 
LUPUS OF THE LARYNX. 
 
 407 
 
 hard cicatrices. All three conditions may exist in the one larynx at 
 the same time. 
 
 Symptomatology. — Primary lupus of the larynx may exist for a 
 long time before developing symptoms. Like its congeners in the face 
 and pharynx, it may exist almost indefinitely without producing pain. 
 After awhile there may he slight huskiness, dyspnoea, and soreness. 
 The secondary disease resembles the primary, but it is more readily 
 discovered, owing to the primary indications. Huskiness may arise 
 from involvement of the cords and commissure, and stenosis from the 
 intralaryngeal development of the disease. Cicatrization occurs after 
 
 Fig. 123. — Lupus of the epiglottis (Vs-inch objective; Ehrlich-Biondi 
 stain). (After Lennox Browne.) 
 
 destruction of tissue, and this may lead to laryngeal stricture. The 
 epiglottis is usually the part first affected (Figs. 123 and 124). 
 
 Diagnosis. — A laryngeal examination will always be necessary for 
 correct diagnosis. It needs to be distinguished from tuberculosis, 
 syphilis, carcinoma, and leprosy. The surface is pale and slightly 
 cedematous. Ulcerations form, but, unlike tuberculosis, they are fol- 
 lowed by cicatrization and consequent distortion with marginal thick- 
 enings. Another peculiarity noted by Lennox Browne is that in lupus 
 of the epiglottis the infiltrations are sometimes so heavy that they make 
 that organ overhang and almost hide the inner larynx. There are no 
 systemic symptoms as in tuberculosis or cancer, and there is no foul 
 secretion as in syphilitic disease. In eastern countries it might be con- 
 
408 DISEASES OP THE LARYNX. 
 
 founded with leprosy. It resembles it most in insensitiveness of tissue, 
 but leprosy never occurs in the larynx alone. The absence of systemic 
 symptoms should make the diagnosis comparatively certain. 
 
 Prognosis. — This in many instances is good, so far as temporary 
 recovery is concerned. The progress of the disease is slow. Sometimes 
 it may be arrested for awhile, and recur at a later date at the old cica- 
 trix. It is not often dangerous to life, but, being a manifestation of 
 the presence of tubercle bacilli, tuberculosis of the lungs may super- 
 vene to carry off the patient. In some instances the disease itself ha* 
 been known to produce fatal stenosis. 
 
 m s 
 
 Fig. 124. — Lupus of the epiglottis (y 2 -inch objective; Ehrlich-Biondi 
 stain). (After Lennox Browne.) 
 
 Treatment. — This does not materially differ from that of laryn- 
 geal tuberculosis. Supporting measures to the system are required, 
 though not so loudly called for as in the sister-disease. Curettage, 
 owing to the hardness of the nodules, needs to be done more vigorously 
 than in tuberculosis, but is followed by better results. Local treat- 
 ment b}' applications of lactic acid, menthol, and creasote are of the 
 highest importance. By the use of one or other of these or all in suc- 
 cession the disease may frequently be arrested, giving the patient 
 months or even years of relief. When operation becomes necessary it 
 is more hopeful than in tuberculous disease. Schroetter's bougies may 
 dilate the stenosed larynx in some cases. Tracheotomy will always 
 
lupus. 409 
 
 afford relief when life is endangered from stenosis. When severe con- 
 striction occurs in the glottic region, intubation may be required, 
 though some authorities claim that the irritation produced by the 
 pressure of the tube will only accentuate the growth of the disease. 
 
CHAPTEE LXXYII. 
 LEPEOSY OF THE AIR-PASSAGES. 
 
 The International Conference on Leprosy held in Berlin in 
 October, 1897, gaYe to the general profession almost the first light 
 they have had upon this obscure subject. Gliick, of Sarajevo, made a 
 report upon 37 cases affecting the air-passages, all taken from the one 
 leprous district; Jeanselme and Laurens, of Paris, based their state- 
 ment upon 26 cases of general leprosy, 60 per cent, of which had lep- 
 rosy of the mouth, nose, or throat. 
 
 The disease always affects the mouth or nose before invading the 
 pharynx or larynx. According to Gliick's experience, the nasal cavity 
 was affected in 90 per cent, of his cases, the larynx in 70 per cent., and 
 the mouth and tongue in 50 per cent. In the large majority of in- 
 stances the skin is attacked much earlier than the mucous membrane. 
 In some cases, however, it is reported to have commenced within the 
 nose. 
 
 One of the leading features of leprosy is to attack (1) the epidermal 
 structures, and (2) the mucous membranes bordering upon them, the 
 two surface epithelial coverings being always affected before the under- 
 lying tissues. 
 
 There are two varieties of leprosy: the nodular and the anaesthetic. 
 
 "The microscopical changes differ somewhat in the two varieties. 
 Those of the nodular, or tuberculous class, commence as an accumula- 
 tion of lymphocytes in the perivascular lymph-spaces, forming a net- 
 work of infiltration-strands .which, increasing in thickness, appear un- 
 der a low power as solid cylinders invading and absorbing the inter- 
 vening tissues. In section under high power these strands appear like 
 nodules with giant cells, and if stained by the Ziehl-Xeelsen or Gram's 
 method are seen to contain bacilli. 
 
 "In the anaesthetic form bacilli are not easily demonstrated; they 
 can, however, be seen in the inflammatory cell-tissue growing along 
 the perineural lymph-spaces. 
 
 "The specific bacillus of leprosy, or Hansen's bacillus, has certain 
 peculiarities which distinguish it from bacillus of tubercle. They are 
 (410) 
 
LEPROSY OF THE NOSE. 411 
 
 from 5 to 6 microns in length and 0.35 to 0.50 micron in thickness. 
 The rods are said by Babes to be interrupted by non-staining, clear 
 spaces, representing doubtful spores. They are, as a rule, readily 
 stained in situ, as may easily be demonstrated by the trituration 
 method, aided by boiling and digesting." (Lennox Browne.) 
 
 Leprosy in the Xose. 
 
 The first symptoms are those of persistent coryza accompanied by 
 formation of crusts. The discharges contain Hansen's bacillus, and 
 are consequently contagious. This is the more dangerous in cases in 
 which the nasal disease is primary, as the leper is consequently not 
 immediately aware of the nature of the disease. Epistaxis is also an 
 early symptom. The bridge of the nose becomes broader and the 
 cuticle thicker, while the organ shortens in length, the anterior nares 
 assuming an almost vertical plane. The disease is usually of the 
 nodular type. 
 
 Soon the cartilaginous septum softens and gives way, the bridge 
 drops, and the nose flattens with the rest of the visage, as in the case 
 of septal destruction from tertiary syphilis. 
 
 In the early stages the mucous membrane is reddened, swollen, 
 and liable to bleed when touched. In the later ones, brown crusts, 
 erosions, and muco-pus are present. The destructive lesions are the 
 whitish- or pinkish- gray, leprous nodules, contrasting forcibly with 
 the deep red of the rest of the membrane. As the nodules become con- 
 fluent, they may close up the nares, producing complete stenosis. 
 
 When septal perforations take place, it is by resorption and with- 
 out sloughing or discharge. As the disease advances, pronounced 
 anaesthesia occurs. The sense of smell is retained, although pallor and 
 atrophy mark the climax of the disease. 
 
 Lupus and syphilis are the only diseases for which leprosy of the 
 nose might be mistaken. Lupus-nodules are firmer. In lupus, also, 
 the nostrils may be eaten away, the septum remaining sufficiently in- 
 tact to support the nose, and always being the last to succumb, while 
 in leprosy it is almost the first to yield. Leprosy also has more anaes- 
 thesia during its progress, and, as the disease advances, invariably 
 affects the cuticle to a greater extent than does the lupus. The two 
 latter symptoms also distinguish this disease from syphilis, the general 
 history of which, with its unilateral development in the nose, should 
 be sufficient to render diagnosis certain. 
 
412 diseases of the larynx. 
 
 Leprosy of the Mouth and Pharynx. 
 
 In these regions smooth patches are first formed, to be succeeded 
 by prominent nodules. The median furrow of the tongue is said to be 
 greatly exaggerated. Anaesthesia and infiltration of irregular patches 
 take place, while the sense of taste, like the sense of smell, is usually 
 retained. Morell Mackenzie, in tabulating the history of twenty-five 
 cases, only reported dysphagia as present in one. It is fortunate that 
 so terrible and loathsome a disease should entail so little physical suf- 
 fering. 
 
 The pharynx is always more or less inflamed. Hypertrophy of the 
 tonsils and other tissues soon follows, to be succeeded at a later stage 
 by atrophy. 
 
 Hearing is also likely to be impaired, through extension of the 
 disease to the Eustachian tubes. 
 
 The diagnosis from syphilis and lupus must be made on similar 
 lines to those already referred to. From tuberculosis of the pharynx, 
 which it somewhat resembles; the intense pain attending the former, 
 with its characteristic high febrile action, should readily be distin- 
 guished from the anaesthesia and low temperature always found in the 
 leprous throat. 
 
 Leprosy of the Larynx. 
 
 The first appearances of this disease in the larynx are usually in 
 the form of little, gray, sensitive nodules on the posterior side of the 
 epiglottis. At first, as they produce no irritation, they are unnoticed 
 by the patient. Later on, as the disease spreads all over the epiglottis 
 and to the arytenoids and aryepiglottic folds, forming a gray, hard- 
 ened mass, respiration as well as vocalization may be interfered with. 
 The interarytenoid commissure, at first appearing like a soft cushion, 
 at a later period becomes crusted and hardened, a general pachydermia 
 of the larynx having taken place. As the disease advances, it is usu- 
 ally impossible to examine with the laryngoscope the lower portions 
 of the larynx, on account of the extensive thickening and fixation of 
 the epiglottis itself (Fig. 125). ■ 
 
 When this organ is eaten away, as in Mackenzie's case, the dis- 
 torted intralarynx may sometimes be examined. 
 
 According to Bergengriin, the implication of the vocal cords does 
 not come on until late in the disease, and sometimes not at all. 
 
 The experience of Lennox Browne, from whose book this chapter 
 
LEPROSY OF THE LARYNX. 
 
 413 
 
 is largely taken, bears out that of other observers, that the changes 
 which first occur in the larynx are those of general thickening and less 
 nodular than when found on the palate, and that the destruction of 
 the natural tissues, as the disease advances, is always more of the nature 
 of absorption than of ulceration. 
 
 "While the functions of phonation, respiration, and deglutition 
 
 Fig. 125. — Leprosy of the tongue and epiglottis. 
 (From Lennox Browne, 1899.) 
 
 may be interfered with to a more or less extent, the patient suffers 
 little, if any, pain in this disease. Structural changes, also, appear to 
 affect the vocal cords last of all. The voice at first is but slightly 
 altered. Then the higher tones may be broken, hoarseness and aphonia 
 coming on at a later period in many cases. 
 
 Deglutition is sometimes difficult, but rarely painful. 
 
 Respiration is always interfered with to a more or less extent, and 
 
414 DISEASES OF THE LARYNX. 
 
 when the vocal cords are affected may be very difficult, producing 
 stenosis and necessitating tracheotomy to prolong the life of the pa- 
 tient. Dr. Abraham has reported a case in which the glottis was re- 
 duced to the size of a goose-quill. Death sometimes occurs from oedema 
 of the glottis the result of the disease. 
 
 Treatment. — No treatment is curative. Palliation is all that can 
 be accomplished. De la Sota reports beneficial results from applying 
 resorcin and iodoform in ether. Hygienic and dietetic measures should 
 be attended to. Lennox Browne suggests the advisability of trying 
 serum-therapy. 
 
CHAPTEE LXXVIII. 
 
 SYPHILIS OF THE LARYNX. 
 
 Pkimaky syphilis of the larynx is so rare as to be almost unknown, 
 and, as a secondary lesion, it is seldom met with. The chief mani- 
 festation of the disease is in the so-called tertiary period, occurring 
 many years after the development of the primary lesion. Congenital 
 syphilis of the larynx is a rare affection. 
 
 Pathology. — The pathological conditions produced by syphilis of 
 
 Fig. 126. — Destruction of epiglottis from syphilitic ulceration. 
 (From Bosworth.) 
 
 the larynx are as variable as those found in the upper portion of the 
 respiratory tract, with the exception of the extreme rarity of the pri- 
 mary stage. 
 
 In secondary syphilis there may be the deep congestion of the 
 mucous membrane, accompanied by dryness. Following this may 
 come infiltration, the swollen membrane quickly becoming the seat of 
 numerous shallow ulcerations, resembling the mucous patches observed 
 in the pharynx, but distributed with less regularity. These occur from 
 six months to two years after the development of the primary sore in 
 some other part of the bodv, and are onlv found in the vocal cords. 
 
 (415) 
 
416 DISEASES OF THE LARYNX. 
 
 The ulcerations occurring in this stage are gray in color, surrounded 
 by an hyperasmic red zone. Secondary syphilis rarely occurs in the 
 larynx until several weeks or months after the appearance of the 
 cutaneous eruption. 
 
 The tertiary stage is also marked by hyperemia. This may he 
 followed by deep and rapid ulceration, destroying cartilage and sur- 
 rounding tissue. Efforts to repair by Nature produce severe contrac- 
 tion from cicatrization, impeding respiration and producing stenosis. 
 The extensive destruction of the epiglottis and other cartilages of the 
 larynx, arising from tertiary disease, may end in gross deformity as 
 well (Fig. 126). 
 
 Gummy tumors are probably the most frequent pathological for- 
 
 Fig. 127. — Cicatricial stenosis of larynx, the result of syphilitic 
 ulceration. (From Bosworth.) 
 
 mation found in the larynx during the course of this disease. They 
 do not occur, however, until years after the primary infection. The 
 interval may be over one and even two decades, the larynx during all 
 this long interval being practically free from disease. Sometimes the 
 gummatous tumor involving one of the vocal cords may break down 
 by ulceration, with extensive destruction of the tissues. In others it 
 may continue as a dark, nodular enlargement impeding the functions 
 of deglutition and respiration. The process of cure after destruction 
 of cartilage is aided by formation of connective tissue; but this rapidly 
 contracts, resulting in the deformities of cicatrization already referred 
 to (Fig. 127). 
 
 Etiology. — Syphilis of the larynx is usually a tertiary, sometimes 
 
SYPHILIS. 417 
 
 a secondary, manifestation of acquired disease. As a primary affection, 
 the case reported by Moure, of Paris, in 1890, appears to be the only' 
 one on record. The canse may be hereditary as well as acquired. Syph- 
 ilis of the larynx occurs more frequently in men than in women. 
 
 Symptomatology. — In secondary syphilis of the larynx the symp- 
 toms of the first stage resemble those of simple acute laryngitis. There 
 will be soreness and hoarseness, and laryngoscopic examination will 
 reveal the congested condition. Soon the rosy appearance becomes 
 mottled. Certain parts assume a raised position and superficial ulcera- 
 tion follows. The voice changes early and the pitch is lowered. Odyn- 
 phagia, as well as hacking cough with expectoration of muco-pus, is 
 also usually present. When mucous patches are present they may be 
 found most frequently upon the vocal cords, then upon the inter- 
 arvtenoid space, the ventricular bands, and the epiglottis. Condylo- 
 mata sometimes occur in this stage. They are usually absorbed, and, 
 like the ulcerations, are only of a few weeks' duration. 
 
 In the tertiary stage the deep ulcerations usually affect the epi- 
 glottis first, the oral surface on the edge being the first to suffer; next 
 the intralaryngeal cavity and infraglottic region. It is during this 
 stage that gummata are likely to develop. They consist of infiltration 
 of the deeper layer of the laryngeal tissues, sometimes extending to 
 the perichondrium. When the cartilages are affected the pain is more 
 severe than when the gummatous deposit is confined to the epiglottic 
 folds and ventricular bands. When the tumor develops within the 
 respiratory tract, dyspnoea may follow as an effect of stenosis, while 
 impairment of voice will result from the disease affecting the cords. 
 
 Apart from the stenosis produced by gummatous enlargement, it 
 arises much more frequently from the vigorous cicatrization following 
 the ulcerative process. Sometimes this is so severe as to threaten im- 
 mediate suffocation. Xot infrequently a cicatricial web forms, uniting 
 the anterior ends of the vocal cords together; and, the slow chronic 
 inflammation of the mucous membrane continuing, the lumen of the 
 glottis may eventually be almost entirely closed. Pain in these cases 
 is much less severe than would be expected, from the severity and 
 extent of the diseased condition. 
 
 Diagnosis. — In the early stages it has to be distinguished from 
 a simple catarrhal laryngitis. This, however, never extends to ulcera- 
 tion, and is easily removed by simple treatment, while the syphilitic 
 lesion only yields to specific treatment. When the mucous patch has 
 formed, it has the like distinguishing features of mucous patch in the 
 
418 DISEASES OF THE LARYNX. 
 
 phaynx. The gummy tumor, as seen in the larynx, is a smooth, 
 rounded tumefaction of hyperemia appearance, and, unless destroyed, 
 by treatment or ulceration, likely to remain for some time. It is this 
 manifestation of the disease which might be mistaken for tuberculosis 
 or cancer. The diagnosis, however, is not always easily made. In 
 tuberculosis the infiltration may be extensive as well as anaemic, in- 
 stead of hypersemic and circumscribed. In the one you have more 
 local pain and febrile action, together with pulmonary lesion and 
 emaciation. In the other these s}^mptoms may all be absent, save the 
 difficulty of deglutition and probable stenosis. From malignant dis- 
 ease it is distinguished by the history of the case; the absence of can- 
 cerous cachexia, exuberance of growth, and haemorrhage should help 
 to make the diagnosis certain. In all doubtful cases administration 
 of antisyphilitic remedies should help to clear away the mystery. 
 
 Prognosis. — Under proper treatment this should always be favor- 
 able, except in cases in which destructive action has already com- 
 menced. In even these it may be arrested. When, however, deep 
 ulceration has followed the gummy deposit, cicatrization is bound to 
 take place, the only hope being to promote absorption and arrest 
 further ulceration. 
 
 Treatment. — The local treatment of secondary symptoms consists 
 of frequent sprays of a mild, alkaline character, the main object being 
 to keep the mucous membrane as free as possible from all irritating 
 or foul secretions. If the ulcerations or mucous patches persist in 
 development, a nitrate-of-silver pigment of 10 per cent., applied on 
 a cotton-holder, will do good service, the parts having been previously 
 deadened by a solution of cocaine. Iodoform or iodol in powder by 
 insufflation, or weak solution of corrosive sublimate by atomizer, is 
 also applied in these cases. Cleansing and disinfectant treatment of 
 the larynx is always in order in tertiary as well as secondary disease. 
 
 The main reliance, however, must be placed on systemic treat- 
 ment. In the earlier stages of syphilitic lanmgitis mercurials are in- 
 dicated, just as when it occurs in other parts of the body, while in ter- 
 tiary disease the iodides are needed in full and regular doses. Some- 
 times a combination of the two is attended by the best results. 
 
 Surgical treatment is not required except in cases in which strict- 
 ure has become so severe as to produce serious laryngeal stenosis. In 
 these cases various methods of treatment may be called for. It is not 
 often that membranous tissue can be removed without danger of in- 
 ducing still more serious stricture. Still, in some cases adventitious 
 
SYPHILIS. 419 
 
 bands may be incised or snipped away. As a rule, when stenosis is 
 severe, laryngeal dilators are called for. Of the many that have been 
 used, Schroetter's, Navratil's, and Mackenzie's are among the best. The 
 object in all is the gradual dilatation of the stricture, the instrument 
 being passed into the larynx and retained as long as possible. The 
 treatment should be repeated at intervals of a day or two and con- 
 tinued for months or until permanent advantage is secured. 
 
 Other means failing to produce the requisite amount of relief, in- 
 tubation possesses, in some respects, a decided advantage over trache- 
 otomy, inasmuch as it does away with any cutting operation. It can 
 also be practiced by means of reflected light, and the tube worn or 
 removed at pleasure. The chief disadvantage of a prolonged use of the 
 
 Fig. 128.— Lennox Browne's hollow laryngeal dilator with cutting- 
 blade (Va measurement). 
 
 instrument may be the defective deglutition which its insertion in a 
 distorted larynx may produce. 
 
 Several years ago J. Mount Bleyer read an exceedingly interest- 
 ing report to the American Medical Association, giving the history 
 of the successful treatment of eight cases of syphilitic laryngeal steno- 
 sis. In all these he combined the use of Lennox Browne's cutting 
 dilator with the after-insertion of O'Dwyer's tubes (Fig. 128). The 
 throat is first sprayed with a 20-per-cent. solution of cocaine. Then 
 the cutting dilator is inserted, a large-sized throat-mirror being used 
 in order to give sufficient reflected light. For the moment breathing- 
 is interfered with, but the incision of the cicatrix is quickly made. 
 Slight bleeding follows. A few minutes later a large-sized hard-rubber 
 intubation-tube is introduced and worn for two weeks. It can be re- 
 moved once or twice during that period, if required, for cleansing pur- 
 
420 DISEASES OF THE LARYNX. 
 
 poses. In every instance there was greatly-improved breathing-space. 
 The several margins of each cicatrix healed without union, leaving 
 an almost normal chink. 
 
 Bleyer closes his article with the following conclusions:— 
 
 "1. In the first place, the destruction of the cicatricial web, by 
 means of the knife, is preferable in every way to the older operation 
 of simple dilation. 
 
 "2. It is a more radical procedure, and the obstructing tissue is 
 destroyed quickly, instead of being pushed aside and thus allowed to 
 slough. 
 
 "3. The operation saves time, a cure being effected with less 
 chance of a recurrence of the difficulty, without increasing the risks 
 of operation, than by means of simple citation." 
 
 In some cases of syphilitic stenosis tracheotomy may be required. 
 
 Coxgexital Syphilis of the Laryxx. 
 
 J. X. Mackenzie was among the first to draw attention to this ex- 
 eeedingry-rare manifestation of syphilitic disease. He says that "laryn- 
 geal lesions have not been found more frequently, simply because they 
 have not been sought. Laryngeal disease is not rare in congenital syph- 
 ilis. It is one of the most constant and characteristic of the pathological 
 phenomena; and we may look for invasion of the larynx with as much 
 confidence in the congenital as in the acquired form of the disease.' 7 
 Two-thirds of the cases so far reported have occurred during the first 
 year. The younger the patient, the more rapidly fatal the malady. 
 The chief symptoms are impairment of voice, catarrhal cough, em- 
 barrassed breathing, painful and difficult deglutition, frequent laryn- 
 gismus, and general wasting cachexia. Frequently the only positive 
 diagnosis can be made by antisyphilitic treatment by mercurials or 
 iodides, or both combined. When adenoids block up the respiratory 
 passages, they should be removed while systemic treatment is in prog- 
 ress. In some cases respiration may be so impeded that tracheotomy 
 and even intubation may be required to relieve and possibly save the 
 life of the little. patient. 
 
CHAPTER LXXIX. 
 
 NEUROSES OF THE LARYNX. 
 
 This subject may very well be divided into: "Neuroses of Sen- 
 sation** and "Neuroses of Motion/" the latter being subject to a further 
 division : of "spasm"' of the larynx, or overactivity, and "paralysis" of 
 the larynx, or diminished activity. 
 
 Neuroses of Sexsation. 
 
 Various conditions of the larynx — such as anaesthesia, hyperes- 
 thesia, paresthesia, and neuralgia — may be grouped together under 
 this head. They all indicate departure from the normal, the form of 
 development being the result of personal tendency in each individual 
 case. 
 
 There is no special pathological condition indicated; hyperemia 
 may or may not be present, but there is usually a neurotic condition 
 of the s} T stem. 
 
 The causes which give rise to these conditions are numerous. 
 Excessive smoking, alcoholic indulgence, unsanitary conditions, in- 
 ordinate use of the voice, and hypertrophic conditions of the nose or 
 naso-pharynx may be mentioned as the most common. Of neuralgia, 
 a rheumatic or uric-acid diathesis is a frequent cause. 
 
 The symptoms are those of lar}mgeal irritation of one form or 
 another, often accompanied by dryness of the throat and "a tendency 
 to cough. Anesthesia may be an exception to this rule, inasmuch as 
 laryngeal accumulations occur almost to the extent of obstruction 
 without their presence being noticed by the patient. 
 
 Treatment. — Except in the latter instance, this should be of a 
 palliative character. Anything that will soothe the irritable larynx, 
 without injury to the general system, will be of benefit. Tablets of 
 chlorate of potassa or muriate of ammonia dissolved in the mouth are 
 often useful. Menthol lozenges containing 1 / i to 1 / 2 per cent, of men- 
 thol are likewise soothing to the irritated parts. 
 
 In the anesthetic larynx stimulating the laryngeal nerves by elec- 
 tricity may be of benefit, together with the administration of strych- 
 nine, arsenic, or phosphide of zinc. 
 
 (421) 
 
422 DISEASES OF THE LARYNX. 
 
 In the neuralgic larynx the cause should be investigated and re- 
 moved. Treatment b} T the galvanic current, the intralaryngeal elec- 
 trode being used, is sometimes beneficial in these cases. In rheumatic 
 or uric-acid cases the salicylates may be of advantage. 
 
 NERVOUS APHONIA. 
 
 Nervous, or hysterical, aphonia is a functional affection of the 
 adductor muscles, giving rise, for the time being, to complete loss of 
 voice. In it there is no pathological lesion. The vocal cords are still 
 controlled by muscles and nerves, anatomically and physiologically in 
 a normal state; but, owing to the hysterical condition of the patient, 
 the psychical power of co-ordination is lost, and no amount of effort 
 on the part of the patient can produce the natural voice. 
 
 It seems to be a functional bilateral paresis of the lateral crico- 
 arytenoid and the thyroarytenoid muscles: the adductors of the larynx. 
 It is a disease peculiar to women of nervous temperament, and is one 
 of the not infrequent manifestations of a highly-hysterical condition. 
 While it lasts, the voice is reduced to a whisper. 
 
 Symptomatology. — The attack is always sudden. From perfect 
 vocalization, the change to complete aphonia may be instantaneous. 
 At the same time the power of audible laughing or coughing, being to 
 a large degree involuntary, may be retained. The paroxysm may cease 
 as suddenly as it commenced. To persons subject to the attack, ex- 
 posure to cold may induce a paroxysm. So may fright or intense nerv- 
 ous excitement. 
 
 Laryngeal examination will reveal the true condition of the vocal 
 cords. Although otherwise healthy and normal in appearance, they 
 cannot be evenly and completely adducted, often exhibiting a trem- 
 ulous outline. 
 
 The prognosis in these cases is favorable, though even after cure 
 a temporary return at any time is possible. 
 
 Treatment. — Mental impression will sometimes restore the voice. 
 The introduction of a throat-mirror or the spraying of the larynx with 
 a stimulating solution may either of them so dislodge the aphonic im- 
 pression as to restore the power of speech. In other cases prolonged 
 treatment may be required. Cleansing aud stimulating sprays to the 
 throat, application of the electric current, toning the system by the 
 administration of strychnine or valerianate of zinc, sustaining diet, 
 and change of air and scene may all be required before a successful 
 result can be accomplished. 
 
spasm of the glottis. 423 
 
 Neuroses of Motion. 
 
 spasm of the glottis. 
 
 As Sir Morell Mackenzie remarked, it is important to bear in mind 
 that this is not in itself a disease, but a symptom of disease, its usual 
 manifestation being in the form of spasm of the glottis, or laryn- 
 gismus stridulus. The nature of this affection is variously estimated 
 by different authors. Many believe that it is of reflex nervous origin, 
 resulting in spasmodic contraction of the adductors of the vocal cords, 
 the difficult breathing and barking cough being the result of the con- 
 sequent stenosis. 
 
 I am afraid we have not got much beyond Marshall Hall's teach- 
 ing of sixty years ago, that it was always produced by reflex action from 
 some region remote from the larynx itself. According to this view, it 
 originates "in the trifacial in teething, in the pneumogastric in improp- 
 erly-fed children, and in the spinal nerves in constipation, intestinal 
 disorder, or catharsis." Some believe that the pathological lesion is 
 disturbance within the cerebral nerve-centres. Hughlings- Jackson has 
 pointed out that the nerve-centres may not be knit so closely together 
 as in the adult, and that a partial convulsion, such as occurs in laryn- 
 gismus, points to the imperfect union of the different sections of the 
 nervous system. The carpopedal contractions in children are explained 
 in the same way. The nerve-centres not being fully developed, spasms 
 of muscles or of groups of muscles, and even general convulsions, occur 
 more readily and frequently than they do in adults. 
 
 Etiology. — This is a disease essentially pertaining to child-life. 
 It usually occurs between the ages of three months and three years. 
 About twice as many boys are affected as girls. 
 
 Physical organization, which is frequently a result of social con- 
 dition, has a decided influence as an etiological factor. Ill-nourished 
 children, living on poor food and in ill-ventilated houses, are particu- 
 larly liable to contract it. In the densely-populated centres of large 
 cities it is more prevalent than in other regions. When bad hygienic 
 conditions and insufficient nourishment are constant, the offspring of 
 the people have a tendency to rachitic disease. As a result a large pro- 
 portion of the children who have spasmodic croup are likewise victims 
 of rickets. 
 
 Symptomatology. — The first attack of spasm or closure of the 
 glottis usually occurs at night-time. The child is taken with sudden 
 convulsive action of the adductors of the glottis. For the time being 3 
 
424 DISEASES OF THE LARYNX. 
 
 respiration is arrested, more or less completely. The hands and feet 
 are clinched, the head thrown back, and, if long continued, the face 
 may become cyanotic. In a few seconds, or minutes at the longest, the 
 adductor muscles of the larynx yield, the abductors come again into 
 action, and respiration returns, sometimes gradually, with long, crow- 
 ing breathing, and sometimes suddenly. 
 
 These attacks vary in duration and also in frequency. When the 
 spasm is purely neurotic, relief may be complete for a time, occurring 
 again at irregular intervals of hours or days. When the stridulous 
 breathing arises from subglottic inflammation, the stenosis will be less 
 complete, and at the same time more prolonged, never leaving entirely 
 until the inflammatory cause is removed. 
 
 Laryngeal spasm, although rarely so, is sometimes fatal. C. H. 
 Hunter (British Medical Journal, April, 1898) gives the history of 
 two remarkable cases. These occurred in brother and sister. Both 
 were perfectly well up to a few minutes before death, and they died 
 within two days of each other. The mother took the boy, aged 19 
 months, up to wash him. In a fit of passion he threw his head back 
 and became livid and rigid. He was put in a hot bath at once, but it 
 was of no avail. Two days later the sister, aged 7 months, suddenly 
 became rigid and blue in the face, and died like her brother, without 
 uttering a sound. In both there were well-marked carpopedal con- 
 tractions, but no general convulsions. Post-mortem examinations were 
 held, but all the organs were found healthy. There were no laryngeal 
 obstructions, but in both were indications of rickets. Frederic Taylor 
 says that rickets occur in 75 per cent, of all cases of laryngismus strid- 
 ulus. 
 
 Diagnosis. — When the spasm is purely neurotic, the diagnosis is 
 not difficult, as the exacerbations are, as a rule, followed by perfect re- 
 lief. There is no febrile action and no change in voice. 
 
 Paralysis of the abductors might produce similar crowing symp- 
 toms, but in this case there would be no exacerbations. Stenosis would 
 be continuous without fever and without vocal change. From the 
 stenosis produced by the presence of laryngeal papillomata, the gen- 
 eral history, together with laryngeal examination, would render the 
 diagnosis plain. 
 
 Prognosis. — Like the croupy symptoms arising from subglottic 
 inflammation, this is usually favorable. A large majority of cases get 
 well. When the spasmodic action of the adductors is complete, as well 
 as prolonged, the result may be at once fatal, as in the cases referred 
 
SPAS^I OF THE GLOTTIS. 425 
 
 to. This rarely occurs. The spasms, although repeated several times, 
 usually disappear even without treatment. The friends of the little 
 patient, however, become alarmed, medical advice is obtained, and the 
 cure hastened. 
 
 Treatment. — For pure nervous spasm of the glottis, immediate 
 inhalation of a few drops of amyl-nitrate or chloroform may be tried. 
 Of course, this would have no effect if the glottis were completely 
 closed. A quick slap on the back, dashing cold water in the face, 
 plunging the little patient into a hot bath, may all be tried. Hypo- 
 dermic injection of minute doses of apomorphia, a milligramme for a 
 child of three years, may also produce diaphoresis and vomiting. 
 
 As, however, the spasmodic closure of the larynx is only a symp- 
 tom of central or peripheral disturbance of the nervous system, mere 
 treatment of this symptom should not suffice. An attempt should be 
 made to ascertain the real seat of the evil, and, by removing it, prevent 
 the recurrence of the attack. 
 
 Eustace Smith in the London Lancet for March 19, 1898, gives 
 the history of a case of constant laryngeal stridor in an infant, caused 
 by the presence of adenoid vegetations. From the age of one month 
 to four months the stridor had been constant day and night. Much 
 of this time was spent in the hospital, but no relief from the continued 
 croaking breathing could be obtained. Then the adenoids, which were 
 not large, were removed. At once the night attacks of acute dyspnoea, 
 which for three months had constantly occurred, ceased, and the child 
 slept undisturbed. In a fortnight the croaking during the day-time 
 could not be heard in ordinary breathing, and in a few more days the 
 child was discharged cured. The history of this case is given as a rare 
 and peculiar instance of constant reflex spasm of the glottis. 
 
 Spasm of the larynx not infrequently occurs in adults. It is usu- 
 ally produced by direct irritation of some portion of the lining mem- 
 brane of the larynx itself. The entrance of some slight portion of food, 
 drink, or any foreign substance will induce an attack. On two occa- 
 sions I have seen severe laryngeal spasm occur in elderly men from 
 separation of a drop of fluid from a cotton-holder, while it was being 
 passed into the naso-pharynx. The drop in each case fell directly into 
 the oj)en larynx, and by reflex action produced, for a great many sec- 
 onds, complete closure of the glottis. I mention this from my own 
 practice as much in the way of warning as anything else. Whenever 
 application is made through the oral cavity into the naso-pharynx, all 
 redundant moisture should be pressed out of the pledget before at- 
 tempting its insertion. 
 
426 DISEASES OE THE LAEYXX. 
 
 PARALYSIS OF THE LAEYXX. 
 
 Up to recent years it was believed that the abductor or adductor 
 muscles might either of them be affected from lesion of the nerve-sup- 
 ply, to the exclusion of the opposite gronp. Also, that, in other cases, 
 the central lesion might be so general as to affect all the motor nerves 
 of the larynx, inducing paresis of both abductors and adductors at the 
 same time. 
 
 Since that period opinions, based upon extensive clinical research, 
 have undergone a material change. Xow it is known that, in paralysis 
 of the larynx, the abductor muscle, the posterior cricoarytenoid, is al- 
 ways the one first affected and that the term paralysis of the larynx, 
 as usually applied, signifies paralysis of one or both of the abductor 
 muscles. Further, when paralysis of the adductor does occur, it is 
 always secondary to primary paralysis of the abductor, except in cases 
 where the lesion is complete at once, as in section of the recurrent 
 nerve. 
 
 Sir Felix Semon summarizes this conclusion as follows: "AYhile 
 there is not a single authenticated case on record in which it has been 
 shown by post-mortem examination that in a slowly-progressive or- 
 ganic lesion of the motor nerves of the larynx the adductors had been 
 primarily or exclusively affected, we are now in possession of quite a 
 number of well-observed cases demonstrating the opposite order of 
 events." That is, in which the abductors had been primarily or ex- 
 clusively affected. 
 
 Semon adduces another curious fact, that, although in general 
 paralysis of the larynx the abductors are always affected first, when 
 recovery occurs the adductors lead the way. The reason assigned is 
 that, from some cause still unknown, the abductors are much more 
 vulnerable to nervous influence than the adductors. 
 
 The recent physiological investigations of Eisien Eussel have 
 proved that, while the recurrent laryngeal nerve is the motor nerve 
 par excellence of the larynx, it can be split for its entire length into 
 three different bundles of fibres, one of which supplies the abductors, 
 another the adductors, while the .third is without motor influence. 
 The fibres which supply the abductors of the vocal cords, being situ- 
 ated on the inner side of the nerve, are thus completely differentiated 
 from those supplying the adductor muscles. 
 
 In the large majority of instances paralysis of the vocal cords is 
 at first unilateral, and from its pathological condition would produce 
 
PAEALYSIS OF THE ABDUCTOE MUSCLES. 427 
 
 no symptoms which would be likely to lead to immediate discovery. 
 Nothing short of laryngological examination could make positive its 
 existence. 
 
 In the first stage of paralysis the cord, which at rest would be in 
 the cadaveric position, leaving abundance of room for respiration, 
 would be drawn to the mesial line by the adductors in phonation. 
 Later on, if the adductor muscle remained unaffected, this constant 
 ■tension, unopposed by the abductor, would lead to permanent reten- 
 tion of the affected cord in the mesial line. Vocalization would still 
 be perfect, while respiration would only be slightly affected, the open- 
 ing made in the glottis, by the unaffected abductor of the opposite 
 side, still being sufficient for breathing purposes. 
 
 When paralysis of the abductor is followed by extension of the 
 lesion to the adductor muscles, the cadaveric position on that side be- 
 comes permanent. This, of course, would leave the breathing space 
 unaffected, and would affect the voice but little, as the unaffected cord 
 during phonation would sweep across the mesial line, to adjust itself 
 to its paralyzed fellow. Hence, even in this extreme case, ordinary 
 symptoms would not indicate the true condition of the vocal cords. 
 
 In cases where the paralysis is bilateral, but in the primary stage, 
 affecting only the posterior cricoarytenoid or abductor muscles, vocal- 
 ization will still be little interfered with, as the cords are adducted to 
 the position required for the production of sound. Eespiration, how- 
 ever, is seriously obstructed. The breathing is labored, even to the 
 extent of impending suffocation. When to this is added adductor 
 paralysis, the breathing may be somewhat easier, as both cords are 
 immovably fixed in the cadaveric position; but with the change the 
 voice is completely lost. 
 
 Laryngoscopic examination should in all cases be made when 
 there is reason to suspect the presence of paralysis; and by it the 
 extent of loss of power should be at once ascertained, if any really 
 exists. 
 
 The causes of paralysis are numerous. In bilateral, the lesion is 
 usually central and may arise from the presence of gummata, sclerosis, 
 tumors, progressive bulbar paralysis, effusions at the nerve-origin, etc. 
 Diphtheria is not infrequently the cause. 
 
 In unilateral paralysis the cause is more frequently pressure upon 
 some part of the course of the nerve itself, as from aneurism of the 
 arch of the aorta, hypertrophied glands in malignant disease, tuber- 
 culosis, etc. 
 
428 DISEASES OF THE LABYXX. 
 
 The prognosis in paralysis of the larynx, whether unilateral or 
 bilateral, is not usually favorable. As a rule, it is but an indication of 
 the presence of some central or peripheral lesion that is itself incurable. 
 When the paralysis is but the sequel of diphtheria or one of the other 
 exanthematous diseases, the outlook is more hopeful; also when arising 
 from the presence of gummata. 
 
 Treatment. — When arising from pressure upon the recurrent 
 laryngeal nerve, the removal of the pressure either by excision of tumor 
 or absorption of gummatous deposit should restore to the posterior 
 cricoarytenoid its normal nervous supply. For the latter iodide of 
 potassa should be freely given. In diphtheritic cases strychnia in sus- 
 tained doses will have a good effect, and, in both, electrical treatment 
 should aid in restoration of muscular power. The faradic current to 
 the interior of the larynx, anaesthetized by cocaine, will be followed by 
 good results in many cases of functional origin, the negative pole being 
 applied to the pararyzed muscles within the larynx, by aid of the laryn- 
 goscope, and the positive pole with a large flat electrode to the external 
 larynx. 
 
 Systemic means to restore the general health are also required in 
 these cases. 
 
 For aneurysmal and tubercular cases, as well as those arising from 
 central lesions, little can be done save of a general character for re- 
 cuperative treatment. 
 
 George F. Eoss, of Montreal, has recently reported a case of bi- 
 lateral, abductor, laryngeal paralysis in a man, aged 50, arising from 
 chronic alcoholism of long standing. The treatment consisted of 
 full diet, together with sedatives and tonics. The local treatment was 
 by galvanism and faradism. The result was very satisfactory, as the 
 chink widened materially under treatment, freeing the patient from 
 his suffocative attacks. 
 
CHAPTEE LXXX. 
 NON-MALIGNANT TUMORS OF THE LARYNX. 
 
 Specimens of nearly all the varieties of benign tumors have been 
 found within the larynx. The majority of these, however, are exceed- 
 ingly rare. Papillomata are the most frequent in occurrence, with 
 fibromata probably as second, while cases of cystoma, myxoma, lipoma, 
 enchondroma, and angioma are among the rarest of laryngeal affec- 
 tions. Pathologically these various neoplasms are the same as when 
 found in the nose or naso-pharynx, the difference in condition being- 
 one of site, and not of history. 
 
 Papillomata may occur at any period of life. They occur most 
 
 Fig. 129.— Papilloma of cord Fig. 130. — Same during pho- 
 
 during respiration. nation. 
 
 Patient male, aged 55. Entirely removed by local application of 
 
 astringents. Under treatment one year. No recurrence. (Author's case.) 
 
 frequently during childhood and mature years. Their site is usually 
 the vocal cords, and they may be single or multiple. They differ in 
 color also, from pink or light red to gray. In early life they are ordi- 
 narily of a bright-reddish color, and may exist in large numbers. Al- 
 though usually sessile, with a warty appearance, they are sometimes 
 pedunculated. In adult life they often occur singly, being attached to 
 the margin of one of the vocal cords (Figs. 129 and 130). 
 
 In childhood recurrence after removal is frequent, while in adult 
 life it is rare. 
 
 Fibromata, although occurring with much less frequency than 
 papillomata, are also usually attached to the vocal cords. Thev never 
 
 (429) 
 
430 DISEASES OE THE LARYNX. 
 
 occur in childhood. They are hard in texture, gray or deep red in 
 color, and may be attached either by a broad pedicle or a wide, sessile 
 base. After complete removal they seldom recur (Fig. 131). 
 
 Of the other varieties of benign tumors, the cystoma, while ex- 
 ceedingly rare, occurs with equal frequency upon the epiglottis and 
 the vocal cords. In Charles Knight's case it occurred in a colored man 
 aged 40 years. The cyst was pale in color, with a number of large 
 blood-vessels on its surface. It was round in form, about the size of 
 a hickory-nut, and attached to the left side of the epiglottis. The 
 tumor was readily removed by means of a cold-wire snare without 
 haemorrhage and without pain, the throat having been previously 
 sprayed with a 10-per-cent. solution of cocaine. Myxoma or polypus 
 when present usually appears on the cord, and the same may be said 
 of angioma. Enchondroma has been observed on a number of occa- 
 
 Fig. 131. — Fibroma situated beneath the right vocal cord, occurring 
 in a man. age 40, and removed by frequent applications of galvanocautery- 
 point, after brushing each time with 15-per-cent. solution of cocaine. 
 (Author's case.) 
 
 sions (Fig. 132). The usual site has been the inner aspect of the 
 cricoid cartilage. The growth is sessile and hard, infringing by its 
 continued development upon the breathing space. Lipoma has its 
 favorite seat upon the aryepiglottic folds. As it enlarges, it falls over 
 into the hyoid fossa or oesophagus, and, attaining great size, threatens 
 suffocation of the patient. Angioma also sometimes occurs (Fig. 133). 
 
 Symptomatology. — Xone of these growths are likely to be at- 
 tended by much pain. The main symptoms are those arising from 
 obstruction of respiration and phonation. In certain cases deglutition 
 may be affected, but only when the growth within the larynx is large,, 
 or else, as in lipoma, when the oesophagus or hyoid is intruded upon. 
 Cough is also present in many of the cases. 
 
 In papillomatous disease the voice is usually severely affected, as^ 
 the neoplasm is located on the margin of the cord. When the papillo- 
 
XOX-MALIGNANT TUMOBS. 
 
 431 
 
 mata are numerous, the voice may be completely aphonic and the 
 respiration interfered with. 
 
 When the growth is situated entirely free from the vocal cords, 
 the voice may not be impaired, although the obstructing neoplasm 
 may be large enough to produce dyspnoea. 
 
 Diagnosis. — This will depend almost entirely upon laryngoscopic 
 examination, which should reveal the size, color, and location of the 
 growth. When the diagnosis is still uncertain, a small piece should 
 be snipped off the neoplasm to be submitted to histological examina- 
 tion. 
 
 The main distinctive features which the laryngoscope reveals are 
 
 Fig. 132. — Chondroma of 
 the epiglottis. (After Bos- 
 worth.) 
 
 Fig. 133. — Angioma of the left 
 aryepiglottic fold. (After Bos- 
 worth.) 
 
 as follow: A papilloma is soft and movable by inspiration and expira- 
 tion. When single, it is a gray or pink, and, as a rule, situated upon 
 the anterior half of the vocal cord. It is usually sessile, although the 
 base is not very broad. When multiple, as in children, the little, soft 
 masses may have a brighter hue, and the whole length of the cords 
 may be studded with them. I have seen the latter condition in a girl 
 of eighteen years. 
 
 A fibroma appears as a hard, rounded mass in some cases; it is 
 multilobular in form in others. It is usually sessile and may vary in 
 size from a grain of wheat to a couple of centimetres in diameter. The 
 mucous membrane covering it is richly supplied with vessels, which 
 heightens the color of the tumor. 
 
432 DISEASES OF THE LARYXX. 
 
 A chondroma, as said before, lies, in the majority of cases, below 
 the vocal cords. It also is round, resisting, and nodulated, but is 
 lighter in color than either papilloma or fibroma. From its color and 
 .appearance it might possibly be mistaken for carcinoma, but for its 
 occurrence in early life, while malignant disease of the larynx occurs 
 only in later years. 
 
 A cystoma usually presents itself as a pedunculated cyst, com- 
 pressible and soft, and of a pinkish-gray color. 
 
 Angioma has a red and strawberry-like surface, while myxoma 
 looks like a nasal polypus transferred to the laryngeal cavity, but tinged 
 with a higher shade of color. 
 
 Prognosis. — Xon-malignant tumors involve little danger to life, 
 <except when they assume such proportions as to threaten suffocation. 
 In children papillomata are sometimes produced in alarming numbers. 
 One unfortunate feature of their development is that after removal 
 they have a strong tendency to reproduction. In adults they can usu- 
 ally be removed, and, if the vocal cords remain uninjured, the voice, 
 when affected, soon regains its normal tone. 
 
 Treatment. — Many instruments have been devised for operation 
 upon these benign neoplasms when necessary, but they are all intended 
 io be used intralaryngeally. A good lanmgoscopic view of the larynx 
 having been obtained, the instrument and method must be chosen to 
 suit the case in hand, care being taken to avoid all undue injury to the 
 healthy soft parts surrounding the diseased tissue. 
 
 In papillomata after free cocainization astringent and stimulating 
 sprays have sometimes been found beneficial, particularly in the multi- 
 ple variety. Of these, perhaps, pure alcohol has the highest reputation. 
 Touching the single growths with fluid extract of thuja occidentalis, 
 20-per-cent. solution of tannic acid, 5- to 10-per-cent. solution of 
 nitrate of silver, 2- to 5-per-cent. solution of sulphate of copper, or 2- 
 to 5-per-cent. solution of chloride of zinc might be mentioned, and, 
 as a caustic, chromic acid melted on the end of the applicator is ad- 
 vocated by some writers. 
 
 To eradicate the growths, however, more effectual measures are 
 required. Before operating a 20-per-cent. solution of cocaine should 
 be freely applied to the inner larynx. Cutting forceps (Fig. 134) of 
 different kinds to suit each case, for the removal of papillomata and 
 fibromata, are the most favored instruments. When the growth is 
 distinctly pedunculated, the snare carefully adjusted is probably even 
 more effective, care being taken to sever the attachment by the wire 
 
NON-MALIGNANT TUMORS. 
 
 433 
 
 before too much traction is made. Very small sized papillomata may 
 be extracted by the use of Schroetters tube-forceps; but, for larger 
 growths, Tobold's, Fauvel's, or Mackenzie's forceps are preferred. 
 
 For cystoma, evacuation by the knife, and subsequent local treat- 
 ment by tincture of iodine or nitrate of silver, are advisable. 
 
 For enchondroma the galvanocautery has been used, as it is also 
 in some cases of fibroma. Myxomata may be snared or picked off by 
 laryngeal forceps, and subsequently the site of attachment touched by 
 
 Fig. 134.— Extirpation instruments, Krause's set of 19, in 
 universal handle. 
 
 the galvanocautery. Angioma also might be treated with the same 
 instrument at a dull-red heat. 
 
 Each individual case should be given the most careful considera- 
 tion by the operator; and be treated, not according to rule, but by the 
 light of experience and upon its own merits. It should ever be remem- 
 bered that some of these benign growths, if left to themselves, will 
 eventually disappear or at all events become innocuous, particularly in 
 cases where the free use of the voice is not of vital importance. There 
 is also the possibility of stimulating reproduction of the neoplasm by 
 operative treatment; and, still further, of inducing the development 
 of malignant disease by officious operative interference. This, at all 
 events, is the view of many able writers, among whom Lennox Browne 
 
434 DISEASES OF THE LARYNX. 
 
 stands prominently forward. Not that these operations should be 
 eschewed altogether, but that a wise judgment should be exercised al- 
 ways in dealing individually with these cases. 
 
 In multiple papillomata of children treatment by tracheotomy has 
 recently been received with favor. Railton, in the British Medical 
 Journal, Februar} 7 , 1898, gives the history of two little girls aged, 
 respectively, 3 and 4 years, treated successfully in this way. One re- 
 quired to wear the tube forty-five months before the growths were all 
 absorbed; the other for twenty-five months. In each the child made 
 a good recovery eventually, without return of the papillomata. At 
 first silver tubes were worn, then soft-rubber ones. The latter were 
 renewed three times a week. Eailton attributes the spontaneous atro- 
 phy of the growths to the removal of the irritation of respiration and 
 coughing. Of course, the period of cure was prolonged, but it must 
 be remembered that, in cases where laryngotomy has been performed 
 to facilitate removal, the growths have subsequently in many instances 
 recurred. 
 
 In some cases it is possible that prolonged intubation might have 
 the effect of promoting absorption by the constant pressure it pro- 
 duced. Still, the difficulty of deglutition would be a hinderance. Pro- 
 longed wearing of laryngeal tubes of any kind has also the possibility 
 of inducing granulations and polypoid growths to form round the mar- 
 gins of the instrument. 
 
 Thyrotomy has frequently been performed for this class of cases 
 in children, but the results have never been brilliant. 
 
 G. Hunter Mackenzie (British Medical Journal, May, 1899), in 
 his remarks on laryngeal growths in } r oung children, advocates trache- 
 otomy as the treatment, of all others, most satisfactory in this condi- 
 tion. He lays it down as an axiom, that the two methods, so frequently 
 advocated, — removal per via natural is and by thyrotomy, — are both 
 inadmissible, the reason given being that direct interference with, or 
 irritation of, the growths is almost always followed by rapid recur- 
 rence. The endolaryngeal method of removal involves a prolonged 
 series of operations, which are usually followed by recurrences, while 
 thyrotomy, when tried, has sometimes required to be repeated three or 
 four times within a year, resulting in more or less permanent impair- 
 ment of the voice, as well as stenosis of the larynx. 
 
 Intubation is objectionable in these cases on account of the irrita- 
 tion it produces. It is also frequently difficult to retain the tube in 
 position. 
 
NON-MALIGNANT TUMORS. 435 
 
 The point that Hunter Mackenzie insists upon is that tracheotomy 
 in this disease is not only a palliative, but also a curative, operation. 
 
 The order of events he describes as follows: First, the breathing 
 is relieved. Second, the growths, being freed from the irritation of 
 coughing and phonation, gradually lose their vitality and become de- 
 tached from the vocal cords, without any tendency to recur. If the 
 expectoration and secretion from the windpipe, as taken from the 
 throat of the patient or from the tracheal wound when cleansing the 
 tube, be examined, the growths will be found to come away in pieces. 
 Gradually, in periods varying from one month to six months or a year, 
 the papillomata shrivel away and finally disappear. 
 
 The tube should not be permanently removed until the growths 
 are all away. This removal of the tracheotomy-tube is always objected 
 to by the child, as at first normal breathing is more difficult than the 
 artificial. Consequently, one or two short reinsertions may be neces- 
 sary. In a short time, however, breathing becomes natural and the 
 voice is o-raduallv restored. 
 
CHAPTEE LXXXI. 
 
 MALIGNANT TUMORS OF THE LARYNX. 
 
 Or these, there are two varieties: carcinoma and sarcoma. The 
 latter is rarer, occurring in about one-third of the cases. The growth 
 of sarcoma is the more rapid of the two. and it may occur earlier in 
 
 Fig. 135.- — Sarcoma of the larynx, as seen from behind. 
 (After Lennox Browne.) 
 
 life, while the general symptoms and history resemble those of car- 
 cinoma, with the exception that it develops less systemic cachexia and 
 less involvement of the cervical glands (Fig. 135). 
 
 Histological examination alone can make the diagnosis positive 
 between the two; and the prognosis in each case is equally unfavorable. 
 
 Carcinoma of the larynx, although it occurs more frequently than 
 (436) 
 
CARCINOMA. SARCOMA. 437 
 
 in the nose, naso-pharynx, and pharynx combined, was, according to 
 Giirlt, only found 63 times in 11,131 cases of carcinoma, or 1 in 176, 
 showing that its frequency is comparatively small, in comparison with 
 its occurrence in other organs of the body. 
 
 Pathology. — The histology of these two diseases is the same as 
 when found in other regions. 
 
 In the larjTix the variety, in a large majority of instances, is epi- 
 thelioma. The most frequent site is the ventricular bands, probably 
 one-half the cases occurring in this region, the other half being found, 
 without any precise order, upon the vocal cords, epiglottis, commissure, 
 aryepiglottic folds, etc. The variety of cancer formerly found in the 
 larynx and called "encephaloid" would now answer to the title "small- 
 celled sarcoma"; while the "scirrhus" of the larynx which history 
 speaks of would agree with our present dense, "spindle-celled sar- 
 coma" (Lennox Browne). Besides these, two other varieties — chondro- 
 sarcoma and myxosarcoma — are both sometimes, though rarely, pres- 
 ent. 
 
 Of epithelial cancer two types are met with in the larynx: the 
 squamous and the alveolar. The first is what is called the nested 
 variety, the epithelial elements forming solid cylinders in the sub- 
 jacent tissue. The second, or alveolar, variety is very rare. Its name 
 implies its character, and it originates in gland-tissue, while the 
 squamous develops in stratified epithelium. 
 
 Primary carcinoma, while confined to the inner cavity of the 
 larynx, shows little tendency to involve the glands of the neck. This 
 well-known fact only relates to cancer well within the larynx, — for in- 
 stance, the ventricular bands and vocal cords, — and does not apply 
 to the disease occurring on the epiglottis, aryepiglottic folds, or aryte- 
 noids. When the cancer is located in these regions the surrounding- 
 glands are quickly affected. 
 
 As Bosworth has already shown, Sappy's anatomical investigations 
 of the lymphatic supply to the larynx would seem to give the reason. 
 While the epiglottis and the aryepiglottic folds are richly supplied with 
 lymphatic vessels, these become attenuated toward the ventricular 
 bands and vocal cords, the supply of lymph to these being very limited, 
 the attenuation increasing with years. Consequently cancer of the 
 inner larynx has less power of communicating itself to the gland- 
 elements than when it occurs in the more richly-supplied region above. 
 
 Symptomatology. — The early symptoms of carcinoma and sar- 
 coma do not differ widely from those attending the formation of non- 
 
438 DISEASES OF THE LABYXX. 
 
 malignant growths. The effect upon the voice will depend upon the 
 situation of the tumor. So long as the vocal cords are unaffected, and 
 can close in phonation. the voice may be clear; but in intrinsic cancer 
 it soon becomes involved, either by direct extension of disease to the 
 cords themselves or by obstruction to adduction from the presence of 
 the growth. 
 
 As infiltration extends, dyspnoea follows, likewise glandular en- 
 largement. A few months from the commencement of the disease 
 ulceration begins, to be followed, in many instances, by haemorrhage 
 and marked cancerous cachexia. The breath becomes foetid and the 
 discharge foul and abundant, accompanied by more or less salivation. 
 
 Pain, too, is almost invariably present, often in an increasing 
 ratio, shooting up to the ears, and across the pharynx. Deglutition, 
 too, becomes painful and difficult. 
 
 Diagnosis. — To accomplish this at as early a date as possible is 
 imperative. Laryngoscopic examination is essential in all cases to diag- 
 nosis. By the use of the throat-mirror the growth can be seen, thick- 
 ened, nodular, and hypersemic in the early stages, ulcerated and cov- 
 ered with fungoid growths later on. The larynx becomes distorted and 
 filled with foul and foetid secretions, which are of themselves of diag- 
 nostic importance. 
 
 By optical examination alone a diagnosis between sarcoma and 
 carcinoma cannot positively be made. Probably in carcinoma there 
 may be more ulceration, and at the same time less rapid growth than 
 sarcoma; but these are only matters of degree, and upon microscopical 
 examination the diagnosis really depends. Possibly, of the two, sar- 
 coma may be the less painful. 
 
 Prognosis. — Wherever it may be located, cancer is one of the most 
 painful as well as most fatal of diseases. Its occurrence in the larynx 
 is no exception to the general rule. Without operation there is no 
 hope whatever of recovery. With operation, although the mortality is 
 still very large, cases have been known to live for years without any 
 return of the disease. The improvement in technique which is now 
 practiced by the skillful operator gives the patient still more reason 
 for hope; and the percentage of - recoveries, after laryngectomy has 
 been performed, is larger at the present time than ever before in the 
 history of this distressing malady, although still it is small. 
 
 Treatment. — The question of relief in all cases is an important 
 one. Unfortunately it is the most we can expect to accomplish in the 
 majority of cases. Life may be prolonged and made more comfortable, 
 
CARCINOMA. SARCOMA. 439 
 
 and relief from pain itself, which is often agonizing, should always be 
 given if at all possible. 
 
 After washing out the throat with a cleansing spray, the pain may 
 be relieved by throwing in a weak solution of cocaine. This may be 
 followed in like manner by a spray of 1 / 2 - or Ys-per-cent. solution of 
 permanganate of potash. Some authorities prefer the insufflation of 
 powdered iodol, aristol, or iodoform. Any of these should diminish 
 the amount of pharyngo-laryngeal sepsis and lessen the discharge. 
 The menthol, thymol, and camphor-menthol solutions already alluded 
 to have the additional effect of cooling the inflamed larynx. 
 
 To control the laryngeal pain, which is often present in an in- 
 creasing ratio as the disease advances, cocaine is probably the best 
 remedy. It can be commenced by fine atomization of a 1- or 2-per- 
 cent, solution, thrown into the throat, gradually increasing the per- 
 centage of the cocaine as the requirements of the case may demand. 
 When he knows that the issue will inevitably be fatal, it would seem 
 to be the surgeon's duty to render the euthanasia, as free from pain 
 .and as comfortable as circumstances will allow. 
 
 While intubation, from the nature of the disease, would be wholly 
 useless, tracheotomy, by preventing impending suffocation, will some- 
 times be of the greatest service, lengthening out the life of the pa- 
 tient at least for months. 
 
 Eemoval of malignant growth by endolaryngeal operation has fre- 
 quently been attempted. So far the reports have, on the whole, been 
 exceedingly unsatisfactory. The nearest to a perfect cure that I have 
 so far seen reported is one by Jurasz, of Heidelberg. It appeared in 
 the Journal of Laryngology, October, 1898. In December, 1897, he 
 Temoved from a woman, aged 44, under local anaesthesia the right 
 vocal cord from the anterior commissure to the processus vocalis; also 
 parts of the left vocal cord and anterior commissure at a different sit- 
 ting. All were proved by microscopical examination to be affected 
 with epithelioma. The instrument used was one specially devised for 
 the purpose. At the time of writing, ten months later, there had been 
 no return, cicatricial membranes had formed in the place of the vocal 
 cords, and the patient could speak with a hoarse voice. 
 
 Jurasz is of the opinion that localized cancer of the inner larynx 
 •can be removed as thoroughly by endolaryngeal operation as by laryn- 
 gectomy. This opinion, however, appears to be based upon the one 
 successful operation. 
 
 When the cancer had been confined to the inner larynx, and has 
 
440 DISEASES OF THE LARYNX. 
 
 consequently been free from glandular complication, laryngectomy has, 
 in a number of instances, been successful. Perhaps the most remark- 
 able case, as it was the first of its kind, was the one operated on early 
 in 1892 by J. Solis-Cohen. It was a case of epithelioma of the larynx 
 in a man about 40. The entire larynx was removed, and the severed 
 trachea was stitched to the skin, thus shutting off entirely the respira- 
 tory passage from the mouth. After recovery the man was able to 
 articulate in a loud whisper. It was supposed that the air taken into 
 the pharynx filled a sort of pouch in the lower part of it, and then by 
 muscular contraction was forced through the tightened faucial mus- 
 cles in imitation of the vocal cords. Five years later this man traveled 
 over America and Europe, exhibiting himself before the various med- 
 ical societies. There had been no return whatever of the malignant 
 disease. 
 
 The Solis-Cohen operation has been performed a number of times 
 since then. The last case recorded is by Depage in Societe Beige de 
 Chirurgie, January, 1898. The operation was performed eight months 
 previously. All communication between the lungs and mouth was cut 
 off, the trachea being attached, as in Solis-Cohen's case, to the skin. 
 He can speak in a whisper and there is no recurrence. 
 
 Indications are beginning to show that the future of patients suf- 
 fering from this disease, when confined to the inner larynx, is not quite 
 so dark as was until recently believed. Bryson Delavan, in a recent 
 issue of the Therapeutic Gazette, speaks squarely upon this matter. He 
 believes the subject should receive the most careful consideration. 
 Three groups of operations are offered: Thyrotomy with or without 
 partial laryngectomy; complete laryngectomy by the Solis-Cohen 
 operation; and complete laryngectomy in cases of extensive laryngeal 
 disease with glandular involvement. 
 
 Delavan also lays down rules for guidance in selecting cases for 
 operation: — ■ 
 
 1. Every malignant growth of the larynx of intrinsic origin, 
 which can be dealt with, should be treated by an operation in the ab- 
 sence of a decided indication to the contrary; and the operation should 
 be performed with the least possible delay. 
 
 2. Every tumor of the larynx suspected to be malignant, of in- 
 trinsic origin, of limited extent, and apparently within reach of free 
 removal justifies an exploratory thyrotomy in a suitable patient, in 
 the absence of infiltration of the surrounding structures and of af- 
 fection of the lymphatic glands. 
 
CARCINOMA. SARCOMA. 441 
 
 3. The method of operating as pursued by Butlin and Semon is 
 recommended. 
 
 In the case operated upon by J. Solis-Cohen the severed end of 
 the trachea was brought to the external edges of the vertical incision 
 and there retained, thus cutting off communication between the 
 pharynx and the lungs. The advantages of this procedure are very 
 evident: the danger from inspiration pneumonia is greatly lessened, 
 swallowing is easily accomplished, the power of phonation can be ac- 
 quired (as shown in the cases operated on in this manner), and the 
 patient's comfort is greatly increased, as the wearing of an artificial 
 larynx is not necessary. 
 
 Several years ago a method of treatment of cancer was devised by 
 Coley which seemed to be efficacious in certain cases of one class of 
 the malignant disease, namely: sarcoma. This was by inoculations of 
 erysipelas in a patient suffering from inoperable sarcoma. The malig- 
 nant tumor would partially shrink away, and remain without regrowth 
 for a prolonged period. As little has been heard, however, of the 
 further advance of this method since Coley's report was first issued, it 
 is doubtful whether the results have realized the expectations of the 
 writer. 
 
 Middlemas Hunt, in the Journal of Laryngology, Rhinology, and 
 Otology for October, 1898, reports an exceedingly interesting case of 
 successful operation for the removal of intrinsic cancer, the chief in- 
 terest being in the great age of the patient, which was 80 years. On 
 examination the anterior part of the glottis was found to be tilled with 
 a pinkish-white growth, which had begun to break down and ulcerate. 
 It sprang from the anterior part of the upper surface of the left vocal 
 cord. 
 
 Owing to the great age of the patient, the operation was divided 
 into two stages: the first, tracheotomy; and, five days later, the second, 
 thyrotomy, removing the growths and surrounding soft parts. 
 
 Although attended by the development of pneumonia during the 
 second week after operation, the man made a good recovery. Nine 
 months later he was still doing well, with steady improvement of the 
 voice. Microscopical examination verified the case to be one of epi- 
 thelioma. 
 
CHAPTER LXXXII. 
 
 FOREIGN BODIES IN THE LARYNX. 
 
 Foreign bodies of one form or another frequently become lodged 
 within the laryngeal cavity. This may occur from the forcible in- 
 spiration of any substance that may be in the mouth or pharynx dur- 
 ing laughter, or from carelessness in the act of swallowing and in 
 some cases even in ordinary inspiration. The names of foreign bodies 
 that have obtained an entrance into the laryngeal cavity and lodged 
 there are legion: bristles, fish-bones, needles, pins, coins, buttons, par- 
 tial plates of false teeth, etc., as described in Eoe's catalogue, have 
 all of them been extracted from the larynx, and some of them quite 
 
 Fig. 130. — Tooth-plate in glottis. (After Lennox Browne.) 
 
 frequently. Sometimes the introduction of the foreign body has been 
 from within. For instance, lumbricoides have found their way into 
 the larynx from the oesophagus, and a number of instances have been 
 recorded which ended fatally. Food has also been vomited up, to be 
 thrown by inspiration into the larynx, the result being fatal. Chil- 
 dren who have formed the habit of carding foreign bodies in their 
 mouths are particularly liable to the accident. While asleep the nerv- 
 ous sensibility of the pharynx and larynx are in a quiescent state, and 
 the object slips into the larynx without warning. Women, who carry 
 pins and needles in their mouths, are liable, during the acts of cough- 
 ing or sneezing, to suddenly find the little instrument lodged in the 
 cavity of the larynx. Figs. 136 and 137 represent a remarkable case 
 (442) 
 
FOREIGN BODIES. 443 
 
 reported by Lennox Browne. The tooth-plate had remained in posi- 
 tion in the larynx for two years and eight months without its presence 
 being suspected, the patient being under the impression that she was 
 suffering from either tuberculosis or cancer. The position left a space 
 for breathing in front and also behind the foreign body. Fig. 137 
 exhibits the large size of the plate after its removal. 
 
 Symptomatology. — Coughing, irritation more or less, and a sense 
 of strangulation are the ordinary symptoms. These vary in degree 
 and character according to the size and form of the foreign body, 
 modified also by the amount of nervous excitability possessed by the 
 patient. When the body is large and soft, filling up the larynx, im- 
 mediate suffocation is likely to be the result, unless relief can be at 
 once obtained. Angular bodies, even when large, are not so quickly 
 fatal, as respiration to a certain extent is practicable past the irregular 
 
 Fig. 137. — Tooth-plate removed. (After Lennox Browne.) 
 
 sides. Rough bodies are likely to produce inflammation. Pointed ones 
 like spiculae of bone, needles, etc., while they do not interfere with 
 respiration, on the slightest motion produce pain, and from this cause 
 often render deglutition impossible. 
 
 Diagnosis. — Quite frequently this may be positive from the per- 
 sonal experience of the patient. He knows the nature of the object, 
 and how it found its way into the larynx. This can be verified by the 
 use of the laryngoscope. In other instances the laryngoscope alone will 
 have to be depended upon. Sometimes in children neither of these 
 methods are of any avail. Kirstein's autoscope, when it can be ap- 
 plied, should reveal the condition of the larynx and the presence of 
 the foreign body. Digital exploration, also, the finger being passed 
 carefully into the larynx, while the organ is held in position by the 
 fingers of the left hand, may lead to the discovery of the foreign body; 
 but, when this is of a metallic character, nothing will reveal its form 
 
444 
 
 DISEASES OF THE LARYNX. 
 
 and location so positively as examination by the Roentgen x-rays, so 
 recently added to our list of methods of investigation. 
 
 Prognosis. — The accidental entrance of a foreign body into the 
 larynx may always be considered a matter of serious moment. It mav 
 
 Fig. 138. 
 
 -Laryngeal polypus-forceps, Mackenzie's, revolving 
 with three attachments. 
 
 possibly cause immediately a fatal result, or lead to it by continued 
 obstruction and inflammatory action. There is also in many instances 
 the possibility of the body settling still farther down into the nar- 
 
 Fig. 139. — Laryngeal polypus-forceps, Waxham's. 
 
 rower passage of the trachea. Still, in a large number of instances, 
 when the body is compact in shape and without projecting angles, it 
 has been coughed out without surgical interference. Sharply-angular 
 bodies are not likely to be expelled by Nature's effort, and will require 
 
FOREIGN BODIES. 
 
 445 
 
 to be removed before the patient can be relieved. When little round 
 bodies like cherry-stones are drawn into the larynx, they usually pass 
 the vocal cords and enter the trachea; and sometimes may get down 
 
 Fig. 140. — Laryngeal polypus-forceps, Fraenkel's, cutting- jaw. 
 
 into the bronchial tubes, completely obstructing respiration in the 
 corresponding lung. 
 
 Treatment. — Sometimes properly combined respiratory effort may 
 succeed in dislodging the foreign body. A slow, deep inspiration, so 
 taken in order not to draw the object farther in, followed by a sharp, 
 
 Fig. 141. — Laryngeal polypus-forceps, Mackenzie's, articulated. 
 
 sudden expiration, may possibly expel it. Eeversing the patient, heels 
 upward, may dislodge a heavy body. Forcible coughing may also aid. 
 These methods failing, laryngeal forceps guided by the throat- 
 mirror may effect a removal. Of instruments, Mackenzie's, "Waxham's, 
 
446 DISEASES OF THE LARYNX. 
 
 FraenkeFs (Figs. 138 to 141), or any other good form may be used. 
 Sometimes a snare carefully applied would lift out an angular body. 
 
 When the object is below the vocal cords tracheotomy may be re- 
 quired, and in cases where it is lodged within the larynx it can be best 
 removed through the tracheal opening. In others it might be pressed 
 up through the larjmx from the trachea. 
 
 "Not infrequently after tracheotomy the body, if located below, 
 may be expelled through the artificial opening, or may be forced up 
 so that it can be grasped and removed. Should this not occur, the 
 patient's body should be shaken or the inverted position assumed, with 
 the hope of bringing the offending. substance within reach of instru- 
 mentation. If it be impossible at the time of operation to locate the 
 body, the edges of the trachea may be stitched to the integument and 
 the wound left open for further search. The introduction of a small 
 mirror may assist in locating the body. Blowing strongly into the 
 trachea may assist in expulsion by the reactionary expiration, or the 
 artificial production of cough by a feather may be also of use in dis- 
 lodgment." (Kyle.) 
 
CHAPTER LXXXIII. 
 ROENTGEN RAYS IN LARYNGEAL SURGERY. 
 
 This was the title of a preliminary note by John Maclntyre, more 
 than two years ago, upon what is acknowledged now to be a very im- 
 portant subject. The question he then asked — "Will this important 
 discovery of the Roentgen rays be of use in the department of laryn- 
 gology?" — has been answered over and over again by actual results in 
 the affirmative. 
 
 Since that time the method of utilizing the Crookes tubes has 
 been greatly improved. The shadows of the skeleton of the living body 
 can be so clearly defined that every bone can be distinguished in posi- 
 tion from the surrounding softer tissues. Still, rays of light pass 
 through even the osseous frame-work, so that any impenetrable metallic 
 substance, situated in the nose, larynx, or oesophagus can be distinctly 
 seen by the x-rays. 
 
 Still further, the outlines of the skeleton can be so clearly de- 
 lineated that any destruction of osseous tissue by malignant, syphilitic, 
 or tuberculous ulceration can also be discovered, as well as fractures 
 and malposition of bones in the different regions of the body. 
 
 Hence it can readily be seen that the discovery of the Roentgen 
 rays was no light addition to the armamentarium of the throat-spe- 
 cialist. 
 
 Over and over again have foreign bodies in the larynx and oesoph- 
 agus been located by the sciagraph, thus materially facilitating their 
 removal. One remarkable thing is the clearness with which thin ob- 
 jects, such as needles and pins, can be defined while completely buried 
 in the soft tissues of the body. 
 
 Two instances of this nature were recently reported by Walker 
 Downie in an October issue of the British Medical Journal. 
 
 In the first, D. G-., aged 19, put a pin in his mouth while asleep. 
 The next morning the first mouthful of breakfast caused a sharp, lanc- 
 ing pain in the throat on swallowing. This was followed by pain on 
 right side of neck close to the thyroid cartilage. Careful examination 
 with the larj^ngoscope revealed nothing. Two months later a satisfac- 
 
 (447) 
 
448 ROENTGEN" RAYS IX LARYNGEAL SURGERY. 
 
 tory lateral view of the parts was obtained by a Crookes tube, and the 
 pin discovered to be located in the centre of the thyroid cartilage. 
 Chloroform was administered and the cartilage laid bare in the middle 
 line. On cutting through the perichondrium, the point of the knife 
 touched the head of the pin. During the two months which time it 
 had been in the larynx the pin had ulcerated through the cartilage. 
 It was readily extracted and proved to be bent upon itself. 
 
 The other case occurred in a girl aged 18. She accidentally 
 coughed with a pin between her teeth. As a result, the pin slipped 
 down her throat. She thought she had swallowed it, and for several 
 days there was no pain. Four days later she turned sick after eating 
 and vomited. While in the act she felt a sharp pain in the right side 
 of the throat, close to the thyroid cartilage. On being examined with 
 the laryngoscope nothing whatever could be seen of the foreign body. 
 A sciagraph, however, taken at once revealed its situation. The next 
 day the larynx was anaesthetized with cocaine, and curved forceps were 
 passed firmly and deeply into the hyoid fossa. The head of the pin 
 was touched and grasped and the pin was withdrawn. 
 
 A number of instances have also been recorded in which sciagraphs 
 have been taken of coins located in the oesophagus, the view by the 
 x-rays being the guide by which successful removal was accomplished. 
 
CHAPTER LXXXIV. 
 
 OPERATIONS FOR NASAL DEFORMITIES. 
 
 When these deformities arise from malformation, defective de- 
 velopment, or pathological lesion of the internal nose, they should 
 rightly he considered as belonging to the legitimate field of the rhi- 
 nologist. When, however, they owe their origin to external injury or 
 
 Fig. 142. — Lead plate for nasal arch. 
 
 Fig. 143. — Steel pin for nasal transfi:_io" . 
 
 disease, they would seem more naturally to belong to the domain of 
 the general surgeon. 
 
 It is of the former class that this chapter treats, and particularly 
 of that unsightly deformity commonly called "saddle-nose.' v This may 
 arise from a variety of causes, hut it consists, as a rule, of a sinking in 
 of the bridge, owing to the destruction of the cartilaginous septum. 
 
 (440) 
 
450 OPERATIONS FOR NASAL DEFORMITIES. 
 
 Professor Annandale (British Medical Journal, November, 189?) 
 has thrown out some valuable suggestions for the treatment of this 
 class of cases. For fifteen years he has practiced what he calls "sling- 
 ing" of the depressed tissues up into their natural position, whether 
 bony or otherwise. 
 
 The appliances used consist of: 1. A piece of sheet-lead (Fig. 
 142) formed into an arch with a ledge on each side to rest on each 
 cheek. The arch should be slightly higher than the nasal bones when 
 in their normal position. On each side of the arch, opposite the bridge 
 of the nose, a slit is made from the cheek-ledge up toward the summit 
 of the arch. 2. A steel pin (Fig. 143) about five centimetres long with 
 a point at one end and a cap at the other — the whole central part being 
 a screw with a nut to be applied to the point. 
 
 To raise the depressed bone the pin is passed deeply through the 
 nose from side to side opposite the bridge or more depressed portion. 
 The nose is then gently lifted up by means of the pin, and the leaden 
 arch slipped over it, the two ends projecting out through the notches. 
 The nut is then screwed on to give lateral support and firmness, and 
 silver wire passed in figure-of-eight around the ends of the needle and 
 over the arch, to put slight traction upon the raised tissues. A cap is 
 also fitted to the needle-point to prevent injury to the cheek. The 
 apparatus requires to be carefully watched to secure good results. The 
 time required for treatment varies, the object being to retain the ap- 
 paratus until the tissues have been solidified and accustomed to their 
 new position. Fig. 144 represents the appliance in position. 
 
 E. C. Ellet (Memphis Medical Monthly, September, 1897) reports 
 a case of successful treatment of saddle-nose by surgical operation. In 
 his case the cartilaginous septum had been destroyed by erysipelatous 
 abscess, resulting in severe depression of the bridge. 
 
 The operation practiced for the removal of the deformity con- 
 sisted, first, in an incision twenty-five millimetres long, down the 
 medial line of the nose, extending above and below the depression. 
 The tissues were then dissected back freely on each side. After check- 
 ing the haemorrhage with hot compresses an oval platinum plate was 
 inserted over the depressed dorsum. This plate had an area of twenty 
 by fifteen millimetres, was curved from side to side to conform to the 
 natural shape of the nose, and was perforated to allow of more perfect 
 retention and fixation during the process of healing. Before insertion 
 the plate had been boiled in soda solution, was preserved in alcohol, 
 and lastly immersed in bichloride solution. After putting the plate 
 
SUBCUTANEOUS OPERATIONS. 
 
 451 
 
 in place the flaps were drawn together and sutured over it, the wound 
 being closed aseptically. After healing the whole nose was solid. The 
 deformity had also been successfully removed. 
 
 Koe, of Kochester, has also written somewhat extensively lately 
 upon the "correction of nasal deformities by subcutaneous operation," 
 and the following is an abstract of his paper (British Medical Journal, 
 November, 1897) upon the subject, read at the Montreal meeting of 
 the association: — 
 
 Fig. 144. — Nasal appliance in position. (After Annandale.) 
 
 "Dr. Eoe pointed out that the early advantage of subcutaneous. 
 operations was the exclusion of air from the wound, thereby avoiding 
 the subsequent inflammation that followed the exposure of the wound 
 to the air, but that at the present time the only advantage of perform- 
 ing operations subcutaneously was the avoidance of a wound of the 
 skin on any of the exposed portions of the body. The importance of 
 correcting nasal deformities on account of the prominence of the nose. 
 
452 OPERATIONS FOR NASAL DEFORMITIES. 
 
 and the conscious effect of such deformities in influencing the habits, 
 thoughts, and social life of a person were then pointed out, and also 
 the importance of correcting these deformities without wounding the 
 skin, so as to leave as few traces as possible of the previous disfigure- 
 ment. Xasal deformities were usually divided into two main classes: 
 idiopathic, or congenital, and traumatic, or acquired; but, from the 
 surgical stand-point, Eoe classified them into the deformities which 
 affected the bony portion of the nose and the deformities which affected 
 the cartilaginous portion. 
 
 "Deformities of the bony portion might be subdivided into (a) 
 vertical — that is, those which distorted the profile, in which the dorsal 
 line was too convex or too concave; and (6) lateral — that is, those 
 which, when viewed from the front, presented unusual deviations from 
 the normal contour, whereby the bony portion might be either spatu- 
 lated or deflected. 
 
 "Deformities of the cartilaginous portion might be subdivided 
 into (a) those which affected the tip of the nose, whether excessive or 
 defective in the amount of tissue or distorted from its normal direc- 
 tion, and (b) those which affected the wings of the nose, which might 
 be either collapsed or abnormally expanded. 
 
 "This classification of nasal deformities, however, did not apply 
 to or include those deformities resulting from extensive destruction of 
 the hard or soft parts by s}-philis, lupus, or other diseases, or by acci- 
 dents in which metallic or other artificial supports or plastic operations 
 involving the integument were required for their correction. 
 
 "Eoe then described the different deformities as they were found, 
 and the etiological relations which they sustained to local causes and 
 various systemic conditions. 
 
 "In the treatment of nasal deformities he pointed out that the 
 beauty of the nose depended almost entirely upon its symmetry, so 
 long as the disproportionate relation between the size of the nose and 
 the size of the face was not too great; therefore, in correcting the de- 
 formities of the nose it was necessary to study the symmetrical rela- 
 tions of the different parts of the nose to one another, rather than its 
 proportionate relations to the face. He also pointed out that, owing 
 to the great variety of causes and conditions of the deformities of the 
 nose, the operations required for the correction of these deformities 
 must be equally varied. 
 
 "There were, however, general underling principles governing 
 the different operations which must be observed in order to accom- 
 
SUBCUTANEOUS OPERATIONS. 453 
 
 plisli the desired results. Thus, in convex vertical deformities of the 
 bony portion of the nose, or excessive development of the tissue of the 
 tip of the nose, the excessive or redundant tissue must be removed; 
 whereas, in the concave vertical deformity of the bony portion of the 
 nose, or the defective development of the end of the nose, the hollow 
 portion must be filled in with tissue taken from some other portion of 
 the nose where it could be spared, and the elevated portions reduced, 
 so as to make the nose symmetrical. In the case of injury to the nose, 
 in which there was displacement rather than destruction of the tis- 
 sues, the operation consisted in placing the tissues in their original 
 position, or so adapting them as to render the contour of the nose sym- 
 metrical. In every instance, however, the operation was to be per- 
 formed subcutaneously from the interior of the nose. 
 
 "The writer then described a number of cases, illustrating the 
 manner in which the various operations were performed, and exhibited 
 enlarged photographic illustrations of patients before and after opera- 
 tions. He also stated that there were three conditions which must be 
 observed in order to insure success in these operations: — 
 
 "1. The first was thorough antiseptic precautions, for, if suppura- 
 tion in the wound should take place, ingrafted tissues would be de- 
 stroyed, and not only the object of the operation be defeated, but the 
 deformity of the nose would be increased thereby. 
 
 "2. In the next place, the plan of the operation must be carefully 
 studied, in order that all the tissues at disposal might be utilized to 
 the best advantage. 
 
 "3. In the third place, great care and attention, subsequent to 
 operation, were as important as the operation itself, for, no matter how 
 well directed the operation might be, the object could not be attained 
 unless scrupulous attention was paid to the healing process. The parts 
 must not only be held in place by retentive appliances, but the shape 
 of these appliances and the dressing must often be changed from day 
 to day, as the swelling subsided and the union of the parts took place. 
 
 "Frequently the principal or main operation must be supple- 
 mented by minor operations for the correction of slight defects. An 
 unduly prominent portion might require lowering and a depressed part 
 raising, and so on until the work was completed. " 
 
CHAPTER LXXXV. 
 OPERATIONS FOR CLEFT PALATE. 
 
 It is widely conceded that operations for cleft palate are inad- 
 visable before trie end of the second year. First operations should be 
 performed, if possible, about that period, and secondary operations by 
 the fourth or fifth year when necessary. Still further, final operations 
 upon the hard palate, or to completely close openings still left in the 
 soft palate, should always be done by the tenth or twelfth year at the 
 latest. After this age, the available tissues are too scanty, and the pos- 
 sibility of improving the voice too limited, to render operation justi- 
 fiable, and the most that can be done is in the way of fixation of ob- 
 turators, to* overcome to some extent the natural deformity. 
 
 Careful observations made by many experienced surgeons have 
 also brought out a number of important facts, which help as guides 
 in the treatment of this defect in development. When there is hare- 
 lip together with cleft palate it is advisable, according to some authori- 
 ties, to operate on the lip even in early infanc}', in order to insure 
 efficient nursing, while the operation in the palate is deferred to a 
 later date. The chief objection to surgical interference with the hard 
 or soft palate during the first two years of life is the extreme delicacy 
 of the tissues affected, with their liability to tear upon the slightest 
 traction. 
 
 The healthier and better tempered the child, the less voracious 
 the appetite; and, the smaller the cleft, the earlier may the operation 
 be performed. 
 
 The higher the vault of the hard palate, the more likely is the 
 operation to be successful, as there is a better supply of soft tissue from 
 which to construct the necessary flaps. 
 
 The longer the palate, also, from before backward, the more hope- 
 ful the prognosis after treatment, as the traction toward the centre 
 has always a tendency to shorten the antero-posterior diameter of the 
 palate. 
 
 In reply to anxious friends who are naturally alarmed at the dif- 
 ficulty in nursing produced by the presence of cleft palate, they can 
 
 (454) 
 
STAPHYLOKKHAPHY. 455 
 
 be assured that this can be accomplished readily by the use of a nurs- 
 ing-bottle with a long nipple with the opening on the lower side or 
 with a projecting flap on the upper one. By putting either of these 
 well into the mouth, the opening in the palate will, to a large extent, 
 be closed. The child can thus, by being better able to swallow, attain 
 the strength and age necessary for successful treatment. 
 
 Staphylorrhaphy is the name applied to operation for the closure 
 of the cleft in the soft palate. This is an old operation, and has been 
 performed for more than a century. There are many methods by which 
 it may be done. Perhaps the simplest is the one generally adopted and 
 described so clearly by J. W. MacDonald in his work upon "Surgical 
 Diagnosis and Treatment," 1898. The position he chooses is for the 
 patient to lie on a high table with the head turned to the right side, 
 so that the blood will not gravitate into the pharynx. Churchill's 
 position would seem to be superior to this. He places the patient upon 
 his back with the head at right angles to the spine, hanging over the 
 end of the table and supported by an assistant. In this position the 
 blood will drain into the naso-pharynx and could readily be sponged 
 away. 
 
 The stages of the operation are the following: — 
 
 1. After anaesthetizing with chloroform or A. C. E., a mouth-gag 
 is inserted and the throat is rendered as aseptic as possible. The end 
 of one side of the cleft is then held tense by a tenaculum forceps and 
 a narrow strip cut off from the edge of the cleft, from the free margin 
 to the angle. This may be done by a thin-bladed knife or a sharp, nar- 
 row, angular scissors. In this preparatory stage both sides are treated 
 alike, the object being to make clear-cut, raw edges throughout. 
 
 2. The sutures may be of silver wire, chromicized catgut, or silk, 
 the last mentioned being as good as any. Of needles, although many 
 kinds are used, the half-curve Hagedorn in a needle-holder is recom- 
 mended by MacDonald as generally applicable. The first needle should 
 be inserted about 6 millimetres from the margin on one side and about 
 12 millimetres from the angle, and passed directly through that por- 
 tion of the velum. It should then be reinserted from behind forward 
 on the other side of the cleft at similar distances, the silk thread care- 
 fully drawn through by means of forceps, and the needle withdrawn. 
 Other needles should be similarly placed at distances of about 12 milli- 
 metres in a similar way until the posterior end of the cleft is reached. 
 
 3. If the cleft can now be closed without too much tension the 
 sutures may at once be carefully tied and the threads cut off. If. how- 
 
456 OPERATIONS FOR CLEFT PALATE. 
 
 ever, the strain is too great, the tensor palati muscles must be cut he- 
 fore closing the cleft. This can he done by making an incision into the 
 soft palate immediately internal to the hamular process and cutting 
 upward until the muscles are severed. This should be done on each 
 side, and then the sutures drawn together and tied. These should not 
 be removed until the seventh or eighth day. 
 
 Throughout the operation the bleeding should be controlled by 
 careful pressure upon the bleeding spots with small pledgets of anti- 
 septic absorbent cotton, care being taken to avoid all unnecessary dis- 
 turbance of the raw surfaces. "When the operation is over the parts 
 should be lightly dusted with iodoform and the incision painted with 
 iodoformized collodion. 
 
 Uranoplasty. — The more difficult and serious operation of closing- 
 fissure of the hard palate is usually performed after Sir William Fer- 
 gusson's plan. First the edges of the cleft should be pared as in the 
 operation for staphylorrhaphy. The sutures also inserted, but left un- 
 tied and held aside by an assistant. Then midway between the cleft 
 and the alveolar margin an incision is made down to the bone, the 
 incision being of equal length with the cleft in the hard palate. The 
 bone is then carefully cut through with the chisel and forced over 
 toward the mesial line. The sutures are then tied and the lateral in- 
 cisions packed with iodoform gauze. 
 
 If the operation is successful, the fissures close up by new bone- 
 formation, and a complete hard palate is eventually formed. 
 
 Mason Warren, of Boston, was among the first to close the hard 
 palate without cutting the bone. His plan was to detach flaps of com- 
 bined periosteum and mucous membrane from the hard palate by means 
 of a periosteal elevator, taking care not to tear the arteries of the ante- 
 rior and posterior palatine canals. The soft palate was also separated on 
 each side from the horizontal plates of the two palate-bones. Before- 
 tying the sutures, cuts were made, if required, midway between the 
 fissure and the alveolar margin on each side. 
 
 The after-treatment in all operations is an important matter. 
 Mild antiseptic irrigation is always needed. It is better also to apply 
 the iodoformized collodion no matter what operation is performed. 
 The food should be of fluid form for a number of days and the sutures- 
 should never be removed inside of a Aveek. The hands of the child 
 when necessary should be controlled, and a careful watch maintained,, 
 until all danger of injury to the tissues be over. 
 
 When isolated spots fail to unite, they may sometimes be enconr- 
 
URANOPLASTY. 457 
 
 aged to close by granulation, the parts being touched by nitrate of 
 silver or singed by galvanocautery. 
 
 With the object of improving voice-production at as early an age 
 as possible, Brophy, of Chicago, has recently devised and practiced 
 successfully a special method of treatment which he considers appli- 
 cable even in early infancy. By it he claims that the muscles, instead 
 of being allowed to atrophy, are developed from the first, and the nasal 
 tone caused by the presence of the cleft is never formed. 
 
 After vivifying the tissues of the soft cleft he trims the bony edges 
 of the hard cleft, thus favoring their union when brought into con- 
 tact. Then he passes a double silver-wire suture through the palatal 
 process of the palate-bone and another through the palatal process of 
 the superior maxillary. This is done on each side. Lead buttons made 
 to suit the parts and perforated for the wires are then placed in posi- 
 tion, one on each side, and the wires are passed through them. To 
 approximate the bony cleft, the right and left wires nearest the apex 
 are twisted together, putting tension upon the parts, the same to be 
 done with the anterior pair. If sufficient tension can be safely put 
 upon them to draw the two sides of the cleft together, incisions will 
 not be necessary. If not, then the hard palate on each side between 
 the cleft and the alveolar is to be cut subcutaneously, thus allowing 
 of greater tension. The buttons can then be drawn closer together by 
 twisting the wire sutures and held in position until union takes place. 
 The parts should now be thoroughly dried, and whenever necessary 
 fine sutures be put in to bring the tissues into perfect apposition. 
 
 Complete control of the child is always required for some days 
 after operation. Antiseptic treatment of the mouth should also be 
 attended to and only soft, liquid food administered. 
 
 As the operative treatment practiced by Edmund Owen, and de- 
 scribed by him at the last annual meeting of the British Medical Asso- 
 ciation, differs somewhat from any of the foregoing methods, and sus- 
 tains some points that are new, this chapter will be closed with a brief 
 description of the three stages which he defines: — 
 
 1. Before operation. It is imperative that the child should be 
 put in a good state of health. The chronic dyspepsia from which many 
 children having cleft palate suffer should be removed. For this, the ad- 
 ministration of a rhubarb-and-soda mixture is an excellent thing. All 
 carious teeth should be removed or cleaned and filled. Adenoids and 
 enlarged tonsils, if present, should also be taken away before operating 
 upon the cleft, and the parts given time to heal. 
 
458 OPERATIONS FOR CLEFT PALATE. 
 
 2. Operation. He uses a modified Smith gag armed with stout 
 spikes, which fit into the crevices of the teeth or into the gums, as he 
 says "harmlessly," but insuring against any slipping of the instru- 
 ment during the operation. The anaesthetic used is chloroform. 
 
 After anaesthesia is produced a strong suture is passed through 
 the tip of the tongue, and the organ drawn well forward before the 
 gag is inserted. The child is then brought to the end of the table with 
 the head hanging over to keep the blood out of the larynx, much as in 
 Churchill's position. 
 
 After denuding the edges of the cleft as in the ordinary method 
 he makes a long incision on the inner side of each alveolar process. 
 These incisions are usually very free, traversing the attachment of the 
 levator and tensor palati muscles as well as the palato-pharyngeus. 
 Then the raspatory is introduced and the muco-periosteal flaps are 
 raised. The attachment also of the aponeurosis of the velum to the 
 posterior border of the hard palate is divided with curved scissors. As 
 these incisions produce a good deal of haemorrhage, this is checked by 
 firm pressure with sponges before the sutures are inserted. 
 
 Owen prefers silver-wire sutures to any others. He uses a modi- 
 fication of Smith's needle, and when the cleft is complete ten or twelve 
 sutures may require to be inserted. 
 
 One important point that he insists upon is that there should be 
 no tension whatever upon the flaps. The incisions at the sides, al- 
 though almost as wide as the original cleft, usually heal without dif- 
 ficulty. 
 
 3. After operation. As anaesthesia passes off, the child may vomit,, 
 but unless this is very prolonged it will not interfere in any way with 
 the sutures. In order to favor mouth-drainage, the child should be so 
 placed upon the pillow that the blood will flow out upon absorbent 
 cotton arranged for the purpose. 
 
 The best food to give is home-made beef -jelly, as it slips down 
 without effort. 
 
 As soon as possible after operation the child may be taken out of 
 bed, and even out of the house, to secure the benefit of inhaling the 
 pure, fresh air. 
 
 Washing the mouth with solution of boric acid or other antiseptic 
 should not be insisted on, unless the child itself is willing, as the strug- 
 gle of opposition could do more harm than the washing would do good. 
 
 If septic infection takes place we must await the result. The 
 wound may be opened by staphylococcic invasion; but after a time, 
 
UEANOPLASTY. 459 
 
 with proper care, the fever will subside, and the sundered and swollen 
 edges of the cleft will look bright and clean again, and then the opera- 
 tion may be repeated, though in a minor degree, and with every prob- 
 ability of being successful. 
 
 Dr. Owen is of the opinion that, while nothing is so prejudicial to 
 prompt union after staphylorrhaphy as septic infection, yet, having 
 once recovered from the septicaemia, a complete immunity is for a time 
 acquired as a result, and further operation may be at once performed 
 with the prospect of a good union. 
 
INDEX TO LITERARY REFERENCES. 
 
 Abbott, 70. 
 Abercrombie, 293. 
 Abraham, 414, 
 Adenot. 137. 
 Alexander. 174. 
 Annandale. 450. 
 Appert, 104. 
 Archambault. 40G. 
 Arnold, 292. ' 
 Asch, 406. 
 
 Baber. 56. 111. 
 
 Babes, 411. 
 
 Baker, 82. 
 
 Ballinger, 83. 
 
 Barrett. 206. 
 
 Beale, Clifford, 398. 
 
 Bellocq, 108. 
 
 Bergengriin, 416. 
 
 Bilbroth. 116, 128. 
 
 Birkett. 230. 
 
 Bishop. 30, 35, 38. 64. 65, 94, 96, 99, 
 
 101, 213, 245, 402. 
 Blackley, 95. 
 Blake, 123. 
 Bonet. 104. 
 Bostock, 93. 
 Bosworth, 18, 24, 36, 38, 41, 44, 60, 
 
 62. 75, 83, 89, 90, 91, 95, 112, 115, 
 
 119, 122, 124, 138, 141, 150, 165, 169, 
 170, 194, 195, 218, 229, 237, 255, 279, 
 286, 311, 358, 365, 393, 401, 437. 
 
 Bovill. 110. 
 
 Bowlby, 295. 
 
 Braun, 39, 64, 65. 
 
 Bresgen, 148. 
 
 Brophy, 457. 
 
 Brown, Moreau, 167. 
 
 Browne, Lennox, 35, 57, 59, 64, 102, 
 
 120, 122, 141, 148, 159, 174, 192, 209, 
 213, 286, 299, 390, 402, 407, 412, 414, 
 434, 437, 443. 
 
 Brims, 125. 
 Bruschke, 194. 
 Butler. 115. 
 Butts, 211. 
 
 Canquoin, 150. 
 
 Capart, 223, 225. 
 
 Carter, 33. 
 
 Cary. 353. 
 
 Casselberry. 83, 124, 130, 245, 397. 
 
 Chapelle. 403. 
 
 Chatellier, 165. 
 
 Cheval, 83, 106, 167, 307. 
 
 Chiari, 144, 458. 
 
 Churchill, 455, 458. 
 
 Clark, 111. 
 
 Cloquet, 114. 
 
 Coakley, 137. 
 
 Cohen, J. Solis-, 41, 103, 440, 441. 
 
 Coley, 441. 
 
 Colin, 279, 280. 
 
 Collier, 60, 75, 81, 211. 
 
 Cooper, 170. 
 
 Corneil, 149. 
 
 Courmont, 319. 
 
 Courtade, 391. 
 
 Crookes, 447, 448. 
 
 Curtiss, Holbrook, 83, 180. 
 
 Damaschino, 279. 
 
 Damieno, 387, 388. 
 
 Davidson, 62. 
 
 De Blois, 255. 
 
 Debrousses, 396. 
 
 De la Sota, 396, 414. 
 
 Delavan, Bryson, 57, 64, 94, 122, 134, 
 
 191, 209, 211, 228, 440. 
 Demochowski, 165. 
 Demoe, 141. 
 Desault, 170. 
 De Simoni, 264. 
 Devasse, 151. 
 Deville, 151. 
 Dobell, 38. 
 Dontrelepont, 150. 
 Downie, Walker, 447. 
 Drake, 60. 
 Dreyfuss, 447. 
 Dupage, 316. 
 
 Ellet, E. C, 450. 
 Erichsen, 115. 
 
 Ferguson, Sir W., 456. 
 
 Ferrard, 316. 
 
 Flatau, 141. 
 
 Flateau, 180. 
 
 Fox, Hingston, 194. 
 
 Fraenkel, 41, 59, 62. 159, 105, 356. 
 
 French, 92. 
 
 Freudenthal, 149. 
 
 Friedlander, 59. 
 
 (461) 
 
462 
 
 INDEX TO LITERARY REFERENCES. 
 
 Gardi, 110. 
 
 Gavel, 169. 
 
 Gee, 293. 
 
 Gehrardt, 390. 
 
 Gelli, 60. 
 
 Gerdy, 130. 
 
 Gibb, J. S., 234. 
 
 Gleason, 107. 
 
 Gleitsmann, 178, 208, 214, 403. 
 
 Gliick, 410. 
 
 Goldstein, 114. 
 
 Gosselin, 132. 
 
 Gottstein, 60, 64, 214, 389. 
 
 Gouguenheim, 168. 
 
 Grant, Dundas, 56, 148, 168, 169, 170. 
 
 Griinwald, 57, 119, 178. 
 
 Giirlt, 437. 
 
 Hall, de Havilland, 209. 
 
 Hall. Marshall, 423. 
 
 Hajek, 175, 181. 
 
 Hansen, 410, 411. 
 
 Harrison, 170. 
 
 Haton, 141. 
 
 Helot, 55. 
 
 Hendley, 110. 
 
 Heryng, 169, 279, 296, 364, 389. 
 
 Hewlett, 143. 
 
 Hilaire, 165. 
 
 Hill, 110, 143. 
 
 His, 191. 
 
 Hodenpyl, 134. 
 
 Hopkins, 141. 
 
 Hopmann, 126. 
 
 Home, Joseph, 128, 234. 
 
 Hunt, Middlemas, 71, 392, 441. 
 
 Hunter, 424. 
 
 Ingals, Fletcher, 83, 102, 107, 177, 225, 
 397. 
 
 Jackson, Hughlings-, 423. 
 
 Jarvis, 54, 76, 122. 
 
 Jeanselme, 410. 
 
 Joal, 94, 104. 
 
 Johnson, 134. 
 
 Jones, Carmault, 28, 56. 
 
 Jonrdain, 169. 
 
 Jullien, 303. 
 
 Jurasz, 439. 
 
 Kanthack, 162. 
 
 Kelly, Brown, 134. 
 
 Kirstein, 345, 346, 347, 349, 368, 443. 
 
 Klebs. 390. 
 
 Knight, C. H., 131, 174, 196, 402, 430. 
 
 Koch, 300. 
 
 Krause, 170, 295, 402. 
 
 Kroulein, 315. 
 
 Kyle, 83, 148, 255, 306, 317. 
 
 Lahory, 114. 
 
 Lake, 71, 83, 88, 246, 404. 
 
 Lameres, 371. 
 
 Lange, Victor, 87. 
 
 Laurens, 410. 
 
 Ledermann. 87. 
 
 Lefferts, 134, 406. 
 
 Leflaive. 94. 
 
 Leland, 245. 
 
 Lermovez, 160. 
 
 Levi, 371. 374. 
 
 Liaras, 371. 
 
 Lincoln, 225. 
 
 Lindemann, 212. 
 
 Loder, 104. 
 
 Logan, 229. 
 
 Lowenberg, 59, 214, 384. 
 
 Lowndes. 112. 
 
 Lugol, 278. 
 
 Luning, 393. 
 
 Luschka, 191, 203. 
 
 MacDonald, Greville, 168. 207. 
 MacDonald. J. W., 455. 
 Maclntyre, 447. 
 Mackenzie, Hunter, 434, 435. 
 Mackenzie, J. Noland, 59, 94, 100, 115. 
 
 175, 420. 
 Mackenzie, Sir Morell, 17, 41, 74, 122, 
 
 255, 311, 412, 419, 423. 
 McBride, 119, 126, 205. 
 Magnam, 319. 
 Major, 396. 397. 
 Marsh, 110. 
 Martin, 216. 
 Mathieu, 267, 268. 
 Mayer, 406. 
 Menzes, 316. 
 
 Meyer, Wilhelm, 204, 208, 211. 
 Michel. 125. 
 Mickulicz, 316. 
 Milligan, 168, 170. 
 Moldenhanr, 165. 
 Morier, 171. 
 Mount Bleyer, 419. 
 Moure, 119, 196, 417. 
 Mulhall, 67, 68. 
 Murdoch. 70. 
 Murray, 296, 402. 
 Myles, 86, 176, 179, 181. 
 
 Navratil, 419. 
 Neisse, 146. 
 Newcombe, 216, 397. 
 Nyles, 165. 
 
INDEX TO LITERARY REFERENCES. 
 
 463 
 
 O'Dwver, 350, 351, 353, 354. 
 Otto, '209. 
 Owen, 457, 459. 
 
 Pakes, 247. 
 Paterson, 191. 
 Patterson, 230. 
 Pawlowskv, 149, 150. 
 Pean, 149.* 
 Pegler, 127. 
 Permewan, 33. 
 Pouchet, 233. 
 Primrose, 9, 79. 
 Pryor, 374. 
 Pynehon, 207, 262, 271. 
 
 Railton, 434. 
 Reclus, 234. 
 Reed. 146. 
 
 Reeve. R. A., 218, 220. 
 Reid, 246. 
 Reidel, 143. 
 Richardson. 280. 
 Robertson, 171, 321. 
 Robinson, Beverly, 165. 
 Roe, 25, 76, 289, 451, 452. 
 Roentgen, 447, 448. 
 Roosa, 185. 
 Rosenberg, 181, 392. 
 Rosenmiiller, 31. 
 Ross, G. F., 428. 
 Roy, 119. 
 
 Sach, 143. 
 
 Saint-Hilaire, 165. 
 
 Sajous, 38, 62, 64, 100, 154. 
 
 Sandford, 211. 
 
 Sappy, 437. 
 
 Schech, 122. 
 
 Scheppegrell, 115, 403. 
 
 Schiffer, 71, 165. 
 
 Schubert, 281. 
 
 Schiiller, 146. 
 
 Schultze, 11. 
 
 Seiler, 60, 125, 130. 
 
 Semon, Sir Felix, 194, 486. 
 
 Sendziak, 272. 
 
 Shurly, 18, 54, 59, 60, 64, 102, 122, 146. 
 
 Siebenmann, 280, 281. 
 
 Sicthoff, 218. 
 
 Sikkel, 128. 
 Simonowsky, 402. 
 Smith, Eustace, 425. 
 Sokolowski, 272. 
 Somers, 233. 
 Spicer, Scanes, 114, 171. 
 Stoerck, 390. 
 Stoker, 131. 
 Straight, Howard, 103. 
 Swain, 117, 119, 194. 
 Symonds, 143. 
 Syne, 141. 
 
 Taylor, Frederic, 424. 
 
 Thomson, St. Clair, 103, 133, 143. 
 
 Thorner, Max, 141, 221, 302, 345, 349, 
 
 353, 374. 
 Tiarus, 374. 
 Toeplitz, 279. 
 Tornwaldt, 203. 
 Trendelenburg, 76. 
 Tresilian, 146, 148. 
 Tyrrell, Shawe, 96. 
 
 Velpeau, 246. 
 Verneuil, 126, 141. 
 Volkmann, 147. 
 Voltolini, 125. 
 
 Wagner, 14, 41, 103, 194, 279. 
 Walton, 295. 
 Ward, 126. 
 Warren, 456. 
 
 Watson, Arthur, 86, 134, 143. 
 Webster, 206. 
 Weichselbaum, 143, 159. 
 Weil, 221. 
 Williams, 143. 
 Willigk, 143. 
 Williston, li4. 
 Wingrave, Wyatt, 58, 61. 
 Wishart, 73, 155. 
 Woakes, 119, 175. 
 Wolfenden, 272, 274. 
 Wright, Jonathan, 92, 115, 119, 175, 
 211. 
 
 Yearsley, 234. 
 
 Zeim, 76, 81, 170. 
 
 Zuckerkan41, 13. 74. 76, 119, 165. 
 
GENERAL INDEX. 
 
 Section I. — Diseases of the Nose. 
 
 Accessory cavities, anatomy of. 7. 
 
 diseases of, 159. 
 Acute sinusitis. 159. 
 
 etiology, 159. 
 
 symptomatology, 160. 
 
 treatment, 161. 
 Adenoma of the nasal passages, 132 
 Anatomy of the external nose, 3. 
 
 accessory sinuses, 7. 
 
 ethmoid cells, 7. 
 
 frontal sinus, 6. 
 
 maxillary sinus, 8. 
 
 nasal fossae, 3, 4. 
 
 septum, 4. 
 
 sphenoid sinus, 7. 
 
 turbinated bones, 5. 
 Angioma of the passages, 132. 
 
 treatment, 133. 
 Anosmia, 104. 
 Antrum, cyst of, 174. 
 Antrum of Highmore, 8. 
 Aprosexia, 121. 
 Asthma, reflex, 120. 
 Atrophic rhinitis, 58. 
 
 Bellocq's cannula in nasal haemor- 
 rhage, 108. 
 Blackley's investigations, 95. 
 Blood-vessels of the nose, 11. 
 Bone, superior turbinated, 5. 
 
 middle turbinated. 5. 
 
 inferior turbinated, 6. 
 
 Carcinoma of the nasal passages, 141. 
 
 diagnosis, 142. 
 
 etiology, 141. 
 
 pathology, 141. 
 
 prognosis, 142. 
 
 symptomatology, 141. 
 
 treatment, 142. 
 Chondroma of the nasal passages. 130. 
 Chronic disease of antrum of High- 
 more, 162. 
 
 diagnosis, 166. 
 
 exploratory puncture, 167. 
 transillumation, 168. 
 
 etiology, 165. 
 
 pathology, 162. 
 
 prognosis, 169. 
 
 svmptomatologv. 165. 
 
 (464) 
 
 Chronic disease of antrum of High- 
 more, treatment, 169. 
 combined operation, 171. 
 direct irrigation, 169. 
 opening of inferior meatus, 169, 
 170. 
 alveolus, 170. 
 canine fossa, 170. 
 cai 
 90. 
 
 perforations of, 91. 
 Congenital syphilis, 155. 
 Cyst of the antrum, 174. 
 Cystoma of the nose, 134. 
 
 Deviations of nasal septum, 74. 
 Disease of the frontal sinus, 181. 
 Disease of the sphenoid sinus, 180. 
 Diseases of the accessory sinuses, 159. 
 Diseases of the ethmoid cells, 175. 
 
 diagnosis. 177. 
 
 etiology, 176. 
 
 pathology, 175. 
 
 prognosis, 177. 
 
 symptomatology, 177. 
 
 treatment, 178. 
 
 Electrocautery puncture in hyper- 
 trophic rhinitis, 55. 
 Electrolysis in septal deformity, 84. 
 Epistaxis, 106. 
 
 diagnosis, 107. 
 
 etiology, 106. 
 
 pathology, 106. 
 
 prognosis, 107. 
 
 symptomatology, 106. 
 
 treatment, 107. 
 Ethmoid cells, 7. 
 disease of, 175. 
 
 Fibroma of the nasal passages, 128. 
 
 diagnosis, 129. 
 
 etiologv. 128. 
 
 pathology, 128. 
 
 prognosis, 129. 
 
 symptomatology, 128. 
 
 treatment, 129. 
 Foreign bodies in the nose, 112. 
 
 diagnosis, 112. 
 
 symptomatology, 112. 
 
 treatment. 113. 
 
GENERAL INDEX. 
 
 465 
 
 FurunculosiSj 105. 
 
 Galvanocautery-battery, 53. 
 Glanders. 148." 
 Glands of the nose. 11. 
 Gottstein's plugs, 64. 
 Griinwald's operation. 57. 
 
 Hay fever, or vasomotor rhinitis. 93. 
 
 diagnosis, 98. 
 
 duration of, 97, 98. 
 
 etiology, 94. 
 
 geographical area, 98. 
 
 pathology, 93. 
 
 periodicity of, 97. 
 
 preventive measures, 98. 
 
 prognosis, 98. 
 
 symptomatology, 96. 
 
 treatment, 99. 
 
 constitutional treatment, 99. 
 treatment of nasal passages, 100. 
 Hydrorrhoea, nasal. 103. 
 Hypertrophic rhinitis, 45. 
 
 Innervation of the nose, 11. 
 Instruments used in nose and throat, 
 15. 
 
 electric photophone, 15. 
 
 laryngoscope, 17. 
 
 nasal specula, 18. 
 
 powder-blowers, 24. 
 
 saws, etc., 25. 
 
 snares, etc., 27. 
 
 spokeshaves, etc., 28. 
 
 Lacrymal canal, 7. 
 Lupus of the nose, 146. 
 
 diagnosis. 147. 
 
 etiology, 146. 
 
 pathology, 146. 
 
 prognosis, 147. 
 
 symptomatology, 146. 
 
 treatment, 147. 
 
 Massage in atrophic rhinitis, 64. 
 Menthol in diseases of nose and throat, 
 35. 
 
 Nasal bones. 3. 
 
 Nasal deformities, operations for, 449. 
 
 Nasal hydrorrhoea, 103. 
 
 Nasal polypi, 116. 
 
 diagnosis. 121. 
 
 etiology, 118. 
 
 pathology, 116. 
 
 prognosis, 121. 
 
 reflex disturbances, 120. 
 
 sex, 119. 
 
 site of attachment. 120. 
 
 Nasal polypi, symptomatology, 119. 
 treatment. 1 22. 
 
 by electrolysis, 125. 
 
 by forceps, 125. 
 
 by snares, 122, 123. 
 Nasal septum, deformities, 74. 
 diagnosis, 81. 
 etiology, 75. 
 prognosis, 82. 
 
 sequelse after operation, 87. 
 symptomatology, 81. 
 treatment, 83. 
 
 electrolysis, 84. 
 
 methods by Bosworth, 83. 
 
 methods by Casselberry, 84. 
 
 methods by Curtiss, 83. 
 
 methods bv Ingals, 83. 
 
 methods by Kyle, 83. 
 
 methods by Lake, 88. 
 
 methods by Watson, 86. 
 
 rubber splints, 88. 
 
 silver tubes, 85. 
 Nasal septum, deformities of, 74. 
 conditions in actual life, 75. 
 skulls of aborigines, 74. 
 
 of civilized races, 74. 
 Nose in phonation, 12. 
 Nose in respiration, 13. 
 
 Olfactory area of the nose, 12. 
 Operations for nasal deformities, 449. 
 
 Annandale's method, 450. 
 
 Ellet's method, 450. 
 
 Roe's method, 451. 
 Osteoma of the nose, 136. 
 
 etiology, 137. 
 
 pathology, 137. 
 
 symptomatology, 137. 
 
 treatment, 137. 
 
 Papilloma of the nose, 126. 
 
 treatment, 126. 
 Parasites, nasal, 113. 
 
 symptomatology. 114. 
 
 Texas screwworm, 114. 
 
 treatment, 115. 
 Parosmia, 105. 
 
 Physiology of nose and accessory si- 
 nuses, 12. 
 
 nose in phonation. 12. 
 in respiration. 13. 
 
 sense of smell. 12. 
 Posterior rhinoseopic image. 30. 
 
 Rhinitis, acute. 32. 
 diagnosis. 33. 
 etiology. 32. 
 pathology, 32. 
 prognosis, 33. 
 
466 
 
 GENERAL INDEX. 
 
 Rhinitis, acute, prophylaxis, 33. 
 
 symptomatology, 33. 
 
 treatment, 34. 
 Rhinitis, atrophic, 58. 
 
 diagnosis, 61. 
 
 etiology, 59. 
 
 pathology, 58. 
 
 prognosis, 62. 
 
 symptomatology, 60. 
 
 treatment, 62. 
 
 by Gottstein's plugs, 64. 
 by massage, 64. 
 Rhinitis, chronic, 37. 
 
 diagnosis, 38. 
 
 etiology, 37. 
 
 pathology, 37. 
 
 prognosis, 38. 
 
 symptomatology, 37. 
 
 treatment, 38. 
 massage, 39. 
 Rhinitis fibrinosa, 70. 
 
 cases by Brun Murdoch, 70. 
 
 cases by Middlemas Hunt, 71. 
 
 cases by Richard Lake, 71. 
 
 cases by Schiffer, 71. 
 Rhinitis, hypertrophic, 45. 
 
 diagnosis, 50. 
 
 etiology, 47. 
 
 pathology, 45. 
 
 prognosis, 51. 
 
 symptomatology, 49. 
 
 treatment, 51. 
 
 by electrolysis, 55. 
 by turbinectomy, 56. 
 Rhinitis, cedematosa, 67. 
 
 treatment, 68. 
 Rhinitis purulentia of children, 41. 
 
 diagnosis, 42. 
 
 etiology, 42. 
 
 pathology, 41. 
 
 prognosis, 43. 
 
 symptomatology, 42. 
 
 treatment, 43. 
 Rhinoliths, 110. 
 diagnosis, 111. 
 prognosis, 111. 
 symptomatology, 110. 
 treatment, 111. 
 Rhinoscleroma, 149. 
 treatment, 149. 
 
 Sarcoma of the nasal passages, 138. 
 diagnosis. 139. 
 etiology, 138. 
 pathology, 138. 
 prognosis, 139. 
 symptomatology, 139. 
 treatment, 139. 
 Sense of smell, 12. 
 Sensitive areas, 94. 
 Septum, anatomy, 3. 
 abscess of, 92. 
 bilateral tumors- of, 127. 
 perforation of. 91. 
 treatment of, 91. 
 ulceration of, 92. 
 Sinus, frontal. 7. 
 maxillary, 8. 
 sphenoid. 6. 
 Soft palate. 13. 
 Syphilis, 151. 
 diagnosis, 153. 
 pathology, 152. 
 prognosis, 154. 
 symptomatology, 152. 
 primary, 152. 
 secondary, 152. 
 tertiary, 152. 
 treatment, 154. 
 Syphilis, congenital, 155. 
 diagnosis, 155. 
 etiology, 155. 
 pathology, 155. 
 prognosis, 156. 
 symptomatology, 155. 
 treatment, 156. 
 
 Tuberculosis of nasal passages, 143. 
 
 diagnosis, 144. 
 
 etiology, 144. 
 
 pathology, 143. 
 
 prognosis, 144. 
 
 symptomatology, 144. 
 
 treatment, 145. 
 Turbinated bones, anatomy of, 5. 
 Turbinectomy, 56. 
 
 Vasomotor rhinitis, 93. 
 Vomer, 4. 
 
 Zeim's experiments on animals, 76. 
 
 Section II. — Diseases of the Pharynx. 
 
 Abscess of the post-pharynx, 258. 
 
 tonsils, 244. 
 Actinomycosis, 306. 
 Acute bulbar paralysis, 320. 
 Acute infectious phlegmon of 
 pharynx, 261. 
 
 the 
 
 Acute pharyngitis, 231. 
 diagnosis, 233. 
 etiology, 231. 
 pathology, 231. 
 prognosis, 233. 
 symptomatology, 232. 
 
GENERAL INDEX. 
 
 467 
 
 Acute pharyngitis, treatment, 234. 
 Acute tonsillitis, 245. 
 Adenoid growths in naso-pharynx, 204. 
 diagnosis, 210. 
 etiology. 200. 
 pathology, 204. 
 prognosis, 210. 
 symptomatology, 207. 
 
 general symptoms, 208. 
 treatment, 211. 
 
 operation by curette, 214. 
 forceps, 214. 
 galvanoeautery, 213. 
 Adenoma of the palate, 291. 
 Advisability of general anaesthesia, 
 
 212. 
 Anaesthesia of pharynx, 212. 
 Anaesthetics, choice of, 212. 
 chloroform, 213. 
 ether, 212. 
 ethyl-bromide, 213. 
 nitrous oxide, 213. 
 Anatomy of pharynx, 185. 
 arteries, 190. 
 faucial tonsils, 191. 
 lingual tonsils, 192. 
 nerves, 190. 
 
 openings into pharynx, 185. 
 pharyngeal glands, 190. 
 pharyngeal tonsil, 190. 
 Aprosexia, 209. 
 
 Benign tumors of pharynx, 290. 
 dermoid growths, 292. 
 nbrochondroma, 291. 
 fibrolipoma, 291. 
 fibrolymphadenoma, 291. 
 fibroma, 290. 
 
 treatment of, 291. 
 papilloma, 290. 
 
 treatment of, 290. 
 
 Carcinoma of the fauces, 311. 
 
 diagnosis, 314. 
 
 etiology, 313. 
 
 pathology, 311. 
 
 prognosis, 315. 
 
 symptomatology, 313. 
 
 treatment, 316. 
 
 external operation, 316. 
 internal operation, 316. 
 Carcinoma of the naso-pharynx, 229. 
 Catarrh of the naso-pharynx, 195. 
 Chondroma of naso-pharynx, 230. 
 Chronic pharyngitis, 237. 
 Cleft palate, operations for, 454. 
 
 Deglutition, 193. 
 
 Dermoid tumors of the pharynx, 292. 
 
 Diseases of the uvula, 252. 
 oedema of the uvula, 252. 
 etiology, 252. 
 prognosis, 252. 
 symptomatology', 252. 
 treatment, 252. 
 elongation of the uvula, 253. 
 etiology, 253. 
 pathology, 253. 
 prognosis, 254. 
 symptomatology, 254. 
 treatment, 255. 
 
 Fibroma of naso-pharynx, 223. 
 
 diagnosis, 224. 
 
 etiology, 223. 
 
 pathology, 223. 
 
 prognosis, 224. 
 
 symptomatology, 224. 
 
 treatment, 224. 
 
 cold-wire snare, 225. 
 electrolysis, 226. 
 galvanocautery-ecraseur, 225. 
 Fibroma of pharyny, 291. 
 Follicular pharyngitis, 240. 
 Foreign bodies in the fauces, 321. 
 
 prognosis, 323. 
 
 treatment, 323. 
 
 Haemorrhage following tonsillotomy, 
 
 269. 
 Hypertrophy of lingual tonsil, 284. 
 
 diagnosis, 287. 
 
 etiology, 285. 
 
 pathology, 284. 
 
 prognosis, 287. 
 
 symptomatology, 286. 
 
 treatment, 287. 
 operative, 288. 
 
 Lacunar tonsillitis, 272. 
 Leukoplakia palati, 310. 
 Lingual tonsil, hypertrophy of, 284. 
 Lupus of pharynx, 297. 
 
 diagnosis, 298. 
 
 etiology, 297. 
 
 pathology, 297. 
 
 prognosis, 300. 
 
 symptomatology, 297. 
 
 treatment, 300. 
 
 Malignant diseases of naso-pharynx, 
 227. 
 carcinoma of naso-pharynx, 229. 
 symptomatology, 229. 
 treatment, 230. 
 sarcoma, 227. 
 
 diagnosis, 227. 
 
468 
 
 GENERAL INDEX. 
 
 Malignant diseases of nasopharynx, 
 sarcoma, etiology, 227. 
 pathology, 227. 
 prognosis, 228. 
 symptomatology, 227. 
 treatment, 228/ 
 
 by galvanocautery, 229. 
 Bosworth's case, 229. 
 Dela van's case. 228. 
 Logan's case, 229. 
 Malignant diseases of oro-pharvnx. 
 307. 
 carcinoma, 311. 
 sarcoma, 307. 
 Mycosis, pharyngeal, 277. 
 diagnosis, 282. 
 etiology, 279. 
 pathology. 277. 
 prognosis, 282. 
 symptomatology. 281. 
 treatment, 282.' ' 
 Myopathic paralysis of fauces, 319. 
 Myxofibroma of naso-pharynx, 217. 
 diagnosis, 219. 
 etiology, 218. 
 pathology, 217. 
 prognosis, 219. 
 Symptomatology, 218. 
 treatment, 219. 
 unusual cases, 221. 
 
 Xaso-pharyngeal catarrh, 195. 
 
 diagnosis, 199. 
 
 etiology, 196. 
 
 pathology, 195. 
 
 prognosis, 199. 
 
 symptomatology, 198. 
 
 treatment, 199. 
 Neuroses of the fauces. 318. 
 
 myopathic paralysis, 319. 
 
 neuralgia of the pharynx, 318. 
 
 neurosis of motion, 319. 
 of sensation, 318. 
 
 paralysis of the fauces, 319. 
 
 Operations for cleft palate, 454. 
 
 Palato - glosso - pharyngeal paralysis, 
 
 320. 
 Pharyngeal mycosis, 277. 
 Pharyngeal papillomata, 290. 
 Pharyngeal tuberculosis, 293. 
 Pharyngitis, acute, 231. 
 Pharyngitis, chronic, 237. 
 
 diagnosis, 238. 
 
 etiology, 237. 
 
 pathology, 237. 
 
 prognosis, 238. 
 
 symptomatology, 238. 
 
 Pharyngitis, chronic, treatment, 239. 
 Pharyngitis, follicular, 240. 
 diagnosis, 242. 
 etiology, 240. 
 pathology, 240. 
 prognosis, 242. 
 symptomatology,- 241. 
 treatment, 243. 
 Pharynx, anatomy of, 185. 
 boundaries of, 185. 
 openings into, 185. 
 Physiology of pharynx. 193. 
 soft palate, 193. 
 tonsils, 194. 
 
 Quinsy, or acute tonsillitis, 245. 
 diagnosis, 248. 
 etiology, 247. 
 pathology, 245. 
 prognosis, 249. 
 symptomatology, 247. 
 treatment, 249. 
 
 Retropharyngeal abscess, 258. 
 diagnosis, 259. 
 etiology, 258. 
 pathology, 258. 
 prognosis, 260. 
 symptomatology, 259. 
 treatment, 260.' 
 
 Sarcoma of the fauces, 307. 
 diagnosis, 308. 
 etiology, 307. 
 pathology, 307. 
 prognosis, 309. 
 symptomatology, 308. 
 treatment, 309. 
 Staphylorrhaphy, 455. 
 Syphilis of the pharynx, 301. 
 diagnosis, 304. 
 etiology, 302. 
 pathology, 301. 
 prognosis, 305. 
 symptomatology, 302. 
 
 primary, 303. 
 
 secondary, 303. 
 
 tertiary/ 303. 
 treatment. 305. 
 
 deformities of pharynx, 306. 
 
 mucous patch, 305. 
 
 ulceration, 306. 
 
 Tonsilliths. 321. 
 Tonsillitis, 321. 
 Tonsillitis, lacunar, 272. 
 
 diagnosis, 274. 
 
 etiology, 273. 
 
GENERAL INDEX. 
 
 469 
 
 Tonsillitis, lacunar, pathology, 272. 
 
 prognosis. 275. 
 
 symptomatology, 273. 
 
 treatment. 275. 
 Tonsillotomy by tonsillotome, 207. 
 
 cold-wire snare, 270. 
 
 curved scissors, 270. 
 
 galvanocautery- knife, 270. 
 secondary haemorrhage, 309. 
 Tonsils, faucial. 191. 
 lingual, 192. 
 pharyngeal, 190. 
 Tonsils, hypertrophy of, 202. 
 
 diagnosis, 205. 
 
 etiology, 204. 
 
 pathology. 202. 
 
 Tonsils, hypertrophy of, prognosi. 
 200. 
 
 symptomatology, 204. 
 
 treatment, 207. 
 Tornwaldt's disease, 203. 
 Tuberculosis of pharynx, 293. 
 
 diagnosis, 294. 
 
 etiology, 293. 
 
 pathology, 293. 
 
 prognosis, 295. 
 
 symptomatology, 294. 
 
 treatment, 295. 
 
 Uranoplasty, 450. 
 Uvula, elongation of, 253. 
 oedema of, 252. 
 
 Section III. — Diseases of the Larynx. 
 
 Abscess of the larynx, 395. 
 Acute laryngitis. 302. 
 
 diagnosis, 303. 
 
 etiology, 302. 
 
 pathology, 302. 
 
 prognosis, 304. 
 
 symptomatology, 303. 
 
 treatment, 304. 
 Acute laryngitis of children, 307. 
 
 diagnosis, 308. 
 
 etiology, 307. 
 
 pathology, 307. 
 
 prognosis, 309. 
 
 symptomatology, 308. 
 
 treatment, 309. 
 Acute cedematous laryngitis, 371. 
 
 diagnosis, 372. 
 
 etiology, 371. 
 
 pathology, 371. 
 
 prognosis, 373. 
 
 symptomatology, 372. 
 
 treatment, 374. 
 Affections of the cricoarytenoid ar- 
 ticulation, 390. 
 American nebulizer, 382. 
 Anatomy of the larynx, 327. 
 
 arteries, 335. 
 
 arytenoids, 329. 
 
 cricoid cartilage, 327. 
 
 epiglottis, 330. 
 
 ligaments, 333. 
 
 lymphatics, 335. 
 
 mucous membrane, 335. 
 
 muscles, 335. 
 
 nerves of larynx, 335. 
 
 thyroid cartilage, 328. 
 
 vocal cords, 333. 
 Arthritic deformities of the larynx, 
 397. 
 
 Atrophic laryngitis, 384. 
 diagnosis, 385. 
 pathology, 384. 
 prognosis, 385. 
 symptomatology, 384. 
 treatment, 3S5. 
 Autoscopy, 345. 
 
 description of autoscope, 34G. 
 instruments for autoscopic work. 
 
 349. 
 Kirstein's tongue-depressor, 345. 
 position in autoscopy, 345. 
 
 Benign growths of the larynx, 429. 
 
 Carcinoma of the larynx, 430. 
 
 diagnosis, 438. 
 
 pathology, 437. 
 
 prognosis, 438. 
 
 symptomatology, 437. 
 
 treatment, 439. 
 
 endolaryngeal operation, 439. 
 inoculation by erysipelas, 441. 
 laryngectomy, 440. 
 Solis-Cohen's operation, 440. 
 Chorditis inferior hypertrophica, 390. 
 Chronic blennorrhea of Stoerck, 390. 
 Chronic laryngitis, 377. 
 
 diagnosis, 379. 
 
 etiology, 377. 
 
 pathology, 377. 
 
 prognosis, 379. 
 
 symptomatology, 378. 
 
 treatment, 380. 
 Cleft palate, operation for, 420. 
 
 staphylorrhaphy, 455. 
 
 uranoplasty, 450. 
 Comminutor for inhalations, 383. 
 Congenital syphilis of larynx, 420. 
 
470 
 
 GENERAL INDEX. 
 
 Difficulties in laryngeal examination. 
 
 341. 
 Diffuse pachydermia, 389. 
 Diseases of larynx, 325. 
 
 Fatal spasm of the larynx, 424. 
 Fibromata of the larynx, 429. 
 Foreign bodies in the larynx, 442. 
 
 diagnosis, 443. 
 
 prognosis, 444. 
 
 symptomatology, 443. 
 
 treatment, 445. 
 
 History of a case of laryngeal peri- 
 chondritis, 394. 
 
 Intubation, 350. 
 
 intubation-tube, improved, 353. 
 
 in diphtheria, 353. 
 
 in laryngeal stricture, 353. 
 O'Dwyer's tubes, 351. 
 operation during infancy, 351, 352. 
 
 during adult life, 352. 
 removal of the tube, 353. 
 
 Kirstein's autoscope, 345. 
 tongue-depressor, 346. 
 
 Laryngeal manifestations of rheuma- 
 tism, 397. 
 Laryngeal perichondritis, 393. 
 
 diagnosis, 394. 
 
 etiology, 393. 
 
 pathology, 393. 
 
 prognosis, 395. 
 
 symptomatology, 393. 
 
 treatment, 396. 
 Laryngitis fibrinosa, 392. 
 Laryngitis, acute, 362. 
 of children, 367. 
 
 atrophic, 384. 
 
 chronic, 377. 
 
 oedematous, 371. 
 
 tubercular, 398. 
 Laryngoscopy, 340. 
 
 author's operating-chair, 344. 
 difficulties of examination, 342. 
 position of the patient, 344. 
 Leprosy of the air-passages, 410. 
 
 anaesthetic form, 410. 
 
 nodular form, 410. 
 Leprosy of the nose, 411. 
 
 larynx, 412. 
 
 mouth and pharynx, 412. 
 treatment of, 414. 
 Lupus of the larynx, 406. 
 
 diagnosis, 407. 
 
 prognosis, 408. 
 
 Lupus of the larynx, symptomatology 
 407. 
 treatment, 408. 
 
 Malignant tumors of the larynx, 436. 
 
 histological examination, 436. 
 Multiple comminutor, 420. 
 Multiple papillomata of children, 434. 
 
 treatment by tracheotomy, 434. " 
 intubation, 434. 
 
 Nervous aphonia, 422. 
 
 symptomatology, 422. 
 treatment, 422." ' 
 Neuroses of larynx, 421. 
 sensation, 421. 
 treatment, 421. 
 Neuroses of motion, 423. 
 diagnosis, 424. 
 etiology, 423. 
 prognosis, 424. 
 spasm of glottis, 423. 
 symptomatology, 423. 
 treatment, 425. 
 Non-malignant tumors of the larynx, 
 429. 
 cystomata, 430. 
 enchondromata, 430. 
 fibromata, 429. 
 lipomata, 430. 
 diagnosis, 431. 
 prognosis, 432. 
 symptomatology, 430. 
 treatment, 432. 
 papillomata, 429. 
 
 I Operations for nasal deformities, 449. 
 Annandale's 450. 
 Ellet's, 450. 
 Roe's 451. 
 
 Pachydermia laryngis, 387. 
 
 diagnosis, 388. 
 
 diffusa, 387. 
 
 etiology, 387. 
 
 pathology, 387. 
 
 prognosis, 388. 
 
 symptomatology, 388. 
 
 treatment, 389. 
 
 verrucous, 387. 
 Papillomata, 429. 
 Paralysis of the larynx, 426. 
 
 etiology, 427. 
 
 treatment, 428. 
 Phvsiology of the larynx, 337. 
 " attributes of the, 339. 
 
 function of phonation, 338. 
 
 function of respiration, 337. 
 
 Semon's theory, 337. 
 
GENERAL INDEX. 
 
 471 
 
 Pseudomembranous laryngitis, 391. 
 recurrent, 391. 
 traumatic, 391. 
 
 Syphilis of the larynx, treatment, 418. 
 Syphilitic laryngeal stenosis, 419. 
 Syphilis, congenital, of the larynx, 
 420. 
 
 Removal of foreign bodies from 
 oesophagus, 448. 
 larynx, 445. 
 Roentgen's rays in laryngeal surgerv, 
 447. 
 Crookes tubes, 447. 
 sciagraph, 447. 
 
 Simple oedema of the larynx, 375. 
 
 diagnosis, 376. 
 
 etiology, 375. 
 
 pathology, 375. 
 
 prognosis, 376. 
 
 symptomatology, 375. 
 
 treatment, 376. 
 Subglottic chronic laryngitis, 390. 
 Syphilis of the larynx, 415. 
 
 diagnosis, 417. 
 
 etiology, 416. 
 
 pathology, 415. 
 
 prognosis, 418. 
 
 symptomatology, 417. 
 
 Thyrotomy, 358. 
 Tracheotomy, 354. 
 
 general anaesthesia, 355. 
 high operation, 357. 
 instruments used, 354. 
 local anaesthesia, 356. 
 low operation, 358. 
 Tuberculosis of the larynx, 398. 
 diagnosis, 400. 
 etiology, 398. 
 pathology, 398. 
 prognosis, 401. 
 symptomatology, 399. 
 treatment, 402. 
 
 contra. - indications of curette- 
 
 ment, 403. 
 eurettement, 403. 
 submucous injection in treat- 
 ment, 403. 
 tracheotomy and laryngectomy, 
 
 403. 
 treatment by electrolysis, 403. 
 
 Verrucous pachydermia, 387.